Effectiveness of therapeutic massage for generalized anxiety disorder: a randomized controlled trial

Applying an osteopathic intervention to improve mild to moderate mental health symptoms: a mixed-methods feasibility study protocol

INTRODUCTION

Mental health services are stretched in the UK and are in need of support. One approach that could improve mental health symptoms is osteopathy. Research suggests that osteopathy influences psychophysiological factors, which could lead to improvements in mental health. The first objective of this protocol is to investigate the feasibility and acceptability of four osteopathic interventions. A secondary aim is to evaluate the interventions' effectiveness for improving psychophysiological and mental health outcomes.

METHODS AND ANALYSIS

This study will be an explanatory mixed-methods design. Participants will be 30 adults who have mild to moderate mental health symptoms and not experiencing any issues with pain. The feasibility and acceptability of the interventions will be the primary outcomes. Secondary outcomes will be physiological measures including heart rate variability, interoceptive accuracy and blood pressure. Psychological outcomes, collected preintervention and postintervention, will also be measured by five standardised questionnaires, which include: (1) the Depression, Anxiety and Stress Scale (DASS); (2) the International Positive and Negative Affect Schedule-Short-Form; (3) Acceptance and Action Questionnaire-II; (4) the Self as Context Scale and (5) and the Multidimensional Assessment of Interoceptive Awareness Version 2. Participants will be randomised to one of four intervention groups and receive a single intervention treatment session. These intervention groups are: (1) high-velocity and articulation techniques, (2) soft-tissue massage, (3) craniosacral techniques, and (4) a combination of these three approaches. Mixed design two (preintervention and postintervention) by the four interventions analysis of covariance models will be used to analyse the quantitative data for each quantitative measure. Participants will also be interviewed about their experiences of the study and interventions and a thematic analysis will be used to analyse this qualitative data. This will aid the assessment of the feasibility and acceptability of the study design.

ETHICS AND DISSEMINATION

The protocol for this feasibility study has received ethical approval from the Department of Psychology Ethics Committee at Swansea University, ethical review reference number: 2022-5603-4810. Feasibility results from this protocol will be published in a peer review journal and presented at both national and international conferences.

DISCUSSION

This study will assess the feasibility and acceptability of conducting osteopathic interventions for improving mental health outcomes. The results from this will help to inform the development of a future randomised controlled trial. The study will also produce original data which could provide preliminary evidence of whether osteopathic approaches are of benefit to individual's mental health in the form of effect sizes, even if they are pain-free.

TRIAL REGISTRATION NUMBER

NCT05674071.

A preliminary descriptive report of the longevity of the effects of Swedish Massage therapy for subjects with Generalized Anxiety Disorder

OBJECTIVE

Generalized Anxiety Disorder (GAD) is a prevalent and costly disorder, and many patients may prefer non-traditional treatment. A proof-of-concept study demonstrated the efficacy of Swedish Massage Therapy (SMT) as a monotherapy for treatment of GAD. Subjects were followed-up 6-12 months after study completion to evaluate post-treatment outcome.

METHODS

Subjects were enrolled into a randomized, single-masked clinical trial between March of 2012 and May of 2013. Forty-seven untreated subjects with DSM-IV diagnosis of GAD were randomly assigned to 6 weeks of twice-a-week light touch (LT) followed by 6 weeks of twice-a-week SMT, or 12 weeks of twice-a-week SMT. The primary outcome measure was reduction in Hamilton Anxiety Rating Scale (HAM-A) scores after six weeks of SMT versus LT. Qualifying participants received a follow-up survey to investigate whether the benefits of SMT for GAD were sustained.

RESULTS

28 of 40 subjects completed at least 12 sessions of SMT and were sent the follow-up survey. Of the 19 subjects with follow-up, nine (47%) reported no return of GAD symptoms up to 1 year after study completion. There were no differences between those randomized to 12 weeks SMT and those receiving 6 weeks LT followed by 6 weeks SMT. Of those reporting a return of some symptoms, 50% associated symptom return with a stressful life event.

INTERPRETATION

In this first monotherapy trial of SMT for the treatment of GAD, follow-up results suggest that the beneficial effects of SMT may last up to 1 year after end of treatment.

Efficacy of Brahmi vati in generalised anxiety disorder - Randomized double blind comparative clinical trial

Background

Generalized Anxiety Disorder (GAD) is the most common anxiety disorder. GAD has high comorbidities and it can affect social, professional and personal life. Ayurvedic medicine, Brahmi vati is explored for the possible role in management of GAD and is compared to Manasmitra vataka.

