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Determine the best massage therapy practices for older adult populations

This is an excerpt from Massage Therapy: Integrating Research and Practice by Trish Dryden & Christopher Moyer.

Effects of Massage Therapy on Older Adult Populations

While consumers identify MT as a favored treatment option (Barnes, Bloom, and Nahin 2008), there is no conclusive evidence supporting any specific MT techniques for the medical conditions common to older adults. This is because study protocols are often not clearly defined. Comparative studies of best practices or dosage have not yet been conducted. In addition, no common taxonomy or nomenclature for techniques has been adopted. That said, the number and kinds of MT studies have been increasing, especially in the past decade. These have provided some evidence that MT is a safe and noninvasive approach to a variety of conditions, such as anxiety and depression (Moyer, Rounds, and Hannum 2004), pain (Tsao 2007), loss of function due to disability (Dryden, Baskwill, and Preyde 2004), and side effects of medical treatments, including constipation (Lämås et al. 2009), fatigue (Currin and Meister 2008), and nausea (Billhult, Bergbom, and Stener-Victorin 2007).

Healthy, Active Older Adults

Thirty-nine percent of noninstitutionalized older adults assessed their health as very good or excellent (AARP and NCCAM 2007). However, aging involves common physiological and psychological changes that affect digestion, vision, balance, mobility, and mood, among others (Davis and Srivastiva 2003). Therefore, even healthy and active older adults may require treatment for commonly occurring functional concerns in these areas. Conditions for which MT has been researched likely to occur in this population include pain, loss of balance, decreased flexibility, and constipation.

Even healthy and active older adults can experience normal symptoms related to aging, including pain, reduced balance, decreased flexibility, and constipation. This section outlines the research literature that examines MT treatment of these symptoms.

Pain

Pain, which is present in 45% to 85% of older adults, might be the most prevalent, complex, and undertreated condition facing this population. Pain is influenced by a variety of factors, including depression, diminished activities and social engagements, sleep disturbances, malnutrition, sensory impairment, numerous medical conditions, and disabilities. Pain reduction has positive effects on a host of conditions, but physicians may be reluctant to refer to CAM treatments, such as massage for pain, due to limited knowledge of these modalities (Davis and Srivastava 2003).

Notably, the pain treatments most commonly prescribed by physicians, including medications, physical therapy, and exercise, are those that are least preferred by older adults. Older adults are more likely to prefer massage, topical analgesics, hot and cold packs, relaxation education, and movement classes (Davis and Srivastava 2003; Reid et al. 2008). In addition, self-care techniques that are easily incorporated into a MT session can also be useful, since they are low-cost and are not associated with side effects. They may also translate into improved self-management of other common chronic conditions (Reid et al. 2008). Massage therapists should be mindful of what older adults consider helpful remedies and should consider adding self-care to treatment plans.

Several randomized controlled trials have examined MT for low back pain (LBP) (Walach, Guthlin, and M. Konig 2005; Hasson et al. 2004; Cherkin et al. 2001; Hernandez-Reif et al. 2001; Preyde 2000), which is the most common painful condition across all ages (Barnes, Bloom, and Nahin 2008). However, there have been no studies on MT for LBP specifically in older adults. It is likely that the protocols with demonstrated effectiveness for treating pain in adults should also be applicable to older adults (see chapter 12), but research with older adults is needed.

Loss of Balance, Decreased Flexibility

Aging brings a progressive decrease in muscle strength and joint flexibility, visual perception, vestibular function, and somatosensory sensitivity. All of these contribute to balance impairments, which increase the risk of falling and affect older adults' safety and ability to live independently. Balance impairments can also be caused or exacerbated by lack of exercise, neurological disorders, arthritis, or other medical conditions and their treatments (Davis and Srivastava 2003; Vaillant et al. 2009). Maintaining strength, flexibility, and endurance limits the risk of falling and helps older adults to stay active and maintain physical health (Berger, Klein, and Commandeur 2007).

