Massage Therapy

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.

Evidence-Based Practice in massage therapy

Evidence for massage is information on massage practice that researchers and therapists collect in a systematic manner (Sackett et al. 2000). In the past, therapists relied heavily on their clinical intuition and past experience to guide treatment decisions. In today's health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement. The use of evidence to guide clinical decision making is evidence-based practice (EBP). The transition from an experience-based approach to practice to EBP is not necessarily intuitive; hence, structured methodologies that can provide guidance on these issues are needed.

Defining Evidence-Based Practice

Sackett and colleagues (2000), who developed the concept of evidence-based medicine, define the three components for EBP as best research evidence, clinical expertise, and client values. Best research evidence is the best available clinical, client-centered research that examines the accuracy, safety, and efficacy of assessment tests and therapeutic interventions.Clinical expertise is therapists' ability to use their clinical skills and past experience to identify each client's unique health needs and the potential risks and benefits of interventions.Finally, client values are the unique preferences, goals, and expectations that each client brings to the therapeutic relationship. The integration of these components is the goal of EBP.

Evaluating Evidence

Many therapists, for whom finding the time to locate and read evidence is challenging enough, find the additional step of evaluating evidence daunting. Fortunately, three approaches provide guidance to therapists. First of all, Sackett and others(2000) created a hierarchy of levels of evidence that ranks research designs based on the extent to which they provide strong evidence of a cause-and-effect relationship between the treatment and the outcome. In this respect, studies at the top of the hierarchy, such as randomized clinical trials, are considered better evidence than those at the bottom, such as qualitative studies. This hierarchy may raise concerns within the field of massage therapy (MT) because the lower-ranked research designs are considered by some to be optimal for studying complex, holistic, or wellness-oriented aspects of massage (Finch 2007).

Both Jonas and Finch offer alternatives to this hierarchical approach. Jonas (2001)proposes an evidence house that includes many kinds of rigorous research methods—different rooms in the house—without ranking the types of research designs. He suggests that including a variety of qualitative and quantitative research methodologies provides a more balanced and complete picture of massage and how it works. Finch (2007) describes how practitioners act like an evidence funnel in the sense that they receive evidence from many sources, and then filter it by evaluating its relevance and merits before integrating it with their own expertise and the client's preferences.

In addition to these systems for evaluating evidence, there are several excellent MT-specific handbooks (Hymel 2006; Menard 2009) that therapists can use for assistance in locating and evaluating evidence. In practical terms, it may be more efficient for a therapist who is new to the concepts of evidence-based practice to use preappraised sources, such as practice guidelines, clinical protocols, or plans of care published by professional associations (Grant et al. 2008).

Effects and Safety of Massage Therapy in Cancer Care

This section reviews research evidence on the safety, feasibility, and effectiveness of MT across the cancer care spectrum in both children and adults and examines the effectiveness and limitations of MT to reduce both cancer- and treatment-related symptoms, such as pain, depression, anxiety, nausea, and fatigue. It also presents the limited evidence on improved biological and immune-response outcomes. It considers the adaptation of treatment sometimes necessary for this population and notes special precautions, such as avoiding radiation sites. In addition, it debunks the myth that MT must be avoided by persons with cancer.

Safety

Serious adverse events are rare and massage is generally safe when given by credentialed and experienced practitioners (Corbin 2009; Deng et al. 2009). More than 60 trials provide evidence for the feasibility and safety of massage for children and adults at every phase of the cancer experience. In a systematic review of 10 studies involving 386 patients with cancer, one case report of a skin rash was the only adverse event reported (Wilkinson, Barnes, and Storey 2008). Other anecdotal reports in patients with cancer include headache, lightheadedness, muscle tenderness, or general feeling of unwellness for a day or two following deep tissue massage. Adverse effects can often be prevented with awareness, modification of touch and pressure, and changes to positioning. The Society for Integrative Oncology recommends the use of massage for cancer pain and anxiety, but cautions against the use of deep or intense pressure near cancer lesions or enlarged lymph nodes, radiation field sites, intravenous catheters and medical devices, and anatomic distortions, or in patients with a bleeding tendency (Deng et al. 2009).

It is a myth that massage spreads cancer (Corbin 2005; Ernst 2003). Metastasis of cancer cells is a complex interaction of structural, biochemical, hormonal, immunological, and genetic factors that control cell growth, adhesion, angiogenesis, cell signaling, and mobility. However, inflammation, pain, or sensitivity to pressure are other reasons practitioners should use a gentle touch and avoid direct or deep massage over a surgical or tumor site, or in a limb distal to lymph node removal. Other problems requiring modification of the depth or location of touch include infection, skin irritation, platelet or clotting disorders, bone metastasis, and nausea. Deep massage should be avoided in fields of radiation, since the skin may be fragile and the underlying tissue may be fibrotic or edematous. No oils or lotions should be used on the field of treatment during the course of radiation. Rocking motions should be avoided with patients who are experiencing nausea (Gecsedi 2002). Practicing diligent hand washing and using clean equipment and linens will reduce the risk of infection.