Aim

To evaluate the efficacy of B. vati on Generalized Anxiety Disorder.

Methods

A randomized double blind controlled trial, with total 56 patients meeting the DSM V criteria of GAD between 20–60 years of age and either sex participated in the study. Participants were randomly divided into two groups, Brahmi group received capsule B. vati 500 mg and Manasmitra group received capsule M. vataka 500 mg thrice a day with water for 45 days. Assessments were conducted through various clinical parameters such as Hamilton Anxiety Rating Scale (HARS), GAD 7 scale (GAD 7), Beck Depression Inventory scale (BDI), Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), WHO Quality of Life- BREF (WHOQOL-BREF), Clinical Global Improvement scale (CGI). Blood variables including Haemoglobin, Erythrocyte Sedimentation Rate (ESR), Liver Function Test (LFT) and serum creatinine were assessed before and after the study. Assessments during intervention were conducted on every 15th day.

Results

Study results indicate that both B. vati and M. vataka were comparable and each produced significant improvement (p < 0.001) in HARS, GAD-7, BDI, ESS, PSQI, WHOQOL-BREF and CGI. Brahmi vati also produced significant decrease in systolic (p = 0.002) and diastolic (p < 0.001) blood pressure. Both groups showed good safety profile evaluated through the assessment of serum creatinine levels and LFT.

Conclusion

B. vati and M. vataka were effective, safe and comparable in the management of GAD. Warrants further studies.

Mind-Body Interventions for Anxiety Disorders: A Review of the Evidence Base for Mental Health Practitioners

Mind-body interventions have gained increasing popularity for use with anxiety symptoms; however, it is unclear what role they play in the treatment of anxiety disorders, such as generalized anxiety disorder, panic disorder, and social anxiety disorder. Although psychopharmacology and psychotherapy treatment interventions are available, mind-body interventions may be low-stigma options that can serve as effective alternatives. The goal of this review is to provide clinicians with an overview of high-quality studies for the most well researched mind-body interventions. This review involved a search of the primary literature, including meta-analyses, systematic reviews, and randomized controlled trials (RCTs), that evaluated mind-body interventions for the treatment of anxiety disorders. When published evidence was limited, lower-quality studies were reviewed. Overall, data were limited on the efficacy of most mind-body modalities for anxiety disorders. The highest-quality data existed for yoga, mindfulness-based interventions, and applied relaxation for anxiety disorders. However, findings were sometimes inconsistent across studies, and some studies were limited by small sample sizes, poorly defined randomization and blinding procedures, and inadequate control groups. Although not enough data exist to recommend mind-body interventions as primary treatment options, they may be considered as part of a larger treatment plan given their relatively low levels of risk. Future steps for researchers include conducting additional RCTs with adequate control groups, comparing mind-body treatments with existing treatments, and examining long-term effects of mind-body interventions.

Six versus twelve weeks of Swedish massage therapy for generalized anxiety disorder: Preliminary findings

Acute treatment of Generalized Anxiety Disorder often requires 3 months or more of care in order to optimize response. As part of an exploratory grant we have previously demonstrated that six weeks of twice-weekly Swedish Massage Therapy (SMT) was more effective than an active control in decreasing Hamilton Anxiety Rating Scale Scores (HAM-A). An additional goal of this project was to determine if an additional six weeks of twice-weekly SMT led to greater clinical and statistical benefit. We found that HAM-A scores did continue to decrease with an additional six weeks of therapy but that the greatest benefit occurred during the first versus the second 12 sessions (-9.91 vs.-3.09, t = 2.21; df = 10; p = 0.052). These preliminary findings suggest that the majority of benefit in symptom reduction occurs in the first six weeks and that six weeks of twice-weekly SMT may be sufficient for the majority of patients.

Optimal Time of Thermotherapy for Reducing Pain, Anxiety, and Side Effects in Arteriovenous Fistula Puncture Patients: A Randomized Controlled Trial

Chronic renal failure patients undergoing hemodialysis complain of moderate pain from repeated punctures of the arteriovenous fistula. This study examined the optimal application time of thermotherapy for reducing pain, anxiety, and side effects during arteriovenous fistula puncture. This study was conducted as a single-blinded randomized controlled trial. The participants were arteriovenous fistula puncture patients with chronic renal failure who were divided into two thermotherapy groups and one control group. This study was approved by the institutional review board and registered with the Clinical Research Information Service (KCT0003768). Differences between groups regarding pain, anxiety, and side effects were analyzed using one-way ANOVA, the χ² test, and the Scheffé test. A significant difference was observed between the 10-min and 20-min thermotherapy groups and the control group in terms of the pain they experienced. Additionally, more side effects were encountered in the 20-min thermotherapy group than in the 10-min group. The 10-min application of thermotherapy for an arteriovenous fistula puncture showed the same pain-reducing effect as the conventional 20-min application. The study confirmed a 10-min application of thermotherapy to be an effective nursing intervention for pain relief without side effects.

