Alternative Medicine. Open Access for Complementary and Alternative Medicine, National. Institutes of Health. Trends in alternative medicine use in …
BMC Complementary and Alternative Medicine
Research article
BioMed Central
Open Access
A survey of training and practice patterns of massage therapists in two US states
Karen J Sherman1,2, Daniel C Cherkin1,3, Janet Kahn4, Janet Erro1, Andrea Hrbek5, Richard A Deyo6 and David M Eisenberg5
Address: 1Center for Health Studies, Group Health Cooperative, Seattle, Washington 98101, USA, 2Department of Epidemiology, University of Washington, Seattle, Washington 98195, USA, 3Departments of Family Medicine and Health Services, University of Washington, Seattle, Washington 98195, USA, 4Department of Psychiatry, University of Vermont, Burlington, Vermont, 05405, USA, 5Harvard Medical School Osher Institute and Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, Boston, Massachusetts 02215, USA and 6Departments of Medicine and Health Services, University of Washington, Seattle, Washington, USA Email: Karen J Sherman - Shermank@ghcorg;
Daniel C Cherkin - Cherkind@ghcorg; Janet Kahn - jkahn@igcorg; Janet Erro - Erroj@ghcorg; Andrea Hrbek - Andrea_hrbek@hmsharvardedu; Richard A Deyo - deyo@uwashingtonedu; David M Eisenberg - David_eisenberg@hmsharvardedu Corresponding author
Published: 14 June 2005 BMC Complementary and Alternative Medicine 2005, 5:13 6882-5-13 doi:101186/1472-
Received: 16 March 2005 Accepted: 14 June 2005
This article is available from: http://wwwbiomedcentralcom/1472-6882/5/13 2005 Sherman et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License http://creativecommonsorg/licenses/by/20, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
Abstract
Background: Despite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists The objective of this study was to
describe these characteristics Methods: As part of a study of random samples of complementary and alternative medicine CAM practitioners, we interviewed 226 massage therapists licensed in Connecticut and Washington state by telephone in 1998 and 1999 85 of those contacted and then asked a sample of them to record information on 20 consecutive visits to their practices total of 2005 consecutive visits Results: Most massage therapists were women 85, white 95, and had completed some continuing education training 79 in Connecticut and 52 in Washington They treated a limited number of conditions, most commonly musculoskeletal 59 and 63 especially back, neck, and shoulder problems, wellness care 20 and 19, and psychological complaints 9 and 6 especially anxiety and depression Practitioners commonly used one or more assessment techniques 67 and 74 and gave a massage emphasizing Swedish 81 and 77, deep tissue 63 and 65, and trigger/pressure point techniques 52 and 46 Self-care recommendations,
including increasing water intake, body awareness, and specific forms of movement, were made as part of more than 80 of visits Although most patients self-referred to massage, more than onequarter were receiving concomitant care for the same problem from a physician Massage therapists rarely communicated with these physicians Conclusion: This study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy
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Background
Although massage is one of the oldest healthcare practices in the world, with references to it found in ancient Chinese medical texts as well as in the writings of Hippocrates, medical doctors in the US have not practiced therapeutic massage for
nearly 100 years [1] In the 1930s and 1940s, massage fell out of favor with nurses and physical therapists as well However, since the 1970s, interest in massage therapy has burgeoned and it is now one of the most popular complementary and alternative medical CAM modalities In the US, Eisenberg, et al [2] found 11 of randomly surveyed Americans had used massage for treating common medical conditions in 1997, with 62 of these receiving massage from a trained massage therapist They found that the number of visits to massage therapists exceeded that to all other CAM providers except chiropractors, with trained massage therapists providing an estimated 114 million massage sessions to Americans in 1997 Eighty percent of randomly surveyed US adults with health insurance claimed they would be likely to use massage, making it the most popular of the 11 therapies included in the survey [3] Palinkas [4] reported that massage was the third most commonly used type of CAM among primary care
