Somatic Research

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, October/November 2004.
Copyright 2004. Associated Bodywork and Massage Professionals. All rights reserved.

Once associated primarily with Indian gurus and counterculture enthusiasts, yoga has grown in popularity and is embraced by Americans from all walks of life. In a recent issue of Alternative Therapies in Health and Medicine (March/April 2004), researchers from Harvard Medical School reported statistics gleaned from David Eisenberg’s well-known 1998 survey on the use of complementary and alternative medicine (CAM) in the United States. This previously unpublished data reflects yoga use over the respondents’ lifetime, with an additional subset of data established for current yoga users. Results indicate that of the estimated 15 million adults who have used yoga at least once during their lifetime, approximately half did so in 1998. “Respondents who practiced yoga in 1998 used it both for wellness and common health conditions (especially back or neck problems), often with high degrees of perceived helpfulness,” the team writes.1

While the study does not tell us anything about the types of yoga being practiced or frequency of use, it does indicate this modality is a popular, low-cost alternative for those seeking good health. Underlying this is the assumption by many that yoga is safe and effective for a variety of purposes. And yet, as the authors point out, there is little in our Western scientific literature to support these claims. Trials have been, and continue to be, small, some with the usual methodological flaws of inadequate sample sizes and control group issues. The team’s urging for larger clinical studies is echoed in several related reports in this particular issue of Alternative Therapies in Health and Medicine.

In his introduction, the journal’s editor-in-chief, David Riley, M.D., points out the three basic ingredients of Hatha yoga, the most familiar form of practice in our country: Postures (asana), which strengthen the body and increase flexibility, breathing exercises (pranayama) for relaxation and focus, and meditation (dhyana), also for calming and focusing the mind. Included in our Western conjecture of physiological explanations for Hatha yoga’s effectiveness in the treatment of illness, he writes, are modulation of the autonomic nervous system tone, stimulation of the limbic system, and increased range of motion and relaxation response through activation of antagonistic neuromuscular systems.2

As the popularity of Hatha yoga has grown, so have individual styles and approaches. The positive aspect of this diversity is that those using yoga can seek out the method best suited to their needs and abilities. Riley recommends Iyengar and Viniyoga as “most appropriate for those with specific medical conditions.” Iyengar, which uses props for added support, emphasizes alignment, Viniyoga gives attention to “the individualized nature” of the practice.3 We begin our review of what’s new with the journal’s report on two randomized controlled trials (RCT) on chronic low back pain.

Lessons and Applications
Noting that Iyengar is the most commonly practiced style of Hatha yoga in the United States, the research team of Jacobs et al. from California’s Osher Center for Integrative Medicine applied this practice to subjects with chronic low back pain. Their hypothesis report includes not only some baseline randomization data but also reflections on the “unique challenges and particular issues that must be addressed with any rigorous research of the medical applications of Hatha yoga.”4

What exactly did they learn? Although small in sample size (52 total subjects), the study — defined as “a pilot, randomized, two-arm, open-label, wait-list controlled, clinical trial”5 — demonstrated some success in feasibility for a larger trial. One of the more progressive aspects was the inclusion of an eight-member panel of Iyengar experts, nationally and internationally known, each with more than 10 years of teaching experience. Their job was to design an experimental protocol that would produce the desired clinical results. Consensus was for 90-minute, semiweekly classes for 12 weeks, with home practice of 30-minute sessions, five times weekly. Specific asanas were included along with a semi-structured approach in which the individualized needs of each subject could be addressed in adherence to yoga tradition. Additionally, the instructors chosen for intervention represented a well-trained cadre, with a minimum of 10 years experience teaching yoga as well as experience working with clients with chronic back pain.6

The majority of massage research aside, it is not uncommon for CAM studies to be cited as flawed because of less than well-thought-out protocol or ambiguity (or other factors) related to training level of practitioners applying the experimental treatment. To take the lead from this team would seem to bode well for the success of larger clinical trials.

Recruitment of subjects was fairly successful, completed within three months, but the team experienced minor difficulties with adherence to the yoga routine. Addressing this factor, they suggest an introductory session for volunteers, highlighting theory and practice and emphasizing the personal commitment involved. Researchers also note the demands for allocation of staff to scheduling and implementing intervention far exceed those in conventional studies, such as pharmaceutical trials in which medication is dispensed and later evaluated.7 Yoga research requires an ongoing expenditure of time and energy, both on the part of subjects and the intervention team.

The team of Galantino et al., in a smaller pilot project, also focused on assessing protocol for application of yoga in treating chronic low back pain. The authors write, “The sample size of this pilot study was not intended for an efficacy analysis but rather to obtain an estimate of the effect size and variance necessary to plan a definitive study, to test and refine individual components of the yoga protocol and measurement tools.” However, results did suggest benefit for improvement in balance and flexibility as well as decreased depression.8

The 22 subjects were randomized equally to modified yoga-based intervention or a control group, with the yoga group receiving formal instruction twice weekly over six weeks and encouraged to continue daily practice at home. Subjects in the control group were instructed to maintain their regular routine and were wait-listed for a similar course of yoga instruction following completion of the study. Despite this incentive, the control group suffered attrition with six subjects dropping out.9 Incorporating other types of interventions into the design, such as movement or physical therapy, is suggested as a possible solution. Additionally, it was found that even with the yoga group reporting benefit, none continued the practice after study completion. The authors emphasize these issues be considered in planning larger scale studies.10

Based on their findings, the team recommends use of several measurements included in the study: Oswestry Disability Index, Functional Reach Test, and Sit and Reach Test. To this they would add pain and discomfort scales along with “an appropriate measurement of the yoga psychological aspect.” These measurements could provide more complete data related to the impact of yoga on functional and emotional well-being. While gleaning important lessons regarding suitable assessment tools, authors note a possible confounding factor of nonspecific effects. It’s feasible that the socialization and mutual support available to subjects meeting together as a yoga group could have impacted on their overall improvement.11

Similar to the Jacob study, Galantino’s team utilized a panel of experts to develop intervention protocol. Two Hatha yoga instructors with more than 10 years of experience were joined by a physical therapist specializing in spine treatment. With yoga postures adapted to the abilities of individual subjects, the protocol also included meditation/relaxation at the beginning and end of sessions. In addition to formal, biweekly classes over six weeks, participants were encouraged to practice one hour daily between sessions, within parameters of personal comfort.12 Both studies, while limited in statistical application, provide a solid base from which to expand into larger clinical trials.

Tidbits of Results
Data from several small exploratory studies and RCTs are also presented in the form of research letters and brief reports in the journal’s yoga-focused issue. Woolery et al., from the psychology department of University of California, Los Angeles, chose the Iyengar method for their study of effects on mild depression in young adults. Comparing a wait-list control group (n=15) to yoga participants (n=13), the team combined self-report measures with cortisol samples to substantiate benefits. The yoga group met twice weekly, over five weeks, for a one-hour session featuring postures recommended to alleviate depression. Attrition was again a problem, with three yoga and two control subjects dropping out despite the incentive of a $30 gift certificate for participation. A significant reduction in depression was found in the yoga group as compared to control, with this benefit evident by mid-course and continuing to completion. However, the team is cautious with interpretation, noting methodological problems and that various aspects of class participation, aside from the actual practice, could have impacted enhanced mood.13

McIver et al. conducted a one-group, pretest/post-test design with 20 residents of a drug/alcohol rehabilitation center to determine yoga’s influence on a desire to quit smoking. Subjects participated in once-weekly, hour-long sessions combining simple yoga stretches and breath awareness, over a period of five weeks. Positive results included one person ceasing smoking entirely, with 30 percent of participants noting a shift toward a desire to quit.14 Another preliminary study by DeMayo et al. involved participation of 23 patients with post-polio syndrome in a yoga retreat, continuing with 12 weeks of follow-up home practice aided by video instruction. As an investigative beginning for developing longitudinal data collection on the application of Hatha yoga in ongoing care and education, the project’s results were positive. Data collected at both retreats’ end and completion of the home practice period indicated significant improvement in measurements of weakness, pain, and self-efficacy, as well as two of three fatigue scales, with the bonus that patients were actively involved in their self-care.15

Adding to this fund of newsworthy tidbits are some recent postings on the PubMed website, a National Library of Medicine database of journal citations. In the Journal of Clinical Psychology (June 2004), a psychology team reports benefit of a yoga-meditation program for dementia caregivers. Results of the small (n=12) pilot study indicated significant reduction of depression and anxiety in the caregivers, along with subjects’ reports of improvement in physical and emotional function.16Reporting in Respirology (March 2004), researchers at Vivekananda Yoga Research Foundation in Bangalore, India, investigated yoga as a complementary therapy for patients with pulmonary tuberculosis. In this RCT, subjects were randomized to yoga (n=25) and breath awareness practice (n=23) for one-hour sessions, six times per week over a two-month period. Significant emphasis was placed on laboratory measurements. Results were more dramatic for the yoga group, with improved infection levels, weight gain, reduced symptoms, and improvement in chest X-ray and pulmonary function tests.17

It’s important to keep in mind the majority of these results are preliminary, with most studies serving as precursors to development of larger, more solid RCTs. And as Riley cautions, not all types of yoga are applicable to specific medical conditions, and some, such as Bikram with its emphasis on heat, would be contraindicated for certain patients.18 As results come in and knowledge of application becomes more refined, yoga moves gradually and purposefully — like its asanas — toward confirming its value in integrative medicine.

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.

References
1 Saper RB et al. Prevalence and patterns of adult yoga use in the United States: results of a national survey. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):44,48.
2 Riley D. Hatha yoga and the treatment of illness. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):20.
3 Ibid., 21.
4 Jacobs BP et al. Feasibility of conducting a clinical trial on Hatha yoga for chronic low back pain: methodological lessons. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):80.
5 Ibid.
6 Ibid., 81.
7 Ibid., 83.
8 Galantino ML et al. The impact of modified Hatha yoga on chronic low back pain: a pilot study. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):58.
9 Ibid.
10 Ibid., 59.
11 Ibid.
12 Ibid.
13 Woolery A et al. A yoga intervention for young adults with symptoms of depression. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):60-2.
14 McIver S et al. The impact of Hatha yoga on smoking behavior. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):22-3.
15 DeMayo W et al. Hatha yoga and meditation in patients with post-polio syndrome. Alternative Therapies in Health and Medicine 2004 Mar-Apr,10(2):24-5.
16 Waelde LC et al. A pilot study of a yoga and meditation intervention for dementia caregiver stress. Journal of Clinical Psychology 2004 Jun,60(6):677-87.
17 Visweswaraiah NK and Telles S. Randomized trial of yoga as a complementary therapy for pulmonary tuberculosis. Respirology 2004 Mar,9(1):96-101.
18 Riley, 21.

A Meta-Analysis of Massage Therapy Studies

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, June/July 2004.
Copyright 2004. Associated Bodywork and Massage Professionals. All rights reserved.

Practitioners and clients espouse the strengths of massage therapy. But what happens when massage studies are subjected to a rigorous meta-analysis? Are the benefits confirmed?

