Originally published in Massage Bodywork magazine, October/November 2002.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.
Birthdays are great opportunities for self-reflection, for dreaming and for goal-setting. As we mark the 10th birthday of Massage Bodywork
, I have been asked to look at the field of massage research and reflect upon where our profession might hope to be 10 years from now.
Ten years. What is its meaning? My dog is not quite 10 years old yet and the vet referred to him yesterday as early geriatric. I cringed. Sailing with my dad last weekend, I realized we had bought our boat almost four decades ago. It seems like yesterday. Time is a funny thing. One can imagine that 10 years might not amount to much in the life of a profession, but for the field of therapeutic massage and bodywork in general, and research specifically, the past decade was developmentally critical. I think the next decade will be at least as important. To help us understand what 10 years can mean, I will take a brief look backwards, then offer some suggestions and predictions about the coming decade. An Idea is Given Form
Ten years ago, very few people were thinking or speaking about research on therapeutic massage and bodywork. Three institutions emerged in the last decade to change that picture. The first was Touch Research Institute (TRI), founded in 1992 by Tiffany Field at the University of Miami. Researchers at TRI have conducted more than 80 studies on a wide variety of potential massage applications. Most of these investigations are relatively small pilot studies. While not establishing definitive effects of massage, they have identified many areas in which massage shows potential and should be further investigated. These studies have helped massage therapists around the globe understand the potential of research to inform our own practices, to answer our own questions and to inform others about our work. I think it is fair to say Dr. Field and TRI have done much to put research on the map for massage therapists, and to put massage on the map for health care researchers. Making massage research a destination site, now that it is on these maps, is our job for the coming decade.
The American Massage Therapy Association (AMTA) Foundation was established in 1990 with the mission of "bringing the benefits of massage therapy to the broadest spectrum of society through the generation, dissemination and application of knowledge in this field." The foundation began offering research grants in 1993. It has provided seed money to massage therapists and university-based researchers, allowing them to gather the kind of preliminary data needed to apply for larger grants from other sources. The AMTA Foundation has brought research closer to home. By launching the Massage Therapy Research Database (2001) it has made massage research findings more accessible to therapists. And in convening the Massage Research Agenda Workgroup (1999), the foundation provided a way for massage therapists and bodyworkers who may not have the training or the inclination to conduct research, to nevertheless influence the types of research being done.
The third organization that warrants attention is the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH). Established as the Office of Alternative Medicine in October 1991, and reborn as NCCAM in 1998, this organization was created by legislative mandate, reflecting the public's widespread use of alternative medicine, and their demand that it be investigated as an aspect of contemporary health care. This is an important organization by virtue of its resources and its location. With a budget of more than $100 million per year and growing, it has the potential to fund significant research (although it has other responsibilities as well). The very existence of an institute devoted to alternative medicine has drawn and will draw many more conventional researchers into the field. NIH is considered to be the pre-eminent health care research center in the world. It will likely be considered an important authority on complementary medicine, including massage.
To date, therapeutic massage has not gotten its share of funding or attention from NCCAM. That is, given the number of Americans who use massage, NCCAM is not funding many studies. The responsibility for this is not all NCCAM's, since there are not many massage research proposals being submitted. In the coming decade, an important task for the field of therapeutic massage and bodywork will be to learn more about NIH, and about NCCAM in particular - to learn what funding mechanisms are available and how to successfully utilize them to advance our profession.
The past decade has also seen a nascent interest in massage research arising in this country outside of the three organizations mentioned. Where 10 years ago very little was said in our professional publications about research, today each of the three major massage periodicals covers massage research in every issue. And ten years ago, I could not name a single massage school that taught research methods or even made reference to the massage-related research that existed at the time. As a final measure of the past decade, there are now health care administrators and practitioners who want to know what the research indicates about massage. They want to know what it is good for, what it is not good for, when they should refer, what deserves reimbursement, etc. In short, a massage research audience has begun to appear in the past decade.
So where do we go from here? Courage, Curiosity and Collaboration
Three watchwords will help us get the most out of the next decade in terms of massage and bodywork research. The words are courage, curiosity and collaboration, and the three of them must go hand-in-hand. Courage is required because we are stepping into a new arena. The mainstreaming of massage and other complementary health systems and modalities brings increased opportunity for us to be of service to more people, and it brings increased scrutiny as well. Increasingly when we make claims about the benefits of massage we are being, and will be, asked how we know that, whether there is any data to support our assertion. We must have the courage to let our work be assessed in many ways. We must have the courage to enter new contexts and work with new kinds of colleagues.
