Understanding Research for the Massage Therapist

Greg Morling

In his foreword to both Glenn M. Hymel’s book, ‘Research Methods for Massage and Holistic Therapies’ and Tiffany Field’s text, ‘Massage Therapy Research’, Leon Chaitow gives high praise to both books and outlines the two different imperatives  that are the driving forces behind both; the need for ever -improving competencies in the application of massage and bodywork and the need for evidence that validates and supports the methods and techniques used in therapeutic massage.[1]

The ‘evidence’ could be found in many ways and I have a bias in research design that will become evident as you progress though this article. This piece will outline the use of both qualitative and quantitative approaches to finding the evidence that Chaitow and others suggest is required to improve competencies in tactile therapy.

I hope that this article will give the massage therapist and most importantly, those who aim to engage in research in our tactile garden, some new perspectives on research designs that might truly reflect the way we work and the wellbeing we hope to foster in our clients.

Research is defined as the creation of new knowledge and/or the use of existing knowledge in a new and creative way so as to generate new concepts, methodologies and understandings. This could include synthesis and analysis of previous research to the extent that it leads to new and creative outcomes. [2]

This definition of research is consistent with a broad notion of what research can be, including the different methodologies that may be used to reach fresh knowledge. Both qualitative and quantitative research methods have equal validity in seeking and uncovering these creative outcomes for the benefit of our clients and patients now and in the future.

Qualitative and Quantitative research methods: the distinction

There are unique characteristics between qualitative and quantitative approaches to research and it is important that natural therapists understand the difference between them when reading scholarly articles on CATM. I now use CATM (Complementary, Alternative and Traditional Medicine), as opposed to just CAM to honour and recognize the traditional healing medicines from the indigenous and first nation peoples around the world.)

or any other piece of writing related to health care. It must also be noted that qualitative research and quantitative research are in no way in opposition. A Hymel states, ‘they are an alternative to the other.' Reductionism can be an oversimplification of an idea when we are researching human experience, but it can be a very useful process to use in developing an aware global society by collecting and analyzing  information about our environment such as, ‘species diversity, global climate patterns, and ocean pollutants.’

Mixed methods research is a third research process that involves the use of qualitative and quantitative data in a single research project. Mixed method research enquiry is certainly worthy of exploration in relation to CATM but I have decided to focus on these separately in this article.

Quantitative research and the ‘dualist model’

When you see ‘quantitative,’ think; experimental and statistical. The goal here is to use tests, measures, statistics and predictions. Practical examples of this form of research underpin the book previously mentioned, written by Tiffany Field, Director of the Touch Research Institute in Miami, Florida. Her research on a broad range of conditions including positive outcomes in growth and development in pre-term and full-term infants, ADHD, depression, eating disorders, lower back pain, fibromyalgia, Parkinson’s Disease and breast cancer. Her book is a review of quantitative research studies from both her laboratory and others which rely exclusively on quantitative research design which is used in the biomechanical model.

The experimental quantitative research model may employ randomized controlled trials (RCT) which have long been held up as the ‘gold standard’ of clinical research. ... In a randomized controlled trial, participants are randomly assigned to receive either the treatment under investigation or, as a control, a placebo or the current standard treatment. An RCT aims to be ‘impersonal, value-free, rational and reliable.’ [3]

There is a very strong reliance on quantitative research methodology using a reductionist model in modern medicine. The original architect of this way of thinking (and research process) was René Descartes, the seventeenth century philosopher who presented a dualist view that Mind and Matter (which includes the brain) are two altogether different kinds of beings that occupy different realms with different rules, with no point in common. [4]  This ‘Cartesian dualism’ philosophy had, and still has, an enormous influence on how we view the world, including medicine, research and health care. Descartes believed that to understand a problem we needed to break it into small pieces of information. (reduction) and his philosophy is the basis for our understanding of the ‘scientific method’, eliminating variables from research design as much as possible.

Qualitative research

Qualitative research, (QR) on the other hand, can be used to ‘understand the complexity of social phenomena through a set of systematic and interpretive practices designed to seek answers to questions that stress how social experiences are created and sustained.’ [5]

Qualitative research methods eliminate nothing in revealing answers to the human condition.   All variables are welcome and well regarded!

Commonly employed qualitative methods that may be used in researching CATM include ethnography, case studies, discourse analysis, and phenomenology which I will address later in this article. An ethnographic question in massage therapy might be, ‘are there changes in my massage practice following engagement with other therapists in a Massage Conference?’  A case study might ask, ‘What is the effects of massage on chronic low-back pain in a patient with four different diagnoses: osteoarthritis, scoliosis, spinal stenosis, and degenerative disc disease?’ The qualitative methods that address the types of questions cited come from strong theoretical traditions. For further evidence of this the reader might like to read the article, ‘How to locate and appraise qualitative research in complementary and alternative medicine’ which appeared in the BMC Complementary Journal. [6]

These type of research questions are positioned in the human sciences as opposed to quantitative studies that are situated in biological reductionist analyses possibly using CRT.