A University of Illinois research team decided to find out. The fact that they were psychologists deserves a notation. It seems massage may offer benefits similar to psychotherapy when it comes to decreasing anxiety and depression, an exciting find says Christopher Moyer, whose research recently appeared in Psychological Bulletin (January 2004). But before we begin to analyze the study, let’s make it clear Moyer’s findings do not suggest the substitution of massage, as a stand-alone modality, in place of professional psychological or medical treatment for these conditions. “We may find it is a good complement for (treatment of) depression,” he says, especially in combination with other forms of care.

As a competitive cyclist, Moyer appreciated the value of massage in training, and this, combined with his work as a graduate student in psychology, sparked an interest in examining the effects of massage therapy. A literature review revealed that of those meta-analyses on record, none had “quantitatively reviewed the range of commonly reported MT [massage therapy] effects in physically mature individuals.”1

The meta-analysis by Moyer et al. is the broadest in scope of its kind. “We were hoping to fill a niche in the research,” he says, “and see if some of the claims made in individual studies would hold up. In general, they did, with a few exceptions.” That such large effects on depression and trait anxiety were substantiated “gives us a whole new way to look at and think about the treatment.”

In addition to evaluating benefits commonly reported in massage research, the team evaluated the impact of specific moderators, such as therapist training and minutes of therapy application. As a psychologist, Moyer was especially interested in commonalities between massage and psychotherapy. In order to make this comparison, the team eliminated studies using subjects too young for verbal interchange and/or understanding of an empathic relationship. Three other criteria were set for inclusion: use of between-groups design (meaning comparison of massage with one or more non-massage control groups), randomization, and sufficient data to generate a between-groups effect on at least one dependent variable.2

Utilizing the definition of massage therapy as “the manual manipulation of soft tissue intended to promote health and well-being,”3 the team identified 144 studies through a literature review. Only 37 met the inclusion criteria. These represented a total of 1,802 subjects, of which 795 were massage recipients. Comparison groups were categorized into wait-list subjects to include standard care, resting, reading, or work break (49 percent), and those receiving another active therapy or placebo treatment (51 percent).4

Studying the Studies
With the premise that massage therapy effects are both physiological and psychological in nature, the team makes a distinction between single-dose and multiple-dose effects. Although pointing out these terms are not commonly used in research, they note a similarity to the “short-term” and “long-term” designation from the Touch Research Institute (TRI) of Miami, Fla.5

Single-dose effects are those that affect transient states: state anxiety, negative mood, pain, cortisol levels, blood pressure, and heart rate. Multiple-dose effects involve those “variables that are typically considered to be more enduring,” or influenced by a more prolonged treatment course as opposed to single application. These include trait anxiety, depression, and delayed assessment of pain.6

Of the nine variables (effects) investigated, the strongest findings were for depression and trait anxiety, leading researchers to state, “Considered together, these results indicate that MT may have an effect similar to that of psychotherapy.” In terms of statistical numbers, “The average MT participant experienced a reduction of trait anxiety that was greater than 77 percent of comparison group participants,” and for depression the reduction was greater than 73 percent of comparison group subjects, closely resembling meta-analysis findings for absolute efficacy of psychotherapy.7

Three of the single-dose effects reached statistical significance. For state anxiety, reduction was greater than 64 percent of participants in comparison groups, with similar findings for blood pressure and heart rate (respectively, reductions greater than 60 percent and 66 percent of subjects in comparison groups). Although a number of individual TRI studies have documented cortisol decrease, this effect did not reach significance.8 According to Moyer, this is not to say there was no effect, but within this particular analysis, the size of the effect in comparison with other groups was not remarkable.

In contrast to the lack of significant finding for effect on immediate assessment of pain, delayed assessment of pain was a significant finding. For subjects assessed several days or weeks after their course of massage treatment, levels of pain “were lower, on average, than 62 percent of comparison group participants.”9

Of the six potentially moderating variables (minutes of therapy, mean age, gender, type of comparison group, therapist training, and laboratory effect), none were determined to be significant. These results were not surprising to the team, with the exception of minutes of therapy and comparison group. The team had sought to “determine whether there are minimum or optimum dosages of MT,” and had also anticipated finding a greater effect in comparison to no treatment than to active/placebo groups.10

While the findings did not support a relationship between minutes of therapy and effect, the authors note this may be due to the insufficient statistical power of the studies within hand, as it would seem logical that longer doses of an effective treatment would produce an even more potent effect. “Nevertheless,” the team writes, “it must be concluded that this moderator may not be as important as we predicted, and that even short sessions of MT can be effective.” Although no studies to date have examined effects of session length, incorporating two levels of this variable in future research could “more powerfully” determine its influence.11

Within the studies measuring anxiety and depression, none incorporated a design of combining wait-list and active/placebo groups within the same study. The influence of comparison groups may be made more evident by incorporating this type of design into research on anxiety and depression,12 but Moyer places more importance on examining how massage brings about these effects.

In the studies cited, qualifications of those applying massage were not specified beyond identification as trained practitioner (65 percent), minimally trained person (22 percent), and no indication of level of training (14 percent). The negative finding for moderating influence, authors write, should not be taken to mean training is inconsequential, as it was not feasible with the information provided to determine the level of expertise. But they do point out that these positive findings indicate even “laypersons provided with some training can provide beneficial MT, information that may be valuable to researchers working with limited resources.”13

TRI has been a leader in massage research, producing a large proportion of the studies in existence to date. But despite the fact that TRI studies constituted 32 percent of those analyzed, there was no evidence of this single laboratory as a moderating influence.14

Puzzles and Pieces of Data
Identifying the explanatory mechanisms behind the effects of massage, the authors write, has received little emphasis in previous massage research. In this review, they attempt to reconcile their findings with those theories predominant in the literature. Gate control theory of pain reduction, the most frequently cited theory, was least supported by the analysis, as substantiated by the results on immediate assessment of pain. This theory holds that massage produces an analgesic effect by supplying sufficient pressure to block the gate, so to speak, before painful stimuli can be experienced and processed by the brain.15

In contrast, the authors state the positive findings for delayed assessment of pain may be more related to the theory that massage reduces pain through facilitation of restorative sleep, although “without data on sleep patterns, this possibility is only conjecture.” Previous research has suggested a connection between sleep deprivation and increases in pain.16

Massage is thought, by some, to bring about a shift in the autonomic nervous system from a sympathetic response, or heightened sense of alert, to a parasympathetic response, or state of calm and relaxation. The theory of promotion of parasympathetic activity is bolstered, authors write, by the results on decreased blood pressure and heart rate. But the fact that no significant effect was found for cortisol reduction (an expected presence in a parasympathetic response) adds inconsistency to results. As for theories of mechanical effects and influence on body chemistry, neither was supported by this particular meta-analysis.17

While these mixed results leave us with no clear-cut answers regarding the more popular theories, the team holds open the door, suggesting, “MT’s effect on state anxiety, trait anxiety, and depression may come about as a result of MT’s influence on body chemistry, whereas the ability of a course of MT treatment to provide lasting pain relief may result from the mechanical promotion of circulation and breakdown of adhesions, or from improved sleep promoted by the treatment.”18

It is important to keep in mind that the intent of a meta-analysis is to summarize, or as Moyer says, “To see where we are so far.” That one particular theory is not substantiated by these results does not mean it has been disproved, he notes. For example, further research on the gate theory, with a specified condition and treatment, may indeed provide a supportive body of work for this explanation. By addressing these issues within the context of the available data, the meta-analysis not only allows us to see where we are thus far, but also helps us plot a future path.

Common-Factors Model
We now turn to the issue of interpersonal contact or attention. While this receives some interest in studies, the authors write, it is more likely to be considered “a nuisance variable, and comparison treatments are selected in such a way that different groups receive the same amount of attention.”19 But what if interpersonal attention itself is part and parcel of the effect?

Another way to look at the effects of massage, the authors propose, is through the perspective of psychotherapy’s common-factors model. In this model, more importance is given to factors such as client expectations, positive regard and warmth on the part of the therapist, and the alliance developed between client and therapist, rather than the specific modality applied. Likewise, benefits from massage may be related to similar elements, including “therapist’s personal characteristics and expectations.”20

Pointing to the size of effects on anxiety and depression, lack of influence of training level as a moderator, and commonalities between psychotherapy and massage in the structure of therapy sessions, the team writes, “Several of the findings in the present study are consistent with such a model applied to MT.” This suggests the similarities between psychotherapy and massage deserve consideration, especially in future research design. “Different questions need to be asked, different moderators tested, and different comparisons made.”21

The team highlights a host of issues to be addressed, especially regarding the process and intricacies of interpersonal contact, should massage research take this route. Comparison groups are another conundrum. “When a common-factors model is applied to MT,” the authors write, “the notion that a comparison treatment such as progressive muscle relaxation controls for attention is incorrect.” While there is no difference in quantity of attention, the quality of attention is not identical.22

Lest we be left with the impression that massage effects might be considered as purely psychological, the team clarifies by stating, “Clearly MT is at least partially a physical therapy, and some of its benefits almost certainly occur through physiological mechanisms. In fact, one of the most interesting aspects of MT is that it may deliver benefit in multiple ways, specific ingredients and common factors may each play a role, with each being differentially important depending on the desired effect.”23 And herein lies a crucial element of massage therapy research — not just what is happening, but how and why.

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.

References
1 ?Moyer CA et al. A meta-analysis of massage therapy research.
Psychological Bulletin 2004 Jan,130(1): 4.
2 Ibid., 8.
3 Ibid., 4.
4 Ibid., 4, 11-12.
5 Ibid., 6.
6 Ibid.
7 Ibid., 14.
8 Ibid., 10-13.
9 Ibid., 13-14.
10 Ibid., 7, 14.
11 Ibid., 14.
12 Ibid.
13 Ibid., 12, 14.
14 Ibid., 14.
15 Ibid., 4-5, 13.
16 Ibid., 5, 13-14.
17 Ibid., 5, 10-14.
18 Ibid., 14.
19 Ibid., 5.
20 Ibid., 14-15.
21 Ibid., 15.
22 Ibid.
23 Ibid.

Clinically Speaking: Research Trials and Alternative Therapies

By Shirley Vanderbilt

Originally published in Massage & Bodywork magazine, October/November 2002.

Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

In review after review of clinical trials on complementary and alternative medicine (CAM), researchers have informed therapists that many of the studies out there are not of high enough quality to prove benefits of the modalities being examined. Furthermore, there’s an inadequate number of trials to move CAM speedily along on the road to universal acceptance. What’s the problem? And why do we need these trials anyway?

This issue emerged in our Aug./Sept. 2002 Somatic Research column on rheumatology (”Massage and other Natural Wonders”) in which Dr. Edzard Ernst, professor and director of the department of complementary medicine at University of Exeter’s post-graduate medical school in England, was quoted as saying, “Generally speaking, complementary and alternative medicine is grossly under-researched. Because of the popularity of complementary and alternative medicine, adequately defining risk-benefit relationships is an urgent matter.”1 His conclusions are typical of those found in current study reviews.

Randomized controlled trials (RCTs) are considered the “gold standard” of clinical research. As to the element of quality, said Ernst in a recent e-mail interview from his office, a high quality trial is one that “minimizes selection bias which otherwise can distort results completely.” While some CAM studies are carefully planned out and do meet RCT criteria, there seems to be a plethora of studies in which methodological weaknesses are the norm.

