Massage Therapy Journal Club ep 2: Moraska & Chandler (2008)

Join us today at 4:30 Mountain Standard Time for the latest episode of the Massage Therapy Journal Club.  I will be joined by Jennifer Barrett, Lauren Davis, Til Luchau, Alice Sanvito, and Ravensara Travillian to discuss a study published by Moraska & Chandler entitled “Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study.”

You can use this link to watch live or the recording after the episode has aired.

Here is an outline of the article that we may use to facilitate the discussion:

 

Moraska, A., & Chandler, C. (2008). Changes in clinical parameters in patients with tension-type headache following massage therapy: a pilot study. The Journal of Manual & Manipulative Therapy, 16, 106-112.

Introduction

Focus is on tension-type headache (TTH)

Most prevalent type

Lack of effective medical options may drive popularity of non-pharmaceutical options

Forty percent of patients visiting a headache clinic reported using one or more CAM modalities

Some (est. 25%) TTH sufferers engage in self-massage for pain relief

Previous studies

Puustjarvi et al. (1990) found that massage reduced TTH frequency in women, including at 6mo follow-up

Quinn et al. (2002) conducted a case series using highly trained massage therapists and found as little as two 30min massage sessions reduced headache frequency 50%

Nature of TTH

Muscular involvement

Physiological and physical abnormalities

Increased tenderness

Greater incidence of myofascial trigger points

Forward head posture

Reduced cervical muscle strength and endurance

Study objective was to “evaluate a specific massage therapy treatment dirercted at cervical and cranial musculature on primary and secondary measurers of headache as well as a measurer of disability associated with headache” (p. 107)

Methods

Study design

3-wk baseline period

6-wk treatment period

Biweekly 45min massage treatments

Massage directed to soft tissues of cervical and cranial regions

3-wk follow-up period

Daily headache diary

Headache Disability Index administered at 3-wk intervals

Subjects

Conformed to international Headache Society guidelines for episodic or chronic TTH

Regular headache pain prior 6+ mos

Headaches lasting 4+ hrs

21-65 yrs of age

<1 migraine headache per month

Subject recruitment via newspaper and flyers at local physician offices

18 subjects enrolled, 2 dropouts/removals = 16 subjects for data analysis

Twelve of sixteen were women

Mean age = 43.8 yrs, range was 28 to 56

In prior six months four reported having received no massage, twelve reported having received at least one massage from a professional massage therapist

Massage therapists

Six therapists

Mean = six years professional experience

All received 6 hrs specific training in treatment protocol for this study

Subjects received all treatment from same therapist for duration of study

“To isolate the effect of the massage procedure from therapist-subject camaraderie, therapists and subjects were directed to minimize conversation…” (p. 107)

Therapists were not informed about subject progress during the study

Massage protocol

Two 45m sessions per week across six-week treatment period

Each session separated by at least 48 hrs

Specifics

First 15min = palmar strokes to “warm-up” tissues of back, shoulders, chest, and neck

Middle 15min = up to six myofascial trigger points palpated and treated; muscles addressed included upper trapezius, sternocleidomastoid, suboccipital, and splenius capitis

Final 15min

5min post-isometric relaxation directed to lateral cervical flexion

5min circular or cross fiber friction on masseter, temporalis, and occipital-frontalis muscles

5min gentle effleurage and petrissage on neck and shoulders

Assessments

Headache diary

Completed daily before bedtime

Indicate if TTH occurred

Duration

Peak intensity on 0-100 scale

Headache disability index

25-item standardized measure of TTH impact on daily living

Separate emotional and functional subscales

Was administered 5x at 3wk intervals

Was never administered on same day as massage was administered

Data analysis

Headache measures averaged for each 3wk phase

Repeated measures ANOVA (i.e., this is a within-group study with no separate control group)

Results

Headache frequency

Decreased significantly across time

Means

Baseline period = 4.7

Tx period 1 = ? (estimated 4.6 from graphic)

