Massage and Bodywork Magazine for the Visually Impaired - State of Evidence

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January/February 2013 Issue

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State of Evidence

Informing Health-Care Reform

By Diana Thompson
[Somatic Research]

The Massage Therapy Research Agenda (MRA),1 set forth by a workgroup of experts (MRAW)2 and convened by the Massage Therapy Foundation, is nearly 15 years old. Since its inception, the state of research involving our profession has changed dramatically. More than 400 articles on massage have been indexed on PubMed per year for the past six years, as compared to the 170 per year average in the 1990s. Nearly half of the 10,562 massage research articles indexed by PubMed since 1883 have been published since the MRAW convened in 1999.3 

A research agenda identifies short and long-term goals to guide researchers to ask meaningful questions and to help direct research funding. Research agendas are typically set by stakeholders within a profession, including clinicians, educators, policy experts, researchers, and consumers, through surveys, focus groups, and committee work. Without the active participation of members of the massage profession in deciding what research should be done, there is every possibility that knowledge generated from future research will not be relevant or of value to massage therapists or their clients.4 

The Massage Therapy Foundation is preparing to update the MRA at the International Massage Therapy Research Conference in Boston, Massachusetts, April 25–27, 2013. The final day of the conference will be dedicated to beginning this conversation via large and small group discussions, panel presentations, the research presented during the previous two days, and the last 15 years of data. All attendees will receive a survey to complete in advance of the conference that will inform the discussion topics and provide talking points for the panelists. Afterward, a summary of the conversation will be made available with another opportunity to comment. Once comments have been gathered, a committee will be appointed to combine the research and comments into the next research agenda.

You may want to have a say in the next 10 years of research. Though you might ask what direct influence this agenda will have on your practice, there is one immediate opportunity that may compel you to act.

Affordable Care Act

While the MRA will recommend global directions for massage research, one of the most pressing topics in the United States is the Affordable Care Act (ACA). The ACA represents the nation’s commitment to shift the focus of health care from sickness and disease to prevention and wellness. Health-care reform, specifically the ACA, was adopted during President Obama’s first term with the intent to provide quality, affordable health care to all Americans, reduce health-care spending, and emphasize prevention and wellness. As stated by US Surgeon General Regina M. Benjamin, MD, “Preventing disease before it starts is critical to helping people live longer, healthier lives, and keeping health-care costs down.” 

Somatic therapies traditionally reside in the prevention and wellness domain. Therefore, it is important for us to consider our role in this new age of health care and identify our strategies for helping people make healthier choices, be more active, and enhance mental, physical, and social well-being. We must ensure that the next generation of research informs these directions.

First, inclusion as a wellness intervention is only possible because a cadre of research already exists providing evidence that somatic therapies are critical components of health care. The ACA, in section 3502, demands that health-care delivery include integrative approaches: “Insurers must establish community health teams that include complementary and alternative (CAM) providers.” Integrative medicine is defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence [emphasis added], and makes use of all appropriate therapeutic approaches, health-care professionals, and disciplines to achieve optimal health and healing.”5

The other component of the ACA that mandates the inclusion of bodyworkers is found in section 2706. Incorporated in the document is a non-discrimination clause, ensuring that insurance exchanges must accommodate for licensed or certified providers acting within their scope. Some states already have this regulation, such as Washington, where it is referred to as the “every category of provider” law. The mandate states that every insurance company must provide at least one plan that includes reimbursement for all licensed providers operating within their scope.6 For example, if a patient is recovering from an injury, and rehabilitation services are included in his or her benefit package, the patient must be able to choose any licensed health-care provider who can provide appropriate rehabilitation services.

But even though massage research has grown exponentially, inclusion in conventional health care currently only exists in a few states. Much of what we experience to be true through clinical practice is still becoming apparent in the research. This reinforces our need to identify what research exists and where the gaps are; gaps that, if filled, would increase our inclusion into health-care delivery systems. We have begun to do so through two documents that currently exist.

