By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, December/January 2003.
Two years ago, researchers Patricia Sohn and Cynthia Loveland Cook surveyed nurse practitioners (NPs) in Missouri and Oregon to assess their knowledge and use of complementary and alternative medicine (CAM). The results of their study, published in a 2002 Journal of Advanced Nursing, revealed that while respondents appeared to embrace CAM on a large scale, a much smaller number actually based that acceptance on formal education.
Of 151 NPs completing the survey, 83 percent said they had recommended CAM to their patients, with 50 percent of those referrals being for massage. In contrast, only 24 percent of the study sample noted formal nursing education as the source of their knowledge for recommending CAM. Sixty-seven percent reported personal experience as a primary source of information, with professional journals, seminars and continuing education following behind. Authors stated, “In response to the first two research questions on the level and source of knowledge about CAM therapy, NPs reported minimal knowledge and did not rely on scientific evidence as their primary source of knowledge when incorporating these modalities into practice.” As noted by the authors, these findings confirm results of past studies in the nursing field in which CAM referrals were high, but formal knowledge was lacking.1
Substantial acceptance of CAM treatments by the general public has been documented in several studies conducted by David Eisenberg, M.D., director of the Consortial Center for Chiropractic Research, and colleagues. For example, their 1997 survey showed a 47 percent increase from 1990 in the number of people seeking treatment from CAM practitioners.2 These results were corroborated with a study researching long-term trends, which indicate that of those reporting CAM use at the beginning of the study, “nearly half continued to use them many years later.” The study concludes, “Use of CAM therapies by a large proportion of the study sample is the result of a secular trend that began at least a half century ago. This trend suggests a continuing demand for CAM therapies that will affect health care delivery for the foreseeable future.”3
The Responsibility of CAM in Nursing Care
The results of these surveys point to the importance of not only carrying out more CAM research, but putting this knowledge in the hands of those recommending it. It’s not good enough for medical staff to say, “Try this, it works.” As the NP researchers suggested, embracing CAM in nursing carries with it a responsibility not only for its inclusion in formal nursing curriculum, but also an effort to closely examine the current research literature and to build on that base. While the nursing profession is the only entity that can address its curriculum needs, there also exists the other side of the coin — responsibility for building the research database.
Studies have, in fact, been emerging from the nursing and medical field on a regular basis over the past few years, reflecting a wide diversity of CAM application in this area. The settings range from ambulance transport and surgery units to rehabilitative care, and have included a variety of massage and bodywork modalities. A study of general application of massage for relaxation and increasing cardiac parasympathetic activity was conducted by nursing researchers in England in an effort to show its relevancy to the nursing profession. Using myofascial trigger point therapy, the team succeeded in producing significant decreases in heart rate and blood pressure, and improving muscle tension and emotional state. Drawing on these findings published in the Journal of Advanced Nursing (Feb. 2002), authors suggested massage could be beneficial in several areas of nursing care, including recovery from myocardial infarction, hypertension and diabetics with autonomic neuropathy.4
Austrian researchers from the University of Vienna published results of a randomized, double-blind trial on the use of acupressure by paramedics during ambulance transport to reduce pain in minor trauma (Anesthesia and Analgesia, 2002). They surmised that as a noninvasive, non-drug treatment, acupressure could provide pain relief in those situations where paramedics are not allowed to administer pain relievers or conduct invasive procedures. Sixty trauma subjects were randomly assigned to three groups: “true point,” sham treatment or no acupressure treatment. Evaluation by an independent observer included recording of vital signs, as well as subjects’ responses to a visual analog scale (VAS) for pain and anxiety pre- and post-treatment. Those in the “true point” group reported a decrease in pain and anxiety, and were observed to have a lower heart rate than the sham and control groups, leading researchers to conclude that acupressure as an effective and easily-learned pain treatment can improve the quality of care in emergency medicine situations.5
According to researchers at the Yale University School of Medicine in New Haven, Conn., the use of alternative medicine prior to surgery has become a common phenomenon. In a survey of 857 presurgical patients, 32 percent reported having used CAM prior to their preoperative period, with the most common treatment or service being massage therapy at 15 percent. Subjects were also queried as to their willingness to use acupuncture as an anti-anxiety modality preoperatively, and 42 percent responded in the positive.6 These figures, published in the Journal of Alternative and Complementary Medicine (May/June 2002), are not surprising in light of previous studies of public acceptance of CAM, specifically those of Eisenberg’s study team.
