Improving Provider Awareness and Utilization of Massage Therapy in Treating Post-Traumatic Stress Disorder (PTSD)

On average, 23% of veterans are diagnosed with post-traumatic stress disorder, (PTSD) and 22 veterans die from suicide each day (U.S. Department of Veterans Affairs, 2018) as a result of it. Current first-line treatment for PTSD is psychotherapy to address the cognitive patterns associated with PTSD. Second-line treatment is pharmacologic interventions to treat the biological symptoms. The corticolimbic circuit is affected in PTSD, leading to such common symptoms as increased fear learning, hyperarousal, numbing, agitation, lack of trust, flashbacks, and avoidance. Massage therapy has been shown to modulate the corticolimbic circuit resulting in stress relief, improved mood, and reduced aggression. Evidence suggests that massage therapy helps to alleviate both physical and mental health ailments, treating the mind and body in unison, which leads to better outcomes, particularly in trauma survivors. The goal of this DNP project was to increase VA outpatient mental health care providers' understanding about the benefits of massage therapy, resulting in an increased use of massage in PTSD treatment plans. Firstly, a comprehensive survey was administered to identify providers' existing awareness of, and confidence in, massage therapy in helping treat PTSD. An educational session was then presented to providers to encourage them to enroll patients in massage therapy. Information regarding the referral process within the VA system was also provided. The project's effectiveness was measured by mental health providers' knowledge of the benefits of massage therapy, using pre- and post-education surveys and increased referral to massage therapy services. Based on the results, the education sessions were successful at increasing awareness about the benefits of massage therapy and health care provider willingness to include massage therapy in treatment plans. The pre-education survey demonstrated an overall mental health provider awareness that PTSD is not adequately treated with current treatment options. Additionally, the majority of the mental health providers did not find long-term psychopharmacology treatments for PTSD to be superior to mind-body-based intervention. The post-education survey demonstrated a statistically significant difference of 48.8% increase in provider knowledge of massage therapy as an effective treatment option for PTSD. Health care providers demonstrated 52.7% increased knowledge of how massage therapy can alleviate symptoms of PTSD and 37.6% enhanced belief that they should include massage therapy among treatment recommendations. They also expressed a desire for future advancements in the use of massage therapy as a treatment option for PTSD. a willingness to refer veterans suffering from PTSD to a properly trained massage therapist. Four providers stated they had made referrals to massage therapy, and six providers stated they had included massage therapy in their treatment plan, compared to zero referrals pre-education. Despite a fairly small sample size in this project, the education sessions increased health care provider knowledge about the benefits of massage therapy. This project requires minimal funding by enriching knowledge through provided education module and utilizing current massage therapists or community referrals.

Running Head: MASSAGE THERAPY AND PTSD Improving Provider Awareness and Utilization of Massage Therapy in Treating Post-Traumatic Stress Disorder (PTSD) Allyson Taylor The University of Utah College of Nursing MASSAGE THERAPY AND PTSD 2 Abstract Improving Provider Awareness and Utilization of Massage Therapy in Treating Post-Traumatic Stress Disorder (PTSD) On average, 23% of veterans are diagnosed with post-traumatic stress disorder, (PTSD) and 22 veterans die from suicide each day (U.S. Department of Veterans Affairs, 2018) as a result of it. Current first-line treatment for PTSD is psychotherapy to address the cognitive patterns associated with PTSD. Second-line treatment is pharmacologic interventions to treat the biological symptoms. The corticolimbic circuit is affected in PTSD, leading to such common symptoms as increased fear learning, hyperarousal, numbing, agitation, lack of trust, flashbacks, and avoidance. Massage therapy has been shown to modulate the corticolimbic circuit resulting in stress relief, improved mood, and reduced aggression. Evidence suggests that massage therapy helps to alleviate both physical and mental health ailments, treating the mind and body in unison, which leads to better outcomes, particularly in trauma survivors. The goal of this DNP project was to increase VA outpatient mental health care providers' understanding about the benefits of massage therapy, resulting in an increased use of massage in PTSD treatment plans. Firstly, a comprehensive survey was administered to identify providers' existing awareness of, and confidence in, massage therapy in helping treat PTSD. An educational session was then presented to providers to encourage them to enroll patients in massage therapy. Information regarding the referral process within the VA system was also provided. The project's effectiveness was measured by mental health providers' knowledge of the benefits of massage therapy, using pre- and post-education surveys and increased referral