I believe the hospital bedside is one of the most important and meaningful places for massage therapy integration. Whether as palliative, rehabilitative, or to support recovery after a procedure, massage therapy offers multiple potential benefits for nearly all patient populations. As massage therapy becomes more common and available in hospitals, so too has research examining massage integration into health-care settings and its outcomes. This research is creating the evidence base for massage professionals seeking a career with populations that might not otherwise access massage as part of their health care.
Research examining massage therapy applied in surgical pain populations was recently highlighted as a third part to the large Massage Therapy Foundation-commissioned systematic review and meta-analysis from the Samueli Institute investigating massage’s impact on function in pain populations.1 Of the 16 studies included in the review, 14 (88 percent) examined massage therapy applied to surgery patients following the procedure. Several different surgery procedures were represented in the existent research; half were cardiac related, making cardiac surgery patients the most studied of massage for postsurgery populations. Also of note about the surgical pain populations included in the review is that all but one focus on adults. A single study examined massage for infants’ distress after craniofacial surgery, but none examined massage for a broad, under-18 pediatric population. With approximately 450,000 people under 18 years old admitted for surgery in the United States per year,2 the pediatric postsurgery population is “ripe” for research. Considering this and the high proportion of postsurgery massage research focused on cardiac procedures, the literature gap for postsurgery massage for pediatric cardiac patients seems pronounced. This literature gap is beginning to be addressed with new research in Pediatric Critical Care Medicine.  

Study Overview and Results

The article “The Impact of Massage and Reading on Children’s Pain and Anxiety after Cardiovascular Surgery: A Pilot Study” examines the safety and feasibility of massage therapy for pediatric patients immediately after congenital heart surgery.3 In addition, the massage intervention’s results are compared to reading visits for postoperative pain and anxiety. The randomized controlled trial took place at Lucile Packard Children’s Hospital Stanford and involved 60 pediatric patients 6–18 years old. Parents and patients were approached about study participation, enrolled, and randomized prior to surgery. Patients randomized to the massage therapy arm received massage 2–3 times per week during their postsurgery hospital stay, with a session and primary data collection occurring at three specific points: (1) within 24 hours postsurgery, (2) within 24 hours intensive to acute care unit transfer, and (3) within the final 48 hours of anticipated discharge. The reading study arm was meant to serve as a control for the attention patients would get from massage therapists and followed the same three-application/data-collection time points as the massage group. Massages were up to 30 minutes long and followed a procedural protocol consisting of intake, introductions, preparation, and positioning. The protocol allowed therapists to create a treatment strategy specific to the patient and situation using techniques modified for population appropriateness such as craniosacral, Swedish massage, reiki, healing touch, acupressure, shiatsu, or neuromuscular therapy. Massage therapists provided the treatments, were part of the hospital’s massage therapy service, and had 6–22 years of inpatient massage experience. Massage therapists also provided the up to 20-minute reading interventions but were not allowed to discuss any massage-related items. Patients or parents selected which of three preselected Dr. Seuss books to read at each session. Readers also followed a procedural protocol that consisted of introductions, preparation, book selection, reading, and showing the pictures while sitting as close as practically possible to the patient, and answering story- or book-related questions.
The study’s feasibility items of measure were safety and adverse events, as well as the extent to which study protocol was followed by participants and massage therapists. Patient outcomes measured in the study were pain, anxiety, and drug exposure.
Several interesting feasibility findings are reported in the article. All participants randomized to the massage arm of the study completed their participation; however, 22 percent of those randomized to the reading arm declined further participation. This contributed to the uneven numbers of participants in each of the study arms (n=36 in the massage arm and n=24 in the reading arm). Therapist treatment documentation indicated Swedish massage was the most-used technique, followed by craniosacral therapy, myofascial release, and energy therapies. The extremities were the areas addressed most often (feet, legs, head, face, etc.) by the therapists and half of the sessions included the chest being touched as an intentional part of treatment. No treatment-related adverse events occurred during the study, and the massage therapy intervention was well tolerated by study participants. Within the discussion section of the paper, several logistical and methodological challenges were presented, including intervention interruptions, scheduling pressures, and an inability to standardize medication dosing across participants. These discussions and considerations will inform this group’s future research in addition to others who wish to replicate the studied program or research in similar or other populations.
Pain- and anxiety-related outcomes indicated that those in the massage group had less pain and anxiety scores by the third measurement point (within 48 hours of discharge) than those in the reading group. While no statistical differences existed between the groups regarding opioid exposure during the first three days postsurgery, benzodiazepine exposure was less for the massage therapy group than for the reading group in the immediate three days after heart surgery. These outcomes provide preliminary evidence that multiple massage therapy sessions applied in conjunction with usual care for children following cardiac surgery provide benefit beyond that of extra caring attention.
While these preliminary findings are promising and exciting, care should be taken when considering and applying them to broader populations due to inherent study limitations acknowledged in the article. Of particular note, the sample size was relatively small overall and group sizes were disproportionate. The statistical methods employed by the researchers on the reported data seem appropriate, but a larger sample would allow more robust statistical testing to be used to better detect potentially subtle but meaningful effects in a relatively short timeframe. The authors also discussed limitations such as control protocol using reading material that may not have sufficiently engaged older participants and prior positive or negative impression of massage therapy (aspects not measured and therefore not considered in analysis). It is for these and other reasons this study’s results are considered preliminary, but every house needs a foundation, and this study provides an excellent foundation for the “massage for postsurgery pediatric patients” house to build on.