patients, with 172 of CAM users reporting use of massage within the last year for the same reason they were seeking primary care Despite this growth in the popularity of massage, little is known about the practices of licensed massage therapists We included massage therapists in our study of random samples of licensed CAM practitioners and their practices [5,6] In this report, we present new information about the demographic and training characteristics of licensed massage therapists, the reasons patients seek their care, the assessment process massage therapists use during visits, and the treatments and self-care recommendations they provide We have included information about massage efficacy and safety and communication between massage therapists and physicians in the Discussion section to assist biomedical healthcare providers in placing our findings in the broader context of patient care
having 500 hours of education and a passing score on the national examination We excluded
providers without identifiable telephone numbers and those not currently practicing The proportion of ineligible practitioners was 47 in Connecticut and 33 in Washington About 84 of ineligible Connecticut massage therapists lacked identifiable phone numbers, while in Washington ineligible therapists were about equally divided between those who were not practicing and those who lacked identifiable phone numbers All participating massage therapists were interviewed about their demographic, training, and practice characteristics Those with at least 10 visits in a typical week were then invited to participate in visit-based data collection A sample of those seeing 5 to 9 visits per week were also invited to collect data on patient visits Massage therapists with less than 5 visits per week were not asked to collect visit data and provided about 2 of all massage visits [6] We obtained approval from the Group Health Cooperative, University of Washington, and Beth Israel Deaconess Medical
Center Institutional Review Boards Visit data were collected between May and September in 1998 in Washington and between June 1999 and March 2000 in Connecticut Massage therapists were given visit forms marked with unique identification codes and were asked to record data on 20 consecutive visits even if the same patient was seen more than once Practitioners were randomly assigned weekdays to begin data collection
Visit form The one-page visit form was modeled after those used in the National Ambulatory Medical Care Survey NAMCS [7] and a copy of the visit form is found in Additional File 1 Whenever possible, questions were worded identically to those in the NAMCS eg, demographic characteristics, smoking status, reason for visit, referral source, source of payment, visit duration, visit disposition New questions asked if the patient was receiving care from a conventional medical provider for the primary problem and if the massage therapist had communicated about this problem with a
conventional provider who also provided care for the patients main problem We also designed special questions to capture information about massage treatments, including information on use of specific assessment techniques, massage techniques, and lifestyle recommendations We asked practitioners to record up to five complaints, symptoms, or other reasons for this visit using the patients own words, listing the most important complaint or reason first These data were classified using the NAMCS Reason for Visit Classification System, which distinguishes among symptoms, diseases, diagnostic/screening/preventive interventions, treatments, and injuries [7] Individual reasons for visit were
Methods
Original study The data presented in this paper were collected as part of a larger study of four licensed CAM professions, including massage therapy The methods are described in detail elsewhere [5,6] and summarized here Our goal was to obtain data on 20 consecutive visits to 50 randomly selected
massage therapists in one Northeastern state Connecticut and one Western state Washington who gave at least 10 massage treatments per week Massage therapists were randomly sampled from state licensure listings in Washington 1998 and Connecticut 1999 In both states, licensing requirements for massage therapists including
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then clustered into larger categories that correspond to International Classification of Diseases, Ninth Edition ICD9 chapters No information was collected on adverse experiences as part of this study
Analysis In the massage therapist analyses, Chi-square and Fisher Exact tests were used to compare proportions, and Kruskal Wallis tests were used to compare medians Even though standard errors are not presented, they are always within 5 percentage points of the estimate Analyses were performed using SAS version 8 SAS
Institute, Cary, NC
