A NEW ERA FOR MASSAGE RESEARCH

Recommendations from the Massage Research Agenda Workgroup have set a clear-cut direction for future projects.

Suggested Secondary Prevention Studies
The MRAW recommended that attention be given to designing high-quality studies examining the potential of massage in the area of secondary prevention. Two examples were given.

Study Of Potential For Massage Therapy To Prevent Falling Among The Elderly
It is well documented that falling among the elderly is a frequent occurrence that has both personal and social costs. With an aging population, this issue will be of great interest.

It is often said by massage therapists that massage could be used to improve "groundedness" and balance, which could be tested in an elderly population. Subjects could be recruited through private physicians or medical centers after their first visit to a doctor for a fall. Age-related inclusion/exclusion criteria would be set. Subjects would be randomized to at least two conditions. One group would receive massage (the frequency and number of treatments to be set by the study team), and the other group would receive no massage treatment. Principle outcome measures could include both objective measures related to falling, such as the time between falling episodes and the severity of injuries incurred during falls, as well as measures related to quality of life.

Secondary Prevention Of Depression
Thousands of Americans yearly experience depression and/or take antidepressants. This is a painful and costly condition, often accompanied by unwanted side effects of antidepressant usage. The numbers are growing, and it is affecting younger and younger populations. It is a worthy subject of investigation, and preliminary data from studies done at the Touch Research Institute indicate massage may be an effective treatment for depression. Subjects in such a study would be patients who already have experienced clinical depression and are deemed in remission. They would be randomly assigned to massage or no-massage treatment. The frequency and duration of treatment would be determined after examination of existing data. The principal outcome measure would be remission/relapse rate as indicated by future diagnoses of depression, use of antidepressants, self-reports, etc.

Investigations Of The Profession Of Therapeutic Massage
Despite its status as a healing modality that has existed for thousands of years across many cultures, there has been little systematic investigation of massage as a profession, including issues of training, public perception and the like. The MRAW recommended strongly that this situation begin to be remedied, and made a few specific suggestions.

The Search For Excellence
Little is known about what makes a good, or great, massage therapist. This sentence has two separate meanings, both of which are important. First, it reflects the fact that there is no agreed-upon definition or description of a good massage therapist. The agreed-upon training standards are stated in terms of hours of training (generally 500 hours in the United States, 2,500 hours in Ontario and 3,200 hours in British Columbia) rather than areas of competence; although, this is about to change. Secondly, it reflects the reality that there has been no systematic evaluation of educational practices in the profession. We do not know how one best trains a good massage therapist, or even the extent to which excellence in this field can be taught.

A range of studies could be designed to fill these gaps, from qualitative work aimed at eliciting definitions of excellence in the field, to quantitative studies designed to ascertain whether such peer or client defined "excellence" corresponds to positive clinical results, to educational evaluation research to determine how both the material and skills can be effectively transmitted. Furthermore, given the lack of uniformity in training in the United States today, it would be useful for the public to know how broad the range of competence levels is among professional massage therapists who were trained at accredited institutions.

How Massage Therapists Are Perceived By Themselves And Others
During the meetings of the MRAW it became clear that the massage therapists regard client education as one of our critical roles, and that the researchers did not initially share this view. This is a significant difference, and served to remind the MRAW that it would be of benefit to both the profession and the public to gather information about how massage therapists view their role and whether there is systematic variation in this by region, degree of training, years in practice, etc. It would also be of value to gather information on how the profession is perceived by the public, including clients, potential clients, referring health professionals and health professionals in general. How do these groups view the work/role of massage therapists, and assess the effectiveness of massage therapists? How do all these groups view the role of clients? Are they thought of as passive recipients of a service or therapy? Do clients expect to learn from their massage therapists?

Assessing Our Assessment Skills
Diagnosis falls outside the scope of practice of massage therapy. At the same time, massage therapists assess and reassess what is happening with clients in order to make decisions about treatment design. In part because of the legal situation, our assessment has not been well studied, but it needs to be. In particular, it is important to study what is taught about assessment and what is practiced. Comparisons of this across regions with differing legal situations would be useful. In addition, it is vital to know whether there is inter-rater reliability in the area of assessment. That is, would different massage therapists, asked to assess the same clients, draw the same or different pictures of what is happening? Would they then design identical, similar or widely varying treatment plans?

Dimensions Of The Therapeutic Encounter
Finally, it was recognized that little investigation has been done on the therapeutic encounter itself within massage treatment. This is an important and potentially delicate area of inquiry, particularly within a climate in which much of what massage therapists may value as good practitioner/client interaction is seen, in another framework, as contamination or placebo effect. Nonetheless, or perhaps because of this, it is important to create ways of investigating the effects of everything from practitioner influence (both purposeful and accidental), to the influence of such environmental factors as music, lighting and so forth. What is the role of the practitioner/client relationship? How important is attunement between them, and how do you measure this? What therapist characteristics matter? How do you measure entrainment (e.g., EEG entrainment between client and therapist, or pulse entrainment)? Finally, assuming there is some "practitioner effect," it would be of value to determine ways of identifying characteristics that help match clients and therapists.

Investigations Of Physiological (Or Other) Mechanisms
Inquiry into the avenues through which massage produces its effects is a wide-open and important area for investigation. Many sorts of studies could be usefully conducted under this general heading.

