Journal of Bodywork & Movement Therapies (2014) 18, 11e16

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/jbmt

SELF-EFFICACY STUDY

A pragmatic investigation into the effects ofmassage therapy on the self efficacy ofmultiple sclerosis clients

Paul Finch, Ph.D., M.Sc., D.Pod.M a,*,Susan Bessonnette, B.A., R.M.T b

aHealth Sciences, Conestoga College Institute of Technology and Advanced Learning, Kitchener,Ontario N2G 4M4, Canadab Sutherland-Chan School of Massage Therapy, Toronto, Ontario M5R 1V9, Canada

Received 15 November 2012; received in revised form 15 March 2013; accepted 30 March 2013

KEYWORDSMassage therapy;Self-efficacy;Multiple sclerosis

* Corresponding author. Tel.: þ1 519E-mail addresses: pfinch@conestog

1360-8592/$ - see front matter ª 201http://dx.doi.org/10.1016/j.jbmt.201

Summary Objective: This research was conducted to examine changes in self self-efficacy,(the perception/belief that one can competently cope with a challenging situation) in multiplesclerosis clients following a series of massage therapy treatments.Method: This small practical trial investigated the effects of a pragmatic treatment protocol us-ing a prospective randomized pretest posttest waitlist control design. Self-Efficacy scores wereobtained before the first treatment,mid-treatment series, after the last treatment in the series,four weeks after the final treatment and again eight weeks after the final treatment had beenreceived.Intervention: The intervention involveda series ofweeklyonehour therapeuticmassage treatmentsconductedovereightweeks anda subsequent eightweek followupperiod.All treatmentsweredeliv-ered by supervised student therapists in the final term of their two year massage therapy program.Outcome measures: Self-Efficacy [SE] was the outcome for the study, measured using the MultipleSclerosis Self-Efficacy survey [MSSE]. Descriptive statistics for SE scoreswere assessed and inferentialanalysis involved the testing of between group differences at each of themeasurement points notedabove.Results: Statistically significant improvement in self-efficacy was noted between treatment (nZ 8)and control (n Z 7) groups at mid treatment series (t Z 2.32; p < 0.02), post treatment series(tZ 1.81; p < 0.05) and at four week follow up (tZ 2.24; p < 0.02). At the eight week follow upself-efficacy scores had decreased and there was no statistically significant difference betweengroups (tZ 0.87; p< 0.2).Conclusion: Studyresults supportpreviousfindings indicatingthatmassagetherapy increases theself-efficacy of clients with multiple sclerosis, potentially resulting in a better overall adjustment to the

748 5220x2395; fax: þ1 519 748 3563.ac.on.ca, paul.finch2@yahoo.ca (P. Finch).

3 Elsevier Ltd. All rights reserved.3.04.001

12 P. Finch, S. Bessonnette

disease and an improvement in psycho-emotional state. The increase in self-efficacy after 4weeks oftreatment suggests thatpositive responseoccursmore rapidly thatwaspreviouslydemonstrated.Theimprovement in self-efficacy endured 4 weeks after the end of the treatment series, which suggeststhat massage therapy may have longer term effects on self-efficacy that were not previously noted.Lack of inter group difference at the eight week follow up reinforces the notion that on-going treat-ment is required in order to maintain the positive changes observed.ª 2013 Elsevier Ltd. All rights reserved.

Introduction

Multiple sclerosis [MS] is one of the most common neuro-logical causes of disability, and is described as a chronic andprogressively disabling inflammatory autoimmune disorderof the central nervous system (Al-Afasy et al., 2013). Thepathogenesis of MS is related to genetic susceptibility andenvironmental factors. Sex linked influences are alsoinvolved as incidence is greater in females than males, but itis interesting to note that despite this, women do not have apoorer prognosis than men (Voskuhl and Gold, 2012). Onsetis usually, although not exclusively, in the fourth decade;the male to female ratio being in the region of 1:1.5 (Allenand Lueck, 1999) or 1:2 (Noseworthy et al., 2000) dependingon the country in question. This being said, there are recentstudies indicating an increase in the incidence of MS inwomen resulting from urbanization (Kotzamani et al., 2012),and an increasing sex ratio in Relapse-Remitting MS, evidentover a sixty year period (Trojano et al., 2012).

