Last issue’s Somatic Research column explored the concept of practice-based research networks (PBRNs) and highlighted several PBRNs aligned with integrative health practices and massage therapy.¹ This column returns to a discussion of recently published massage therapy research and focuses on a study derived in part from the MassageNet PBRN, which examined the inclusion of, and attitudes about, health promotion activities in massage therapy practice.²

A connection between massage therapy, health promotion, and positive health messaging is obvious. Because of the focused time spent during a massage session, the potential is great for massage therapists to have impact on client health and related behaviors beyond treatment effects through education and behavior modeling.

When I was a practicing massage therapist, I did my best to model healthy living and behaviors to increase my personal and field credibility with clients and others who knew I was a massage therapist.

This credibility afforded me the opportunity to support clients during health behavior changes such as quitting smoking, decreasing sedentariness, or seeking preventive or diagnostic screening. Massage therapy is described as encompassing more than just the massage application because it also consists of “non-hands-on components including health promotion and education messages for self-care and health maintenance.”³ We all likely have anecdotes about how either the time we get to spend with clients, or the developed trusting relationship with a client, afforded the opportunity to provide or reinforce positive health messaging. My standout anecdote is how the trusting relationship I had with a longtime doctor-abhorrent client resulted in them getting a cancer screening that likely saved their life. Despite the fact that health promotion and positive health messaging is a part of massage therapy, little related research exists.

“Advancing Health Promotion Through Massage Therapy Practice: A Cross-Sectional Survey Study” was published in 2018 in Preventive Medicine Reports and is a product of the collaborative efforts of researchers from the University of South Carolina School of Medicine and National University of Health Sciences.⁴ Researchers involved in the study wanted to know massage therapists’ practices and attitudes toward health promotion; which health promotion messages or practices massage therapists include as part of their treatments; what health promotion activity barriers exist for massage therapists; and the extent to which therapist characteristics or attitudes are associated with perceived barriers. Survey methodology was used in gathering data to address these questions, and participants were recruited in two waves. The first wave sought to recruit massage therapists practicing in the United States exclusively through MassageNet, while the second wave added social media recruitment efforts to the PBRN outreach. The three-month recruitment efforts yielded 256 respondents and 182 completed surveys for data analysis.

Between one and nine massage therapists from most states participated in the survey, with the exception of New York and Illinois, which each provided 19 and 24 respondents, respectively. No respondents were from Washington, D.C., Ohio, Mississippi, North or South Dakota, Nebraska, Oklahoma, Wyoming, Montana, or Delaware. There were several sample attributes that were more prominent than others, with only the high proportion of female (82 percent) and white (84 percent) participants relatively reflective of the massage therapy field. For example, the study sample’s median age of approximately 50 years is older than that of the general profession (45 years) and more than 55 percent of the study sample earned a bachelor’s degree or higher compared to industry reports suggesting less than 40 percent of those in the massage field hold a bachelor’s degree or higher. In addition, the study sample were very experienced, with fewer than 35 percent reporting being in the profession for less than 10 years and most having greater than 600 foundational training hours and over 200 hours of continuing education. 

Over 90 percent of respondents indicated they agreed or strongly agreed that it is important for massage therapists to include health promotion messages as part of their work with clients/patients, and half thought therapists should spend more time conveying such messages. When asked what sort of sources they used to locate and confirm their client/patient health promotion information, the highest proportion indicated professional associations (69 percent), followed by seminars (64 percent), scientific journals (62 percent), health-related websites (60 percent), textbooks (57 percent), and trade publications (42 percent). Fewer respondents indicated news outlets (21 percent), social media (25 percent), and national guidelines (35 percent) as sources for health promotion information, and 22 percent indicated they used other, non-articulated sources.

The survey gave participants a list of 22 health promotion topics and asked for indication if they provided messages, referred client/patients to another health-care professional for messages, or provided no message or referral related to each topic in their practices. On average, massage therapists reported including 9–10 of the inquired health promotion messages in their practices, while referring to other health-care professionals for 8–9 topics, and not providing or referring on 2–3 queried topics. In other words, respondents either included or referred health promotion messages or activities to other professionals for most of the queried topics. Self-massage was the health promotion topic receiving the highest proportion of respondents indicating they provided related health messages in their practice (93 percent) followed by stretching (90 percent), body awareness (90 percent), hot/cold therapy (89 percent), and topical therapy usage (86 percent). A high proportion of respondents also indicated offering messages related to breath work (78 percent), water intake (71 percent), stress management (69 percent), mindfulness (65 percent), and healthy lifestyle (57 percent) in their practices.