to massage therapy services. MASSAGE THERAPY AND PTSD 3 Based on the results, the education sessions were successful at increasing awareness about the benefits of massage therapy and health care provider willingness to include massage therapy in treatment plans. The pre-education survey demonstrated an overall mental health provider awareness that PTSD is not adequately treated with current treatment options. Additionally, the majority of the mental health providers did not find long-term psychopharmacology treatments for PTSD to be superior to mind-body-based intervention. The post-education survey demonstrated a statistically significant difference of 48.8% increase in provider knowledge of massage therapy as an effective treatment option for PTSD. Health care providers demonstrated 52.7% increased knowledge of how massage therapy can alleviate symptoms of PTSD and 37.6% enhanced belief that they should include massage therapy among treatment recommendations. They also expressed a desire for future advancements in the use of massage therapy as a treatment option for PTSD. a willingness to refer veterans suffering from PTSD to a properly trained massage therapist. Four providers stated they had made referrals to massage therapy, and six providers stated they had included massage therapy in their treatment plan, compared to zero referrals pre-education. Despite a fairly small sample size in this project, the education sessions increased health care provider knowledge about the benefits of massage therapy. This project requires minimal funding by enriching knowledge through provided education module and utilizing current massage therapists or community referrals. MASSAGE THERAPY AND PTSD 4 Introduction Problem Description Post-traumatic stress disorder (PTSD) is a serious and potentially debilitating mental health condition that affects around eight million Americans (Reisman, 2016). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria define PTSD with five core features: 1) a person experienced or was exposed to an act of violence, assault, or death; 2) a traumatic event is persistently re-experienced; 3) a person avoidance of trauma-related stimuli, thoughts, or feelings; 4) a person experiences negative thoughts/feelings/affect and exaggerated blame toward self/others; and 5) a person has traumarelated arousal and reactivity, irritability or aggression, hypervigilance/startle reaction, difficulty concentrating, and difficulty sleeping (U.S. Department of Veterans Affairs, 2018). These symptoms can also lead to dissociation expressed in depersonalization or derealization (U.S. Department of Veterans Affairs, 2018). Additionally, these symptoms last longer than a month, cause a decrease in daily functionality, and have no other known cause (U.S. Department of Veterans Affairs, 2018). By understanding how PTSD affects the brain, appreciation of how massage may help treat this condition will be enhanced. The corticolimbic circuit is affected in PTSD; the prefrontal cortex (PFC), hippocampus, and amygdala are all activated to create neural pathways that increase fear learning and fear consolidation (Steckler & Risbrough, 2012). The hypothalamic-pituitary-adrenal (HPA) axis is responsible for the hyperactive stress response and increased cortisol associated with PTSD (Steckler & Risbrough, 2012). The common PTSD symptoms that require treatment are hyperarousal, numbing, agitation, lack of trust, flashbacks, MASSAGE THERAPY AND PTSD 5 avoidance, and disconnection of bodily sensations, which are created from the corticolimbic circuit being consolidated (Hoskins, et al., 2015). PTSD occurs in almost a quarter of our veterans (23%) (U.S. Department of Veterans Affairs, 2018). Stigma surrounding mental illness, along with lack of access to services, prevent many veterans from seeking help for their mental illness. The rate of suicide among veterans in 2015 was approximately 38/100,000. This may not seem like a large number, but this total is 22% more deaths than in the general population (U.S. Department of Veterans Affairs, 2018). Further, this disorder is often accompanied by multiple comorbidities, including depression, anxiety, and substance abuse (Hoskins et al., 2015). Chronic pain accompanies many of these conditions; 15-35% of veterans with pain have PTSD (Reisman, 2016). Further, veterans have significantly higher levels of pain intensity and pain-related disability, in addition to psychosocial disability (Ravn, Vaegter, Cardel, & Andersen, 2018). On average, each veteran cost about $8,300 per year, those suffering from PTSD cost 3.5 times more than others without PTSD, which is a heavy economic burden (Reisman, 2016). Available Knowledge Psychotherapy is considered a first-line treatment option for PTSD (Reisman, 2016). Cognitive processing therapy (CPT), prolonged exposure (PE), and eye-movement desensitization and reprocessing (EMDR) are considered to be the best treatment options for PTSD (Reisman, 2016). However, many veterans do not want to relive their experience, and thus they do not participate in psychological interventions. Additionally, stigma prevents veterans from seeking help in fear of appearing "weak," although this is clearly not the case. Currently, Paxil, Prozac, and Zoloft are the only FDA-approved medications for PTSD (Hoskins et al., 2015). These medications have "adverse effects including GI