They studied 48 Dominican children ages 2-8 with untreated HIV/AIDS, randomizing them to receive twice weekly sessions of either massage or play therapy for 12 weeks. The abstract said that those in the massage group improved in self-help abilities and communication, and that children over the age of 6 showed a decrease in depressive/anxious behaviors and negative thoughts. That’s what the abstract said. The text revealed a more complex story.
One thing that may be irrelevant but that bothered me: there were several errors that should have been caught by an editor, a proofreader, a peer reviewer, or even a spell-checker:
• Caribbean was spelled “Carribean,”
• “…for enhancing varying behavioral and developmental domains” (I have no idea what this means).
• “A second objective of our work was to determine the absence of antiretroviral treatment on the impact of HIV infected Dominican children’s mood and behavior.” (I have trouble even guessing what they meant to say here.)
• “in helping reducing” instead of “in helping reduce”
• “interesting” where it should say “interestingly”
• The abstract referred to 20 minute sessions, but the text said 30 minutes.
When a journal overlooks errors like these, I always wonder if they’ve overlooked more serious errors of science or logic. In this case, it appears that they did.
The introduction usually provides a brief review of the literature and explains the rationale for doing the study. In this case, the rationale was not clear. They seemed to make two main claims for massage: enhancement of immune function and psychological/developmental effects. This study was not designed to assess immune function, but it suggested that improved immune function would improve psychological/developmental outcomes; in fact, it speculated about possible mechanisms for this.
They stated as a fact that massage improves immune function; they failed to acknowledge that the evidence is mixed. Some studies have shown an increase in certain parameters like natural killer cell counts, others have shown no benefits, like this study and this one involving HIV patients.
No study has shown that massage produces any objective improvement in outcome for HIV/AIDS patients.
There is research showing that massage improves outcome for premature babies, but a Cochrane review concluded, “Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage.” Another Cochrane review of normal infants concluded, “The only evidence of a significant impact of massage on growth was obtained from a group of studies regarded to be at high risk of bias.”
Their stated hypothesis was “that Dominican pre-school age children infected with HIV would show improved mood, fewer behavioral problems, and enhanced development following massage therapy.” I don’t think they made a good case that such a hypothesis was plausible.
Each child had 30 minutes of one-on-one interaction with a trained nurse, who either administered a standardized massage protocol or the play therapy protocol, which consisted of giving the child a choice of coloring/drawing, playing with blocks, playing cards, or reading children’s books. Parents were present throughout, and they were interviewed to score the Child Behavior Checklist (CBCL) and Developmental Profile (DP-II).
On the CBCL, on the empirically based scales used to evaluate children under the age of 5, there were no significant differences between the massage and the play groups. (The scales include emotionally reactive, anxious/depressed, somatic complaints, withdrawn, attention problems, aggressive behaviors, other problems and sleep problems.)
For children over the age of 6, they reported “significant” improvements for the massage group in
• anxious/depressed behaviors (p = .026)
• negative thoughts (p=0.059)
• overall internalizing scores (p=0.02)
Note that p=0.059 is above the usual cutoff of p=0.05 and would be reported as not significant by most researchers.
Their definition of significance seems to vary with whether it supports their hypothesis or not. Interestingly, 100% of the children in the play group showed an increase in their score on rule breaking behaviors, significant at a p=<0.05 level. Interestingly, the researchers commented that this significant change “was not clinically meaningful.”(!?)
They characterized a change in IQ data as “marginally significant” for the massage group at p=0.07. Most researchers would simply call anything over p=0.05 not significant.
They only provide part of the data. They do not explain that this checklist involves 8 “syndrome” scores and 3 general scores (total, externalizing and internalizing). So presumably there was no significant difference for 2 of the 3 overall scores, and for the 8 syndrome scores they did not report a significant change in 6, and reported a significant improvement in one and a significant loss in another, which sort of cancelled each other out. Not very impressive.
