This article—and the next —will put together the elements of massage research articles into bigger pictures, each element informing and influencing the others.

Let’s jump right in by working through a possible massage practice scenario to see how we might address it using the literature. If you have access to the Internet, follow along with the steps below.

The scenario: An older client mentions that the pain from his arthritis is unmanageable using only over-the-counter medication. His doctor will write a prescription for stronger medicine, but the client wants to minimize his use of prescription medications. He asks you whether massage would help. Your experience involves using massage to treat chronic musculoskeletal pain, so you want to find out whether there is evidence that massage offers similar benefits for non-pharmacological treatment of arthritis pain.

Locate Free Articles
Define the Search

The first step is a literature search, where we’ll look for any studies that address this question. Various databases are available to people with access to medical libraries, but many people do not have such access. To make this exercise as simple as possible, let’s use a database available to everyone. PubMed (www.ncbi.nlm.nih.gov/pubmed or www.pubmed.gov), hosted by the National Library of Medicine, is a taxpayer-funded website that allows you to search a catalog of medical and scientific research articles for free. Doing a search here provides much more reliable results than doing a general Internet search using an engine such as Google. In fact, PubMed serves as the basis for other online databases, such as the one hosted by the Massage Therapy Foundation.

These searches will return links to articles and their abstracts; some articles are free, but others aren’t, depending on the policies of the journals. Here, we’ll use PubMed to search only for free articles.

Decide on the search strategy. A common search structure in evidence-based medicine involves writing a PICO question, where PICO stands for: Patient, Intervention, Comparison, and Outcome. Writing out our search as a PICO question might look something like this: In older adults with arthritis (patient), does massage therapy (intervention), when compared to pharmacological treatment (comparison), reduce pain (outcome)?

Execute the Search

Now that our research question is spelled out, let’s search in PubMed. First, go to the site (Image 1, page 118).

In the blank text box to the right of “Search PubMed for,” type the search terms. We’ll form our search from the elements in our PICO question. The more search terms, the narrower the results, so we’ll keep that in mind.

We decide there are probably few articles available on our specific subject, so—even though our interest is older adults with arthritis—we’ll consider articles about other age groups. We decide not to restrict the search by age, so arthritis is the only patient term we’ll add to the search box.

Our intervention is massage, so that definitely belongs in the search. However, if you’ve ever tried searching for the word massage, you’ve probably noticed that, in addition to the articles on therapeutic massage, you also get many unwanted or inappropriate ones: articles on cardiac massage to resuscitate dying patients, uterine massage after childbirth, etc. To avoid this problem, let’s instead use PubMed’s medical subject headings (MeSH). MeSH defines massage as a “Group of systematic and scientific manipulations of body tissues best performed with the hands for the purpose of affecting the nervous and muscular systems and the general circulation.”¹ Using the “Massage”[MeSH] format, with [MeSH] in brackets, tells PubMed that we want only articles in which the concept of massage matches the MeSH definition. This is not a perfect filter, but it usually excludes tangential articles.

We add “Massage”[MeSH] in the text box, along with the term arthritis and the connector AND to join them. (Just as in addition where 3 + 5 = 5 + 3, terms joined with a simple AND can appear in any order.)

Our comparison, pharmacological treatment, may belong in the search as well. However, there are many ways to express this idea—medication, prescription, the names of specific pain medications, and so on. Let’s make the search as broad as possible, first trying it without any of these possible comparison terms. If the search returns an unmanageably large number of results, we’ll go back and narrow our comparison.

Finally, our desired outcome is pain reduction, so we’ll filter out articles focused on other effects of arthritis (stiffness, inflammation, and so forth) by adding another restricting term—AND pain—to the search box. Now our search terms tell PubMed we want only articles dealing with 1) therapeutic massage as defined in MeSH; 2) in the context of arthritis; 3) that have to do with pain in some way.

Refine the Search

There’s one more thing before we proceed. To ensure our search returns articles that are freely available to everyone, we’ll place a limit on our search. Click on the limits tab, below and to the left of the search text box (Image 2).

Under the third blue bar, titled Full Text, Free Full Text, and Abstracts, click the middle checkbox: Links to free full text. Now the search will return only articles matching all the search criteria that can be read for free.

Now that the search terms are complete, click the Go button. If the search had returned no results, we would have had to broaden it by reducing the number of search terms or by changing them. If we had received hundreds of results, we would have to narrow the search by adding comparison terms as discussed above. In this case, our search returned two results, a manageable number.

