Massage Research

What is research?

Research is a conversation that builds knowledge over time.  It is a way of taking all of our stories from our hands on work and putting it into a format that can help us to make sense of what massage does and what we are doing in our daily massage practice.   It is asking questions in a very particular way that is objective (free of bias, facts and opinions).   It also has to be reproducible by others and get the same results – that would be good!  It allows research to build on itself and go forward to the next steps.

Levels of Evidence

It is all about the levels of evidence and the strength/impact of the research.  Not all research is good research! Research that shows something works on a high number of people is better.  Research that also reduces bias is better.

The highest level of evidence is shown in systematic reviews such as a metaanalysis that collects info from many research studies and makes meaning of all the research on a topic.

A Randomized controlled Trial (RCT) is the next highest level – the Gold Standard as it is called.  There is a control group that separates the question from the study. It has to be random as in you put names in a hat and pick participants.  One group gets the massage and one group gets no treatment.   It’s random!

Pilot studies are usually done with 30 people and will usually tell us that we need more studies on a specific area.

Case Reports/Case Studies are the stories from our clinical work so others can begin to understand what it is that you do.  A case series can also be done on a few clients with the same issues like all of them have headaches or back pain or one issue.   You can’t prove anything with a case report but it is a very good place to start.  One of the most famous findings was in a case report – Five Young Men with Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California.

 Why is Research important for the massage profession?

One of the main reasons for doing research is so that we will have the best methods and techniques for clients to be able to help them more.   The more we know, the better our sessions can be or so it is said by many of the researchers.

The other main reason is that many insurance companies are requiring us to show them more research in order for massage to be covered by health insurance.

Health insurance companies do not really understand that allowing massage would help save them money.  They still  have the idea that they would be paying the massage therapist $1000  and also having to pay for surgery (an additional 20k rough guess). From what I have seen here in WA with being one of the only states where it is a mandate that insurance companies cover massage is that doctors still do not really understand the benefits of massage.  In general, they will prescribe massage for back/neck pain but don’t really send people with larger complaints like carpal tunnel or thoracic outlet syndrome.

“Reiki” (ray-key) is Japanese for ‘universal life energy’, a term used to describe a system of natural healing. This healing tradition was founded by Dr Mikao Usui in the early 20th century and evolved as a result of his research, experience and dedication.  Massage Therapists are often found taking classes in Reiki and it is also popular in the nursing profession with nurses using it often in the hospital with sick patients.

One of the hot topics of discussion on Facebook among massage therapists has been – Does Reiki Work? and the latest question asked was why does the NCBTMB approve Reiki classes as part of their continuing education requirements if there is no scientific evidence that there is even such a thing called Reiki.

There are many research studies that do try to show that Reiki works.  I just Goggled Reiki Research and there were many pages that showed many different studies on Reiki.

The problem though with all the research studies though is that they assume that there is something called ‘Universal Energy’.  I am told by Chris Moyer, PhD a well known researcher in the massage profession and Professor of Psychology at University of Wisconsin-Stout, that indeed there is no such thing as ‘Universal Energy’.

Most reiki research is also lacking in valid research methods that show what it really is that is happening because there are so many positive results that happen. Many Reiki practitioners will usually see some results in their clients.  It is my understanding that Reiki or so called laying on of hands or holding your hand over people does help them feel better- helps them feel calmer, more relaxed. It is not apparently because of the so called “universal energy field.”

The problem for me lies in how do we get this message to people who are doing Reiki and what really would need to be done?  Could people doing Reiki just change what they say about how it works to be more credible and just say we don’t know what is happening?  Does using Reiki and saying that Reiki works actually hurt the massage profession because it makes the profession look less reputable when they promote things that are not accurate methods of healing?

Personal note:  I don’t get Reiki.  I never have felt anything when someone said they were doing Reiki on me.  I took an energy class once (not specifically reiki) and they told me to imagine I felt the energy.  I was out of there!  The reason this topic interests me so what to do with all the Reiki practitioners out there spreading the word of Reiki.  I am sure that their reaction to this is going to be reactionary as I am guessing they may feel like they are being attacked both professionally and personally as I have seen in other cases of where research does not currently support a technique or process. My concern with this is how I see it separating the profession even more when there is already so much going on that separates us (Side bar: 2 major professional associations, 2 major testing organizations, the ELAP project, the Alliance for Massage Education – why can’t there be one org? that unites us all because it is needed if we want to be recognized as part of the health care profession and get massage to be covered by insurance.)  I also have been struggling for years to understand the meaning of research and what does it say or not say – does research ‘prove beyond a doubt’ that something works or doesn’t work and how much research do we need to prove something.

This effects of massage or what most massage therapists also refer to as the benefits of massage have been passed on by many massage schools as the way it is.  Unfortunately, most of the benefits of massage have not been widely researched and many of the things that are taught in basic massage school are not correct.

