Looking at the Literature on Massage Research Ravensara S. Travillian, MS, MA, LMP Univ. of...

Looking at the Literature

on Massage Research

Ravensara S. Travillian, MS, MA, LMP

Univ. of Washington Biomedical & Health Informatics Grad. Program

September 23, 2005

September 23, 2005 Travillian, Albuquerque 2005: "Looking at the Literature"

Welcome!

• Schedule:– 1:30-2:20 Science and Massage– Break in place (10 minutes) – 2:30-3:20 Research Article Structure– Break (10 minutes)– 3:30-4:20 Topics in Massage

Research I– Break in place (10 minutes)– 4:30-5:20 Topics II and Wrap-Up


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


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 science—this talk assumes no background


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?


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


What is science?

• Possibilities and implications

• Empowerment

• Trust across disciplines


What is science?

• Possibility 1: Science is what scientists do.

Sciencecause


What is science?

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

Science cause


What’s 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.


Power Paradigm 1:

Authority figure

Pronouncement

Patient



• 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?

• What’s the alternative?



• 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?


Consider the flip side

• If a scientist is someone who does science…

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


So…

• That means:

• A scientist who denies the valid, available evidence for massage decreasing pain…

• is not acting as a scientist in that case.


And…

• That also means:

• An LMP who is conducting a study according to the scientific method…

• …is as valid a scientist as any other.


Power Paradigm 2

Expert P

Expert 1

Expert 2

Expert 3

Expert 4

Patient


A new paradigm: EBM

• Patient-centered, non-hierarchical• Scientist as expert rather than

authority figure• What’s 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.


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)


What does it take?

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


What it doesn’t take

• Practicing cookbook massage– “Best evidence” approach: take

strongest evidence available– Integrate with own clinical

experience and judgment

• Denying our own spirituality– You don’t have to turn off your heart

and soul


Why the scientific method?

• One way of understanding the world around us—not the only way

• Emphasis on objectivity decreases chance of mistaken observations through bias



• 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 you—I got it wrong the first time.



• 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.



• 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.



• These kinds of judgments are universal and very human.

• Psychologists, cognitive scientists, and others study them as “heuristics and biases” in our decision-making.



• 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.


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.


The trade-off

• Limitations: Not applicable to every domain. If it can’t be observed and measured in the natural world, we can’t apply the scientific method.

• Spirituality: different domain entirely. Science has nothing to say about that which cannot be measured.


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 effort”—what does that mean?

• Finding your best balance!


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


Scientific Method: Steps

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

hypothesis• “Until tomorrow…”


You already do this everyday…

• Evaluating patients for massage

• “The Scientist in the Crib”


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


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


Test hypothesis

• Come up with an experiment to test your explanation

• Take 2 groups of older people with back pain

• Massage one group, don’t massage the other group

• See if there is a difference in pain between groups after the massage


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


Revise hypothesis

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

hypothesis• “Until tomorrow…”


Who is it aimed at?

• First and foremost: the scientist!• We all see what we want to see—we

are all alike in this way• This is one way the scientist can be

sure the experiment really did what was intended—not just wishful thinking

• Scientific method is a tool for gaining additional certainty of knowledge in a specific, smaller domain


Science and Massage

• Can you have rigor AND compassion?


The Scientific Method

• When we talk about rigor—why science?

• What does the scientific approach get us?

• Keep returning to trade-offs


Just Enough Statistics

• Mean, median, mode: flavors of average

• SD• p• Power• Trade-offs


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 Oct;115(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 Jun;11(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 Oct;99(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 Winter;37(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.


What this means

• If you’re reading the literature…– Different ways of trying to describe

the diversity of the subjects in the study

• If you’re conducting research…– You need to learn this in more depth

than we’re going into here


Standard deviation

• Hardest concept we’re going to go over today

• “mean of the mean”: the story behind the data


Standard deviation

• Let’s start with the concept of normal distribution of data

• Think about a situation you’ve been in with a lot of other people—a few people are extreme one way or the other, but most people are pretty close to average


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


Standard deviation

• What does a normal distribution look like?

Number of very small

babiesNumber of very

large babies

Birthweight

Number of babies Number of “normal” birthweight

babies


Standard deviation

• What does it mean?

68%

95%

99%


Variations


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


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 < p <

1.00• The lower the p, the higher the

chance of a real treatment effect• Look for p < 0.05 (5%)


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?


Causation vs. Correlation

• What is the difference?

• How can we tell?

• Jung’s synchronicity


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


The Power of the Placebo

• What is a placebo?

• Implications for massage: how can you do a “placebo” massage?


The Experiment

• Theory

• Practice

• “Until tomorrow…”


RCTs

• Randomization• Controls• Blinding• Levels of evidence: strongest;

case study weakest (low power)


“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


Putting this into practice

• Types of research article

• Research article as report of experiment


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 effort”—what does that mean?


Time, effort, results

Time

Results “Sweet spot”: optimal combination for you between clinic and bench

Primarily clinical emphasis

Primarily scientific emphasis

Maximum combination of bench and clinic

for a clinician

for a scientist


Finding your “sweet spot”

• What you’re 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


Massage research articles in PubMed by year, 1965-2004

0

50

100

150

200

1965

1968

1971

1974

1977

1980

1983

1986

1989

1992

1995

1998

2001

2004

Year

Nu

mb

er

of

art

icle

s

Landmark study on CAM usage by Eisenberg et al

How many articles?


How many articles in all?


How many articles—pain?


How many articles—cancer?


How many articles—infant?


How many articles—pregnancy?


How many articles—elderly?


How relevant?


How many articles?

Age Language


What you can do about it

• Learn to “read for essentials”• Get what you need from the

article• Don’t get bogged down in details

you don’t need


Examples

• Applying the principles

• Tanaka exercise


Tanaka article

• We’ll do this one together– I’ll read the abstract out loud– Pick a section you want to discuss

• Introduction/Background, Methods, or Discussion and Conclusions

• (I’ll take us through Results, as it’s very dense)

– Take 10 minutes to read your section and make notes of what you find important

– I’ll ask questions for us to discuss


Exercise: Tanaka article

• Introduction/Background– What is Tanaka’s hypothesis?

– Why is his group studying it?



• Methods– What is Tanaka’s control?

– Does his methodology seem robust to study what he claims to study? In other words, do you see any mistakes or weaknesses?



• Results:– Kolmogorov-Smirnov test (don’t

worry about this! ) indicated test acceptably normally distributed (remember SD)

– EMG measurements good reliability– Significant (p < 0.05) VAS

differences in fatigue between 1) second load and first load, 2) massage and rest conditions



• 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?


Problems?

• Don’t assume it’s just you…

• Common author problems with the literature– Errors– Misinterpretations– Jargon

• Author’s job: make article clear


Topics I

• The big picture of massage research literature

• Specific concentrations

• Examples


Transport of elderly patients


Bertalanffy 2004


Acupressure control point


Autistic children


Outcomes vs. mechanisms

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


Prenatal effects of massage


Topics II

• Examples


Presurgery


Bone marrow transplants


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 Sep;18(3):157-63.


Ahles 1999


Burns


Next topics?

• What questions do you want to see addressed?

• The next generation of massage researchers will choose the research questions to be studied


Applying what we’ve learned

• Reading the literature from a patient-centered focus

• Where do we go from here?


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


Wrap-Up

• Questions and Discussion

Looking at the Literature on Massage Research Ravensara S. Travillian, MS, MA, LMP Univ. of...

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