From a global perspective, the prevalence of multiplesclerosis varies considerably (Weinshenker and Rodriguez,1994), and recent work by Evans et al. (2013) reinforcesthis as it relates to the Americas. Different areas of theworld have been classified as being low (less than 5 cases per100,000), intermediate (5e30 cases per 100,000) or high(more than 30 cases per 100,000) prevalence zones (Kurtzke,1991). The reason for the world wide variability in incidenceand prevalence of MS is not well understood (Noseworthyet al., 2000), but it is clear that the rates are highest inNorthern Europe, Southern Australia and North America.

MS can be categorized in a number of different ways, eachassociated with a different pattern of disease progression.These are termed RelapseeRemitting, Chronic Progressive,Secondary Progressive, Progressive Relapsing, and Fulminant[also known as the Marbug variant] (MS Society of Canada,2013; MedicineNet, 2013; Allen and Lueck, 1999). With theexception of the Marburg variant, massage therapistsencounter clients within all of these categories. As the clin-ical presentation is related to the anatomical site of demyli-nation and axonal loss, the treatment requirements of amultiple sclerosis population are highly variable. Theplethora of impairments most relevant to the massage ther-apist include fatigue, spasticity, rigidity, weakness, tremors,proprioreceptive deficit, inefficient movement patterns,altered posture, compensatory musculoskeletal changes,sensory changes, emotional changes and cognitive deficits.Bladder and bowel dysfunction, speech disturbances, vertigoand visual problems also forman important part of the clinicalpicture (Rattray and Ludwig, 2000).

At Sutherland-Chan School and Teaching Clinic, secondyear students are required to take a number of clinical

specialty rotations, which include an MS clinic option.Historically, it has been the school’s experience thatmassage therapists are uniquely placed to address many ofthe problems mentioned above, and to meaningfullycontribute to the well being of clients with multiplesclerosis.

The MS specialty clinic is busy, which is to be expectedgiven reports that 57.1% of the multiple sclerosis popula-tion use Complimentary and Alternative Medical/Healththerapies in general, and more specifically, that 23.3%access massage therapy as a treatment option (Nayaket al., 2003).

Although there has been a recent, and much needed,increase in massage therapy research in general, a litera-ture search revealed only a small number of studies wherethe work focused on multiple sclerosis specifically.Hernandez-Reif et al. (1998) demonstrated significantlyimproved social lifestyle and functional activity status, andalso noted lower levels of anxiety and depression in sub-jects receiving massage therapy. The effect of massagetherapy in clients with MS was also investigated by Dixon(2004), who concluded that treatment positively affectedcertain symptoms related to both physical and psycho-emotional domains, while Finch and Becker (2007) in pre-liminary work investigating changes in self-efficacy in MSpatients receiving massage therapy, found significantimprovement after an 8 week series of treatments.

These results are aligned with the findings of a numberof authors who investigated other forms of bodywork.Johnson et al. (1999) demonstrated lower stress and anxi-ety levels in subjects receiving treatment using the Fel-denkrais method, and Siev-Ner et al. (2003) found thatreflexology reduced paresthesias, spasticity and urinarysymptoms associated with MS.

In addition to the outcomes noted above, self-efficacyhas been found to be a predictor of health status (Riaziet al., 2004), and the concept is implicitly linked topsycho-emotional morbidity. Notably, a negative percep-tion of control [a key component of self-efficacy] has beenassociated with both decreased optimism and increasedhopelessness (Sinnakaruppan et al., 2010).

These findings collectively suggest that massage therapyhas the potential to positively influence the life of clientswith multiple sclerosis, and it was with the intent ofcontributing to this body of knowledge that the presentresearch was conducted.

Research aims and hypothesis

The aim of the study was to examine changes in the self-efficacy of multiple sclerosis clients following massage

A pragmatic investigation into the effects of massage therapy 13

therapy. The context for this is captured in the previoussection, and in particular is related to previous work thatfound positive change in self-efficacy of MS clientsfollowing massage therapy (Finch and Becker, 2007). Thehypothesis stated that self-efficacy scores of multiplesclerosis clients would be significantly increased in com-parison to control after a series of eight massage therapytreatments.

Method

Design

The research undertaken was a practical trial that investi-gated the effects of a pragmatic massage therapy treat-ment protocol using a prospective randomized pretest,posttest waitlist control design. During the recruitmentperiod fifteen participants were randomly assigned totreatment and waitlist control groups.