Curiosity is at the heart of research. Research is designed to answer questions. We begin with hunches, clinical observations, public health needs and wonderings. We begin with curiosity about whether massage really moves fluids, can help alleviate depression, is better than surgery for people with carpal tunnel syndrome, etc. We begin with curiosity about why the premature babies in Field's studies gain more weight when they are massaged, and about what aspect of therapeutic massage treatment leads to its effectiveness in relation to persistent low back pain as demonstrated by Cherkin and his colleagues. What is the contribution of the specific soft tissue work itself? Of generalized relaxation? Of the extent to which the client and practitioner connect? Of the client's belief in massage? Of the homework suggestions for exercise or ergonomic improvement the therapist offered to the client? Curiosity will drive the research to improve our work.
While courage and curiosity are instrumental to research, collaboration is the most important of the watchwords. Collaboration is the key to our own participation in naming the kinds of research that should be done and to mustering the resources to see it is done.
In October 1997, NCCAM awarded a $2.5 million grant to Palmer College of Chiropractic to establish the Consortial Center of Chiropractic Research (CCCR). Five chiropractic colleges joined forces to provide the infrastructure to the CCCR, offering training, database development and research opportunities. Since that time, five more chiropractic schools have joined this effort. An advisory committee composed of nationally known scientific and chiropractic experts directs the CCCR on programmatic aspects, sets research priorities and makes final decisions related to the support of selected research projects. In 2001, NCCAM gave an award to Bastyr University to establish The North American Naturopathic Medical Research Consortium with the initial goal of developing a prioritized research agenda. Again, while Bastyr is listed as the lead organization, this is a consortium that involves all five of the major accredited naturopathic colleges and universities in the United States and Canada.
In accordance, there will be a massage research consortium established in the next 10 years. It will be created by a small group of courageous and curious individuals, many of them representing exemplary massage schools. Since massage schools do not have the kinds of research experience and orientation, nor the faculty and financial resources of a Bastyr University or Palmer College, I believe this consortium will include an academic or medical center. In order to create this massage research consortium and serve our profession and the public, we will have to compete less and collaborate more. It is time for us to take on something bigger than one massage school can handle and bigger than one professional association can handle.
Research doesn't exist in a vacuum. It is conceived and conducted by researchers who in turn require resources such as money, office space, access to patients, laboratories, imaging equipment, computers and the like. To be utilized, research requires an audience and vehicles through which results are made available to that audience. In the next 10 years, we need to purposefully build this infrastructure.The Educational Role
While the creation of a consortial massage research center will be important, it is not by any means the whole picture. Massage schools are central to building the infrastructure research needs. It is their job to create massage professionals who understand research and its role in professionalization, who know how to locate and critically read the research literature, and who can adapt their practice based on research results. In 10 years time, I hope all of this will be taught in many massage schools. A smaller number of schools will also provide students who are interested in research experience - through their clinics or through internship placements at medical centers and academic institutions. All of this will require support from the faculty. In some cases, new faculty with research skills and experience will need to be hired; in other cases, faculty will need to be supported as they retrain to meet these needs. The schools should also be using research to answer pedagogical questions like how best to teach palpation, or for tracking changes in the student body, client population and treatment contexts which could have implications for what should be taught.
We already see some students relocate to attend a massage school they believe offers superior education. In 10 years time, massage education which includes an introduction to research, at a school that has formed a partnership with a local university or medical center, will be seen as worth matriculating to. These schools will grow in size, length of program, tuition level and more. We have more than 900 state-approved massage schools in the United States today. In 10 years time, perhaps 20-30 schools will have emerged as those offering significant research exposure. The growing number of massage programs being created in colleges will be logical sites for this education. I hope some of the established, free-standing massage schools also take on this challenge.
It is wonderful and appropriate that our magazines now report on research. It is also appropriate that we have no peer-reviewed massage journal. At this stage of our development it is important not to isolate research findings on massage, but rather to put them in the professional journals already being read by the researchers, administrators and practitioners who need to learn about our work. But in 10 years, we will be ready for a journal of massage and bodywork research. By that time, we should be generating enough research activity and audience to warrant a bi-monthly journal.
