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.
Ronna Moore
21/02/2021 - 10:20 pm
Thank you, it’s a great idea to look at research in the blog….a bit like a journal club.
As an oncology massage therapist and a lymphoedema practitioner, both reviews presented are of acute relevance to me. But there is particular significance for other therapists who may be familiar with or interested in MLD.
The act of acquainting oneself with research can be interesting in itself and systematic reviews can be really useful in teasing out papers that are related to a particular research question in which you are interested and of which you may not have been aware.
Like everything else in research, to be useful, systematic reviews with or without meta-analysis must also be subject to critical appraisal and elicit a response to the following question:
What, if anything, can these reviews meaningfully contribute to practice?
So, in summary, my review of the reviews yields this:
I was aware of the first review, but not the second. They both alerted me to a number (4) of papers that I had not yet come across…two from the MLD review and two from the sleep studies, that is in itself helpful.
In regard to the latter, sleep disturbances arising from multiple causal factors are well established indicators for massage referral within this client population, very familiar to oncology-trained massage therapists. So, this review serves to collate and favourably confirm the existing body of evidence and validate clinical experience.
The second review/meta-analysis is more problematic. Of the diverse health professionals accredited by the National Lymphoedema Practitioners Register around 30% are massage therapists. All certified practitioners have extensive training in the assessment and management of lymphoedema (and oedema and lipedema). LO is a chronic and progressive condition with multiple aetiologies and which requires multiple management strategies delivered across a series of treatment phases. (MLD…and the related simple, customised self-lymphatic drainage/SLD… being just one). The complexity of this condition is why it is recommended that people at risk of developing or with LO seek supportive care from trained lymphoedema practitioners.
MLD is very rarely the only treatment or management strategy. Clinical guidelines (per International Lymphoedema Framework) indicate compression, skincare, exercise, MLD and SLD as the foundation elements of management. Examples of recent additions/advancements include bio-modulation/low level laser therapy and lymph-taping (both of which all LO services and most private LO practitioners, including MTs, will offer), surgery (lymphovenous anastamosis and lymph node transfer), pneumatic and other advanced forms of compression and, excitingly, but still in experimental stages, image-guided MLD.
The point here is that LO (and its related conditions) is extremely individual and variable, therapists employ all strategies recommended under the guidelines and others available to them, with varying degrees of emphasis and in combination, on a trial and error basis to find the best approach for each client, and, remembering this is a life-long condition, with modifications over time….this is, BTW, in accordance with the third leg of the EBP model.
In addition, and as commented upon in the discussion section of the review paper, MLD is known to address the components of the condition which are not captured in assessments by volume measurements alone (which was the inclusion criterion in all the review studies), pain for example. They are, however, reflected in other non-volume related aspects of the routine assessments conducted by LO therapists.
Finally, the conclusion drawn regarding the first month post surgery was interesting/perplexing in that ordinarily, swelling in that time frame would not be assessed as lymphoedema. Whilst there are papers indicating that significant swelling/oedema post surgery may be indicative of higher risk of the later onset of LO (which can take years post surgery to emerge), post-surgical swelling/oedema is most often transient. I do provide MLD post surgery, primarily in a “plastics” surgical setting for a range of surgical procedures, but this is not lymphoedema management.
There are a number of features of the review and its analysis which lead me to conclude that it will not influence me to change practice. (As compared to the individual papers, the Ridner one in particular of which I was already aware).
The question of the effectiveness of MLD in the setting of LO has been the subject of long and sometimes contentious investigation/debate. This review adds to the debate but its limitations mean that it does not really illuminate it by much.
Lymphoedema is a fascinating, challenging, complex area of practice (often debilitating for the people impacted by it) .
MLD has multiple applications, including for LO, but for this, therapists need extensive training in the other aspects of management which comprise Complex Decongestive Therapy. As such, the MLD taught in weekend workshops and as one element in a standard massage course, whilst a useful technique, cannot equip therapists to apply MLD in this context.
It is in the light of this that I felt compelled to respond to this blog…. just as if it were a journal club.