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PATHOLOGY PERSPECTIVES | BODY AWARENESS | FUNCTIONAL ANATOMY | SOMATIC
The Epidemic of Pain
Massage as a Solution
By Diana L. Thompson
The Centers for Disease Control and Prevention (CDC) announced late last year that deaths involving prescription pain medications have more than tripled over the past decade.1 According to the Los Angeles Times’s analysis of the data, deaths by drug overdose now outnumber traffic fatalities.2 Even over-the-counter pain medications are not without complications of death.
According to Janet D. Pearl, MD, “Over-thecounter products—while easing pain and reducing inflammation—can present problems, especially if taken with alcohol or in excess of recommended doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause ulcers or bleeding in the gastrointestinal tract, even if taken properly. Also, acetaminophen can be toxic to the liver in doses greater than 4 grams (and even less if taken with alcohol or by someone with liver disease). Acetaminophen is also contained in other medications, so an accidental overdose is possible if you’re not careful.”3 “For chronic pain, narcotics should be the last resort,” says Thomas Frieden, MD, director of the CDC in Atlanta, which issued the report.4 But more than 116 million American adults live with chronic pain.5 In an effort to identify how to help those in pain, yet curb unnecessary prescriptions, pain projects are forming locally, nationally, and internationally. Government funding for pain research is increasing. In the report, Relieving Pain in America, the Institute of Medicine has charged the US Department of Health and Human Services with creating a comprehensive plan to address chronic pain as a complex disease, not just a symptom of injury and illness.6 Blogs such as Pain-Topics.org are also joining the debate, analyzing the data, and suggesting that while drug abuse is a problem, opioids are not the killers they are portrayed to be. Pain is the true epidemic at hand.7 As the debate rages, how are doctors helping their patients cope with chronic pain if the trend is to cut back on prescription pain medication? Sites such as Sciencedaily. com and WebMD promote exercise, tai chi, and yoga for pain relief, and occasionally suggest enlisting the help of a physical therapist. Rarely do these sites mention massage when recommending alternatives for coping with pain. As frustrating as this is, I understand why these websites are not promoting massage therapy. When I look for supporting evidence, of the 1,782 current studies on chronic pain, only 10 trials are studying the effects of massage therapy on pain.8 According to a National Institutes of Health survey on the use of complementary and alternative medicine, Americans choose massage therapy as their number one out-of-pocket, practitioner-based expense for treating pain, stress, and the negative side effects of conventional medicine.9 This statistic is our best friend and must be flaunted to influence the government-sponsored conversations on pain, the policy-makers’ conversations on pain, and the communitybased conversations on pain. Most of all, the doctors treating people with chronic pain need to hear this statistic repeatedly and see studies showing evidence that massage provides relief from pain, assistance with pain management, and a reduction in the emotional side effects of pain.
massage & bodywork
you may choose to focus on a recent client that presented with a troubling pain condition.nih. I currently tout working with acute postoperative pain and chronic pain as my primary specialties. Use PICO (Population. physical therapists. sports injuries. select the search term for the intervention. and is often used as a general term. search for acute pain. 4. or you may want to get more specific. Search for systematic reviews. Once you have identified a general or specific search term for pain. A variety of tutorials are accessible on PubMed to assist you in navigating the site. Search for clinical trials. Success with one of the clients from the pain clinic could lead to relationships not only within the pain clinic’s staff. sharing the articles with our clients’ doctors. For example. Identify your search terms. This is best done by finding the research that supports our clinical findings and. but we must take some responsibility. You might be interested in myofascial techniques and the latest information that came out of the International Fascia Research Congress held in March. here are a few suggestions on how to begin a search on massage and pain: 1. Some terms that will yield limited results include Celebrate ABMP’s 25th anniversary and you may win a refund on your membership. I recently moved my practice within a block of a pain specialist. This scenario—pain—could yield a variety of research questions. We could pursue chronic pain. It is time to take an active role in promoting massage therapy for pain relief and as an alternative to prescription and over-the-counter pain medications. nlm. neurogenic pain. A few conclusive research articles could assist in marketing your skills and services. Jump in with the information provided here and know that if you get stuck. demanding prescriptions for massage and seeking out massage therapists on their own to find relief from painful and stressful conditions. avoiding surgery. massage is not described in detail in research (something I hope improves in the near future). or osteoarthritis.` help is available. IDENTIFY SEARCH TERMS The first step in conducting a literature search on massage therapy and pain is to identify the words that will best represent the information you seek. Comparison.com. or traumatic injuries. You may explore massage therapy in general. ABMP.ncbi. or recovering from an unsuccessful surgical intervention. 49 . Many physicians. Over 21 million references are indexed on PubMed. Print articles that provide supporting evidence and use them to promote your practice to healthcare providers that treat pain patients. 3. FIND SUPPORTIVE EVIDENCE The most accessible place to look for evidence supporting massage as a treatment for pain is PubMed (www. with a well-written introductory letter. or specify postoperative pain.gov/pubmed). Or. and chiropractors refer to this clinic when their patients need help managing pain conditions that are complicated or unresponsive. but also with many other health-care providers in the area. the use of specific techniques or modalities in your search may not be fruitful. Outcome) to refine your search. If you are more interested in acute pain.I am grateful that our clients are our advocates. and many of these references provide links to full-text articles. Narrow the focus of your search by identifying your area of expertise and interest. Typically. 5. 2. or identify specific bodywork modalities. A very general search done on massage and pain may yield more results than you wish to investigate. Therefore. PubMed is a free database of medical research citations that provides access to the MEDLine database of references and abstracts. Intervention. or choose specific topics like fibromyalgia. To get you started.