If findings are only preliminary, what aspects of this study can be applied to practice?

Even though these results are preliminary, there are several aspects that can be gleaned from this study and applied to practice. Things that may make research problematic or “lesser” on the evidence hierarchy pyramid may not produce the same limitations in practice and have meaningful application. For example, study researchers had to figure out what to do when intervention sessions were interrupted for various reasons (e.g., medical care necessities, housekeeping, etc.). When faced with interruption in practice, therapist and treatment recipient need only consider how to resume or conclude the treatment for the most therapeutic benefit within given restraints (time, scheduling, etc.); they do not have to concern themselves with protocol integrity or whether the treatment will “count” per research parameters. However, as a therapist, knowing and considering the potential for interruptions such as these provides the opportunity to think of how such situations could be handled beforehand. This may be of particular benefit for therapists new to work with those who are inpatient or with ongoing or continuous medical need. The information provided about the techniques and areas addressed also provide a starting place for a therapist either new to a hospital setting or asked to provide care for a person following cardiac surgery.
One thing this study highlighted was the choice to provide some light touch when possible to the child’s chest. While there is nothing specific in the article reporting how the children responded to that particular technique, just seeing that it can be done and was done in half of the study’s massages with no adverse events provides a framework for therapists to consider how to bring comforting, physical touch to surgically traumatized areas. The procedural massage session protocol is provided as a supplementary item to the article and outlines appropriate steps and approach for delivering a massage session for children postcardiac surgery. The protocol provides an excellent framework for therapists to implement into practice for any inpatient treatment or those receiving a lot of in-home medical care.
Administrators, policy makers, and families can point to the article when discussing the safety and feasibility of providing meaningful massage benefit for children postsurgery and while in intensive and acute inpatient care. It is reasonable for those not familiar with or knowledgeable of massage therapy to have concerns when considering application for such vulnerable and delicate patients. Concerned massage skeptics may also have prior experiences or expectations that reflect negatively on the massage field. This study’s demonstration of safety and established treatment framework beyond an anecdotal or single-experience account has more potential to inform decisions about including massage as part of postsurgical care. The description of the study’s massage therapists’ experience and inclusion as part of the overall health-care team provides additional positive context for massage skeptics’ consideration.
The article highlights various medical procedures and necessities for these pediatric patients that would apply to various other patient populations but are not covered in entry-level massage therapy training. These procedures include sedation protocols, sternotomies, and patient monitoring and medical care application devices. Studious massage therapists may take it upon themselves to look up and learn about unknown terms and procedures to apply critical consideration as to how and why they might approach such things in a treatment session. Such critical-thinking exercises broaden a therapist’s intellectual prowess, especially when personal reflection is compared to and, when possible, discussed with experienced or otherwise skilled massage therapists or care professionals. This is an ideal application of evidence-informed practice that also includes inner- and intra-discipline dialogue and engagement.
Bottom line, even though the research presented in the article is primarily a feasibility study, several practice-informing information nuggets exist, including, but not limited to, those outlined above.

