Massage and Touch for dementia
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
The first objective is to give the best possible assessment of the effectiveness of a range of massage and touch therapies offered to patients suffering from dementia, given the body of published empirical studies of their effects. Since studies of such interventions are still relatively small and heterogenous it is likely that the conclusion on this question will be that there is not enough data of sufficient quality to give any assessment. However, the overview of the research available can make the review a valuable resource for the planning of future studies. Also any information on experienced harmful side effects or practical difficulties will be recorded and systematically presented.
Background
There are many elderly people in the Western world and their number is growing. A considerable fraction of this population develops dementia. This is a cause of suffering and risks for relatives and caregivers as well as for the patients themselves, and requires substantial resources of professional care either in the home or in residential units. A smaller but still significant group of younger patients suffer from early‐onset dementing conditions, e.g. early Alzheimer's disease. A range of pharmacological and non pharmacological interventions are frequently used in order to achieve one or several ends: counteracting the decay of cognitive and/or neurological function, reducing the frequent accompanying problems of depression, anxiety, aggression and related psychological and behavioural manifestations caused by the distress of dementia, improving quality of life, or improving general health and ultimately survival.
Massage and touch are sometimes perceived as belonging to a field of traditional or common‐sense interactions with people ‐ something belonging to a "tacit knowledge" of care that would be a matter of course in a setting that was not institutionalised or professional. However, even if touch therapies only amounted to reintroducing something which has been "lost" in the professionalization and institutionalisation of care, it may still turn out to be a relatively effective, inexpensive and low‐risk intervention in the given setting. Furthermore, it may be that the professionalization and training of massage/touch therapists could have added something beyond an implicit culture of caring touch, in terms of scope or intensity.
A preliminary search for literature revealed a great variety of massage forms studied under a great variety of methodologies. Forms of massage and touch that have been reported to be systematically used in the care of the demented include a spectrum from forms involving deeper manipulation, via stroking and gentle touch, to forms that involve some measure of touching or healing at a distance. Sometimes massage / touch is confined to a particular body part, most frequently hands, but also feet, shoulders, temples, etc., sometimes it is given on larger parts of the body ‐ back, arms, legs, combinations of these, or the full body (Anon 2003; Armstrong 2002; Aveyard 2002; Braverman 1999; Brooker 1997; Bush 2001; Ernst 2003; Field 1998; Gaylord 2002; Giasson 1999; Kilstoff 1998; Kim 1999; Kostrzewa 2000; Malaquin‐Pavan 1997; Meehan 1998; Moraga 2000; Nelson 2001; Opie 1999, Remington 2002; Richards 1996; Roberson 2003; Rowe 1999; Sansone 2000; Scherder 1995; Scherder 1995a; Scherder 1998; Smallwood 2001; Snowden 2003; Snyder 1995; Snyder 1995a; Vanderbilt 2000; Wiles 2003; Woods 2002).
One type of plausible model for explaining a possible positive effect of massage and touch for persons with dementia is that the sensation of touch or proximity has an immediate calming, reassuring influence, mediated, for example, by the production of oxytocin, and hence modifies the symptoms of agitation and mood disorders. Another more psychological model sees touch and massage as a way to provide sensory stimulations which may help activate non verbalized patterns of memories and meanings. Under such assumptions it would be conceivable that massage and touch modalities could also help counteract a progressing decay of cognitive abilities if this decay is at least partly due to lack of use and meaningful stimulation. In any case there seems to be a broad consensus that the potential short‐term effect to be obtained and looked for lies primarily in behaviour, mood and well‐being, while a limited degree of modification of the decay of cognitive competence may be looked for on a longer time scale.
The production of this review will serve to close a "gap" in the series of existing Cochrane Reviews on "complementary" therapies frequently offered to this group of patients (aroma therapy, music therapy, snoezelen). This, again, gives a strategic reason that the review should operate with a sufficiently broad definition of massage and touch related therapies to be able include all the interventions of this family which are actually in use.
Objectives
The first objective is to give the best possible assessment of the effectiveness of a range of massage and touch therapies offered to patients suffering from dementia, given the body of published empirical studies of their effects. Since studies of such interventions are still relatively small and heterogenous it is likely that the conclusion on this question will be that there is not enough data of sufficient quality to give any assessment. However, the overview of the research available can make the review a valuable resource for the planning of future studies. Also any information on experienced harmful side effects or practical difficulties will be recorded and systematically presented.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials will be treated as the only source of "evidence" in the evaluation of treatment effects. Controlled clinical trials, time‐series in which patients serve as their own controls, and studies with other designs will be considered only as a source of information on the existence of treatment modalities, applications and hypotheses.
