Ramblemuse Touch Points

It’s far from an easy task to reshape something that is not exactly a health care profession toward being one. The task becomes even more challenging when the tool of choice is voluntary education. This, however, appears to be the challenge taken on by the Massage Therapy Foundation (MTF). As the MTF expresses it, “It is our vision that the practice of massage therapy is evidence-informed and accessible to everyone.” April’s International Massage Therapy Research Conference (IMTRC) in Boston upheld that vision. This is my first segment of observations from there.

Massage therapy has long been a profession that couldn’t define itself in terms of core competencies; a landscape of trademarked empires; a haven for those escaping the complexities and dehumanization of modern medicine by going to the land of magical thinking. Magical thinking, however, is a poor basis for gaining credibility as a health profession. But how does a profession move away from that?

One answer that the MTF has has been actively pursuing is promoting research literacy. This doesn’t mean that all practitioners are going to participate in research, but that they should, at a minimum, be able to read a research paper and assess its conclusions. Jeanette Ezzo pushed that theme forward with her conference-opening keynote talk.

Mechanisms and Beyond: What is Needed to Prove the Effectiveness of Massage?

Jeanette Ezzo led off IMTRC’s plenary sessions talking about translating massage research into practice. Ezzo noted that there are now between 750 to 1000 random controlled trials (RCTs) and systematic reviews for massage therapy. “Research helps practitioners give evidence-based answers to clients’ questions, but the coverage isn’t uniform”, she said.

Hierarchy of Evidence

To help conference participants understand evidence-informed practice, Ezzo showed a four-level hierarchy of evidence, ranging in order of increasing strength: from case reports or case series, to non-randomized controlled trials, to randomized controlled trials (RCTs), up to systematic reviews. The top two levels test hypotheses and show efficacy while the bottom two levels help generate ideas. The various types of studies are looking at clinical outcomes, which are measures of how a patient feels, functions, or survives.

The efficacy of an intervention is a measure of the intervention’s effect under ideal conditions. RCTs generate the base data on efficacy, while systematic reviews collect, summarize, and assess that data. Such a meta-analysis, however, is only as good as the studies put into it. In contrast to efficacy, efficiency is based on effects under everyday (i.e. real-world) conditions.

The efficacy of an intervention is separate from understanding its mechanism of action. In this, massage therapy joins the ranks of other branches of health care who have learned what things work, but do not yet know why. The ‘legal’ way to establish a mechanism, according to Ezzo, is to show an outcome first and then look for a mechanism. If you don’t know that the intervention works, it’s premature to think about mechanisms.

Ezzo talked about the progression from a survey-based Consumer Reports analysis of treatments for low-back pain to a Cochrane study on massage effectiveness for non-specific low-back pain. Consumer Reports reported that 48% of its readers found massage therapy to be very helpful. CR concluded that “There is not enough research to be certain about the benefit of massage in treating lower-back pain. But it might be beneficial for patients with nonspecific subacute or chronic lower-back pain lasting four weeks or more.”

The Cochrane analysis, updated in 2008, found that “massage was more likely to work when combined with exercises (usually stretching) and education.” The authors concluded, “In summary, massage might be beneficial for patients with subacute (lasting four to 12 weeks) and chronic (lasting longer than 12 weeks) non-specific low-back pain, especially when combined with exercises and education.”

Last year (2012), The Ottawa Panel published “Evidence-Based Clinical Practice Guidelines on Therapeutic Massage for Low Back Pain”, finding that “massage interventions are effective to provide short term improvement of sub-acute and chronic LBP symptoms and decreasing disability at immediate post treatment and short term relief when massage therapy is combined with therapeutic exercise and education.”

These guidelines indicate that massage therapy is effective at patient pain relief and improving functional status. Ezzo noted that 90% of fresh low-back pain will resolve in six weeks if nothing is done. There’s a definite consumer choice. Do you want to wait six weeks?

Ezzo noted that the dose of massage is important. Lessons from best research on low back pain say that the ideal treatment should be 30-60 minutes weekly for 6-10 treatments. There’s a “Goldilocks effect”. If you plot gain versus dosage, you initially see greater benefits with more treatment but that eventually saturates. After that, there’s little or no gain from a further increase in dosage.

Having factorial studies allows for making statements about the combination of massage with postural education plus exercise. There’s a high level of evidence that the combined protocol is more effective than either protocol alone.

Ezzo related a number of deficiencies of past studies. Too often studies are done in which the selection of practitioners was not recorded or not based on knowledge and experience. In general, trials done with experienced MTs have had better results than those with less experienced MTs. This may seem obvious but it’s important. The choice of what areas to treat for a specific condition can also be an issue. Not including important tissue areas leads to flawed evidence. Evidence from bad studies stick around for years, stressed Ezzo. We need to step up and bring our A game.

On the Cochrane ladder of evidence: efficacy, effectiveness, and cost-effectiveness, too often research has stopped on the first rung. Ezzo stressed that we need studies with adequate follow-up time (e.g. 1 year); cost effectiveness over time, not just immediate treatment. She cited the Sherman et al. neck pain trial as a stellar example of using experienced therapists with a time series of observations. “Give it 4 weeks!! Massage shows significant neck pain relief in the first 4 weeks”, said Ezzo.

Massage Therapy may be expensive up front, but not in the long run if it reduces health care utilization costs. Data for LBP shows that there can be 40% lower health care costs when massage therapy is included in the treatment [p=0.15]. Massage can also help to address the problem of “Once we get them there, how do we keep them there (i.e. pain-free, functional)”.

Finally, Ezzo encouraged, “Keep doing what you are doing, until all the evidence is in.”