I recently spoke with Dr. Maria Hernandez-Reif of the Touch Research Institute (TRI) in Miami, Fla., about the current status of massage therapy research. TRI researchers have been at the forefront in providing sound clinical research in the field and have added significantly to our current body of knowledge on the effects of massage.

“I think it is very important for massage therapy research to follow the guidelines of other quality scientific research,” said Hernandez-Reif, “which includes having at least a comparison group, randomly assigning participants to the groups and having outcome measures. Think carefully about why you’re doing the particular study, have solid questions you would like to answer at the end of the study and have the controls.”

Does it Fit?
One might wonder if some methodological weaknesses in CAM research could be related to the fact this is a holistic field in which many treatments are individualized. For instance, we have previously reported on research of flower essences for depression. This approach necessarily demands a treatment protocol designed to fit each individual subject. How can this type of research fulfill the criteria of group protocol and controls? Are we trying to force a square peg in the round hole of standards originally established for allopathic medicine?

Dr. Jonathan Berman, director of the Office of Clinical and Regulatory Affairs at the National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH) had this to say: “Standard, medically-oriented clinical trials have two fundamental requirements: therapeutic materials and procedures that can be reproduced, and trials that are conducted in a reproducible manner. The first requirement means doctors and patients know what the patients are getting in the trial and can give similar treatment to future patients. The second requirement means that if the results of the trial are favorable, future patients are likely to have favorable outcomes,” he said.

“Some CAM therapeutic materials, such as vitamins and acupuncture needles, can easily be made in a reproducible manner. Others, such as plant extracts, are more complex and more difficult to make reproducibly. Nevertheless, even the latter can probably be made so that variation is acceptable. People are people, whether they are receiving CAM or conventional therapies, and clinical trials involving CAM therapies can be performed just as well as clinical trials involving other products.

“One of the arts of clinical trials,” he continued, “is designing them to address issues that are meaningful to patients in everyday use. As already mentioned, complex botanicals can be reproducibly made and studied. But if everyday use of the therapy requires highly individualized treatments, it may or may not be possible to design formal studies of those treatments.”

Ernst takes a slightly different stance. “The problems we encounter in CAM are seen also in other fields, e.g., surgery, psychotherapy and occupational therapy. Individualization is no real obstacle.” As an example, he emphasized “the many RCTs of homeopathy that have incorporated this principle.”

Researchers at TRI have consistently adhered to the RCT criteria for randomization and controls. “Regardless of what treatment you are studying,” said Hernandez-Reif, “the study has to follow the same rigors of clinical trials.” Even in an individualized flower essence study, she said, it is necessary to include a control group receiving a dummy flower essence. “I think that’s the primary problem — studies are lacking control groups. You also need to have other types of measures. In massage therapy, subjects feel obligated to tell you their pain went from (a rating of) 8 to 4, and they know they’re expected to feel better. There might be some bias on the part of the participant.”

To counter the possible bias of self-reporting, TRI researchers try to incorporate objective measures in their studies, such as physiological (heart rate, blood pressure), biochemical (stress hormones) or immunological change in immune systems (natural killer cells). By collecting saliva or urine samples and measuring biochemistry, she noted, researchers “might be able to document better or complement self-report measures.”

“More Research Needed”
This recurring phrase, found in the conclusions section of so many meta-analyses, points to the complicated and sometimes frustrating task of amassing sufficient data to prove benefits of a CAM therapy. Hernandez-Reif explained the process: “In meta-analysis, researchers go through the literature and find articles published on a particular subject. They will be trying to collapse across a number of studies to see whether, if you combine them all, you have an effect.” A specific criteria is established which generally includes randomization, controls, having sufficient sample size or having enough participants in a study, she said.

“Typically the studies that have been published were not rigorously done to the point where they would meet the criteria,” she said. Thus, the reviewers may end up with only five or six sound, scientific studies meeting their criteria. At this point, they “take the means and standard deviations (SD) from those studies, if those are not present, then the studies are out. The researchers collapse across the good studies and perform a statistic that comes up with an effect size. The power of that effect is based on mean and standard deviations.”

Mean represents the average score, while the SD represents variability within scores. For example, the massage therapy and control groups are both asked for a self-reported rating (such as degree of discomfort or pain) on the first day of the study. Individual scores are added in each group and divided by the group number, a mean score is the result. The SD is then computed in this way, said Hernandez-Reif. “How much does each individual number differ from the mean? If the SD is high, that means groups are not very similar within. In order for you to understand the group dynamics, you have to study the SD. When the SD is as high or higher than the mean, scores are spread out all over the place. You are looking for consistency,” she said.

“When doing a meta-analysis,” Hernandez-Reif explained, “you look at the mean and SD of solid studies, then do a bigger analysis across all the studies.” Researchers also look at other types of analysis, such as effect size. “Meta-analysis typically uses a lot of statistics. From the effect size, they can tell whether effects are small, medium or large.” When effects are small, more research is needed.

Hernandez-Reif emphasized the importance of conducting a good clinical study with groups that are comparable. If, after treatment, “the mean goes from 8 to 4, but the SD is 5 or 6, your effect might not be strong enough.” In this case, there is too much variability in the scores, the SD is too high. “You also have to compare findings of the massage group to the control group. Sometimes it’s just a placebo effect from participating in a study. They report less pain and are less anxious. You have to have a strong effect.”

The Road to Success
The source of this lack of an appropriate number of high-quality CAM trials is not only limited to inadequate efforts on the part of some researchers, but also can be found within the existing research environment. While Ernst stated there is no easy answer, as failings are so diverse, he noted, “In principle, the problem, in my view, is lack of funds, lack of expertise and lack of rigor.” Berman’s comments further expand this exploration of the root cause. “Demonstration that any therapy (CAM or non-CAM) is effective and safe involves two steps. In Step 1, a therapy is selected for scientific investigation. Since there are limited resources, choices must be made among many therapies.2 For some CAM therapies, there is already widespread use, but little if any systematically collected data is available,” said Berman.

“In Step 2, a therapy that has appeared to be effective and safe in the first stages of investigation is formally tested in large numbers of patients using scientifically rigorous procedures. It is only through these large, very expensive (often $20 million or more), and very time-consuming (easily five years or longer) studies that the clinical value of a therapy can be scientifically proven. In the CAM field, I see us at Step 1. One might say the present use of many therapies has suggested they appear to be effective and safe. However, more remains to be learned about them through formal studies.”

So we return once again to the problem of “more research needed.” What we have learned is the importance of adhering to RCT protocol - providing randomization and controls, and utilizing appropriate data analysis. Funding is, of course, a whole other matter. But as results come in and funding sources envision the potential of generating income from proven benefits, perhaps this hurdle may also be overcome.

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.

References
1. Ernst, E., “Complementary and alternative medicine for pain management in rheumatic disease,” Current Opinion in Rheumatology 14, 1 (Jan. 2002): 58.
2. The procedure for selection by NCCAM of therapies for clinical study is detailed in the Five-Year Strategic Plan, located at http://nccam.nih.gov/about/plans/fiveyear/index.htm.

Survey Reveals Consumer Trends

Originally published in Massage & Bodywork magazine, April/May 2005.
Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.

Massage therapists elicit an impressive level of goodwill and increasing popularity among American adults. Fully two out of five adults have visited a massage therapist and 12 percent received at least one massage in 2004, putting massage on par with consumer use of chiropractic and physical therapy services.

These results come from a Jan. 3 to 11, 2005, national telephone survey of a representative sample of 1,027 adults aged 21 and older. The study was commissioned by Associated Bodywork & Massage Professionals (ABMP) in Evergreen, Colo., and conducted by Harstad Strategic Research, Inc., a national public opinion research firm in Boulder, Colo.

Experiencing a massage therapy session is its own best advertisement for changing perceptions,” says Bob Benson, president of ABMP. According to the survey, receiving a massage promotes favorable regard of its value: 96 percent of those who received at least one massage in 2004 have favorable feelings toward massage therapists as compared to 72 percent of previous users and 32 percent of those who have never had a massage.

More impressive than Americans’ lopsidedly favorable feelings is their trend in feelings toward massage therapists over the past decade. A 45 percent plurality say their feelings have changed for the better over the past 10 years, 3 percent say for the worse, 40 percent say no difference, and 12 percent are not sure. This 15-to-1 better-to-worse feelings ratio is promising confirmation of growing acceptance and goodwill toward massage therapists.

“What is striking about the overall survey results is that there are very few detractors, few negative expressions about massage,” Benson says. Most of those who haven’t yet received a massage simply haven’t felt a need for it. According to the survey, 51 percent have favorable feelings about massage therapists versus just 6 percent with unfavorable feelings.

“The massage therapy profession has worked to legitimize its standing among complementary therapies, distancing itself from out-dated, negative stereotypes. Massage now generally enjoys a receptive, welcoming climate,” Benson says. Compared to the 12 percent of adults who reported visiting a massage therapist in 2004, the survey found that 13 percent went to a chiropractor and 10 percent to a physical therapist. Of those who received massage in 2004, their average number of visits was nine — quite similar to frequency numbers for individuals accessing chiropractic (10) and physical therapy (11) services. “What’s especially impressive about these comparisons,” Benson says, “is that most chiropractic and physical therapy treatments are reimbursed by health insurance while more than 90 percent of massage therapy sessions are paid out of the client’s own pocket.”

Massage therapists are especially popular among adults under age 50 (58 percent favorable) and women (also 58 percent favorable). Indeed, those favorably-disposed include two-thirds of women under age 45 and two-thirds of women with at least two years of college. Those least favorable and least familiar with massage therapists are aged 65-plus (37 percent favorable).

The market strength among younger adults bodes well for massage therapists as these Americans age. “The combination of these baby boomers reaching peak earning years just as their bodies begin to creak suggests that massage demand will only grow,” Benson says. For the amount of stress relief, restoration, and relief of muscular soreness massage provides, that service remains a relative bargain. The survey found the median price nationally for a one-hour massage is just $60. Prices vary regionally and by setting, charges in spa settings tend to be higher than elsewhere.

The finding of 12 percent of adults visiting a massage therapist has a statistical margin of error of plus-or-minus 2 percent, at the 95 percent confidence level. In other words, the chances are 95 percent that the response about utilization of massage in 2004 would be between 10 percent and 14 percent if all adults in telephone-equipped households were interviewed. This 12 percent finding contrasts with two recent studies of the same behavior that produced widely divergent estimates. An August 2004 Opinion Research Corporation study commissioned by the American Massage Therapy Association estimated 21 percent received a massage that year while a 2002 National Institutes of Health study found only 5 percent of adults received a massage for health reasons during the prior 12 months.

“A lot has to do with how the questions are framed and phrased,” says Paul Harstad, president of Harstad Strategic Research, Inc. “The NIH survey asked about massage received ‘for your own health,’ which phrasing may have limited affirmative answers since many people receive a massage for relaxation or enjoyment and may not perceive it as for their health per se. The Opinion Research Corporation survey solely asked about receiving a massage. It isn’t clear whether that survey distinguished between massage work provided by a massage therapist versus other healthcare professionals, whose inclusion would drive up the affirmative response rate.

