Focus on Research – February Edition
By Rebecca Barnett
This is the first article of a regular series on AMT’s blog. Each quarter, we’ll examine a selection of recent research relevant to massage therapists.
It’s exactly 3 months since I sat down to compile the research review for AMT’s 2020 yearbook. Since that time, there’s been a whole batch of new studies we can delve into using the nifty PubMed searching device (or another health and medical research database of your choosing).
Let’s kick off with the obligatory hat tip to unusual things that turn up when you seek out massage therapy research. I did not previously know why we might need to cryopreserve ferret semen and, further, why we would need better protocols for doing this but I actually feel surprisingly gratified now that I do know why this is pretty important.
And, if last year’s crop of research on massage therapy and constipation gave us all the shits in a good way, you’ll be pleased to hear that other gastric themes are now being explored. It’s only a matter of time before we’ll start seeing claims about massage therapy enhancing the gut microbiome, so hopefully some quality research can head off any potential massage myths that manipulative marketers might be mulling. (Just earned my alliteration miles for this post.)
For this first edition of ‘Focus on Research’, I have chosen to focus on a couple of systematic reviews that have been published recently, both involving cancer survivors: a review of the benefits of massage therapy on sleep and another on Manual Lymphatic Drainage (MLD) for prevention and reduction of lymphedema.
There’s a few reasons I chose these. First of all, systematic reviews are on the top of the evidence pyramid, so every time a new one is published about massage therapy, it’s a significant milestone. Now, we could debate the epistemological basis for why systematic reviews are afforded such high status until the prodigal cows come home to malapropistically roast their mixed metaphors, but that won’t change the current status quo.
Systematic reviews are important to the medical and scientific establishment, therefore they’re important to us – we have the natural therapy review process in Australia as testament to their influence over our fate.
Second, both systematic reviews are open access – you can read them in depth and not take my word for it.
Lastly, but perhaps most significantly, they will support and challenge our biases in distinct ways. On cursory examination, the sleep study will seem like the good cop and the MLD study the bad cop but further digging will hopefully reveal some gems.
PD Reflection Idea: If you’re an AMT member, you could read these two systematic reviews and submit a reflection to clock up an hour or two of professional development time.
Here we go …
Benefits of Massage and Relaxation Therapy on Sleep in Cancer Survivors
OK, did you know that sleep disturbance is an ongoing issue for 51% of cancer survivors? I didn’t until I read this paper. (That’s roughly twice the rate of sleep disturbance in the general population, by the way.)
Sleep disturbance is also one of the most distressing symptoms experienced by cancer survivors. Long term, it can lead to distress, increased morbidity, reduced productivity, and poor quality of life, so investigating the effectiveness of non-pharmacological interventions like massage and relaxation therapy is kinda important.
Four randomised controlled trials (RCTs) of massage therapy met the inclusion criteria for this review. To be included, trials had to involve:
- Cancer survivors of any ages and type of cancer
- Massage or relaxation therapy as the primary intervention
- Comparisons to usual care or active/sham treatments
- Self-reported or objectively measured sleep outcomes
- RCT designs, with the results reported in peer-reviewed journals.
The most common reasons for exclusion included non-randomised controlled trial methodologies and a lack of reported sleep outcomes. The were 205 participants recruited for the 4 RCTs studying the effect of massage therapy, out of which 187 completed the entire study. This table provides a summary of the massage therapy studies included in the review, including a description of the intervention, the control and the duration/frequency of treatment. Two of the four studies also monitored adverse events from the massage (SPOILER: there weren’t any).
Two of the four studies of massage therapy observed statistically significant self-reported sleep quality (PSQI) or objective improvements in sleep outcomes (number of long sleep episodes) in cancer survivors. This is also consistent with the findings reported for postmenopausal women and patients with fibromyalgia. These improvements are clinically significant because the duration of massage therapy provided was shorter compared to other non-pharmacological interventions like exercise and Cognitive Behaviour Therapy.
How excellent is it that this one paper is opening up some cool related research in other populations?
Like most massage therapy research, the main cautions regarding this review relate to small sample sizes and the lack of long-term follow up. The reviewers also point out that many cancer survivors may not be able to afford ongoing massage therapy so investigating the efficacy of carer, friend and family delivered (non-certified) massage should be considered in future research.
MLD For Lymphedema In Patients After Breast Cancer Surgery
Lymphedema affects about 15% to 30% of patients after breast cancer surgery, so it’s easy to see why finding effective ways to prevent or treat it is a big deal.
Seventeen RCTs involving 1911 patients were included in this systematic review. Characteristics of the included studies are summarised in this table. Go on. Have a squiz. I promise it’s worth the effort to give you a picture of how RCTs are set up to assess interventions like MLD.
Selected studies met the following criteria:
- Type of study – randomised control trial
- Study subjects – breast cancer patients
- Study methods – RCTs enrol breast cancer patients who are receiving MLD, describe the definition of lymphedema, and provide the inclusion and exclusion criteria for enrolling participants
- Intervention – The experimental group received MLD, while the control group received compression bandaging and other methods, such as physical therapy, simple lymphatic drainage (SLD)
- Main outcomes: RCTs evaluate the severity of lymphedema or the incidence of lymphedema.
Here is how the outcomes were assessed:
“The effect of MLD on the prevention of lymphedema was evaluated by the incidence of lymphedema, and the efficacy of MLD in the treatment of lymphedema was assessed by the percentage reduction in total of lymphedema from baseline to follow-up period. The volume of the arm was measured by submerging the affected and unaffected arm in a container with water and the volume displacement was measured in millilitre. The arm volume with circumferential measurement was marked in 4 cm increments up the arm from the ulnar styloid to the axilla. The definition of lymphedema is an increase of more than 10% in volume between the abnormal and normal arm; a difference of more than 200 ml in arm volume or more than 20 mm in the circumference between the abnormal and normal arm.”
Five of the RCTs in this review (1431 patients) reported the effect of MLD on the prevention of lymphedema in post-surgery patients. Analysis showed that MLD could not significantly prevent the long-term risk of lymphedema, However, the researchers found that MLD significantly prevented the risk of lymphedema within 1-month of surgery. So there may indeed be beneficial short-term effects.
In the eight RCTs comparing MLD with other therapies, MLD added no benefit in reducing the arm volume of the affected side. Here’s where things get a bit interesting: in subgroup analyses of the included studies, the researchers found that MLD could significantly reduce lymphedema in patients under the age of 60 years in the short term (within 1 month post-surgery). Further research into this could help us to direct MLD to where/when it is most beneficial and advise/treat clients accordingly.
Accepting that MLD may not be an effective option for post-surgery clients over 60 seems like a small price to pay for offering evidence-informed, targeted treatment recommendations.
If you’ve followed the links to either of these studies, you’ll notice all the hyperlinks to related information and studies. For fellow lovers of rabbit holes, you can imagine how many happy trails you can get a bit lost in! And if you are interested in working with a particular demographic or condition, following these happy trails is an intrinsic way of ensuring that your knowledge of that population is current – a fair bit could have changed since you graduated from your Diploma or attended that last workshop.
Happy wanderings! I will see you back here in 3 months.
About the Author
AMT CEO Rebecca Barnett is a research wanderer. She is glad that many massage therapists are fellow wanderers.