ABMP Position Statement

Two years ago, Massage & Bodywork’s publisher Associated Bodywork & Massage Professionals (ABMP) responded to a call for public comment to assist with the development of a national integrative health-care strategy. The ACA had just passed, and part of the initial effort was to identify priorities and strategies for implementing health-care reform. The National Prevention, Health Promotion, and Public Health Council (National Prevention Council), convened by the US Surgeon General, was tasked with obtaining input on evidence-based models of health care and environmental strategies that improve health and save lives. In December 2010, ABMP submitted a position statement supporting massage therapy and bodywork as an integral component in advancing prevention, wellness, and health-promotion practices.7 

The position statement commented on the first draft priorities for health-care delivery and cited nearly 100 research articles. I highly recommend you read the position statement in its entirety, as it can be useful to you in your marketing efforts, but in the meantime, here are a few excerpts (citations can be found on the website within the document):8

“Studies not only reflect the use of massage therapy for treatment purposes (back and neck pain, headaches, arthritis, constipation) but also for functional and wellness purposes (balance, mobility, stress, sleep). By improving balance and mobility in older adult populations, massage therapists can help prevent falls, encourage activity, and help maintain active lifestyles. By reducing stress and improving sleep in healthy adults, massage can help reduce the onset of stress-related disease such as heart disease, digestive conditions, and headaches, and reduce workplace health-related expenses.”

“Conventional medical practitioners may not be aware of the full scope of CAM professions and may therefore miss opportunities to employ cost-effective and efficacious CAM services. For example, massage therapy is often not prescribed for acute care. There are increasingly common applications of massage therapy that are just beginning to be reflected in the research, for example, pre- and post-surgical massage, massage for acute inflammation due to trauma, and massage for labor and delivery. By treating acute injuries we may be able to circumvent nervous system dysfunctions that lead to chronic pain.”

“Recognize that making healthy choices ‘easy and affordable’ does not ensure that people will abandon previous lifestyles for healthier options. Low self-esteem and depression, coupled with a lack of self-awareness, often interfere with change motivation. Massage therapy has been shown to increase self-esteem and self-awareness and decrease depression. This type of shift in orientation may prompt healthier choices: people who are aware of the impact of their actions may be more apt to make choices that help them feel better physically and emotionally, especially when they believe they deserve to feel better. In addition, massage therapists typically spend one hour with patients, 1 to 4 times per month, at relatively low cost, providing effective and efficient support for change management as prescribed by primary health-care providers.”

The culmination of the National Prevention Council’s efforts and the input from the American public (including ABMP and its members) resulted in the nation’s first National Prevention and Health Promotion Strategy (National Prevention Strategy), published in June 2011.9 This document outlines strategic directions for improving the health of Americans by helping to create healthy and safe communities, expand clinical and community-based preventive services, empower people to make healthy choices, and eliminate health disparities. The goal of the National Prevention Strategy is to help all of us understand how to “weave prevention into the fabric of our daily lives.”

Essential Health Benefits Document

More recently, as the health-care exchanges were being defined (the products to be included in the health-care market for individuals and small businesses), the insurance commissioner of Washington suggested that CAM professions document the research that supports their inclusion in the exchanges. State mandates may not be upheld once the federal law is in effect, meaning the “every category of provider” law may be in jeopardy. As previously stated, the ACA has a clause for nondiscrimination, but it never hurts to reinforce those critical one-liners in a document that has thousands of sections. 

The ACA ensures Americans have access to quality, affordable health insurance by requiring that health plans offer a comprehensive package of items and services, known as the essential health benefits (EHBs). EHBs (Section 1302[b] of the ACA) must include items and services within at least the following 10 categories:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10.
Pediatric services, including oral and vision care.

