Complementary Therapies in Clinical Practice 21 (2015) 52e56
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
A decade of building massage therapy services at an academic medical center as part of a healing enhancement program Nancy J. Rodgers a, Susanne M. Cutshall b, Liza J. Dion b, Nikol E. Dreyer b, Jennifer L. Hauschulz b, Crystal R. Ristau a, Barb S. Thomley b, Brent A. Bauer b, * a b
Complementary and Integrative Medicine Program, Mayo Clinic, Rochester, MN, USA Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
a b s t r a c t Keywords: Alternative medicine Complementary therapies Integrative medicine Massage therapy
The use of complementary and integrative medicine therapies is steadily becoming an integral part of health care. Massage therapy is increasingly offered to hospitalized patients for various conditions to assist with the management of common symptoms such as pain, anxiety, and tension. This article summarizes a decade of building the massage therapy service at a large tertiary care medical center, from the early pilot studies and research to the current program offerings, and the hopes and dreams for the future. © 2014 Elsevier Ltd. All rights reserved.
Complementary and integrative medicine therapies have become an integral part of health care for a number of Americans. Many complementary and integrative therapies specifically target pain and anxiety, and for this reason they can assist with addressing the needs of hospitalized patients who are not fully helped by conventional approaches. Massage therapy is an integrative therapy that has been shown to effectively improve several outcomes. Mild to moderate pressure massage techniques can decrease pain, anxiety, fatigue, stress perception, nausea, depression, lymphedema, muscle tension, heart rate, and blood pressure, and it can increase sleep quality, plasma b-endorphin levels, skin temperature, and blood flow [1e29]. Studies of massage therapy outcomes and feasibility have examined several patient populations, including hospitalized patients, intensive care unit patients, palliative care patients, and hospice patients [30e37]. Additional research has focused on massage therapy outcomes related to various conditions (drug addiction, labor pain, cancer, acute myocardial infarction, dementia, preterm birth, Parkinson disease, and human immunodeficiency virus infection), and procedures
Abbreviations: CIMP, Complementary Integrative Medicine Program; CVS, Division of Cardiovascular Surgery. * Corresponding author. Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (B.A. Bauer). http://dx.doi.org/10.1016/j.ctcp.2014.12.001 1744-3881/© 2014 Elsevier Ltd. All rights reserved.
(abdominal surgery, bone marrow transplant, and cardiac surgery) [3,4,6,8,10,11,14,25,37e42]. The massage therapy literature suggests that massage therapy has been provided safely in the hospital setting and has the potential to substantially improve clinical care. A literature review and a desire to improve clinical care for cardiac patients at a large tertiary care medical center started a decade of building clinical massage therapy services and a hospital program to enhance healing. The process of building this clinical massage therapy service will be discussed in more detail and is outlined in a timeline (Fig. 1). 1. Background The impetus to bring massage to the hospital bedside originated in early 2002 when the Division of Cardiovascular Surgery (CVS) team identified pain-free cardiac surgery as a key goal. This multidisciplinary collaboration included surgeons, anesthesiologists, pain specialists, pharmacists, nurses, and Complementary Integrative Medicine Program (CIMP) leaders. Several changes were incorporated (eg, novel anesthetic techniques and different types of chest tubes to facilitate easier removal), but some of the key concepts to emerge from the original discussions centered on various integrative medicine approaches, resulting largely from the advocacy of a clinical nurse specialist and other nursing leaders. From their extended experience and greater daily contact with postsurgical patients, the nurses made many proposals that centered on
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Fig. 1. Timeline for developing the massage therapy program. FTE indicates full-time equivalent.
the potential utility of modalities such as acupuncture, music therapy, animal-assisted therapy, and massage therapy. A spirit of collaboration was fostered across the various disciplines, leading eventually to the willingness of the CVS leaders to scientifically evaluate the various proposals from nursing and integrative medicine proponents. The first proposal to be tested involved massage therapy. In 2004, there was still significant concern about the potential risks associated with massage for postoperative patients. Older literature raised concerns about the potential for blood clots or bleeding problems. There were also fears that massage could cause mishaps such as displacing chest tubes or manipulating wounds inappropriately. Thus, a pilot study was proposed to evaluate massage therapy for a small number of patients. The primary outcomes focused on feasibility, effects on patient care flow, risks, and adverse events. The pilot study included 58 patients, with 30 in the massage group and 28 in the placebo group. Much thought was given to the intervention and how the study would be distinct from other massage studies. The team chose to allow the massage therapists to use all appropriate interventions and skills as applicable to the individual patient according to the massage therapist's assessment. That is, no attempt was made to restrict the regions and techniques of massage or the time spent on each anatomical site for massage. The massage therapists were free to use any of the skills for which they had received specific training. These included Swedish massage, reflexology, neuromuscular techniques, myofascial and connective tissue release techniques, trigger point release, acupressure, manual lymphatic drainage, and gentle stretching. As a result, compared with previous studies, this was a truer evaluation of the actual practice of massage therapy in a hospital setting. Even though variability was introduced, the pilot study was thought to have greater validity since it more closely mimicked the actual practice of massage therapy. The optimal control group was discussed at length. The final decision was to match the human contact by assigning the same massage therapist to visit the control patients for the same duration of time as was spent providing massage for patients in the massage group. This design was intended to minimize interprovider
variability and to control for the warmth and personality of the massage therapist. Although no active massage was provided, the massage therapists were encouraged to reassure the patients and assist with any simple care needs while they were in the room. The key results showed that massage was safe, and no adverse events were associated with massage [43]. Opinions were solicited from nurses and surgeons as to whether the massage therapy had interfered with the flow of care. The comments were universally favorable. Many nurses noted that massage therapy helped their workload by addressing symptoms that they could not otherwise address adequately. In fact, instead of massage therapy impeding nursing care, most nurses thought that the massage therapy had enhanced patient care overall and helped reduce their workload because the patients were less anxious and more comfortable. After reviewing these favorable effects, the CVS leaders were intrigued but requested further validation. Therefore, a larger confirmatory trial involving 113 patients was begun. That study also returned significantly positive results for decreasing pain, anxiety, and tension [44,45]. Patients were highly satisfied with the intervention, and no barriers to providing massage therapy were identified. As a result, the CVS leaders hired massage therapists so that massage therapy would be offered routinely for all cardiovascular surgical patients. Soon other surgical practices (eg, colorectal surgery, thoracic surgery, and breast surgery) became interested in rapid succession. Several of these surgical practices also approached CIMP colleagues for assistance in creating similar research evaluations of massage for their specific patient populations [46,47]. Each of these evaluations in turn yielded positive results and led to further expansion of the implementation of massage. At that time (2008), massage was widely available to most surgical patients at no charge, with the cost borne by the Department of Surgery. In 2009, our institution's Hospital Practice Committee and Clinical Practice Committee noted the favorable effects on massage therapy in the hospital and charged the CIMP with finding a way to make massage therapy more broadly available to all patients in the hospital. This led to several considerations, but the decision was made that a fee-for-service approach would allow widespread
