CRITICALLY APPRAISED PAPER (CAP)

Transcription

1 CRITICALLY APPRAISED PAPER (CAP) Donoyama, N., Suoh, S., & Ohkoshi, N. (2014). Effectiveness of Anma massage therapy in alleviating physical symptoms in outpatients with Parkinson's disease: A before-after study. Complementary Therapies in Clinical Practice, 20, CLINICAL BOTTOM LINE: Clients with Parkinson s disease (PD) are often referred to occupational therapists for rehabilitation and reintegration of daily life activities. Symptoms comprise not only the four cardinal features (resting tremor, rigidity, akinesia, and postural instability), but also features such as pain, autonomic nervous disorders, fatigue, sleep disorders, and emotional problems. To alleviate these complaints, patients with PD often resort to complementary and alternative medicine (CAM), with massage being one of the most commonly used CAMs worldwide. Massage has been used to improve motor symptoms, pain, fatigue, constipation, and quality of life. This article provides preliminary evidence on the usefulness of Anma massage therapy and its effectiveness in alleviating symptoms of people with PD in an outpatient setting. Anma massage therapy could be a useful preparatory technique for occupational therapists to use to promote optimal functional performance during and after treatment sessions. Occupational therapists often employ massage and neuromuscular therapy to intervene in clients with PD. With appropriate training, Anma massage can prove to be a highly useful and effective intervention employed by occupational therapists that can affect not only the peripheral nervous system, but also the central nervous system to help alleviate various physical symptoms in patients with PD. RESEARCH OBJECTIVE(S) List study objectives. Evaluate the effectiveness of a single Anma massage therapy session and multiple Anma massage therapy sessions with people with PD in a regular clinical setting with standard conventional medication. Examine how Anma massage therapy sessions alleviate the symptoms of resting tremors, rigidity, akinesia, and postural instability. 1

2 Examine any alleviation of secondary issues of PD such as pain, autonomic nervous system disorders, fatigue, sleep disorders, and emotional problems. DESIGN TYPE AND LEVEL OF EVIDENCE: Level III: One group, non-randomized, pre-post design SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. The research team recruited patients who had consulted a neurologist between August 2011 and November 2012 at The Center for Integrative Medicine, Tsukuba University of Technology, and who had submitted consent forms to participate in this study. To observe the effects of continuous Anma massage therapy, outpatients who wanted to continue receiving Anma massage sessions after completing the first Anma massage intervention could register for continuous treatment, and received seven additional 40-minute Anma massage sessions given weekly over a 2-month intervention period (continuous Anma massage group). Inclusion Criteria Patients with PD Stages 1 4 seeking treatment at The Center for Integrative Medicine, Tsukuba University of Technology in Japan. Exclusion Criteria NR SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 21 #/ (%) Male 12 / 57% males #/ (%) Female 9 / 43% females Ethnicity NR Disease/disability diagnosis Parkinson s disease (Stages 1 4) INTERVENTION(S) AND CONTROL GROUPS Group 1: Single Anma Massage Intervention Brief description of the intervention Participants received a single session of Anma massage therapy. Anma massage therapy generally includes whole-body massage with a focus on muscles and incorporating brief joint exercises. Anma massage is applied through clothing. Standard Anma massage techniques consist mainly of kneading, with lesser amounts of stroking and pressing, which are rhythmic massaging motions, and 2

3 How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? brief joint exercises. Stimulation intensity is adjusted according to each patient's range of comfort. Each full-body Anma massage lasted 40 minutes and included upper and lower limb exercises and excluded the face, neck, and abdomen. First, patients were briefly massaged on their less severe side while lying on their severe side. Next, their position was reversed and they were given an elaborate massage on their severe side. The goal was to give somatosensory cueing through massage stimuli of rhythmic stroking, kneading, and pressing. Patients were required to pay attention to the rhythm of the motions during the upper and lower limb exercises by orally counting along with the therapist. Upper and lower limb exercises were performed with the intent of extending the range of motion and stretching the attached muscle fibers of each joint. 14 Intervention took place in an outpatient clinic. Each participant received an initial Anma massage by the same therapist, who is nationally certified and has practiced and taught Anma massage for over 20 years. Single session 40 minutes Group 2: Continuous Anma Massage Intervention Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? Patients received continuous Anma massage therapy after the initial Anma massage session. Participants in this group received 8 massage sessions over a period of 2 months. Each full-body Anma massage lasted 40 minutes and included upper and lower limb exercises and excluded the face, neck, and abdomen. Each massage also targeted specific problematic areas cited by patients. The protocol for the continuous massages was the same as for the single massage. 6 All interventions took place in an outpatient clinic. Each participant received an initial Anma massage by the same therapist, who is nationally certified and has practiced and taught Anma massage for over 20 years. For the remainder of the massage sessions, a different nationally certified therapist with 2 years experience performed the sessions on each participant. 8 sessions over a 2-month period. 4 participants received 8 sessions, 3