Tx period 2 = 3.7

Follow-up period = 3.2

Headache intensity

Decreased significantly across time

Means

Baseline period = 46.9

Tx period 1 = ? (estimated 38 from graphic)

Tx period 2 = ? (estimated 33 from graphic)

Follow-up period = 32.8

Headache duration

Decreased significantly across time (but not as uniformly as other effects)

Means

Baseline period = 4.0

Tx period 1 = ? (estimated 4.2 from graphic)

Tx period 2 = 3.4

Follow-up period = 2.8

Headache Disability Index

Total and subscale scores decreased across time

Means for total score

Baseline period = 44.2

Tx period 1 = ? (estimated 37 from graphic)

Tx period 2 = ? (estimated 24 from graphic)

Follow-up period = 25.1

Similar trajectories for Functional and Emotional subscales

Discussion

Summary of results is restated

Observation that improvements generally persisted or continued in follow-up phase

Detailed discussion of trigger point theory

Consideration of whether longer (60min) treatments might be superior

Consideration of whether early phase of treatment is a period of becoming accustomed to treatment

Noted that observed 19.1 point improvement on Headache Disability Index does not meet 29 point improvement that some have said is indicative of “clinical significance”

“The comparison to a baseline standard and not a placebo control group limits the ability to assess causality of the treatment” (p.111)

Conclusion

“The observed improvement in clinical headache parameters provides an intriguing look into the therapeutic effect of massage and is encouraging for placebo-controlled research in complementary and alternative treatments for TTH” (p. 111)

 

Discussion points and questions

What specific challenges might arise when studying treatment of headache?

Symptoms were generally reduced to a statistically significant degree – what the possible explanations for this finding?  How is the study limited by not having a control group?

The Discussion section of the paper includes much discussion of trigger point theory.  How important is that theory in relation to this study?  Is this study a test of trigger point theory?

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Massage Therapy Journal Club ‘postgame’ summary

In launching the new Massage Therapy Journal Club, I’ve made the decision to learn some things as I go and to refine and improve things as the project progresses.  A couple days after we completed the first episode, it occurred to me that it would be worthwhile to make a blog post that summarizes some of the key discussion points and which includes helpful links for folks who might want to learn more.

We talked about a lot of different things as we considered Field’s 1998 article entitled “Massage Therapy Effects” and I would like to try and summarize and expand on three of those here. They are (1) publication bias; (2) the possibility that reduction of cortisol is the mechanism by which massage therapy works; and (3) models and methods that massage therapy research could borrow and adapt from other research areas.

Publication bias. In her article Field mentioned the likelihood that the body of massage therapy research might make massage therapy appear to be more uniformly effective than it actually is in reality due to publication bias. This can happen in many areas of science and research. Briefly, it is much more likely that a study will be published if it reports upon a positive finding, and especially if that finding is strong, unexpected, or very positive. Studies with null findings or an absence of findings may never be written up or submitted for publication by the persons who conduct them, and when they are submitted for publication they are more likely to be rejected because they may be judged to be uninteresting and/or a poor use of a scientific journal’s limited space for presenting studies. This is an important concept to be aware of when evaluating clinical research. Fortunately, there are quite a few good ways to account for it in quantitative reviews of research. For more detail on what publication bias is, and also how we can avoid being misled by it, have a look at the Wikipedia entry on publication bias.

Cortisol. Cortisol is a stress hormone produced by the adrenal glands. In her 1998 review article Field argues that massage therapy may work by reducing the recipient’s cortisol level; notably, she continues to strongly assert that this is how massage therapy works in many of her subsequent publications. My own research counters this. When my colleagues and I have carefully analyzed the data examining the effect of massage on cortisol, we consistently find that massage therapy does not significantly reduce cortisol. (Here is a detailed scientific paper on this, and here is Part 1 and Part 2 of a YouTube presentation that gives a slightly less technical summary of that research.) Some of the participants noted, also, that even though cortisol is a “stress hormone” it was probably not accurate to conceptualize it as having anything like a 1:1 relationship to stress. They are exactly right to be thinking this way – the relationship between stress and cortisol is complicated and is only one part of a complicated system for responding to a range of stressors.