As the sensation and awareness of touch is likely to be essential to these interventions, study design elements such as placebo control, and blinding of patient and therapist, are probably not relevant, and will not be given positive weight in the review. (However, blinding in the assessment of response will be considered one important element of study quality, and useful information may be obtained from trials comparing a full massage session with a session containing some of its elements only ‐ e.g., aromatic oil alone, or merely talking to the sympathetic therapist.)
No limits are set as to the length of trials or number of measurements, but we will attempt to assess whether the study's main outcome measure stands in a reasonable relationship to the length of trial and number of treatments, as a reflection of the observation that it may be practically interesting to be able to modify "soft" measures of well‐being and behaviour in the short term through a single or a few treatments, while effects on "harder" measures of cognitive ability and general health would seem to be only conceivable and interesting in a longer time perspective.
Types of participants
Patients diagnosed as suffering from dementia of any cause and receiving standard professional care for this condition, in their homes, in hospitals, or in residential institutions.
Types of interventions
Any type of massage and touch, compared with other treatments, no treatment or placebo (if applicable, cf. above.)
This includes regular massage forms ("Swedish", "Esalen" etc.) in which a touch with some pressure is applied in a moving way over parts of the body (typically neck, shoulders or hands), therapies based on finger pressure on specific points (reflexology, shiatsu), and "therapeutic touch" ‐ that is, interventions where the therapist's hands may be held at a short distance from the patient's body rather than in direct physical contact. (By "short distance" we will mean close enough to be perceived by patients as warm, intimate and bodily present ‐ excluding e.g. prayer and distant healing.)
Types of outcome measures
Primarily changes in the frequency and severity of various types of agitated behaviour as observed by staff or investigators (using any rating method, and short‐term as well as long‐term), and in emotional well‐being / quality of life of the patients (rated by any method by staff, investigators and/or patients themselves). Secondarily, outcomes in terms of cognitive abilities, survival, the use of medication, the burden on caregivers, where such data are available.
If the data permit, we will attempt to give overall assessments of overall response via a formal summary of all recorded response types.
It seems likely that there are considerable individual differences in response ‐ descriptive data summaries will address this, if possible in terms of "global response".
Search methods for identification of studies
The CDCIG Specialized trials Register will be requested, for any study related to "massage", "touch", "therapeutic touch", "reflexology", and "shiatsu". This register contains records from all major health care databases and many ongoing trial databases and is update regularly.
Additionally patients' and therapists' organizations will be asked if they know of unpublished data.
Texts in English, French, German, Dutch and Scandinavian can be used directly by the reviewers ‐ we do not expect to find any studies published in other languages, but if necessary we will seek assistance for interpretation.
Almost all published trials on complementary / alternative medicine are less than 20 years old, so it is deemed unnecessary to look further back than the time of coverage of the databases.
Data collection and analysis
All references returned by the searches will be assessed for relevance by 2 reviewers, on the basis of title and abstract. References found potentially relevant by one reviewer will be included at this stage. The criterion of relevance is that studies should involve interventions and participants as described above.
One reviewer, NVH, will maintain a database of all relevant articles, published and unpublished, with abstracts where possible (using RefMan software), and retrieve hard copies of them (with the assistance of the University Library at Aarhus).
An electronic form will be developed (under consultation and testing with all reviewers, and using standard office software ‐ Access and Excel) with fields to enter study types, quantitative and qualitative information about patients and treatments, and assessment of the study's quality and eligibility for statistical analysis/meta analysis with regard to the primary question of treatment effectiveness. This assessment will be performed with a validity/bias score to be constructed and agreed beforehand, along the lines of chapter 8 in the Cochrane Manual (Alderson 2004), by 2 reviewers (TJ, NVH). In case of disagreement about eligibility, the third reviewer (LOE) will be called upon as arbiter.
Studies found to be of insufficient quality (including all non‐RCT studies) will still be included in a descriptive review to produce a systematic overview of intervention types, numbers and characteristics of participants, effect measures, etc.
If any studies are found of sufficient quality to enter statistical analysis, data will be extracted, imported into RevMan, and analysed by methods appropriate according to the form of data (continuous, discrete, series, etc.), again along the lines of the Cochrane Manual (Alderson 2004).
Interpretation of the results will be drafted by NVH and discussed with all reviewers until agreement is achieved.
NVH will undertake to update the review regularly as part of his work for ViFAB.