and identify future directions for research. and determine if cross-study consensus is sufficient to draw meaningful conclusions. 50 massage & bodywork may/june 2012 . To specify “Review” in your search. SYSTEMATIC REVIEWS Once you’ve identified your search terms. massage and chronic pain). You may also wish to select “English” under Languages if you want to limit your search to research written in English. Click on “Massage” to view the subheadings. rather than basing clinical decisions on the results of a single study. I chose to use the general term massage. summarizing studies that have been conducted on this topic and that meet the criteria for the research question expressed in the title of the review. A systematic review can identify if sufficient research exists on a particular topic.13 Neither article was available for a free download. Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question. read it critically to see if it meets your needs and can be used to market your skills and convince referring caregivers of the benefits of massage therapy for pain management. and the full-text article is freely available. and subject tree included in every MeSH search of the word massage. narrow the search by getting more specific.” 3. 2. if available. Heart massage refers to massage performed directly on the heart during open-heart surgery. Medical Subject Headings (MeSH) is a comprehensive. Pain. After looking at the expansive definitions for pain. craniosacral therapy. evaluate if the body of research meets quality standards. controlled vocabulary for the purpose of indexing articles. It can also identify gaps in the evidence that can then be used to inform future studies. 6. there must be consensus across a wide range of studies. enter the term you wish to define. In the search bar. and acts like a thesaurus when searching the database. 4. for example. click on “Limits” directly under the search bar.If the search yield is overwhelming. perform the following: 1. It was time to look for clinical trials to further support and inform my cause. You may wish to also select “Humans” under Species if you wish to only read reviews of human trials. check the box “Review. Read the abstracts. The articles listed will all be reviews of research.11 Systematic reviews are a critical component of evidencebased health care. a topic often discussed in this column. specify that the term massage must be in the title or abstract. yields 54 groups of terms in the MeSH classification system. Under Type of Article. On the home page of PubMed. On the PubMed homepage. Type in your search terms in the search bar at the top of the page (for example. to see if the reviews match your area of interest. This was more than I was willing to investigate. and reflexology. so I narrowed my search even further and typed “massage and fibromyalgia” into the search bar.10 The primary objective of a research review is to draw conclusions useful for clinical practice and policy-making. Test search terms to see if the information you seek is specifically available. This didn’t satisfy my search. It is helpful to see how PubMed defines the terms we wish to search to ensure the net we cast is going to adequately capture the studies we are interested in. 5. That search yielded 17 reviews. I decided to narrow my search to chronic pain. For my search. Only one review mentioned massage therapy in the title. If so. on the other hand. I recommend limiting your initial search to research reviews. click on “MeSH Database” under More Resources on the right side of the page. My search for “massage and chronic pain” yielded 76 results. The term massage identifies two groups of terms. In order for evidence to better inform practice.12 and one focused on myofascial techniques. entry terms. Click on “Search” near the bottom of the page. lymphatic drainage. or if more general searches are required.