Notably, this exact subject was raised at the end of Robert Sapolsky’s keynote address at last year’s San Diego Pain Summit. After Sapolsky – one of the world’s experts on stress and health – finished his talk, my friend Ruth Werner asked him about the nature of the stress-cortisol relationship including how it might relate to the discrepant conclusions in massage therapy research. You can view the exchange in the first seven minutes of this video taken during the Q&A portion of his talk. (And if you’ve never seen it, consider watching the National Geographic documentary “Stress: Portrait of a Killer” which features Dr. Sapolsky’s work; here is a link to it on YouTube.

Models for massage therapy research. This is a complicated topic so I am only going to touch on it here. Briefly, our discussion touched on the fact that people interested in massage therapy research sometimes believe that this area of research presents unique problems, such as how can massage therapy ever be understood by science if science demands that it be studied under controlled and standardized conditions? And, if the success of massage depends on there being a good therapeutic relationship between the provider and the recipient, doesn’t that mean we can never really measure what it most important in treatment?

These are very important things to consider, and they can make it difficult to do good research. However, they are not insurmountable. More importantly, they are not problems that are unique to massage therapy research. There are other areas of clinical research and of intervention research that also confront these and related problems and which have developed clever and effective methods for addressing them. I have argued that the well-developed are of psychotherapy research can be an excellent model for massage therapy research. The fields of medicine, education, and occupational therapy are some other areas that have dealt with these and similar challenges and are ones that the field of massage therapy research can look to, and borrow from, to hasten its own progress. Massage therapy research does have some challenging elements due to the fact that it is based on interpersonal contact and may work best when it is not performed according to a standardized protocol; however, massage therapy researchers do not need to ‘reinvent the wheel’ to address these issues. They can and should look to these other areas of clinical and intervention research for partial or even complete solutions to these challenges.

-CM

P.S. I am conducting a promotion to help ensure the success of the Massage Therapy Journal Club. Have a look at this short video to learn how you can be entered to win a free copy of my book, Massage Therapy: Integrating Research and Practice, and please share the link if you can.

Win my book

Would you like to win a copy of my book, Massage Therapy; Integrating Research and Practice, while also staying informed about the new Massage Therapy Journal Club? Great! This short video contains all the details on how to join the list of people who receive occasional email updates about the Massage Therapy Journal Club while also entering yourself for a chance to win a brand new copy of the book. If the response is good (500+ people made a part of the list), I have plans to give away two copies. Good luck!

-CM

Massage and Fitness Magazine Winter 2017 issue

Hey Folks, if you do not already know about this you should. Nick Ng is doing some great stuff with his Massage and Fitness online magazine.  It is an antidote to some of the other industry publications that fill their pages with pseudoscience.

Have a look at the new Winter 2017 issue that was just published and consider subscribing to get well-reasoned, scientifically-grounded  information about massage therapy and related topics.

MT Research Journal Club ep 1: Done

Earlier today I, along with some top-flight participants, completed the first episode of the online Massage Therapy Research Journal Club. This was our first ‘real’ episode but it was also a test of the idea, format, and technology. It felt like a success.  There were a couple of small technical issues to overcome, and other than that I think it went very well.

You can view it here.

I want to thank Marla Cohen, Meg Donnelly, Deetria Egeli, Beth Ivy, Mark Olson, Kim Stumpf, and Julie Wolff for volunteering, taking a chance, and helping me pilot this project with their terrific involvement. Thank  you so much.

I also want to thank Allissa Haines, Alice Sanvito, and Ravensara Travillian for helping me refine the idea and test the format. You are great friends.

I think the project is off to a good start, and it seems to have generated some real interest from folks who are interested in the science of massage therapy.  I look forward to refining and improving the format.

