Veteran Perceptions of Massage Therapy

Ann Arbor VA Healthcare System

Development of the Massage Therapy Program at our VA

• Our first study involved patients up to 5 days post surgery who had major abdominal or thoracic incisions.

Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy

A Randomized Trial Allison R. Mitchinson, MPH, NCTMB; Hyungjin Myra Kim, ScD; Jack M. Rosenberg, MD; Michael Geisser, PhD; Marvin Kirsh, MD; Dolores Cikrit, MD; Daniel B. Hinshaw, MD

Hypothesis: Adjuvant massage therapy improves pain management and postoperative anxiety among many patients who experience unrelieved postoperative pain. Pharmacologic interventions alone may not address all of the factors involved in the experience of pain. Design: Randomized controlled trial. Setting: Department of Veterans Affairs hospitals in Ann Arbor, Michigan, and Indianapolis, Indiana. Patients: Six hundred five veterans (mean age, 64 years) undergoing major surgery from February 1, 2003, through January 31, 2005. Interventions: Patients were assigned to the following 3 groups: (1) control (routine care), (2) individualized attention from a massage therapist (20 minutes), or (3) back massage by a massage therapist each evening for up to 5 postoperative days.

Main Outcome Measure: Short- and long-term (4 days) pain intensity, pain unpleasantness, and anxiety measured by visual analog scales. Results: Compared with the control group, patients in the massage group experienced short-term (preintervention vs postintervention) decreases in pain intensity (P=.001), pain unpleasantness (P.001), and anxiety (P=.007). In addition, patients in the massage group experienced a faster rate of decrease in pain intensity (P=.02) and unpleasantness (P=.01) during the first 4 postoperative days compared with the control group. There were no differences in the rates of decrease in long-term anxiety, length of stay, opiate use, or complications across the 3 groups. Conclusion: Massage is an effective and safe adjuvant therapy for the relief of acute postoperative pain in patients undergoing major operations. Arch Surg. 2007;142(12):1158-1167

Ann Arbor Massage Therapy Program

• One licensed therapist, Allison Mitchinson • Includes clinical, research and education

components. • Populations receiving massage limited to palliative

care (inpatients and outpatients), chronic pain and veterans enrolled in one outpatient mental health program.

• Over 4700 massages given to date. One third to inpatients.

• Research paper published in Feb 2013 describing implementation of massage into Palliative Care service

Medical Manuscript

Integrating Massage Therapy Within the Palliative Care of Veterans With Advanced Illnesses : An Outcome Study Allison Mitchinson, MPH, NCTMB1, Carol E. Fletcher, PhD, RN1, Hyungjin Myra Kim, ScD2, Marcos Montagnini, MD3, and Daniel B. Hinshaw, MD, FACS4 Abstract Aims: To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses. Methods: Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time. Results: All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients’ sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001). Conclusion: Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients. Journal of Hospice and Palliative Medicine, Published Online Feb 2013

• Volunteers trained to give hand/foot massages (Soft Touch) to veterans as part of No Veteran Dies Alone program

• Hand/foot massages also being offered by volunteers to patients in rehab unit and chemo infusion room

• Initiated Touch, Caring and Cancer program to educate caregivers of patients with cancer how to give massage

• Participating in research project funded by National Center for Complementary and Alternative Medicine with Allina Healthcare.

Additional Activities

JRRD Volume 53, Number 1, 2016 Pages 117–126

Perceptions of other integrative health therapies by Veterans with pain who are receiving massage Carol Elizabeth Fletcher, PhD, RN;1* Allison R. Mitchinson, MPH, NCTMB;2 Erika L. Trumble, MPH;1 Daniel B. Hinshaw, MD, FACS;3 Jeffery A. Dusek, PhD4 Departments of 1Research, 2Medicine, and 3Palliative Care, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; 4Abbott Northwestern Hospital, Penney George Institute, Minneapolis, MN Abstract—Veterans are increasingly using complementary and integrative health (CIH) therapies to manage chronic pain and other troubling symptoms that significantly impair health and quality of life. The Department of Veterans Affairs (VA) is exploring ways to meet the demand for access to CIH, but little is known about Veterans’ perceptions of the VA’s efforts.To address this knowledge gap, we conducted interviews of 15 inpatients, 8 receiving palliative care, and 15 outpatients receiving CIH in the VA. Pain was the precipitating factor in all participants’ experience. Participants were asked about their experience in the VA and their opinions about which therapies would most benefit other Veterans. Participants reported that massage was well-received and resulted in decreased pain, increased mobility, and decreased opioid use. Major challenges were the high ratio of patients to CIH providers, the difficulty in receiving CIH from fee-based CIH providers outside of the VA, cost issues, and the role of administrative decisions in the uneven deployment of CIH across the VA. If the VA is to meet its goal of offering personalized, proactive, patient-centered care nationwide then it must receive support from Congress while considering Veterans’ goals and concerns to ensure that the expanded provision of CIH improves outcomes.

Table 1. Interview questions for patients.

1) In what ways, if any, did massage therapy change your level of pain and mobility? How did it make you feel?