In the visit analyses, each visit in the sample was weighted by the inverse of its sampling probability, which reflected both the chance that the particular provider participated and the estimated proportion of that providers annual visits included in the study Consequently, our results represent estimates of all visits made to massage therapists in each state, except for the 2 of visits made to providers with fewer than 5 visits per week or visits to therapists who were not licensed Because of the two-stage sampling design, we used SUDAAN software Research Triangle Institute, Research Triangle, NC to calculate standard errors and confidence intervals using Taylor series linearization Because of the large sample sizes 965 and 1040 visits the weighted percentages presented in the tables have small standard errors, generally between 05 and 25 percentage points and rarely exceeding 3 percentage points As a result, moderate to large differences between the states are
also statistically significant Therefore, the standard errors are not included in the tables
Most massage therapists 82 in Connecticut and 89 in Washington reported additional hours of training after graduation, receiving a median of 60 hours Nearly 80 of the massage therapists in Connecticut and about half in Washington reported specialty or advanced training ie, continuing education, with 43 and 31, respectively, reporting multiple types of such training Continuing education was extremely heterogeneous, with practitioners noting 56 different types of training in Connecticut and 37 types in Washington However, only 4 types of training were received by more than 10 of practitioners in Connecticut meridian -based therapies, craniosacral, myofascial release and Reiki and only one type of training was received by more than 10 of practitioners in Washington craniosacral therapy Table 1 Ten percent of massage therapists in Connecticut and 8 of those in Washington held other healthcare
profession licenses All but one of those acupuncture were in biomedical areas, most commonly nursing Connecticut massage therapists reported a median of 10 patient visits per week and 12 hours of direct patient care per week, compared with 15 patient visits per week and 17 hours of direct patient care, for massage therapists in Washington p 002 for hours of direct patient care
Reasons for visits to massage therapists Visits to massage therapists were for a limited number of conditions About 60 of visits were for musculoskeletal symptoms, particularly back, neck, and shoulder symptoms Table 2 Visits for wellness ie, relaxation accounted for another 20 of visits and mental health concerns, largely anxiety and depression, for another 6 to 9 of visits Virtually all other visits were for general body symptoms mostly generalized pain or nervous system symptoms most commonly headache
Results
Participation rates Participation rates for the massage therapist interview were 86 114 of 133 in
Connecticut and 84 in Washington 112 of 134 Of the massage therapists who saw enough clients per week to be eligible to collect visit data, 66 in Connecticut 61 of 93 and 70 in Washington 65 of 93 complied Data were collected on 965 visits in Connecticut and 1040 visits in Washington Characteristics of the massage therapists In both states, massage therapists were typically white, female and had a median age of 42 years Table 1 Virtually all of them received their basic training in the US, with most having trained in the state where they were currently practicing A small fraction had no formal training In both states, massage therapists reported training a median of about 600 hours Massage therapists reported a median of 4 to 5 years in practice, with only 18 in Connecticut and 13 in Washington reporting more than 10 years
Most visits were for chronic problems, either problems that were ongoing 41 in Connecticut and 32 in Washington or for flare-ups of chronic problems 12 in
Connecticut and 15 in Washington About a quarter to a third of all visits were for non-illness care 32 in Connecticut and 27 in Washington and the remainder of visits were for acute problems 15 in Connecticut and 17 in Washington
Interaction with other healthcare providers and insurance Most massage visits resulted from self-referrals 64 or 75 but 4 in Connecticut and 11 in Washington resulted from referrals by medical or osteopathic physicians virtually all for musculoskeletal symptoms Although massage therapists discussed the care of the patient with another provider in 22 of visits in Connecticut and 30 in Washington, that provider was a medical or osteopathic physician less than one-third of
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Table 1: Demographic and training characteristics of massage therapists
State Connecticut N 114 practitioners Demographic Characteristics
Women White Hispanic Median Age Basic Training Formal Schooling US other states US same state Foreign No Formal Schooling Median Years in Practice Post-graduate Training Any Craniosacral Neuromuscular Reflexology Reiki Polarity Lymph Drainage Meridian based Shiatsu, Tuina, acupressure Myofascial Release Pregnancy Massage p 005; p 001; p 0001 Washington N 112 practitioners p value
85 95 4 415 yrs 93 12 81 1 6 5 yrs 79 14 10 10 13 5 3 22 14 6