The Trials and Tribulations of Selecting Comparison Groups in Randomized Trials of Nonpharmacological Complementary and Integrative Health Interventions

Editor's Note: For over two decades, JACM Editorial Board member Karen Sherman, PhD has been among the most respected clinical trialists in complementary and integrative health research. The epidemiologist and Senior Researcher at Kaiser Permanente Washington Health Research Institute has focused on pain conditions and has led or been part of teams exploring the roles of such therapies as yoga, acupuncture, mind-body and manual therapies. In this Invited Commentary, Sherman shares wisdom gleaned from the process: trial designs, principles for selecting controls, benefits and liabilities of placebo and sham controls, attention controls, usual care controls, and more. She also discusses the effects of comparison groups on sample sizes, comparison groups for mechanistic studies, and other comparison groups' considerations. This commentary should prove a useful primer wherever research methods in complementary and integrative health are taught. We are pleased to offer it here through JACM. -John Weeks, Editor-in-Chief, JACM (johnweeks-integrator.com).

A community-based survey on massage therapy in Saudi Arabia

Massage therapy (MT) is the physical manipulation of the soft tissues. It primarily consists of manual or hands-on techniques such as applying fixed or movable pressure, holding, and moving muscles and body tissues. MT is beneficial for pain relief, sport-related injury rehabilitation, stress reduction, and to address psychological disorders. MT is the most prevalent form of complementary and alternative (CAM) therapy worldwide. The aim of this study was to evaluate the knowledge, attitudes, and perceptions regarding MT among the Saudi community. A cross-sectional online survey using WhatsApp©, Google Forms©, Facebook©, and Twitter© was conducted among the general community of the Kingdom of Saudi Arabia (KSA) to assess the knowledge, attitudes, and perceptions regarding MT. Data was collected using a 20-item, self-administered questionnaire consisting of a series of both closed-ended and Likert-type questions. A total of 436 respondents completed the survey. Most of the respondents were female 84.2% (n = 367). Approximately 65% resided in the central region of KSA. The majority of the respondents, 81.4%, believed that MT is effective, 27.7% thought that MT leads to complications, and more than half of the residents, 55.7%, believed that patients should consult with their physicians prior to MT. The most common reasons for MT were to treat muscle pain, for relaxation purposes, to treat bone and joint pain, and backache relief, which were reported by 49%, 20%, 19%, and 16% of the participants, respectively. The knowledge, attitudes, and perceptions of the Saudi population towards MT are insufficient in some aspects. The establishment of community-based health education programs to improve knowledge of MT is recommended.

Complementary and Alternative Medicine Treatments for Generalized Anxiety Disorder: Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The objective was to evaluate efficacy/safety of complementary and alternative medicine (CAM) methods for generalized anxiety disorder (GAD) based on randomized controlled trials in adults.

METHODS

Data sources. Six electronic databases ("generalized anxiety (disorder)" and "randomized trial") and reference lists of identified publications were searched to March 2017.

STUDY SELECTION

Eligibility: full-text publications (English, German language); CAM versus conventional treatment, placebo/sham or no treatment; GAD diagnosed according to standard criteria; and a validated scale for disease severity. Of the 6693 screened records, 32 were included (18 on biologically-based therapies, exclusively herbal preparations; eight on manipulative and body-based therapies; and three on alternative medical systems and three on mind-body therapies).

DATA EXTRACTION

Cochrane Collaboration methodology was used for quality assessment and data extraction.

RESULTS

Direct comparisons of Kava Kava (Piper methysticum) extracts to placebo (4 quality trials, n = 233) were highly heterogeneous. Network meta-regression reduced heterogeneity and suggested a modest Kava effect [end-of-treatment Hamilton Anxiety scale score difference adjusted for baseline scores and trial duration: - 3.24 (95% CI - 6.65, 0.17; P = 0.059), Kava Kava 4 arms, n = 139; placebo 5 arms, n = 359]. Lavender (Lavandula angustifolia) extract (1 quality trial, 10 weeks, n = 523) and a combination of extracts of C. oxycantha, E. californica and magnesium (1 quality trial, 12 weeks, n = 264) were superior to placebo and balneotherapy was superior to paroxetine (1 quality trial, 8 weeks, n = 237) indicating efficacy. All other trials were small and/or of modest/low quality and/or lacked assay sensitivity. Safety reporting was poor.