I know that after attending the Massage Therapy Foundations Research Conference a few years ago here in Seattle.  Even with all of that information, the stories continue on.  I recently attended the Alliance for Massage Therapy Education Conference (AFMTE) and took the class on Busting Myths and Teaching Truths about the Effects of Massage, with Tracy Walton (who by the way is one of Gods blessings for the massage profession!  If you ever get to take a class with her, she is absolutely fabulous! She is involved with doing research on massage and cancer.)

The rest of this post are based on my notes from the class!

There are three types of different outcomes that can be measured as a result of doing massage. (You can also read more in Chapter 6 in Tracy Waltons book – Medical Conditions and Massage

1. Clinical Outcomes are subjective reports about whether or not
   clients are doing better with their treatments.  Are they coping and managing better as a result of the massage?  Massage reduces stress is a clinical outcome.
2. Mechanistic outcomes are based on science.  They are measured in blood tests or other physiological mechanisms such as saliva tests.  Reducing Cortisol is a mechanistic outcome.
3. Financial Outcomes are is the treatment cost effective?  Can they save money on medications, reduce surgery and things like that.

In general, we use mechanistic outcomes more often even though there is not enough scientific evidence that they are true.  Mechanistic outcomes are weak and the clinical outcomes would be stronger without them. How many times have you heard or read a MT website and their claims:  increases endorphins, increases immunity, reduces cortisol, detoxifies, increases circulation or that they can’t do massage on someone who has cancer because it is spread through the body when.

There isn’t much research to support those effects of massage…sorry.

[Side Note:  Research Literacy.

In research, not all research is created equally and there are different levels of evidence and different classifications of research studies.  That means that there are research studies that are better than others because of the way that they are done.

The Highest Level of research – the one’s that are the best as far as what they show are Qualitative Reviews.  That is when a researcher researches research and make a review of the research that is done -aka Met-analysis. Narrative Reviews are reviews of literature (any type of literature on the topic) are the next top level of evidence, and then Randomized Control Studies -RCT, where there are groups of people who don’t get massage, Case Series which is a series of case studies on one topic, a case report (written by one therapist on one client and explores the massage sessions and results) and then the story or Anecdote that was told.

(This article from the AMTA has more info on research literacy (PDF).)

So back to the effects of massage one by one.

1. Massage increases endorphins.  T or F ? …………..sorry – F.  There are only two 2 RCT studies ever done.
2. Massage enhances immunity.   T of F? ……………sorry – F.  There are only a few studies done by the Touch Research Institute done on that which means that there could be research bias because of it being done at the same place.  We need more research on this.
3. Massage reduces cortisol.     T or F?………………sorry.  F.  Yes you were taught this over and over in massage school and there are many studies by the Touch Research Institute, but there was a big bomb that went off in the form of a Meta-analysis done by Chris Moyer, PhD that shows that massage does not lower cortisol. (see video below)
4. Massage detoxifies tissues.   T of F…….again. F   There are no studies what so ever on massage and toxins. Toxins are things like mercury or heavy metals or chemical compounds.  Some were taught that the waste products from normal cellular metabolism were called toxins and that massage moved them out of the tissues.  The body takes care of these products from what we know now.  Yes people feel better after massage, but it isn’t because the massage got rid of toxins.
5. Massage increases circulation.  T or F?  ………are you catching on?  F.  There are only a few RCT’s that were done a really long time ago and were not done with ultrasound so there isn’t any proof that massage increases circulation.  Because we just don’t know what massage does, there are many contraindications around circulatory effects such as blood pressure, blood clots and things like that.  It isn’t really a good idea to ignore the contraindications until more research is done.
6. Massage Spreads Cancer.    T or F?……… Yes.  F   There is plenty of research that now shows that it is OK to massage people with cancer.  If it was true that massage spreads cancer, patients would also be told to stop exercising and in fact they are usually told to exercise.

So there you have it….the truth about the effect of massage.  Be sure to share this on your Facebook walls, in your newsletters and start changing that long list of things on your website.

So what is the evidence for what massage can do?  The strongest evidence is also a meta-analysis by Chris Moyer that shows that massage reduces depression and anxiety as much as psychotherapy does.  Will massage one day be under psychology boards?

There are many problems that arise when doing research on massage therapy.  You will find many of these are objections from the massage therapists themselves as to why we should have or even use research in massage.  The biggest problem is how do you really measure what happens in a session and recreate a real massage in a controlled environment?  Massage is not done in a controlled environment where a particular type of massage is done on a particular body part for a specified amount of time.  The way most massage works is that the massage therapist will let their hands and ‘gut feelings’ lead the massage.  How do you really measure or recreate that?

