Incorporating Massage Therapy in Advance Practice Nursing



Incorporating Massage Therapy in Advance Practice Nursing

Submitted by Jill Collins and Sandy Seibert

Washburn University School of Nursing

For NU 504 Integrative Healing Modalities

April 27, 2010

Incorporating Massage Therapy in Advance Practice Nursing

Introduction

Massage, as defined by Merriam-Webster, is “manipulation of tissues (as by rubbing, kneading or tapping) with the hand or an instrument for therapeutic purposes” (Merriam-Webster Online, 2010). It is recognized as one of the oldest methods of healing. References to massage therpy date back over 4,000 years and even Hippocrates, who was often referred to as the “father of medicine”, made reference to massage when he wrote “the physician must be acquianted with many things, and assuredly with rubbing” (Massage Today).

There has been much research done and many articles written about the effects of massage therapy including the many potential clinical benefits it can provide. These include but are not limited to: lowering blood pressure and heart rate, improving concentration, strenghening the immune system, reducing tension headaces, reducing anxiety, improving pulmonary function in young asthma patients, decreasing serum glucose levels in diabetics and increasing weight gain in premature infants (Massage Today) (Lee & Kemper, 2000). Massage has also been shown to be a great method of reducing stress in healthcare providers (Bost & Wallis, 2006)

As registered nurses move into the advanced practice role, a unique opportunity is afforded to them in refernce to alternative and complimentary medicine. At the advanced practice level, nurses now have the opportunity to work with their clients in deciding what the client’s healthcare goals and needs are and then prescibing alternative therapies appropriate to those needs. The advance practice nurse will need to become well versed in complimentary and alternative therapies so as to only prescribe those therapies that have been proven to be beneficial and do not have contraindications to a client’s current health state.

Review of Literature

Introduction

A literature search for massage was conducted using the following terms: massage therapy, massage therapy and health benefits, massage and health, massage, what is massage therapy, and massage therapy and ethical considerations. Representation of the number of hits in the data bases and websites are listed in the table below:

|Massage Therapy |Google |30,200,000(0.19 seconds) |

|Massage Therapy and Health Benefits |CINAHL |81 |

|Massage and Health |CINAHL |178 |

|Massage |CINAHL |89 |

| |Google |84,200,000(0.30 seconds) |

|What is Massage Therapy | |9,550,000 |

|Massage &Ethical issues |Google |96,700(0.26 seconds) |

The purpose of this review of literature is to develop an understanding of the effects of massage therapy as an intervention on patients. The articles selected for review were those which best met this criteria.

Critique of Studies

Melancon and Miller (2005) explored whether there was significant difference in perceived low back pain relief between patients receiving massage versus traditional therapy using a two-variable by three-variable fully crossed, factorial, comparative research design. Statistical results showed slightly more efficacy for traditional therapy, however, the additional benefits of massage add to its value for holistic nursing practice. The research took place in a rural physician’s practice in southern Louisiana. Participants were assigned identification numbers. The study used a nonrandomized convenience sample of 60 consenting patients with low back pain ages 18-63 years. This sample divided alternately into two groups of 30 participants. One group received massage therapy by a massage therapist and the other group continued with traditional therapy. Results in this study were similar between traditional therapy and massage therapy. One of the weaknesses of this study was that it was limited to patients from one physician’s office. The wide age range of patients was strength of this study (Melancon & Miller, 2005).

According to Dryden, Baskwill and Preyde (2004), the small number and mixed methodological quality of studies on the effectiveness of massage therapy makes drawing definite conclusions about its usefulness for patients with non-specific low back pain difficult. The best available evidence at this time supports the use of massage therapy for orthopaedic patients suffering from pain in other areas, such as cervical or shoulder regions, may also experience pain and dysfunction reduction with massage therapy: however, research has yet to provide clear confirmation. Massage appears to be a relatively safe form of treatment with high levels of patient satisfaction for pain reduction. In the case of low back pain, massage has relatively long-lasting effects and therefore has the potential to be cost effective by reducing the use of more costly care. This article compared four studies done on massage from 1994-2001 comparing; sample, methods, duration of study, and outcome measures. Reports on the effectiveness of massage for the treatment of low back pain are anecdotal reports and are limited in their scientific merit (Dryden, Baskwill, & Preyde, 2004).

Touch is a language spoken through the hands and understood by the heart. Together, intention and touch set the tone and provide the basis for healing (Walton, 2009). Data was obtained from 60 adult clients who were confined to bed in orthopaedic wards in St. John’s Medical College and Hospital, Bangalore. Purposive sampling technique was used to select the sample. The instruments used for data collection were interview schedule for baseline information, record of physiological parameters, visual analogue scale and state trait anxiety inventory. The patients were identified according to inclusion and exclusion criteria. The physiological components (blood pressure, heart rate, respiratory rate, pain scale, and anxiety scale) were assessed before effleurage back massage. Next, the patients were turned to lateral or prone position and effleurage back massage was given for three minutes. After the procedure the patients were repositioned comfortably. After a gap of five minutes, the physiological components were assessed. After 30 minutes physiological and psychological components were assessed again. The data was analyzed using descriptive and inferential statistics. It was found that effleurage back massage was effective on all the physiological components. A weakness of this study was that it was only conducted on orthopaedic patients. One of the strengths of the study was that it could be utilized in nursing practice (Walton, 2009).