Caution should be used for patients with cancer-related pain. Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement (radiating pain), or bone pain from metastases. Light-touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing inflammation or causing fragile bones to break.

It is important to assess and adapt touch for each client. In one study, children declined therapeutic massage if they were feeling nauseated, in pain, or ill, but responded positively to light and comforting caress of their arms or legs from their parents (Post-White, Fitzgerald, Savik, et al. 2009). Long, slow, light touch triggers a parasympathetic (relaxing) response, whereas deep massage stimulates the sympathetic nervous system, which increases heart rate and blood pressure and may lead to distress. To provide safe and effective massage, MacDonald (2007) recommends reducing the pressure, slowing the strokes, shortening the session length, and working gently.

Cancer treatment can leave patients feeling lonely and vulnerable. Children may be particularly sensitive to experiencing changes in body image and being unclothed. Asking permission and proceeding gently when touching an amputated limb stump, a bald head, or a scar, even if it is well healed, conveys compassion and respect. Massage to the abdomen can trigger emotional responses. Calm, confident, and loving touch can be restorative and healing as the patient adjusts to a new body image and sense of self. (See chapter 14.)

Efficacy and Effectiveness

Efficacy is the assessment of whether treatment works under controlled conditions in a clinical trial. Controls within the study design reduce bias and eliminate alternate explanations for observed effects, resulting in a cause-and-effect prediction of a given probability. A treatment is efficacious when it proves to be superior to placebo or control conditions. By contrast, effectiveness is the assessment of whether treatment works in a typical clinical setting and is clinically relevant. Both are important to assessing the value of massage to the care of persons with cancer.

Several excellent summaries and systematic reviews evaluate the efficacy of massage research for children and adults with cancer. They include detailed tables of study samples, design, massage techniques, and findings (Ernst 2009; Fellowes, Barnes, and Wilkinson 2008; Hughes et al. 2008; Jane et al. 2008; Myers, Walton, and Small 2008; Russell et al. 2008; Wilkinson, Barnes, and Storey 2008; Beider and Moyer 2007).This chapter summarizes the findings and includes additional research published subsequent to the reviews.

Studies in Adults With Cancer

The most consistent and strongest effect of massage, aromatherapy massage, and foot reflexology in adults with cancer is reduced anxiety (table 17.1). Although most studies measure short-term effects, Wilkinson and colleagues (2007) found patients experienced less anxiety 2 weeks after 4 weekly aromatherapy massage sessions. Future research should determine the length of effects experienced following massage and the clinical relevance is for short-term reduction of anxiety.

Massage reduced depressive symptoms or depressed mood in some patients (table 17.1). Treatment with a single massage therapist over time was more effective than having different therapists in reducing depression in breast cancer survivors (Listing et al. 2009).

In most studies, massage relieved pain immediately after the session (table 17.1). However, some studies found no effect or only selective effects (Weinrich and Weinrich 1990). In longitudinal studies, Listing and colleagues (2009) found pain was reduced after 5 weeks of twice-weekly massage, while Kutner and others (2008) found similar pain-reduction effects for both massage and simple touch. In two other studies, patients used fewer analgesics after receiving massage (Post-White et al. 2003; Wilkie et al. 2000). Massage appears to be most effective for short-term relief of pain (Liu and Fawcett 2008). However, many of the studies assessing pain are limited by small sample sizes, inclusion of different stages of cancer and sources of pain, or a lack of control conditions (Cassileth and Vickers 2004; Currin and Meister 2008; Ferrell-Torry and Glick 1993; Sturgeon et al. 2009). More research is needed to determine the long-term effects and the clinical relevance of massage as an adjunct for pain control.

The effect of massage on nausea is inconclusive, with some studies showing effectiveness and other studies showing no effect (table 17.1). Specific stimulation of the P6 acupressure point was more effective for nausea than body massage (Dibble et al. 2000; Dibble et al. 2007; Shin et al. 2004).

Although massage is standard care for lymphedema (Williams et al. 2002), other symptoms have not been studied sufficiently to draw conclusions. Patients report improved energy following massage, but few studies demonstrate effects on fatigue (table 17.1). In longitudinal studies, fatigue remained lower 6 weeks after 10 sessions of biweekly massage (Listing et al. 2009), but massage was not quite significantly better (p = 0.057) than control groups in reducing fatigue after four weekly massage sessions (Post-White et al. 2003).