“In the 2005 telephone survey conducted for ABMP, visitation with massage therapists was posed in a battery among other healthcare providers — which approach often reduces any possible respondent resistance or inclination to provide socially acceptable answers. Respondents were not told at the outset of the interview who commissioned the survey, nor could they have had any clue at the time of this early question that the survey would focus more on massage therapy. To help minimize possible confusion between physical therapists and massage therapists, respondents were always asked about massage therapists after physical therapists,” Harstad says.

Why Does Massage Benefit the Body?

By Ross Turchaninov, M.D., Ph.D.

Originally published in Massage & Bodywork magazine, December/January 2001. Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

As we discussed in the first part of this article, the mechanical stimuli applied to the place of injuries are able to increase collagen production by the stimulation of fibroblasts’ functions and by attracting new cells from the neighboring areas. However, increased collagen production alone is not enough to heal the injured site. The correct orientation of collagen fibers is an equally important element. Without the proper orientation of collagen fibers, an increase in collagen production is useless. Are mechanical stimuli in the form of massage strokes somehow able to affect this process as well? We should answer this question positively. Numerous scientific reports support this conclusion. However, we should start this discussion with a quick review of the piezoelectrical phenomenon because of its direct connection to this matter.

Phenomenon of Piezoelectricity
Piezoelectricity is the ability of inorganic and organic substances to generate electrical potentials in response to pure mechanical deformation without any external electrical or magnetic field. The effect of piezoelectricity was discovered in inorganic crystals by the Curie brothers in 1880 (Williams, 1974). It was also found that the application of an external electrical field to these crystals causes their mechanical deformation as well. For several decades the piezoelectric effect was considered a feature of asymmetric inorganic crystals only. However, in 1957, Japanese scientists Fukada and Yasuda detected the existence of the piezoelectric effect in the human bone. This effect was detected as electrical potentials registered in the bone during the application of mechanical stimuli, which cause bone deformation.

Let’s discuss this. At the moment pressure is applied, the negative potentials can be registered on the compressed side of the bone because of displaced electrons inside the specimen. The electrical activity returns to zero as soon as there is no further increase in pressure, but already achieved pressure is still maintained. However, at the moment pressure is released and bone returns to its previous shape, the smaller positive potential is registered as well. This positive charge is detected on the stretched side of the bone specimen and indicates the return of electrons to their places. Thus, mechanical deformation of bone (e.g. during regular walking) produces the bi-polar electrical potentials.

The first attempts to explain the piezoelectric properties of bone reasonably concluded that the inorganic part of the bone is responsible for this effect. This assumption seemed correct because the inorganic part of the bone is arranged in crystals as well. These crystals are called apatite and consist of calcium and phosphorus. The inorganic part of the bone makes it hard.

Demineralization of the bone specimen leaves only collagen fibers and the bone becomes soft and elastic like tendons. However, in the early 1960s two American scientists, R.0. Becker, M.D., and C.A.L. Basset, M.D., conducted a series of brilliant electro-physiological experiments which proved the collagen in bone is mostly responsible for piezoelectricity. The collagen molecules produced the negative potential during the bone’s deformation, compared to the apatite crystals which exhibited the positive charge. Now we know that negative potentials are responsible for tissues’ proliferation — i.e. growth. Positive potentials have the opposite effect, because they inhibit any proliferation of the tissues. This discovery had enormous impact on medicine, especially on orthopedy. Today, the acceleration of fracture healing and stimulation of callus formation in cases of nonunion fractures by external and internal electrical devices is a common medical procedure.

After Becker and Basset published their results, scientists in different countries started to examine the piezoelectric properties of other biological materials. The results were astonishing. It was found that keratin (Fukada, 1982), elastine of the skin (Shamos and Lavine, 1967, Basset, 1971) and ligaments (Fukada and Hara, 1969), collagen in the tendon (Anderson and Eriksson, 1968), actine and myosin in the skeletal muscles (Fukada and Ueda, 1970), hyaluronic acid (Barrett, 1975) and even DNA molecules (Fukada, 1982) and some individual amino acids (Vasilesku, et al., 1970, Furukawa and Fukada, 1976) exhibited piezoelectric properties as well. Gross et al. (1983) considered the possibility of piezoelectricity playing a role in the conduction of nervous impulses along the nerve. All of this allowed Shamos and Lavine (1967) to conclude “piezoelectricity is a property of most, if not all, tissues in the plant and animal kingdoms.”

In 1977, B. Lipinski, in Medical Hypotheses, formulated the theory which links the therapeutic effects of osteopathic medicine with soft tissue manipulations, acupuncture, hatha yoga and the action of negatively charged air ions with piezoelectrical properties of the biological tissues. According to the author’s hypothesis, proteins, nucleic acids and mucopolysaccharides, which compose all tissues of the human body, exhibit piezoelectric properties. Thus, they are capable of transducing a mechanical energy into an electric energy. The author assumed stimulation of specific areas on the surface of the body produces the electrical current. This piezoelectrically induced current activates the healing processes in the stimulated area, and/or is able to flow “toward the internal organs along the semiconductive channels of biological macromolecules.” Thus, this mechanically induced electrical energy has great regulatory effect on the cellular and molecular levels.

Implications in Massage
What is the theoretical and practical meaning of these findings for massage therapy? They are crucially important for understanding the therapeutic mechanism of massage treatment. The collagen in the bone is absolutely identical to the collagen in any other tissue. Thus, piezoelectrical properties of collagen are similar throughout the body. Collagen is the more important and abundant protein in the human body, and its piezoelectric properties have been sufficiently examined. Let’s look at the local electrophysiological response of collagen molecules to the external application of mechanical stimuli in the form of massage strokes.

A molecule of collagen is a strong dipole — i.e. it has two oppositely charged ends. The head has a positive charge and the tail has a negative charge. However, the overall charge of a collagen molecule is positive. Collagen molecules unite together to form different anatomical structures (tendon, fascia, aponeurosis, bone, etc.) and, consequently, these structures exhibit the fixed electrical charge.

Massage therapy is a form of delivery of mechanical stimuli to the soft tissues, and two major electrophysiological mechanisms will be triggered in the massage area: piezoelectric phenomenon and streaming potentials.

Piezoelectric Phenomenon
External mechanical stimuli deform the collagen molecules, causing the piezoelectric effect and changes in the fixed charge of collagen molecules. This process can be seen as increasing the negative fixed charge of collagen molecules or decreasing their positive fixed charge. Both descriptions are equally correct. Thus, the mechanical deformation of collagen during the massage treatment is responsible for an increase in the negative charge in the soft tissues. These negative potentials have strong proliferative impact on the tissues in the massaged area.

As Shamos and Lavine showed in 1967, human skin from the forearm exhibited piezoelectric properties under direct mechanical stimulation. Collagen was mostly responsible for this phenomenon, however, the piezoelectric properties of elastine and keratin also played a role. The authors also pointed out the largest magnitude of piezoelectric effect was registered when mechanical stimuli were applied at an angle of 45 degrees to the main orientation of collagen fibrils. This is an important practical outcome, which can be used by practitioners to optimize the therapeutic results of massage treatment. The main orientation of collagen fibers can be easily detected in the skin according to the lines of cleavage and in other soft tissues according to their anatomical structure.

Streaming potentials
As I mentioned above, the molecule of collagen exhibits a fixed electrical charge. The extracellular collagen is surrounded by extracellular fluid, which is extremely movable and carries a huge number of different molecules, anions, cations and dipoles with different electrical charges (e.g. Na, Cl, K amino acids, etc.). When they pass by the molecule of collagen with its fixed electrical charge, the difference of electric potentials creates an electric field (see Fig. 2A). These electrical potentials are called streaming potentials (Basset, 1971, Lee, et al. 1979, Guzelsu, 1982). The magnitude of these potentials is mostly dependent on the pH of the soft tissue (Gross and Williams, 1982). The streaming potentials were originally detected inside the blood vessels when charged particles passed with the flow of blood near the endothelial cells, which form vascular walls and also have a fixed charge. Later, however, the streaming potentials were also detected in the soft tissues, e.g. in the fascia and tendon (Anderson and Eriksson, 1968, Basset, 1971). Gross et al. (1983) considered the transmembrane streaming potentials a result of fluctuations in the hydrostatic pressure — as one of the possible mechanisms of conductance of impulses along the nerve.

Massage strokes deliver interruptive mechanical stimulation to the soft tissues and cause a fluctuation of interstitial pressure in the extracellular space. Massage increases the interstitial pressure and stimulates the flow of interstitial fluid, which carries the charged particles around the structures with fixed electrical charges — collagen, cellular membranes, etc. As a result, a stronger electrical field develops between these structures and charged particles, which move with the flow of interstitial fluid caused by the fluctuation of interstitial pressure during massage strokes. Thus, an additional amount of stimulating electrical energy is produced in the massaged area.

Both of these events, in equal degree, are responsible for the collagen deposit at the injured site and, more important, the proper orientation of collagen fibrils. Basset (1971) concluded “tension exerts a major influence on the alignment of collagen bundles in tendons, fascia, ligaments and arteries.”

Myers et al. (1984) in an experimental study on human cartilage showed that changes in the extracellular fluid movement and structure of collagen fibers are mostly produced when mechanical stimulation is applied in the form of direct compression. When mechanical stimuli were applied to produce a pure shear deformation, no changes of these parameters were detected. This matches exactly with the clinical observations of the therapeutic impact of different massage techniques. The healing potential of effleurage and light friction on the tissues’ regeneration is significantly lower compared to strong friction, compression, vibration and kneading techniques.

As we can see, mechanical stimulation produces the changes in the electrical environment of the extracellular matrix. These changes immediately affect the cellular membrane and receptor-proteins, with the stimulation of cellular activity to follow, as discussed in Part 1. Thus, mechanical stimulation introduces some kind of electrical commands into the extracellular matrix which affects the extracellular events and intracellular activity.

Events Responsible for the Local Therapeutic Effect of Massage
From all the information we’ve discussed here and in Part 1, a cellular theory to explain the local stimulation of the healing process by massage is slowly emerging. I don’t want to mislead the readers with a well-established theory. It does not exist at this point. These are only preliminary results and speculations, but all authors (in the discussions of their articles/studies) made conclusions which support and complete each other as missing parts of the same puzzle. Some of the theoretical considerations which the reader will find below reflect this author’s personal opinion, which is based on a detailed analysis of modern literature and 17 years of personal clinical experience with medical massage therapy.

If we analyze the new information about the effect of pressure on the cellular and subcellular levels and incorporate it into already established views on the local mechanisms of massage therapy, we can try to generally reconstruct the chain of events.

For example, the massage practitioner applies strong mechanical stimuli in the form of deep friction and compression in the place of somatic pathology. In such a case, the practitioner triggers four major processes in the massaged tissues: pain relief, peripheral arterial vasodilation with increasing venous and lymph drainage, microtraumatization of soft tissues, and cellular stimulation.

