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.
Female veterans are more likely to have musculoskeletal issues after deployment and have higher rates of anxiety, PTSD, and depression compared with those of male veterans.3,4,18,19 Determining relationships between and causes of chronic pain, depression, and PTSD is very challenging but the increased prevalence of chronic pain and comorbid mental health conditions in female veterans may be partially related to MST or other trauma experiences.20-22 Female veterans are most likely to have more than one source of chronic pain.23-25 Female patients with chronic musculoskeletal pain report more pain-related disability.26 Furthermore, greater disability in the context of depression is reported by women with pain compared with those of men.27 Most (78%) female veterans in a primary care population reported chronic pain.23 Similarly, 79% of the female veterans in this study population had chronic pain and 81% had a history of mental health disorders, including depression, anxiety, and PTSD.
Studies have shown that massage therapy improves pain in populations experiencing chronic low back, neck, and knee pain.28-32 A 2020 Agency for Healthcare Research and Quality review determined there is some evidence that massage therapy is helpful for chronic low back and neck pain and fibromyalgia.33 Research also has demonstrated that massage reduces anxiety and depression in several different population types.13,34,35 Li and colleagues showed that foot massage increased oxytocin levels in healthy males.36 Although further research is needed to determine the mechanisms of massage therapy, there are important physiologic effects. Unlike most medications, massage therapy is unique in that it can impact health and well-being through multiple mechanisms; for example, by reducing pain, improving mood, providing a sense of social connection and/or improving mobility.
Patients using CIH therapies report greater awareness of the need for ongoing engagement in their own care and health behavior changes.37,38
Driscoll and colleagues reported that women veterans are interested in conservative treatment for their chronic musculoskeletal pain and are open to using CIH therapies.39 Research suggests that veterans are interested in and, in some cases, already using massage therapy.23,40-43 Access to massage therapy and other CIH therapies offers patients choice and control over the types and timing of therapy they receive, exemplified by the 80% of patients in our study who previously received a massage and sought another before a potentially stressful situation.
Access to massage therapy or other CIH therapies may reduce the need for more expensive procedures. Although research on the cost-effectiveness of massage therapy is limited, Herman and colleagues did an economic evaluation of CIH therapies in a veteran population, finding that CIH users had lower annual health care costs and lower pain in the year after CIH started. Sensitivity analyses indicated similar results for acupuncture, chiropractic care, and massage but higher costs for those with 8 or more visits.44
The prevalence of comorbid mental health conditions with MSD suggests that female veterans may benefit from multidisciplinary treatment of pain and depression.3,26 Women-centered programs would be both encouraging and validating to women.39 Massage therapy can be combined with physical therapy, yoga, tai chi, and meditation programs to improve pain, anxiety, strength, and flexibility and can be incorporated into a multimodal treatment plan. Likewise, other subpopulations of female veterans with chronic pain, mental health conditions, or cancer could be targeted with multidisciplinary programs that include massage therapy.
Limitations
This study has several limitations including lack of a control group, a self-selected population, the lack of objective biochemical measurements, and possible respondent bias to please the MTs. Eighty percent had previously experienced massage therapy and may have been biased toward the effects of massage before receiving the intervention. The first report of the effects of massage therapy in an exclusively female veteran population is a major strength of this study.
Further research including randomized controlled trials is needed, especially in populations with coexisting chronic pain and mental health disorders, as is exploring the acceptability of massage therapy for female veterans with MST. Finding viable alternatives to medications has become even more important as the nation addresses the challenge of the opioid crisis.45,46