85 95 4 415 yrs 94 8 85 1 6 4 yrs 52 12 10 6 6 5 5 10 3 1
the time The most frequent consultations were with chiropractors Massage therapists indicated that medical or osteopathic physicians were treating their patients for the same condition for 24 Connecticut or 32 Washington of visits Massage therapists noted that they had discussed their patients care with the physicians of 29 Connecticut or 49 Washington of their physicianreferred patients compared with only 12 14 of their other physician-managed patients Two percent of visits
in both states ended with a referral to a medical or osteopathic physician Insurance covered only 8 of visits in Connecticut and 26 of visits in Washington, and almost all the remainder were paid for by the patient
Care during visits to massage therapists Massage therapists performed assessments in about twothirds to three-quarters of the visits Table 3 The most common methods were tissue assessment via palpation, range of motion, and postural assessment Multiple assessments were used in 38 Connecticut or 48 Washington of visits
Virtually all visits included a massage that emphasized at least two techniques Table 4 The most commonly emphasized techniques were Swedish massage, deep tissue, and trigger point/pressure point techniques Massage therapists in both Connecticut and Washington emphasized five other techniques in between 14 and 25 of visits: energy work, hot/cold therapy, movement re-education, craniosacral, and reflexology Massage therapists in Connecticut were more likely to
emphasize Oriental bodywork ie, meridian based techniques such as shiatsu while those in Washington were more likely to emphasize neuromuscular therapy Definitions of some of the most commonly emphasized techniques are provided in Additional File 2 More than 80 of visits included self-care recommendations Table 5, with 50 Connecticut or 64 Washington of visits including multiple recommendations Increasing water intake, movement especially active movement, body awareness, and breathwork were the most common recommendations Visits lasted a median of 60 minutes
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Table 2: Most common reasons for visits to massage therapists licensed in Connecticut 1999 and Washington 1998 by broad and specific categorization
Connecticut N 965 visits Broad Categories with Primary Reason 592 195 88 45 37 957 with Primary Reason Any Reason 204 344 195 258
130 241 84 231 88 174 50 100 40 63 31 45 16 52 14 22 852 Broad Categories
Washington N 1040 visits with Primary Reason 630 187 57 49 37 960 with Primary Reason Any Reason 202 398 200 385 187 265 74 266 52 123 37 84 26 63 21 35 19 67 18 56 836
1 Musculoskeletal Symptoms 2 Wellness 3 Psychological and Mental Health Symtoms 4 General Symptoms 5 Nervous System Symptoms Top 5 Categories Specific Reasons 1 Back Symptoms 2 Massage Wellness 3 Neck Symptoms 4 Shoulder Symptoms 5 Anxiety or Depression 6 Leg Symptoms 7 Unspecified Muscle Symptoms 8 Generalized Pain 9 Headache 10 Unspecified Joint Symptoms Top 10 reasons
1 Musculoskeletal Symptoms 2 Wellness 3 Psychological and Mental Health Symtoms 4 Nervous System Symptoms 5 General Symptoms Top 5 Categories Specific Reasons 1 Back Symptoms 2 Neck Symptoms 3 Massage Wellness 4 Shoulder Symptoms 5 Anxiety or Depression 6 Headache 7 Leg Symptoms 8 Generalized Pain 9 Hip Symptoms 10 Arm Symptoms Top 10 reasons
Broad Categories of Primary
Reason for Visit Codes correspond to ICD chapters Wellness was not originally part of the NAMCS Reason for Visit Classification Most of these visits are for relaxation
Table 3: Diagnostic assessments performed by massage therapists licensed in Connecticut 1999 and Washington 1998
Connecticut N 965 visits Diagnostic Assessment At least one Applied Kinesiology Postural Assessment Range of Motion Tissue Assessment Other eg, acupressure point assessment 672 20 198 349 563 71 Percent Using
Washington N 1040 visits
740 58 307 460 608 27
Discussion
To our knowledge, this is the first study that describes the demographic and training characteristics of US massage therapists and uses systematically collected visit data to describe their treatment patterns Strengths of the study are the collection of data from licensed massage therapists practicing in geographically separated parts of the country where CAM use is relatively common, random sampling
of providers from state licensing
lists, relatively high response rates, and large sample sizes The main limitation is that we collected data from only two states, which may not be representative of massage practice in other states However, licensure requirements in Connecticut and Washington are similar to those in most other states with
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Table 4: Massage techniques emphasized during visits to massage therapists licensed in Connecticut 1999 and Washington 1998