-CM

P.S. Deetria Egeli mentioned a couple of papers from the field of occupational therapy that informed her perspective on the psychological dimensions of the therapist-recipient dynamic. She made the references available to us in some email correspondence just after the episode was completed. Here they are:

Fearing, V. (c2000). Environments that enable therapist and client occupation. In V. Fearing, & J. Clark (Eds.), Individuals in context: A practical guide to client-centered practice (pp. 15-24). Thorofare, NJ: Slack.
 
Frank, A. W. (1998). Just listening: Narrative and deep illness. Families, Systems & Health, 16(3), 197-212. doi:10.1037/h0089849 This is available via google scholar Direct link: https://www.researchgate.net/profile/Arthur_Frank3/publication/232469291_Just_Listening_Narrative_and_Deep_Illness/links/54ef402f0cf2432ba656357b.pdf

January 18th: The Debut Session of the Massage Therapy Journal Club

Wednesday, January 18th 2017 at 6:30 EST / 3:30 PST will be the debut session of the Massage Therapy Journal Club. This is a new project which will attempt to present a seminar-style journal club on the internet.

I, along with seven participants from the massage therapy profession, will get together using Google Hangouts to discuss the seminal massage therapy research article entitled “Massage Therapy Effects” by Tiffany Field.  Our discussion will be broadcast live on my YouTube channel, and will also be posted for later viewing. The planned duration for the session is 90m.

I am in the process of creating the structure to have these regularly, with each session having a new set of participants and focusing on a different article. This first session is the real deal, but it is also going to be a test of the format. I plan to use what I learn from this session to tailor things going forward.  I can admit that I am both excited and a little nervous.

I prepared an outline from the article that will help me in hosting the session, but I expect the most important input, questions, and perspective will come from my esteemed participants. Nevertheless, I present the outline below in case it is of interest.

I hope you will either join us live, or view the session after it is completed.  I also hope that you may join us for one or more of the sessions I am planning for the future.

-CM

Field, T. (1998). Massage therapy effects. American Psychologist, 53, 1270-1281

Background

Currently the most-cited massage therapy research article (506 citations in Google Scholar)

One of the earliest massage therapy research articles to appear in a major journal

Article type = narrative review

Article appeared when I was a college senior preparing for graduate school

Why choose this article to kick off the Journal Club?

Introduction

Brief history of massage

Growing popularity is asserted and (casually) linked to the “alternative medicine movement”

Scant research – Medline database search yields only 200 articles across prior 30 years

That research suffers from “classic methodological problems” (p. 1270)

Few clinical trials

Studies often lack control groups, instead rely on within-group design

Studies often fail to use random assignment

Samples/groups often very small

Massage often part of a combination treatment

Failure to account for initial ‘level’ of symptom or clinical variable

“The use of inappropriate statistics” (p. 1270)

Likely publication bias in existing body of studies (positive results published, negative results go unpublished)

Asserts that these shortcomings motivated the Touch Research Institute (TRI) research program

TRI studies always used “deep tissue manipulation” (p. 1270) based on presumption that pressure receptors must be stimulated for there to be clinical effect

Effects organized into five categories: facilitating growth; reducing pain; increasing alertness; diminishing stress, anxiety, and depression; and enhancing immune function

Enhancing growth

Schanberg & colleagues finding that rat pups grow in response to stimulation that resembles mother rat’s licking, pinching, and carrying behaviors; results suggest a touch-growth relationship

Studies by Meaney et al. suggest handling modulates impact of the stress hormone cortisol

Weight gain in infants in response to massage across several studies

Hospital cost savings of $10,000 per premature infant

Norepinephrine and epinephrine levels increased compared with controls

Better performance on infant behavior assessment scale

Similar pattern of results reported for cocaine-exposed infants, HIV-exposed infants, and full-term infants

Pregnant women who received massage reported lower anxiety and depression, had lower stress hormone (cortisol, norepinephrine) levels, less pain, and fewer complications

Pain reduction

Positive results reported for childbirth labor, burn treatment, postoperative pain, juvenile rheumatoid arthritis, fibromyalgia, lower back pain, and migraine headache

