Chapter 5 Justifying massage as treatment

INTRODUCTION

Chapter 1 defines headache and neck pain, Chapter 2 describes causes for these conditions, Chapter 3 investigates how conventional medicine diagnoses and treats head and neck pain, and Chapter 4 discusses pain as a major treatment focus. This chapter looks at the current research to discover if scientific investigation supports the use of massage to help those who experience various types of headache and neck pain.

RESEARCH CONTENT

The most commonly used complementary modalities in the research were:

• chiropractic

• massage therapy

• acupuncture

• mind–body relaxation techniques.

If adaptation processes (Box 5.1) are the primary cause of head and neck pain, then whatever treatment is offered should achieve one of three things:

• Removal or reduction in the stress load to which the local tissues (or the body as a whole) are adapting.

• Improvement in the way(s) the local tissues (or the body as a whole) are coping, adapting.

• Symptomatic treatment to make the recovery period more comfortable – without adding to the adaptive load.

Box 5.1 Adaptation

Adaptation represents the story of the contest between the ‘load’ and the tissues handling the load.

Tissues adapt to the load imposed on them. Think of athletic or weight training as easy examples. To run a marathon, or perform high jump or any other specialized task or activity (gardening, working on a production line, painting ceilings, etc.), particular muscles and joints have repetitive demands imposed on them.

After an initial acute phase (alarm phase of the local or general adaptation syndromes – LAS or GAS) when stiffness and soreness may be experienced, the tissues start to adapt and no longer react with stiffness and soreness. This is the adaptation phase of LAS (involving a local area, such the shoulders or knees) or GAS (involving the whole person), which continues until the load (the stress demands) or the tissues themselves can no longer adapt (like a piece of tired elastic), at which time the ‘breakdown’ or ‘exhaustion’ phase of LAS or GAS starts – and symptoms of pain and dysfunction become apparent.

Sometimes all three elements can be achieved, sometimes only one.

Since healing is a self-generated function (cuts heal, broken bones mend, etc.) the important element in any treatment choice is that it should be safe, should not add to the load, and should hopefully help recovery to be more rapidly achieved, and if not more rapidly, more comfortably.

Massage seems able to offer a number of these features, with education and rehabilitation exercises doing the rest in most cases.

RESEARCH INDICATIONS

Research is mixed for the efficacy of massage for headache and neck pain. Generally massage for headache and neck pain was not found to be a definitive treatment on its own but was supportive of many other interventions, either enhancing effects or managing side effects of other treatments. Massage was found to be generally safe. Some benefits of massage related to other conditions such as low back pain can be logically applied to neck pain. This is helpful in justifying massage for headaches and neck pain since more studies have involved low back pain and massage (Chaitow & Fritz 2006). Other researchers have looked at massage for pain in general and others have delved into the general benefits of massage.

Based on an internet search using the terms ‘massage’, ‘massage therapy’, ‘therapeutic massage’, ‘headache’, ‘neck pain’ and ‘pain’, the following is the summation of the research presented. Since research is an evolving process, the studies and conclusions presented can be either confirmed or questioned as new research becomes available. The massage professional needs to remain current with advances in the understanding of the benefits of massage.

The search process for this text involved mainly internet search using the Massage Therapy Foundation database, Google Scholar, MedlinePlus and PubMed (Box 5.2). Representative studies, especially meta-analyses, were analyzed and the content of one of these reports – Manipulative and Body-Based Practices: An Overview, which is one of five background reports on the major areas of complementary and alternative medicine undertaken by the National Center for Complementary and Alternative Medicine – is illustrated in Box 5.3.

Box 5.2 Internet resources

• The Massage Therapy Foundation advances the knowledge and practice of massage therapy by supporting scientific research, education and community service: http://www.massagetherapyfoundation.org

• Google Scholar: http://scholar.google.co.uk

• MedlinePlus for Complementary and Alternative Medicine (CAM): http://www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html

• PubMed: http://www.ncbi.nlm.nih.gov/pubmed

Box 5.3 Manipulative and Body-based Practices: An Overview

INTRODUCTION

Under the umbrella of manipulative and body-based practices is a heterogeneous group of complementary and alternative medicine (CAM) interventions and therapies. These include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and a host of others (a list of definitions is given at the end of this report). Surveys of the U.S. population suggest that between 3 and 16% of adults receive chiropractic manipulation in a given year, while between 2 and 14% receive some form of massage therapy.¹^–⁵ In 1997, US adults made an estimated 192 million visits to chiropractors and 114 million visits to massage therapists. Visits to chiropractors and massage therapists combined represented 50% of all visits to CAM practitioners.² Data on the remaining manipulative and body-based practices are sparser, but it can be estimated that they are collectively used by less than 7% of the adult population.

