Ann Blair Kennedy, LMT, BCTMB, DrPH
Executive Editor, IJTMBDepartment of Biomedical Sciences, Division of Behavioral, Social, and Population Health, University of South Carolina School of Medicine Greenville, Greenville, SC, USA.
I feel that it is important to know the stories behind those who are working hard in the field to bring forward massage therapy research. Interviews with massage therapy researchers will now occasionally be included in the Journal as a new editorial feature. The first interview is with Virginia S. Cowen, PhD, LMT a New York State-licensed and NCB board-certified massage therapist with a PhD from Arizona State. She first became interested in massage therapy research while in massage therapy school, and her most recent work is investigating the integration of massage therapy into medical settings. Dr. Cowen states that massage therapy needs to move to Phase 3 research, and aligning with massage therapy practice and research on massage therapy education are areas ripe for research development. She urges the massage therapy profession to work together to develop clinical practice guidelines which could help move the profession forward.
KEYWORDS: massage therapy, practice guidelines, interview, research personnel, health care
As a qualitative and mix methods researcher, I am drawn to the stories of people. I appreciate what another qualitative researcher, Brené Brown, has said that she feels that stories are “just data with a soul.”(1) Therefore, I feel that it is important to know the stories behind those who are working hard in the field to bring forward massage therapy research. Research can be difficult and isolating, and if practitioners and other researchers know our massage therapy scientist’s stories, connections may be made and isolation could be reduced. For these reasons, a new occasional editorial feature begins with this issue; the Journal will be publishing interviews with massage therapy researchers.
This first interview is with Virginia S. Cowen, PhD, LMT. Dr. Cowen is a New York State-licensed and NCB board-certified massage therapist. She holds fitness certifications as a Certified Strength and Conditioning Specialist (National Strength and Conditioning Association), Health and Fitness Instructor (American College of Sports Medicine), and personal trainer (American Council on Exercise), and is an experienced registered yoga teacher (Yoga Alliance). She received a PhD from Arizona State University in curriculum and instruction with a concentration in exercise and wellness, a MA from Columbia University in applied physiology, and a BS from Indiana University in music and English. She received a certificate in massage therapy from The Swedish Institute in New York City and she completed teacher training at I.T.M. in Chiang Mai, Thailand. Currently, she is an assistant professor at the Rutgers University School of Health Professions where she oversees the research curriculum for the physician assistant program. She has conducted outcomes research studies evaluating health-related outcomes of massage,(2) yoga,(3,4) and aromatherapy. Her current research is in the areas of health services and medical/health sciences education.(5,6) She is author of Pathophysiology for Massage Therapists: a Functional Approach,(7)Therapeutic Massage and Bodywork for Autism Spectrum Disorders,(8) and What Students Learned in Gym Class.(9) Dr. Cowen maintains a small private therapeutic bodywork practice in New York City, focusing on clients with chronic, complex conditions.
My recent work has been on the health services aspects of massage: examining the integration of massage into medical settings.(5,6,10) As faculty at an academic health center, I try to find opportunities to bring massage into my work whenever I have the chance. This type of work uses existing data sources that can be helpful mentoring students on research and statistical analysis. One of my favorite methodologies is content analysis—coding text for quantitative analysis. We have used it for a range of projects including a few studies examining massage in outpatient cancer care. We have also conducted preliminary analyses of the National Health Interview Survey massage data. This probably sounds rather dry, but the data analysis phase is exciting when results appear and students run the statistics and see patterns emerge. Although this is one small area within massage therapy research, it provides insight as to how massage is actually fitting into the overall health care arena.
Massage school. Research on massage was relatively young at that point. Several of us in my class already had bachelor’s degrees, so we had undergraduate training in research fundamentals. We had lots of great discussions that piqued my interest and inspired me to go further. I had to look very hard for graduate schools that would accommodate my research interests.