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availability, maintain sustainability, and meet the needs of most patients. To help defray the cost for patients for whom financial considerations were a limitation, access was made available to benefactor funds. As part of the initial success with massage, the nursing leaders of the CVS further collaborated with colleagues in the CIMP to evaluate the use of several other complementary and alternative medicine modalities, including acupuncture, music therapy, animal-assisted therapy, guided imagery, and nature sounds. As each modality was tested and found to be efficacious, it was quickly incorporated into the suite of approaches made available to postoperative patients. Eventually, these were organized into the Cardiovascular Surgical Healing Enhancement Program. Brochures were made available to patients preoperatively and postoperatively so that they would be aware of the services available in addition to the excellent conventional care they already received. This suite of services quickly expanded to other surgical and medical units. In 2004, organic growth and expansion of the outpatient clinic practice included massage therapy, acupuncture, and consultations with CIMP physicians. This resulted from work completed by the Integrative Therapies Task Force and from research and practice initiatives developed by the CIMP. Among the numerous details reviewed to launch the outpatient practice was the fee structure. A market analysis of various fees and services included local, regional, state, and nationwide price points for therapeutic treatments. Billing codes were identified, fee structures completed, and referral criteria created. Patients must be referred by a provider at our institution to receive massage in the outpatient clinic, which has been a great option for patients who wanted to continue massage therapy in a medical environment. Because of the number of massage therapy precautions for patients after surgery or after hospitalization, an evaluation process was created to configure an appropriate treatment plan for each patient. The massage therapist reviews the patient's medical history and the reason for referral to determine an individualized treatment plan. The treatment plans consist of appropriate massage techniques to be used, patient positioning, appropriate pressure, duration of time per visit, and frequency of massage therapy. During patients' initial evaluations, goals are discussed and patients are made aware that they will be dismissed when the goals have been met or if their progress plateaus. 2. Taking notice and spreading the word As demand for massage therapy spread through our institution, the breast surgical team was approached to consider a feefor-service pilot study for postsurgical patients. This team had expressed interest in having massage therapy available for its patients, and the team had completed a survey in 2005 examining the interest in massage therapy and other forms of integrative medicine among patients with breast disease. Thirty-five patients responded to that survey, and all indicated that massage therapy was effective in helping to reduce stress, and 34 believed that it was very effective or somewhat effective in reducing muscle tension. Although the sample was small, the study showed that massage therapy may help patients with breast disease reduce stress and feel better overall [48]. The survey responses supported moving forward with a pilot study, in which a small sample of 46 patients was offered massage therapy sessions of 20 min at a fee of $1.00 per minute up to $20.00. This massage therapy was offered on postoperative day 1 or 2 before discharge. The pilot study showed an acceptance and enthusiasm for massage therapy and a willingness by patients to pay an outof-pocket fee for this service. After the results of this pilot study
were presented to the Hospital Practice Committee, a fee-forservice policy was implemented for all massage therapy services throughout our institution. The outpatient clinic has faced challenges meeting patient demand. Patient growth has been remarkable over the past 10 years and continues to increase. Meeting the demand, however, has been challenging because of a limited availability of patient rooms and the availability of more providers than treatment rooms. The outpatient clinic is open only during normal business hours, so weekend or evening hours have not been available. After the massage therapists discussed options for meeting the need, they designed a patient call list so they could fill canceled appointments as they arose. Initially, the number of requested appointments was high. The outpatient calendar filled quickly, so new patients had to schedule appointments far in advance, which led to patients forgetting their appointment or having to cancel at the last minute because of scheduling conflicts. To address this concern, a policy was implemented to limit the number of prescheduled appointments. The policy is reviewed with each patient during the initial evaluation, so the patient understands the expectations for future appointments. The demand for outpatient appointment is strong, with a full calendar and patients with various medical diagnoses. In the outpatient clinic, many of the referrals come from the Oncology Clinic, the Fibromyalgia Clinic, the Pain Clinic, Sports Medicine, Transplant Surgery, Neurology, and Family Medicine. These areas often recommend massage therapy to patients as part of the recovery for various indications. 3. Meeting the demand and setting the expectations The challenges with meeting the demands for massage therapy across a large medical center became obvious to the massage therapists. The initial expectation when incorporating massage therapy into the hospital setting was that patients would request 1 massage before dismissal. Owing to an overwhelming acceptance from patients and staff, patients were requesting multiple sessions while they were hospitalized. During this time, 2 massage therapists were available on a part-time basis. It quickly became evident that there was not enough support to meet the growing demands of the patients. After discussing the problem, the massage therapy team and CIMP leaders agreed that priority would be given to the initial patient requests before the follow-up requests. This procedure was implemented to accommodate as many new patient requests for services as possible. Additional massage requests for these same patients could not be guaranteed because of the limited availability of massage therapists. This restriction was explained to patients at their initial visit. The massage therapists worked with medical staff and patients to set the expectations for the goals and availability of massage therapy. The timing of massage therapy sessions also needed clarification. Massage therapists would not be available during the evening or on weekends. Patients would be seen according to the time the consultation was added to the massage therapists' request lists. Priority was also given to patients with significant pain. 4. Refining the processes The expansion of offering fee-for-service massage therapy hospital-wide required implementation of a billing process. To explore the feedback and process of a fee-for-service model, a pilot study was conducted in the breast surgery practice, where patients were offered massage for $1.00 per minute, which would be included in the hospital bill. This pilot study indicated that many patients were still interested in massage even if they were billed for