Anecdotal and research evidence exist to support the use of massage for comfort, pleasure, and respite from the stress of cancer. Massage is generally accepted to promote relaxation, relieve muscle tension (Pruthi et al. 2009), and improve quality of life for patients receiving cancer treatment (Sturgeon et al. 2009) or at the end of life (Kutner et al. 2008; Smith et al. 2009). Patients, caregivers, and family members benefit from both giving and receiving massage (Field et al. 2001; Goodfellow 2003).

Early massage studies are limited by small sample sizes, high dropout rates, and lack of comparison groups or analysis between groups. Almost half of the early studies either lack a control group or fail to use randomization to groups. More recent studies in adults use randomized controlled trials (RCT) with larger sample sizes of 100 to 300 subjects (Campeau et al. 2007; Kutner et al. 2008; Mehling et al. 2007; Post-White et al. 2003). Considerable variation remains in the depth of touch and the types and dose of massage administered in individual studies, which makes comparisons among studies difficult and limits the translation of findings to practice.

Studies in Children With Cancer

Although massage is used clinically for children with cancer, only five studies have tested its effectiveness. Consistent with adult studies, decreased anxiety was the most commonly observed effect in children receiving massage for a variety of conditions (Beider, Mahrer, and Gold 2007) and for cancer (table 17.1). Other findings included improved mood (Field et al. 2001; Haun, Graham-Pole, and Shortley 2009), reduced discomfort (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2005), and decreased heart rate (Post-White, Fitzgerald, Savik, et al. 2009) and respiratory rate (Haun, Graham-Pole, and Shortley 2009). In these small studies, massage did not lower blood pressure (Haun, Graham-Pole, and Shortley 2009; Post-White, Fitzgerald, Savik, et al. 2009), lessen symptoms of pain, nausea, and fatigue, or reduce cortisol levels (Post-White, Fitzgerald, Savik, et al. 2009). Phipps and colleagues (2004) found that massage reduced the time to engraftment after bone marrow transplant, but had no effects on mood or symptoms. Importantly, these studies support the feasibility and safety of both massage for children with cancer provided by both therapists (Haun, Graham-Pole, and Shortley 2009; Phipps et al. 2004; Phipps et al. 2005; Post-White, Fitzgerald, Savik, et al. 2009) and parents (Field et al. 2001; Phipps et al. 2004; Phipps et al. 2005). In two studies on the effects of massage for parents of children with cancer, parents reported less anxiety (Post-White, Fitzgerald, Savik et al. 2009), less fatigue, and greater vigor (Iwasaki 2005).

Conducting massage research in children with cancer presents unique challenges. Small sample sizes and low statistical power are common problems (Beider and Moyer 2007; Phipps et al. 2004; Phipps et al. 2005), as are lack of standardization in dose, frequency, and style of massage (Underdown et al. 2006). Few self-reporting instruments are validated for children, and parent proxy reports are often an inaccurate reflection of the child's perspective. Multisite studies make larger sample sizes possible, but they usually also require standardization of massage across settings, which may limit the effectiveness of treatment and the generalizability of study results. This is important because children often have unique needs and very specific tolerances and preferences that make standardization problematic. When children are undergoing treatment for cancer, massage therapists need to consider their health status and energy level, as well as their families' overwhelming schedules. More than one massage session may be needed to help the child feel comfortable with therapist-provided massage.

Biological and Immunological Effects of Massage in Children and Adults With Cancer

The weakest evidence for massage effects is in biological and immunological outcomes. Some responses of the autonomic nervous system (heart rate, blood pressure) consistently decrease immediately following massage (Ahles et al. 1999; Billhult et al. 2009; Grealish, Lomasney, and Whiteman 2000; Post-White et al. 2003; Post-White, Fitzgerald, Savik, et al. 2009; Wilkie et al. 2000). However, effects on salivary cortisol and immunological measures of stress are often insignificant. Only Stringer, Swindell, and Dennis (2008) found decreased serum cortisol and prolactin 30 minutes after massage compared to a control group. No differences were captured beyond 30 minutes, suggesting a short-term response of this circulating stress-related hormone. Similarly, only one study by Billhult and colleagues (2009) showed a stabilizing effect of a massage on cytotoxicity of natural killer (NK) cells, with no change in numbers of NK cells.