Pain Relief
According to the “gate-control” theory of pain, proposed by Mezlak and Wall (1965), our body has two major systems that conduct pain stimuli from the peripheral receptors to the spinal cord and brain. The nervous impulses are generated in the free nerve endings (i.e. pain receptors) and conducted to the central nervous system through two types of nervous fibers. Large, unmyelinated C fibers conduct the nervous impulses at low speed (about 0.5-2 m/s). Small, myelinated A fibers conduct the nervous impulses at high speed (about 12-30 m/s). Thus, we have two types of pain: fast and slow pain. The fast pain is sharp and precisely localized. The slow pain is dull, aching and poorly localized. The predominance of fast or slow pain completely depends on the activity in the A or C nervous fibers.

In the case of chronic visceral or somatic disorders, pain stimuli was mostly conducted through C fibers with lower speed — i.e. slow pain system is activated. In the contrast, nervous impulses that are generated in the peripheral receptors of the skin and connective tissue structures by massage strokes propagate to the central nervous system with greater speed through A fibers, using pathways similar to the fast pain system. From this point of view we can easily explain the phenomenon of counterirritation, which is partly responsible for the analgesic effect of massage therapy. The nervous impulses produced by soft tissues’ stimulation reach the brain earlier than chronic pain stimuli reach the spinal cord. In such cases, the activity of the hypothalamus is inhibited because the brain’s relay-station is overflowing with nervous impulses produced by massage strokes in the affected area. As a result, the hypothalamo-cortical discharge ceases with the following inhibition of areas of cortex that previously were overstimulated by the permanent bombardment of chronic pain stimuli from the affected area. Additionally, the brain also has time to elicit central control over the “gates” in the spinal cord to suppress the continuous flow of pain stimuli from the affected area of the body.

Another mechanism of analgesic action of massage therapy is releasing endogenous opiate substances in the corresponding segment of the spinal cord (Watson 1982, Goats and Keir, 1991). The pain receptors which were activated by the massage strokes “initiate reflex activity leading to the release of endogenous opiate substances in the spinal segment at which the pain bearing nerves enter” (Goats and Keir, 1991). Proof toward this assumption is the long-lasting analgesia produced by massage, compared to the more short-living analgesic effect elicited by other more simple types of counterirritation, for example application of an ice cube.

Peripheral Arterial Vasodilation and Increased Venous and Lymph Drainage
Peripheral vasodilation has two components: vasodilation of already functioning capillaries and the opening of reserve capillaries. Four different mechanisms are in charge of peripheral vasodilation:

1. Mechanical effect of massage strokes
As a result of the mechanical effect of massage strokes, more blood is pushed through the massaged area. Besides this, the massage strokes support the venous and lymphatic drainage from the massaged segment or part of the body.

2. Axon reflex
Besides the mechanical effect of massage strokes, LeRoy (1941), and later Jacobs (1960), pointed to the so-called axon reflex. Afferent (sensory) nervous fibers, which deliver information from the peripheral receptors to the central nervous system, give direct branches or collaterals to the nearby vascular structures located in the same areas of stimulated tissues. These nervous pathways are called the axon reflex. As soon as the practitioner activates the sensory receptors in the skin and connective tissue structures by the massage strokes, these receptors form and send the afferent nervous impulses. The major part of these impulses propagates to the central nervous system. However, some amount of afferent impulses are delivered directly to the vascular structures in the skin and skeletal muscles in the massaged area using the existing short collaterals of the axon reflex. Thus, vasodilation in the massaged tissues is produced quicker and maintained longer, compared to the regular heating procedures (i.e. diathermia, paraffin, heating pack, etc.).

One has to remember that the first reaction of vascular structures is vasoconstriction, as soon as the impulses are perceived as harmless, and repeated over the same area, long-lasting local vasodilation is produced. Thus, massage treatment on each new area has to be prolonged to achieve the appropriate therapeutic effect.

3. Ischemic compression
The compression of soft tissues, with gradual increase of applied pressure, causes the reflex vasodilation after pressure’s release. For this purpose, the soft tissue compression should be applied several times over the same area. Every time, very quick release of pressure should follow. During each soft tissues’ compression, pressure should be maintained for at least 15-30 seconds.

4. Reflex vasodilation
Vasodilation in the area of reflex zones is caused by reflex mechanism, which involves the central nervous system. This mechanism is employed in cases of chronic somatic or visceral disorders. The reflex vasodilation also can be a result of the release of vasoactive substances from the massaged tissues into the general blood circulation.

Micro-traumatization of Soft Tissues by Intense Massage Strokes
Energetic friction, vibration and strong compression cause microtraumas of soft tissues and capillaries which lead to microhemorrhages (i.e. microbleedings) and controlled inflammation. When microhemorrhages occurr, the blood in the tissues acts as a natural biological stimulator. In such a case, the blood protein and the remains of cellular elements should be oxygenated and removed from the tissues, but to do this, the process of local metabolism has to be stimulated. Thus, this activation of local metabolism at the site of an injury stimulates the healing of somatic disorders or post-traumatic rehabilitation.

More changes occur from evoking local controlled inflammation. This process starts after the end of massage treatment and continues for 24-48 hours. The physiological reaction of the body to any kind of trauma is local inflammation. Thus, after the energetic massage, the first reaction to the tissues’ damage is the emergence of neutrophils from circulation into these tissues, with the accompanying attraction of macrophages (Smith et al., 1994). Their major function is to pick up tissue debris at the place of trauma. These cells engulf the remains of damaged cells and release enzymes which, additionally, produce cytolysis (i.e. cell distraction) in the tissues that have little chance of survival after the trauma. Thus, at the beginning of controlled inflammation, the actual trauma becomes even worse. However, this is the major signal for fibroblasts from neighboring regions to migrate into the area of controlled inflammation to restore the normal structure of soft tissues.

Cellular Stimulation
As we discussed in Part 1, the mechanical stimuli activate the fibroblasts which are normally present in soft tissues, and they start to produce new collagen and components of extracellular matrix to repair the injured site. Additionally, newly migrated fibroblasts increase the amount of extracellular matrix and collagen production. Repetitive application of mechanical stimuli during the following sessions further stimulates the activity, proliferation and collagen production of all fibroblasts in this area.

The formation of a new capillary network under the influence of mechanical stimuli on the endothelial cells is another equally important healing factor in the place of original somatic pathology.

Newly synthesized procollagen molecules leave fibroblasts and form collagen deposits at the site of injury. Mechanical stimuli applied to the same area now produce the chain of electrophysiological events that speed up the process of collagen deposit, as well as the correct orientation of collagen fibrils. This process restores the normal anatomical structure in place of an original injury or somatic pathology.

All these events don’t happen in one day. This is why the massage practitioner and the client can expect stable results of treatment only when massage therapy is performed as a course of treatment. Only in such cases do massage treatment procedures employing a correctly developed protocol deliver the combination of different healing factors on the organic, cellular and subcellular levels and produce the maximal therapeutic effect.

Author’s Note: To find out more about the medical benefits of massage therapy and various techniques of medical massage treatment visit my website at www.aesculapbooks.com. You can find comprehensive educational information on every subject regarding the theoretical foundation and practical application of medical and therapeutic massage in my publications: “Medical Massage, Vol. I” and “Therapeutic Massage: A Scientific Approach.”

Ross Turchaninov, M.D., Ph.D., is the author of “Medical Massage, Vol. I” and “Therapeutic Massage: A Scientific Approach.” He lives in Phoenix, AZ.

The Science to Back It Up

By Ross Turchaninov, M.D., Ph.D.

Originally published in Massage & Bodywork magazine, October/November 2000.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

The present time opens exciting perspectives for American massage and bodywork practitioners. Thanks to a new philosophy, the medical values of massage are getting more and more recognition from clients/patients, as well as from other health and medical practitioners. I am sure that this inevitable process will finally restore massage therapy within the arsenal of modern American medicine. Massage practitioners are playing a major role in this process. It is their job to help the clients and convince other health practitioners of the benefits of massage therapy. This latter task is especially difficult because the general opinion of doctors, chiropractors and physical therapists regarding the medical benefits of massage therapy remains skeptical. Noting this, it would be extremely helpful to equip massage practitioners with the latest information about scientific discoveries that help us to understand mechanisms of the therapeutic impacts of massage therapy on the body, organ, tissue and cellular levels.

Pressure’s Therapeutic Impact
Massage therapy has a limited arsenal of therapeutic remedies. The massage practitioner can count only on different forms of pressure (including vibration), stretching, and the activation of temperature receptors. Between these three modalities, pressure is the main therapeutic tool, with stretching and temperature receptors’ activation playing a supportive role in the treatment. Thus, discussion of mechanisms of the therapeutic effect of massage treatment will refer us mostly to the mechanisms of pressure’s therapeutic impact.

Pressure is a physical force which is used by massage practitioners to achieve therapeutic results. Thus, the therapist converts the kinetic energy of massage strokes into various physiological phenomenons on tissue and cellular levels of the body (e.g. changes of interstitial pressure), as well as into a chain of electrochemical reactions in the massaged area and the whole organism.

The final success of therapeutic or medical massage treatment directly depends on the correct application of this pressure. That includes the right combination of proper techniques, the form of application (i.e. permanent or intermittent), speed of application, intensity of application (i.e. light-moderate-deep pressure), and the area of application. Only after careful evaluation of all these parameters and formulation of the right protocol of treatment can a massage practitioner expect stable results from the therapy. If the chosen schema does not work, adjustments to the protocol have to be made. Sometimes these adjustments can completely change the initial schema of treatment. Remember one important rule: If treatment is unsuccessful, of course in cases when massage is indicated, it means that the practitioner developed the wrong protocol of treatment.

Indirect Reflex Mechanism of Massage Therapy
Massage has two mechanisms of therapeutic impact: reflex (indirect) effect and local (direct) effect. This classification is very approximate because for example the local mechanism is a component of the reflex mechanism. However it makes representation of the material easier. Reflex therapeutic impact of massage therapy has a complex mechanism. This is an important subject for another discussion. However, I want to emphasize one important point. The basic concept of reflex mechanism of massage therapy is the formation of reflex zones. Reflex zones are areas of soft tissue abnormalities which are secondarily formed as a reflex response to the various visceral and somatic disorders. In the cases of visceral (i.e. inner organ) disorders, the reflex zones are formed only after three months of medical history of these pathologies. In the cases of somatic pathologies this period is shorter but still takes at least two to three weeks. Thus, in the every new case of somatic disorders, the local therapeutic effect of massage treatment is the leading mechanism. Therefore, I will concentrate on the local mechanism of massage therapy. I refer those who are interested in knowing more about the reflex mechanism of massage therapy to Massage & Bodywork, June/July 1999 or to the Medical Massage textbook, Vol. 1.

Direct Local Mechanism of Massage Therapy
Everyone who practices massage as a treatment procedure experiences cases when two to three sessions eliminate the patient’s somatic problem with complete restoration of all affected functions. I don’t mean just pain relief, I am talking about actual stimulation of the healing process to obtain stable therapeutic results. Examples can be found in cases of epycondylitis, tendinitis, muscular and ligamental injuries and so on. What mechanisms are responsible for such a “miraculous” effect? The local effects which traditionally explain the therapeutic impact of massage treatment are pain relief, peripheral arterial vasodilation, increasing of venous and lymph drainage, and stimulation of local metabolism. However, practically all experts agree that these positive changes have transitory character and slowly faded within 2-3 hours after the end of a session. Thus, to obtain stable therapeutic results, the massage practitioner has to perform a course of treatment. If we accept this point of view as ultimately correct, we cannot fit cases with rapid stimulation of the healing process into this concept or we should not take them into consideration. However, they do exist and do demand explanation. As you will see below, more powerful mechanisms than we once thought play a major role in the healing potential of massage therapy on the local level.