Connecticut N 965 visits Techniques Emphasized Any Craniosacral Deep Tissue Emotional Bodywork Energy Work Guided Imagery Hot/Cold Therapy Manual Lymph Drainage Movement Re-education Neuromuscular Therapy Oriental Bodywork Pregnancy Massage Reflexology Somatherapy Swedish Techniques Trager Trigger Point/Pressure Point Other eg, Esalen, Thai Two or more techniques 994 153 628 57 249 53 199 38 192 58 166 14 150 12
806 67 515 71 867 Percent Using
Washington N 1040 visits
999 151 653 40 172 47 242 63 242 205 86 07 154 50 768 141 456 42 925
Table 5: Self-care recommendations given by massage therapists licensed in Connecticut 1999 and Washington 1998
Connecticut N 965 visits Self-Care Recommendations Any Body Awareness Breathwork Hot/Cold Therapy Movement any Movement active Movement passive Movement resisted Visualization Water Intake, Increase Other eg, self-massage, relaxation 811 372 284 290 392 266 173 72 83 484 56 Percent Using
Washington N 1040 visits
846 377 252 332 446 351 135 78 87 561 34
licensure requirements As of December, 2004, 33 states and the District of Columbia had passed legislation regulating massage practice Of those, 21 require exactly 500 hours of training for licensure and 12 require between 570 and 1000 hours [8] Licensure in both Connecticut and Washington requires 500 hours of training plus a passing
score on the national certification exam administered
by the National Certification Board for Therapeutic Massage and Bodywork NCBTMB The latter is required for licensure in 24 states and is an option for licensure in another 5 states In some states, including Massachusetts and California, massage regulations vary within the state ie,
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between townships, cities or counties By contrast, the two provinces in Canada with regulatory requirements mandate that massage therapists receive 2500 hours Ontario or 3300 hours British Columbia of training
Characteristics of the massage therapists Our study describes an eclectic group of health professionals Most massage therapists have taken continuing education training that includes both Western-oriented treatment techniques eg, neuromuscular therapy, myofascial release, and non-Western oriented treatment techniques eg, Reiki, meridian-based massage
Our finding that most massage therapists are white females with a median age around 40 is consistent with the findings of the only other published study of the characteristics of massage therapists, which surveyed 82 massage practices in the Boston area [9] However, that study reported that the median length of practice was 7 years compared to our 4 to 5 years, that providers received a median of 1000 hours of clinical training compared to our 600 hours, and that practitioners saw a median of 20 patients per week compared to our 10 to 15 visits per week The other study used the telephone book in a single urban area to recruit massage therapists whereas we used state wide licensing lists Their restriction to an urban area, their recruitment methods and their lower response rate may have biased their sample toward busier practitioners Why patients visit massage therapists and evidence for efficacy The majority of visits to massage therapists focused on musculoskeletal conditions,
possibly reflecting the extensive use of massage by physical therapists for rehabilitation during the first half of the 20th century [10] These are conditions for which Western medical care is often of limited value, which may explain why back and neck pain are the most common reasons why patients seek CAM care in general [2] While massage as a relaxation technique has received abundant attention in the popular culture, we found that less than one-third of all visits to licensed massage therapists focused on non-illness care
resentative sample of US adults reported that massage therapy was one of the most common CAM therapies used for back problems, neck problems and fatigue [2] While fatigue was not a commonly listed reason for visiting massage therapists in our study, some patients who received wellness care or care for anxiety or depression could conceivably have had fatigue as a symptom The use of massage for treating medical conditions has grown substantially since 1990 [2]
Although massage is one of the most popular forms of CAM care and has been found to have intriguing physiological effects reviewed by Field [12], few studies with moderate to large sample sizes have been conducted to evaluate its clinical effectiveness, even for most musculoskeletal conditions, conditions for which massage is frequently sought and for which conventional medicine has few good treatments Three recent studies, including two that were well designed and had reasonable sample sizes, evaluated therapeutic massage as a treatment for subacute or chronic back pain and all three found positive results [13] In addition, several studies of acupressure for back pain have also found positive results [14,15] A recent Cochrane review of massage for back pain [16] concluded that massage might be beneficial for patients with subacute and chronic non-specific back pain, especially when combined with exercises and education More studies are needed to confirm these conclusions While even