On the DP-II developmental profile, five areas are assessed: physical, self-help, social, academic, and communication. The massage group showed significant improvements in self-help and communication. The play group showed a significant improvement in social development, while the massage group showed a significant decrease in social development. There were no significant differences in the physical or academic scores. If you add up all the gains and losses on their bar graph (figure 1), it looks like a gain of about 8 points for the massage group compared to a gain of 9 for the play group. It may not be statistically legitimate to draw any conclusions from adding all 5 together, but I’m not sure the inferences the authors draw are legitimate either.
All in all, I don’t find their data very compelling, especially since it is based on subjective caregiver reports and the caregivers were not only not blinded but were present for all the treatment sessions.
They interpreted their data to mean that “massage therapy was effective in reducing maladaptive internalizing behaviors in children aged 6 and older” and that “children 2-8 years of age who received massage demonstrated enhanced self-help and communication skills.” They found it “interesting” that children in the massage group remained at the same social developmental level, suggesting that it was because those children had little or no play activity at home. (Did they? We don’t know.)
They were “puzzled” by their failure to find any effect on behaviors in the under-5 age group because they were so sure massage therapy improves children’s moods and anxiety levels. They tried to rationalize what might have gone wrong.
They commented that “anecdotally, the nurses who conducted the massages reported changes in the children over time, including better mood.”
Their whole discussion gave the impression that they believed in massage and were trying to make it look as good as possible given their marginal data.
They recommended massage therapy as a cost-effective option to improve symptoms and functioning in children with untreated HIV.
What Does This Mean?
The whole idea of treating these children with massage in lieu of drugs is abhorrent. These are children who are going to die, children whose lives might be saved with modern medical treatment. Instead of saving their lives, these researchers propose to give them a cheaper treatment (massage) that at best can only hope to produce small short-term improvements. It is demeaning to these children to treat them like second-class citizens and just accept that they will continue to be denied effective treatment. I won’t call it racism, but some might. At the very least it reminds me of Val Jones’ newly coined “shruggies.” Not our problem. Not in our job description. These kids are doomed, but we can tell their parents to massage them. Massage is good.
They observed that AIDS patients treated with antiretroviral drugs show improvements in cognitive and affective symptoms. They speculate that since the drugs improve immune function, they reduce physical symptoms and improve quality of life, thereby attenuating the psychological impairments caused by the disease. Alternative medicine advocates frequently accuse scientific medicine of treating the symptoms instead of the disease. Here’s a case where science addresses the underlying cause (the HIV virus) whereas massage therapy only attempts to address secondary factors (symptoms and possibly immune function). Even if their premise that massage improves immune function is correct, massage is surely not a very effective way to achieve that.
If this study accomplished anything, it was to highlight the plight of these children who are dying and who need not die. It got full ethical approval from the Institutional Review Board, but was it really ethical? Was this study really justified? Was it designed to improve the lives of these children, or were they used as guinea pigs for massage advocates seeking to justify what they believe in and like to do?
This study reminds us that all children need human interaction, play, touch, and TLC. It does nothing to convince me that massage is a useful therapeutic tool beyond the feel-good and human-interaction effects. It certainly does nothing to justify using massage as an alternative to life-saving anti-AIDS drugs.
The money that was spent on this research might have saved lives if it had been spent instead on getting antiretroviral drugs to these unfortunate children. I know it was not a choice between those two options, but I think it must have been very difficult to stand by and see a child get a research-funded massage knowing that you could have spared the money from your own salary to save that child’s life. I wonder if the researchers have nightmares.
M. Hernandez-Reif, G. Shor-Posner, J. Baez, S. Soto, R. Mendoza, R. Castillo, N. Quintero, E. Perez, G. Zhang (2006). Dominican Children with HIV not Receiving Antiretrovirals: Massage Therapy Influences their Behavior and Development Evidence-based Complementary and Alternative Medicine, 5 (3), 345-354 DOI: 10.1093/ecam/nem032
This article was originally published in the Science-Based Medicine Blog.