I was enlisted to help prepare a list of research citations that support the inclusion of massage therapy in the EHBs. The resulting document, “Summary of Evidence: Massage Therapy is an Integral Component in the Affordable Care Act’s Essential Health Benefits,” was presented along with ABMP’s position statement to the Office of the Insurance Commissioner in October 2012.10

This document selected four EHBs (ambulatory services, mental health, rehabilitative services, and preventative and wellness services), and identified subcategories of conditions most commonly treated by somatic therapists that have a cadre of current research supporting the use of these therapies. Summary statements were written to support each category’s inclusion and 995 citations were referenced.

Here are two summary statements from the document, which is available by request.11

Mental Health

“Drawing from 21 randomized controlled trials (RCTs) and 1,026 adult subjects, Moyer et al. (2004) found a ‘small to medium’ statistical effect on state anxiety from a single dose of massage therapy. The same single dose appears to have a stronger effect in children, as seen across four RCTs using 81 total pediatric subjects, showing a ‘medium to large’ statistical effect. In children, the single-dose effect also increased in strength with multiple doses, possibly due to increased comfort with the treatment environment and the practitioner administering treatment. The effect of multiple doses of massage therapy on Trait Anxiety also appears to be strong, yielding a ‘medium to large’ statistical effect across seven RCTs that studied 194 total participants.”

Rehabilitation

“A review of CAM determined that massage therapy, among other CAM modalities was just as effective in treating neck pain as conventional (allopathic) medicine. An evidence-based clinical guideline that reviewed 10 studies concludes: ‘Therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain.’ Research provides evidence for the short-term relief of neck and shoulder pain symptoms. Additionally, research suggests that massage therapy may interrupt inflammatory processes contributing to neck or shoulder pain, and the reduction of anxiety from massage therapy treatment may help with underlying symptoms of muscle tension and pain. ‘The best available evidence for treatment of neck pain includes … massage therapy.’”

Summary

Between these two landmark documents, we have begun to identify areas where evidence is available and uncover holes in the research that, if filled, could advance our position in health-care delivery, and provide us with employment opportunities and increased referrals from health-care providers. It becomes more evident that research plays a critical role in securing our future: jobs, health-care choices, etc. Together, these documents can be used to ensure our place in the new age of health care. 

Notes

1. J. Kahn, “Massage Therapy Research Agenda,” AMTA Foundation, 2002. 

2. Massage Therapy Research Agenda Workgroup committee members: Researchers—Alan Best, PhD; Leon Chaitow, DO; Dan Cherkin, PhD; David Eisenberg, MD; Robert L. Kahn, PhD; Brian Marcotte, PhD; James Oshman, PhD; Candace Pert, PhD; Massage Therapists—Doug Alexander; Judith Aston; Debra Curties; George Kousaleos; Carole Osborne-Sheets; Lawrence E. Warnock, PhD; Organizational Representatives—Janet Kahn, PhD; E. Houston LeBrun; Martha Menard, PhD; Gini S. Ohlson; Deborah Worrad.

3. PubMed, “Search term: ‘massage’,” accessed December 2012, www.ncbi.nlm.nih.gov/pubmed?term=massage.

4. J. Kahn, “Massage Therapy Research Agenda.”

5. Consortium of Academic Health Centers for Integrative Medicine, “About,” accessed December 2012, www.imconsortium.org/about/home.html.

6. Washington State Legislature, “Every Category of Health Care Providers,” accessed December 2012, http://apps.leg.wa.gov/wac/default.aspx?cite=284-43-205.

7. Associated Bodywork & Massage Professionals, “ABMP Files Comments on National Prevention Strategy,” accessed December 2012, www.abmp.com/news/abmp-files-comments-on-national-prevention-strategy.

8. Ibid.

9. National Prevention Council, National Prevention Strategy (Washington, DC: US Department of Health and Human Services, Office of the Surgeon General, 2011).

10.
D. Thompson et al., “Summary of the Evidence: Massage Therapy is an Integral Component in the Affordable Care Act’s Essential Health Benefits,” AMTA-WA, 2012; this document is not yet published, but is available upon request. For more information, email editor@abmp.com. 

11. Ibid.

 A licensed massage practitioner since 1984, Diana L. Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.

 


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