Looking at the Literature on Massage Research

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Looking at the Literature on Massage Research

• Ravensara S. Travillian, MS, MA, LMP
• Univ. of Washington Biomedical Health
  Informatics Grad. Program
• September 23, 2005

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Welcome!

• Schedule
• 130-220 Science and Massage
• Break in place (10 minutes)
• 230-320 Research Article Structure
• Break (10 minutes)
• 330-420 Topics in Massage Research I
• Break in place (10 minutes)
• 430-520 Topics II and Wrap-Up

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Who am I?

• PhD candidate in Biomedical and Health
  Informatics at the University of Washington in
  Seattle
• LMP since 1992
• Massage for refugees with PTSD, physical trauma
• High-risk pregnancy massage
• Massage for stroke patients

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And who are you?

• Interested in massage research
• Probably a clinician, interested in applying
  research for benefit of your patients
• Possibly interested in carrying out research
  yourself
• May or may not have any previous background in
  sciencethis talk assumes no background

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Why are we here?

• A user-friendly introduction to some of the
  massage research literature
• Why do we care about reading the literature?
• Needs of clinicians
• Needs of scientists
• How are these needs different?
• How can you get what you need?

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I Science Massage

• Objectives
• introduce basic concepts of the scientific method
  and the design of research studies
• provide structure for participants to use in
  navigating the literature.
• list the sections of a research article
• explain the concept of levels of evidence,
• describe the basics of the scientific method

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What is science?

• Possibilities and implications
• Empowerment
• Trust across disciplines

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What is science?

• Possibility 1 Science is what scientists do.

cause
Science
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What is science?

• Possibility 2the opposite Scientists are people
  who do science.

cause
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Whats the difference?

• If science is what scientists do
• That means that something unscientific can
  become scientific because it is said by a
  scientist
• And that makes scientists authority figures.

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Power Paradigm 1
Authority figure
Pronouncement
Patient
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Whats the difference?

• Example there is a great deal of validated,
  published evidence that massage decreases pain.
• If a scientist says Massage does not decrease
  pain, is that pronouncement scientific just
  because a scientist said so?
• Whats the alternative?

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Whats the difference?

• If an LMP has an idea to study pain in a
  particular group of people, and
• develops a solid research question and designs a
  robust study method
• collects data, analyzes it, and draws valid
  conclusions based on the data
• Is that then not scientific because the LMP is
  not a scientist?

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Consider the flip side

• If a scientist is someone who does science
• then anyone who does real, valid science is
  therefore a scientist.

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So

• That means
• A scientist who denies the valid, available
  evidence for massage decreasing pain
• is not acting as a scientist in that case.

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And

• That also means
• An LMP who is conducting a study according to the
  scientific method
• is as valid a scientist as any other.

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Power Paradigm 2
Expert 1
Expert 2
Expert P
Patient
Expert 3
Expert 4
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A new paradigm EBM

• Patient-centered, non-hierarchical
• Scientist as expert rather than authority figure
• Whats the difference? Based on reproducible
  evidence rather than arbitrary pronouncements
• Implication if you will put in the work to do
  so, you can be an expert.

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What does this mean for you?

• Empowerment
• If you want to read the literature, you can learn
  to evaluate it as a scientist.
• An LMP who is conducting a study according to the
  scientific method is as much a scientist as any
  other.
• Trust across disciplines
• Peer-to-peer (expert-to-expert)

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What does it take?

• Scientific method
• Common language
• Same rules to level playing field
• Techniques to minimize bias

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What it doesnt take

• Practicing cookbook massage
• Best evidence approach take strongest evidence
  available
• Integrate with own clinical experience and
  judgment
• Denying our own spirituality
• You dont have to turn off your heart and soul

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Why the scientific method?

• One way of understanding the world around usnot
  the only way
• Emphasis on objectivity decreases chance of
  mistaken observations through bias

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Why the scientific method?

• Example Which person is more likely to be a
  librarian?
• Person A, who wears glasses
• Person B, who wears glasses and knows the Dewey
  Decimal System
• The answer may surprise youI got it wrong the
  first time.

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Why the scientific method?

• Person A, who wears glasses, is more likely to be
  a librarian than is Person B, who wears glasses
  and knows the Dewey Decimal System
• Why The more narrow we make the definition, the
  fewer people fit the definition. So
  mathematically, the probability is lower.

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Why the scientific method?

• Our common sense and judgment from experience
  leads us to form the wrong conclusion
• We tend to think the Dewey Decimal System makes
  it more likely the person is a librarian, rather
  than less likely as a member of a smaller group.

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Why the scientific method?

• These kinds of judgments are universal and very
  human.
• Psychologists, cognitive scientists, and others
  study them as heuristics and biases in our
  decision-making.

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Why the scientific method?

• As we have seen, the human mind naturally falls
  into certain cognitive traps.
• The scientific method is an attempt to take these
  kinds of cognitive errors out of the
  interpretation of observations of the world
  around us.
• But it has a trade-off.

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The trade-off

• The scientific method gives us greater confidence
  in the accuracy of our observations and their
  interpretations.
• A powerful tool for how sure we can be of certain
  kinds of knowledge.