Massage in Hospitals
Massage has been the focus of several recent studies conducted in hospital settings. A large teaching hospital in England was the site for investigation of foot massage and guided relaxation to promote psychological well-being in patients recovering from cardiac surgery. The study, published in the Journal of Advanced Nursing (Jan. 2002), sought to establish these modalities as effective, noninvasive techniques easily implemented by nursing staff for post-operative care. The small sample size (n=25)*, short time scale and nonblinding of the evaluator leave questions regarding methodological strength of this trial, but authors noted the results are promising. Overall, results in experimental groups did not reach statistical significance. However, foot massage produced statistically significant improvement in subjects’ calm scores on the VAS, and ratings for other psychological measurements (pain, tension, relaxation and rest) showed a larger improvement than for either the guided relaxation or control groups.7
In another hospital setting in South Korea, researchers tested the power of hand massage to decrease anxiety in patients having cataract surgery under local anesthesia. In addition to assessing anxiety by VAS, the study team also included physiological measurements. The experimental group (n=29) received hand massage five minutes prior to surgery and exhibited significant positive changes in anxiety, blood pressure and pulse rate after massage treatment and before the end of surgery. This group also had significantly decreased norepinephrine and epinephrine levels, while the control group (n=30) showed an increase in these and cortisol levels.8
A study team from New York Presbyterian Hospital’s integrative medicine program investigated the use of a 10-minute massage to decrease anxiety in patients undergoing cardiac catheterization (Alternative Therapies in Health and Medicine, 2002). In the experimental group (n=43), subjects were given an upper-body massage by a licensed massage therapist just prior to the medical procedure. Control subjects (n=35) were instructed to remain quietly at rest for 10 minutes in the presence of the therapist during pre-procedure waiting, in an environment that duplicated that of the massage group. While researchers claimed success in the feasibility of incorporating a brief massage into this pre-procedure time period and its acceptance by patients (the study’s primary purpose), outcome measures failed to show any significant statistical difference between the two groups regarding self-reported anxiety and pain, or in clinical measures of vital signs, cortisol levels and medication usage. These negative findings do not necessarily diminish the possibility of success in some future research effort. Massage was of short duration, and external factors — such as interruptions by medical staff — may have affected the results. Although the pilot was fraught with limitations, it does open the door for more thoughtfully-executed inquiry.9
In a somewhat limited trial from North Carolina, nursing researchers used slow stroke back massage on patients undergoing general, orthopedic and stroke rehabilitation. Publishing their results in Rehabilitation Nursing (Sept./Oct. 2001), the team stated the study’s positive results have “implications for improving nursing care in a rehabilitation setting.” Back rubs, they noted, were once an integral part of nursing care but have been displaced, in part, by time constraints on staff. Limitations in this quasi-experimental design included small sample size (n=24), lack of randomization, lack of gender or race mix, short time scale and use of the experimental group as their own controls. Despite these drawbacks, the positive responses from patients point to the value of inclusion of massage in nursing care. “On all occasions,” said the authors, “responses indicated that the intervention left (patients) feeling cared for, happy, physically relaxed, less anxious, closer to the nurse, calm and restful.”10
CAM for the Caregiver
Oncology is a field in which nurses find themselves in frequent contact with their patients’ caregivers. A group of oncology nurses in Nebraska, noting the stress inherent in these caregiving situations, conducted a study on the therapeutic effects of massage and Healing Touch for caregivers of patients undergoing stem cell transplants (Oncology Nursing Forum, 2002). In this quasi-experimental design, the 36 subjects were studied over a three-week period. The massage (n=13) and Healing Touch (n=10) groups received two 30-minute treatments weekly while the control group (n=13) received a 10-minute supportive visit along with usual nursing care. The massage group demonstrated significant improvement in scores for depression, anxiety and fatigue, with decrease in anxiety and depression scores also evident in the Healing Touch group. Encouraged by their findings, the authors advocated for the inclusion of this intervention as a means of providing support and decreasing feelings of stress in caregivers of oncology patients.11
As authors of the NP survey pointed out, a substantial proportion of their respondents recommending CAM are doing so without a foundation of knowledge in scientific inquiry. The above studies show the current diversity in attempts to document the benefits of CAM treatments in nursing and medical care. Although results are promising, some lack the strict methodological design to qualify under the “gold standard” of randomized controlled trials. With increasing public demand for CAM and the concomitant increase of its use within the medical setting, the need for quality research to prove or disprove benefits of these treatments must take precedence.