We were getting into the weeds—as research nerds do—during a lively Q&A at the 2010 International Massage Therapy Research Conference in Seattle, discussing where it made the most sense to dedicate our admittedly limited resources. More specifically, we were debating the question, “Which is more important to measure: mechanism or effect?” Needless to say, the debate was spirited.
During our discussion, my mind took me to an imaginary deserted island where there were just two cans of data “food.” Everyone on the island would have to live on the contents of the can we decided to open. I wondered which can would “feed” more practitioners: the can that would reveal what massage does (the effect) or the can that would reveal how it does what it does (mechanism)?
There are people doing really important and valuable research who would disagree with me, but I’d open the can about what massage does every single time. Don’t get me wrong—I’m dying to know how it works, but I don’t think we get to have both in my lifetime, and I’m totally OK with the how of massage remaining a mystery. I actually wonder if we’ll lose some of the what when we think we know how. The truth is that massage is so deeply complicated and multifactorial that we’re in no real danger of truly demystifying the array of mechanisms behind massage therapy in the near future.
The Study
In 2017, Healwell partnered with MedStar Washington Hospital Center (a 912-bed hospital serving two of Washington, D.C.’s poorest wards), using a Palmer Foundation grant to conduct a palliative care massage therapy dosing study. At Healwell, a nonprofit that partners with hospitals and facilities to deliver integrated massage therapy to patients, we hoped the study would shed light on a few important questions, such as: Is a single massage received while lying in your hospital bed as “effective” as a massage every day for three consecutive days? Is 10 minutes of massage received while lying in your hospital bed as effective as 20 minutes of massage? What is the effect of any of these interventions on the nuanced experience of pain and anxiety? How will all of this stack up against the control group, which was “standard of care?” On some basic level, we wanted to see if we could reasonably tell hospital administrators that an hour of a massage therapist’s time could be translated into three to five discreet patient contacts.
The study resulted in data from over 1,000 massage sessions provided to 417 hospitalized patients over the course of a little less than two years. We collected a lot of data—a lot of which is still being analyzed.Healwell and our study partners will spend the remainder of 2020 and the better part of 2021 teasing out the most compelling and curious data from those sessions in two to four additional quantitative papers.
A Closer Look
In this article, we’ll focus on a paper we recently published in Complementary Therapies in Medicine, which analyzes the experiences of a subset of 12 patients (out of 417) who participated in that larger study.1 These 12 participants engaged in “semi-structured interviews” conducted by a research assistant and one palliative care physician who worked on the study.
In order to qualify for the study, a patient had to be deemed “palliative care eligible.” Palliative care is interdisciplinary care (detailed care plans created by practitioners from various medical disciplines or specialties) that is intended to improve symptoms and quality of life. Palliative care is not—as many people assume—end-of-life care. However, when educating other providers about the “types” of patients qualified to participate in the study, the misunderstanding of palliative care persisted, and most of our study patients were, indeed, very seriously or terminally ill.
Some patients experienced hospitalizations in which they knew their lives would end as a result of the inevitable progression of disease. Some were recovering from invasive surgeries that resulted in painful healing processes. Others were dealing with months-long, intractable infections or fractures, or chronically malfunctioning long-term care equipment. These were people whose quality of life was understandably challenged or diminished.
Each participant in the semi-structured interviews received at least one massage session during their hospitalization. Some received a massage every day for three consecutive days at some point during their hospitalization. None of the sessions were longer than 20 minutes. In contrast, the average length of stay for the study patients was 40 days. Some had been in the hospital for 60 or even 100 or more days by the time they received massage as study subjects. Massage therapy, thereby, was a relatively small aspect of their hospital experience.
These interviews yielded some vitally important insights:
• Patients shared that the most important aspects of their hospitalization were things like loneliness, monotony, difficulty sleeping, and discomfort caused by the invasive nature of frequent measurements and procedures. (It’s important to note that many of the patients also remarked that, as a result of a variety of factors, they did not have family or friend visitors, so they felt isolated and separated from their usual support networks.)
• Patients reported a variety of direct and measurable improvements in their symptoms of pain and anxiety, including an increased sense of peacefulness and a decreased sense of distress.
• Patients remarked that the massage therapists—not the actual techniques—supported them in feeling cared for, important, and connected, creating a sense of companionship.