4 1 participant received 2 sessions, and 1 participant received 5 sessions. For how long? 40 minutes Group 3: Relaxing Chat Intervention Brief description of the intervention How many participants in the group? Participants received a relaxing chat intervention separately from the Anma massage sessions. This relaxing chat served as a control for the study. Most participants received relaxing chat, in addition to single or continuous Anma massage sessions. 1 participant received relaxing chat only. 15: 1 participant received relaxing chat only; 11 participants received relaxing chat in addition to single Anma massage session; and 3 participants received relaxing chat in addition to continuous Anma massage sessions. Where did the intervention take place? Who Delivered? How often? For how long? Outpatient clinic Massage therapist Single session 40 minutes Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: NR Co-intervention: Timing: Site: Participants did not alter their existing medication regimens during the study. Therefore, participants did not enter the study on the same medication regimens. The duration of the intervention was very short, but the study reports a noticeable difference in the outcomes of interest. All participants were outpatients in one medical facility. 4

5 Use of different therapists to provide intervention: To avoid any differences in technical skill, the same therapist provided all initial message sessions. The therapist had national certification and more than 20 years of experience. Anma massage was given to the continuous group by a different therapist. This therapist had national certification and 2 years of experience. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Subjective symptoms. VAS (visual analog scale) used to assess severity of subjective symptoms. Participants placed a tick mark correlating with their perceived pain on a sheet of paper, the left side of the paper representing mild pain and the right side of the paper representing severe pain. Participants perceived pain was measured. Pain was categorized as muscle stiffness, movement difficulties, pain, fatigue, and other. NR NR Before and after treatment protocol Measure 2: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Measure 3: Name/type of measure used: What outcome was measured? Upper limb function: Pegboard set SOT Participants placed 20 pegs into 20 holes in the board. The time required to complete all 20 pegs was recorded. NR NR Before and after treatment protocol Gait performance: gait speed, stride length, and cadence Gait speed was measured using the 20 meter walk test, the number of steps and gait speed were measured using the 25 meter linear walk test, and stride length and cadence were also calculated. 5

6 reliable? valid? When is the measure used? Measure 4: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? NR NR Before and after treatment protocol Painful shoulder Range of motion of active motion, flexion, and abduction of both shoulder joints. NR NR Before and after treatment protocol Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. One author assigned the groups, while another performed the treatment protocols and analyzed the collected data. The authors chose to have the same individual perform both treatment protocols to limit differences between administrators; however, this produced awareness of treatment status. Recall or memory bias. Check yes, no, or NR, and if yes, explain. NR Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p < 0.05) Include effect size if reported Single Anma Massage Session 1. VAS scores after the single Anma massage session were significantly lower than 6

7 pre-session scores for all four subjective symptoms examined: muscle stiffness, movement difficulties, pain, and fatigue (p < 0.05). 2. Upper limb function: In the timed pegboard test using the dominant hand, speed after the single session was significantly shorter than before the session (p = ), whereas for the non-dominant hand, no significant difference was found between the two values. For the more severely impaired hand, speed after the single session was significantly shorter before the session (p = ), whereas for the less severely impaired hand, speed was shorter but not significantly so. 3. Gait performance: Gait speeds in the 20-m walk test (10-m walk and return) after one Anma massage session was significantly shorter than those before the session (p = ). Stride length after the session was significantly longer than before the session (p = ). Cadence showed little change 4. Painful shoulder: In the more severely impaired shoulder joint, the range of motion after one Anma massage session was significantly more extended for degree of angle of flexion (p = ) and degree of abduction than before the session (p = ). Likewise, in the less severe impaired shoulder joint, range of motion was significantly more extended after the session for degree of angle of abduction (p = ) and was extended, although not significantly, for flexion (p = ) Continuous Anma Massage Sessions: Patients who received continuous Anma massage (total of 8 sessions over 2 months) had VAS scores that showed a reduction in physical complaints, except movement difficulty in one patient. Relaxing Chat Session: There is no significant difference between pre and post reporting for patients receiving relaxing chat for all measured outcomes (p >.05). Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. NR Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Was the percent/number of subjects/participants who dropped out of the study reported? YES 7

8 Limitations: What are the overall study limitations? 1. The study was conducted in one medical facility in a small local city with a population of only about 200,000, so matched historical controls could not be obtained. 2. Patient autonomy prevents complete control of the adherence to the desired protocol. Most patients were dependent on family assistance to come to intervention sessions, which reduced adherence and follow-through. 3. The researchers do not specify order of interventions or discuss statistical analysis of order effect on results. The potential for recall bias is present because it was not reported whether patients had previously received Anma therapy in their lifetime. Prior experiences (positive and negative) may have affected results and participation levels. A screen to access pre and post attitudes toward Anma therapy might have been appropriate because it is a popular form of complementary and alternative medicine in Japan. CONCLUSIONS State the authors conclusions related to the research objectives. Anma massage can be used as an effective treatment protocol for Parkinson's patients to treat several of the symptoms representative of PD, including subjective symptoms, upper limb function, gait performance, and painful shoulder. Furthermore, these findings imply that stimulation via Anma massage affects not just the location of the body to which Anma is applied, but the central nervous system as well. Because Anma massage therapy is given through clothing, patients do not need to disrobe before treatment, presenting a distinct advantage for treating PD patients with movement difficulties. This work is based on the evidence-based literature review completed by Megan Diamond, OTS; Elizabeth Kubis, OTS; Russell Ramm, OTS; and Rochelle Mendonca, PhD, OTR/L, Faculty Advisor, Temple University. CAP Worksheet adapted from Critical Review Form--Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 8