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the service [47]. During the breast surgery pilot study, the massage therapist submitted a paper bill that was sent to the medical facilities billing office, but this process was very inefficient. Many different forms of patient billing were discussed, including adding the bill to the patient's room charge and asking the patient to pay the therapist at the bedside. The most efficient model was direct billing to the patient's hospital bill electronically. The massage therapist billed for only the hands-on portion of the treatment. Extensive benchmarking evaluated the appropriate massage therapy fee scale for billing in our region of the country. Patients were notified that a fee would be charged and that insurance would likely not cover this service. This process was then adopted as a standard for massage therapy billing. 5. Meeting with specialty practice leadership and providing education As the demand for services increased, the massage therapists and CIMP leaders met with colleagues in specialty practices to provide education and information on massage therapy services. The massage therapists also provided education to the nursing staff on simple relaxation techniques and positioning techniques that they could administer to their patients if a massage therapist was not available, including hand and foot massage, breathing techniques, and acupressure points for nausea, headaches, and anxiety. The massage therapists were requested to give presentations twice yearly at the Exploring Complementary Therapies for Pain Management class that was offered for nursing staff. These efforts to provide education enhanced an understanding of the benefits of massage therapy, its indications, and how to order it for patients. This education also increased consultations for the service. 6. Professional development opportunities Massage therapists began to widen their scope of interest and education, seeking out courses that would enhance their set of hospital-based skills. The CIMP supported these endeavors, which included specialty ongoing training in acupressure, reflexology, kinesiology, and mobilization of scar tissue. Certification in pediatric and infant massage and certification in lymphedema were also explored. The massage therapists had many opportunities to present research findings and provide case examples at local and national conferences, and they were engaged in additional research studies based on their clinical experiences in specialty areas. The massage therapists became visible throughout the hospital, not only working with patients but also serving on various committees. These committees were involved with cardiovascular transplant, palliative care, bereavement, pediatric pain, and healing enhancement. 7. Hospital-based massage therapy course development As the massage therapists became specialized in their training and knowledge while working in the hospital setting with clinically complex patients, they began to recognize that there was a need for sharing their expertise with others who might be interested in working as a massage therapist in a medical setting. The therapists were eager to present their knowledge to new graduates and established therapists who were interested in furthering their career to hospital-based massage therapy. This led to exploring the options for creating a hospital-based massage therapy training course. The course includes 5 days of intensive training with an additional 25 h of an externship with a massage therapist preceptor. In this externship, students shadow a hospital-based massage
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therapist and provide limited hands-on massage with supervision and feedback. Course content includes documentation; medical terminology; medical positioning; working with tubes, lines, and incisions; communication with health care teams; self-care; ethics; and healthy boundaries. A wonderful opportunity for these students is 8 h of hands-on treatment time in a simulation center, complete with actors fulfilling the roles of the patients. The students are videotaped during the scenarios and critiqued by the instructors. This course is offered twice yearly to an overwhelming number of applicants. 8. Hopes and dreams As the massage therapy program moves forward and expands, it is time to examine the vision, hopes, and dreams for the future of hospital-based massage therapy. The hope is for inpatient massage therapists to be integrated into the patient's care team and to be considered an integral part of the patient's health and well-being. Massage therapists would actively participate and collaborate with the medical team and attend rounds with physicians, nurses, social workers, and pain management teams. Owing to the large number of medical conditions and specific patient needs, the vision and hope is for massage therapists to become highly specialized. Therapists can be assigned to specific areas to create a specialized plan of care for the patient's needs. Many of the massage therapists have already started to follow their own interests and have become certified in modalities above and beyond what is required. The specific certifications that the therapists have pursued include Oncology Certified Massage Therapist, Infant and Pediatric Massage Therapist and Instructor, Palliative/ Hospice Care, Aromatherapy, and Certified Manual Lymph Drainage Massage Therapist. The therapists have received academic ranks for their teaching, presentations, and publications. There is a need for ongoing education for staff and patients on the true benefits of hospital-based massage therapy to address the most common symptoms experienced by hospitalized patients: pain, anxiety, and tension. The trained hospital-based massage therapist is aware of contraindications that are required to deliver a safe and beneficial session. These safety standards need to be shared more broadly with hospital staff and included in practicebased guidelines. Educational programs will help to elevate the role of the hospital-based massage therapist from providing what is perceived as “comfort care” to providing standard therapy in health care. There are opportunities for massage therapists to provide education on the preventive benefits of massage therapy for staff and caregiver health and well-being. Another part of the vision is to provide massage therapy as a standard offering for staff in the hospital environment and to study the effects on staff burnout, prevention of injury, and time away from work. Providing massage therapy to caregivers would allow for opportunities to study the effects on stress level and the overall caregiver experience. As more massage therapists enter the hospital-based practice, there will be opportunities for ongoing research. This research will assist with expanding the evidence base for massage therapy with the hopes that it may be included as a therapy covered by insurance for specific indications such as pain, anxiety and stress management, rehabilitation, sports injury, oncology, obstetrics, and spinal and joint conditions. These visions, hopes, and dreams are important to present to groups looking at the future of higher education for hospital-based massage therapists. Massage therapists currently working in hospital environments have the knowledge, skills, and experience to make these visions, hopes, and dreams a reality over the next decade.
