The Centers for Disease Control and Prevention (CDC) announced late last year that deaths involving prescription pain medications have more than tripled over the past decade.1 According to the Los Angeles Times’s analysis of the data, deaths by drug overdose now outnumber traffic fatalities.2 Even over-the-counter pain medications are not without complications of death.
According to Janet D. Pearl, MD, “Over-the-counter products—while easing pain and reducing inflammation—can present problems, especially if taken with alcohol or in excess of recommended doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause ulcers or bleeding in the gastrointestinal tract, even if taken properly. Also, acetaminophen can be toxic to the liver in doses greater than 4 grams (and even less if taken with alcohol or by someone with liver disease). Acetaminophen is also contained in other medications, so an accidental overdose is possible if you’re not careful.”3
“For chronic pain, narcotics should be the last resort,” says Thomas Frieden, MD, director of the CDC in Atlanta, which issued the report.4
But more than 116 million American adults live with chronic pain.5 In an effort to identify how to help those in pain, yet curb unnecessary prescriptions, pain projects are forming locally, nationally, and internationally. Government funding for pain research is increasing. In the report, Relieving Pain in America, the Institute of Medicine has charged the US Department of Health and Human Services with creating a comprehensive plan to address chronic pain as a complex disease, not just a symptom of injury and illness.6 Blogs such as Pain-Topics.org are also joining the debate, analyzing the data, and suggesting that while drug abuse is a problem, opioids are not the killers they are portrayed to be. Pain is the true epidemic at hand.7
As the debate rages, how are doctors helping their patients cope with chronic pain if the trend is to cut back on prescription pain medication? Sites such as Sciencedaily.com and WebMD promote exercise, tai chi, and yoga for pain relief, and occasionally suggest enlisting the help of a physical therapist. Rarely do these sites mention massage when recommending alternatives for coping with pain. As frustrating as this is, I understand why these websites are not promoting massage therapy. When I look for supporting evidence, of the 1,782 current studies on chronic pain, only 10 trials are studying the effects of massage therapy on pain.8
According to a National Institutes of Health survey on the use of complementary and alternative medicine, Americans choose massage therapy as their number one out-of-pocket, practitioner-based expense for treating pain, stress, and the negative side effects of conventional medicine.9 This statistic is our best friend and must be flaunted to influence the government-sponsored conversations on pain, the policy-makers’ conversations on pain, and the community-based conversations on pain. Most of all, the doctors treating people with chronic pain need to hear this statistic repeatedly and see studies showing evidence that massage provides relief from pain, assistance with pain management, and a reduction in the emotional side effects of pain.
I am grateful that our clients are our advocates, demanding prescriptions for massage and seeking out massage therapists on their own to find relief from painful and stressful conditions, but we must take some responsibility. It is time to take an active role in promoting massage therapy for pain relief and as an alternative to prescription and over-the-counter pain medications. This is best done by finding the research that supports our clinical findings and, with a well-written introductory letter, sharing the articles with our clients’ doctors.
A few conclusive research articles could assist in marketing your skills and services. For example, I recently moved my practice within a block of a pain specialist. Many physicians, physical therapists, and chiropractors refer to this clinic when their patients need help managing pain conditions that are complicated or unresponsive, avoiding surgery, or recovering from an unsuccessful surgical intervention. I currently tout working with acute postoperative pain and chronic pain as my primary specialties. Success with one of the clients from the pain clinic could lead to relationships not only within the pain clinic’s staff, but also with many other health-care providers in the area.
Find Supportive Evidence
The most accessible place to look for evidence supporting massage as a treatment for pain is PubMed (www.ncbi.nlm.nih.gov/pubmed). PubMed is a free database of medical research citations that provides access to the MEDLine database of references and abstracts. Over 21 million references are indexed on PubMed, and many of these references provide links to full-text articles.
To get you started, here are a few suggestions on how to begin a search on massage and pain:
1. Identify your search terms.
2. Search for systematic reviews.
3. Use PICO (Population, Intervention, Comparison, Outcome) to refine your search.
4. Search for clinical trials.
5. Print articles that provide supporting evidence and use them to promote your practice to health-care providers that treat pain patients.