Manipulative and body-based practices focus primarily on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. Some practices were derived from traditional systems of medicine, such as those from China, India, or Egypt, while others were developed within the last 150 years (e.g., chiropractic and osteopathic manipulation). Although many providers have formal training in the anatomy and physiology of humans, there is considerable variation in the training and the approaches of these providers both across and within modalities. For example, osteopathic and chiropractic practitioners, who use primarily manipulations that involve rapid movements, may have a very different treatment approach than massage therapists, whose techniques involve slower applications of force, or than craniosacral therapists. Despite this heterogeneity, manipulative and body-based practices share some common characteristics, such as the principles that the human body is self-regulating and has the ability to heal itself and that the parts of the human body are interdependent. Practitioners in all these therapies also tend to tailor their treatments to the specific needs of each patient.

Scope of the research

Range of studies

The majority of research on manipulative and body-based practices has been clinical in nature, encompassing case reports, mechanistic studies, biomechanical studies, and clinical trials. A cursory search in PubMed for research published in the last 10 years identified 537 clinical trials, of which 422 were randomized and controlled. Similarly, 526 trials were identified in the Cochrane database of clinical trials. PubMed also contains 314 case reports or series, 122 biomechanical studies, 26 health services studies, and 248 listings for all other types of clinical research published in the last 10 years. On the other hand, for this same time period, there have been only 33 published articles of research involving in vitro assays or employing animal models.

Primary challenges

Different challenges face investigators studying mechanisms of action than those studying efficacy and safety. The primary challenges that have impeded research on the underlying biology of manual therapies include the following:

• Lack of appropriate animal models

• Lack of cross-disciplinary collaborations

• Lack of research tradition and infrastructure at schools that teach manual therapies

• Inadequate use of state-of-the-art scientific technologies

Clinical trials of CAM manual therapies face the same general challenges as trials of procedure-based interventions such as surgery, psychotherapy, or more conventional physical manipulative techniques (e.g., physical therapy). These include:

• Identifying an appropriate, reproducible intervention, including dose and frequency. This may be more difficult than in standard drug trials, given the variability in practice patterns and training of practitioners.

• Identifying an appropriate control group(s). In this regard, the development of valid sham manipulation techniques has proven difficult.

• Randomizing subjects to treatment groups in an unbiased manner. Randomization may prove more difficult than in a drug trial, because manual therapies are already available to the public; thus, it is more likely that participants will have a pre-existing preference for a given therapy.

• Maintaining investigator and subject compliance to the protocol. Group contamination (which occurs when patients in a clinical study seek additional treatments outside the study, usually without telling the investigators; this will affect the accuracy of the study results) may be more problematic than in standard drug trials, because subjects have easy access to manual therapy providers.

• Reducing bias by blinding subjects and investigators to group assignment. Blinding of subjects and investigators may prove difficult or impossible for certain types of manual therapies. However, the person collecting the outcome data should always be blinded.

• Identifying and employing appropriate validated, standardized outcome measures.

• Employing appropriate analyses, including the intent-to-treat paradigm.

Summary of the major threads of evidence

Preclinical studies

The most abundant data regarding the possible mechanisms underlying chiropractic manipulation have been derived from studies in animals, especially studies on the ways in which manipulation may affect the nervous system.⁶ For example, it has been shown, by means of standard neurophysiological techniques, that spinal manipulation evokes changes in the activity of proprioceptive primary afferent neurons in paraspinal tissues. Sensory input from these tissues has the capacity to reflexively alter the neural outflow to the autonomic nervous system. Studies are underway to determine whether input from the paraspinal tissue also modulates pain processing in the spinal cord.

Animal models have also been used to study the mechanisms of massage-like stimulation.⁷ It has been found that antinociceptive and cardiovascular effects of massage may be mediated by endogenous opioids and oxytocin at the level of the midbrain. However, it is not clear that the massage-like stimulation is equivalent to massage therapy.

Although animal models of chiropractic manipulation and massage have been established, no such models exist for other body-based practices. Such models could be critical if researchers are to evaluate the underlying anatomical and physiological changes accompanying these therapies.