Hernandez-Reif and colleagues (2004; 2005) provide the strongest evidence to date for biological and immunological effects in response to massage. Although sample sizes in one study were too small to compare immune effects by group (2005), increases in number of NK cells and positive psychological outcomes were associated with increases in dopamine and serotonin immediately after massage and again 5 weeks later. By contrast, Billhult and colleagues (2008) found no changes in oxytocin in patients with cancer, even though oxytocin has been shown to increase after repeated massage in other populations and in highly controlled studies using rat models (Lund et al. 2002; Wikstrom, Gunnarsson, and Nordin 2003).

Lack of evidence is not synonymous with lack of effect. Because of individual variability in immune responses and differential effects of acute and chronic stress, immunological effects are difficult to capture and to compare to normative values or standards. Detecting changes in response to massage requires large sample sizes, large effects, or both. Effects may also be missed because of an emphasis on single cross-sectional assessments or a measurement schedule that does not capture circulating responses to massage. Alternately, statistically significant effects can be found and erroneously attributed to massage if distributions are skewed or if other important variables (e.g., sleep, infection, medications) are uncontrolled. Statistical significance does not imply clinical significance; short-term immune changes captured on isolated posttest assessments may not have clinical relevance. Longitudinal studies will provide findings of greater clinical relevance.

Teaching Research Literacy and Evidence-Based Practice (EBP)

The skills needed for research literacy and EBP have been traditionally taught in medical education as stand-alone courses or workshops. However, knowledge was better retained or translated to practice when the learning was integrated into clinical settings rather than taught in traditional settings (Coomarasamy and Kahn 2004).

Early educational programs in MT research literacy also focused on stand-alone classes and workshops, principally on critical appraisal techniques, with no direct requirement to apply these skills directly in the clinical setting. In one of the first online research-literacy courses for massage therapists, learners showed significant gains in their knowledge of research-literacy skills and improved attitudes towards evidence-informed practice (Achilles and Dryden 2002). Little is known, however, concerning learners' long-term retention of that knowledge, application of the skills to practice, or increased use of EBP.

Among medical professions, studies on teaching that integrated EBP into clinical settings in real time, which includes asking answerable clinical questions or going online to find the evidence and applying it to immediate practice or treatment planning, support the usefulness of these kinds of interventions for improvements in skills, attitudes, and behavior. Stand-alone courses are equally effective for improving knowledge, but not skills, attitudes, and behavior (Coomarasamy and Kahn 2004). Clearly, it is important to integrate EBP teaching and research-literacy skills into clinical practice.

Consistent with best practices in adult learning, integrating EBP and research literacy into all aspects of MT programs increases the opportunity for real-world, real-time learning and the likelihood of behavioral change in practitioners. In addition, adult learning is best accomplished when it is facilitated through coaching and mentoring (Das, Malick, and Khan 2008). Since MT programs vary widely in terms of requirements for teacher training and supervised clinical work with clients, opportunities for MT students and practitioners to observe exemplary role models using EBP in the clinical setting and to practice the skills for themselves may be rare in many jurisdictions and schools.

In addition, skills acquisition in taking health histories, performing clinical assessments, planning treatments, keeping records, learning about pathophysiology, and assessing treatment outcomes all vary widely in MT programs. Without strong assessment skills and a working knowledge of pathophysiology, integrating EBP into training and practice is a challenge. In order to successfully incorporate real-time EBP activities into their lesson plans, teachers of science and clinical courses will need time and training, as well as access to online journals and databases, professional librarians, and computers in their classrooms, clinics, and labs. However, the ubiquity of smart phones and other personal data devices, along with wireless Internet access and growing numbers of digitally literate students (and one hopes, teachers), are likely to facilitate the incorporation of real-time EBP more easily and economically into diverse MT learning environments than in the past (Higher Ed Café 2010). In one innovative program, research-literacy skills are taught online through the use of a graphic novel. Learners engage in didactic activities that are integrated components of a compelling and futuristic storyline (Atack et al. 2010). Gaming and online case simulation as instructional delivery methods for teaching research literacy and EBP need to be further developed in MT education and evaluated for effectiveness and learner satisfaction.

Access to just-in-time online EBP modules for busy MT professionals will help accelerate the uptake of best evidence to practice (see chapter 20 for information on clinical case reports). The creation of easy-to-access pathways between MT programs and degree-granting postsecondary institutions will enable the cross-training of massage therapists in disciplines such as adult education, research methods, health administration, and specializations in diverse subject areas within the sciences and humanities. As noted earlier, it is anticipated that recent innovations will drive changes in the incorporation of EBP and research literacy at all levels. Utilization of electronic health records systems in MT, including the necessary creation of a coordinated system for reporting adverse events, would rapidly accelerate the kinds of information needed to develop best-practice guidelines and to answer key questions about client safety. To ensure their use by MT students and massage therapists in the field, both at the entry level and throughout their practices, educators, professional associations, and regulatory bodies need to mandate and evaluate competencies in research literacy and EBP through career-long learning and quality-assurance requirements.