The Effect of Mechanical Stimuli on the Cellular Metabolism Role of Cytoskeleton
The therapeutic potential of different types of massage has started to slowly attract the attention of scientists in the various fields of medicine. In previous years, scientists drew their conclusions mostly from clinical experiments and observations. However, modern technical devices with high resolution capacity allowed scientists to obtain important information from the purely experimental models as well. These findings revealed mechanisms of physiological and therapeutic impacts of mechanical pressure on the cellular and subcellular level. To fully represent this information, I think it will be helpful to take a short trip into cellular biology and biochemistry.

Every cell contains a cellular membrane and cytoskeleton, cytoplasm with organelles, and nucleus with nucleous. Figure 1 presents the general view of the cell. The structure and functions of all cellular components are well known and it is not the subject of our discussion. However, latest findings about the cytoskeleton and its relation to external mechanical stimuli applied to the cell are breakthroughs in the understanding of the therapeutic effect of mechanostimulation on living cells and tissues.

The cytoskeleton is a complex system of fibrillar structures in the cytoplasm. It can be compared to the human skeleton which provides a frame for our body and its dynamic support. There are three types of fibrils in the cytoplasm which form the cytoskeleton:

- Microtubules — Microtubules have a diameter of approximately 25 nm and build up from protein tubulin. During mitosis, microtubules form the spindle which pulls chromosomes into newly-formed cells.

- Actin filaments — These have a diameter of approximately 10 nm and consist of proteins: actin, myosin and energy source APT. They are a major contractile apparatus of the cell.

- Intermediate filaments — These fibrils have a diameter of 7 nm and form a net throughout all the cytoplasm with especially high density around the nucleus. This net is not flat, but is instead a three-dimensional structure through the entire thickness of cytoplasm. It links cellular organelles, the nucleus and cytoplasmic membrane together to form the cell.

Jain, M.K., et al. (1990) in an experimental study on human fibroblasts showed that microfibrils of the cytoskeleton have a special arrangement responsible for an increase in intercellular stress in the direction of applied pressure and an actual decrease of intercellular stress in the direction which is perpendicular to the applied pressure. Thus, the cytoskeleton is able to transfer the mechanical energy of external stimuli into the cell or annihilate these stimuli.

Opposite to the human skeleton, the cytoskeleton is an extremely dynamic structure. It is in a state of permanent change. In fact, the cell is able to completely dissolve and resynthesize the cytoskeleton in several minutes. Fibroblasts are major repair cells of the human body, because they produce the direct precursor of collagen, known as procollagen. The collagen itself is a most abundant protein which forms the structural frame of all organs and tissues.

From the time of its discovery at the beginning of the century, the cytoskeleton was always viewed as a purely mechanical structure that provides the shape of the cell and participates in cell motility and migration (e.g. leukocytes, natural killer cells, etc.). The cytoskeleton was also viewed as one of the key mechanical components of cell division. However, modern experimental equipment allowed scientists to set up and conduct more detailed studies of the structure and functions of the cytoskeleton. Thanks to these studies, we now know the following functions of the cytoskeleton:

1. Providing the cellular morphology, (i.e. shape of the cell).
2. Distribution of the cellular organelles.
3. Intercellular movements of cytoplasm and organelles.
4. Participation in cellular division.
5. Motility of the cell.
6. Control over the cytoplasmic membrane.
7. Connection of the cytoplasmic membrane to the nucleoskeleton and stabilization of the nucleus.
8. The regulation of protein production.
9. Control over genes’ expression.

Functions 1-5 were always associated with the cytoskeleton. However, for our discussion, Functions 6-9 are extremely important, and their discovery is one of the greatest achievements of modern cellular biology. Of course, we are interested in theoretical conclusions that can be projected onto massage therapy and clarify its healing mechanisms. Let’s see how the cytoskeleton and, consequently, cellular functions are affected by the external mechanical stimuli.

Control Over Cytoplasmic Membrane
A cytoplasmic membrane surrounds the cells and actively interacts with the environment (i.e. extracellular matrix). It has a thickness of 7.5 nm or 1/4,000 of an inch, and is made up of double layers of phospholipids with integrated proteins. Figure 3 shows the structure of the cytoplasmic membrane. The integrated proteins work as gates which connect the external environment and inner part of the cell. Any macromolecules the cell needs for its metabolism pass into the cell through these gates. They also allow the new synthesized proteins or waste to be secreted from the cell. Cytoplasmic proteins have approximately 50 percent of the membrane’s mass and form the net of receptors over the entire outer surface of the cytoplasmic membrane. Thus, any outside molecule has to first interact with these receptors to be recognized. Only after this occurs will the gate open and let it in.

Any mechanical stimuli (e.g. changes in the interstitial pressure) affect the receptors on the cytoplasmic membrane. After exposure to the original stimuli, receptors are able to convert mechanical energy into chemical stimuli that can be conducted inside of the cell. Jain, M.K., et al. (1990) concluded that mechanical signals can be converted into chemical signals in the form of cyclic-AMP. Komuro, I., et al. (1991) also pointed out the activation and participation in this process of one of the key enzymes of cellular metabolism, protein kinasa C. Not all receptors in the cytoplasmic membrane act as mechanoreceptors. More likely, that one particular family of proteins, called integrins, reacts to the mechanical stimulation (Wang, et al., 1993).

The fibrils of the cytoskeleton are deeply anchored in the membrane, including the protein receptors. The cytoskeleton has major regulatory control over the function, arrangement and even amount of protein receptors incorporated into the membrane. Thus, by regulation of cytoplasmic proteins, the cytoskeleton changes the metabolism of the whole cell by controlling the amount and intensity of impulses conducted from the extracellular matrix into the cell (Jain, et al., 1990).

Gataullin, R.R. and Zaripov, A.T. (1988) examined the effect of colchicine on the mechanoreceptive ability of single Pacinian corpuscles which were isolated from the mesentery of a cat. Pacinian corpuscles are receptors which are activated by vibratory stimuli. Thus, any form of external vibratory stimuli activate Pacinian corpuscles which form the afferent sensory flow of nervous signals (i.e. action potentials) to the central nervous system. As a result, the perception of vibration is formed.

The colchicine is known to selectively disrupt the intracellular microtubules of the cytoskeleton without any additional damage to the living cell. After the exposure of the Pacinian corpuscles to the colchicine, the complete depression of the mechanoreceptor’s ability to generate action potentials was detected. The results of this study leave no doubt about the controlling function of the cytoskeleton over the cytoplasmic membrane. The authors tested the single mechanoreceptor cell which normally produces the action potentials after the direct deformation of its cytoplasmic membrane by vibration stimuli. The colchicine disrupted the fibrils of the cytoskeleton and, consequently, the Pacinian corpuscle lost its ability to generate action potentials because of interruption of conductance from the cytoplasmic membrane’s receptors into the cell.

Connection of the Cytoplasmic Membrane to the Nucleoskeleton
The nucleus stores the vital information of all living objects — DNA. The nucleus is surrounded by its own nuclear membrane which has pores that open into the cytoplasm and endoplasmic reticulum. Through these pores, the permanent interchange of different molecules between the cytoplasm and the nucleus occurs. The nucleus also has its own nucleoskeleton. Some authors consider the cytoskeleton and nucleoskeleton as the same, continuous structure because of their striking similarity (McKeon, F.D. et al., 1986). However, even if this hypothesis is wrong, the cytoskeleton still has very high density all around the nucleus, and is also able to control the activity of the pores in the nuclear membrane.

One of the most important functions of the cytoskeleton is its ability to conduct information from the receptors of the cytoplasmic membrane directly to the nucleus, with the following changes in cell proliferation, protein synthesis and genes expression. Every mechanical stimulus which is applied to the living cell affects the mechanoreceptors first. Their activation immediately causes the reorientation of cytoskeletal fibrils with subsequent nucleus distortion (Maniotis, J. et al., 1977).

Wang, N., et al. (1993) see cytoplasmic receptors, cytoskeleton fibrils and the nucleus as one “hard-wired” structure, where mechanical stimulation of the receptor’s site immediately produces deep morphological and biomechanical changes in the whole cell, including the nucleus.

Regulation of Protein Production of Genes Expression
After we clarified the relationship between the external mechanical stimuli receptors, cytoplasmic membrane, cytoskeleton and nucleus, we have to look at how this chain of events affects the cell functions (i.e. proliferation, protein synthesis and genes expression). One more time, let’s start from the beginning with the example of the human fibroblast.

The external mechanical stimuli activates the receptors in the cytoplasmic membrane of the fibroblast. These mechanical stimuli are converted into chemical signals and cause the reorientation of the cytoskeleton in the direction of the applied force. The cytoskeleton reorientation causes nucleus distortion, and it responds with increased DNA synthesis and replication (Curtis and Seehar, 1978, Sornjen et al., 1980, Brunett, 1984), increasing the synthesis of messenger-RNA (m-RNA) — i.e. transcription of information from the replicated DNA (Komuro et al., 1991). The newly synthesized chain of m-RNA, which carries identical information about the structure of the replicated DNA, leaves the nucleus through the pores in the nuclear membrane directly into rough endoplasmic reticulum. Here, m-RNA associates with ribosomes and starts the process of translation — i.e. protein synthesis. This process is also supported by transport-RNA (t-RNA), which pulls the required amino acids from the cytoplasm to the m-RNA-ribosomal complex and attaches them to the newly synthesized molecule of procollagen. This transport of amino acids by t-RNA is also under control of the cytoskeleton (Bereiter-Hahn et al., 1987). Procollagen is a direct precursor of collagen. Procollagen needs to be secreted from the fibroblast into extracellular matrix, where its conversion into a newly formed molecule of collagen occurs. Thus, mechanical stimuli activate the fibroblasts and stimulate procollagen synthesis which leads to the increasing of collagen and extracellular matrix production at the injured site. Collagen is the most abundant protein of any life organism and it comprises approximately one-third of all proteins in the body (Geneser, 1986). The role of collagen is critical for every living organism because it forms the actual frame of all tissues and inner organs.

Practical Outcomes
What practical outcomes are caused by all these changes on the cellular level, and how can they explain the therapeutic impact of massage therapy?

Leung, D.Y.M. et al. (1976) reported that smooth muscle cells significantly increased production of collagen after the application of mechanical stimuli. However, their proliferation was not detected.

Curtis, A.S.G. and Seehar, G.M. (1978) showed that mechanical stress stimulates the DNA synthesis and division of fibroblasts from chick embryos. The authors detected the increase in the mitotic index in the experimental study up to 5.1 ± 1.5, vs. the same parameter in a control study, 2.3 ± 0.7. The mitotic index reflects the mitotic frequency and proportion of cells in the phase of cellular division. Thus, mechanical signals are able to augment the cells’ proliferation (especially fibroblasts), which is very important for the stimulation of the healing process at the site of an injury.

