This edition of Massage & Bodywork is focused largely on aspects of the exploding and thrilling field of massage therapy research. For Pathology Perspectives, I will follow the theme by discussing why making declarative cause-and-effect statements about massage is so difficult.
To do that, we need to review a little bit of research vocabulary. Half the battle in learning how to become comfortable in this world of research is dealing with the language, so here are just a few terms that have very specific meanings.
Efficacy Studies
The study of the efficacy of a given intervention asks the question, “Does this work under these specific circumstances, and if it does, how well does it work?” Efficacy studies look at a particular intervention in a controlled setting in an effort to limit the influence of variables or confounds that might alter the results.
A shortcoming of this type of study is the regimentation of technique: “six bilateral strokes of effleurage followed by 2 minutes of petrissage and 5 minutes of friction on the paraspinals” has little to do with what really happens in a professional massage setting. Not surprisingly, the results of massage therapy studies in this model—if there are any results at all—tend not to be strong.
Efficacy studies by definition are narrow in scope, but they do open the door to other types of research that can pursue whether real-world settings impact findings: these are called effectiveness studies.
Effectiveness Studies
Effectiveness studies look at interventions implemented by professional practitioners. These studies leave the laboratory and enter a close approximation to a true session or treatment room.
This is particularly important for massage therapy, which is so highly personalized, but the inherent weakness is that any number of variables may influence results. For instance, what if a massage therapist customizes a session for a particular client: obviously we do this in real life, but at what point are we trying to compare apples to oranges when we then ask how massage impacts various conditions? Other variables include whether the client has some personal issue that interferes with her ability to receive or enjoy a massage on a particular day, or whether client A’s pain comes from one source, but client B’s pain comes from entirely another; the possibilities for variables that may change results is virtually endless. This is why good effectiveness studies must have a large participation base: when the number of subjects is high, small anomalies don’t have a big impact on results.
Dosing Studies
Having settled the questions of efficacy and effectiveness, dosing studies ask about the best combination of modality, frequency, and duration of an intervention for a specific population group. For instance, the best approach for treating people preparing for a marathon who want to train more efficiently probably looks different from the best way to help people with Parkinson’s disease who want to sleep better.
Comparative Effectiveness Research Studies
These studies compare different interventions by asking three main questions: “Is this intervention effective in a particular setting, is it financially practical, and is it safe?” Settings might include hospitals, integrated-care clinics, chemotherapy outpatient centers, or others. If the answers to these questions are positive when compared to other options, then the intervention—massage, for instance—can find a home where these studies are conducted.
All of these study designs help us gather important data that can influence how we build our business and even our scope of practice. But have you noticed something missing? Efficacy and effectiveness studies—and all their variations—can yield a lot of information about whether massage is as powerful as we think, but none of these approaches asks the quintessential question, “What is really happening when someone receives a massage?” To get at those answers we need mechanistic studies.
Mechanistic Studies
Rather than asking if massage works, mechanistic studies ask how massage works, that is, “What are the mechanisms that make changes happen?” This is much harder than it seems. In other scientific disciplines, asking how something works is often “un-mysterious.” Laws of physics and chemical reactions are basically predictable and easily explained (at least to the people who speak those languages). But when we take the complexity of a human body, add a lifetime of experience and wear and tear, and then throw in a complicating condition or two, it becomes much harder to say, “We fully understand that massage does this, but it doesn’t do that.” For instance, we see that most people become more relaxed when they receive massage, but we still aren’t sure whether that reflects an increase in vagal activity, a decrease in sympathetic response, a neuroendocrine reaction, a response triggered by something happening entirely elsewhere, or a combination of all of the above.
Why do we need to know how massage works? Simple: so we can make choices that aim for the best possible outcomes. If we can narrow down some of the mechanisms for how manual therapies affect human function, then we can work with purpose and intention, instead of with best guesses. That knowledge allows us to apply specific techniques or modalities to their very best advantage, and ultimately to the benefit of the client.
Further, consider your own personal choices: would you rather pursue a health-care strategy if you know how it is intended to work, or simply on the basis that because it works for a lot of people, it might work for you? Having a rudimentary understanding of the mechanisms of the interventions we choose—from diet, to medication, to exercise regimens—gives us the power to support those choices with other behaviors.
As a person interested in pathology, I am especially invested in understanding how massage might impact factors contributing to illness, but even more, how we might impact factors contributing to healing or prevention. Here are some examples of fields of inquiry that I find especially thrilling:
Scar tissue: A pilot study of burned children found that those who received massage had better range of motion than those who didn’t.1 A larger review found that the evidence for massage in treating scar tissue is generally better for postsurgical situations than for burns, but that the research to date leaves much to be desired.2
Diabetes: A study of massage with type 2 diabetes patients found that leg circulation was so significantly better among the massage group that an argument could be made for massage therapy as a strategy to delay or prevent the development of peripheral artery disease.3 Poor circulation also leads to diabetic ulcers on the feet and a high risk of amputation. If this can be applied on a larger scale, just imagine the impact that could make on this community.
