Real-World Massage Research

... and Massage Therapist Involvement

By Jerrilyn Cambron, DC, PhD
[Somatic Research]

Back pain is a condition on which a lot of massage therapy research has been conducted, and for good reason. Back pain is the leading cause of years lost to disability1 and one of the top reasons people seek out massage therapy. A recent study in Pain Medicine highlights real-world massage therapy for chronic low-back pain and found outcomes beneficial for study participants.2  The study was conducted at the University of Kentucky and examined massage therapy for pain with disability and health-related quality of life in primary care patients with chronic low-back pain.

The study is important for the massage therapy field because unlike earlier large-scale research studies, this one used community practicing massage therapists who developed individualized treatment plans for study participants assigned to them. The whole study was set up to reflect the way real chronic low-back pain patients would access massage therapy in most parts of the country. Several Central Kentucky family and internal medicine primary care providers participated in the research and their referrals were how patients entered the study.
Primary care providers referred patients with chronic low-back pain to the study if they thought massage would be beneficial. Once enrolled, patients were matched with community massage therapists who practiced close to either where they lived or worked. Patients were allowed to access up to 10 complimentary one-hour massage sessions over 12 weeks (massage therapists were compensated by the study team). All aspects of the massage sessions occurred as typical in the massage field after the initial patient-to-therapist match by study personnel. Patients scheduled with the massage therapist per their availability and the treatment plan, and they attended sessions in their therapist’s clinic. Therapists documented each treatment session with a study-provided SOAP notes template that they submitted to study personnel. Details of the community practicing massage therapists were reported prior to the publication of the study results in the open-access International Journal of Therapeutic Massage and Bodywork.3
I sat down with Niki Munk, PhD, LMT, co-lead author on the study, at the Alliance for Massage Therapy Education conference back in July to talk about the study, its importance to the field, and the various ways massage therapists can contribute to, or be involved in, massage research.
Jerrilyn Cambron: The buzz word for this study is real world. What does “real world” mean and why is this study considered real world?
Niki Munk: Real world essentially means what it implies: as it happens or occurs in the real world, in real applications. The words pragmatic and effectiveness are related research terms that indicate, along with real world, that the research does not seek to examine interventions or make observations in controlled settings. Our study design was real world from several perspectives. We had a very open inclusion criteria, which allowed for medically complex participants who are often excluded from research or controlled studies. For example, we did not have an upper age limit for participants, which allowed us to include much older participants who, up to that point, had been excluded from large clinical trials examining massage for back pain. We also allowed chronic low-back pain patients with co-morbidities such as diabetes, hypertension, depression, and obesity to participate, as well as patients who were on scheduled medications such as opioids. Essentially, the participants in this study reflect the real world: complex individuals who massage therapists work with every day in a variety of practice settings, all across the country.
JC: And the treatments provided by the community massage therapists were real world too?
NM: Yes. Therapists were allowed to develop and apply individualized treatment plans within their scope of practice and skill set to meet the needs of each study participant within the study parameters of 10 one-hour sessions within 12 weeks. There were two non-real-world study aspects related to the massage therapists, though. First, only those who were decision-makers for their practice environment could be study therapists, and second, therapists had to be at least five years out of their foundation massage training program.
JC: Why were these non-real-world study parameters needed?
NM: The decision-maker parameter simply became a necessity for logistical reasons. The study budget was only able to compensate massage therapists $25 for each completed massage session. Because study therapists were asked to provide all the needed massage materials, schedule the appointments, and provide study-related treatment documentation that became study data (study treatment notes did not remain with the therapist at the end of the study), these were individual decisions that the therapist had to weigh with regard to their client load, the study parameters and compensation policy, their schedule, and what they were willing to do. Environments in which therapists are paid on a percentage split of the charged amount would have required contact and negotiation with multiple decision-makers, which was just beyond this study’s management capacity.
With regard to the five years’ post-foundation education requirement: again, from the logistical side of things, we needed to work with therapists who had had time to build a reliable practice environment and who wouldn’t be using their work with the research study as a way to build a clientele. In addition, the five-year experience expectation allowed for study therapists to accumulate more treatment experience and additional education— the logic being that these therapists would have more tools to address the complex cases that people with chronic low-back pain present.   
JC: You are a trained and licensed massage therapist and a researcher. Which were you for this study?
NM: I actually had a couple of separate, but related, roles on this study. When the study was first being designed for the initial National Institutes of Health (NIH) grant submission over 10 years ago, I consulted with the study’s principal investigator (William Elder, PhD) on the study design. I was a doctoral student at the time, focused on completing my research training, so was not actually involved in the multiple subsequent grant revisions, funding procurement, or start of the study. Another, even more experienced community massage therapist (Katie Stewart, who also happened to be one of my massage therapy instructors) was the study’s primary massage field consultant and served as the massage liaison for the study duration. I officially joined the research team as the study’s program manager four years after my initial consulting role and after having completed my doctoral training. The study had commenced about two years prior, and, in addition to my coordinating and management role, I served the study as another massage field liaison and statistician due to the statistics emphasis with my doctoral training. After the study was complete, I organized and analyzed the data and was a key contributor to the results dissemination process. These later roles earned me an investigator and co-lead-author role with Elder, who served as the study’s principal investigator. Ultimately, while I am a licensed massage therapist in Kentucky, I did not provide treatments for any of the study participants. I served on the study in a research capacity, but with a deep knowledge of the massage field context and with an eye for what was meaningful within the work from a massage field standpoint.  
JC: Why were you able to have such a significant role on a prominent and federally funded massage therapy research study?         
NM: Part of it was that I happened to be in the right place at the right time and had a basis of knowledge that aligned with study needs. I was already enmeshed in the research environment at the University of Kentucky during my doctoral training and met Elder at a local research conference. Elder happened to be interested in complementary therapies for chronic pain populations and be a researcher in family medicine. The rest of the story actually has a lot of other twists and turns, but the bottom line is that I had the training and skills that meshed with and filled a gap in the research team at the time, and I was able to take the opportunity when it presented itself. While the roles were different, the same can be said for the several community massage therapists who worked on the study as well; there was an opportunity to be involved in a large, NIH-funded study, they recognized and accepted the opportunity, and fulfilled the study requirements. They were valuable members of the study team and reliable in their completion of the necessary tasks.
JC: Are you still conducting research?
NM: Yes! I am in fact still conducting research, and I am building a massage therapy research program at Indiana University (IU) on the Indiana University–Purdue University Indianapolis campus. I have been at IU for four years now and have developed a cadre of local community therapists who provide the massage treatments examined in my various research studies for chronic pain conditions. In my professor role at the university, I also train undergraduate to doctoral students in research, aging, and theory building. I’ve had a handful of undergraduate students cross my path who were also massage therapists, and working with them has been great! The IU doctoral program I am affiliated with is in health and rehabilitation sciences—a field with a logical alignment to massage therapy. It is my hope that eventually I will train massage therapists interested in becoming researchers in my lab while they earn their PhD in health and rehabilitation.
Our field needs more research, and ideally, future massage research will be conducted by professionals in our field like other applied disciplines such as nursing, physical therapy, medicine, etc. This is a little challenging right now because there are only a few trained massage therapist researchers in positions that make them eligible for, and capable to conduct, large-scale research studies and build research programs, which takes oh-so-much time. Many of the leading massage therapy researchers are from other disciplines, like medicine or nursing, but there are a few of us out here, and hopefully there will be more in the coming years.  
JC: It seems like another way the chronic low-back pain study is real world is that it provides an example of several ways massage therapists can be a part of research with the appropriate training and/or experience.
NM: Sure. Research involvement can include roles as a consultant, liaison, therapist, coordinator, research assistant, investigator, or lead investigator with the right experience and training. The study’s progression from conception to completion was concurrent with my development as a massage-therapist-turned-research professional. There are all manner of ways in which massage therapists can get involved with, or train for, various roles in research. In certain cases, particularly for doctoral training, there is even the potential for funding support. Interested potential students just have to inquire about student support or the potential for research or teaching assistantships associated with doctoral programs of interest.
That was actually a surprise to me when I was looking into getting my doctorate. The program in which I received my training only admitted students who the program could support, which means my tuition was paid and I was paid a stipend for the research assistance work I provided during my training. It was a win-win situation, and now I am developing massage-focused research programs of my own at a research-focused institution and looking forward to training future massage therapist researchers.

