As a young person who inherently received care from others, the reminder on airplanes for people to put their own mask on first before helping others was kind of unnecessary … of course I’d put my own mask on first. My self-preservation was high, I considered myself independent, each seat gets their very own oxygen mask, and I certainly did not want my mother passing out because she was busy helping me put my mask on!
Then, I developed a helping-centered career, I had kids, my parents began aging into older adulthood, and others who I began traveling with required assistance in general. My perspective changed as I experienced the impulse to neglect self and spring immediately to focus only on ensuring the health and needs of those within my care and who in many instances, I love. I now understand why those airplane announcements are necessary.
Caregivers often prioritize the needs of those they care about, particularly when those loved ones are vulnerable. In the airplane announcement example, the aviation industry has taken it upon themselves to provide reminders in support of the greater (safety) good of everyone on the plane in the event of an emergency. This reminder, and lesson, is a great metaphor for many massage-related situations, whether in regard to clinician self-care or as a reminder to clients.
In this column, we will focus on the application of the “put my mask on first” metaphor on a massage population often overlooked: informal caregivers—those who provide unpaid, “informal” care for family members or friends with temporary or permanent conditions that limit functional independence.

Informal Caregiving

Informal caregiving, for any population, has its stressors and particular burdens in the home and supportive care environments. Informal caregiver health and well-being are particularly vulnerable during and following hospital stays due to stress, worry, and related concerns.1
Increasingly, massage-related research is examining massage benefits for admitted patients or patient populations in particular. This is excellent, and bodes well for the progression of the field. However, there are other populations within the hospital and health-care environment that would also benefit from massage, including clinicians, support staff, and informal caregivers of admitted patients. The research evidence base is building for anxiety, depression, and stress, which are generally experiences informal caregivers have in abundance. In the health-care environment particularly, informal caregivers tend to suppress their needs while focus is heightened on their loved one who is recovering from a serious illness or injury, or whose health is deteriorating.2

Study Description

Recently published research sought to examine massage for informal caregivers in the rehabilitation hospital setting. The article, “Therapeutic Massage to Enhance Family Caregivers’ Well-Being in a Rehabilitation Hospital,” details a trial in which researchers identified two goals: (1) to understand the impact of massage dosage on the psychological functioning of family caregivers, and (2) to identify implementation barriers and challenges along with caregivers’ perceptions of the program.3
For the study, researchers conducted a trial in which data were gathered through questionnaires and interviews prior to and following completion of the intervention. Caregivers of adult and pediatric patients admitted to the study hospital (with admission expectations of three weeks or more) were invited to participate in the study if they were older than 18 years and did not have a health condition contraindicated for massage. (Patients in the hospital were those with traumatic brain injuries, severe stroke, spinal cord injuries, and complex neurological medical conditions.)
Those who enrolled in the study were randomized to receive either one 60-minute massage per week for two weeks or three 60-minute massages per week for two weeks. The massages would take place in a private massage room in or near the hospital by a trained and licensed massage therapist.
Massages followed a standardized protocol that allowed for individualization based on each participant’s needs, engaged moderate pressure, and addressed the whole body. Study researchers hypothesized that caregivers receiving three massage sessions per week would have better outcomes with regard to their mental well-being and health and indicate more pronounced reductions in their stress.

Assessment Scales for Data Collection

Four standardized assessment scales were used to collect data for analysis: two scales related to the primary outcomes of interest (caregiver well-being and stress), one to account for potential confounding factors, and one to assess the participants’ perceptions and acceptability of the massage intervention.
• The Brief Symptom Inventory 18 (BSI 18)4 produced three symptom scales for depression, anxiety, and somatization, and also provided an overall index of psychological distress.
• The Perceived Stress Scale (PSS)5 was used to quantify the extent to which respondents perceived situations in their lives to be overwhelming, uncontrollable, and unpredictable.
• Prior to the intervention, participants completed the Client Expectations of Massage Scale (CEMS)6 to account for potential confounding aspects of participants’ prior experiences and perceptions of massage therapy.
• Finally, participants completed an exit survey after they completed study activity, which incorporated Likert-scale questions from the Behavior Intervention Rating Scale (BIRS).7
The exit interview also included open-ended questions, so participants could provide more detailed responses about what they liked and didn’t like about the massage and the program, what they would change, and how they would describe the program to a loved one.