During the treatment phase of the study, the treatmentgroup received a one hour treatment per week for eightweeks. The decision as to the length of the treatment serieswas pragmatic and related to the length of the students’specialty clinic rotations, which are scheduled over an eightweek period.

Massage therapy is aligned with the wellness paradigm ofhealth and health care (Alexander, 2006; Yates, 2004),which speaks to a holistic client centered approach totreatment. Accordingly, if the current research was toconform to the requirements of model fit/ecological val-idity (Menard, 2003; Mason et al., 2002), it was incumbenton the therapists to construct individualized treatmentplans recognizing the importance of the client’s physical,psychological and emotional needs. The heterogeneity ofthe client/participant population precluded an overly pre-scriptive approach to treatment, and it is worth noting thatthis heterogeneity is also a component of the normal clin-ical reality of therapists involved with multiple sclerosisclients.

Following the treatment phase of the study, neithertreatment nor control groups received massage therapy forthe follow up period of eight weeks. At this point the studywas concluded and the control group received treatmentonce a week during the eight week post study period.

Outcome measures

The outcome measures for the current research were thescores yielded by the Multiple Sclerosis Self Efficacy (MSSE)survey. For both treatment and control groups, self-efficacyscores were obtained before the first treatment, mid-treatment series, after the last treatment in the series,four weeks after the final treatment and again eight weeksafter the final treatment had been received. Thus, beyondbaseline measurement there were four independent vari-ables e these being the MSSE survey scores at differentpoints in time.

The MSSE survey was originally developed and validatedby Schwartz et al. (1996), based on the work of Lorig et al.(1989), who created a similar tool for use with peoplesuffering from arthritis.

The nature of the MSSE survey is such that the clients’self-efficacy rating is captured through a series of eighteenquestions to which they respond on a scale ranging from tento one hundred. The instrument focuses on the clients’perception of their ability to function, and the degree ofcontrol they have within the context of their disease state.

The MSSE instrument has been found to demonstrate ahigh level of internal consistency, yielding a Cronbach’scoefficient alpha of 0.89. Testeretest reliability is alsohigh, with an overall value of 0.75 (Schwartz et al., 1996).Thus, the MSSE instrument has been accepted as a valid andreliable measurement tool, and to date has not beenrefuted as such.

Studies indicate that higher self-efficacy scores arereflective of an improved ability to adjust to multiplesclerosis (Schnek et al., 1995; Wassem, 1992). Thisimproved adjustment then leads to reduced psychologicalmorbidities such as stress, anxiety and depression, whichwill result in improved quality of life. Additionally, it hasbeen found that efficacy expectancies as a component ofoptimism explained variability in depression within a groupof clients with multiple sclerosis (Fournier et al., 1999).

Most directly related is previous work in whichimprovement in self-efficacy was noted in a group of MSclients following massage therapy (Finch and Becker, 2007).This study was based on a single group pretest posttestdesign and the current research was intended to further theknowledge base through use of a more rigorous design,investigating essentially the same question.

In the context presented above, the use of MSSE scoresas the outcome measure in the current research reflectsthe notion that massage therapy has the potential toimprove client well-being and adjustment to living withmultiple sclerosis, through improving perceptions of func-tion and control.

Participants

Participants were clients seen in the multiple sclerosisclinics at Sutherland-Chan School, in which the study wasconducted. Clients were provided with information aboutthe clinic by the local chapter of the Multiple SclerosisSociety, and self selected on that basis. Of the fifteen studyparticipants, all had previously received a diagnosis ofmultiple sclerosis. The time since diagnosis ranged fromthree to forty-one years (with a mean of 19 years) at thetime of the study. Nine participants were categorized asRelapse eRemitting, four as Secondary Progressive and twoas Primary Progressive.

The clients presented to the clinic with a variety of im-pairments, including some specifically related to the dis-ease process and others that were primarily musculoskeletalin origin. The latter category included, for example, over-use injuries associated with compensatory patterns result-ing from functional impairment of neurological origin. Withrespect to the ambulatory status of the participants, sixwalked unassisted, five used a cane, and four used a walker.All participants had prior experience of massage treatmentat the clinic. Further information regarding participantcharacteristics can be found in Table 1 (Participant Char-acteristics) below.

Table 1 Participant characteristics.