fewer studies of massage have been conducted for other musculoskeletal pain conditions, there are small studies suggesting that massage may have benefits for patients with fibromyalgia [17], shoulder pain [18] and diffuse chronic pain [19], while Irnich [20] did not find massage effective for neck pain Most of those studies lacked follow-up after the treatments had stopped, but Hasson found that the benefits of massage did not persist three months after the last treatment A recent meta-analysis of randomized trials of massage for various conditions found that massage had its greatest short-term benefits in reducing trait anxiety and depression, but no studies have evaluated these effects after the end of the treatment period [21] A systematic review of massage for symptom relief in cancer patients found preliminary evidence that massage had short term benefits on psychological well-being and possibly anxiety [22], but called for additional studies to confirm and extend these findings
The modest evidence base for massage therapys clinically important effects provides physicians with little information for advising patients about its effectiveness for conditions other than subacute or chronic back pain However, given the safety profile and preliminary evidence of effectiveness for back pain, physicians should feel comfortable
CAM is also commonly used for self-defined anxiety and depression [2,11] Among such a group of respondents to a national survey, 5 and 2 of respondents said that they used massage therapy to treat these conditions, respectively [11] Since massage therapists do not make diagnoses, no information is available on whether patients visiting for anxiety and depression in our study actually had these disorders diagnosed by physicians We could find no other published studies presenting data on patients reasons for visits to massage therapists from a large population-based sample of visits, so we do not know how comparable these results are A survey of
a rep-
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recommending massage for selected patients with musculoskeletal conditions and, possibly, for mild stress-related anxiety
Care during visits to massage therapists Massage therapists in Washington were more likely than those in Connecticut to use postural assessment and range of motion as assessments tools Such differences likely reflect differences in training In general, these differences in assessment were not associated with differences in the massage techniques emphasized by practitioners Swedish, deep tissue, and trigger pressure point were by far the most popular techniques in both states In their survey of massage therapists in Boston, Lee and Kemper [9] found similar results: 90 of practitioners reported using Swedish techniques and more than half reported using trigger point massage, sports massage, myofascial release,
and aromatherapy
Despite these scattered reports of adverse experiences, common forms of massage eg, Swedish, deep tissue, and neuromuscular are considered very low risk, especially when massage is tailored appropriately to the individual eg, possible pressure or anatomic site restrictions, as massage therapists are commonly trained to do [10] While it is still generally assumed that patients with deep vein thrombosis should not receive massage to the lower extremities, many previous contraindications, such as proscribing massage to patients with metastatic cancer, are no longer considered warranted Massage therapists are trained not to massage anatomic sites containing localized conditions such as skin injuries or burns
Communication between massage therapists and physicians Massage therapy is an increasingly popular form of care used by patients who are often also being treated by a physician for the same condition Nevertheless, we found that massage therapists and physicians rarely
communicated with each other Possible barriers to communication include our observation that most patients who see both a physician and a massage therapist for a particular condition were not referred to massage by the physician Furthermore many massage therapists are not trained in charting language familiar to physicians, nor are they permitted to make diagnoses In addition, referring patients to massage therapists has not been part of the training of physicians Finally, we suspect that most massage therapists, who are typically part-time solo practitioners, lack office staff and record systems to assist with administrative tasks, including routine and written communication with other care providers
