Testing Massage Research
By Chris Wheeler
In the 2012/2013 budget, the then Federal Labor Government announced that there would be a review of the government private health insurance rebate for natural therapies. The purpose of the review was to examine the evidence of clinical efficacy, cost effectiveness and safety and quality of natural therapies with the ultimate aim of regulating which natural therapies would continue to receive the government rebate. AMT’s 200-page submission to the 2013 Natural Therapies Review can still be downloaded here. Those of you who have been in the industry for more than 5 years will no doubt recall the outcome of that review – remedial massage and myotherapy were the only therapies that remained eligible for a rebate, and around 15 other therapies, including reflexology and aromatherapy were dropped.Rebecca Barnett, AMT CEO
Could Do Better?
Having a background in science and a post-graduate degree that gives me knowledge of research methodology, I got to thinking about the Review of the Australian Government Rebate on Natural Therapies for Private Health Insurance. I found it a little embarrassing to have the evidence returned with a ‘could do better’ mark. As a scientist, I fully understand the need for firm evidence, especially when it involves the allocation of funds. It is difficult to argue against the case that any funding or rebate should be appropriately targeted. So, what do we do?
The Government Report details “paucity of good quality studies of sufficient size” (page 106), “low quality evidence” (page 102), “the evidence base for massage therapy is not of high quality and many of the individual studies were poorly designed and conducted” (page 110), “the majority of SRs (systematic reviews) included in this overview were of low quality” (Page 103) and an overriding criticism is the lack of randomised controlled trials (RCT). Obviously what we do is address these issues. Easy!
First, let’s consider the way a lot of ‘evidence’ is collected. A large amount is subjective:
- How does the client ‘feel’ afterwards?
- What is the pain on a 1-10 scale?
This may seem to be a measurement, as you are able to compare two numbers, but how does it actually compare?
I deal with a couple of footballers. If I hit them with an engineer’s mallet, they would probably give it a 3 out of 10. As therapists, we can argue that it doesn’t really matter as long as the client feels better but that will not satisfy the report’s authors. There is also the assumption that any improvement after an intervention is the result of that intervention. Tempting, but the same logic tells you that walking under a ladder brings you bad luck.
There may be some form of pre-test, post-test. How far can you move it before the treatment and how far can you move it after? Again, tempting but can we be sure it is the intervention that has caused a difference? The Hawthorne Effect tells us a person’s behaviour is apt to change when they know they are part of a study or being observed or measured.
The randomized controlled trial (RCT) is referred to as the ‘gold standard’ of research. OK, let’s go for gold – what are we controlling and what is random?
A variable is anything that can affect the outcome of an experiment or trial. If we are going to compare groups, all variables must be identical in each group, except one group will have one variable different – they will receive the treatment. This is the control aspect. If there is any difference in the groups, it can only be the result of the intervention.
Easier said than done.
How many variables come into play when dealing with massage treatment on a person? Is everybody having exactly the same tissue targeted in exactly the same way with exactly the same technique and exactly the same amount of pressure? Are some of the subjects also attending an exercise class or others swimming every other day and mobilising the tissue? Go on, try it. How many other variables can you list? I’ll bet there are plenty without really trying hard.
Random groups mean that a representative sample of the population is allocated to either a treatment group or a control group. Easy enough? Well, not really. People who seek out massage treatment are, overwhelmingly, people who believe in the effects of treatment, so our population is skewed to begin with. Groups are ‘blinded’. In a drug trial, this would mean that the subjects don’t know if they are taking the drug or a placebo. In a ‘double blind’, the subjects and data gatherers don’t know who is taking the drug and who receives the placebo. The conclusions then come from statistical analysis and all is revealed at the end. Well, good luck blinding somebody to a massage treatment!
Our study must have validity – are we actually testing what we say we are testing and actually measuring what we say we are measuring? It sounds simple but you will be surprised by the number of studies criticised for lack of validity.
Our studies must also be reproducible – if the same treatments are given to a similar group of people, they would give similar results. This means our methods are reliable in that they have eliminated the possibility that the results are due to chance.
It also requires a large number of subjects; studies of 10 or 20 are not enough. True reliability requires thousands. Our gut feeling or heartfelt belief that ‘massage works’ will not cut it.
Realistically, the very nature of our profession makes RCTs very difficult. One purpose of this article is to provide a starting point for our thinking, ‘well what do we do?’ Is it realistic to have many therapists targeting exactly the same tissue, using exactly the same technique, controlling many other variables? Not really.
If not RCT, then what?
Fortunately, there are alternatives and we must examine them with a view to designing studies that pass the standards for validity, reliability and objectivity, so providing a firm evidence base for our work. It requires us to collect data but, more importantly, carefully consider the data being collected to ensure it is meaningful. It requires an education campaign for therapists interested in providing evidence:
- What do we do?
- How do we do it?
- What will we measure?
- How will we measure it?
Without health fund rebates, we may lose clients due to financial concerns. In that case, to continually attract clients, fees would have to be reduced but unfortunately our overheads will not decline with our fees.
An alternative way of thinking is, how dependent are we on health funds? Does it really matter to our clients if we don’t give health fund rebates? If they are satisfied with our services without a rebate, do we need to worry that much? Personally, about one third of my clients ask about provider numbers. Is this worth examining further and actually collecting data? As I said before, I’m just trying to start the debate. As a scientist I like empirical evidence but, as a therapist, if my clients are happy, I’m happy!
The Final Word
It took a while for the Liberal/National Coalition Government to enact the changes from the 2013 Review but, since the transition, there has been a mounting backlash. Despite frequent howls to the contrary from within the natural therapies industry, the private health insurance industry isn’t thrilled with the changes. The private health funds rely heavily on natural therapies to attract young, healthy people into taking out private health insurance. Fast forward to 2019, when the Government decided to commence a review of the natural therapies review. The current review is ongoing, albeit COVID interrupted. In AMT’s pragmatic view, it is likely to deliver a different outcome for many of the therapies that were dropped in the first review.Rebecca Barnett, AMT CEO
About the Author
Chris Wheeler taught Biology, Chemistry and Physical Education since the time the syllabus was written in Latin and is now in his second life working as a remedial therapist in the Jervis Bay area. Chris can now be relaxed before going to work, relaxed at work and relaxed when finished and he doesn’t have to mark any of it. Chris is energised by the enthusiasm and dedication of the therapists with whom he works.