Central nervous system function: A study using nuclear magnetic imaging captured some physiologic responses to massage among cancer patients.4 They found that massage had an immediate effect on local fascia, muscles, and nerves, but a delayed effect on the central nervous system—including some observed remodeling of plastic (that is, changeable) neuronal connections. The implications of this for “intractable” pain situations are huge: if massage can help build new neural pathways, then we may be able to address pain patterns that range from complex regional pain syndrome to ingrained migraines.
Chronic low-back pain: Speaking of chronic pain, a study investigated the vicious circle of pain leading to lack of movement leading to fascial restrictions and pain, then compared massage to increased activity and changing movement patterns to see what had the best results.5 The conclusion was that a multidisciplinary approach is best, and now we are getting some clues about how to put those treatment options together for the most effective results.
Limitations of Mechanistic Studies
One of the greatest problems with mechanistic studies about massage and other CAM interventions is that we lack two things: a comprehensive understanding of human function, and a widely agreed-upon rubric by which to evaluate mechanistic inquiries.
The fact is, the human body is still largely a mystery. Until 30 years ago, we understood almost nothing about the immune system. The human genome project has only just begun to yield powerful information about how cells do their work and what positive and negative influences are carried in our genes. Other fields of exploration, from intestinal microbiota to neuroendocrinology, continue to change how we look at health and wellness from the inside out.
What do microbiota and genetic expression have to do with massage? This is what is so exciting: we don’t know yet! But with better imaging techniques, combined with people asking more sophisticated questions, we are in a position to begin to find out. Already we can predict some alterations in cellular behavior with the influence of welcomed touch;6 we can observe different biologic reactions with very light touch as compared to firmer touch;7 and we can observe changes in preterm infants’ vagal nerve activity when they receive massage, which may influence their ability to gain weight.8
Face time
The lines of communication between massage therapists and researchers can seem tenuous, but researchers truly want to know our points of interest. The more we reach out to them with our priorities, the better they can serve our field. Three opportunities to have “face time” with people who do research about massage and other CAM interventions are coming up:
• The International Fascia Research Congress in Vancouver, British Columbia, on March 28–30, 2012. (www.fasciacongress.org).
• The International Research Congress on Integrative Medicine & Health in Portland, Oregon, on May 15–18, 2012. (www.imconsortium-congress2012.org/).
• The International Massage Therapy Research Conference, presented by the Massage Therapy Foundation in Boston, Massachusetts, on April 27–29, 2013. (www.massagetherapyfoundation.org).
These are your opportunities to let the leaders in bodywork research know what you want to find out in terms of mechanistic and other studies.
Ultimately, mechanistic studies may ask questions that don’t have clear-cut answers. That’s fine; we still need to ask them. Whatever findings we come up with should be informing our work, and our work should be influencing future research questions. This is where our art meets our science, and it can be a beautiful partnership.
Notes
1. A. Morien, D. Garrison, and N.K. Smith, “Range of Motion Improves After Massage in Children with Burns: A Pilot Study,” Journal of Bodywork and Movement Therapies 12, no. 1 (2008): 67–71.
2. T.M. Shin and J.S. Bordeaux, “The Role of Massage in Scar Management: A Literature Review,” Dermatologic Surgery (2011), doi: 10.1111/j.1524-4725.2011.02201.x.
3. A. Castro-Sanchez et al., “Connective Tissue Reflex Massage for Type 2 Diabetic Patients with Peripheral Arterial Disease: Randomized Controlled Trial,” Evidence-based Complementary Alternative Medicine (2011), doi: 10.1093/ecam/nep171.
4. S.M. Sagar, T. Dryden, and C. Myers, “Research on Therapeutic Massage for Cancer Patients: Potential Biologic Mechanisms,” Journal of the Society for Integrative Oncology 5, no. 4 (2007): 155–62.
5. H. Langeven and K.J. Sherman, “Pathophysiological Model for Chronic Low Back Pain Integrating Connective Tissue and Nervous System Mechanisms,” Medical Hypotheses 68, no.1 (2007): 74–80.
6. L. Lindgren et al., “Pleasant Human Touch is Represented in Pregenual Anterior Cingulated Cortex,” NeuroImage (2011), www.ncbi.nlm.nih.gov/pubmed/22100768.
7. M. Rapaport, “A Preliminary Study of the Effects of a Single Session of Swedish Massage on Hypothalamic-Pituitary-Adrenal and Immune Function in Normal Individuals,” Journal of Alternative and Complementary Medicine 16, no. 10 (2010): 1079–88.
8. T. Field, M. Diego, and M. Hernandez-Reif, “Potential Underlying Mechanisms for Greater Weight Gain in Massaged Preterm Infants,” Infant Behavior and Development 34, no. 3 (2011): 383–9.
Ruth Werner is a writer and educator approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2012), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.
US Department of Health & Human Services Agency for Healthcare Research and Quality. “What is Comparative Effectiveness Research?” Accessed March 2012. www.effectivehealthcare.ahrq.gov/index.cfm/what-is-comparative-effectiveness-research1/.
The fifth edition of Ruth Werner’s A Massage Therapist’s Guide to Pathology reflects new research on pathologies, and maintains the focus on not only explaining the disease, but also its applicability and indications in massage therapy. The reader learns how massage influences disease and healing processes, and how massage therapists can offer clients maximum benefits while minimizing risks. Available for $64.95 at 800-638-3030 or www.lww.com.