Cambron, Desheimer, Coe and Swenson researched the amount and type of negative side-effects and positive (unexpected) effects experienced after a massage session. Subjects participating in this study were consecutive new and returning clients at a massage therapy clinic within a metropolitan complementary and alternative medicine (CAM)-integrated university. Information on client demographics and negative and positive side effects were descriptively compiled. Chi-square analysis and t tests were completed to determine factors independently associated with side-effects. Factors independently associated with side-effects were included in multivariable logistic regression models using SAS 8.0 (SAS institute Inc., Cary, NC) to determine the factors associated with presence of positive and negative side-effects. This study demonstrated that 10% of clients receiving massage care had a minor negative side-effect and 23% had unexpected positive effects. Weakness of this study was a small sample size. Strength of this study is that at the time written was the first known study on the side-effects of massage care (Cambron, Dexheimer, Coe, & Swenson, 2007).

Bost and Wallis investigated the effectiveness of massage therapy in reducing physiological and psychological indicators of stress in nurses employed in an acute care hospital. A randomized controlled trial was conducted in one 200 bed campus of a 650 bed regional hospital in South East Queensland. Approximately 350 full-time and part-time nurses were employed on the campus. The study was supported by funding from the local Hospital Foundation and received approval from the Human Research Ethics Committees of both the district and a local university. Sixty nurses, including enrolled nurses, registered nurses and nurse managers volunteered for the study. The outcome measures used in this study were the Spielberger State-Trait Anxiety Inventory (STAI), mean arterial blood pressure and urinary cortisol levels. Data was collected over a five-week period. Univariate descriptive statistics were calculated for the total sample. The Chi-Square Test was used to test for differences between groups when the data were measured at the nominal level. The Mann Whitney U test was used to test differences between groups when the data were measured at the interval level. One weakness of this study was small sample size (Bost & Wallis, 2006).

Kaye, Swinford, and Lambert describe the effects of deep tissue massage on systolic, diastolic, and mean arterial blood pressure. The study was performed at Lindsey’s Salon and Day Spa in Lubbock, TX between November 2004 and March 2006. The study involved 263 volunteers (12% males and 88% females), with an average age of 48.5 years. Overall muscle spasm/muscle strain was described as either moderate or severe. Baseline blood pressure and heart rate were measured via automatic blood pressure cuff. The massages were between 45 and 60 minutes in duration. The data were analyzed using analysis of variance with post-hoc Scheffe’s F-test (Excel 2002, Microsoft, Redmond, WA.). One of the strengths of this study was the large number of volunteers. Weakness of study was research was done at only one spa (Kaye, Swinford, & Lambert, 2008).

Conclusion

The six articles reviewed for this paper discussed the benefits and possible side-effects of massage. Only one of the studies had more than 100 participants in the study. Overall the articles were mostly positive concerning the benefits of massage. Massage is very low cost compared to some other stress relieving treatments. One of the gaps in the research of massage seems to be studies done on a broad range of hospitalized patients.

Theoretical Framework

The theoretical framework chosen for this integrative healing modality of massage therapy is that of Myra Levine’s Conservation Model. Levine’s Conservation Principles consist of four principles which maintain or restore a person to a state of health. The first principle is conservation of energy, which avoids excessive fatigue by balancing energy output/input. The second principal is conservation of structural integrity with the goal of maintaining or restoring body structure. Principle three is conservation of personal integrity which involves maintaining or restoring the patient’s sense of identity and self-worth. The fourth conservation principal is that of social integrity which acknowledges the patient as a social being. Using Levine’s theory, people with low back pain seek treatment attempting to conserve structural integrity. It is then the responsibility of the advanced practice nurse to recognize patient response and to then guide and support appropriate treatment choices such as massage therapy (Melancon & Miller, 2005).

Refer to appendix A for a diagram of the theoretical model.

Cultural, Legal and Ethical Issues

Cultural Issues

One of the major cultural issues surrounding this modality is the very foundation of the modality itself, touch. Touch may be viewed in either a positive or negative way. There are many cultures in which touching another person, especially in the manner of massage, is taboo. In other cultures, touch is seen as a very positive healing power. It is important, as an advanced practice nurse, to familiarize oneself well with his/her client to understand how prescribing a certain healing modality may impact that person.

Legal Issues

One of the major legal issues of this modality would be prescribing it to someone who has contraindications for the therapy. For example, if a client came to see an advance practice nurse for calf pain and swelling and the nurse did not first rule out a deep vein thrombosis before sending the client for massage for pain relief, the client could end up having the thrombosis dislodged and then suffering the consequences of a pulmonary embolus. The nurse could then be sued for malpractice. This also works the other way. Quite often, a client may talk to their massage therapist about symptoms he/she may be having and the therapist may choose to try and treat something he/she should not be treating instead of referring the client back to the primary care provider. This could potentially cause more problems for the client.