Vaillant and colleagues (2009) found significant improvement in elders' performance in two out of three balance tests after a single session of MT, including the application of friction, static and glide pressure, and mobilization techniques focused on the foot and ankle, combined with mobilization. In other studies, mobility increased and pain decreased when MT was combined with water-based mobilization therapy (Forestier et al. 2009). The reduced muscular loads associated with movement in water may reinforce proprioceptive input, thereby leading to improvement (Berger, Klein, and Commandeur 2008). Massage therapists who work in a spa environment or have access to warm pools should consider MT and mobilizations done underwater or in combination with water therapy.

Constipation

Older adults are five times more likely than younger adults to report constipation, which accounts for more than 2.5 million physician visits per year in the United States (Lämås et al. 2009). The increased prevalence in this population may be partly attributable to pain, medications, decreased mobility, decreased bowel motility, illnesses such as strokes, decrease in fluid intake (often due to self-
management of incontinence), and poor diet (Davis and Srivastava 2003). A randomized controlled trial of abdominal massage for the management of constipation found that this treatment decreased the severity of gastrointestinal symptoms, especially symptoms associated with constipation and pain syndrome (Lämås et al. 2009; Lämås et al. 2010), which are outcomes that may represent particular value for older adults.

Older Adults Living With Chronic Conditions

Though 39% of noninstitutionalized older adults self-report excellent to very good health, it is simultaneously true that 80% of older adults have one or more chronic health conditions (AARP and NCCAM 2007; Greenberg 2008; Federal Interagency Forum on Aging-Related Statistics 2008). Although older adults may present with a positive outlook on their health, massage therapists must be mindful of possible underlying or undiagnosed conditions, such as insomnia, arthritis, cancer (see chapter 17), and anxiety or depression (see chapter 13). Chronic conditions for which there is specific MT research that are likely to be encountered with this population include arthritis, dementia, and insomnia.

Arthritis

The term arthritis refers to joint inflammation, and is used to describe more than 100 rheumatic conditions that affect the joints, the tissues surrounding the joints, and other connective tissue. The most common form of arthritis is osteoarthritis, a disease characterized by degeneration of cartilage and its underlying bone within a joint, as well as bony overgrowth. The breakdown of these tissues leads to pain and joint stiffness. An estimated 27 million American adults have osteoarthritis, 17 million of whom are older adults. In fact, 50% of older adults report having arthritis. Other common rheumatic conditions include gout, fibromyalgia (see chapter 16), and rheumatoid arthritis (CDC 2006).

Currently, no cure exists for osteoarthritis. Treatment focuses on relieving symptoms and improving function. Recent studies have investigated the effects of MT on osteoarthritis, though none has focused exclusively on older adults. In a randomized controlled trial investigating MT for osteoarthritis of the knee, Swedish massage techniques were administered to 68 adults with osteoarthritis. One-hour sessions were provided twice weekly for the first 4 weeks, then weekly for the next 4 weeks. Results suggest that MT is efficacious in the treatment of osteoarthritis of the knee, with beneficial results persisting for weeks following treatment. Massage therapy was well tolerated by people with painful osteoarthritis, and it decreased pain and improved function in participants who were allowed to maintain their usual treatment (Perlman et al. 2006). Spa therapies, including mud and paraffin application, shower massage, and manual massage and exercises under water, also have a positive effect on osteoarthritis by reducing pain and improving health status in patients suffering from osteoarthritis (Vaht, Birkenfeldt, and Ubner 2008; Forestier et al. 2009).

