Janet Kahn

A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial

BACKGROUND Few studies have evaluated the effectiveness of massage for chronic low back pain. OBJECTIVE To compare the effectiveness of 2 types of massage and usual care for chronic back pain. DESIGN Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384) SETTING An integrated health care delivery system in the Seattle area. PATIENTS 401 persons 20 to 65 years of age with nonspecific chronic low back pain. INTERVENTION Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133). MEASUREMENTS Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful. RESULTS The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small. LIMITATION Participants were not blinded to treatment. CONCLUSION Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms. PRIMARY FUNDING SOURCE National Center for Complementary and Alternative Medicine.

A survey of training and practice patterns of massage therapists in two US states

BackgroundDespite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists. The objective of this study was to describe these characteristics.MethodsAs part of a study of random samples of complementary and alternative medicine (CAM) practitioners, we interviewed 226 massage therapists licensed in Connecticut and Washington state by telephone in 1998 and 1999 (85% of those contacted) and then asked a sample of them to record information on 20 consecutive visits to their practices (total of 2005 consecutive visits).ResultsMost massage therapists were women (85%), white (95%), and had completed some continuing education training (79% in Connecticut and 52% in Washington). They treated a limited number of conditions, most commonly musculoskeletal (59% and 63%) (especially back, neck, and shoulder problems), wellness care (20% and 19%), and psychological complaints (9% and 6%) (especially anxiety and depression). Practitioners commonly used one or more assessment techniques (67% and 74%) and gave a massage emphasizing Swedish (81% and 77%), deep tissue (63% and 65%), and trigger/pressure point techniques (52% and 46%). Self-care recommendations, including increasing water intake, body awareness, and specific forms of movement, were made as part of more than 80% of visits. Although most patients self-referred to massage, more than one-quarter were receiving concomitant care for the same problem from a physician. Massage therapists rarely communicated with these physicians.ConclusionThis study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy.

Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain.

PURPOSE This trial was designed to evaluate the optimal dose of massage for individuals with chronic neck pain. METHODS We recruited 228 individuals with chronic nonspecific neck pain from an integrated health care system and the general population, and randomized them to 5 groups receiving various doses of massage (a 4-week course consisting of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times weekly) or to a single control group (a 4-week period on a wait list). We assessed neck-related dysfunction with the Neck Disability Index (range, 0–50 points) and pain intensity with a numerical rating scale (range, 0–10 points) at baseline and 5 weeks. We used log-linear regression to assess the likelihood of clinically meaningful improvement in neck-related dysfunction (≥5 points on Neck Disability Index) or pain intensity (≥30% improvement) by treatment group. RESULTS After adjustment for baseline age, outcome measures, and imbalanced covariates, 30-minute treatments were not significantly better than the wait list control condition in terms of achieving a clinically meaningful improvement in neck dysfunction or pain, regardless of the frequency of treatments. In contrast, 60-minute treatments 2 and 3 times weekly significantly increased the likelihood of such improvement compared with the control condition in terms of both neck dysfunction (relative risk = 3.41 and 4.98, P = .04 and .005, respectively) and pain intensity (relative risk = 2.30 and 2.73; P = .007 and .001, respectively). CONCLUSIONS After 4 weeks of treatment, we found multiple 60-minute massages per week more effective than fewer or shorter sessions for individuals with chronic neck pain. Clinicians recommending massage and researchers studying this therapy should ensure that patients receive a likely effective dose of treatment.

Therapeutic Massage Intervention for Hospitalized Patients with Cancer: A Pilot Study