How do you measure the amount of pressure or the massage technique that is done?  You can teach a 12 MT a specific technique and it will be done 12 different ways with each persons own unique touch and intention behind the technique. How do you regulate or measure the amount of pressure that is applied and how do you regulate or measure the exact spot in each muscle or muscle group so that you know exactly what it is that is making the difference?

There is also nothing really in massage that could replicate the idea of a placebo or sugar pill.  You can hand someone a pill that they don’t know what is in it, but how do you really do that with massage?

How do you control for all of the other factors in a persons life also – I guess that is a problem with all research – was it the intervention or the change in diet that they made or them getting more sleep or them living their life.

Yet one of the ways we will get the insurance companies and the general public’s attention is with having more research.  The insurance companies especially are moving toward using research to determine where they spend their money for their patients – what works best for the money spent.  It is also just as important to have research for the spa or relaxation division of the massage profession.  Spa massage, heat and special spa therapies are just as important in healing.

Getting massage therapists interested in research is another part of this challenge.  They are taught various techniques in school that are actually not proven scientifically and the research that is done to support various modalities is usually flawed in some way but massage therapists do not really know it because they are not trained in research literacy and more importantly – they see these same things work when they practice it.   When the ‘researchers’ show up and say something doesn’t work to the many massage therapists who are practicing that modality – it is like a slap in the face (even though the researchers that I have interacted with online don’t mean it that way- their approach is very well for lack of a better work -egotistical).   That is not going to get any points for research!  From what I understand so far in this process of learning about research is that it isn’t that it doesn’t work but more of the way that it is explained as to how it does work -(does that make any sense?)  For example – research does not support the practice of Reiki but there are many massage therapists, nurses and even people in hospitals and hospice units who practice it.  It does work but the reason it does work is a mystery really or so it is said to be by science.  Is it the therapeutic presence?  Most likely but we don’t really know.  Supposedly there is no such thing really (scientifically speaking) as Universal Energy according to this article- Reiki Can Not do Harm – or can it? by Christopher Moyer, a well known massage researcher and Assistant Professor of Psychology at University of Wisconsin-Stout

“universal energy” on which it is based cannot possibly exist, for if it did, it would have to do so in contradiction of the conservation of mass-energy principle, and that is as well supported by scientific evidence as practically any principle that we know

The problem with researching massage is how do we combine science with the art of massage and preserve the art of massage – of being present, of connecting, of being compassionate care givers, with science?  We (I) just want to do massage!

Why do we need massage therapy research especially since we as massage therapists already see so much of the proof on a daily basis in the practice of massage?

Research is an important part of the next steps for the massage profession.  The biggest reason is that it can help the massage profession and your massage business gain the respect that is needed by the general public and also the medical profession.  It will also help get massage covered by insurance.  One of the things that Debra Senn (a past insurance commissioner in WA State who made it possible for WA State MT to become contracted providers with insurance) said one of the most interesting things about the process.  She said when insurance companies first heard they were going to have to pay for massage, they complained thinking that it would cost them more money.  They thought they would have to pay $10,000 for the carpal tunnel surgery (or whatever type of surgery and that amount is just for example- how much does a carpal tunnel surgery really cost?)  and then pay a few extra thousand to cover the massage.  They did not understand that massage could eliminate the need for massage.  I still don’t think they really get it as what I see in the way of referrals from most doctors is generally for back and neck pain.  The doctors don’t really understand how massage can be used for various things like musculo-skeletal injuries such as plantar fasciaitis, tennis elbow, sprained ankles, and things like that.  Doctors will relate more to evidence and research that shows how massage can help.  They will also start getting it when more people provide start using massage for just those kind of issues and start giving feedback to the doctors.

One of the other things about research is that it is important to have research that shows what massage does.  Many of the things that are currently being taught in massage school are inaccurate and have just been handed down through classes because that is what they are taught.  There are still many schools saying that massage should not be used on people with cancer which was debunked many years ago. (See massage and cancer)   The other big myth is that of toxins being removed (See Massage and toxins) from the body through massage and also the myth that massage removes lactic acid. (See Lactating Mythers – Massage and the Lactic Acid Myth)   Right now there are many massage therapists that continue to say those things and don’t have the latest research that shows otherwise and having so much misinformation makes massage confusing to the general public.

But having more research is not really enough since most massage therapists are not research literate- that is the don’t understand how to evaluate a research study.  Just because a study was done and shows positive outcomes does not mean that it shows anything unless you can understand it.  Research literacy is needed and it begins with having to read and learn about things that most have no interest in.  Most massage therapists are just happy to be doing massage or are struggling to get clients or find a high paying job.  Who has time for research or learning any more when of course we already know that massage works?