3. Type the term massage in the search bar next to “Title/Abstract. or alternative medicine in general.org. A licensed massage practitioner since 1984.” 2. Lisa Girion. September 17. S. Jain. neck pain. “Are Opiod Pain Reliever Deaths an Epidemic?” accessed April 2012. conduct a search of clinical trials to find supporting evidence. G. interesting articles were not freely available.usatoday. In addition. “Massage Therapy for Fibromyalgia Symptoms. L. Larger studies demonstrate generalizability over studies with only a few participants. physical therapy. 3. Change the following limits on your search: 1. Introduction to Systematic Reviews Workbook.pain-topics.html. 13.” accessed April 2012. Malanga and E. “Complementary and Alternative Medicine Use Among Adults and Children.latimes.L. 5.clinicaltrials.” Physical Medicine & Rehabilitation Clinics of America 21. “Search of: Pain and Chronic.) 12.” accessed April 2012. 9. C. writing. Contact her at soapsage@comcast. Kalichman. accessed April 2012.” 5. 4.org/2011/11/ are-opioid-pain-reliever-deaths. “Vital Signs: Overdoses of Prescription Opioid Pain Relievers.” This results in 22 articles listed.M. Care. Click on “Search. Barnes. all massage therapy clinical trials. “Drug Deaths Now Outnumber Traffic Fatalities in US.metrowestdailynews. for example.” uncheck the box for “Reviews” and check the box for “Clinical Trials. 2011. “Painkiller Overdose Deaths Triple in Decade.B.” Los Angeles Times. and Doug Smith. 8. http://yourlife. The list includes studies on headaches. Diana L. and W. but instead were reviews on chiropractic. Read several that you find interesting. Data Show. Note the sample size.gov. 2011).com/lifestyle/ columnists/x10289243/Physician-FocusDont-let-back-pain-get-you-down?zc_p=1. and volunteering. USA Today. Clinical trials that randomize participants and test against control groups rank higher than pilot studies or case reports.com/2011/sep/17/ local/la-me-drugs-epidemic-20110918. Check the level of evidence. 4.com/health/ story/2011-11-01/Deaths-from-painkilleroverdose-triple-in-decade/51027242/1. http://articles. Institute of Medicine.” Annals of Internal Medicine 126.htm. ABMP. Specify free. Cruz Colon. www. specify that the term massage must be in the title or abstract. all with free access to the full-text articles in English. Check the methods. Jonas. no.gov/ mmwr/preview/mmwrhtml/mm6043a4. consulting. Pain-Topics.J. If the search yield is overwhelming.” Rheumatology International 30. P. narrow the search by getting more specific. Thompson has created a varied and interesting career out of massage: from specializing in pre. scroll down the first list under “All Fields” and click on “Title/Abstract. “Physician Focus: Don’t Let Back Pain Get You Down. and R. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Bloom. 51 . 9 (July 2010): 1. www. and many others that look promising. 2. Share these with potential referring health-care providers and promote your ability to help safely relieve chronic pain.gov/ ct/search?term=Pain+and+Chronic.com.” National Health Statistics Reports 12 (2008): 1–23. 11. no. Ibid. 4 (November 2010): 711–24. 2. Click “Advanced” below the search bar and use the builder to specify that massage is in the title or abstract of the study. Deborah J. http://updates. 6. Under “Limits. (Author workbook for private seminar. ClinicalTrials.and postsurgical lymph drainage to teaching. 7. 10. Relieving Pain in America: A Blueprint for Transforming Prevention.” accessed April 2012. Crawford. osteoarthritis of the knee.net. MetroWest Daily News. Cook et al. To do so. www. Centers for Disease Control and Prevention.A. Celebrate ABMP’s 25th anniversary and you may win a refund on your membership. 6 (1997): 376–80. Scott Glover. full-text articles and see if this is fruitful. Education and Research (Washington. low-back pain. “Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions. B. “Myofascial Low-Back Pain: A Review. Was the massage protocol performed by licensed massage therapists or untrained caregivers? Does the protocol make sense? Is this how you might work with someone in practice? Print out the studies that best reflect the population you wish to work with and that demonstrate the efficacy of massage for pain. Leave the next “All Fields” as is and type “chronic pain” in the search bar. Notes 1. Nahin. and critique them according to the guidelines presented in previous Somatic Research articles: 1..” accessed April 2012.cdc. or if the few that exist do not meet your criteria.” 3.151–7. which can be costly and frustrating. Samueli Institute.SOMATIC RESEARCH REFINE SEARCH: CLINICAL TRIALS If a review has not yet been conducted on your preferred subject. DC: The National Academies Press. no. You may be able to go back to the original search terms and get a manageable list of articles to review. We learned in the previous search that many references were listed that did not focus on massage therapy. 2012.
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