Treatment group Control group

Gender Male 2 0Female 6 7

Mean age (Range) 49 (29e65) 54 (46e65)Mean years since diagnosis (Range) 16 (3e40) 22 (3e41)Prior experience of massage therapy All AllMS category Relapse remitting 5 4

Secondary progressive 1 3Chronic progressive 2 0

Ambulatory status Unassisted 4 2Cane 3 2Walker 1 3

168

307

267

332

162

0

50

100

150

200

250

300

350

1 2 3 4 5

MS

SE

S

co

re

Measurement point

Difference in Tx to Control MSSE Scores

Figure 1 Difference in Tx to control MSSE scores.

14 P. Finch, S. Bessonnette

Procedures

Clients attending the clinic were interviewed, and theircase histories recorded. The research project wasexplained, and written informed consent was obtained. TheMultiple Sclerosis Self-Efficacy (MSSE) survey was then givento the client to complete.

An appropriate history and physical examination wasperformed, and a treatment plan determined, this beingreflective of the therapist’s assessment and the mutuallyset goals for the treatment series.

The inclusion criterion for the study was a diagnosis ofmultiple sclerosis, and therefore the spectrum of clinicalpresentations was broad, as would be expected in thisclient population. All treatment plans were approved bythe clinical teacher in charge. The teacher also monitoredtreatment delivery, which involved the application of avariety of techniques appropriate to the client’s needs.These included effleurage, petrissage, stroking, frictions,vibrations, tapotment, rocking and shaking, details ofwhich have been reviewed by Yates (2004). These tech-niques all involve the manipulation of soft tissues to whichwas added joint mobilization, myofascial techniques,rehabilitative exercise and hydrotherapy in order to reflectthe broad therapeutic armamentarium of the massagetherapist.

Data analysis

The data were analyzed on an intention to treat basis, witha focus on the differences between mean MSSE values ofthe control and intervention groups. Inferential comparisonof scores was conducted using independent t-tests at fivemeasurement points: baseline, mid-intervention, post-intervention, mid follow up and final follow up.

Results

Fig. 1 below, indicates the difference in MSSE scores for thecontrol and treatment groups. Measurement point #1 is atbaseline, #2 at mid treatment, #3 at post treatment, #4 atmid follow up and #5 at final follow up. At all measurementpoints the treatment group score was higher than that forcontrol.

As indicated in Table 2 below, when comparing controland intervention group differences in MSSE at baseline, thetreatment group reported higher scores but not signifi-cantly so (t Z 1.44, df Z 13, p Z 0.09). After 4 weeks oftreatment (mid treatment) this difference had increased toa significant level (t Z 2.32, df Z 13, p Z 0.02). After 8weeks of treatment (post treatment series) the differencewas somewhat reduced although it remained significant(tZ 1.81, dfZ 13, pZ 0.05). 4 weeks after treatment wasdiscontinued (mid follow up) the inter group differenceremained significant (t Z 2.24, df Z 12, p Z 0.02), and atfinal follow up (8 weeks after treatment was discontinued)the difference dropped to insignificant level (t Z 0.87,df Z 9, p Z 0.2).

Discussion

Discussion of the study’s results is necessarily framed by awellness perspective, in which health is viewed as a multi-faceted concept incorporating psychological, emotionaland spiritual well-being, in addition to the absence ofphysical disease (Yates, 2004; Alexander, 2006). Within thisparadigm it can be argued that even in the context ofchronic incurable disease an individual can be healthy, andthat their wellbeing can be optimized. This is supported bythe perspective of the Centers for Disease Control andPrevention, an overarching objective being to ensure that“that all people . will achieve their optimal lifespan withthe best possible quality of health in every stage of life”

Table 2 Comparison of MSSE scores.

Measurement point Control group Treatment group Difference df t stat p value

1 Baseline 1121 1289 168 13 1.44 0.092 Mid treatment 999 1306 307 13 2.32 0.02*

3 Post treatment 1053 1320 267 13 1.81 0.05*

4 Mid follow up 982 1314 332 12 2.24 0.02*

5 Final follow up 1067 1229 162 9 0.87 0.2

Note: bold/asterisk Z significant difference.

A pragmatic investigation into the effects of massage therapy 15

(Steinberg, 2007). Towards this end, it has been noted thatpeople must be empowered to take responsibility for theirown wellbeing (Mattila et al., 2010), wellness being an on-going process involving decision making that results inmovement towards optimal health or away from it (Russell,2009).