That is an interesting question—it depends on the type of project. For work in the health services area, stakeholders would be conventional health care providers and administrators because they are the folks who could help get massage in the door. Massage therapists and patients/clients already buy into the idea that massage could/should be part of overall treatment options.
From a logistical perspective, making connections is tricky because of geography, as well as funding and resources. Because massage therapy education programs are not part of academic health centers, massage therapy runs the risk of being researched upon rather than directing research to revitalize what is practiced and taught. This is unlike other health professions, where research is conducted by faculty in the same profession. I am very sensitive to that. A few years back, I started reaching out to massage schools to look at ways we could collaborate. This has been a very interesting experience, but we have formed a small, merry band.
I hope we get to Phase 3. By that I mean, the body of massage research has loads of small-sample, placebo-controlled studies. These are essentially the equivalent of a Phase 2 clinical trial. Those types of studies are essential in bringing a pharmaceutical to market because they measure safety and efficacy. Although that is commonly described as the “gold standard”, it is not applicable to all areas of research. Psychotherapy, physical therapy, and mathematics education are good examples. Placebo-controlled studies are not required—nor would they be appropriate because the treatments have already made it to market. So research on these has progressed to comparing different treatment approaches to each other. That is a different research question—more suited to the place massage occupies in health care and the wellness industry. Yet research rhetoric continues to point out that massage research lacks placebo-controlled trials. We lack those for mathematics education, too.
As a profession, we have not critically examined this issue and banded together to progress to Phase 3 research, which is where we could be. This next phase of research is where we—as massage therapists— have the opportunity to chart a course. Although we lack a common language to describe what we do, we could potentially change that to better describe the individualized and personalized approach to treatment. We are no more heterogeneous than psychotherapy, physical rehabilitation, or mathematics education than physical therapy.
A good example of this is the updated guidelines from the American College of Physicians for non-pharmacological treatments for chronic low back pain. (11) The review upon which the guidelines are based provides general insight about the choice of whether to refer for massage—or not.
At present, a search of the National Practice Guideline Clearinghouse using the word ‘massage’ yielded roughly 40 entries, compared to over 500 entries for ‘physical therapy’. That substantial difference indicates opportunities for our profession to advocate for ourselves. Something that might help this along is the writing of critical reviews of massage research studies to identify knowledge gaps. For example, the clinical practice guidelines for integrative breast cancer care(12) included only four massage studies. Each of those used considerably different massage protocols and assessments of indirect outcomes that are not what we typically employ in practice. The reporting does not discuss the heterogeneity because the aim was general: to figure out whether patients should be referred for massage. What happens next is up to the massage therapist. In our case, comparing the protocols in the four studies to what massage therapists actually do in practice would be a good start.
Aligning research with massage practice presents a great opportunity. This includes direct outcomes of massage (e.g., pain, range-of-motion), functional outcomes (activities of daily living, lost work days), and integration of massage (e.g., decreases in pain medication). This type of information would be valuable to different stakeholders. Insurers and employers would probably be very interested if large pools of data revealed interesting results in the functional and integration outcomes areas.
Research on teaching massage is another important area of potential growth. I suspect there are a lot of massage therapy educators doing really interesting things in classrooms and clinics. That information is waiting to be harnessed.
I have enjoyed the range of research I have been able to design. But I am probably most proud of two books I wrote on massage. Writing Pathophysiology for Massage Therapists: a Functional Approach gave me the opportunity to really dig into standard practices for massage and critically examine research evidence. It became very clear to me that we hear a lot about massage being beneficial for patients with disorder X, Y, or Z. But the emphasis in research on indirect outcomes like anxiety, mood, or fatigue did not help translate into specific recommendations for how to design a massage session. Since we treat the patient/client and the symptoms—not a medical diagnosis—this helped me clearly see gaps in research. Take multiple sclerosis, for example: patients have different presentations. Massage for intermittent spasticity of the hip extensors and knee flexors might help one patient, while another patient with balance issues might be more effectively treated with passive range of motion. Individualization of treatment is necessary in order to benefit the patient (but we could still document this and analyze it later for multiple patients with multiple sclerosis.)
