Foreword by Leon Chaitow
Two different imperatives are the driving forces behind this important book : the need for ever improving competencies in the application of massage and bodywork, and the need for evidence that validates and supports the methods and techniques used in therapeutic massage in particular, and manual therapies in general. The question is how these imperatives are to be satisfied?
Without competence, and an optimal skill base, the safety and efficacy of the methods used in therapeutic massage would be compromised, and results would be poor.
Without an evidence base that informs educators, therapists, other health care professions with whom collaboration and integration may be possible and desirable – including regulating authorities, insurance reimbursement sources, the media, and ultimately the public – confidence in massage therapy will decline.
Evidence derives from a variety of sources, most obviously clinical experience and the results experienced by patients/clients, but also from clinical and basic research that satisfies the demand for proof that what is being done, when massage is applied, is safe, efficacious and cost effective.
Lack of confidence in the methods of any profession result if training standards are low; if professional and/or ethical behaviour is poor; if the methodologies used are of an unproven nature and/or if potentially useful methods are applied inappropriately.
It is vital for an emerging profession that national and local licensing authorities be supportive of the profession, and that insurance reimbursement is available. Additionally, and most importantly, other health-care professions need to feel confident and comfortable in any move toward collaboration and integration. These objectives can only result when those applying treatment methods are well trained, and their techniques appropriate to the needs of their patients/clients. And in an era of ‘evidence-based medicine’ this cannot simply be assumed, it has to be shown to be so by research.
Massage is now conceived by the public to be one of the safest, most effective, trusted (and widely used) forms of complementary health care, however a degree of resistance to its wider use in medical settings remains. (Field 2000, Eisenberg 1998)
The evolution to this position of public and media acceptance over the past 50 years, has seen massage and bodywork change from being a part of ‘fringe’ medicine, following which it became slightly more respectably ‘alternative’, until it emerged as complementary to mainstream medicine – becoming in a more recent evolution a part of integrated health care.
The impetus for these shifts has derived largely from a combination of an increasingly improved quality of training, enhanced professional and ethical standards, supported and encouraged by a trickle of research evidence demonstrating the range and potential of hands-on touch therapy. Much of this has come from people such as Tiffany Fields and her team at the Touch Research institute, University of Miami. With limited resources, despite ongoing funding from sources such as Johnson & Johnson, this team has demonstrated the value of touch therapies such as massage in a huge range of conditions. (Field 2000, Rich 2002).
To paraphrase Kahn (in Rich 2002) –‘If massage is safe and benign, why research it?’
Her answer is that the very widespread use of massage makes it essential that more research be performed.
Kahn also explains the background to the relative dearth of research papers, and it is not just about lack of funding. Most importantly there is less research into massage than their should be because quite simply there are not enough researchers involved in the field, not enough research proposals, not enough pressure on funding agencies. Put most simply……. Not enough enthusiasm.
This book should go a long way toward remedying that deficit, as it is written with a patient enthusiasm, which will hopefully be infectious.
Questions needing more answers include:
What are the benefits of massage?
If there are benefits what are the mechanisms?
How do benefits differ from those obtained by other (often infinitely more expensive) methods?
Are there potential dangers, and if so what?
Researching a topic such as ‘massage’ in far from easy, due to variables that are inherent in the interaction between patient and therapist. In real life each treatment should reflect the current individual needs of the patient/client, as perceived by the therapist, whose clinical approach is in any case likely to vary, to some extent, from that of any other therapist.
A potential criticism of the methods used in Touch Research Institute’s trials is that they almost always involve the use of a standard protocol, involving a fixed, and frequently fairly limited, amount of time per treatment session, with specified strokes applied in a predetermined sequence. And this does not match what happens in a real-life massage treatment.
And yet despite the limitations imposed by use of fixed protocols the results of most off Fields’ studies have been extremely supportive of the value of massage therapy.
It is certainly true that many forms of research demand a standardised methodology, to overcome the accusation that apples are not being compared to other apples, rather than to oranges instead.
How is this impasse to be overcome?
A different choice might be to focus attention on outcomes rather than the fine detail of methodology. Renowned osteopathic researcher Irvin Korr (1991) suggested that measurement of objective findings relative to the patient’s condition, as well as assessment of subjective feelings relative to their symptoms, before and after an individualized treatment, could help to avoid the problem of ‘standardised’ therapeutic input.
More recently Ernst (2002) has expressed similar thoughts, saying that the gold standard of researchers, the randomized control trial, could be modified to compare outcomes following some patients receipt of standard care, with others receiving individualized attention based on the therapists perception of needs.
These examples suggest that more meaningful research into systems such as massage can be achieved if sufficient attention is given to posing well constructed questions.
What Glenn Hymel has done in this remarkable text is to cover the entire spectrum of research and audit needs, associated with all levels of documenting and investigating the profession he so clearly loves.
He has defined the needs of the massage therapy profession in relation to understanding research, as well as of participating in these processes, ideally under the auspices of suitably qualified researchers.
He has explained the complex processes involved in quantitative, qualitative and integrative research approaches, and has also offered detailed analysis and direction for those researchers drawn to work in this relatively unexplored field.
Researching massage therapy and manual methods requires an understanding of the categories, (what type of research?) strategies, methods, designs and procedures. It also demands recognition of the problems of resources.
At present research funding is difficult to obtain, and fundamental research without funding is nigh on impossible. This excludes all but the most dedicated of researchers from involvement, and precludes large studies. So much has to be achieved on a shoe-string, often involving small scale projects. Organizations such as the Massage Therapy Foundation have a variety of initiatives that aim to overcome these limitations and obstacles.
This book should help to change that climate by creating an enthusiasm for research, even in the average therapist, trained in the disciplines of massage but not research-literate, encouraging a cohort of therapists to dedicate themselves to levels of advanced study, in order to be able to participate in, and/or to conduct, research.
At the very least it can lead to an appreciation of the methods involved, and to help consumers of research information to be able to discern ‘good’ from ‘bad’ research when faced with articles and papers in peer reviewed journals. This is extremely important, since a clear understanding of new evidence can help the therapist to modify what is done clinically, as well as allowing a deeper understanding of the nature of the conditions being treated and the methods used, leading to more meaningful communication with clients, as well as with other health care professionals.
The book certainly offers educators the tools with which to start the process of demystifying research as they instruct the next generation of therapists.
It also, and most importantly, provides existing researchers with guidelines as to the special needs and methods required for the investigation of complex holistic systems such as massage
Ultimately research competence requires an understanding of the body of knowledge that Glenn Hymel has laid before us. It also calls for an enthusiasm and passion that he has demonstrated in compiling this very important text.
Leon Chaitow ND DO
University of Westminster, London
Eisenberg, D David R Ettner S. 1998 Trends in Alternative Medicine in use in USA 1990-1997. Journal of American Medical Association 280:1569-1575
- Ernst E 2003 Obstacles to research in complementary and alternative medicine. Medical journal of Australia 179:279
- Field T 2000 Touch Therapy. Churchill Livingstone, Edinburgh
- Korr I 1991 Osteopathic Research: the needed paradigm shift. Journal American Osteopathic Association. 91:156-171
- Rich J (ed) 2002 Massage Therapy: The evidence for practice. Mosby St.Louis