Study Results

Thirty-eight people enrolled in the study and were randomized to massages either one or three times per week for two weeks. The hour-long massage protocol indicated the body area addressed, order, and time allotment for each portion of the session.
Therapists used clinical decision making with regard to muscle address and technique, so participants received individualized care—which is a signature feature of real-world massage. Most of the participants (53 percent) were mothers of patients in the hospital, while another 34 percent were spouses, and almost all participants were white (92 percent).
Sixteen percent of participants (n=6) were unable to complete the intervention due to their loved one being discharged earlier than anticipated or feeling too overwhelmed with their loved one’s medical condition and treatment/support needs. Most participants had 100 percent compliance (two or six total massages) in the study, but there were several from each group who were unable to complete all of the assigned treatments. Specifically, 79 percent of all planned massages for enrollees were completed, and if only those who finished the data collection are considered, 89 percent of planned treatments were completed.
All emotional well-being and perceived stress scores significantly improved from pre- to postintervention for both groups. However, no between-group differences were found. In other words, both groups had less depression, anxiety, somatization, and perceived stress at postintervention than at baseline, but massage three times per week for two weeks was not better than once per week as hypothesized.
The program exit surveys provided meaningful feedback about the program’s acceptability for this population and allowed participants to suggest ways to improve program implementation. Four themes emerged from qualitative analysis of exit interviews for those who completed the program: physical benefits, emotional benefits, enhanced caregiving capacity, and improved health care experience.
Participants referred to pain and tension relief, better sleep, and relaxation from the massages (physical benefits). In addition, nearly all participants indicated that their mental health improved during the program (emotional benefits). Several participants also indicated the massage-induced breaks helped them rejuvenate, have a better attitude, and feel more focused with their caregiving responsibilities (enhanced caregiving capacity). Finally, participants indicated that being a part of the study and being able to participate in the massage program benefited their perception of the hospital and the care team. Several highlighted quotes from the exit interviews pointed to the appreciation participants had of being valued and affirmed as a caregiver by the hospital and the program (improved health care experience).
Scheduling the massages was a major challenge for participants and the research team. Appointment availability was limited due to the two therapists’ schedules, and while this challenged the once-per-week participants, it was doubly challenging for those who were supposed to schedule three per week.
Participants suggested massages be scheduled per their admitted family member’s treatment schedule and to extend the program to inpatient families regularly for the duration of the stay. Ultimately, participants of the study thought the program should be available to all patient caregivers and that everyone should be robustly encouraged to take part and get the massages. In this case, participants seemed to advocate for the hospital to take up the “self-care for the caregiver” (put your mask on first) message for the overall good of patient care.