Therapeutic Massage and Bodywork for Autism Spectrum Disorders: a Guide for Parents and Caregivers is dear to my heart because it has made a difference. After being approached by several parents of children with sensory and motor issues related to autism, I wanted to help sort out their questions, especially when they were being sold on “the right” treatment for their child. Because there is no single best treatment, it can be difficult to understand options. My hope was—and is—that parents can connect with massage therapists. Together they will find ways to join forces with the interprofessional teams that treat individuals with autism spectrum disorders. It is a lofty goal.
There is a pervasive misperception that developing clinical practice guidelines will take away freedom of individual massage therapists. This is not really accurate and I believe it hampers progress. Other fields are heterogeneous in nature (e.g., physical therapy, occupational therapy, surgery, emergency medicine), but have managed to get over this hurdle. We have a great opportunity to critically examine the body of massage research and use what we find to chart a course forward. Collaborations are definitely needed to make that happen.
1 Brown B. The Power of Vulnerability [Internet]. TED talk presented at: TEDxHouston; 2010 Jun; Houston, Texas. Available from: https://www.ted.com/talks/brene_brown_on_vulnerability
2 Cowen VS, Burkett L, Bredimus J, Evans DR, Lamey S, Neuhauser T, et al. A comparative study of Thai massage and Swedish massage relative to physiological and psychological measures. J Bodyw Mov Ther. 2006;10(4):266–75.
3 Cowen VS. Functional fitness improvements after a worksite-based yoga initiative. J Bodyw Mov Ther. 2010;14(1):50–54.
4 Cowen VS, Adams TB. Physical and perceptual benefits of yoga asana practice: results of a pilot study. J Bodyw Mov Ther. 2005;9(3):211–219.
5 Cowen VS, Thomas PA, Gould-Fogerite SE, Passannante MR, Mahon GM. Interprofessional integrative medicine training for preventive medicine residents. Am J Prev Med. 2015;49(5 Suppl 3):S257–S262.
6 Cowen VS, Cyr V. Complementary and alternative medicine in US medical schools. Adv Med Educ Pract. 2015;6:113–117.
7 Cowen VS. Pathophysiology for Massage Therapists: a Functional Approach. Philadelphia: F.A. Davis Company; 2016.
8 Cowen VS. Therapeutic Massage and Bodywork for Autism Spectrum Disorders: a Guide for Parents and Caregivers [Internet]. London: Singing Dragon, an imprint of Jessica Kingsley Publishers; 2011. Retrieved 2017 Aug 4. Available from: https://books.google.ca/books?hl=en&lr=&id=d0kSBQAAQBAJ&oi=fnd&pg=PA3&dq=Therapeutic+massage+and+bodywork+for+autism+spectrum+disorders+a+guide+for+parents+and+caregivers+&ots=ELcVoMMxJz&sig=snkTeA63msZuxJ1MZCj4BacVuqY#v=onepage&q=Therapeutic%20massage%20and%20bodywork%20for%20autism%20spectrum%20disorders%20a%20guide%20for%20parents%20and%20caregivers&f=false
9 Cowen VS. What Students Learned in Gym Class: a Qualitative Study of Required Physical Education. Lewiston, N.Y: Edwin Mellen Press; 2010.
10 Cowen VS, Kaufman D, Schoenherr L. A review of creative and expressive writing as a pedagogical tool in medical education. Med Educ. 2016;50(3):311–319.
11 Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493–505.
12 Greenlee H, Balneaves LG, Carlson LE, Cohen M, Deng G, Hershman D, et al. Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. JNCI Monogr. 2014;2014(50): 346–358.
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INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK, VOLUME 10, NUMBER 4, December 2017