Shirinsky, V.P. et al. (1989) showed that the mechanical deformation of human endothelial cells in vitro produces their rapid growth and elongation (within three hours), with the formation of a multilayered structure from the monolayer culture. Within 48 hours, endothelial cells became uniformly oriented along the axis of the future vessel. Endothelial cells form the walls of arterial, venous and lymphatic vessels. Thus, mechanical energy is able to stimulate the new capillaries’ formation.

Jain, M.K. et al. (1990) showed that direct mechanical influence on human fibroblasts causes cellular growth to increase 1.7 times, increasing protein synthesis up to 48 percent, and increasing intercellular cyclic adenosine monophosphate (cAMP) 3.7 times in 24 hours after the mechanical stimulation. The fibroblast activation, with a subsequent increase in collagen production, is a major process of healing which affects practically every tissue in the human body.

Wirtz, H.R.W. and Dobbs, L.G. (1990) reported that after a single application of mechanical stimuli to the alveolar type II cells, they were able to increase Ca +2 exocytosis and surfactant secretion during the next 15-30 minutes. The surfactant is a special fluid that covers the inner surface of alveoli and prevents their collapse during expiration. Thus, the authors showed that the functions of the inner organs’ cells also can be affected by mechanical stimulation.

Komuro, I. et al. (1991) found in an experimental study on rats’ neonatal cardiocytes that mechanical stress stimulates the cardiac cells’ hypertrophy and specific genes’ expression. The authors showed that total RNA content in the experimental group increased up to 45 percent, vs. no increase in the control group during 24 hours. The genes’ expression is one of the most intimate processes of nature. The ability of mechanical stimuli to affect the genes’ expression brings a new understanding of the mechanisms that are responsible for many visceral disorders.

Chen, B. M. and Grinnel, A.D. (1995) found that stretching the skeletal muscle of a frog in the physiological range (up to 2 mm) more than doubled the spontaneous and evoked release of the neurotransmitter acethylcholine from its motor nerve terminal, with an accompanying increasing of frequency of end-plate potentials. The mechanism of this effect is the activation of integrins in the cytoplasmic membrane, and additional mobilization of Ca +2 from internal and external sources. These data allow us to conclude that light stretching of the skeletal muscles at the end of massage treatment will stimulate the muscle tone and muscular performance.

Davidson, C.G. et al. (1997) examined the effect of soft tissue mobilization (intense cross-friction) on experimental tendinitis caused by the injection of enzyme collagenase into the Achilles tendon of 20 rats. The results obtained from experimental and control groups were examined with light microscopy, electron microscopy, immunoelectron microscopy and by gait analysis. The authors found that the mean increase of the fibroblast count in an experimental group was 15 ± 11, vs. 3 ± 3 in the control group. All fibroblasts in the experimental group exhibited a highly developed rough endoplasmic reticulum, which is clear evidence of the stimulation of collagen production. Thus, the mechanical stimuli, cross-friction in this case, attract the fibroblasts from the neighboring areas to the site of treatment, with an accompanying stimulation of collagen production and healing of affected tendons.

Gehlsen, G.M. et al. (1999) also examined the effect of soft tissue mobilization with different amounts of applied pressure on the fibroblasts. The authors used the same experimental model of tendinitis in the Achilles tendon. They found that the application of strong pressure stimulated the healing process in the tendon much faster (fibroblast count = 375) compared to the treatment with light (fibroblast count = 190) or moderate (fibroblast count = 250) pressure. For the first time in modern literature, the authors also established a clear connection between mechanical stimuli, their therapeutic effect on somatic pathology in the form of soft tissue mobilization, and their effect on cellular functions.

To really understand the significance of all this information, the reader should realize that some of the reported effects were obtained from cells placed in the experimental conditions outside of the body (i.e. in vitro). Thus, stimulation of cellular activity was a result of purely mechanical stimulation of these cells without the participation of any other systems traditionally responsible for the coordination of cellular activity: nervous, endocrine or immune.

At the end of this short review, I want to quote the conclusion from an article by A.J. Maniotis, C. S. Chen and D.E. Ingber published in Proc. of the National Academy of Sciences of the USA in 1997: “… direct mechanical linkages throughout living cells raise the possibility that regulatory information, in the form of mechanical stress or vibration, may be rapidly transferred from these cell surface receptors to distinct structures in the cell and nucleus, including ion channels, nuclear pores, nucleoli, chromosomes, and perhaps even individual genes, independent of ongoing chemical signaling mechanisms.”

Thus, the latest scientific discoveries of cellular biologists and biochemists do not leave any doubts about the stimulating impact of mechanical stimuli on the cellular functions. Mechanical stimuli in the form of massage or any other type of soft tissue mobilization repetitively applied to the place of injury are able to increase collagen production by the stimulation of fibroblasts’ functions and by attracting new cells from neighboring areas. However, increased collagen production alone is not enough to heal the injured site. The correct orientation of collagen fibers is an equally important element. Without the proper orientation of collagen fibers, an increase in collagen production is useless. Are mechanical stimuli somehow able to affect this process as well? We should answer this question positively. Numerous scientific reports support this conclusion. The piezoelectric phenomenon in the soft tissues is a unique electrophysiological mechanism responsible for the correct orientation of collagen fibers. We will discuss this equally exciting topic in the next issue of Massage & Bodywork.

To find out more about the medical benefits of massage therapy and various techniques of medical massage treatment, visit www.aesculapbooks.com. You can find comprehensive educational information on every subject regarding the theoretical foundation and practical application of medical and therapeutic massage in Medical Massage, Vol. I and Therapeutic Massage: A Scientific Approach 1. To order, call 602/404-1583 , or purchase on-line at www.aesculapbooks.com.

Ross Turchaninov, M.D., author of the Medical Massage textbook, graduated in 1983 from the Odessa Medical School in the Ukraine and was selected to the Kiev Orthopedic Institute for Scientific Research where he specialized in trauma surgery and post-traumatic rehabilitation. From 1985-88, the author worked as chief supervisor of the rehabilitation program of the Ministry of Public Health of the Ukraine. In 1990, he graduated from the chiropractic and medical massage program designed for medical doctors at the Kiev Institute and worked as a senior scientific researcher there. He is the author of 20 scientific articles and two patents in the Ukraine. In 1992, Turchaninov moved to the United States.

Resources
1. Bereiter-Hahn, J., Anderson, O.R., Rief, W.E.: Cytomechanics. “Springer-Verlag,” Berlin, 1987.
2. Brunett, D.M.: Mechanical Stretching Increases the Number of Epithelial Cell Synthesizing DNA in Culture. J Cell Sci., 69: 34-35, 1984.
3. Chen, B-M., Grinnell, A.D.: Integrins and Modulation of Transmitter Release from Motor Nerve Terminals by Stretch, Science, 269: 1578-1580, 1995.
4. Curtis, A.S.G., Sheehar, G.M.: The Control of Cell Division by Tension or Diffusion, Nature, 274: 52-53, 1978.
5. Davidson, C.J., Ganion, L.R., GehIsen, G.M., Verhoestra, B., Roepke, J.E., Sevier, T.I.: Rat Tendon Morphologic and Functional Changes Resulting from Soft Tissue Mobilization. Med Sci. Sports Exer., 29: 313-319, 1997.
6. Gataulin, R.R., Zripov, A.T.: “The Role of Cytoskeleton in Mechanoreceptor Activity of Pacinian Corpuscles,” Mechanoreceptors: Development, Structure and Function: 209-211. Edited by E.P. Hnik, T. Soukup, R. Vejsada, J. Zelena. “Premium Press,” New York, 1988.
7. Gehlsen, G.M., Ganion, L.R., Helllfst, R.: Fibroblast Responses to Variation in Soft Tissue Mobilization Pressure. Med. Sci. Sports Med., 31(4): 531-535, 1999.
8. Geneser, F.: Textbook QJ’Histology. “Munksgaard Lea & Febiger,” Philadelphia, 1986.
9. Jain, M.K., Berg, R-A., Tandon, G.P.: Mechanical Stress and Cellular Metabolism in Living Soft Tissue Composites. Biomaterials, It: 465-471, 1990.
10. Komuro, I., Katoh, Y., Kaida, T., Shibazaki, Y., Kurabayashi, M., Hoh, E., Takaku, F., Yazaki, Y.: Mechanical Loading Stimulates Cell Hypertrophy and Specific Gene Expression in Cultured Rat Cardiac Myocytes. J Biol. Chem., 266(2): 1265-1268, 199 1.
11. Leung, D.Y.M., Gladov, S., Mathews, M.B.: Cyclic Stretching Stimulates Synthesis of Martix Components by Arterial Smooth Muscle in Vitro. Science, 191: 475-477, 1976.
12. Maniotis, A.J., Chen, C.s., Ingber, D.E.: Demonstration of Mechanical Connections Between Integrins, Cytoskeletal Filaments, and Nucleoplasm that Stabilize Nuclear Structure. Proc. Nat. Acad Sci. USA, 94(3): 849-854, 1997.
13. McKeon, F.D., Krischner, M.W., Caput, D.: Homologies in Both Primary and Secondary Structure Between Nuclear Envelope and Intermediate Filament Proteins. Nature, 319: 463-468, 1986.
14. Shirinsky, V.P., Antonov, A.S., Birukov, K.G., Sobolevsky, A.V., Romanov, Y.A., Kabaeva, N.V., Antonova, G.N., Smirnov, V.N.: Mechano-Chemical Control of Human Endothelium Orientation and Size. J. Cell Biol., 109, 331-339, 1989.
15. Sorn en, D., Binderman, I., Berger, E., Harell, A.: Bone Remodeling Induced by Physical Stress in Protoglandin E2 Mediated. Biochim. Biophys. Acta., 627: 91-100, 1980.
16. Wang, N., Butler, J.P., Ingber, D.E.: Mechanotransduction Across the Cell Surface and Through the Cytoskeleton. Science, 260: 1124-1127, 1993.
17. Wirtz, H.R.W., Dobbs, L.G.: Calcium Mobilization and Exocytosis after One Mechanical Stretch of Lung Epithelial Cells. Science, 250: 1266-1273, 1990.

Patricia A. Sharpe, PhD, LMT

Prevention Research Center, Norman J. Arnold School of Public Health

University of South Carolina, Columbia, SC 29208

pasharpe@sc.edu

Objective.
The objective was to test the effects of massage therapy on physical function, stress perception, sleep, and general well-being among older adults compared to a guided relaxation control condition.

Design.
After screening for eligibility and contraindications, physical clearance for participation was obtained. Eligible participants were randomly assigned to massage or guided relaxation. Sessions were provided twice-weekly for four consecutive weeks. Functional assessments and interviews were conducted before the first session and after the last session.

Setting.
Participants came to the university for all sessions where a massage room had been reserved for the study.

Participants.
Forty-nine participants aged 60+ completed the study (25 massage and 24 guided relaxation). Three-fourths of participants were female; 88% white, 10% African American, and 2% Asian. Participants were independently living, relatively “well” older adults rather than a clinically defined group of patients.