The health promotion topics with the highest proportion of referrals from respondents included mental health (85 percent), nutritional supplementation (74 percent), possible skin cancers (73 percent), other skin health/care (72 percent), smoking cessation (71 percent), healthy eating habits and nutrition (67 percent), and weight management (66 percent). Respondents were less likely to neither provide nor refer on the queried topics, but a handful of topics received relatively high proportions of non-provision or non-referral. Specifically, visualization (25 percent), sexual health (22 percent), weight management (21 percent), and aromatherapy (21 percent) had the highest proportions of respondents to indicate they did not provide health messages on the topic or refer their clients/patients to other health-care professionals. Other health promotion message topics that were offered by participants included those related to sleep and sleep-related issues, pain, and ergonomics.

Several barriers were reported by respondents as inhibiting to their inclusion of health promotion messaging or referral, including the lack of guidelines (45 percent); knowledge, competence, and/or other skills (41 percent); massage time (32 percent); community resource knowledge (26 percent); management/administration support (21 percent); and reimbursement (19 percent). Other barriers to health promotion inclusion or referral (24 percent reported lumped together in an “other” category) included client/patient lack of interest, changing evidence, and time. The number of barriers reported by participants ranged as high as 9, and, on average, each participant reported 2.3 barriers to health promotion inclusion or referral. Analysis revealed some interesting associations between participant descriptors and the number of reported barriers. Those with more experience, who believed that health promotion should be a priority in massage therapy practice, and who believed massage therapists should spend more time including health promotion in practice, reported fewer barriers. On the other hand, those with a bachelor’s degree or higher reported more barriers compared to those with less education.

Interesting Research Literacy Points Related to the Study

Survey research is a fundamental and important methodology in the progression of any field. While perhaps less exciting than clinical trials or experimental designs for applied fields such as massage therapy, survey research produces real-world, empirical data with higher potential for generalization due to its ability to cover a broader swath of the interest population in a relatively short time, and at relatively lower costs, than other types of research.⁵  While survey data is typically more generalizable to broader populations, the authors highlight an important note that these survey responses may be biased toward the inclusion of, or referrals for, more health promotion messages within massage therapy practice due to the high education and experience of respondents. This potential for results skewing is likely also linked with a known sample bias in research generally that indicates those who are willing and interested in participating in research are often better educated, more experienced, healthier, and more generally engaged. On the flip side, those less likely to participate in research (survey or otherwise) are those with less experience and education, poorer health, and lower general engagement. This coupled with the seemingly increased efforts on the part of various technology-driven platforms to collect and use personal data for marketing purposes also makes people wearier of clicking links and actively providing additional information.

This leads to a research challenge highlighted in the article and that also faces research in general: recruitment. Recruitment is one of the most difficult aspects of research, yet its challenge is often underappreciated by those not involved in research. It is very easy when thinking about research to fall into the trap of expecting “If you build it, they will come,” whether the research is a clinical trial, survey, or otherwise. When I tell people about the research I do that involves participants actually getting multiple free massages, non-research people inevitably say something like, “You must have people tripping over themselves to be a part of that study!” Even when positively perceived participation incentives exist, recruitment is always hard for research, and in cases like surveys, in which it really is just people taking the time to complete them, there has to be some other compelling reason for people to choose to participate. Indeed, with all the things competing for people’s time in today’s society, it’s a wonder all surveys don’t come with a cute kitten incentive video to try to increase participation! For this study, the authors report that over 3,900 emails were sent to potential participants and that at least 2,581 people saw social media recruitment posts. From those, only 182 surveys were completed and included in reporting and analysis. It is also notable that a much greater recruitment yield came from social media recruitment (~64 percent) rather than direct emailing to the PBRN pool. However, there was likely quite a bit of overlap between the audiences because some social media recruits came from the MassageNet Facebook page. Strategies to incentivize or otherwise encourage people to take the time to complete surveys and other types of research can be challenging. I hope the takeaway readers get from this point is to be good massage research citizens whenever possible. Participate in research; particularly those of the low “time cost” variety like surveys.