CONCLUSION

Evidence about efficacy/safety of most CAM methods in GAD is limited. Apparent efficacy of certain herbal preparations and body-based therapies requires further confirmation.

Massage Therapy for Psychiatric Disorders

This article reviews the current state of knowledge of the role of massage therapy in the treatment of common psychiatric disorders and symptoms. It briefly discusses the prevalence of psychiatric disorders and the popularity of complementary and integrative treatments in the general population. The authors touch on the growing literature describing the biology and neurobiology of massage therapy. The impact of massage as both a therapy for major psychiatric disorders and a treatment for psychiatric symptoms is reviewed, and how massage therapists conceptualize and treat their patients with psychiatric complaints is discussed. If psychiatrists are going to partner with massage therapists, they need to understand how massage therapists' perspectives differ from those of traditional practitioners of allopathic medicine. A model of how psychiatrists and other mental health professionals can work with massage therapists to care for patients is proposed, followed by a summary of the article's key points.

The Effect of Slow-Stroke Back Massage on the Anxiety Levels of Iranian Women on the First Postpartum Day

Background

Anxiety disorder is common during the postpartum period. Back massage relaxation techniques are one of the most important nonpharmacological interventions to prevent and control postpartum-related anxiety.

Objectives

To determine the effectiveness of slow-stroke back massage on the anxiety levels of primiparous mothers in the first days after delivery.

Materials and Methods

This single-blind controlled clinical trial consisted of 100 primiparous mothers with normal deliveries. The mothers were randomly allocated to interventional (n = 50) or control (n = 50) groups using binary blocks. Both groups were followed up just before, immediately after, and the morning after the intervention. Data were collected using a demographic questionnaire and Spielberger’s state anxiety inventory (STAI) questionnaire.

Results

The mean age of the mothers was 22 years. There were no significant between-group differences in age (P = 0.333), education (P = 0.427), and medication during labor and the postpartum period (P = 0.412). There was no statistically significant difference between the mean anxiety scores of the experimental (6.66 ± 35.48) and control groups (9.05 ± 37.42) before the intervention (P = 0.268). Immediately after the massage and the next morning, there was a significant between-group difference in the anxiety scores (P < 0.001).

Conclusions

The findings demonstrate that slow-stroke back massage is a simple, inexpensive, noninvasive, and effective method to reduce the anxiety levels of primiparous women during the first postpartum day.

Evolving with modern technology: Impact of incorporating audiovisual aids in preanesthetic checkup clinics on patient education and anxiety

BACKGROUND AND AIMS

Perioperative stress is an often ignored commonly occurring phenomenon. Little or no prior knowledge of anesthesia techniques can increase this significantly. Patients awaiting surgery may experience high level of anxiety. Preoperative visit is an ideal time to educate patients about anesthesia and address these fears. The present study evaluates two different approaches, i.e., standard interview versus informative audiovisual presentation with standard interview on information gain (IG) and its impact on patient anxiety during preoperative visit.

SETTINGS AND DESIGN

This prospective, double-blind, randomized study was conducted in a Tertiary Care Teaching Hospital in rural India over 2 months.

MATERIALS AND METHODS

This prospective, double-blind, randomized study was carried out among 200 American Society of Anesthesiologist Grade I and II patients in the age group 18-65 years scheduled to undergo elective surgery under general anesthesia. Patients were allocated to either one of the two equal-sized groups, Group A and Group B. Baseline anxiety and information desire component was assessed using Amsterdam Preoperative Anxiety and Information Scale for both the groups. Group A patients received preanesthetic interview with the anesthesiologist and were reassessed. Group B patients were shown a short audiovisual presentation about operation theater and anesthesia procedure followed by preanesthetic interview and were also reassessed. In addition, patient satisfaction score (PSS) and IG was assessed at the end of preanesthetic visit using standard questionnaire.

STATISTICAL ANALYSIS USED

Data were expressed as mean and standard deviation. Nonparametric tests such as Kruskal-Wallis, Mann-Whitney, and Wilcoxon signed rank tests, and Student's t-test and Chi-square test were used for statistical analysis.