Research Literacy according to Ravensara Traviallian from her article in Massage and Bodywork Magazine in the Research Perspectives column is :

the ability to read, understand, and
apply information from published
research—

Once you are research literate, then you have the opportunity to start influencing research and even creating research studies.

In your massage practice, you will be able to look up research to help you address the needs of your clients when they come in with more difficult diseases and conditions and when you want to know if massage can help them.  When clients ask you how massage works, you will be able to give a knowledgeable answer.  When clients understand more how their bodies work, they have the power to take care of it better.  They also may pass this information on to their doctors- and so it goes.

So please share your comments or insights as to why we do need research and need to also be able to understand research.

One of the problems I see from attending the research conference and thinking about research is that there seems to be more than just a vocabulary problem in understanding research and using it to create evidence based practices and to use research to get and keep clients.

Whitney Lowe touched on it in his closing keynote address. The big thing is motivation – what is in it for me (the intuitive, caring, empathetic, massage therapist?) What is in it for my clients?  How will it make their lives better or make me a better massage therapist?   After attending the conference and seeing many great research studies (half of which I don’t know what they were talking about) I am not going to be changing anything in the way I do massage or talk to people about massage in my efforts to get and keep clients.  Whitney also talked about his passion for taking research and trying to implement it into his practice. It did make me want to learn more about that as his passion is really contagious!

To me I don’t have any interest in doing that.  I have been doing massage full time for 23 years and like what I am doing and it seems to work fine for most people.

The biggest question that I have for researchers is SO WHAT?  Why do I need proof that massage works for back pain or reduces anxiety?  I already know that and see the evidence in my practice everyday.   I also use this question when working with massage therapists who are trying to explain what it is that they do -the so called benefits of massage.  Clients don’t care about the benefits of massage which are usually nicely listed on their websites – reduces inflammation, increases circulation. (Tracy Walton also once said that the benefits of massage are not really scientifically proven to be valid!  You also can’t say that things are proven because one or two or even 20 studies doesn’t make it so!)

The whole time during the conference I kept thinking of a really good book I am reading for the second time “Made to Stick” by Dan Heath.  He talks about something he calls the Made to Stick: Why Some Ideas Survive and Others Die
– you forget that you used to know nothing about something and all the knowledge that you have gained makes you sound so smart but it doesn’t help you connect with others and ‘make your idea stick’.  Once you know something it is hard to imagine what it was like before you didn’t know.  Sharing knowledge is difficult and nearly impossible when you are not able to put yourself in the listeners shoes!  Of course you can’t unlearn what you now know but I can’t help but think that you could reach more massage therapists and the general public when you keep that concept in mind.

I know there is also a lot of talk and efforts going into teaching research methods to massage therapists and how is that going to happen.  There are more and more classes being taught on that and massage schools are trying to figure out how to put it into their curriculum.  But I still say So What?  Will taking 50 hours of research methods help people get and keep clients?  They won’t be able to take the classes in a CE format unless they are making enough money to do so.  Yes I am making this all about money but it seems to be the challenge of many massage therapists – just trying to get by and make a living.

So my challenge to the many massage researchers, people talking about research is to start at the beginning and start telling and showing people why research is important.  How will having research help the average intuitive, empathetic, caring massage therapist be more successful?  Or I guess maybe it isn’t the researchers job to make their work more applicable but maybe more of the profession – the  Massage Therapy Foundation and other massage research groups and other people who are not researchers but just love research. ( I met a bunch at the conference!)

Ok and the other thing is where are all the researchers blogs or websites?  I couldn’t find any anywhere which is another interesting thing.  That seems to me like they are just doing the research for themselves and not even wanting to connect with the people who they are doing the research for.  So if there are websites out there let me know.  I do know of a few sites being done my people who are massage therapists and are interested in research- www.mt-researchonline.com and a Bodhi Haraldssons Blog on Evidence Based Practice and this massage research blog who I can’t quite figure out who is the author.

The best site to find research related to massage is at the Massage Therapy Foundation’s website but it doesn’t help break it all down into usable information.

My favorite study in massage is the Meta Analysis of Massage Research by C.A. Moyer (who I got to meet and didn’t even really get that it was his research until now when I started writing this post!) It came out in 2004 but at the time there were a lot of people talking about it and there was also a good article about it in Massage and Bodywork Magazine that helped me understand what it really meant for the profession.  You can read the whole study on www.anatomyfacts.com

So maybe this isn’t so much to the massage reseearchers because they are busy doing massage research – but to the massage profession:  Can you please make massage research more understandable?

Can you start with why is research important to the massage profession?  I am sort of getting an idea why but am still very mixed about the whole thing. I’ll probably write another post on that later today or this week.  But now off to the spa and the far infrared saunas which there is some research on that looks promising (or so they say – I couldn’t find anything with a 2 minute search! ha!)  But I still love it and will go!