A variety of tutorials are accessible on PubMed to assist you in navigating the site. Jump in with the information provided here and know that if you get stuck,` help is available.
Identify Search Terms
The first step in conducting a literature search on massage therapy and pain is to identify the words that will best represent the information you seek. A very general search done on massage and pain may yield more results than you wish to investigate, or you may want to get more specific.
This scenario—pain—could yield a variety of research questions. We could pursue chronic pain, or choose specific topics like fibromyalgia, neurogenic pain, or osteoarthritis. If you are more interested in acute pain, search for acute pain, or specify postoperative pain, sports injuries, or traumatic injuries. Narrow the focus of your search by identifying your area of expertise and interest. Or, you may choose to focus on a recent client that presented with a troubling pain condition.
Once you have identified a general or specific search term for pain, select the search term for the intervention. You may explore massage therapy in general, or identify specific bodywork modalities. You might be interested in myofascial techniques and the latest information that came out of the International Fascia Research Congress held in March. Typically, massage is not described in detail in research (something I hope improves in the near future), and is often used as a general term. Therefore, the use of specific techniques or modalities in your search may not be fruitful. Some terms that will yield limited results include craniosacral therapy, lymphatic drainage, and reflexology. Test search terms to see if the information you seek is specifically available, or if more general searches are required.
It is helpful to see how PubMed defines the terms we wish to search to ensure the net we cast is going to adequately capture the studies we are interested in. Medical Subject Headings (MeSH) is a comprehensive, controlled vocabulary for the purpose of indexing articles, and acts like a thesaurus when searching the database. On the PubMed homepage, click on “MeSH Database” under More Resources on the right side of the page. In the search bar, enter the term you wish to define. The term massage identifies two groups of terms. Heart massage refers to massage performed directly on the heart during open-heart surgery. Click on “Massage” to view the subheadings, entry terms, and subject tree included in every MeSH search of the word massage.
For my search, I chose to use the general term massage. Pain, on the other hand, yields 54 groups of terms in the MeSH classification system. After looking at the expansive definitions for pain, I decided to narrow my search to chronic pain.
Systematic Reviews
Once you’ve identified your search terms, I recommend limiting your initial search to research reviews. Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question.10 The primary objective of a research review is to draw conclusions useful for clinical practice and policy-making, and identify future directions for research.11
Systematic reviews are a critical component of evidence-based health care, a topic often discussed in this column. In order for evidence to better inform practice, there must be consensus across a wide range of studies, rather than basing clinical decisions on the results of a single study. A systematic review can identify if sufficient research exists on a particular topic, evaluate if the body of research meets quality standards, and determine if cross-study consensus is sufficient to draw meaningful conclusions. It can also identify gaps in the evidence that can then be used to inform future studies.
To specify “Review” in your search, perform the following:
1. On the home page of PubMed, click on “Limits” directly under the search bar.
2. Under Type of Article, check the box “Review.”
3. You may wish to also select “Humans” under Species if you wish to only read reviews of human trials.
4. You may also wish to select “English” under Languages if you want to limit your search to research written in English.
5. Type in your search terms in the search bar at the top of the page (for example, massage and chronic pain).
6. Click on “Search” near the bottom of the page.
The articles listed will all be reviews of research, summarizing studies that have been conducted on this topic and that meet the criteria for the research question expressed in the title of the review. Read the abstracts, if available, to see if the reviews match your area of interest. If so, and the full-text article is freely available, read it critically to see if it meets your needs and can be used to market your skills and convince referring caregivers of the benefits of massage therapy for pain management.
My search for “massage and chronic pain” yielded 76 results. This was more than I was willing to investigate, so I narrowed my search even further and typed “massage and fibromyalgia” into the search bar. That search yielded 17 reviews. Only one review mentioned massage therapy in the title,12 and one focused on myofascial techniques.13 Neither article was available for a free download.
This didn’t satisfy my search. It was time to look for clinical trials to further support and inform my cause.
