During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that require research and writing. Some of these assignments result in very insightful and well thought out information and decision-making outcomes. I am happy to share some of their assignments for you to enjoy.

Based on surveys by the American Massage Therapy Association, one of the primary motivations today for people seeking massage is for health and wellness reasons (AMTA, 2017), clearly indicating that massage therapy is becoming accepted as a form of healthcare. Yet, under the umbrella of the term "massage therapy," many modalities exist that claim the ability to help lessen the discomfort of numerous conditions. The primary means that we, as a society, have to attempt to validate the claims about massage therapy is the application of scientific research methodology. However, our current system relies on large amounts of money being funneled into research for patentable substances that, if successful, provide a large financial reward to the patent-holding creator. As massage cannot be patented past a registered trademark for someone's name, limited funding is available for the research. Thankfully, though, as massage gains in popularity, there is a grassroots push for more information and continued research into various types of massage therapy.

Within scientific research there is a hierarchy of journal articles: randomized clinical trials (RCT's)-specifically, double-blind, randomized, placebo-controlled studies--are considered the "gold standard" by the medical establishment. In this type of study (ideally), the variables are stringently controlled and bias is almost completely eliminated. Then the written results undergo peer review so that any potential shortfalls in the process can be found and remedied. The goal is to create a situation in which the experiment can be duplicated by any other researcher, thus confirming the findings and verifying that the results apply to the majority, that is, that the results are statistically significant to a specific percentage of a group and that the results are not random.

There are a number of other types of research articles that rank "below" the RCT but are still considered valid research (and are accepted into the peer-review process of a journal), or are at least indicative of an area of continued study and where RCT's should be designed and undertaken. These include systematic reviews, cohort studies, case-control studies, case reports and pilot studies. Today, due to the efforts of many people, a quick search for "massage therapy" in PubMed shows a large variety of these types of articles, although some modalities and some types of research have received much more attention than others, and some modalities lend themselves to the scientific process more readily than others.

I believe that all of these types of studies are valid when looking for studies to expand our understanding of how massage works and what we should offer our clients, as long as we understand that nothing will ever be one hundred percent effective. Ultimately, there is no perfect piece of research. That's the one true absolute in scientific analysis. The "gold standard" is based on statistical analyses that calculate how the experiment affects the group or cohort. It's impossible to run an experiment on the entire population of the planet. By design and definition, a study has to be performed on a representative group, and even then the goal is to find a "treatment" that affects the majority of the group rather than all of the group, because there will always be "outliers": those who don't respond when it is effective for the majority, or those who will be affected when the majority aren't. In other words, statistics deal with group results while the individual is concerned about the response of themselves or their loved ones. This is the fundamental struggle in utilizing research in providing services for individuals.

However, all of these types of research work well together: case studies build case reports that can then be built into case-control studies. When the subjects are followed for a period of time, a cohort study is produced. Pilot studies initiate work into new sub-areas and systematic reviews look at the results of various studies. All of these together build a comprehensive understanding of an area as well as point to new experiments to pursue. It all adds to our knowledge base and I believe that's the best result.

Given that research about massage therapy is increasing, it would probably be wise for any therapist who wishes to be involved in research to take a "Statistics for the Social Sciences" type class at a local community college or university. It makes understanding research abstracts much easier, as well as assisting the therapist in spotting the weaknesses in writing about new research that is very common in today's internet connected world. In an ideal world, there would be many RCT's with cohorts numbering in the thousands, but given the realities of research, I'm happy when they number over fifty. I also find case studies very interesting precisely because they discuss how one person was helped with a specific treatment and that's where research starts.

As massage therapy encompasses so many modalities, and the technological advances in various forms of diagnostics and measurements continue at a brisk pace, I believe that research in massage therapy will continue to grow. It expands our knowledge of what we do and how we can assist our clients in their goals. It also furthers the standing of massage therapy as a method of health care. As there are still those who criticize and "debunk" various aspects of massage therapy, rightly or wrongly, research is necessary to find the truth.

In examining the statement "ischemic compression for trigger points should be done as deep and hard as possible" with regard to current research, it's useful to look at the verity of the statement first. My first concern about this statement is that it's an absolute. While the word "always" is not in the sentence, it's implied. As I mentioned earlier, absolute statements about the care of others are dangerous as they are unprovable, and adhering to blanket statements about the care of individuals makes you blind to possible exceptions, which in turn leaves you open to charges of client neglect. Secondly, trigger points, by definition, are "hyperirritable:" they're painful when subjected to pressure, one of the diagnostic criteria as listed in Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, the authoritative work in the field. If a massage therapist simply puts as much pressure on a trigger point as is possible, it hurts. The therapist can also activate the nociceptive reflexes of their client which will cause the client to tense up and pull away as they attempt to protect themselves. This can result in the loss of the client at least, as well as potentially injuring a client, both situations that an ethical therapist hopes to avoid. So, the statement is questionable to begin with.

But in looking at available research studies on ischemic compression and trigger points, there does seem to be agreement on how to apply ischemic compression, although what's used in the papers I've read is something of a combination of what's suggested by Simons and Travell. In the 1st edition of The Trigger point Manual, published in 1983, both ischemic compression and deep stroking massage are mentioned as possible manual treatments for trigger points, and in a 1987 monograph Simons repeats that "pressure is applied directly on the spot of greatest tenderness (the TP) with a steady moderately painful (tolerable) pressure." This is to be held for 15 seconds to one minute (Simons, 1987). It is perhaps the reading of this that encouraged some therapists to adopt a use of "as deep and hard as possible" even though, in my opinion, that would be a misinterpretation given the words "moderately" and "tolerable."