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The trade-off

• Limitations Not applicable to every domain. If
  it cant be observed and measured in the natural
  world, we cant apply the scientific method.
• Spirituality different domain entirely. Science
  has nothing to say about that which cannot be
  measured.

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Reading for Essentials

• There is no mystery to science
• Openness/transparency (showing your work)
• Given enough time and effort, anyone here can do
  scientific research
• Given enough time and effortwhat does that
  mean?
• Finding your best balance!

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Reading a research article

• Parts of a research article
• Introduction, background
• Methodology
• Results
• Analysis, discussion, conclusion, recommendations
  for further work
• Using this structure to help you read the article

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Scientific Method Steps

• Observation
• Hypothesis
• Test hypothesis
• Draw conclusions
• Tentatively accept or reject hypothesis
• Until tomorrow

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You already do this everyday

• Evaluating patients for massage
• The Scientist in the Crib

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Observation

• Notice something about the physical world
• Example when an animal feels pain, it often
  licks the painful site
• We assume from this observation that rubbing
  relieves pain

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Hypothesis

• Come up with a possible explanation for the
  observation that you can test
• Form Intervention causes effect in
  population
• Example If it is true that rubbing relieves
  pain, then perhaps a back rub will reduce low
  back pain in elderly patient

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Test hypothesis

• Come up with an experiment to test your
  explanation
• Take 2 groups of older people with back pain
• Massage one group, dont massage the other group
• See if there is a difference in pain between
  groups after the massage

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Draw conclusions

• Results the massaged group reported less back
  pain after the massage
• Tentatively conclude that massage relieves low
  back pain in elderly
• Why tentatively? You never prove, as in logic
  you either disprove, or you reinforce your
  hypothesis

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Revise hypothesis

• Observation
• Hypothesis
• Test hypothesis
• Draw conclusions
• Tentatively accept or reject hypothesis
• Until tomorrow

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Who is it aimed at?

• First and foremost the scientist!
• We all see what we want to seewe are all alike
  in this way
• This is one way the scientist can be sure the
  experiment really did what was intendednot just
  wishful thinking
• Scientific method is a tool for gaining
  additional certainty of knowledge in a specific,
  smaller domain

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Science and Massage

• Can you have rigor AND compassion?

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The Scientific Method

• When we talk about rigorwhy science?
• What does the scientific approach get us?
• Keep returning to trade-offs

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Just Enough Statistics

• Mean, median, mode flavors of average
• SD
• p
• Power
• Trade-offs

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Examples

• Field T, Hernandez-Reif M, Diego M, Schanberg S,
  Kuhn C. Cortisol decreases and serotonin and
  dopamine increase following massage therapy. Int
  J Neurosci. 2005 Oct115(10)1397-413. In studies
  in which cortisol was assayed either in saliva or
  in urine, significant decreases were noted in
  cortisol levels (averaging decreases 31).
• Murakami S, Shirota T, Hayashi S, Ishizuka B.
  Aromatherapy for outpatients with menopausal
  symptoms in obstetrics and gynecology. J Altern
  Complement Med. 2005 Jun11(3)491-4. RESULTS
  The mean value of the KI score was significantly
  lowered after the aromatherapy trial from 31.4
  /- 6.8 to 22.9 /- 6.1 (p 0.00)
• Dullenkopf A, Schmitz A, Lamesic G, Weiss M, Lang
  A. The influence of acupressure on the monitoring
  of acoustic evoked potentials in unsedated adult
  volunteers. Anesth Analg. 2004 Oct99(4)1147-51.
  Corresponding data were compared by Wilcoxon's
  signed rank test (Bonferroni correction, P 0.05). Data are median (range). AAI decreased
  from 73 (40-99) to 53 (33-94) after 10 min of
  pressure on EP (P 0.0044).
• Field T. Violence and touch deprivation in
  adolescents. Adolescence. 2002 Winter37(148)735-
  49. In the studies we have conducted to date,
  there has been a relatively high incidence of
  anger and aggression in high school samples, even
  those that were relatively advantaged, as well as
  high levels of depression (one standard deviation
  above the mean), suggesting significant
  disturbance in these youth.

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What this means

• If youre reading the literature
• Different ways of trying to describe the
  diversity of the subjects in the study
• If youre conducting research
• You need to learn this in more depth than were
  going into here

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Standard deviation

• Hardest concept were going to go over today
• mean of the mean the story behind the data

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Standard deviation

• Lets start with the concept of normal
  distribution of data
• Think about a situation youve been in with a lot
  of other peoplea few people are extreme one way
  or the other, but most people are pretty close to
  average

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Standard deviation

• Example weight at birth in all healthy babies
  born in the US
• A few very big babies
• A few very small babies
• Most babies somewhere around 7 pounds or so, more
  or less called normal birthweight because it
  forms a normal distribution

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Standard deviation

• What does a normal distribution look like?

Number of babies
Number of normal birthweight babies
Number of very small babies
Number of very large babies
Birthweight
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Standard deviation

• What does it mean?

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95
99
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Variations
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Why is this useful?