• Some patients remarked that the sessions resulted in better sleep and less pain specifically.
• All patients reported feeling more able to cope with their situation after the massage—whether it was a single session or three sessions.
I strongly encourage you to read the paper. It’s a quick read, and if you’re not well-versed in research, you will still find it quite accessible.
It Takes a Village
Humans are nowhere near solving the problem of deep-level touch deprivation on the planet Earth, so when nurses—or even lay volunteers—provide kind but scripted “massage,” it often shows positive effect and reinforces that contact of this kind should be supported and fostered in care settings everywhere. That’s great news, and this type of research is not a threat to our profession, but it does not inherently advance it either. Kind touch is a part of massage therapy, but it’s not the whole picture.
If you are researching massage therapy, it is essential to have a resource who understands massage therapy from the inside. It is unfortunate that much of massage therapy research has been designed and conducted without the input of massage therapists, and some of the research also involves interventions provided by nonmassage therapists.
In our research, we explain that the intervention is provided by a practitioner of the discipline of massage therapy by referencing “specially trained massage therapists” throughout the paper. When data is published in a majority of massage therapy studies, there is little or no information about the training or experience of practitioners who worked on the study. This omission makes replication difficult, while also suggesting that the intervention has little or nothing to do with the practitioner.
Many studies argue that the omission of practitioner training and experience is intentional to “control for therapist effect” (the idea that a personal connection might develop between patient and a practitioner), which could skew the data in an artificially positive or negative way. Of course, we know that when removing the person, the intervention is different. If we want to continue to put—and keep—humans at the center of caring for other humans, our efforts are better spent designing protocols that allow for the technical and interpersonal skills of a well-trained practitioner to shine.
A Different Perspective
In our study, we chose to look at the “usual” measures of pain and anxiety so often seen in massage therapy studies, but we also included a measure of “peacefulness” and a measure called “distress.” Our understanding of pain and anxiety as multifactorial experiences has undergone a sea change in the past 10–20 years. Even so, the addition of these two more fluid states of peace and distress helped us discover the way that the whole perception of a person’s experience affects the usual, less nuanced measures of pain and anxiety.
Peacefulness is a relatively simple concept to grasp, but distress can be a bit tougher. The National Cancer Institute defines distress as “emotional, social, spiritual, or physical pain or suffering that may cause a person to feel sad, afraid, depressed, anxious, or lonely. People in distress may also feel they are not able to manage or cope with changes caused by normal life activities or by having a disease, such as cancer.”2
The Distress Thermometer3 is a commonly used tool in patient experience and medical research. In our study, we used it to limit survey burden for patients (we did not have them complete the full “problem list”) and learned that distress is similar to wind chill. You know in the winter when they say it’s 28 degrees, but it “feels like” 19 degrees when the wind blows? The thermometer doesn’t actually read 19 degrees when the wind blows, but you’d bet anything that it’s colder than they’re telling you it is.
Using the Distress Thermometer, we measured distress by asking a series of questions like: “How hard are you finding it to be alive today? How hard is it to form a coherent thought? How hard is it to think about things other than your illness?” This is where the value of the most relevant themes in the interviews comes clear. Participants pointed to loneliness, monotony, and invasive procedures as aspects of hospitalization that increased distress, decreased peacefulness, and colored their overall experience.
With the inclusion of massage therapists, patient perception of their hospital experiences shifted. While they often reported no change (or comparatively little change) in their pain or anxiety scores, many reported a decrease in scores of distress and an increase in peace scores. If we had captured only pain or anxiety, massage therapists and their interventions would have appeared ineffective for many of these patients who did, indeed, experience palpable relief. The addition of distress and peace measures allowed us to see that, while the subjective pain “score” may have remained the same, the experience of that pain or anxiety became more “manageable.”
The Value of Supported Coping
I remember one of our therapists telling me she worked with a patient who had extensive surgery and intense debridement (removal of infected, damaged, or dead tissue) to address an aggressive and idiopathic (of unknown origin) infection in his knee. The patient’s wound was open, so the therapist was unable to work anywhere near the specific site of his most intense pain. After the massage, though, the patient told her, “Yep. I still have pain but it is no longer my predominant sensation.” This patient’s experience in the shift of pain experience is the tip of an incredibly important iceberg.
