Massage For Occupational Stress

Can massage therapy reduce occupational stress for healthcare workers? 

The Study Question

Does massage therapy or other forms of physical relaxation reduce occupational stress for health care workers?

Chronic exposure to work related stressors such as long hours and job strain is well known to have negative effects on physical and mental health. Health care workers are an especially vulnerable group, with stressful environments and work pressure often leading to burnout, a situation exacerbated during the Covid-19 pandemic.

While cognitive approaches such as mindfulness and cognitive behavioral therapy have demonstrated benefits for stress reduction, physical approaches such as yoga, progressive muscle relaxation, and massage therapy have not been studied as extensively. This study provides an updated systematic review and meta‐analysis of all randomized controlled trials using physical methods of relaxation in healthcare workers on occupational stress reduction.

The Study Methods

This meta‐analysis was conducted using PRISMA (Preferred Reporting Items for Systematic Review and Meta‐analyses) guidelines. Inclusion criteria were randomized controlled trials employing physical relaxation methods compared to non‐intervention control or other physical relaxation methods for occupational stress in health care workers, with change from baseline or both pre‐ and post‐intervention stress data at any duration of follow‐up.

Physical relaxation was defined as any method that involved light muscular tension and relaxation, including movement‐based techniques such as yoga and related exercises, stretching, and walking, as well as passive techniques such as massage and progressive muscle relaxation. Vigorous exercise, such as heavy aerobic activity and weightlifting, was excluded. Techniques devoid of muscular activity, such as aromatherapy without massage and music therapy, were also excluded.

The PubMed, SCOPUS, Web of Science and the Cochrane Library databases from inception to February 21, 2021, were searched. A manual search of references in pertinent review articles in this area was also conducted. Exclusion criteria were non‐randomized-controlled trials such as quasi‐randomized and quasi‐experimental studies, lack of non‐intervention or another physical relaxation comparison group, lack of stress assessment data or data that was otherwise insufficient for extraction, studies involving rigorous physical exercise or strength training, studies on subjects with preexisting mental illness, articles without full‐text, and non‐English manuscripts.

Two authors independently extracted data from all studies deemed eligible for inclusion, with disagreements addressed through discussion until a consensus was reached. For the primary outcome of stress, mean changes of stress scores and standard deviation from baseline for both arms were used. When multiple scales were used, preference was given to measures more specific for stress and those more commonly used in other identified studies, including the Perceived Stress Scale (PSS), the Maslach Burnout Inventory for emotional exhaustion (MBI‐EE), and the Nursing Stress Scale (NSS). A secondary outcome was mean changes in assessments examining mental and physical health.

Two authors independently assessed the quality of included RCTs with the Cochrane Collaboration’s Risk of Bias tool. Manuscripts were evaluated on five domains of bias: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Disagreements were resolved through discussion until a consensus was reached. Statistical analysis was performed with the meta‐package in RStudio version 1.4.1106. To compare various methods of physical relaxation to each other, a random‐effects frequentist network meta‐analysis was conducted with the R package netmeta.

The Results

The authors identified 3414 articles from databases, with another 37 through manual searching of review articles. After screening, 15 studies were included in the final analysis. A total of 688 subjects were enrolled across the 15 studies, with 341 participants having undergone physical relaxation compared to 347 non‐intervention controls. Of those, 139 were involved in yoga or a yoga like exercise (tai chi and qigong); 167 received some type of massage therapy; 15 were engaged in progressive muscle relaxation (PMR); and 20 performed stretching exercises. All studies were assessed as having some degree of bias. Massage protocols used in these studies ranged from a single session of a 10-minute seated massage to multiple 90-minute sessions of aromatherapy massage over 6 weeks. The most common health care profession represented was nursing.

Pooled results show that all interventions involving yoga (seven trials), massage therapy (six trials), PMR (one trial), and stretching exercises (one trial) significantly reduced measures of occupational stress at the longest duration of follow‐up vs baseline compared to non‐intervention controls, with p < .00001. Yoga was found to rank the highest in effectiveness, followed by massage therapy, PMR, stretching and finally no intervention. In the network analysis, both yoga alone and massage therapy alone significantly reduced measures of occupational stress compared to a non‐intervention control at the longest duration of follow‐up vs. baseline.

Limitations of the Study

A wide variety of massage approaches and lengths were included across the different studies, which may have made statistical effects harder to demonstrate. No information regarding the training or experience of the massage practitioners was included.

Implications for Evidence-Informed Practice

Systematic reviews and meta-analyses of RCTs are considered to be among the strongest types of studies to show a cause-and-effect relationship. A massage therapist could credibly cite this study in support of a massage program for nurses in the workplace as part of an organization’s effort to reduce stress and avoid burnout.

According to PTSD United, an organization dedicated to providing support and resources for people who suffer from PTSD, roughly 24.4 million people are dealing with PTSD at any given time. Although nearly everyone experiences a traumatic event at some time or another, the difference for people who develop PTSD is that their reactions to the trauma continue instead of resolving naturally over time. Often, people with PTSD will feel stressed even when they aren’t in danger.

“People experience PTSD when their choices over what happens to their bodies are taken from them,” says Pamela Fitch, the author of Talking Body, Listening Hands: A Guide to Professionalism, Communication and the Therapeutic Relationship, and a massage therapist with extensive experience working with clients with PTSD. “When actions are taken that they have no control over, then no place or person feels safe. Add to this the context of how a person was loved or not loved, and the more strikes against them, the harder it is to overcome the trauma.”