Three ‘models’ for this set of effects are offered:

Gate theory, briefly explained as having a stimulus that competes with and overrides or interrupts a ‘pain stimulus’ (nociception)

Increase of the neurotransmitter serotonin, which may inhibit nociception

Promotion of sleep, because persons deprived of sleep show increased propensity for pain, possibly due to decreased somatostatin and increased substance P

Reduction of neuromuscular problems

Positive outcomes for multiple sclerosis

Positive outcomes for spinal cord injury

Enhancing attentiveness

Positive outcomes for autism

Positive outcomes for attention-deficit hyperactivity disorder

Enhanced alertness and better performance on a math task in medical school faculty and staff who received workplace massage – EEG patterns associated with this are mentioned but not detailed

Alleviation of stress, depression, and anxiety

Positive outcomes reported for/with:

Post-traumatic stress disorder

Child and adolescent psychiatric patients

Adolescent women with eating disorders

Chronic fatigue

Depressed elderly volunteers who massaged infants

Models offered for alleviation of stress, anxiety, and depression:

“Depressed mood was decreased, and anxiety levels and stress hormones (norepinephrine, epinephrine, cortisol) were reduced in all of the above studies” (p. 1276)

EEG shift

Increase in vagal activity: “The nucleus-ambiguous branch of the vagus (the “smart” vagus) stimulates facial expressions and vocalizations, which contribute to less depressed affect” (p. 1277)

Cardiovascular symptoms of stress – this section briefly highlights some findings that massage appears to lower blood pressure

Autoimmune disorders

Because vagal activity and insulin levels may be linked, a study of massage therapy for diabetic children was warranted

Anxiety and depressed mood lowered

Parents’ assessment of insulin and food regulation is improved

Children’s glucose levels decreased

Asthmatic children showed general (anxiety, mood) and specific (pulmonary measures) improvements in response to massage

Immune disorders

“Immune disorders might be expected to benefit from massage therapy because of the decrease in cortisol levels noted in several previous studies” (p. 1277)

Positive results reported for HIV+ men, and for women with breast cancer, are reported

Summary

In addition to condition-specific effects, “across studies, decreases were noted in anxiety, depression, stress hormones (cortisol), and catecholamines” (p. 1278)

“Increased parasympathetic activity may be the underlying activity for these changes” (p. 1278)

Asserts that pressure is critical (possibly to activate vagus) and that light stroking is “generally aversive” (p. 1278)

Among future directions: Are any particular massage therapy techniques more effective than others?

In relation to massage therapy effects in healthy individuals, some discussion of sports/athletic massage

A “mixed-results literature” (p. 1278)

Some discussion of whether massage should be expected to diminish inflammation, or not, with no clear consensus

Some discussion of mechanical vibration as a therapeutic intervention and whether massage therapy parallels this

Some discussion of effect of massage on blood flow

“In summary, these questions highlight the need for further research”

“There will need to be a shift in the social-political attitude toward touch [for massage therapy to be more widely used and benefitted from]”

“A larger body of methodologically sound research is needed”

Keynote speech at 2017 RMTAO Education Conference

I am pleased to announce that I have been invited to give a keynote speech at the Registered Massage Therapists Association of Ontario’s 2017 Education Conference. Here is the brief description:

 

Challenges in Massage Therapy Research

Christopher A. Moyer, Ph.D.

To conduct scientific research that examines massage therapy, and which has the potential to inform practice, is challenging. Of course, many of the challenges that are encountered when conducting massage therapy research are ones that also arise in other areas of clinical research (e.g., How does one get funding to conduct a study? Does a controlled study ever truly capture what happens in the real world?). At the same time, there are also challenges that are unique to conducting massage therapy research that relate to the culture of the profession and to the institutions that guide, oversee, and support scientific research. Using examples from his own scientific career, Dr. Moyer will outline these challenges in detail and offer his perspective on how they can be addressed to advance massage therapy research and practice.