Another legal issue surrounding this modality is that of insurance billing as some insurance companies do pay for massage therapy. There is a fine line between receiving a modality for a medically necessary reason versus recreational reasons.

Ethical Issues

A few of the ethical issues surrounding massage therapy are informed consent, confidentiality and boundaries. With regard to informed consent, clients should be fully informed of how the modality has the potential to help him/her, how it could negatively affect him/her and what exactly will be done to him/her. Along with this, comes the right to refuse the treatment if the client does not feel comfortable or the client does not believe he/she will benefit from the treatment. Confidentiality is an issue surrounding all of health care. Clients have the right to expect that any information shared with a practitioner will be kept between them. Boundaries are determined by each individual with regard to a space within a perimeter. The boundaries may be physical or emotional. It is important for the therapist and the client to discuss these boundaries before beginning a session so that both the client and the therapist remain comfortable.

Incorporation into Advanced Nursing Practice

As evidenced by the review of literature, massage therapy has been shown to have positive outcomes for multiple chronic and acute physical and mental conditions. Given these research findings, it seems that massage therapy is a very feasible alternative healing modality to incorporate into advanced nursing practice. With the rising costs of conventional medicine and pharmaceuticals and the current state of the economy in the United States, alternative healing methods such as massage could certainly become more cost effective for clients as well as third party payors.

With regard to limitations of use by the advanced practice nurse, as mentioned above, underlying conditions the client may have that massage therapy could be contraindicated for must always be explored before referral. Not doing so could cause serious harm to the client. For many advanced practice nurses, referrals for their clients may be limited by insurance coverage of the modality. If insurance does not cover it, some clients may not be able to pursue this option.

Massage therapy is an invaluable option to advanced practice nurses to prescribe for their clients. Most people’s lives these days are fast-paced and often quite stressful. Many studies have shown the negative impact that stress can have on people’s health. As evidenced by the review of literature, massage can provide a significant amount of stress reduction thus creating a positive effect of people’s health. Massage is a non-invasive and inexpensive way to assist in overcoming and aid in deterring many health problems.

It is essential that more research be done not only on the actual positive outcomes on people’s health which massage can bring about, but how those positive effects translate into money savings to taxpayers and third party payors. The authors of this paper feel this would be one of the ways to convince insurance companies as well as Medicare and Medicaid to cover these services.

International nursing organizations should work together to provide each other with information on the effects of massage therapy. The way we utilize massage therapy for medical intervention in the United States is probably very different than that of other countries. Sharing of this information can only bring about more positive outcomes for the clients we are caring for as advanced practice nurses.

Conclusion

Alternative healing modalities such as massage therapy are not widely accepted as useful interventions in the modern medical practices of practitioners in the United States nor is it covered by most major insurance companies (Cleary-Guida, Okvat, Oz, & Ting, 2001). This is unfortunate given the amount of research showing the positive effects of massage therapy on a population’s general health. Advanced practice nurses have the opportunity to utilize this modality more to bring about better outcomes for their patients at a lower cost and with less risk than many modern medical alternatives. This may in turn may cause more people to recognize the value of this alternative healing modality.

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References

Bost, N., & Wallis, M. (2006). The Effectiveness of a 15 Minute Weekly Massage in Reducing Physical and Psychological Stress in Nurses. Australian Journal of Advanced Nursing, 23 number 4, 28-33.

Cambron, J., Dexheimer, J., Coe, P., & Swenson, R. (2007). Side-Effects of Massage Therapy: A

Cross-Sectional Study of 100 Clients. The Journal of Alternative and Complementary

Medicine, 13, 793-796.

Cleary-Guida, M. B., Okvat, H. A., Oz, M. C., & Ting, W. (2001). A Regional Survey of Health

Insurance Coverage for Complementary and Alternative Medicine: Current Status and

Future Ramifications. The Journal of Alternative and Comlementary Medicine , 7

number 3, 269-273.

Dryden, T., Baskwill, A., & Preyde, M. (2004). Massage Therapy for the Orthopaedic Patient. Orthopaedic Nursing, 23, 327-332.

Kaye, A., Swinford, J., & Lambert, T. (2008). The Effect of Deep-Tissue Massage Therapy on

Blood Pressure and Heart Rate. The Journal of Alternative and Complementary

Medicine, 14 number 2, 125-128.

Lee, A. C., & Kemper, K. J. (2000). Practice Patterns of Massage Therapists. The Journal of

Alternative and Complimentary Medicine , 6 number 6, 527-529.

Massage Today. (n.d.). Retrieved April 11th, 2010, from Massage Today:

Melancon, B., & Miller, L. (2005). Massage Therapy versus Traditional Therapy for Low Back

Pain Relief. Holistic Nursing Practice, May/June, 116-121.

Merriam-Webster Online. (2010). Retrieved April 11th, 2010, from Merriam-Webster Online:



Susan Kun Leddy. (2006). Integrative Health Promotion (second ed.). Sudbury Massachusetts:

Jones and Bartlett Publishers.

Walton, M. (2009). Immediate effects of Effleurage Back Massage on Physiological and Psychological Relaxation. Nursing Journal of India, C Number 10, 230-232.

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