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Conflict of interest statement The authors declare no conflicts of interest. Acknowledgment No sponsors were involved in the studies described in this manuscript. References [1] Albert NM, Gillinov AM, Lytle BW, Feng J, Cwynar R, Blackstone EH. A randomized trial of massage therapy after heart surgery. Heart Lung 2009 NoveDec;38(6):480e90 [Epub 2009 Jun 28]. [2] Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Rep 2008 Dec 10;(12):1e23. [3] Listing M, Krohn M, Liezmann C, Kim I, Reisshauer A, Peters E, et al. The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer. Arch Womens Ment Health 2010 Apr;13(2): 165e73 [Epub 2010 Feb 19]. [4] Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage 2004 Sep;28(3): 244e9. [5] Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med 2001 Apr 23;161(8):1081e8. [6] Grealish L, Lomasney A, Whiteman B. Foot massage: a nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalized with cancer. Cancer Nurs 2000 Jun;23(3):237e43. [7] Hernandez-Reif M, Field T, Krasnegor J, Theakston H. Lower back pain is reduced and range of motion increased after massage therapy. Int J Neurosci 2001;106(3e4):131e45. [8] Sturgeon M, Wetta-Hall R, Hart T, Good M, Dakhil S. Effects of therapeutic massage on the quality of life among patients with breast cancer during treatment. J Altern Complement Med 2009 Apr;15(4):373e80. [9] Piotrowski MM, Paterson C, Mitchinson A, Kim HM, Kirsh M, Hinshaw DB. Massage as adjuvant therapy in the management of acute postoperative pain: a preliminary study in men. J Am Coll Surg 2003 Dec;197(6):1037e46. [10] Braun LA, Stanguts C, Casanelia L, Spitzer O, Paul E, Vardaxis NJ, et al. Massage therapy for cardiac surgery patients: a randomized trial. J Thorac Cardiovasc Surg 2012 Dec;144(6):1453e9. 1459.e1. [Epub 2012 Sep. 7]. [11] Parlak Gurol A, Polat S, Akcay MN. Itching, pain, and anxiety levels are reduced with massage therapy in burned adolescents. J Burn Care Res 2010 MayeJun;31(3):429e32. [12] Black S, Jacques K, Webber A, Spurr K, Carey E, Hebb A, et al. Chair massage for treating anxiety in patients withdrawing from psychoactive drugs. J Altern Complement Med 2010 Sep;16(9):979e87. [13] Field T, Morrow C, Valdeon C, Larson S, Kuhn C, Schanberg S. Massage reduces anxiety in child and adolescent psychiatric patients. J Am Acad Child Adolesc Psychiatry 1992 Jan;31(1):125e31. [14] Ang JY, Lua JL, Mathur A, Thomas R, Asmar BI, Savasan S, et al. A randomized placebo-controlled trial of massage therapy on the immune system of preterm infants. Pediatrics 2012 Dec;130(6):e1549e58 [Epub 2012 Nov 12]. [15] Moyer CA, Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychol Bull 2004 Jan;130(1):3e18. [16] Stephenson NL, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncol Nurs Forum 2000 Jan-Feb;27(1):67e72. [17] Kaada B, Torsteinbo O. Increase of plasma beta-endorphins in connective tissue massage. Gen Pharmacol 1989;20(4):487e9. [18] Labyak SE, Metzger BL. The effects of effleurage backrub on the physiological components of relaxation: a meta-analysis. Nurs Res 1997 JaneFeb;46(1): 59e62. [19] Kaufmann MA. Autonomic responses as related to nursing comfort measures. Nurs Res 1964;13:45e55. [20] Longworth JC. Psychophysiological effects of slow stroke back massage in normotensive females. ANS Adv Nurs Sci 1982 Jul;4(4):44e61. [21] Fakouri C, Jones P. Relaxation Rx: slow stroke back rub. J Gerontol Nurs 1987 Feb;13(2):32e5.
