Integrating Massage Therapy Into the Health Care of Female Veterans
Background: Female veterans experience higher rates of chronic pain, depression, and anxiety than do male veterans. Gynecologic examinations and procedures can be stressful, painful, and anxiety provoking. Research has shown that massage can help reduce pain and anxiety. The purpose of this study was to examine the relationship between massage and well-being in female veterans.
Methods: A pre- and postvisit study design was used. In advance of their clinic visit, female veterans were asked by clinic staff whether they would like a relaxation massage in conjunction with their visit. Effleurage massages were administered by licensed volunteer massage therapists in a private space and performed on the back, neck, hands/arms, legs/feet. Patients rated their pain intensity, pain unpleasantness, anxiety, shortness of breath, relaxation, and inner peace pre- and postmassage on 0 to 10 scales. Demographics and data were abstracted from the medical records.
Results: Results are based on the first massage received by 96 individuals: A majority of participants were aged ≤ 40 years (53%) and were White women (68%). Most (70%) were scheduled for an invasive procedure (eg, pelvic examination, biopsy). Seventy-nine percent had a history of chronic pain; 65% had a diagnosis of depression. Mean scores for pain intensity decreased by 1.9 points, pain unpleasantness by 2.0, and anxiety by 2.4. Relaxation increased by 4.3 points and sense of inner peace by 3.5 points. These changes were all statistically significant ( P < .001).
Conclusions: Results from this pilot study suggest massage therapy may be an effective, inexpensive, and safe treatment for pain and/or anxiety in female veterans attending a gynecology appointment. Further research should assess the effects of massage therapy in female veterans with chronic pain and coexistent mental health conditions.
Study Measures
Pain intensity, pain unpleasantness (the affective component of pain), anxiety, shortness of breath, relaxation, and inner peace were rated pre- and postmassage on a 0 to 10 scale. Shortness of breath was included due to the relationship between breathing and anxiety. Inner peace was assessed to measure the calming effects of massage therapy. Beck and colleagues found the concept of inner peace was an important outcome of massage therapy.17 The scale anchors for pain intensity were “no pain” and “severe pain”; and “not at all unpleasant” and “as unpleasant as it can be” for pain unpleasantness. For anxiety, the anchors were “no anxiety” and “as anxious as I can be.” Anchors for relaxation and inner peace were reversed so that a 0 indicated low relaxation and inner peace while a 10 indicated the highest state of relaxation and inner peace.
Chronic pain was defined as pain existing for > 3 months. A history of chronic pain was determined from a review and synthesis of primary care and specialty care recorded diagnoses, patient concerns, and service-connected disabilities. The diagnoses included lumbosacral or cervical strain, chronic low back, joint (knee, shoulder, hip, ankle), neck, or pelvic pain, fibromyalgia, headache, migraine, osteoarthritis, and myofascial pain syndrome. The presence of mental health conditions, including depression, anxiety, bipolar disorders, and PTSD, were similarly determined by a review of mental health clinical notes. Sex was determined from the gynecology note.
Statistical Analysis
Means and medians were calculated for short-term changes in symptom scores. Due to skewness in the short-term changes, significance was tested using a nonparametric sign test. Significance was adjusted using the Bonferroni correction to protect the overall type I error level at 5% from multiple testing. We also assessed for differences in symptom changes in 4 subgroups, using an unadjusted general linear model: those with (1) chronic pain vs without; (2) an anxiety diagnosis vs without; (3) depression vs without; and (4) a PTSD diagnosis vs without. Data were analyzed using SPSS 25 and SAS 9.4.
Results
Results are based on the first massage received by 96 unique individuals (Table 1). Fifty-one (53%) patients were aged 21 to 40 years, and 45 (47%) were aged ≥ 41 years. Most participants (80%) had had a previous massage. Seven (7%) participants were currently on prescription opioids; 76 (79%) participants had a history of one or more chronic pain diagnoses (eg, back pain, migraine headaches, fibromyalgia) and 78 (81%) had a history of a mental health diagnosis (eg, depression, anxiety, PTSD). Massage sessions ranged from 30 to 60 minutes; most patients received massage therapy for 50 minutes.
Prior to massage, mean scores were 3.9 pain intensity, 3.7 pain unpleasantness, 3.8 anxiety, 1.0 shortness of breath, 4.0 relaxation, and 4.2 inner peace. Short-term changes in symptom scores are shown in Table 2. The mean score for pain intensity decreased by 1.9 points, pain unpleasantness by 2.0 points, anxiety by 2.4 points. The greatest change occurred for relaxation, which increased by 4.3 points. All changes in symptoms were statistically significant (P < .001). For subgroup comparisons
Verbal feedback and written comments about the massage experience were all favorable: No adverse events were reported.
Discussion
Massage therapy may be a useful treatment for female veterans experiencing chronic pain, anxiety disorders, depression, or situational anxiety related to gynecologic procedures. After receiving a relaxation massage, female veterans reported decreased pain intensity, pain unpleasantness, and anxiety while reporting increased relaxation and feelings of inner peace. The effects of massage were consistent for all the symptoms or characteristics assessed, suggesting that massage may act on the body in multiple ways.
These changes parallel those seen in a palliative care population primarily composed of male veterans.14 However, the female veterans in this cohort experienced greater changes in relaxation and feelings of inner peace, which may be partly due to relief of tension related to an upcoming stressful appointment. The large mean decrease in anxiety level among female veterans with PTSD is notable as well as the larger increase in inner peace in those with chronic pain.
Many patients expressed their gratitude for the massage and interest in having access to more massage therapy. Female patients who have experienced sexual trauma or other trauma may especially benefit from massage prior to painful, invasive gynecologic procedures. Anecdotally, 2 nurse chaperones in the clinic mentioned separately to the massage program supervisor that the massages helped some very anxious women better tolerate an invasive procedure that would have been otherwise extremely difficult.
