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Study points to the benefits of alternative care
Most people know massage therapy for its relaxation benefits. Now there is growing evidence that massage therapy can reduce pain, a hallmark of hospice and palliative care. Based on these measurable clinical benefits, hospices may want to include massage therapy as part of its stable of alternative therapies.
"Massage therapy is very compatible with hospice care," says Adela Basayne, LMT, a private practice massage therapist in Portland, OR. "Massage therapists aren’t looking to change the health status of patients. Instead, their goal is to treat symptoms."
Hospices that are not yet offering massage therapy along with other alternative therapies, such as art therapy, should consider the results of a recent study published in Hospice Journal.1
Researchers studied 56 hospice patients whose average age was 64. Patients were randomly assigned to receive either massage therapy or usual care that did not include massage therapy. Those receiving massage therapy were given the therapy twice weekly for two weeks by a licensed massage therapist.
When the study began, about half of the patients had constant pain. Massage therapy and normal care both reduced patients’ pain
to episodic or intermittent pain in 14% of the patients in each group. Overall, patients suffered half as much pain by the end of the study as they had at the beginning.
But pain intensity decreased more in the massage group than in the usual care group — a 42% decrease in the massage group vs. a 25% decrease in the usual care group. Nearly three-quarters of the patients receiving massage — compared with only 57% of the usual-care patients — reported pain levels of 0 or otherwise lower than at the beginning of the study. About one-third of the massage patients received massages in between the sessions scheduled as part of this study. The effect of massage on pain intensity was immediate, according to researchers, decreasing the pain scores after each massage. Pulse rate and respiratory rate also fell, indicating a relaxation response.
The therapists followed a standardized protocol for the massage, specifying full-body massage, when possible, and the types and duration of the strokes to be used, such as effleurage strokes and others. The massages lasted 30 to
45 minutes. About half of the patients could
not complete the study because death intervened or their condition deteriorated to an extent that precluded their completing the study questionnaire.
There is also a psychological benefit, Basayne says. Sadly, many dying patients are touch-deprived as a result of their disease. Friends and family members are less inclined to embrace, caress, or even hold hands out of irrational fear of contracting the same disease or some other personal reasons. Massage therapy brings back the human touch that patients are craving, says Basayne.
The reasons behind the effect massage has
in reducing pain is well known, says Basayne. Experts have theorized that its relaxation effect reduces anxiety, which in turn lowers pain intensity.
Massage therapy is a broad term that describes a discipline that encompasses a number of techniques, Basayne says.
The type of massage therapy most commonly used to treat anxiety and pain is traditional European massage, which includes methods based on conventional Western concepts of anatomy and physiology and soft tissue manipulation. There are five basic kinds of soft tissue manipulation techniques:
• effleurage (long flowing or gliding strokes, usually toward the heart, tracing the outer contours of the body);
• petrissage (strokes that lift, roll, or knead the tissue);
• friction (circular strokes);
• tapotement (percussion or tapping).
Swedish massage is the most predominant example of traditional European massage and is the most commonly used method in the United States. It was developed by Per Henrik Ling in Sweden in the 1830s and uses a system of long, gliding strokes, kneading, and friction techniques on the more superficial layers of muscles. It usually goes in the direction of blood flow toward the heart because there is an emphasis on stimulating the circulation of the blood through the soft tissues of the body. Swedish can be a relatively vigorous form of massage, sometimes with a great deal of joint movement included.
Oil is usually used, which facilitates the stroking and kneading of the body, thereby stimulating metabolism and circulation. Its active and passive movements of the joints promote general relaxation, improve circulation and range of motion, and relieve muscle tension. Swedish massage is often given as a complete, full-body technique, though sometimes only a part of the body is worked on.
Hospices, however, may encounter more recently developed disciplines. Among them is contemporary Western massage. This includes methods based primarily on modern Western concepts of human function, anatomy, and physiology, using a wide variety of manipulative techniques. These may include broad applications for personal growth, emotional release, and balance of mind-body-spirit in addition to traditional applications. These approaches go beyond the original framework or intention of Swedish massage. They include Esalen or Swedish/Esalen, neuromuscular massage, deep tissue massage, sports massage, and manual lymph drainage. Most of these are American techniques developed from the late 1960s onward, though the latter was developed in the 1920s.
• Esalen and Swedish/Esalen. Esalen massage is a modern variation that focuses not so much on relieving muscle tension or increasing circulation as on creating deeper states of relaxation, beneficial states of consciousness, and general well-being. Swedish is more brisk and focuses on the body; Esalen, on the other hand, is more slow, rhythmic, and hypnotic and focuses on the mind/body as a whole. Esalen massage is not widely taught as a pure form. Rather, a marriage of sorts has been formed by the integration of Swedish and Esalen as a way of incorporating the strengths of each. Many massage therapists describe their method as Swedish/Esalen, and this hybrid is commonly taught in massage schools.
• Neuromuscular massage. This is a form of deep massage that applies concentrated finger pressure specifically to individual muscles. This is a very detailed approach, used to increase blood flow and to release trigger points, which are intense knots of muscle tension that refer pain to other parts of the body (they become trigger points when they seem to trigger a pain pattern). This form of massage helps to break the cycle of spasm and pain and is often used in pain control. Trigger point massage and myotherapy are varieties of neuromuscular massage.
Deep tissue work focuses on specifics
• Deep tissue massage. This approach is used to release chronic patterns of muscular tension using slow strokes, direct pressure, or friction. Often the movements are directed across the grain of the muscles (cross-fiber) using the fingers, thumbs, or elbows. This is applied with greater pressure and at deeper layers of the muscle than Swedish massage, which is why it is called deep tissue. It is also more specific. For example, in the case of someone with a sore shoulder, the practitioner may focus on the trapezius and the rhomboid underneath, trying to work in all the layers of muscle that might be involved. Deep tissue massage lends itself to being more focused on a problem area.
Basayne warns that there is opportunity for untrained practitioners of massage to pass themselves off as trained massage therapists. Hospices should require national certification in massage therapy and/or proof of licensure in states that require massage therapists to be licensed.
"You want a massage therapist with training in pathology," Basayne says. "They need to understand the disease process and have an understanding of end-of-life care."
This is important because a poorly trained massage therapist can add to a patient’s pain rather than help relieve it. Basayne recalls an AIDS patient she treated a few years ago who benefited from massage in the early stages of therapy. But as the disease progressed, she was limited in the places she could manipulate.
"By the end, I was just caressing his head and neck," she says. "A therapist is trained in informed touch. A therapist has to determine tolerance to touch."
1. Wilkie DA, Kampbell J, Cutshall S, et al. Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: A pilot study of a randomized clinical trial conducted within hospice care delivery. Hospice J 2000; 15:31-53.