F orty-two (42) percent of Americans use some form of alternative medicine, spending 21.2 billion dollars annually,1 and one of the most commonly sought alternative and complementary medicine (ACM) therapies is therapeutic massage, which was used by an estimated 11 percent of the U.S. adult population in 1998. In that year, adults made an estimated 114 million office visits to receive massage treatments.2 Massage has been used as a therapeutic intervention for a variety of illnesses for thousands of years. The Asian roots of massage go back a t lea s t to 1000 BC and so do the or ig in s o f Ayurvedic medicine. Descriptions of massage appear in the ancient medical texts of India, China, Japan, and Tibet. The European roots of massage can be traced back to the seventh century BC. Massage was associated with the cures offered at the temples of Aesculepius and was described in the writings of Hippocrates. Massage has been used to promote relaxation and relieve pain and has been suggested as a useful adjunctive treatment for symptom control for patients at the end of life. Pain is one of the most common symptoms experienced by dying patients. More than 40 percent of patients’ families reported that patients experienced severe pain in the last 3 days of life.3 Others have reported that 60 percent of patients who have cancer have pain.4,5 In many cases (42 percent), pain was inadequately treated in patients with cancer.6 Nearly 80 percent of hospitalized patients have reported pain, while less than half had any mention of pain noted in progress notes by their doctors.7 Even in palliative medicine and in hospice settings, 64–88 percent of patients had inadequately relieved pain, and the most severe symptoms occurred 2 days prior to death.8 During the last 7 days of life, narcotic usage increased significantly. Although symptoms of pain and nausea were reduced, drowsiness worsened substantially and resulted in worse symptom distress scores. Between 15 and 20 percent of patients needed treatment for pain, requiring complete sedation to obtain relief.9 Caregivers often experience symptoms of anxiety and sadness near the end of a patient’s life. Grief phenomena have been welldescribed. Compared to their experience 6 months following death, feelings of sadness are most intrusive in the 6 weeks following the patient’s death as are symptoms such as tearfulness, depression, and anxiety.10 Physical symptoms, such as pain, are most prominent at 6 weeks as well. Small studies have suggested that interventions that provide support to caregivers can improve their satisfaction with care as well as decreasing their physical and emotional stress.11 Only a few studies on the use of massage at the end of life have been reported. In a small study of massage given to patients in a hospice, investigators reported that slow-stroke back massage resulted in changes in vital signs, suggesting improved relaxation.12 Other studies have indicated that massage may be useful in managing cancer pain.13,14 Studies on other populations have suggested a number of potential benefits of massage that are relevant to patients with metastatic cancer. For example, massage has been shown to promote relaxation, reduce anxiety and depression, and improve sleep patterns.15–18 In addition, other studies have indicated that massage may reduce patients’ experience of pain ,13 ,14 ,19–22 ease breathing,23 faci l i tate weight gain,24–26 and increase alertness.27 Finally, data indicate that giving as well as receiving massage may reduce anxiety and depression,28 suggesting that caregivers may benefit from providing massage to patients. In this pilot study, we provided daily massage to hospitalized patients with metastatic or end stage lung or gastrointestinal (GI) cancer. Hospital admissions were screened daily to identify eligible patients. Patients received daily therapeutic massage and family caregivers were also instructed in the use of massage during hospitalization. Data were collected from massage therapists’ detailed documentation and from patients’ daily questionnaires about their experiences with the massage therapy. We also collected data from medical records via chart reviews and interviews with patients’ nurses and physicians.

Development of a manualized protocol of massage therapy for clinical trials in osteoarthritis

BackgroundClinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials.MethodsThe manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists’ clinical judgment and maintaining consistency with a prior pilot study.ResultsThe manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated.ConclusionsThe massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings.Trial registrationClinicaltrials.gov NCT00970008 (18 August 2009)

Dosing study of massage for chronic neck pain: protocol for the dose response evaluation and analysis of massage [DREAM] trial

BackgroundDespite the growing popularity of massage, its effectiveness for treating neck pain remains unclear, largely because of the poor quality of research. A major deficiency of previous studies has been their use of low “doses” of massage that massage therapists consider inadequate. Unfortunately, the number of minutes per massage session, sessions per week, or weeks of treatment necessary for massage to have beneficial or optimal effects are not known. This study is designed to address these gaps in our knowledge by determining, for persons with chronic neck pain: 1) the optimal combination of number of treatments per week and length of individual treatment session, and 2) the optimal number of weeks of treatment.Methods/designIn this study, 228 persons with chronic non-specific neck pain will be recruited from primary health care clinics in a large health care system in the Seattle area. Participants will be randomized to a wait list control group or 4 weeks of treatment with one of 5 different dosing combinations (2 or 3 30-min treatments per week or 1, 2, or 3 60-min treatments per week). At the end of this 4-week primary treatment period, participants initially receiving each of the 5 dosing combinations will be randomized to a secondary treatment period of either no additional treatment or 6 weekly 60-min massages. The primary outcomes, neck-related dysfunction and pain, will be assessed by blinded telephone interviewers 5, 12, and 26 weeks post-randomization. To better characterize the trajectory of treatment effects, these interview data will be supplemented with outcomes data collected by internet questionnaire at 10, 16, 20 and 39 weeks. Comparisons of outcomes for the 6 groups during the primary treatment period will identify the optimal weekly dose, while comparisons of outcomes during the secondary treatment period will determine if 10 weeks of treatment is superior to 4 weeks.DiscussionA broad dosing schedule was included in this trial. If adherence to any of these doses is poor, those doses will be discontinued.Trial registrationThis trial is registered in ClinicalTrials.gov, with the ID number of NCT01122836

P05.31. Development of a manualized protocol of massage therapy for clinical trials in osteoarthritis

Background: Clinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials. Methods: The manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists’ clinical judgment and maintaining consistency with a prior pilot study. Results: The manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated. Conclusions: The massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings. Trial registration: Clinicaltrials.gov NCT00970008 (18 August 2009)