Specifically, qualitative research is not designed to test theory and has no relationship to CRT or the reductionist way of research enquiry. Instead, it questions broadly from an inductive approach rather than deductive. It is a process of naturalistic inquiry that seeks in-depth understanding of social phenomena within their natural setting.  It focuses on the "why" rather than the "what" of social phenomena and relies on the direct experiences of human beings as meaning-making agents in their everyday lives.

This method or research is human science research and involves the study of lived, human experience. In our field of massage therapy and other CATM, a question could be, ‘how does a client feel when they are having massage?’ Another question might be, ‘what meaning does massage therapy hold for an individual client? ’This is an idiographic focus where we are interested in what the phenomenon holds for an individual, not a cohort or representative sample.

We should acknowledge that human science operates with its own criteria for precision, exactness, and rigor.[7] Research in the field of complementary, alternative and traditional medicine is underused and, ‘when used, done so defensively.’ [8] The development of medical research methodologies, has, at least in part been a result of concerns about the intrusion of CATM practices in health care which may explain why CATM has not always emerged from ‘scientific’ examination unscathed. [9]  CATM and the Randomized Control Trial (RCT) (mentioned previously as the preferred method of enquiry for biomedical research) are not a good fit due to the complexities of CATM interventions, the many variables in therapy (non-standardization of treatment), the reasons for a client/patient seeking CATM treatment, and placebo issues.

The critical concern from the standpoint of the CATM practitioner is the importance of a wholistic understanding of the individual patient. Objectivity in humanistic, qualitative research can be critical to the accuracy of this research process.  The ‘pure science’ (reductionist) view is that measuring variations across a population has far more meaning than information about changes, feelings or the lived experience of the individual client/patient and subjectivity in research is essential.

Qualitative research methods can encompass the complexities of CATM and identify richer and more appropriate veins for research exploration for both us as CATM therapists from a different research paradigm.  The rigorous application of wholistic research using qualitative research design, exercised non-defensively, can only benefit CATM and the knowledge base of science.

The CATM therapist’s pursuit of legitimacy

The debate surrounding the politics of ‘evidence-based medicine’ and what value qualitative methods have in health research have led to some CATM practitioners compromising their professionalism by blindly attempting to legitimize their practice by pseudo-scientific claims.

In my own CATM area, the field of tactile therapy, it seems nonsensical to attempt quantitative research where the interconnected variables of our practice make this type of research so difficult to assess; intensity and duration of massage, levels of tactile temperature, extent and style of massage. The list is extensive and obviously intimates that the qualitative research methods would be far more revealing and offer greater value. Qualitative methods may address ‘why a tactile intervention works’, ‘how a participant is experiencing the massage intervention’, and /or ‘how they give meaning to these experiences’.

Ann Verhoef argues strongly in JACM that qualitative research methods should be added as another ‘Gold Standard’ [10] and I hope this article, ‘contributes to your search in how we might research our tactile garden, to find therapeutic truth in our work. I hope this article has persuaded you to see the value of qualitative research methods to the practice of CATM and in particular, massage therapy.

The philosophy underpinning qualitative research.

Approaches to research have a philosophical base. For example, René Descartes, considered the father of modern philosophy, gave us one of the deepest and most lasting legacies; his thesis that mind and body are quite distinct—a thesis now called "mind-body dualism." This philosophy gave us empiricism, and of course, quantitative research methodology.

However, some of the greatest minds of the 20^th Century; Edmund Husserl, Jean – Paul Sartre and Merleau – Ponty strongly refuted Descartes philosophy and his way of looking at the world.  Merleau -Ponty wrote that, ‘the Cartesian separation of emotion from behavior radically misconstrues our experience of others.’ [11]  He repudiates the idea of ‘mind-body dualism’ that pervaded the philosophy of Descartes. They would probably not explicitly state it as such (if they were alive today) but their writings, and ideas enthrall us with insights into the enigma of life as we experience it and they have given us the underpinnings of qualitative research methodology by using phenomenology.

Phenomenology

The study of phenomenology has its roots in philosophy and while it has been studied in various forms throughout history,[12] I believe it has certain relevance to us as CATM therapists currently practicing in the existing permeating biomechanical, reductionist health environment.

Phenomenologists are interested in the analytical and descriptive experience of phenomena by individuals (in our case, patients and clients) in their everyday world. For example, a phenomenological study on osteoarthritis may concentrate on the experience of what it is like to be someone with osteoarthritis from the individual’s point of view and try and describe how he or she interprets the everyday world. Phenomenological research would endeavor to capture the essence rather than measure the number of osteoarthritic sufferers or define the causes of osteoarthritis. [13]

Phenomenologists are interested in all types of experience, which can include the mundane to dramatic experiences.

Phenomenologists perceive that human experience of the everyday world is a valid way to interpret the world and therefore reject the notion that that the detached, scientific empirical tradition is the superior method of research. Phenomenological research differs from other modes of qualitative inquiry in that it attempts to understand the essence of a phenomenon from the perspective of someone who has experienced it. [14]

The great living phenomenologist, Max van Manen, wrote that, ‘(research) asks us to be forever attentive to the fascinating varieties and subtleties of primal, lived experience and consciousness in all its remarkable complexities, fathomless depths, rich detail, startling disturbances and luring charms. [15]