Study Applications

There are many applications to massage practice one can glean from this research and article. One is obvious and was the intro premise for this column: self-care for the caregiver. The other two applications I’d like to touch on relate to therapist scheduling-related challenges and massage-application protocols.
In the last issue (“Massage for Young People with Cystic Fibrosis,” July/August 2019), we discussed the various usages and application of massage protocols in research and practice.8 This study is a nice example of an intervention protocol that bridges both application scenarios (research and support for early careers or novel situations) in that it provides a standardized framework for each massage session, so there is a foundation of measurable consistency between each applied intervention—while also allowing for clinician decision making and individual needs tailoring, which is reflective of real-world practice. The article includes the massage protocol as a table, which allows for replication and adaptation in future research or as a guide to evidence-based practice treatment planning.
Several challenges exist for massage-program implementation into hospital settings, whether implementation is for service, care-team treatment application, or research purposes. With more massage programs becoming available in hospital and similar health-care settings and related research, articles that report feasibility and implementation data do the field an important service. By reporting challenges and barriers faced by the research team, important “lessons learned” are shared that may keep others from having similar issues or help future teams and programs plan for, or successfully meet, those challenges.
Scheduling challenges are obvious for patient participants, but this article points out similar—and perhaps less obvious—challenges in the nonpatient massage recipient. These differences may point to the need for treatment delivery variation in hospital-based massage programs to meet multiple scheduling accommodation realities.
The article also discussed massage therapist anecdotal feedback that suggested missed appointments by participants led to inefficient use of therapist time. This, coupled with the challenges participants had with keeping their appointments, highlights the reality of conflicting needs for massage in hospital settings and sometimes in research generally.
The final application-to-practice point this article highlights is the importance for caregivers to also receive care, and how patient care can be improved by including informal caregiver support. Participants in this study indicated the research and affiliated massage program reflected well on their view of the hospital and supported them in their caregiving role with the patient.
As massage therapists, we are well aware of the challenges faced by our clients who are themselves caregivers for the various people in their lives. These clients, in many cases, are indeed informal caregivers for loved ones with temporary or permanent conditions that limit functional independence. We have these clients’ attention in relation to their own self-care and renewal needs, but other avenues may exist to support other caregivers in need through caregiver support services or programs, such as the one highlighted in this research.
Ideally, hospitals and other patient advocacy proponents can take up the “take care of yourself first” approach the airline industry has adopted with their own “importance of self-care through massage” message to accompanying caregivers of admitted patients. This study is an evidence-based example of how even weekly massage for caregivers is beneficial for individual well-being and perspectives on continued caregiving capacity.

Final Thoughts

After selecting this study as one I wanted to focus on for Somatic Research, I discovered it was funded by the Massage Therapy Foundation, which made my smile about this work widen just a bit more. The Massage Therapy Foundation provides modest funding each year through a competitive process for community service and research projects like this one.
As mentioned in prior columns, research is time-consuming and, in most cases, requires financial support to cover related costs, such as people’s time, materials and supplies, incentives, and dissemination. While the large-scale massage intervention trials that are so exciting to our field are typically funded by national governmental funding agencies, such as the National Institutes of Health, the Veterans Health Administration, or other similarly large institutions, funding and support avenues for smaller scale, early research career, and clinical research is important. The selection of this research project by a funder with its sole focus on the massage therapy field speaks to this study’s alignment with the field’s interests, as well as its reflection of real-world massage therapy practice and relevance.

Notes

1. Ilse van Beusekom et al., “Reported Burden on Informal Caregivers of ICU Survivors: A Literature Review,” Critical Care 20, no. 1 (2015): 16.
2. J. Nick Dionne-Odom et al., “The Self-Care Practices of Family Caregivers of Persons with Poor Prognosis Cancer: Differences by Varying Levels of Caregiver Well-Being and Preparedness,” Supportive Care in Cancer 25, no. 8 (2017): 2,437–44.
3. Natalie A. Williams et al., “Therapeutic Massage to Enhance Family Caregivers’ Well-Being in a Rehabilitation Hospital,” Complementary Therapies in Clinical Practice 35 (2019): 361–67.
4. Leonard R. Gerogatis, Brief Symptom Inventory (BSI)-18: Administration, Scoring and Procedures Manual (Minneapolis: NCS Pearson, 2001).
5. Sheldon Cohen et al., “A Global Measure of Perceived Stress,” Journal of Health and Social Behavior (1983): 385–96.
6. Karen T. Boulanger et al., “The Development and Validation of the Client Expectations of Massage Scale,” International Journal of Therapeutic Massage and Bodywork 5, no. 3 (2012): 3.
7. Taelyr Weekly et al., “Impact of a Massage Therapy Intervention for Pediatric Palliative Care Patients and Their Family Caregivers,” Journal of Palliative Care (2018), https://doi.org/10.1177/0825859718810727.
8. Niki Munk, “Massage for Young People with Cystic Fibrosis: Dissemination Choices Bring Wider Access,” Massage & Bodywork 34, no. 4 (July/August 2019): 42–45.