[22] Hovind H, Nielsen SL. Effect of massage on blood flow in skeletal muscle. Scand J Rehabil Med 1974;6(2):74e7. [23] Barr JS, Taslitz N. The influence of back massage on autonomic functions. Phys Ther 1970 Dec;50(12):1679e91. [24] Kirshbaum M. Using massage in the relief of lymphoedema. Prof Nurse 1996 Jan;11(4):230e2. [25] Mirolo BR, Bunce IH, Chapman M, Olsen T, Eliadis P, Hennessy JM, et al. Psychosocial benefits of postmastectomy lymphedema therapy. Cancer Nurs 1995 Jun;18(3):197e205. [26] Ironson G, Field T, Scafidi F, Hashimoto M, Kumar M, Kumar A, et al. Massage therapy is associated with enhancement of the immune system's cytotoxic capacity. Int J Neurosci 1996 Feb;84(1e4):205e17. [27] Nixon M, Teschendorff J, Finney J, Karnilowicz W. Expanding the nursing repertoire: the effect of massage on post-operative pain. Aust J Adv Nurs 1997 MareMay;14(3):21e6. [28] Cawley N. A critique of the methodology of research studies evaluating massage. Eur J Cancer Care e Engl 1997 Mar;6(1):23e31. [29] Field T. Massage therapy research review. Complement Ther Clin Pract 2014 Aug 1. pii: S1744e3881(14)00042-5. [Epub ahead of print]. [30] Osaka I, Kurihara Y, Tanaka K, Nishizaki H, Aoki S, Adachi I. Endocrinological evaluations of brief hand massages in palliative care. J Altern Complement Med 2009 Sep;15(9):981e5. [31] Smith MC, Stallings MA, Mariner S, Burrall M. Benefits of massage therapy for hospitalized patients: a descriptive and qualitative evaluation. Altern Ther Health Med 1999 Jul;5(4):64e71. [32] Dunn C, Sleep J, Collett D. Sensing an improvement: an experimental study to evaluate the use of aromatherapy, massage and periods of rest in an intensive care unit. J Adv Nurs 1995 Jan;21(1):34e40. [33] Hayes J, Cox C. Immediate effects of a five-minute foot massage on patients in critical care. Intensive Crit Care Nurs 1999 Apr;15(2):77e82. [34] Lewis P, Nichols E, Mackey G, Fadol A, Sloane L, Villagomez E, et al. The effect of turning and backrub on mixed venous oxygen saturation in critically ill patients. Am J Crit Care 1997 Mar;6(2):132e40. [35] Tyler DO, Winslow EH, Clark AP, White KM. Effects of a 1-minute back rub on mixed venous oxygen saturation and heart rate in critically ill patients. Heart Lung 1990 Sep;19(5 Pt 2):562e5. [36] Meek SS. Effects of slow stroke back massage on relaxation in hospice clients. Image J Nurs Sch 1993 Spring;25(1):17e21. [37] Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. J Adv Nurs 1999 May;29(5):1113e20. [38] Corner J, Cawley N, Hildebrand S. An evaluation of the use of massage and essential oils on the wellbeing of cancer patients. Int J Palliat Nurs 1995 Apr;1(2):67e73. [39] Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nurs 1993 Apr;16(2):93e101. [40] Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois JM, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med 2012 Feb 1;4(119):119ra13. [41] Brooker DJ, Snape M, Johnson E, Ward D, Payne M. Single case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia. Br J Clin Psychol 1997 May;36(Pt 2):287e96. [42] Stevensen C. The psychophysiological effects of aromatherapy massage following cardiac surgery. Complement Ther Med 1994 Jan;2(1):27e35. [43] Cutshall SM, Wentworth LJ, Engen D, Sundt TM, Kelly RF, Bauer BA. Effect of massage therapy on pain, anxiety, and tension in cardiac surgical patients: a pilot study. Complement Ther Clin Pract 2010 May;16(2):92e5 [Epub 2009 Nov 14]. [44] Bauer BA, Cutshall SM, Wentworth LJ, Engen D, Messner PK, Wood CM, et al. Effect of massage therapy on pain, anxiety, and tension after cardiac surgery: a randomized study. Complement Ther Clin Pract 2010 May;16(2):70e5 [Epub 2009 Jul 14]. [45] Wang AT, Sundt 3rd TM, Cutshall SM, Bauer BA. Massage therapy after cardiac surgery. Semin Thorac Cardiovasc Surg 2010 Autumn;22(3):225e9. [46] Dion L, Rodgers N, Cutshall SM, Cordes ME, Bauer B, Cassivi SD, et al. Effect of massage on pain management for thoracic surgery patients. Int J Ther Massage Bodyw 2011;4(2):2e6 [Epub 2011 Jun 29]. [47] Drackley NL, Degnim AC, Jakub JW, Cutshall SM, Thomley BS, Brodt JK, et al. Effect of massage therapy for postsurgical mastectomy recipients. Clin J Oncol Nurs 2012 Apr;16(2):121e4. [48] Pruthi S, Degnim AC, Bauer BA, DePompolo RW, Nayar V. Value of massage therapy for patients in a breast clinic. Clin J Oncol Nurs 2009 Aug;13(4): 422e5.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
A decade of building massage therapy services at an academic medical center as part of a healing enhancement program Nancy J. Rodgers a, Susanne M. Cutshall b, Liza J. Dion b, Nikol E. Dreyer b, Jennifer L. Hauschulz b, Crystal R. Ristau a, Barb S. Thomley b, Brent A. Bauer b, * a b
Complementary and Integrative Medicine Program, Mayo Clinic, Rochester, MN, USA Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
a b s t r a c t Keywords: Alternative medicine Complementary therapies Integrative medicine Massage therapy
The use of complementary and integrative medicine therapies is steadily becoming an integral part of health care. Massage therapy is increasingly offered to hospitalized patients for various conditions to assist with the management of common symptoms such as pain, anxiety, and tension. This article summarizes a decade of building the massage therapy service at a large tertiary care medical center, from the early pilot studies and research to the current program offerings, and the hopes and dreams for the future. © 2014 Elsevier Ltd. All rights reserved.