In the psycho-emotional sphere, diagnosis of multiplesclerosis engenders both fear and uncertainty about thefuture, in conjunction with which there will be a degree offunctional impairment. These effects can result in psycho-emotional morbidity such as depression, anxiety, stress,and a reduced sense of wellbeing, which in turn can resultin a lower level of confidence, and a perception that re-flects greatly reduced control and functional capabilities.That is, reduced self-efficacy.

As the social learning theory proposed by Bandura (1977)suggests, these negative perceptions can result in behaviorsand responses which will render the individual less able toadjust to their disease state. This can then lead to furtherpsycho-emotional morbidity, thus establishing a viciouscircle of sorts. Given that the MSSE survey measuresperception, it can be suggested that higher self-efficacyscores reflect improved mood (i.e. reduced depression,anxiety and stress), and a better ability to cope with andadjust to the disease. This is supported by the work ofSinnakaruppan et al. (2010) who determined that negativeperception of control was associated with decreased opti-mism and increased hopelessness, and Riazi et al. (2004)who found that self-efficacy was a predictor of reportedhealth status.

As indicated in Table 1, although randomly assigned tocontrol and treatment groups, the latter presented withhigher baseline scores, but not significantly so. Visual in-spection of participant characteristic information suggeststhat this may be due to the treatment group being slightlyyounger, with fewer years since diagnosis, and a greaternumber of individuals able to walk unassisted.

Previous work (Finch and Becker, 2007) based on a singlegroup pretest, posttest design, demonstrated improvedMSSE scores after an 8 week treatment series. As well asbeing controlled, the present study was more sensitive tochange in that a greater number of measurement pointswere introduced. It was interesting to note that after 4weeks significant change was noted. It may be that thisoccurred even earlier in the treatment series, and futurework could incorporate weekly or biweekly measurement.Significant difference between control and treatmentgroups was maintained to the end of the treatment series,although the gap had narrowed somewhat. The reason forthis is unclear, but could be related to the fact that this

data was collected on the day of the last treatment, andthis “ending” may have had an adverse effect on the pa-tient’s responses.

In the same work (Finch and Becker, 2007) it was notedthat 8 weeks after the last treatment, self-efficacy hadreturned to baseline levels. Again, the present design wasmore sensitive in that an additional measurement point wasintroduced mid follow up, 4 weeks after the last treatment.It was interesting to note that a significant difference be-tween control and treatment groups was maintained up tothis point, suggesting that the effect of massage therapy onself-efficacy is cumulative and endures for a periodfollowing treatment. This being said, the duration iscertainly, and unsurprisingly, finite as indicated by lack ofsignificance at final follow up 8 weeks post treatment,which is aligned with previous findings.

Conclusions

Although further work would be beneficial, the results ofthis study support previous findings indicating that massagetherapy increases the self-efficacy of clients with multiplesclerosis, potentially resulting in a better overall adjust-ment to the disease and an improvement in psycho-emotional state.

The increase in self efficacy noted after only 4 weeks oftreatment suggests that positive response to treatmentoccurs more rapidly than was previously demonstrated. Theimprovement in self-efficacy endured 4 weeks after the endof the treatment series, which suggests that massagetherapy may have longer term effects that were not pre-viously noted. Lack of inter group difference at the eightweek follow up reinforces the notion that on-going treat-ment is required in order to maintain the positive changesobserved.

Limitations

The limitations of this research relate primarily to threeissues. The first is the small sample size, and in order tobetter establish the veracity of the findings this needs to belarger. Secondly, while randomly allocated to waitlist con-trol and treatment groups, the participants were selfselected. As such, the degree of applicability to the generalmultiple sclerosis population is not clear, because the re-sults may reflect the response of a sub-population who aremassage-friendly in their orientation, and who have priorexperience of this intervention. The third point to note isthe pragmatic nature of the protocol. This is a strength in so

16 P. Finch, S. Bessonnette

far as it reflects the norms of massage therapy practice inthe student teaching clinic, but is a limitation in that nospecific protocol was tested.

Funding

Sutherland-Chan School and Teaching Clinic and ConestogaCollege Institute of Technology and Advanced Learningsupported the work in the form of researcher time, but nofunding was received either external or internal.

Conflicts of interest

None

Acknowledgments

The authors would like to thank Sutherland-Chan Schooland teaching Clinic for hosting the research, and theTeaching Assistants and students who participated in theproject.

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