More studies are needed to evaluate the effectiveness of EBP education in MT. Kirkpatrick's hierarchy is a useful tool that can be adapted to evaluating knowledge, attitudes, and behavior, and, ultimately, client outcomes in EBP (table 18.2).

Telling a Story: The Content of a Case Report

Writing a CR can seem daunting. What background information is necessary? How detailed should the methods section be? What kind of language is best? These questions are easier to answer when you have a clear understanding of the likely audience for your CR. Imagine describing a massage treatment to healthcare professionals, such as nurses or physicians. They are not trained in MT, but they are familiar with anatomy, physiology, and client care. Consider the details they would want and need to know to best understand the case, and be sure to include them.

Keep in mind that a CR is similar to a conversation; essentially, it is a structured form of storytelling (see table 20.2). Set out to command attention, use clear language, and earn the audience's trust and interest.

CRs have the same basic structure as other research articles, but also have some unique features. What follows is an overview of the major sections.

Introduction

The introduction gives the reader the necessary background information needed to understand the current study's methods, evaluate the client's clinical condition, and interpret the significance of the results. It is essential to include a review of the relevant literature in this section. As you decide which sources and information to include, consider the following questions. What information would a fellow clinician need to treat this client? What consensus or controversies exist related to the condition, the specific population, or the MT modalities being investigated? How does this background data support the research question? An effective introduction is thorough but is not necessarily exhaustive. By the end of the introduction, a CR reader should have a clear sense of what is known, what remains to be discovered, and why the topic matters. These, in turn, lead logically to the research question itself, which should be explicitly stated for the sake of clarity.

Methods

The methods section should provide enough detail that a skilled colleague could carry out a similar study. This means including a well-rounded profile of the client, a lucid description of the treatment plan and any deviations from that plan, and a clear account of the measurements used. Basic details are important. At a minimum, be sure to indicate session length and frequency, the specific modalities applied, when and how measurements were taken, relevant details of the participant's health history, and the goals of treatment.

Box 20.1

Description of Massage Techniques

An often overlooked aspect of massage CRs is a sufficiently detailed description of technique (Moyer, Dryden, and Shipwright 2009). In much of the research literature, massage is treated as a uniform practice, yet any practicing therapist knows that an immense variety of applications can be made in a single massage session. Detailed descriptions of massage applications make for a better definition of massage, better research methods, and a better-informed health care world.

Examples of Methods to Discuss in a CR

• Which body regions were the focus of the massage, and approximately how much time was spent on each region?
• Which structures were specifically targeted? (Muscles, fascia, bones, viscera, nerves?)
• What was the intention behind the overall treatment approach? To create more mobility and functionality? To reduce stress and pain? To foster body awareness or trauma recovery?
• Were any aspects of communication with the patient worth mentioning?
• Were there important elements in the therapist's body mechanics or hand shape?

Results

A good treatment summary is concise and is more detailed on key points. Special attention should be paid to those aspects of MT that are frequently under-represented in the literature. These include the utterances and behaviors of the client, as well as the author's qualitative observations. In addition to your narrative summary of the results, you should also consider graphical, tabular, and quantitative methods for presenting your findings effectively. These approaches, when done well, allow for efficient use of journal space and can add to the clarity and interpretability of your results. Finally, keep in mind that it is essential to avoid prejudging the data. A good results section is balanced, pertinent, and compelling, but does not contain your conclusions. These belong in the discussion
section.

Discussion

The discussion section is your opportunity to offer aninterpretation of results. It is important to restate the research question and to make a balanced appraisal of any conclusions to be drawn from the results. Keep in mind that an individual CR cannot definitively prove anything by itself, nor is that its purpose. Authors can and should report their hunches, assert likelihoods, and otherwise opine on what happened, but they should avoid the temptation to state these as proven fact (Gleberzon 2006).

This section also presents the opportunity to reflect on the study's design and execution. Were there unforeseen challenges? Could certain methods have been improved? In hindsight, how effective was the clinical approach? What kinds of studies or questions would be most appropriate for future research? Discussion of such issues shows that you have been thoughtful in completing your research. It can guide future clinicians in most effectively contributing to the base of research evidence.

Finally, you may want to take the opportunity to place your findings into the context of the profession or health care in general. If appropriate, you might indicate how you think the MT profession could employ your CR's techniques or clinical approaches in similar cases. You could also outline the lessons your CR offers to health care, MT educators, or the public.