If massage therapists might facilitate a window of real coping and presence in a patient’s experience, what are the possibilities? What if a massage therapist could work with a patient in advance of a scheduled family meeting? What if a massage therapist could work with a patient right before or right after a session of physical or occupational therapy? We don’t yet know how moments of manageability and supported coping can affect the overall trajectory of a patient’s hospital stay or illness, but there are real possibilities here for augmentation of what is now standard of care.
What Got Us Here Won’t Get Us There
When we look at research, there are so many things we can measure and ways we can measure them. When we wrote our paper, we referred to methods and findings revealed by research tools used in social work, chaplaincy, and psychotherapy studies. These tools are designed to capture factors influenced by human connection that can be hard to quantify. Many of the symptoms patients complained about (lack of peace, need for companionship, difficulty coping, and lack of touch) are things that cannot be reasonably addressed by pharmacology or equipment. And this is where I get really excited. Beyond the assertions of patients who reported that therapists were “caring” or “nice,” or that there was a “connection,” there were further details about how this sense was achieved.
Patients reported an appreciation that massage therapists have the ability to essentially “read the room.” They didn’t remark that therapists were funny or offered great conversation, or that they were entertaining. The interviews revealed that it was the therapists’ ability “to talk or to not talk” and to simply be with the patient that allowed them to feel connected and cared for.
I have a somewhat stubborn bias toward the idea that shutting up is one of the most important skills of any care provider. When we talk about “properly trained practitioners,” it’s worth noting that the training to which we refer is about 15 percent hands and 85 percent ears and heart. Training a person to understand that they can’t fix the suffering they see with their eyes—and they feel under their hands—is no easy task. I imagine I would get enthusiastic nods of agreement from my hospital-based massage therapy education colleagues on this point. You must know what a port is and what a PEG tube is and what PRN means, but if you think you’re going to lessen the pain score of a person whose sternum was just sawed through for an emergency surgery 24 hours ago, nobody in that dynamic will be successful. If, instead, you think you’re going to make the pain a little more bearable, you might be onto something.
As massage therapists, we must show up, which takes so much unlearning it hurts just to think about it. Showing up is what makes therapists who have ears like antennae, hearts like canyons, and mouths that know when to wait insanely capable of facilitating an experience of massage therapy that delivers on the true promise of the discipline.
Charting a New Course
In our study, we reached back to research that measured patient experience in chaplaincy, psychotherapy, and social work encounters and found that “comfort, contact, connection, and caring” were common themes that were noticed and appreciated by patients—but were also noted as lacking in most health-care encounters. If the health-care system were filled with kind, compassionate, and mindful providers, massage therapy would still be valuable. There is a lot of work for all providers to do, in terms of realizing these human-centered, heart-centered skills, and massage therapists have incredible potential to model and normalize these aspects of care.
At the end of the day, we have to create and engage in research that measures the value of massage therapy, but also more specifically the value of massage therapists. We have to be willing to loosen our grip on the value of mechanical technique and learn to embrace the deep benefits of bringing our whole selves to the table, the bed, the chair, or wherever care is needed.
Notes
1. Anne Kelemen et al., “ ‘I Didn’t Know Massages Could Do That:’ A Qualitative Analysis of the Perception of Hospitalized Patients Receiving Massage Therapy from Specially Trained Massage Therapists,” Complementary Therapies in Medicine 50 (August 2020), https://doi.org/10.1016/j.ctim.2020.102509
2. National Cancer Institute, “distress,” in NCI Dictionaries, accessed September 2020, www.cancer.gov/publications/dictionaries/cancer-terms/def/distress.
3. National Comprehensive Cancer Network, “NCCN Distress Thermometer and Problem List for Patients,” March 11, 2020, accessed September 2020, www.nccn.org/patients/resources/life_with_cancer/pdf/nccn_distress_thermometer.pdf.
Cal Cates is an educator, writer, and speaker on topics ranging from massage therapy in the hospital setting to end-of-life care and massage therapy policy and regulation. A founding director of the Society for Oncology Massage from 2007–2014 and current executive director and founder of Healwell, Cates works within and beyond the massage therapy community to elevate the level of practice and integration of massage overall and in health care specifically. Cates also is the co-creator of the podcast Massage Therapy Without Borders.