However, in the 2nd edition of the Trigger Point Manual, published in 1999, their recommendations change, even stating that they prefer to call it "trigger point release therapy" rather than ischemic compression, and it's described as a "barrier resistance technique" to underscore a more moderate approach (Simons et al., 1999). They recommend that the therapist use a moderate pressure on the center of the trigger point until the therapist encounters a resistance that they label "the barrier." The pressure is held until the resistance decreases somewhat, and then the pressure is increased until it again meets the barrier. Again this is maintained until the barrier releases or "let's go" under the finger. This technique is specifically recommended because it is painless (Simons et al., 1999). Again, there is nothing here to suggest "as hard and deep as possible."

When looking at several studies completed since the publication of the 2nd edition, the accepted technique for applying ischemic compression seems to be somewhere in the middle of these two techniques. Generally speaking, the practitioner would apply pressure to the center of the trigger point until pain was first felt, usually described by the participant as a 7 on a scale of 1 to 10 with 10 being the most painful. The pressure was held until an initial decrease in discomfort was experienced, then the pressure was increased to the tolerance threshold again and held until there was another decrease in discomfort, usually from 15-90 seconds (Abu Taleb et al., 2016, Cagnie at al., 2013, de las Penas et al., 2006).

A pilot study comparing the effects of ischemic compression and transverse friction massage on active and latent trigger points on a study group of forty people, published in 2006, utilized this procedure for the ischemic compression part of their testing. This was compared to transverse friction applied slowly with pressure that created a tolerable pain for 3 minutes. Interestingly, both methods achieved statistically significant results based on measurement of the decrease in the pain pressure threshold (PPT) (de las Penas et al., 2006).

A cohort study in 2013 that followed the treatment of nineteen office workers treated with ischemic compression for upper trapezius trigger points for 8 sessions over 4 weeks (2 sessions per week), utilized the same protocol. At the end of the 4 weeks/8 sessions there was a statistically significant decrease in the PPT as well as at a 6-month follow-up, and there was also a significant increase in mobility and strength (Cagnie et al., 2013).

More recently a clinical study was completed that examined the results of manual pressure release (ischemic compression) compared to that delivered by an algometer with sham ultrasound as the control (Abu Taleb et al., 2016). Instead of just using the algometer to measure the pre- and post-treatment PPT they also used it (with the addition of a piece of cloth for comfort) to administer the manual pressure release to the trigger point (the APR group) along with sham ultrasound. The second group received similar treatment from a trained therapist (the MPR group) along with sham ultrasound while the third group (the US group) only received the sham ultrasound. While there was no significant difference between the 3 groups post-treatment for the PPT, the APR group had a statistically significant increase in passive side-bending range of motion.

While all three of these studies seem to indicate that manual pressure release (ischemic compression) has positive results for trigger point treatment, there are other studies that show less consistent results. However, what all of these studies do indicate is that the accepted protocol of ischemic compression on trigger points is to apply pressure to the trigger point to a level of tolerable pain for the client, hold until that decreases, then increase and hold again until another decrease occurs, and then repeat the procedure another 1-2 times to equal 90 seconds. Not one of these experiments utilizes ischemic compression that is "as deep and hard as possible."

When Dr. Janet Travell and Dr. David Simons first published their Trigger Point Manual in 1983, it was an effort to create a compendium of their work and research into the treatment of trigger point pain. Primarily meant as a resource for physicians and physical therapists, it mainly discusses the use of methods such as trigger point injection and "stretch and spray" that can easily be employed in office settings. However, their mention of ischemic compression as a manual therapy really opened the door to the therapuetic use of massage in this area, given how many people dislike needles. And, while the research into manual pressure release as a viable means to treat trigger points is somewhat limited, as most of the research examines dry needling and injections, I believe the existing research indicates that it's at least of some value. However, I also think that it's very important to use the protocol that is consistently recommended and used by these research articles in only applying pressure to a tolerable level of pain rather than following the mandate that it "should be done as deep and hard as possible."

References:

Abu Taleb W., Rehan Youssef, A. and Saleh, A. (2016) "The effectiveness of manual versus algometer pressure release techniques for treating active myofascial trigger points of the upper trapezius," J Bodyw Mov Ther, 20(4), pp. 863-869.

AMTA (2017) Massage Therapy Industry Fact Sheet: American Massage Therapy Association. Available at: https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html (Accessed: May 16 2017)

Cagnie, B., Dewitte, V., Coppieters, I., Van Oosterwijck, J., Cools, A. and Danneels, L. (2013) "Effect of ischemic compression on trigger points in the neck and shoulder muscles in office workers: a cohort study," J Manipulative Physiol Ther, 36(8), pp. 482-9.

de las Penas, C.F., Alonso-Blanco, C., Fernandez-Carnero, J., and Miangolarra-Page, J. (2006) "The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study," Journal of Bodywork and Movement Therapies, 10(1), pp. 3-9.

Simons, D.G. 1987. Myofascial Pain Syndrome Due to Trigger Points. In: Association, I.R.M. (ed). Gebauer.

Simons, D.G., Travell, J.G., and Simons, L.S. (1999) Travell & Simons' Myofascial Pain and Dysfunction: the Trigger Point Manual. 2nd edn. (2 vols). Baltimore: Williams & Wilkins.