RESULTS

Patient's IG was significantly more in Group B (5.43 ± 0.55) as compared to Group A (4.41 ± 0.922) (P < 0.001). There was significant reduction in total anxiety from the baseline values in both the groups. This reduction was significantly more in Group B (8.47 ± 1.861) as compared to Group A (9.29 ± 1.616) (P < 0.001). PSS was also more in Group B (29.27 ± 2.378) as compared to Group A (25.62 ± 1.745) (P < 0.001).

CONCLUSION

Audiovisual presentation provides unhurried, detailed, and reliable information about the perioperative environment and anesthesia procedure. This helps in significant IG and reduction of patient anxiety.

Process for massage therapy practice and essential assessment

BACKGROUND

Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice.

METHODS

31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes.

RESULTS

Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded.

DISCUSSION

Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed.

CONCLUSION

The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.

Immediate Effects of Traditional Thai Massage on Psychological Stress as Indicated by Salivary Alpha-Amylase Levels in Healthy Persons

BACKGROUND Stress can cause psychological and physiological changes. Many studies revealed that massage can decrease stress. However, traditional Thai massage has not been well researched in this regard. The purpose of this study was to investigate the immediate effects of traditional Thai massage (TTM) on salivary alpha-amylase levels (sAA), heart rate variability (HRV), autonomic nervous system (ANS) function, and plasma renin activity (PRA). MATERIAL AND METHODS Twenty-nine healthy participants were randomly allocated into either a traditional Thai massage (TTM) group or Control (C) group, after which they were switched to the other group with a 2-week wash-out period. Each of them was given a 10-minute mental arithmetic test to induce psychological stress before a 1-hour session of TTM or rest. RESULTS Within-groups comparison revealed that sAA was significantly decreased (p<0.05) in the TTM group but not in the C group. HRV and ANS function were significantly increased (p<0.05) and PRA was significantly decreased (p<0.05) in both groups. However, low frequency per high frequency ratio (LF/HF ratio) and ANS balance status were not changed. Only sAA was found to be significantly different between groups (p<0.05). CONCLUSIONS We conclude that both TTM and rest can reduce psychological stress, as indicated by decreased sAA levels, increased parasympathetic activity, decreased sympathetic activity, and decreased PRA. However, TTM may have a modest effect on stress reduction as indicated by a reduced sAA.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Naturopathic reflex therapies for the treatment of chronic back and neck pain - Part 1: Neurobiological foundations

Evidence from recent RCT's has shown that naturopathic reflex therapies such as massage, Gua Sha massage, cupping, wet packs, or rhythmic embrocation etc. are helpful in reducing symptoms of chronic pain. These bodily oriented therapies are likely able to influence chronic pain not only through brain mechanisms such as expectation or the feeling of well-being, but also through mechanisms at the level of the peripheral nociceptor and the spinal cord. However, the neurobiological basis of these effects has rarely been investigated even though the accumulating knowledge of the pathophysiology of chronic pain syndromes allows for developing specific hypotheses. This essay discusses specific reflex therapies (cupping, Gua Sha massage, classical massage, and rhythmic embrocation) and their possible mechanisms of action via ascending pathways to the brain.

Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial

Background

In a previous trial of massage for osteoarthritis (OA) of the knee, we demonstrated feasibility, safety and possible efficacy, with benefits that persisted at least 8 weeks beyond treatment termination.

Methods

We performed a RCT to identify the optimal dose of massage within an 8-week treatment regimen and to further examine durability of response. Participants were 125 adults with OA of the knee, randomized to one of four 8-week regimens of a standardized Swedish massage regimen (30 or 60 min weekly or biweekly) or to a Usual Care control. Outcomes included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analog pain scale, range of motion, and time to walk 50 feet, assessed at baseline, 8-, 16-, and 24-weeks.

Results

WOMAC Global scores improved significantly (24.0 points, 95% CI ranged from 15.3–32.7) in the 60-minute massage groups compared to Usual Care (6.3 points, 95% CI 0.1–12.8) at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analog pain scale also demonstrated significant improvements in the 60-minute doses compared to usual care. No significant differences were seen in range of motion at 8-weeks, and no significant effects were seen in any outcome measure at 24-weeks compared to usual care. A dose-response curve based on WOMAC Global scores shows increasing effect with greater total time of massage, but with a plateau at the 60-minute/week dose.

Conclusion

Given the superior convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, establishing a standard for future trials.

Trial Registration

ClinicalTrials.gov NCT00970008