And if in 10 years we get this entire infrastructure in place, what is the research we should actually be doing? There are three major categories of information a profession needs to generate in order to understand itself. The first is socio-cultural information - that which helps us to understand who we are, how we are regarded, and so forth. The second arena of inquiry is information about what effects our work has. And the third is information about how that happens. This is traditionally called mechanism studies, but for now we'll refer to them as avenues of effect. Your imagination and your clinical experience will be beneficial in terms of conceiving the kinds of studies that could be done.
Socio-cultural studies could look at the demographics of student and client populations, cost-effectiveness, client-practitioner relationships, practice philosophies, regulatory issues and more. If you have any doubt about the importance of this kind of investigation, consider the impact of David Eisenberg's surveys on Americans' use of complementary and alternative medicine. When Eisenberg alerted the medical community and the public at large to the fact that more than 40% of Americans were using some form of CAM every year, and that few of them were discussing this with their physicians, our field received the kind of attention it had only dreamt of before. For the field of massage, it was incredibly helpful to know that more than 1#8260;3 of American adults - more than 100 million visits per year - were paid for out of pocket.
In terms of safety and efficacy studies, our attention should be steered in four directions. First, let us conduct research on the kinds of conditions we are treating. The National Alternative Medicine Ambulatory Care Study by Dan Cherkin found 63% of visits to massage therapists were for musculoskeletal complaints, but there is relatively little research on these conditions. Neck pain accounted for 17% of visits, but I know of no studies on massage for neck pain. Secondly, whereas massage research in the past 10 years has investigated at the surface level a wide range of possible applications, I encourage us to spend the next 10 years going deeper in a few areas. Consider that in the early 1990s when the Agency for Health Care Policy and Research (AHCPR) issued their consensus guidelines for Acute Low Back Problems in Adults, they recommended chiropractic care based upon the research, but could only say too little data existed to make any recommendation about therapeutic massage. We have begun to remedy that situation with multiple studies on massage and both acute and chronic low back pain. We need to identify other areas - workplace stress or neck pain, perhaps - for which we will systematically build a body of research literature to really help us understand the potential of massage to treat these issues.
The third focus I would give to our efficacy studies is to think in terms of both primary and secondary prevention. Most of us believe that by alleviating stress, regular massage helps people avoid a whole host of conditions generated by stress. We need to design studies that can test that hypothesis. That is primary prevention. Secondary prevention means we need to conduct research that looks at the potential for massage to help people who are already diagnosed with pathologies; for instance, how to avoid a worsening of that condition.
Finally, I want to suggest efficacy studies based on what practices are best for various conditions. The field of therapeutic massage and bodywork is filled with name brand treatments, but the public finds this confusing. Most names tell little about the treatment and more about the person who named it (Hellerwork, Rolfing, Alexander Technique, etc.). We need, whenever possible, to move to generic descriptors for our work and then to be willing to see whether certain kinds of bodywork are better than others for certain conditions. Are Swedish massage, myofascial techniques and neuromuscular techniques equivalently effective in relation to migraine headaches? Is there some combination of framework and techniques that is optimal? Or does method not matter because the key is the relationship between client and practitioner? We should look at such questions because when the time comes to compare massage with usual medical care, surgery, acupuncture or Ayurveda, we want to make sure we are putting our best treatment forward. This search for best treatments will require the kind of courage, curiosity and collaboration discussed earlier, but will hopefully lead to greater use of massage and enhanced massage education.
The next 10 years will be exciting for massage and bodywork research. As a profession we will be finding our comfort with this new enterprise. Where we have spent much time in the past decade watching, hoping and praying, in the next decade we will learn how to take the reins and see that our research agenda is being pursued.
The watchwords of courage, curiosity and collaboration apply to us as individual practitioners as well. Demand of your continuing education providers they offer opportunities for you to learn the research literacy skills that will be offered to the next decade's students in their basic education. Read the literature, think about your own practice, the questions that arise from it and might prompt a study. When you have an idea, be willing to reach out to local resources. The college or hospital nearest you may well have folks with research skills willing to collaborate with you on a study you can name, but can't design. Let it be an exciting decade for you. Dr. Janet Kahn is both a practicing massage therapist and a senior partner in Integrative Consulting, an organizational and research consulting firm based in Burlington, Vt. She is also a member of the National Advisory Council for Complementary and Alternative Medicine at the National Institutes of Health, and president of Peace Village Projects, a non-profit organization providing trauma-relieving bodywork for children in war-torn areas. Reach her at firstname.lastname@example.org.Resources
1 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey. JAMA 1998; 280:1569-1575.
2 Cherkin D, et al, Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists and naturopathic physicians. Journal of the American Board of Family Practice, in press.