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A NEW ERA FOR MASSAGE RESEARCH Recommendations from the Massage Research Agenda Workgroup have set a clear-cut direction for future projects.
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By Janet R. Kahn In March 1999, the AMTA Foundation convened a three-day working conference of massage therapists/bodyworkers and research scientists. The number one goal of this event was to have these two groups of professionals collaborate to frame a research agenda for the field of therapeutic massage and bodywork. Why did the AMTA Foundation think a research agenda workgroup was an important investment of time, money and effort? There are a number of reasons, some more global, some quite specific. First of all, research is a key to the professionalization of any health-care field. While there are specific research methods that are particularly valued in this country in this era, the centrality of research to the generation of reliable information, and therefore to the professionalization of a field, are not time-bound. It is our responsibility as professionals to continually improve our practice. We do this as individual therapists by taking continuing education to learn new skills, by studying to better understand the dynamics underlying a pattern we see repeatedly in our clients, by making sure we have the equipment we need to treat people, etc. Collectively, as the profession of therapeutic massage and bodywork, one of the ways we improve our offering to the public is through the continual generation of a relevant body of knowledge. And this we do, in large part, by engaging in research to answer the questions that arise in our daily practice of caring for the clients who come to us.
Almost 10 years ago, a consensus conference was held to review allowable treatments for low back pain. The result of that conference is that for the first time chiropractic was included among the treatments for which there was evidence of benefit, and massage was not. What was the difference between massage and chiropractic? Did they have better lobbyists? Is chiropractic really a better treatment for low back pain? The answer to those last two questions is maybe. The answer to the first question is that the chiropractors had spent the past 10 years systematically funding and conducting research on the potential of chiropractic to treat back pain. When the consensus conference was called, they were ready. There was a body of literature published in reputable journals reporting the results of studies on chiropractic and back pain. They had the necessary research data. We did not. If massage research is so important, one might wonder why the foundation didnŐt just fund more research? Why call together a research agenda workgroup? At the beginning of this article, I said that a profession must engage in the continual development of a relevant body of knowledge. The key word here being relevant. Without the active participation of members of the massage profession in deciding what research should be done, there is every possibility that the knowledge generated would not be relevant and would be of little value to us in our practice. It was recognized going into the meeting that various constituencies already held agendas that would need to be articulated and addressed. Summarizing the results of Web site surveys and focus groups conducted by the AMTA Foundation, it seemed that massage therapists had three key goals that needed to inform the research agenda. We stated them this way:
Other health-care professionals and sectors also have concerns and questions that would drive their agenda for our field. This is true of the individual physician wondering when and how to refer responsibly for massage, and for entities like the Agency for Health Care Quality and Research, or HMOs and insurance companies, wondering when to responsibly approve and pay for treatment. We summarized their agenda as follows:
There is another reason why it is important to have massage therapists involved in the research design process. If you look at the literature that already exists on therapeutic massage, you will see studies looking at the potential for massage to treat migraines, dementia among the elderly, back pain, postsurgical pain and so on. The interesting, and somewhat alarming, thing about these studies, from my perspective as a massage therapist, is that far too often there is almost no rationale given for the particular kind of massage used as the intervention in a study. Many studies are done using a very simple Swedish protocol of anywhere from five- to 60-minutes duration. In my practice I don't use a simple Swedish protocol very often. Do you? I don't give the same kind of treatment to someone with a migraine as I do to someone with back pain. Do you?
From my experience, I believe that most researchers who are not massage therapists think about massage with something like the sophistication I bring to chemotherapy. They think in terms of massage as a treatment, not as a broad category of potential, yet-to-be-defined treatments. One of the most effective ways to raise the level of sophistication of the research being conducted on massage is to promote contact between massage therapists and research scientists. These contacts can give members of each profession both the opportunity and the motivation to deepen their understanding of the others' field of expertise. And so the group known as the Massage Research Agenda Workgroup (MRAW) was called together in part to give a cluster of massage therapists and research scientists a chance for real dialogue, for real collaboration. A research agenda produced through such collaboration, we reasoned, would be far more likely to generate high-quality and relevant knowledge than research designed by any one of these groups in isolation from the other. For just as it is true that many of the really interesting research questions in our field will be generated by us, as practitioners, in response to our day-to-day observations, successes and frustrations, it is also true that there is a real difference between an interesting question and a researchable question, and it takes a research scientist to turn the former into the latter. Thus in March 1999, the Massage Research Agenda Workgroup was called together. It included bench scientists, social scientists and clinical research scientists, as well as massage therapists and bodyworkers selected to represent a relatively broad spectrum of expertise in the field. It included individuals from the United States and Canada. In preparation for the meeting, the AMTA Foundation commissioned a background paper to look at issues of model fit between the realities of massage treatment and the requirements of currently accepted research methodologies; examined claims made in major massage texts about the effects