Complementary and integrative medicine therapies have become an integral part of health care for a number of Americans. Many complementary and integrative therapies specifically target pain and anxiety, and for this reason they can assist with addressing the needs of hospitalized patients who are not fully helped by conventional approaches. Massage therapy is an integrative therapy that has been shown to effectively improve several outcomes. Mild to moderate pressure massage techniques can decrease pain, anxiety, fatigue, stress perception, nausea, depression, lymphedema, muscle tension, heart rate, and blood pressure, and it can increase sleep quality, plasma b-endorphin levels, skin temperature, and blood flow [1e29]. Studies of massage therapy outcomes and feasibility have examined several patient populations, including hospitalized patients, intensive care unit patients, palliative care patients, and hospice patients [30e37]. Additional research has focused on massage therapy outcomes related to various conditions (drug addiction, labor pain, cancer, acute myocardial infarction, dementia, preterm birth, Parkinson disease, and human immunodeficiency virus infection), and procedures
Abbreviations: CIMP, Complementary Integrative Medicine Program; CVS, Division of Cardiovascular Surgery. * Corresponding author. Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (B.A. Bauer). http://dx.doi.org/10.1016/j.ctcp.2014.12.001 1744-3881/© 2014 Elsevier Ltd. All rights reserved.
(abdominal surgery, bone marrow transplant, and cardiac surgery) [3,4,6,8,10,11,14,25,37e42]. The massage therapy literature suggests that massage therapy has been provided safely in the hospital setting and has the potential to substantially improve clinical care. A literature review and a desire to improve clinical care for cardiac patients at a large tertiary care medical center started a decade of building clinical massage therapy services and a hospital program to enhance healing. The process of building this clinical massage therapy service will be discussed in more detail and is outlined in a timeline (Fig. 1). 1. Background The impetus to bring massage to the hospital bedside originated in early 2002 when the Division of Cardiovascular Surgery (CVS) team identified pain-free cardiac surgery as a key goal. This multidisciplinary collaboration included surgeons, anesthesiologists, pain specialists, pharmacists, nurses, and Complementary Integrative Medicine Program (CIMP) leaders. Several changes were incorporated (eg, novel anesthetic techniques and different types of chest tubes to facilitate easier removal), but some of the key concepts to emerge from the original discussions centered on various integrative medicine approaches, resulting largely from the advocacy of a clinical nurse specialist and other nursing leaders. From their extended experience and greater daily contact with postsurgical patients, the nurses made many proposals that centered on
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Fig. 1. Timeline for developing the massage therapy program. FTE indicates full-time equivalent.
the potential utility of modalities such as acupuncture, music therapy, animal-assisted therapy, and massage therapy. A spirit of collaboration was fostered across the various disciplines, leading eventually to the willingness of the CVS leaders to scientifically evaluate the various proposals from nursing and integrative medicine proponents. The first proposal to be tested involved massage therapy. In 2004, there was still significant concern about the potential risks associated with massage for postoperative patients. Older literature raised concerns about the potential for blood clots or bleeding problems. There were also fears that massage could cause mishaps such as displacing chest tubes or manipulating wounds inappropriately. Thus, a pilot study was proposed to evaluate massage therapy for a small number of patients. The primary outcomes focused on feasibility, effects on patient care flow, risks, and adverse events. The pilot study included 58 patients, with 30 in the massage group and 28 in the placebo group. Much thought was given to the intervention and how the study would be distinct from other massage studies. The team chose to allow the massage therapists to use all appropriate interventions and skills as applicable to the individual patient according to the massage therapist's assessment. That is, no attempt was made to restrict the regions and techniques of massage or the time spent on each anatomical site for massage. The massage therapists were free to use any of the skills for which they had received specific training. These included Swedish massage, reflexology, neuromuscular techniques, myofascial and connective tissue release techniques, trigger point release, acupressure, manual lymphatic drainage, and gentle stretching. As a result, compared with previous studies, this was a truer evaluation of the actual practice of massage therapy in a hospital setting. Even though variability was introduced, the pilot study was thought to have greater validity since it more closely mimicked the actual practice of massage therapy. The optimal control group was discussed at length. The final decision was to match the human contact by assigning the same massage therapist to visit the control patients for the same duration of time as was spent providing massage for patients in the massage group. This design was intended to minimize interprovider
variability and to control for the warmth and personality of the massage therapist. Although no active massage was provided, the massage therapists were encouraged to reassure the patients and assist with any simple care needs while they were in the room. The key results showed that massage was safe, and no adverse events were associated with massage [43]. Opinions were solicited from nurses and surgeons as to whether the massage therapy had interfered with the flow of care. The comments were universally favorable. Many nurses noted that massage therapy helped their workload by addressing symptoms that they could not otherwise address adequately. In fact, instead of massage therapy impeding nursing care, most nurses thought that the massage therapy had enhanced patient care overall and helped reduce their workload because the patients were less anxious and more comfortable. After reviewing these favorable effects, the CVS leaders were intrigued but requested further validation. Therefore, a larger confirmatory trial involving 113 patients was begun. That study also returned significantly positive results for decreasing pain, anxiety, and tension [44,45]. Patients were highly satisfied with the intervention, and no barriers to providing massage therapy were identified. As a result, the CVS leaders hired massage therapists so that massage therapy would be offered routinely for all cardiovascular surgical patients. Soon other surgical practices (eg, colorectal surgery, thoracic surgery, and breast surgery) became interested in rapid succession. Several of these surgical practices also approached CIMP colleagues for assistance in creating similar research evaluations of massage for their specific patient populations [46,47]. Each of these evaluations in turn yielded positive results and led to further expansion of the implementation of massage. At that time (2008), massage was widely available to most surgical patients at no charge, with the cost borne by the Department of Surgery. In 2009, our institution's Hospital Practice Committee and Clinical Practice Committee noted the favorable effects on massage therapy in the hospital and charged the CIMP with finding a way to make massage therapy more broadly available to all patients in the hospital. This led to several considerations, but the decision was made that a fee-for-service approach would allow widespread
