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MASSAGE THERAPY FOR PAIN AND FUNCTION

IN PATIENTS WITH ARTHRITIS: A SYSTEMATIC

REVIEW OF RCTs

Plan for Today:

• Why did we pick this topic?

• Our process of gathering and grading evidence

• What did we find?

• Limitations

• Certain uncertainties: Our journey is just beginning!

Nelson, N.L., Churilla, J.R. Massage Therapy for Pain and Function in Patients with Arthritis:

A Systematic Review of Randomized Controlled Trials. Am J Phys Med Rehabil 2017; 36(5):

665-673

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MT AND ARTHRITIS

Our Goal: Synthesize and appraise the current evidence

regarding MT and arthritis symptoms.

Why MT

and

Arthritis

?

Epi

Perspective

The

statistics

are

staggering!

Practitioner

Perspective

Mercurial

relationship

with MT

COLLECTION AND APPRAISAL

PLAN AT A GLANCE

SEARCH

Google Scholar, MEDLINE, and PEDro Databases

APPRAISAL

Risk of Bias Assessment: PEDro scale

Quality of Evidence: GRADE approach

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INCLUSION CRITERIA• Participants-Studies involving individuals with osteoarthritis or

rheumatoid arthritis, with no limitations on participant age, sex, or nationality were included.

• Intervention-Massage therapy (MT) was used as the sole intervention.

• MT was defined as the intentional and systematic manipulation of the soft tissues of the body to enhance health and healing.

• Studies using energy manipulation (e.g., Reiki), or mechanical devices were excluded.

• Control-comparison groups involved either no treatment, or an intervention not involving a form of massage therapy.

• Outcomes- Studies were included if the main outcomes of interest included pain and physical function outcomes (e.g., ROM).

• Study Design- RCTs reported in English.

RISK OF BIAS

PEDro Scale (0-10)

2 Trials6,7 HIGH QUALITY (≥ 6)

5 Trials1-5 LOW QUALITY (<6)

OBSTACLES IN MT RESEARCH

Blinding

Concealed allocation

Blinding of therapists, subjects, and assessors

Follow-up

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OUR COMPARISONS

MT VS. NON-ACTIVE CONTROL GP:

SIX TRIALS1-3,5-7 (332 PARTICIPANTS)

MT VS. ACTIVE CONTROL GP:

ONE TRIAL4 (20 PARTICIPANTS)

Wait list Anything that participants

received/perceived as attention.

Usual care (e.g., cold packs,

medications)

No treatment

We divided the studies based upon control

group

OUTCOMES OF INTEREST

MT VS NON ACTIVE CONTROL MT VS ACTIVE CONTROL

PAIN

VAS

WOMAC Subscale

PAIN AND MORNING STIFFNESS

VAS

FUNCTIONAL OUTCOMES

GRIP STRENGTH

WALKING

ROM

Among the groups, we looked at individual outcomes

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GRADING THE EVIDENCEFor each outcome, we graded the evidence using a modified

GRADE approach.

RCTs considered high quality evidence, until…

GRADE OUR INTERPETATION:

“ACCORDING TO THE EVIDENCE, ________________________.”

HIGH WE ARE VERY CONFIDENT MT WAS RESPONSIBLE FOR THE EFFECT

MODERATE THE EFFECT WAS THE PROBABLY THE RESULT OF MT

LOW OUR CONFIDENCE IS LIMITED. MAYBE?? MAYBE NOT??

VERY LOW WE ARE NOT VERY CONFIDENT, THE EVIDENCE IS NOT THERE

DOWNGRADINGCRITERIA OUR INTERPRETION:

RISK OF BIAS MAJORITY OF STUDIES RECEIVED <6 ON THE

PEDro SCALE

INDIRECTNESS OF

EVIDENCE

THE STUDY POPULATION AND MASSAGE

DELIVERY METHOD DID NOT DIRECTLY

ADDRESS OUR QUESTION

INCONSISTENCY OF

RESULTS

CONFLICTING RESULTS FOR THE OUTCOME

IMPRECISION OF

RESULTS

SMALL # OF EVENTS AND THRESHOLD OF

SIGNIFICANCE (P<0.05).

WHAT DOES THAT MEAN??? WITH ADDITION

OF 1-2 MORE PARTICIPANTS; POTENTIAL

FOR A VERY DIFFERENT REPORTED

RESULT.

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MT VS. NON-ACTIVE CONTROL

OUTCOME: PAIN

NUMBER OF

TRIALS

6 TRIALS1-3,5-7

NUMBER OF

PARTICIPANTS

332 PARTICIPANTS

KEY FINDINGS Low evidence that MT is superior to a non-active

therapy for reducing pain in those w/arthritis.

WHY THE

DOWNGRADE?