What is the purpose of a feasibility and/or pilot study?

Large and fully powered clinical trials provide some of the strongest evidence for interventions, whether pharmacologically based or provider administered. While still a clinical trial, the massage and reading for pediatric postcardiac surgery pilot study was not large or fully powered, but is an absolutely necessary step in developing an evidence base. Clinical research, particularly large clinical trials, takes a lot of time and costs a lot of money. Before money and other valuable resources are spent on the largest and most impactful endeavors, several things should be established and demonstrated to ensure these important commodities are not wasted. For example, interventions must be conceived and procedures devised, before they are implemented in a real but small-scale research setting (whether that setting is in a controlled lab space or a practice clinic) to see if the intervention is logistically practical, acceptable to the study participants and related study or clinic personnel, and, perhaps most importantly, reliably measurable. For planning and budgeting purposes, researchers and funders need to have a good estimate of how long it will take to recruit participants, how much attrition (drop out) to expect, and what procedures may be needed to address known and unknown obstacles to completing the research as needed—including how compliant participants and research personnel will be to the study’s protocol. In addition, there has to be confidence that the way outcomes are measured is accurate, valid, and relevant in the grand scheme of things.    
Feasibility and pilot studies provide the opportunity to establish these important items at a fraction of the cost and give the research team the opportunity to complete an important dry run of everything to work out any last-minute kinks. As a person whose spouse starts two-month home-improvement projects that last six years, I heed the adage, “by failing to plan, you plan to fail.” Jumping right into a full-scale, large project without first establishing and testing all of the processes in any field is folly; doubly so for those in which stewardship is needed to safeguard public and private funds and resources. Feasibility and pilot studies are crucial steps in the research endeavor. While such steps add more time to the foundational evidence-building timeline, they reap benefits by improving the quality, and thereby the impact, of the large clinical trials.

Summary

Conducting research takes a long time. This is true whether considered from the micro perspective of a single study or the macro perspective of a cumulative, multi-study research program. The highlighted research in this column is only the first step in a long research process, and I look forward to the future work in this area from this and other research teams. However, the massage profession need not sit back and wait for the final, big clinical trial to be completed and disseminated before being aware of and incorporating the available research evidence into practice. The “Impact of Massage and Reading on Children’s Pain and Anxiety after Cardiovascular Surgery: A Pilot Study” begins to fill a gap in our field’s research literature and demonstrates the feasibility and safety of massage by experienced and trained professional massage therapists for children recovering from cardiac surgery.
While I have highlighted many items from this study that can be incorporated into practice, I encourage everyone to read this article and ask yourself how the procedures and processes discussed can inform practice. Better yet, get together with others in your massage therapy community and have broader discussions of the work. In addition to developing a research-informed massage support network, you will improve your research literacy and potential public reach for this important work.

Notes

1. Courtney Boyd et al., “The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations,” Pain Medicine 17, no. 9 (2016): 1757–72.
2. Sandra L. Staveski et al., “The Impact of Massage and Reading on Children’s Pain and Anxiety After Cardiovascular Surgery: A Pilot Study,” Pediatric Critical Care Medicine (2018), https://doi.org/10.1097/PCC.0000000000001615.
3. Keane Y. S. Tzong et al., “Epidemiology of Pediatric Surgical Admissions in US Children: Data from the HCUP Kids Inpatient Database,” Journal of Neurosurgical Anesthesiology 24, no. 4 (2012): 391–95.