• Tells how spread-out the population is
• The larger the SD, the more chance you should be
  somewhat skeptical of the study

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p

• How likely is it that the results of the study
  are due to chance, rather than to a real
  treatment effect?
• Called statistical significance
• Percentage, written as 0.00
• The lower the p, the higher the chance of a real
  treatment effect
• Look for p

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Power

• Is a study large enough?
• External validity does it represent the
  population at large?
• Can you extrapolate the results from this study
  to larger groups?

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Causation vs. Correlation

• What is the difference?
• How can we tell?
• Jungs synchronicity

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Outcomes vs. Mechanisms

• What happens? vs. How does it happen?
• Example ? pain in patient (Outcome) vs. Gate
  Control Theory (Mechanism)
• If it works, that may be enough results for a
  clinician and patients
• But scientists want to fully under-stand and
  describe how it works

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The Power of the Placebo

• What is a placebo?
• Implications for massage how can you do a
  placebo massage?

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The Experiment

• Theory
• Practice
• Until tomorrow

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RCTs

• Randomization
• Controls
• Blinding
• Levels of evidence strongest case study weakest
  (low power)

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Until tomorrow

• Unlike mathematics or logic, science never proves
  anything beyond a doubt
• Scientists who come along later can revise,
  refine, or even refute earlier findings
• This makes us part of a chain that stretches all
  the way back to the first observers, and ties us
  to scientists yet to be born

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Putting this into practice

• Types of research article
• Research article as report of experiment

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Reading for Essentials

• There is no mystery to science
• Openness/transparency (showing your work)
• Given enough time and effort, anyone here can do
  scientific research
• Given enough time and effortwhat does that
  mean?

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Time, effort, results
Sweet spot optimal combination for you between
clinic and bench
Results
Primarily clinical emphasis
Primarily scientific emphasis
for a clinician
for a scientist
Maximum combination of bench and clinic
Time
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Finding your sweet spot

• What youre up against
• Information overload It's been said that a
  clinician who read journals for two hours a day
  would be eight years behind in his or her reading
  at the end of a year.
• Learning style journal articles favor verbal
  learners, disadvantage visual and kinesthetic
  learners

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How many articles?
Landmark study on CAM usage by Eisenberg et al
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How many articles in all?
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How many articlespain?
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How many articlescancer?
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How many articlesinfant?
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How many articlespregnancy?
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How many articleselderly?
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How relevant?
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How relevant?
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How many articles?
Language
Age
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What you can do about it

• Learn to read for essentials
• Get what you need from the article
• Dont get bogged down in details you dont need

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Examples

• Applying the principles
• Tanaka exercise

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Tanaka article

• Well do this one together
• Ill read the abstract out loud
• Pick a section you want to discuss
• Introduction/Background, Methods, or Discussion
  and Conclusions
• (Ill take us through Results, as its very
  dense)
• Take 10 minutes to read your section and make
  notes of what you find important
• Ill ask questions for us to discuss

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Exercise Tanaka article

• Introduction/Background
• What is Tanakas hypothesis?
• Why is his group studying it?

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Exercise Tanaka article

• Methods
• What is Tanakas control?
• Does his methodology seem robust to study what he
  claims to study? In other words, do you see any
  mistakes or weaknesses?

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Exercise Tanaka article

• Results
• Kolmogorov-Smirnov test (dont worry about this!
  ?) indicated test acceptably normally distributed
  (remember SD)
• EMG measurements good reliability
• Significant (p between 1) second load and first load, 2) massage
  and rest conditions

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Exercise Tanaka article

• Discussion and Conclusions
• How does Tanaka interpret what happened?
• Did he answer his research question?
• What does this mean for further massage research?
• What does this mean for your practice?

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Problems?

• Dont assume its just you
• Common author problems with the literature
• Errors
• Misinterpretations
• Jargon
• Authors job make article clear

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Topics I

• The big picture of massage research literature
• Specific concentrations
• Examples

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Transport of elderly patients
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Bertalanffy 2004
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Acupressure control point
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Autistic children
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Outcomes vs. mechanisms

• Cause and effect (left) or synchronicity (right)?

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Prenatal effects of massage
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Topics II

• Examples

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Presurgery
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Bone marrow transplants
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Ahles 1999

• Ahles TA, Tope DM, Pinkson B, Walch S, Hann D,
  Whedon M, Dain B, Weiss JE, Mills L, Silberfarb
  PM.
• Massage therapy for patients undergoing
  autologous bone marrow transplantation.
• J Pain Symptom Manage. 1999 Sep18(3)157-63.

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Ahles 1999
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Burns
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Next topics?

• What questions do you want to see addressed?
• The next generation of massage researchers will
  choose the research questions to be studied

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Applying what weve learned

• Reading the literature from a patient-centered
  focus
• Where do we go from here?

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My deepest thanks to

• U. Washington graduate program in Biomedical and
  Health Informatics
• National Library of Medicine Informatics Grant
  1T15LM07441-01
• All my teachers the shoulders of giants for me
  to stand on
• All my students you are the future of massage
  research

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Wrap-Up

• Questions and Discussion