A Time for Massage.

Conflicts of interest: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or United States Government. There are no conflicts of interest to report.

Disclosure: The Evidence for Massage Therapy (EMT) Working Group (diverse stake-holders making up the steering committee and subject matter experts) contributed to the protocol development and provided input throughout the entire project; all analyses were conducted independently by Samueli Institute. All recommendations set forth in this report were made collectively with the EMT Working Group and Samueli Institute during an expert round table and are based on the evidence revealed through the systematic review and gaps that emerged through the process.

The effect of simple human touch, particularly in the alleviation of pain, is one of the oldest approaches to healing known to humankind. There is growing evidence for its efficacy against pain that has been summarized in this series of Pain Medicine, published in the July, August and September issues and highlighting therapeutic massage research. This series of three systematic reviews [1-3] demonstrates good evidence for massage in the management of musculoskeletal pain, cancer-associated pain, and surgical pain. Despite this evidence, it will be difficult to get the attention, time, and resources for widespread delivery of massage for pain. Full acceptance by conventional care providers remains a barrier. The lack of financial drivers undercuts other activities such as research, education, and training and systems integration, which are all needed to determine how we might implement massage for pain treatment in an integrative manner.

Gradually, but all too slowly, the readiness and enthusiasm for non-pharmacological approaches to pain in the nation is increasing. The epidemic of chronic prescription opioid use and abuse, the gateway role its use has to street narcotics like heroin, the costs of inadequately managed pain, and the need for new approaches to its management are now front and center nationally. Reports from the military departments and veterans administration, the Institute of Medicine, [4] and even the President of the United States [5] have all made “calls to action” for better pain management with less dependence on opioid-centered therapeutic approaches. The link connecting the opioid drug prescriber to the heroin drug trade, the costs incurred in our justice system, and the toll on people, families, business, and the economy are harder to ignore. We are starting to wonder if opioids, as too often used, are not as safe or effective as we thought. Thus, the time is ripe to move these evidence-based complementary approaches to the forefront.

This series of reviews complement the April 2015 Pain Medicine supplement “Are Active Self-Care Complementary and Integrative Therapies Effective for Management of Chronic Pain?,” [6] produced by the same primary authors as this series, discussing the need for more research evaluating massage therapy. In 2010, the Department of Defense Pain Management Task force identified massage as one of the most promising complementary and integrative therapies for pain management. In this series of articles, Samueli Institute (SI) teamed with a diverse group of pain and massage experts to fill that gap by evaluating the evidence for massage therapy on function as it relates to three pain populations. Both initiatives used SI’s Scientific Evaluation and Review of Claims in Healthcare (SEaRCH™) and Rapid Evidence Assessment of the Literature (REAL©) methodology [7,8] to critically evaluate the literature and link that evidence to practice and research recommendations. The results are clear: when properly delivered by certified massage therapists, massage can be effective for the treatment of pain in these populations. The limitations and gaps in the current research literature are clearer, and priorities for the field are offered. We now have a plan on where to go both in practice and research.

As clinicians, it is our duty to help our patients with pain as quickly, as safely, and as effectively as possible. But how do we make massage more widely available in prevailing medical care systems? How can we translate this evidence into practice? The challenges abound. These include the ubiquity of, and financial incentives for, drug treatments—our “fast food” for pain; lack of understanding about the training and competencies, certification, and licensure of (or lack of ways to license) massage therapists for these specific pain problems; the confusion over when to use massage vs other pharmacological and non-pharmacological approaches; team training for proper integration of massage into the delivery system; reimbursement for massage services; rapid measurement and feedback of the impact of massage on patient and the health care system outcomes. This translation into real world delivery requires a different type of research than randomized clinical studies. It requires approaches like SI’s Chronic Pain Breakthrough Collaborative, in which multiple clinics and hospitals gather together and learn from each other about how to solve these “system” problems, conducting outcomes and health services research in their local hospitals and clinics. As stated by Dr. Chester Buckenmaier in an editorial [9] at the start of this series, “Massage therapy is the evidence-based new thinking that will, with other integrative, non-pharmacologic approaches, help pain medicine overcome the current opioid-focused old thinking that has devastated so many lives.”

We agree. It is time for massage to enter the main stream for the care of pain.