Main Outcome Measures.
The main outcome measures were range of motion at shoulder, hip, and ankle by goniometer measurement; flexibility (chair sit-and-reach); tandem balance; agility (timed up and go test); general well-being (General Well-Being Scale, with subscales for anxiety, depression, positive well-being, self-control, vitality, and general health); Perceived Stress Scale; and Sleep (two items from the Philadelphia Sleep Quality Index).

Results.
The massage group improved significantly more than the guided relaxation group on anxiety, depression, vitality general health, positive well-being, timed up and go test, chair sit and reach test, shoulder abduction, and hip flexion.

Conclusion.
Massage therapy has positive effects on psychosocial and functional health of older adults.

SHELEIGH LAWLER & LINDA CAMERON

IN COLLABORATION WITH

THE NEW ZEALAND COLLEGE OF MASSAGE

This study assessed the effectiveness of massage therapy as an intervention for coping with stress in healthy university students approaching final examinations (N = 34). Participants were randomly assigned to an attention control condition (watching 3 different television programmes) or to a massage therapy group, who received one 45-minute massage per week for 3 consecutive weeks. Measures of blood pressure, heart rate, and state anxiety (State Trait Anxiety Inventory – short form) were taken before and after each of the sessions. Stress (Perceived Stress Scale) and coping (Coping Efficacy) were measured three times at baseline (T1), immediately after the three sessions (T2), and at one week follow up (T3). Both groups reported lower anxiety after each of the sessions; however, the massage group had a greater reduction in comparison to the television group (p < .05). The massage group had a lower heart rate after each of the massages, while the television group showed no change (p < .05). There were no significant differences between the groups for systolic and diastolic blood pressure. At T2 the massage group reported a significant decrease in perceived stress and an increase in coping efficacy (p < .05). However, by time 3 these effects are no longer evident. Implications for stress and coping from a self-regulatory perspective will be discussed, using Leventhal’s (1997) Parallel Response Model.

by Lucy Candib, MD Family Health Center, 26 Queen St. Worcester MA 01610 USA
508-860-7700 fax 508-860-7855 lcandib@massmed.org

Abstract:
In this randomized crossover study we enrolled low income Anglo and Hispanic women with chronic pain in a program of 8 weekly one-hour whole body massage treatments. Patients were randomized to either active treatment or an 8 week waiting period followed by the massage program. In preliminary analyses we found a significant and lasting improvement on physical functioning on the SF-36 but no improvement in mental health functioning. The study was limited by the high dropout rate.

Background:
Chronic pain is a frustrating problem for both patients and physicians. Despite frequent office visits and expensive and sometimes harmful medications, many patients do not improve. Sometimes the pain is part of a more complex mental health problem like depression, anxiety, or somatization. Low income patients with chronic pain may be particularly difficult to treat for a variety of reasons. Patients from developing countries or minority ethnic groups may be more likely to articulate distress in bodily symptoms; yet these same patients are also more likely to suffer from chronic debilitating diseases and have fewer resources available to manage their health care. Whole body massage therapy offers an alternative approach to the treatment of chronic pain patients. Massage therapy is widely used in sports medicine to reduce pain and promote flexibility and has been documented to reduce pain and behavioral and biochemical measures of anxiety and depression in various populations.

Objectives:
Our objectives are to present the design and preliminary results of a study of massage therapy for women patients with chronic pain. The following information will be presented and discussed.

Study Design:
Randomized controlled trial (double cross-over) with four months of follow-up observations.

Setting:
Inner-city community health center serving low-income multi-ethnic families.

Participants:
A total of 70 low-income Anglo and Hispanic women patients age 18-65 referred by their family physician or family nurse practitioner were enrolled of whom 48 completed at least 6 massage treatments and at least two follow-up measures. Eligibility requirements: at least one year of primary care at the health center and chronic pain lasting at least 6 months documented in the medical chart.

Intervention:
After completion of the baseline assessment measures, patients were randomized to either the first or second treatment group by means of a random number table. Within each cohort, the initial treatment group received 8 weekly one hour full-body massage treatments by an experienced licensed female massage therapist in a quiet setting within the health center. Follow-up evaluations were performed at the end of treatment and 2 and 4 months later. The crossover group had a baseline assessment and then underwent an 8 week period without any change in treatment (that coincided with the time that the initial group was receiving treatments). At 8 weeks, after assessments had been repeated, the crossover group then received the 8 week massage intervention and the three post-treatment observations. Patients were assigned to one massage therapist for the duration of the program. Whole body massage was conducted using soft tissue manipulation of the head, neck, arms, legs and trunk, focusing on symptomatic areas. A combination of adjunctive therapies such as trigger point, cross fiber friction, Reiki, and oriental massage techniques were incorporated on an individual basis.

Main Outcome Measures:
The composite SF-36 mental health (MCS) and physical functioning (PCS) scores over time; CES-D and STAI-S scores over time; Dartmouth COOP scores over time.

Statistical Methods:
SF-36 scores were available for the 48 subjects who completed at least 6 weeks of massage therapy and 38 subjects had observations out to the final follow-up. A mixed model analysis with repeated measures was employed. The mixed models approach is similar to Analysis of Variance procedures but without some of the assumptions of ANOVA that are often not satisfied in the data. In this particular situation, it was important to employ an analytic approach that allowed cases with missing data to be included in the analysis and also allowed for selection of the appropriate variance-covariance matrix since the more restrictive assumptions of ANOVA were not met. The SAS PROC MIXED procedure was used for the analysis.

Results:
The group undergoing 8 weeks of observation after enrollment and before the intervention experienced no improvement in symptoms and SF-36 scores did not differ significantly from baseline in this group. Therefore, the two groups were combined and subsequent analyses were carried out using only baseline, post-treatment and the 2 follow-up observations for all subjects. Mental health scores (MCS) differed significantly between Latino and Anglo subjects (lower for Latino subjects) but there was no improvement in MCS following massage therapy. Physical health scores (PCS) were similar for Latino and Anglo patients and differed significantly over time (p<.01). There was no significant interaction between ethnicity and time with respect to either outcome. In particular, PCS scores improved in both groups following massage therapy and this improvement was sustained through the entire follow-up period. Scores on CES-D, STAI-S and Dartmouth COOP scales all improved during massage therapy but returned to pretreatment levels within 4 months of completing treatment. Of note, 86% of the Anglo patients and 53% of Latino patients acknowledged some form of prior physical or sexual victimization in either childhood or adulthood.

Conclusions:
Massage therapy may be an effective treatment for some chronic pain patients. For patients who completed 6 or more massage therapy treatments there was an improvement in physical functioning and furthermore, this improvement was sustained over a 4-month follow-up period. In this setting most Anglo women with chronic pain and more than half of Latino women with chronic pain were survivors of prior violent victimization.

Discussion:
This study suggests that massage therapy was a lasting and effective treatment for improving physical functioning in those women with chronic pain problems who were able to participate in a sustained treatment program. The study was limited by the high number of dropouts from treatment. Dropouts offered two main reasons for not continuing in the program: 1) logistical problems typical for low-income families including moving away, sickness in the family, multiple conflicting appointments, and work and child care obligations; and 2) discomfort with massage therapy itself, or lack of result from the initial massage. To offset the first set of difficulties, future studies might need to offer childcare and transportation and increased flexibility in the scheduling appointments. Massage therapy may not be a suitable modality for the second group.

Improvement in physical functioning rather than mental health functioning after a course of massage therapy is a plausible outcome since patients experience chronic pain problems as physical, and the modality of massage directly addresses the location of the pain in the body. Insofar as chronic pain is sometimes linked with depression and somatization, a long-standing improvement in physical functioning may have the potential to improve mental health functioning. The likelihood of prior violent victimization in women with chronic pain should be addressed in considering the use of massage therapy. We were unable to demonstrate any significant effect on mental health scores over a four month follow-up period. However, this analysis included only SF-36 composite scores; more sensitive measures of mental health symptomatology and pain should be assessed in the future.

Jan Locke, LMT & Glenda Dennis, RN, CCRN

As the public begins to focus on integrative medicine, many healthcare systems are seeking to incorporate more holistic ways to deliver care. After incorporating massage therapy into the ICU, staff observed increased relaxation in patients and restoration of a degree of tranquility. Patients often encounter many invasive and frightening experiences while in the hospital, including the placement of PICC (Percutaneously Inserted Central Catheters) and Mid-Arm catheters. The goal of this study was to determine the impact of using massage on improving the patient’s physical comfort and reducing stress and anxiety levels during PICC and Mid-Arm catheter insertion. A Likert-scale survey was administered pre-procedure and post-procedure to 21 patients who required PICC/Mid-Arm catheter insertion at McKenzie-Willamette Hospital over a 15-month period of time. Results indicate a 39% improvement in anxiety levels and 23% improvement in physical comfort levels in the group who received massage during the catheter insertion. Those patients who experienced massage as a relaxation technique were also generally easier to cannulate for line placement.

METHODOLOGY:

· Patients were surveyed pre and post procedure using a Likert scale.

· 21 adult patients were surveyed.
9 of the patients received massage during the procedure.
12 patients did NOT receive massage.

· Massage was offered according to the patient’s comfort level. The massage therapist and the patient determined where the patient would feel most comfortable receiving touch during the procedure.

· Generally massage (light effleurage) was provided to the hand, arm (not receiving the catheter), feet, neck or scalp.

· The focus of massage was to redirect the attention of the patient and provide soothing, calming, comforting touch during the procedure.

FINDINGS:

· Those patients receiving massage indicated:
23% improvement in physical comfort levels post procedure.
39% improvement in anxiety levels post procedure.

· Those patients NOT receiving massage indicated:
08% improvement in physical comfort levels post procedure.
29% improvement in anxiety levels post procedure.

· Patients receiving massage demonstrated significant improvement in physical comfort and anxiety levels over those that did not receive massage.

· It was also observed that there was less vascular constriction and a more peaceful recovery among those patients receiving massage during the procedures.

· 77% of patients, when asked if massage affected their physical comfort level indicated, “very much” (the highest score they could give).

· 67% of patients, when asked if massage affected their anxiety levels indicated “very much.”

PATIENT COMMENTS:

· “I think the massage caused a definite improvement in my comfort level. It kept me from focusing on the procedure and relaxed me.”

· “I’m glad that the massage was given. I have had this done three times before without massage. This was the lowest level of anxiety.”

· “Very good to me. Kept my mind off what you’re doing.”

· “Having had two PICC installs without massage, I can say it helped to have it. Thanks!”

RECOMMENDATIONS:

· Highly recommend using massage to reduce anxiety and improve patient comfort during PICC/Mid-Arm catheter placements.

· Highly recommend trying massage to compliment other potentially anxiety or pain producing procedures such as thorocentesis, pre-cardioversion, or with naso-gastric or naso-duodenal feeding tube placement.

OUR PLAN is to modify our survey to include demographics such as gender and age to see if there is any correlation regarding perception of massage or its benefits. We also plan to gather data regarding massage as it affects physical comfort levels and anxiety levels during other invasive procedures in addition to the PICC/Mid-Arm catheter placements.