2) What, if anything, did you like about the massage therapy? 3) What, if anything, did you dislike about the massage therapy? 4) There are many types of therapy that people use on their own without a

doctor’s prescription. These are called complementary or alternative therapies. In the past have you or anyone that you know used any other types of these therapies such as acupuncture, healing touch, aroma therapy, herbs, yoga, meditation, chiropractic, or hypnosis? If yes, please describe when, how often, why, and whether it was helpful?

5) Would you like to have the VA offer other types of therapy besides massage? If yes, please look at this list* and tell me which ones would you be most likely to use and why?

6) Is there anything else that you would like to tell me about massage or other complementary therapies? If yes, please feel free to do so.

Table 2. Demographics of participants receiving massage therapy

Inpatient (n=15) Outpatient (n=15) TOTAL (n=30)

Gender

Male 14 13 27

Female 1 2 3

Race

Caucasian 13 15 28

African American 2 0 2

Age (years)a

up to 40 1 0 1

41-60 4 7 11

61 and older 10 8 18

Referring Serviceb

Palliative care 8 1 9

Manual Medicine 3 11 14

Pain Clinic 2 2 4

Rehabilitation 1 0 1

Inpatient Medicine 1 0 1 a Age at time of study enrollment.

b The medical records of one outpatient contained no information about the service referring to massage therapy but the participant was likely referred by a family member.

Table 3. Outpatient experiences and recommendations for CIH therapies for veterans (n=15).

CIH Therapy Used N CIH Therapy Recommended N

Massage 15 Massage 13

Manual manipulation 10 Yoga 8

Diet/herbal 9 Acupuncture 7

Pet 9 Chiropractic 6

Meditation 8 Meditation 5

Chiropractic 8 Biofeedback 5

Aroma 7 Manual manipulation 4

Tens unit 7 Hypnosis 3

Acupuncture 6 Diet/herbal 2

Music 6 Pet 2

Biofeedback 6 Reiki 1

Yoga 4 Tai chi 1

Qigong 3 Tens unit 1

Hypnosis 2

Touch 2

Tai chi 2

Reiki 1

Mantram repetition 1

Table 4. Inpatient experiences and recommendations for CIH therapies for veterans (n=15).

CIH therapy used N CIH therapy recommended N

Massage 14 Massage 10

Meditation 6 Chiropractic 5

Chiropractic 5 Music 5

Pet 5 Pet 4

Music 3 Yoga 4

Yoga 2 Acupuncture 3

Hypnosis 2 Hypnosis 3

Diet/herbal 2 Diet/herbal 3

Aroma 2 Meditation 1

Marijuana 2 Reiki 1

Acupuncture 1 Aroma 1

Water aerobics 1 Qigong 1

Touch therapy 1

Biofeedback 1

Table 5. Patient quotes related to access to CIH.

• “I would do anything to meet the obligation to release pain. If it was required and available I’d be here more often.”

• “It’s obvious, she doesn’t have time to get to everybody as quick as she’d like.”

• “I haven’t seen her in a while.” • “It’s beautiful; they should have it for all veterans.” • “It’s not available to enough veterans… and I don’t get to be seen as much as

I’d like to be seen.” • “Sometimes she’s overwhelmed and I don’t get the benefits even on a month

to month basis.” • “If you only get one massage every 3 months, that’s not effective at all.” • “I would like to see them be able to fund more massage therapists and more

manual medicine people because your body is connected from the tip of your toes to the top of your head and if one place is irritated then it’s going to affect the rest of your body and it also affects your temperament.”

• “If I had my druthers, I’d be up here about every week.”

Veteran Inpatient • “Well when she got finished with my massage I

was asleep. I don’t know how many minutes I lost. Really, I don’t care. Al I know is when the body is 100% relaxed, you’re asleep. And when she got finished, she asked me how my feet were. I said, “What feet?” because I could not feel my feet. It was like somebody had taken them off, fixed them all up, brushed them off, put a nice wax job on the feet and left them laying there till I woke up….She asked for my stress level, my anxiety level. I had no levels. Everything was almost zero.”

Veteran Outpatient

• “She actually finds problems I’ve got that I don’t know I’ve got….She’s done me a world of good since I’ve been coming. It’s why I do not mind driving-you know-about 130 miles round trip to get up here for this because every time it does me good….Yeah, it definitely relieves pain, relieves tension….Yeah, it just frees me up. Usually I’m hobbling coming in here doing my old farmer walk and I walk more like a human when I’m going out so it does help out.”

Veteran Outpatient

• Veteran: “I have chronic pain in my left hip and my shoulders and my left knee was reconstructed in a motorcycle wreck in 1990. So, I’ve had a lot of PTSD related things going on with me. It’s a lot of depression too because it feels like –you know-when will I ever feel right again or is this it? I’ve kind of got some anhedonia, which means I don’t have any reaction whatsoever or feelings on something….”

• Interviewer: “Is there anything in particular that you don’t like about massage?”

• Veteran: “No, nothing at all, I get a lot of benefit from it. I feel more vibrant or more alive after I’ve had it done. Yeah, I just don’ t feel the pain this intense. I’d recommend it to anybody”

Sociological Massage Biological

Psychological

Spiritual

Our Contact Information

• Carol E Fletcher, PhD, RN • Carol.fletcher@va.gov

• Allison R Mitchinson, MPH, NCTMB • Allison.mitchinson@va.gov

• VA Ann Arbor Medical Center • 2215 Fuller Road • Ann Arbor, MI 48105