What Are the Symptoms?

PTSD is highly individualized, meaning that few people are going to experience PTSD in exactly the same way. Being familiar with some of the primary symptoms, however, will help you better understand how massage therapy may prove helpful. According to Fitch, symptoms usually manifest in some of the following ways:

Hyperarousal

Generally speaking, hyperarousal refers to an increased psychological and physiological tension. For example, the person might feel anxious or tired, or suffer from insomnia. Additionally, their tolerance for pain might decrease while their startle responses become exaggerated. Here, too, personality traits might become accentuated.

Hypervigilance

Abnormal awareness of environmental stimuli, or being alert and attentive to potential threats, are signs of hypervigilance. You might also notice clients holding their breath or clenching their fingers, for example.

Guilt and shame

Clients who suffer from PTSD may also feel guilty or shameful, faulting themselves for what happened or having feelings of humiliation and unworthiness.

Dissociation

Dissociation describes how a person might distance themselves from a traumatic event. Some may detach emotionally or appear absent or unconscious. Other people suffering from PTSD might “lose time” and be unable to remember significant aspects of the trauma, for example. Panic, nausea and fear can also be aspects of dissociation.

Intrusive thoughts

Recurrent, unwanted and distressing memories of the traumatic event might also occur, along with upsetting dreams or flashbacks. According to the Mayo Clinic, PTSD symptoms typically begin within three months of the trauma occurring, although it’s also possible for years to pass before symptoms surface.

No matter how symptoms manifest and when they appear, the one constant for many people dealing with PTSD is that their symptoms significantly affect their daily lives, sometimes making it difficult to work and develop and maintain personal and professional relationships.

Remember, however, that even with an understanding of symptoms, you absolutely must stay within your scope of practice when working with clients with PTSD. “It is not within a massage therapist’s scope of practice to actively engage in conversation about the trauma, other than to listen, support and refer,” says Fitch.

Treatment for PTSD

Similar to other mental health diagnoses, like depression or anxiety, PTSD is commonly treated with an integrative approach that may include both medication and some form of psychotherapy, with the goal being to help the person effectively work through the trauma.

Cognitive therapy, for example, is a type of talk therapy that focuses on helping the person recognize patterns in their thinking that keep them “stuck,” like misinterpreting normal situations as threatening. Exposure therapy, where a person works to re-enter the setting where trauma was experienced, sometimes through the use of virtual reality, aims to help people suffering from PTSD safely confront what they find threatening or frightening so they can learn to more effectively cope with the traumatic event.

Many times, talk therapy (such as cognitive therapy) and exposure therapy are used in combination, along with anti-depressants or anti-anxiety medication, in some cases.

For clients with PTSD seeking massage therapy, Fitch believes working through their trauma history with an experienced psychologist or psychotherapist is a must. “If clients with PTSD seek massage therapy before they have done some reflection with a psychotherapist, they could be at risk of worsening their symptoms, becoming triggered by the touch, or feeling depressed or angry,” she explains.

How Can Massage Therapy Help Clients with PTSD?

Stess relief, decreasing anxiety, reducing depression¹ and improving personal mood are all positive outcomes massage may provide clients. Additionally, a 2012 study focusing on how integrative therapies can help promote reintegration among veterans found that those participants who received massage therapy reported significant reductions in physical pain, tension, irritability, anxiety/worry and depression.²

Another recent study of Somali women refugees with chronic pain—the majority of whom reported military and/or sexual trauma—found that massage therapy provided enormous relief for distressing physical and psychological symptoms largely attributed to the exposure to trauma,³ according to Cynthia Price, a research professor at the University of Washington and massage therapist.

Research also indicates massage therapy may be effective for those clients who experience dissociation as a symptom of PTSD,^4,5 allowing these clients to experience a more coherent sense of self, which for some is a primary reason they initially seek out massage therapy .^6,7

While almost all studies on the subject point to the positive effects of massage therapy, making sweeping generalizations about its effectiveness for PTSD would be unwise.

“Given that the studies to date have involved small samples, we do not know the magnitude of these effects, nor do we know how massage facilitates health in trauma recovery,” says Price. “However, research findings suggest that dissociation reduction, i.e., a more coherent sense of self, may play an important role in positive massage therapy effects.”

There are aspects of massage therapy, too, that appear to provide some unique benefits to clients with PTSD—mainly giving these clients a feeling of comfort, safety and control they often can’t achieve on their own.

According to Fitch, some of the massage therapist’s most powerful tools come from how the massage therapy session itself is handled, from the informed consent and opportunity for a client to ask questions that start each session to the therapist’s ability to respond to the individual’s needs during a session, whether that’s stopping altogether, changing positioning or adapting levels of pressure. “All of these actions ensure that clients are safe and know they can stop the treatment at any time, providing them a safe environment to experience touch,” she explains.

Massage therapists can also provide clients with self-care strategies to help prolong the positive benefits achieved, not only in massage therapy sessions, but with other integrative treatment approaches as well. “People who have been traumatized are no longer at home in their bodies,” Fitch says. “Massage therapists can teach clients safe and effective ways of self-soothing and stress management.”

Article Source:

Brown Menard, Ph.D., LMT, M. (2023, August 1). Massage for occupational stress: Massage therapy journal; American Massage Therapy Association. https://www.amtamassage.org/publications/massage-therapy-journal/massage-and-aromatherapy-benefits3/