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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

o the data, deaths by drug

overdose now outnumber trafc

atalities.2 Even over-the-counter 

pain medications

are not without

complications o death.

 According to Janet D.Pearl, MD, “Over-the-counter products—whileeasing pain and reducinginammation—can present problems, especially i 

taken with alcohol or inexcess o recommendeddoses. Nonsteroidalanti-inammatory drugs(NSAIDs) such as ibuproencan cause ulcers or bleedingin the gastrointestinal tract,even i taken properly. Also, acetaminophen

can be toxic to the liver in dosesgreater than 4 grams (and even lessi taken with alcohol or by someone with liver disease). Acetaminophen isalso contained in other medications,so an accidental overdose ispossible i you’re not careul.”3 

“For chronic pain, narcotics should be the last resort,” says Thomas Frieden, MD, director o theCDC in Atlanta, which issued the report.4 

But more than 116 million American adults live withchronic pain.5 In an eort to identiy how to help those inpain, yet curb unnecessary prescriptions, pain projects areorming locally, nationally, and internationally. Government 

unding or pain research is increasing. In the report, Relieving Pain in America, the Inst itute o Medicine hascharged the US Department o Health and Human Services with creating a comprehensive plan to address chronicpain as a complex disease, not just a symptom o injury 

and illness.6 Blogs such as Pain-Topics.org are also joiningthe debate, analyzing the data, and suggesting that whiledrug 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 theirpatients cope with chronic pain i the trend is to cut back on prescription pain medication? Sites such as Sciencedaily.com and WebMD promote exercise, tai chi, and yoga or

pain relie, and occasionally suggest enlisting the help o aphysical therapist. Rarely do these sites mention massage when recommending alternatives or coping with pain. Asrustrating as this is, I understand why these websites arenot promoting massage therapy. When I look or supportingevidence, o the 1,782 current studies on chronic pain, only 10 trials are studying the eects o massage therapy on pain.8 

 According to a National Institutes o Health survey on theuse o complementary and alternative medicine, Americanschoose massage therapy as their number one out-o-pocket,

practitioner-based expense or treating pain, stress, andthe negative side eects o conventional medicine.9 This

statistic is our best riend and must be aunted to inuencethe government-sponsored conversations on pain, thepolicy-makers’ conversations on pain, and the community-based conversations on pain. Most o all, the doctorstreating people with chronic pain need to hear this statisticrepeatedly and see studies showing evidence that massageprovides relie rom pain, assistance with pain management,

and a reduction in the emotional side eects o pain.

48  massage & bodywork may/june 2012

PATHOLOGY PERSPECTIVES | BODY AWARENESS | FUNCTIONAL ANATOMY | SOMATIC RESEARCH

education

 The Epidemic o PainMassage as a SolutionBy Diana L. Thompson

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I am grateul that our clients are our advocates,demanding prescriptions or massage and seeking out massage therapists on their own to fnd relie rom

painul and stressul conditions, but we must take someresponsibility. It is t ime to take an active role in promotingmassage therapy or pain relie and as an alternative toprescription and over-the-counter pain medications. This

is best done by fnding the research that supports ourclinical fndings and, with a well-written introductory letter, sharing the articles with our clients’ doctors.

 A ew conclusive research articles could assist in marketing your skills and serv ices. For example, I recently moved my 

practice within a block o a pain specialist. Many physicians,physical therapists, and chiropractors reer to this clinic when their patients need help managing pain conditionsthat are complicated or unresponsive, avoiding surgery,or recovering rom an unsuccessul surgical intervention.I currently tout working with acute postoperative painand chronic pain as my primary specialties. Success with one o the clients rom the pain clinic could lead to

relationships not only within the pain clinic’s sta, but also with many other health-care providers in the area.

FIND SUPPORTIVE EVIDENCE

 The most accessible place to look or evidence support ingmassage as a treatment or pain is PubMed (www.ncbi.nlm.nih.gov/pubmed). PubMed is a ree database o medical research citations that provides access to the MEDLine database o reerences and abstracts. Over 21million reerences are indexed on PubMed, and many 

o these reerences provide links to ull-text articles. To get you started, here are a ew suggestions

on how to begin a search on massage and pain:1. Identiy your search terms.

2. Search or systematic reviews.

3. Use PICO (Population, Intervention, Comparison,

Outcome) to refne your search.

4. Search or clinical trials.

5. Print articles that provide supporting evidence

and use them to promote your practice to health-

care providers that treat pain patients.

 A variety o tutorials areaccessible on

PubMed to assist  you in nav igating thesite. Jump in with theinormation provided

here and know that i you get stuck,`help is available.