Research Related Practice Implications

One of this study’s limitations highlighted by the authors is that while which topics of health promotion massage therapists included in their practices were identified, the actual content and accuracy of these messages and practices were not. This raises the issue of epistemology (essentially, how what is known is known) for health promotion messages used by massage therapists. Health promotion is a key component to several applied health disciplines, particularly public health, but few massage therapists receive public health or related training, and the extent to which therapists have the competency to locate, access, and implement reputable, relevant, and accurate health promotion information is unclear.

The researchers sought to clarify this as much as possible within the confines of their survey study design and did ask how therapists got their health promotion information. Indeed, several of the sources such as scientific journals, professional associations, and current textbooks and national guidelines likely provide sound related information to massage therapists wishing to incorporate meaningful health promotion messages in their practice. However, other information sources such as seminars, websites, and social media may be at higher risk of bias or inaccuracies depending on the sources from which their information is based, which is sometimes a bit harder to determine. It is therefore important for massage therapists to consistently reinforce and further cultivate their critical thinking and research literacy skills and identify their sources and resources whenever possible for clients and patients about health promotion messages. Citing sources and sharing resources is a good practice to build client/patient trust and to also help empower them in their own health education skills.

Another practice application takeaway point this article presents to massage therapists is a list of potential health promotion topics they could educate themselves about and implement into their practice. For instance, I found it interesting that such a high proportion of therapists indicated referring their clients/patients to other health-care professionals for mental health-related health promotion. This high proportion speaks to the great potential massage therapists can have in helping link those in need of mental health support to professionals able to provide that care. This could have profound impact on various populations, including those at risk for, or experiencing, depression and anxiety, declining mental cognition, suicide, or violence. Unfortunately, little, if any, foundational massage or continuing education time is specifically allotted to this sort of inter- and cross-discipline education and the extent to which massage therapists can screen for, identify risks or decline in these regards, or have the resource knowledge to link people to appropriate and accessible support is unknown. While it is not within the massage therapist’s scope of practice to diagnose or prescribe treatment for these sorts of issues, it is likely that massage therapists will have these situations present themselves in practice at some point and referral to reputable and appropriate health-care professionals is within the massage therapist scope and/or standard of practice. Therefore, a responsible massage therapist will have some resources available or prior consideration to fall back on when situations arise. The health promotion topics list provided in this article could be used as a personal development road map to reinforce or educate yourself about for the benefit of your practice and clients. I have encouraged readers in past issues to form research literacy or practice support networks, and the exercise of solidifying topical health promotion messages into practice would be excellent to do in a supportive peer environment in which local resource repositories could be developed and shared.

Final thoughts 

The focus in this column may be a stretch for some with regard to how relevant this research is to currently practicing massage therapists. However, I truly believe that massage therapists have an untapped potential to become important clinicians in health care, particularly related to individual health, through the adoption of public health strategies like health promotion messaging. An important attribute of massage therapy is the amount of focused time therapists have with treatment recipients. Such time is scarce for most other applied clinicians within health-related fields, with actual appointment contact time becoming less and less even as patient need increases. Several fields within health care, particularly medicine, lament the compressed time they have with patients and the expectation placed on them to be the primary deliverer of important health promotion messaging.

Massage therapists have the “luxury” of spending treatment time just on treatment application and for now, without other treatment and care needs interfering (think of the administration of medications and other patient needs nurses attend to) or the split attention due to the simultaneous care of multiple patients at all times. This research highlights a place where massage therapy practice can meaningfully expand for the improvement of client/patient care and outcomes. Perhaps this work can lead to related education and field policy considerations beginning to appear for consistent and clear health promotion guidelines in the massage therapy field.

Notes

1. Niki Munk, “Practice-Based Research Networks, Practice-Based Research, and the Increased Potential for Massage Therapist Engagement with the Growing Massage Evidence Foundation,” Massage & Bodywork 34, no. 1 (January/February 2019): 52–5.

2. MassageNet Research Network, accessed January 2019, available at www.massagenet.org/about.

3. Ann B. Kennedy et al., “Clarifying Definitions for the Massage Therapy Profession: The Results of the Best Practices Symposium,” International Journal of Therapeutic Massage & Bodywork 9, no. 3 (2016): 15.

4. Ann B. Kennedy et al., “Advancing Health Promotion Through Massage Therapy Practice: A Cross-Sectional Survey Study,” Preventive Medicine Reports 11 (2018): 49–55.

5. Kate Kelley et al., “Good Practice in the Conduct and Reporting of Survey Research,” International Journal for Quality in Health Care 15, no. 3 (2003): 261–66.