For additional information about advanced search techniques, access the resources listed in the menu on the left-hand side of the PubMed home page for FAQs and tutorials.

Examining Search Results

Let’s examine each result to see if it is relevant to our question. The first article is “Massage Therapy for Osteoarthritis of the Knee: A Randomized Controlled Trial.” The title of this article seems like it could be very relevant. We’ll definitely take a look at this article.

The second is “Juvenile Rheumatoid Arthritis: Benefits from Massage Therapy.” Although we decided not to restrict our search by age, the title of this article makes clear that it is not likely to be as relevant to our client’s situation as we might want. This study concerns a different form of arthritis (an autoimmune disease) rather than osteoarthritis, which is the wear and tear on the joints that sometimes happens to older adults. So, this second article is about a different disease process. While there may be some useful information in it, it is not likely to be as relevant to our client as the first one. Let’s get that first article and practice our research literacy skills to evaluate whether it does a good job of answering our client’s question.

To get a copy of an article returned by a PubMed search on the screen of displayed results, click on the blue underlined title of the article you want. More information about the article,² including the abstract, appears on the screen.

The abstract gives us more indicators that this article will be useful for addressing our question. It tells us the article deals with our massage therapy intervention, our patients with osteoarthritis, and our reduced pain outcome. It also mentions that massage therapy is compared to delayed intervention; our comparison with pharmacological treatment is not exactly covered, and all our PICO criteria are not exactly matched. However, there are so few articles relevant to our clinical question that this is the closest we can come at the moment to answering our client’s concern as he posed it. The abstract indicates massage is effective in reducing pain and other symptoms of osteoarthritis, and the results are statistically significant, so this free article is definitely worth downloading.

Note that it is never ethically acceptable just to read the abstract and claim to have read the research. Abstracts may contain errors and frequently leave out important nuances needed to fully understand the research.

To access the full article, watch for a button on the same screen as the abstract. In this case, there is a blue, white, and yellow button labeled “Free Text at Archives of Internal Medicine” at the top right of the screen. This contains a link to the article at the publisher’s website. Click on the button to link to the website, where a free copy of the article is available. There are slight variations on the websites that provide free articles, so the directions may vary. Look for buttons or links that read “Free Text at,” “Free Final Text,” or similar. The file itself will most likely be available as a PDF; some download automatically or, for others, look for a link to begin a manual download.

Answering Questions

Read the article to see how well it addresses questions about whether massage is effective for pain relief in osteoarthritis. Mark it up as you read—making notes, drawing diagrams, using colored markers to connect ideas—whatever method helps you understand and retain the information.

Below are the questions I’m bringing to this article. I’ve referenced the point in the research where such questions are usually addressed.

• Why did the researchers do this study (from the Introduction)? What is their research question? Does their context mean anything to my practice?

• How does their PICO compare to ours (from the Introduction)? What does that mean for applying their results in our practice?

• How did the researchers study their research question (from the Methods)?

• What did the researchers find out (from the Results)?

• What do the researchers say their results mean (from the Discussion)? What do you think of their interpretation?

• In our scenario, would this article provide useful information for your client? If so, what?

• What problems or gaps did Perlman’s team find with previous massage research studies (from the Introduction)? What limitations in their own study did they address (in the Discussion)? In your assessment, are any of these problems severe enough to invalidate their study?

• Having read the article, do you think the Abstract is an accurate representation of it?

• What else is notable?

• How much did our exercise reflect your real-life experience in finding research articles to inform your practice?

I encourage you to think critically about each question. I’ll print my answers in the next column, so that you can compare them with your own.

 Ravensara S. Travillian is a massage practitioner and biomedical informatician in Seattle, Washington. She has practiced massage at the former Refugee Clinic at Harborview Medical Center and in private practice. In addition to teaching research methods in massage since 1996, she is the author of an upcoming book on research literacy in massage. Contact her at
researching.massage@gmail.com.

Notes

1. Available at www.ncbi.nlm.nih.gov/sites/entrez?Db=mesh&Cmd=ShowDetailView&TermToSearch=68008405&ordinalpos=1&itool=EntrezSystem2.PEntrez.Mesh.Mesh_ResultsPanel.Mesh_RVDocSum (accessed March 28, 2009).

2. Adam I. Perlman et al., “Massage Therapy for Osteoarthritis of the Knee: a Randomized Controlled Trial,” Archives of Internal Medicine 166, no.22 (December 2006): 2,533–8.