IDENTIFY 

SEARCH TERMS

 The frst stepin conducting aliterature searchon massagetherapy and painis to identiy the words that will best represent theinormation you seek. A very general search done on

massage and pain may yield more results than you wishto investigate, or you may want to get more specifc.

 This scenario—pain—could yield a variety o researchquestions. We could pursue chronic pain, or choose specifctopics like fbromyalgia, neurogenic pain, or osteoarthritis. I  you are more interested in acute pain, search or acute pain,or speciy postoperative pain, sports injuries, or traumaticinjuries. Narrow the ocus o your search by identiying yourarea o expertise and interest. Or, you may choose to ocus ona recent client that presented with a troubling pain condition.

Once you have identifed a general or specifc searchterm or pain, select the search term or the intervention.

 You may explore massage therapy in general, or identiy specifc bodywork modalities. You might be interested inmyoascial techniques and the latest inormation that cameout o the International Fascia Research Congress heldin March. Typically, massage is not described in detail inresearch (something I hope improves in the near uture),and is oten used as a general term. Thereore, the use o 

specifc techniques or modalities in your search may not beruitul. Some terms that will yield limited results include

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craniosacral therapy, lymphatic drainage, and reexology. Test search terms to see i the inormation you seek isspecifcally available, or i more general searches are required.

It is helpul to see how PubMed defnes the terms we wish to search to ensure the net we cast is going to adequately capture the studies

 we are interested in. Medical Subject Headings (MeSH) is a comprehensive,controlled vocabulary or the purposeo indexing articles, and acts like athesaurus when searching the database.On the PubMed homepage, click on“MeSH Database” under More Resourceson the right side o the page. In thesearch bar, enter the term you wish to

defne. The term massage identifes twogroups o terms. Heart massage reersto massage perormed directly on theheart during open-heart surgery. Click on “Massage” to view the subheadings,entry terms, and subject tree included inevery MeSH search o the word massage.

For my search, I chose to use thegeneral term massage. Pain, on the other

hand, yields 54 groups o terms in the MeSH classifcation system. Ater look ingat the expansive defnitions or pain, I

decided to narrow my search to chronic pain.

SYSTEMATIC REVIEWS

Once you’ve identifed your searchterms, I recommend limiting your initialsearch to research reviews. Systematic

reviews can help practitioners keepabreast o the medical literature by summarizing large bodies o evidenceand helping to explain dierencesamong studies on the same question.10  The primary objective o a researchreview is to draw conclusions useul orclinical practice and policy-making,

and identiy uture directions or research.11

Systematic reviews are a critical component o evidence-based health care, a topic oten discussed in this column. Inorder or evidence to better inorm practice, there must beconsensus across a wide range o studies, rather than basingclinical decisions on the results o a single study. A systematicreview can identiy i sufcient research exists on a part iculartopic, evaluate i the body o research meets quality standards,and determine i cross-study consensus is sufcient to draw 

meaningul conclusions. It can alsoidentiy gaps in the evidence that canthen be used to inorm uture studies.

 To speci y “Review” in yoursearch, perorm the ollowing:1. On the home page o PubMed, click on

“Limits” directly under the search bar.

2. Under Type o Article,

check the box “Review.”

3. You may wish to also select “Humans”

under Species i you wish to only 

read reviews o human trials.

4. You may also wish to select 

“English” under Languages i 

 you want to limit your search to

research written in English.5. Type in your search terms in the

search bar at the top o the page (or

example, massage and chronic pain).

6. Click on “Search” near the

bottom o the page.

 The art icles listed will all be reviewso research, summarizing studies that have been conducted on this topic and

that meet the criteria or the researchquestion expressed in the title o thereview. Read the abstracts, i available,

to see i the reviews match your area o interest. I so, and the ull-text articleis reely available, read it critically tosee i it meets your needs and can beused to market your skills and convincereerring caregivers o the benefts o 

massage therapy or pain management. My search or “massage and

chronic pain” yielded 76 results. This was more than I was will ing toinvestigate, so I narrowed my searcheven urther and typed “massage andfbromyalgia” into the search bar. That search yielded 17 reviews. Only onereview mentioned massage therapy 

in the title,12 and one ocused onmyoascial techniques.13 Neither article was available or a ree download.

 This didn’t satisy my search. It  was time to look or clinical trials tourther support and inorm my cause.

If the

search

yield is

overwhelming,

narrow thesearch by

getting more

specific; for

example,

specify that

the term

massage must

be in the title

or abstract.

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SOMATIC RESEARCH

REFINE SEARCH:

CLINICAL TRIALS

I a review has not yet been conductedon your preerred subject, or i the ew that exist do not meet your criteria,conduct a search o clinical trials to

fnd supporting evidence. I the search yield is overwhelming, narrow thesearch by getting more specifc; orexample, speciy that the term massage must be in the title or abstract. Welearned in the previous search that many reerences were listed that did not ocus on massage therapy, but instead were reviews on chiropractic, physical

therapy, or alternative medicine ingeneral. In addition, interesting articles were not reely available, which canbe costly and rustrating. Speciy ree, ull-text articles and see i this isruitul. You may be able to go back to the original search terms and get amanageable list o articles to review.