Risk of bias

Imprecision

MT VS. NON-ACTIVE

CONTROL OUTCOME: ROM

NUMBER OF

TRIALS

5 TRIALS1-2,5-7

NUMBER OF

PARTICIPANTS

310 PARTICIPANTS

KEY FINDINGS Low evidence that massage is superior to non-

active therapy for improving ROM.

WHY THE

DOWNGRADE?

Risk of Bias

Imprecision

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MT VS. NON-ACTIVE CONTROL

*WOMAC Physical Function Subscale (e.g., degree of difficulty climbing stairs, etc.)

OUTCOME: *WOMAC FUNCTIONAL SCORES

NUMBER OF

TRIALS

3 TRIALS1,6-7

NUMBER OF

PARTICIPANTS

233 PARTICIPANTS

KEY FINDINGS Moderate quality evidence that MT is superior to

non-active therapies in improving WOMAC

functional subscales.

WHY THE

DOWNGRADE?

Imprecision

MT VS. NON-ACTIVE CONTROL

OUTCOME: PERCEIVED GRIP STRENGTH

NUMBER OF

TRIALS

1 TRIAL3

NUMBER OF

PARTICIPANTS

22 PARTICIPANTS

KEY FINDINGS Low quality evidence that MT is superior to a non-

active therapy for improving perceived (0-10

scale; 5 s fist clench) grip strength.

WHY THE

DOWNGRADE?

Risk of bias

Imprecision

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MT VS. NON-ACTIVE CONTROL OUTCOME: WALKING

NUMBER OF

TRIALS

3 TRIALS2,6,7

NUMBER OF

PARTICIPANTS

233 PARTICIPANTS

KEY FINDINGS Moderate quality evidence that MT is superior to a

non-active control for improving walking function.

WHY THE

DOWNGRADE?

Imprecision

Inconsistency

HOW WAS WALKING ASSESSED?

50-FT walk time6,7

8-FT walk time2

MT VS ACTIVE CONTROLOUTCOME: PAIN AND MORNING STIFFNESS

NUMBER OF

TRIALS

1 TRIAL4

NUMBER OF

PARTICIPANTS

20 PARTICIPANTS

KEY FINDINGS Very low-quality evidence that parent delivered MT

is superior to PRT for pain and morning stiffness

among children with juvenile RA.

WHY THE

DOWNGRADE

?

Risk of bias

Imprecision

Indirectness

What is PRT? Progressive relaxation therapy

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LIMITATIONS TO THIS REVIEW

Yep, it’s imperfect…

• Did we get all the data?

• Small number of studies (only 7)

– 4 from the same research group

• Subjectivity of grading the evidence

• No data pooling or statistical analysis

– Heterogeneity of investigations

– small # of studies per outcome

CERTAIN UNCERTAINTIES

Not OR, but AND… combining MT with other modalities (e.g., exercise, explain pain)?

Dose?

Cost effectiveness?

Long-term effectiveness?

Is MT effectiveness dependent upon the culprit?

Central and peripheral sensitization

Psychosocial factors e.g., pain beliefs

Joint space narrowing and osteophyte formation

Obesity/overweight

Age

Physical activity or inactivity

Sleep

Genetics

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WRAP UP

THREE WISHES

1. Large rigorously performed RCTS

including subgroup analysis

2. Position Stand: MT AND OA, RA

3. Improved dissemination of research

to MT schools and CE providers

THANK YOU!!!

I HOPE YOU HAVE SOME QUESTIONS FOR ME

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REFERENCES1. Atkins DV, Eichler DA. The effects of self-massage on osteoarthritis of the knee: a randomized, controlled trial. Int J Ther Massage Bodywork Res Educ Prac.. 2013; 6(1):4,14 11p.

2. Field T, Diego M, Gonzalez G, Funk CG. Knee arthritis pain is reduced and range of motion is increased following moderate pressure massage therapy. Complementary Therapies in Clinical Practice. 2015; 21:233-7.

3. Field T, Diego M, Hernandez-Reif M, Shea J. Hand arthritis pain is reduced by massage therapy. Journal of Bodywork and Movement Therapies. 2007; 11:21-4.

4. Field T, Hernandez-Reif M, Seligman S, et al. Juvenile rheumatoid arthritis: benefits from massage therapy. J Pediatr Psychol. 1997; 22(5):607-17.

5. Field T, Diego M, Gonzalez G, Funk CG. Neck arthritis pain is reduced and range of motion is increased by massage therapy. Complementary Therapies in Clinical Practice. 2014; 20:219-23.

6. Perlman AI, Ali A, Njike VY, et al. Massage Therapy for Osteoarthritis of the Knee: A Randomized Dose-Finding Trial. PLoS ONE. 2012; 7(2):1-9.

7. Perlman AI, Sabina A, Williams A, Njike VY, Katz DL. Massage therapy for osteoarthritis of the knee: A randomized controlled trial. Archives of Internal Medicine. 2006; 166(22):2533-8.