Refine Search: Clinical Trials
If a review has not yet been conducted on your preferred subject, or if the few that exist do not meet your criteria, conduct a search of clinical trials to find supporting evidence. If the search yield is overwhelming, narrow the search by getting more specific; for example, specify that the term massage must be in the title or abstract. We learned in the previous search that many references were listed that did not focus on massage therapy, but instead were reviews on chiropractic, physical therapy, or alternative medicine in general. In addition, interesting articles were not freely available, which can be costly and frustrating. Specify free, full-text articles and see if this is fruitful. You may be able to go back to the original search terms and get a manageable list of articles to review.
Change the following limits on your search:
1. Click “Advanced” below the search bar and use the builder to specify that massage is in the title or abstract of the study. To do so, scroll down the first list under “All Fields” and click on “Title/Abstract.”
2. Type the term massage in the search bar next to “Title/Abstract.”
3. Leave the next “All Fields” as is and type “chronic pain” in the search bar.
4. Under “Limits,” uncheck the box for “Reviews” and check the box for “Clinical Trials.”
5. Click on “Search.”
This results in 22 articles listed; all massage therapy clinical trials, all with free access to the full-text articles in English. The list includes studies on headaches, osteoarthritis of the knee, low-back pain, neck pain, and many others that look promising.
Read several that you find interesting, and critique them according to the guidelines presented in previous Somatic Research articles:
1. Check the level of evidence. Clinical trials that randomize participants and test against control groups rank higher than pilot studies or case reports.
2. Note the sample size. Larger studies demonstrate generalizability over studies with only a few participants.
3. Check the methods. Was the massage protocol performed by licensed massage therapists or untrained caregivers? Does the protocol make sense? Is this how you might work with someone in practice?
Print out the studies that best reflect the population you wish to work with and that demonstrate the efficacy of massage for pain. Share these with potential referring health-care providers and promote your ability to help safely relieve chronic pain.
Notes
1. Centers for Disease Control and Prevention, “Vital Signs: Overdoses of Prescription Opioid Pain Relievers,” accessed April 2012, www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm.
2. Lisa Girion, Scott Glover, and Doug Smith, “Drug Deaths Now Outnumber Traffic Fatalities in US, Data Show,” Los Angeles Times, September 17, 2011, accessed April 2012, http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918.
3. MetroWest Daily News, “Physician Focus: Don’t Let Back Pain Get You Down,” accessed April 2012, www.metrowestdailynews.com/lifestyle/columnists/x10289243/Physician-Focus-Dont-let-back-pain-get-you-down?zc_p=1.
4. USA Today, “Painkiller Overdose Deaths Triple in Decade,” accessed April 2012, http://yourlife.usatoday.com/health/story/2011-11-01/Deaths-from-painkiller-overdose-triple-in-decade/51027242/1.
5. Institute of Medicine, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research (Washington, DC: The National Academies Press, 2011).
6. Ibid.
7. Pain-Topics.org, “Are Opiod Pain Reliever Deaths an Epidemic?” accessed April 2012, http://updates.pain-topics.org/2011/11/are-opioid-pain-reliever-deaths.html.
8. ClinicalTrials.gov, “Search of: Pain and Chronic,” accessed April 2012, www.clinicaltrials.gov/ct/search?term=Pain+and+Chronic.
9. P.M. Barnes, B. Bloom, and R.L. Nahin, “Complementary and Alternative Medicine Use Among Adults and Children,” National Health Statistics Reports 12 (2008): 1–23.
10. Deborah J. Cook et al., “Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions,” Annals of Internal Medicine 126, no. 6 (1997): 376–80.
11. C. Crawford, S. Jain, and W.B. Jonas. Introduction to Systematic Reviews Workbook, Samueli Institute, 2012. (Author workbook for private seminar.)
12. L. Kalichman, “Massage Therapy for Fibromyalgia Symptoms,” Rheumatology International 30, no. 9 (July 2010): 1,151–7.
13. G.A. Malanga and E.J. Cruz Colon, “Myofascial Low-Back Pain: A Review,” Physical Medicine & Rehabilitation Clinics of America 21, no. 4 (November 2010): 711–24.
A licensed massage practitioner since 1984, Diana L. Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.