of massage, and found many claims but little research cited; reviewed the existing massage research literature, and circulated to participants two recent reviews of the literature, noticing shortcomings and areas of promise; and created mechanisms (including focus groups conducted at the AMTA Council of Schools meetings and the AMTA National Convention, and a survey available on the foundationŐs Web site) through which massage therapists could inform us about their research priorities. What follows is a review of the recommendations of the MRAW. Arenas Of Inquiry The general arena of clinical research on safety and efficacy, which many people think of when the term research is mentioned, was subdivided into two distinct categories--studies that examine massage in comparison with other treatments (e.g., usual allopathic care, chiropractic treatment, etc.), and studies that compare the relative effectiveness of specific massage modalities to one another, seeking the strongest treatment for each condition/population/situation. Studies of efficacy and outcome lead to the question of mechanism. There has been little done in this area for the field of massage. Do you know, for instance, why or how massage helps premature infants gain more weight when they are not eating more than the nonmassaged infants? The final arena of inquiry that was identified is the whole realm of sociocultural knowledge, which includes basic descriptive information about who seeks massage, how it is viewed by consumers, physicians, and others, how massage therapists define the goals of treatment, etc. Specific Recommendations Build A Massage Research Infrastructure
Priority Areas Of Inquiry A host of considerations went into identifying the recommended studies. First among these was public health and safety. Studies were given higher priority if they had greater potential to lead to alleviation of human suffering and the associated costs. Studies are likely to meet these criteria when the current usual treatment is unacceptable in one or more ways, including high cost, adverse side effects or the pain and/or inconvenience of the treatment itself. In addition, it was agreed that the condition being studied should be sufficiently prevalent that the study will address a situation affecting many people's lives; study subjects should be readily available; the expectation that massage therapy/bodywork will be beneficial in this situation should rest on good anecdotal evidence, pilot data and/or theoretical base; there should be some stakeholder interested in the study; the treatment, if successful, should be relatively easy to adopt; the study must have a clearly defined massage intervention; and the endpoints to be measured must be well-defined and of importance to stakeholders. It was acknowledged that such high-impact efficacy studies might focus on either primary or secondary prevention, within a clinically oriented pathology model, or draw more upon a "wellness agenda." Illustrative examples were generated during preliminary design sessions that utilized small teams, including at least one massage therapist, one clinical researcher and one basic science researcher. Suggested Primary Prevention Studies Massage To Prevent Congestive Heart Failure
Massage And Musculoskeletal Disorders Such As Scoliosis The goal of such a study would be preventing the need for scoliosis surgery. It was stressed that this study should be done as a comparison of massage and usual care only after the within-massage/bodywork studies have been done to determine the most beneficial treatments for this condition. Subjects would be adolescents, recruited from a scoliosis clinic at the point when they are designated as candidates for future surgery. The length of treatment would be determined on the basis of existing data, but would be likely to be lengthy. The principle endpoint would be whether surgery was needed. The length of time to follow the subjects would be determined after consultation with experts in the field. Low Back Pain Studies Initial work has begun in this field. High-quality comparisons of massage and other treatments for low back pain (both acute and persistent) are being conducted by researchers at Group Health Center for Health Studies and Beth Israel Deaconess' Center for Alternative Medicine Research and Education. The recent work by Cherkin et al.1 indicates possible directions for additional work. For instance, given the relative success of massage compared to acupuncture and self-education shown in the Cherkin study, further investigations could try to determine whether there is a "best" massage treatment for persistent low back pain. |
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In this culture, research is also a prerequisite for access to some of the contexts in which we would like to practice. While there are certainly many individual massage therapists who, reasonably enough, have no interest in practicing in medical contexts, in being reimbursed by insurance, or in dealing with the changing demands of managed care, it is also true that as a profession, it is good for us to open that doorway for those who would like to practice in those contexts. Opening that doorway means making massage therapy available to many who cannot now afford it. And research is fundamental to opening that doorway. For instance, within the federal government and within the Department of Health and Human Services, there is an agency called the Agency for Health Care Quality and Research, which oversees, among other things, which treatments will be reimbursed for people whose health care is paid for by the
government--that is, for recipients of Medicaid and Medicare. These decisions are typically made following a consensus conference process in which a group of experts review the literature in a given field and decide for which treatments there is evidence of benefit outweighing harm, that is sufficient to justify use of the treatment for a given population.
It was our firm belief at the foundation that massage therapists must be involved in defining the questions around which research studies are being designed, and the kinds of massage being used in the studies. When I talk about cancer, as a layperson, I may have opinions on the pros and cons of chemotherapy versus radiation, radical versus minimalist surgery, etc. My friends may listen to me, but no one in their right mind would think that I should be designing either treatment or research on cancer treatments. Chemotherapy is a broad term used to refer to many particular drugs and combinations of drugs administered quite differently, depending on various characteristics of the patient and the cancer. Only a layperson like me would think that the term chemotherapy means much. To an oncologist it is the beginning of the discussion, not the end. It names a category of treatment, not a treatment.