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availability, maintain sustainability, and meet the needs of most patients. To help defray the cost for patients for whom financial considerations were a limitation, access was made available to benefactor funds. As part of the initial success with massage, the nursing leaders of the CVS further collaborated with colleagues in the CIMP to evaluate the use of several other complementary and alternative medicine modalities, including acupuncture, music therapy, animal-assisted therapy, guided imagery, and nature sounds. As each modality was tested and found to be efficacious, it was quickly incorporated into the suite of approaches made available to postoperative patients. Eventually, these were organized into the Cardiovascular Surgical Healing Enhancement Program. Brochures were made available to patients preoperatively and postoperatively so that they would be aware of the services available in addition to the excellent conventional care they already received. This suite of services quickly expanded to other surgical and medical units. In 2004, organic growth and expansion of the outpatient clinic practice included massage therapy, acupuncture, and consultations with CIMP physicians. This resulted from work completed by the Integrative Therapies Task Force and from research and practice initiatives developed by the CIMP. Among the numerous details reviewed to launch the outpatient practice was the fee structure. A market analysis of various fees and services included local, regional, state, and nationwide price points for therapeutic treatments. Billing codes were identified, fee structures completed, and referral criteria created. Patients must be referred by a provider at our institution to receive massage in the outpatient clinic, which has been a great option for patients who wanted to continue massage therapy in a medical environment. Because of the number of massage therapy precautions for patients after surgery or after hospitalization, an evaluation process was created to configure an appropriate treatment plan for each patient. The massage therapist reviews the patient's medical history and the reason for referral to determine an individualized treatment plan. The treatment plans consist of appropriate massage techniques to be used, patient positioning, appropriate pressure, duration of time per visit, and frequency of massage therapy. During patients' initial evaluations, goals are discussed and patients are made aware that they will be dismissed when the goals have been met or if their progress plateaus. 2. Taking notice and spreading the word As demand for massage therapy spread through our institution, the breast surgical team was approached to consider a feefor-service pilot study for postsurgical patients. This team had expressed interest in having massage therapy available for its patients, and the team had completed a survey in 2005 examining the interest in massage therapy and other forms of integrative medicine among patients with breast disease. Thirty-five patients responded to that survey, and all indicated that massage therapy was effective in helping to reduce stress, and 34 believed that it was very effective or somewhat effective in reducing muscle tension. Although the sample was small, the study showed that massage therapy may help patients with breast disease reduce stress and feel better overall [48]. The survey responses supported moving forward with a pilot study, in which a small sample of 46 patients was offered massage therapy sessions of 20 min at a fee of $1.00 per minute up to $20.00. This massage therapy was offered on postoperative day 1 or 2 before discharge. The pilot study showed an acceptance and enthusiasm for massage therapy and a willingness by patients to pay an outof-pocket fee for this service. After the results of this pilot study
were presented to the Hospital Practice Committee, a fee-forservice policy was implemented for all massage therapy services throughout our institution. The outpatient clinic has faced challenges meeting patient demand. Patient growth has been remarkable over the past 10 years and continues to increase. Meeting the demand, however, has been challenging because of a limited availability of patient rooms and the availability of more providers than treatment rooms. The outpatient clinic is open only during normal business hours, so weekend or evening hours have not been available. After the massage therapists discussed options for meeting the need, they designed a patient call list so they could fill canceled appointments as they arose. Initially, the number of requested appointments was high. The outpatient calendar filled quickly, so new patients had to schedule appointments far in advance, which led to patients forgetting their appointment or having to cancel at the last minute because of scheduling conflicts. To address this concern, a policy was implemented to limit the number of prescheduled appointments. The policy is reviewed with each patient during the initial evaluation, so the patient understands the expectations for future appointments. The demand for outpatient appointment is strong, with a full calendar and patients with various medical diagnoses. In the outpatient clinic, many of the referrals come from the Oncology Clinic, the Fibromyalgia Clinic, the Pain Clinic, Sports Medicine, Transplant Surgery, Neurology, and Family Medicine. These areas often recommend massage therapy to patients as part of the recovery for various indications. 3. Meeting the demand and setting the expectations The challenges with meeting the demands for massage therapy across a large medical center became obvious to the massage therapists. The initial expectation when incorporating massage therapy into the hospital setting was that patients would request 1 massage before dismissal. Owing to an overwhelming acceptance from patients and staff, patients were requesting multiple sessions while they were hospitalized. During this time, 2 massage therapists were available on a part-time basis. It quickly became evident that there was not enough support to meet the growing demands of the patients. After discussing the problem, the massage therapy team and CIMP leaders agreed that priority would be given to the initial patient requests before the follow-up requests. This procedure was implemented to accommodate as many new patient requests for services as possible. Additional massage requests for these same patients could not be guaranteed because of the limited availability of massage therapists. This restriction was explained to patients at their initial visit. The massage therapists worked with medical staff and patients to set the expectations for the goals and availability of massage therapy. The timing of massage therapy sessions also needed clarification. Massage therapists would not be available during the evening or on weekends. Patients would be seen according to the time the consultation was added to the massage therapists' request lists. Priority was also given to patients with significant pain. 4. Refining the processes The expansion of offering fee-for-service massage therapy hospital-wide required implementation of a billing process. To explore the feedback and process of a fee-for-service model, a pilot study was conducted in the breast surgery practice, where patients were offered massage for $1.00 per minute, which would be included in the hospital bill. This pilot study indicated that many patients were still interested in massage even if they were billed for