1. US Burden of Disease Collaborators, “The State of US Health, 1990–2010: Burden of Diseases, Injuries, and Risk Factors,” JAMA 310, no. 6 (August 14, 2013): 591–608; Christopher J. L. Murray et al., “Disability-Adjusted Life Years (DALYs) for 291 Diseases and Injuries in 21 Regions, 1990–2010: A Systematic Analysis for the Global Burden of Disease Study 2010,” Lancet 380, no. 9859 (December 15, 2012): 2,197–223.   
2. William G. Elder et al., “Real‐World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study,” Pain Medicine 18 (2017): 1,394–405.
3. Niki Munk et al., “Intersection of Massage Practice and Research: Community Massage Therapists as Research Personnel on an NIH-Funded Effectiveness Study,” International Journal of Therapeutic Massage & Bodywork 7, no. 2 (June 2014): 10–19.

Passing the Torch
There is much more Niki Munk, PhD, LMT, could talk about related to the chronic low-back pain study, massage therapy research in general, research education, and research implications for the massage field—and she will. I am pleased to share that authorship of this Somatic Research column will transfer to Munk beginning with the January/February 2018 issue. During my four years on the job, I have enjoyed covering various topics in the column, and I look forward to watching the continued discussion in the years ahead.
Dr. Munk and I have actually known each other for quite some time, and it is my pleasure to have Somatic Research in her capable hands. In the next issue, she will pick up the conversation started here about the outcomes of the real-world massage for chronic low-back pain study and discuss potential practice implications of the study’s results. For now, I encourage readers interested in learning more about becoming involved in massage research to consider if further education is of interest to them, and if so, explore the various program options at your local or not-so-local universities.
The field needs more practitioners trained in research, and who knows, maybe a future Massage & Bodywork Somatic Research column will report on a research study conducted by you!

Jerrilyn Cambron, DC, PhD, MPH, LMT, is dean of the College of Allied Health Sciences and Distance Education at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at