A substantial minority of visits included techniques with a non-Western origin, such as some forms of energy work eg, Reiki and meridian-based massage In addition, this study as well as a previous study [23], found that massage therapists often emphasize self-care eg, drinking more
water, movement, body awareness Recommendations often include increasing the patients awareness of how they are using their bodies coupled with exercises designed to enhance movement and posture, based on the assumption that many musculoskeletal conditions result from poor use of the body While these recommendations have not been scientifically validated, they are likely to be safe and may enhance the patients sense of well-being
Safety of massage In a review of the safety of massage therapy, Ernst [24] found 16 case reports and 4 case series in the biomedical literature over a 6 year period describing adverse effects associated with various forms of massage However, only 3 reports including 7 cases described adverse effects that were probably attributable to treatments by massage therapists practicing Western forms of massage These included the displacement of a ureteral stent, a hepatic hematoma after deep tissue massage [25] and the deterioration in hearing among patients who
received neck massage Ernst found three additional reports of adverse events associated with shiatsu, the most serious of which was retinal artery embolism with partial loss of vision after application of shiatsu to the upper neck Although the rate of adverse effects over this period of time is unknown, in the US alone an estimated 113 million visits were made to massage therapists in 1997 [2], suggesting that serious adverse experiences due to massage are extremely rare
We believe that patients may benefit from increased communication between their physicians and massage therapists Physicians can foster improved communication by asking patients about the care they are receiving from a massage therapist and learning about the treatment plan Some patients will want to try massage therapy only after consultation with their physician In these circumstances, physicians can use the framework recommended by Eisenberg [26] to guide patients through the process of selecting a well-trained,
therapeutically-oriented massage therapist, jointly negotiating the treatment plan, and monitoring the effects of the treatment over time
Conclusion
While substantial barriers to the full integration of massage therapy into the healthcare system remain eg, variability between states in licensure and practice regulations, lack of widespread insurance reimbursement, lack of solid studies on efficacy for many frequentlytreated conditions, ambivalence on the part of massage therapists as to the advisability of mainstreaming[27],
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the information provided in this report should be informative to physicians and other healthcare providers interested in advising their patients about massage therapy
2
Competing Interests
The authors declare that they have no competing interests
3 4 5
Authors contributions
KJS participated in the design of the
overall project and the data analyses and drafted this manuscript DCC was the PI on one of the grants funding the study, designed and directed the data collection and analysis of the overall project JK helped design the data collection instruments JE participated in the design of the overall project, directed the data collection, quality control, and participated in the analyses for this paper AH directed the data collection for Connecticut RD participated in the design of the overall project and data collection procedures and helped to obtain funding DME was the PI on one of the grants funding the study and participated in the design of the overall project and data collection procedures All authors read and approved the manuscript
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7
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Additional material Additional File 1
Massage Care Survey The visit form used for each of the massage therapy visits Click here for file [http://wwwbiomedcentralcom/content/supplementary/14726882-5-13-S1doc]
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12 13
14
Additional File
2
Glossary of Selected Massage Techniques Definitions of selected massage techniques Click here for file [http://wwwbiomedcentralcom/content/supplementary/14726882-5-13-S2doc] 15 16 17
Acknowledgements
This project was supported by grants from the Group Health Foundation, Grants HS09565 and HS08194 from the Agency for Health Care Policy and Research and Grant AR43441-04S1 from the National Institutes of Health In-kind support was provided by the Centers for Disease Control and Prevention The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary and Alternative Medicine, National Institutes of Health We thank the 33 members of the original massage therapy study team for data collection and Kristin Delaney for help with data analysis