Change the ollowing

limits on your search:1. Click “Advanced” below the search

bar and use the builder to speciy 

that massage is in the t itle or abstract o the study. To do so, scroll down

the frst list under “All Fields”

and click on “Title/Abstract.”

2. Type the term massage in the search

bar next to “Title/Abstract.”

3. Leave the next “All Fields” as is and

type “chronic pain” in the search bar.

4. Under “Limits,” uncheck the

box or “Reviews” and check 

the box or “Clinical Trials.”

5. Click on “Search.”

 This results in 22 art icles listed;all massage therapy clinical trials, all with ree access to the ull-text articles

in English. The list includes studieson headaches, osteoarthritis o theknee, low-back pain, neck pain, andmany others that look promising.

Read several that you fndinteresting, and critique themaccording to the guidelines presentedin previous Somatic Research articles:

1. Check the level o evidence. Clinical

trials that randomize participants and

test against control groups rank higher

than pilot studies or case reports.

2. Note the sample size. Larger studies

demonstrate generalizability over

studies with only a ew participants.

3. Check the methods. Was the massage

protocol perormed by licensed

massage therapists or untrained

caregivers? Does the protocol

make sense? Is this how you might 

 work with someone in pract ice?

Print out the studies that best reect the population you wish to

 work with and that demonstrate theefcacy o massage or pain. Share these with potential reerring health-careproviders and promote your ability tohelp saely relieve chronic pain.

Notes

1. Centers or Disease Control and Prevention, “Vital

Signs: Overdoses o Prescription Opioid Pain

Relievers,” accessed April 2012, www.cdc.gov/ 

mmwr/preview/mmwrhtml/mm6043a4.htm.

2. Lisa Girion, Scott Glover, and Doug Smith,

“Drug Deaths Now Outnumber Trafc Fatalities

in US, Data Show,” Los Angeles Times,

September 17, 2011, accessed April 2012,

http://articles.latimes.com/2011/sep/17/ 

local/la-me-drugs-epidemic-20110918.

3. MetroWest Daily News, “Physician Focus: Don’t

Let Back Pain Get You Down,” accessed April

2012, www.metrowestdailynews.com/liestyle/ 

columnists/x10289243/Physician-Focus-

Dont-let-back-pain-get-you-down?zc_p=1.

A licensed massage practitioner since 1984, Diana L. Thompson

has created a varied and interesting career out o massage: romspecializing in pre- and postsurgical lymph drainage to teaching,

 writ ing, consulting, and vo lunteer ing. Her consul ting 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. Contact her at soapsage@comcast.net.

4. USA Today , “Painkiller Overdose Deaths

 Triple in Decade,” accessed Apri l 2012,

http://yourlie.usatoday.com/health/ 

story/2011-11-01/Deaths-rom-painkiller-

overdose-triple-in-decade/51027242/1.

5. Institute o Medicine, Relieving Pain in America:

 A Blueprint for Transforming Prevention, Care,

Education and Research (Washington, DC:

 The National Academies Press, 2011).

6. Ibid.

7. Pain-Topics.org, “Are Opiod Pain Reliever

Deaths an Epidemic?” accessed April 2012,

http://updates.pain-topics.org/2011/11/ 

are-opioid-pain-reliever-deaths.html.

8. ClinicalTrials.gov, “Search o: Pain and Chronic,”

accessed April 2012, www.clinicaltrials.gov/ 

ct/search?term=Pain+and+Chronic.

9. P.M. Barnes, B. Bloom, and R.L. Nahin,

“Complementary and Alternative Medicine

Use Among Adults and Children,” National 

Health Statistics Reports 12 (2008): 1–23.

10. Deborah J. Cook et al., “Systematic

Reviews: Synthesis o Best Evidence

or Clinical Decisions,” Annals of Interna l 

Medicine 126, no. 6 (1997): 376–80.

11. C. Craword, S. Ja in, and W.B. Jonas.

Introduction to Systematic Reviews

Workbook , Samueli Institute, 2012. (Author

workbook or private seminar.)

12. L. Kalichman, “Massage Therapy or

Fibromyalgia Symptoms,” Rheumatology 

International 30, no. 9 (July 2010): 1,151–7.

13. G.A. Malanga and E.J. Cruz Colon,

“Myoascial Low-Back Pain: A Review,”

Physical Medicine & Rehabilitation Clinics of 

 America 21, no. 4 (November 2010): 711–24.