Dementia

Loss of memory and decline in cognitive functioning are some of the most tragic consequences of aging. Although no research exists on the effects of MT on improving memory or cognitive function, the effect of MT on agitation, which is associated with the advanced stages of dementia and affects up to 80% of adults with Alzheimer's disease (Woods, Craven, and Whitney 2005; Gerdner, Hart, and Zimmerman 2008), has been studied. In a recent study titled “Massage in the Management of Agitation in Nursing Home Residents with Cognitive Impairment,” five dimensions of agitation were assessed. These were wandering, being verbally agitated or abusive, acting physically agitated or abusive, being socially inappropriate or disruptive, and resisting care. Fifty-four elders with moderate to severe dementia were given six massage therapy sessions, consisting primarily of gentle effleurage, over a 2-week intervention period. Decreases in agitation were significant both during and following massage intervention for all dimensions except for socially inappropriate or disruptive behavior (Holliday-Welsh, Gessert, and Renier 2009). Finally, it should be noted that because persons with dementia are less able to adapt to common environment and mental changes, consistency and a predictable treatment routine may be especially important components of MT with this population.

Insomnia

Sleep patterns change with age. The elderly sleep less than when they were younger and many have difficulty falling asleep. They may also wake more easily and often and may spend less time in deep sleep. In some cases, these changes may be related to anxiety, pain associated with a chronic illness, or an increased need to urinate at night. Sleep deprivation can lead to confusion and other mental deficits. Treatment of insomnia in older adults is made more difficult by the fact that use of sedatives is discouraged because of the added risks of delirium and falls for this population (Flaherty 2008)

Acupressure, which can be a component of MT, has been shown to have a positive effect on insomnia in patients with cancer who were previously nonresponsive to pharmacological interventions (Cerrone et al. 2008). In studies of measures on pain and quality of life (QOL), statistically significant results were noted improvement in sleep and depression after massage therapy, even when few results were noted for pain and QOL (Soden, Vincent, and Craske 2004). In a study comparing massage to the use of relaxation recordings, older adults preferred massage therapy, even though both interventions showed significant results (Hanley, Stirling, and Brown 2003).

Older Adults Requiring End-of-Life Care or Palliative Care

Palliative care seeks to improve the quality of life for people with a terminal illness, as opposed to focusing on curing the illness. Hospice care, a specific form of palliative care, is especially valuable when the end of life is imminent (Beider 2005). An estimated 1.45 million people received hospice services in 2008, and approximately 38.5% of all U.S. deaths occurred under hospice care. Thirty-eight percent of these were due to cancer, followed in frequency by heart disease, dementia, and lung disease (NHPCO 2009). Massage therapy is a popular palliative care treatment in Canadian and U.S. hospices, since it is capable of offering support and comfort to those at the end of their lives and to their families (Oneschuk et al. 2007; Kozak et al. 2009). In this setting, MT treatment goals do not vary greatly, given that the primary goal is providing comfort. For example, since long-term benefits are not the priority for a hospice resident whose condition is advanced, MT practitioners may not focus on reducing fibrous adhesions.

Massage therapy is one of the most commonly offered complementary therapies in U.S. and Canadian hospices, although researchers note that lack of funding and insufficient staff knowledge limit its wider use (Oneschuk et al. 2007; Kozak et al. 2009).

A study that illustrates the value of qualitative research captured the experience of persons in palliative care who received MT. It found that MT generated physical well-being and mental relaxation, as well as feelings of inner respite, freedom, and liberation from illness. Individual participants remarked that they “felt uplifted and happy,” experienced “relaxation without the illness because [they] did not think about it at all,” and “felt strengthened in some way” (Cronfalk et al. 2009).

Similarly, patients in a study that combined MT and meditation showed significant improvement in overall and spiritual quality of life. These benefits may not have occurred with meditation alone, since meditation effects may be blunted unless the patients' need for physical contact is also addressed (Williams et al. 2005). Touch is a valuable component of end-of-life care, both for symptoms like pain, anxiety, and sleep, and for QOL concerns, including communication, comfort, and spiritual care. Although evidence exists that MT may have immediate benefits on pain and mood in end-of-life care, simple touch is also an effective intervention for this population, with documented benefits for QOL (Kutner et al. 2008). MT can also be used to address end-of-life patients' need for human contact, comfort, and communication (Russell, Beinhorn, and Frenkel 2008; Kolcaba, Schirm, and Steiner 2006).

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