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References
1 Rubik B, Pavek R, Ward R, Greene E, Upledger J, Lawrence D, Ramsden E: Manual Healing Methods In Alternative
Medicine: Expanding Medical Horizons A report to the National Institutes of Health on
Alternative Medical Systems and Pratices in the United States: 14 16 September 2002; Chantilly, VA 1994:113-157 USA: NIH Pub No 94-066 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC: Trends in alternative medicine use in the United States, 19901997: results of a follow-up national survey JAMA 1998, 280:1569-1575 Landmark Health Care, Inc: The Landmark Report on Public Perceptions of Alternative Care Sacramento, CA; 1998 Palinkas LA, Kabongo ML: The use of complementary and alternative medicine by primary care patients A SURFNET study J Fam Pract 2000, 49:1121-1130 Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Davis RB, Cramer E, Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg DM: Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians J Am Board Fam Pract 2002, 15:378-390
Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Davis RB, Cramer E, Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg DM: Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians J Am Board Fam Pract 2002, 15:463-472 Schneider D, Appleton L, McLemore T: National Center for Health Statistics: A reason for visit classification for ambulatory care In DHEWPub No Public Health Service PHS, ed Vital and Health Statistics Washington, DC: U S Government Printing Office; 1979:79-1352 American Massage Therapy Association : Massage Practice Laws Information Guide [http://wwwamtamassageorg/pdf/ 2005_StateLawspdf] Lee AC, Kemper KJ: Practice patterns of massage therapists Altern Complement Med 2000, 6:527-529 Braverman DL, Schulman RA: Massage techniques in rehabilitation medicine Phys Med Rehabil Clin N Am 1999, 10:631-649 Kessler RC, Soukup J, Davis RB, Foster DF, Wilkey SA, Van Rompay MI, Eisenberg
DM: The use of complementary and alternative therapies to treat anxiety and depression in the United States Am J Psychiatry 2001, 158:289-294 Field TM: Massage therapy effects Am Psychol 1998, 53:1270-1281 Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG: A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain Ann Intern Med 2003, 138:898-906 Franke A, Gebauer S, Franke K, Brockow T: Acupuncture massage vs Swedish massage and individual exercise vs group exercise in low back pain sufferers a randomized controlled clinical trial in a 2 2 factorial design Forsch Komplementarmed Klass Naturheilkd 2000, 7:286-293 Hsieh LL, Kuo CH, Yen MF, Chen TH: A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy Prev Med 2004, 39:168-176 Furlan AD, Brosseau L, Imamura M, Irvin E: Massage for low back pain Cochrane Database Syst Rev 2002, 2:CD001929 Sunshine W, Field T, Quintino
O, Fierro K, Kuhn C, Burman I: Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation J Clin Rheumatol 1996, 2:18-22 van den Dolder PA, Roberts DL: A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain Aust J Physiother 2003, 49:183-188 Hasson D, Arnetz B, Jelveus L, Edelstam B: A randomized clinical trial of the treatment effects of massage compared to relaxation tape recordings on diffuse long-term pain Psychother Psychosom 2004, 73:17-24 Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, Natalis M, Senn E, Beyer A, Schops P: Randomised trial of acupuncture compared with conventional massage and sham laser acupuncture for treatment of chronic neck pain BMJ 2001, 322:1574-1578 Moyer CA, Rounds J, Hannum JW: A meta-analysis of massage therapy research Psychol Bull 2004, 130:3-18 Fellowes D, Barnes K, Wilkinson S: Aromatherapy and massage for symptom relief in patients with cancer Cochrane Database Syst Rev
2004, 2:CD002287 Cherkin DC, Eisenberg DM, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, Deyo RA: Randomized trial comparing traditional
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http://wwwbiomedcentralcom/1472-6882/5/13
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Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain Arch Intern Med 2001, 161:1081-1088 Ernst E: The safety of massage therapy Rheumatology Oxford 2003, 42:1101-1106 Trotter JF: Hepatic hematoma after deep tissue massage N Engl J Med 1999, 341:2019-2020 Eisenberg DM: Advising patients who seek alternative medical therapies Ann Intern Med 1997, 127:61-69 Eisenberg DM, Cohen MH, Hrbek A, Grayzel J, Van Rompay MI, Cooper RA: Credentialing complementary and alternative medical providers Ann Intern Med 2002, 137:965-973 Levine AS, Levine VJ: The Bodywork and Massage sourcebook Los Angeles: Lowell House; 1999
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