Systematic Documentation Of The Physiological Effects Of Massage
It would be useful to conduct research designed to describe the physiological effects of massage separate from the matter of clinical impact. There are physiological effects that are regarded by many as established, but which have not been investigated since the advent of recent generations of measurement tools. The claim that massage increases circulation of blood and lymph would be an example of this, as would investigation of the extent to which massage elicits sympathetic or parasympathetic response. Also, it would be useful to conduct research on the nature of fascia and its role in the effects of massage.

Seeking Explanations Of Established Effects
Where certain effects of massage have been repeatedly demonstrated, it would be beneficial to establish how the body produces the effect. For instance, studies investigating the effects of massage on premature infants have consistently shown that those infants receiving massage have significantly greater weight gain than the unmassaged infants (a range of 28 to 47 percent), without any greater caloric intake. The mechanism of this weight gain has never been investigated, let alone established.

Explorations Of Subtle Energy
It was acknowledged by the MRAW that much is speculated or claimed, but little is actually known about subtle energy and its role in healing in general and therapeutic massage, in particular. Nonetheless, some massage schools and modalities teach "energy balancing" of one sort or another, and some massage education includes instruction in awareness of energy resonance and/or exchange between practitioner and client. While there are no agreed-upon instruments of measurement for such subtle energy, the MRAW recognized the importance of the development of this field for full understanding of the effects of therapeutic massage and bodywork. It was suggested that subtle energy should be studied both as a dimension of the therapeutic encounter and as a purposeful aspect of treatment.

Research Agenda Stemming From A Wellness Paradigm
Contemporary clinical research methodology, and the questions it is designed to address, have developed largely from within allopathic medicine, and thus within a pathology-oriented framework. While therapeutic massage and bodywork is used to address such allopathically defined conditions, it is also, perhaps even more frequently, used for what clients and practitioners refer to as "wellness."

There are research questions that arise from a wellness paradigm that may never arise from a pathology paradigm, and these, too, are important to pursue for an understanding of the effects of therapeutic massage. While these may be the least "reimbursable" treatments at present, they may also be those most likely to ultimately change modern medicine and public health. The research needed includes qualitative studies aimed at eliciting operational definitions of heretofore vague terms (e.g., wellness, groundedness, centeredness, balance, etc.), descriptive studies and "clinical" research. The following questions arose during MRAW discussions of these issues:

• What is wellness? More than 25 percent of client visits to massage therapists are made for wellness, according to client reports. We need to know how clients define wellness when they seek it, and how they know when they have received it. We need to know how massage therapists define wellness when they say they offer treatments designed to enhance it.
• If we assume that the body is "self-healing" and that massage can somehow jump-start that healing process, how does that happen? Are the effects we see, such as weight gain in premature infants, enhanced immune function among HIV-positive men, etc., indications of this? What does jump-start mean?
• What is the interaction of consciousness and wellness? Do massage therapists practicing "wellness massage" tend to make suggestive comments during treatment? Are silent treatments more or less effective than treatments that include such suggestions?

Beyond "wellness," once that is defined, there lies the potential to investigate the role of massage in achieving peak performance. Such studies could include athletes, musicians and other performers already exploring the issues of human potential and peak performance. The issues can also be explored in relation to enhanced performance in other roles, such as defense personnel, air traffic controllers, people in or just before high-performance task situations (e.g., students taking exams), medical interns, 911 operators, children showing difficulty at school, caregivers of all kinds and those at end of life.

Replication Studies
One effect of the relative lack of funding for massage research, and the lack of acknowledged agenda for the work, is that few studies with promising results have been replicated. This is a serious, but easily remedied, problem, and the MRAW named replication of the best studies as one of the research priorities for the field of therapeutic massage and bodywork.

The Importance Of Multidisciplinary Teams
All workgroups of the MRAW included at least one massage therapist, one clinical or survey research scientist, and one bench or biological scientist. Members of the MRAW were struck by how valuable these multidisciplinary groups were. The MRAW cautioned against the all-too-frequent practice of research in complementary and alternative medicine in general and therapeutic massage specifically, being designed and conducted without the benefit of any practitioners involved in conceptual roles. We highly recommend the creation of multidisciplinary teams during the design phase.

Conclusion
The field of research in therapeutic massage and bodywork is just beginning to develop. This is an important development for a health-care modality that is both fairly widely used and lacking in available data on its safety and efficacy. It is also tremendously useful to the field of therapeutic massage at this point in its development when the public, and some within the profession, are calling for increased standardization of the training and perhaps even of the treatments. Many forms of research are beneficial during such a formative developmental phase, and it is hoped that between federal and private funding sources, significant aspects of the work suggested here can be accomplished in the near future.

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Janet Kahn, Ph.D., former president of the AMTA Foundation, is a massage therapist, a research scientist and a member of the NIH Advisory Council on Complementary and Alternative Medicine. She consults to hospitals, medical schools and massage schools on research and curricular issues. She can be reached at: jkahn@igc.org.

References

1. Cherkin, Daniel C. et al. "Randomized Trial Comparing Traditional Chinese Medical Acupuncture, Therapeutic Massage, and Self-care Education for Chronic Low Back Pain." Archives of Internal Medicine, 161: 1081-1088, 2001.