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the service [47]. During the breast surgery pilot study, the massage therapist submitted a paper bill that was sent to the medical facilities billing office, but this process was very inefficient. Many different forms of patient billing were discussed, including adding the bill to the patient's room charge and asking the patient to pay the therapist at the bedside. The most efficient model was direct billing to the patient's hospital bill electronically. The massage therapist billed for only the hands-on portion of the treatment. Extensive benchmarking evaluated the appropriate massage therapy fee scale for billing in our region of the country. Patients were notified that a fee would be charged and that insurance would likely not cover this service. This process was then adopted as a standard for massage therapy billing. 5. Meeting with specialty practice leadership and providing education As the demand for services increased, the massage therapists and CIMP leaders met with colleagues in specialty practices to provide education and information on massage therapy services. The massage therapists also provided education to the nursing staff on simple relaxation techniques and positioning techniques that they could administer to their patients if a massage therapist was not available, including hand and foot massage, breathing techniques, and acupressure points for nausea, headaches, and anxiety. The massage therapists were requested to give presentations twice yearly at the Exploring Complementary Therapies for Pain Management class that was offered for nursing staff. These efforts to provide education enhanced an understanding of the benefits of massage therapy, its indications, and how to order it for patients. This education also increased consultations for the service. 6. Professional development opportunities Massage therapists began to widen their scope of interest and education, seeking out courses that would enhance their set of hospital-based skills. The CIMP supported these endeavors, which included specialty ongoing training in acupressure, reflexology, kinesiology, and mobilization of scar tissue. Certification in pediatric and infant massage and certification in lymphedema were also explored. The massage therapists had many opportunities to present research findings and provide case examples at local and national conferences, and they were engaged in additional research studies based on their clinical experiences in specialty areas. The massage therapists became visible throughout the hospital, not only working with patients but also serving on various committees. These committees were involved with cardiovascular transplant, palliative care, bereavement, pediatric pain, and healing enhancement. 7. Hospital-based massage therapy course development As the massage therapists became specialized in their training and knowledge while working in the hospital setting with clinically complex patients, they began to recognize that there was a need for sharing their expertise with others who might be interested in working as a massage therapist in a medical setting. The therapists were eager to present their knowledge to new graduates and established therapists who were interested in furthering their career to hospital-based massage therapy. This led to exploring the options for creating a hospital-based massage therapy training course. The course includes 5 days of intensive training with an additional 25 h of an externship with a massage therapist preceptor. In this externship, students shadow a hospital-based massage
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therapist and provide limited hands-on massage with supervision and feedback. Course content includes documentation; medical terminology; medical positioning; working with tubes, lines, and incisions; communication with health care teams; self-care; ethics; and healthy boundaries. A wonderful opportunity for these students is 8 h of hands-on treatment time in a simulation center, complete with actors fulfilling the roles of the patients. The students are videotaped during the scenarios and critiqued by the instructors. This course is offered twice yearly to an overwhelming number of applicants. 8. Hopes and dreams As the massage therapy program moves forward and expands, it is time to examine the vision, hopes, and dreams for the future of hospital-based massage therapy. The hope is for inpatient massage therapists to be integrated into the patient's care team and to be considered an integral part of the patient's health and well-being. Massage therapists would actively participate and collaborate with the medical team and attend rounds with physicians, nurses, social workers, and pain management teams. Owing to the large number of medical conditions and specific patient needs, the vision and hope is for massage therapists to become highly specialized. Therapists can be assigned to specific areas to create a specialized plan of care for the patient's needs. Many of the massage therapists have already started to follow their own interests and have become certified in modalities above and beyond what is required. The specific certifications that the therapists have pursued include Oncology Certified Massage Therapist, Infant and Pediatric Massage Therapist and Instructor, Palliative/ Hospice Care, Aromatherapy, and Certified Manual Lymph Drainage Massage Therapist. The therapists have received academic ranks for their teaching, presentations, and publications. There is a need for ongoing education for staff and patients on the true benefits of hospital-based massage therapy to address the most common symptoms experienced by hospitalized patients: pain, anxiety, and tension. The trained hospital-based massage therapist is aware of contraindications that are required to deliver a safe and beneficial session. These safety standards need to be shared more broadly with hospital staff and included in practicebased guidelines. Educational programs will help to elevate the role of the hospital-based massage therapist from providing what is perceived as “comfort care” to providing standard therapy in health care. There are opportunities for massage therapists to provide education on the preventive benefits of massage therapy for staff and caregiver health and well-being. Another part of the vision is to provide massage therapy as a standard offering for staff in the hospital environment and to study the effects on staff burnout, prevention of injury, and time away from work. Providing massage therapy to caregivers would allow for opportunities to study the effects on stress level and the overall caregiver experience. As more massage therapists enter the hospital-based practice, there will be opportunities for ongoing research. This research will assist with expanding the evidence base for massage therapy with the hopes that it may be included as a therapy covered by insurance for specific indications such as pain, anxiety and stress management, rehabilitation, sports injury, oncology, obstetrics, and spinal and joint conditions. These visions, hopes, and dreams are important to present to groups looking at the future of higher education for hospital-based massage therapists. Massage therapists currently working in hospital environments have the knowledge, skills, and experience to make these visions, hopes, and dreams a reality over the next decade.
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