upset, feeling MASSAGE THERAPY AND PTSD 6 emotionally numb, sexual problems and weight gain" (Cartwright, Gibson, & Dehar, 2016, p. 1401). Additional serious side effects include suicidality and serotonin syndrome, both potentially life-threatening conditions (Cartwright, Gibson, & Dehar, 2016). The adverse and serious side effects with medications also contribute to poor adherence, further contributing to subpar mood management. Approximately 60% of patients respond to the treatment, and only about 20-30% of patients will achieve full remission (Steckler & Risborough, 2012). This lack of efficacy demonstrates the limitations with current pharmacotherapy options. As previously mentioned, pharmacotherapy is not the first-line treatment option due to the inconsistent results and undesirable side effects (Cusack, 2016). Health care providers are interested in finding a new medication specifically for PTSD (Reisman, 2016). Additionally, research demonstrates that the benefit of the medications has a small positive effect compared to the placebo; "mean reduction in PTSD symptoms of those on placebo was greater than 40%" (Hoskins, et al., 2015, p. 95). This suggests minimal benefit from these medications, beyond placebo effect, if any at all. The World Health Organization (WHO) and Australian guidelines have been updated stating pharmacological interventions are not preferential of PTSD over psychological treatments (Hoskins et al., 2015). Thus, exclusive reliance on pharmacological treatments for PTSD can lead to detrimental side effects and longterm poor treatment responses. Therapeutic treatment options are limited to the above options, which is marginally helpful with minimizing the retrieval of aversive memories or treating the extinction of the fearrelated memories. Further, increased somatization and chronic pain are common PTSD symptoms that do not respond to the standard treatment plan and contribute to depressive disorder (Siqveland, Ruud, & Hauff, 2017). Standard treatment modalities currently target MASSAGE THERAPY AND PTSD 7 biological and cognitive symptoms, but few integrate the somatic response, thus failing to treat the person as a whole. Rationale The Theory of Planned Behavior looks at attitudes and how providing education leads to a behavior change (Ajzen, 1991). In this conceptual framework, attitudes refer to whether a person considers the topic (massage therapy) to be positive or negative, whereas behavior intention looks at the motivation or intent to perform the request (refer veterans for massage therapy treatments). By observing each of these subparts in the learning process, interventions and increased education can focus on improving health care providers' motivation to include massage therapy in the multidisciplinary treatment plan. Research demonstrates that massage therapy modulates the amygdala, hypothalamus, and anterior cingulate cortex- the areas involved in regulating stress and emotion (Field, 2014). Massage has been shown to decrease cortisol and increase serotonin and dopamine (Field, 2014). Additionally, massage therapy has been shown to reduce aggression, increase acceptance and trust, reconnect the mind and body, and decrease numbing, dissociation, and chronic pain (Gonçalves, Voos, de Almeida, & Caromano, 2017). In the study, "Dissociation Reduction In Body Therapy During Sexual Abuse Recovery," (2006, p. 8), it was discovered that, "individuals who had elevated dissociation experiences at baseline also experienced elevated psychological and physical distress, and less body connection at baseline." Massage therapy has been shown to significantly decrease dissociation across time, leading to increased psychological and physical well-being (Price, 2006). Further, individuals experience an increased ability to be present in the moment, allowing greater awareness of body sensations and enhancing the mind-body connection. Massage therapy facilitates healing MASSAGE THERAPY AND PTSD 8 emotional memories in the body, leading to the release of both tension and pain to produce a more coherent sense of self (McCafferty, 2016). "Another recent study of Somali women refugees with chronic pain-the majority of whom reported military and/or sexual trauma- found that massage therapy provided enormous relief for distressing physical and psychological symptoms largely attributed to the exposure to trauma" (McCafferty, 2016, para. 17.). Further, Collinge, Kahn, and Soltysik (2012) report a highly significant reduction after massage in physical pain, physical tension, irritability, anxiety/worry, and depression. Massage therapy allows for an increased awareness of lifestyle, mind, and body. A growing body of evidence suggests that massage therapy may increase perceptions of control over pain and self-efficacy for managing pain (Eaves et al., 2015). Combining massage therapy with other body awareness treatments results in a 73% improvement on the PTSD ChecklistCivilian Version (PCL-C) (a common PTSD screening tool), a 72% increase in partner compassion, and a 74% increase in self-compassion (Collinge, Kahn, & Soltysik, 2012). This evidence suggests that massage therapy helps to alleviate both physical and mental health ailments, treating the mind and body in unison, and resulting in better outcomes, particularly in trauma survivors. Therefore, massage therapy may offer a novel and underutilized treatment approach to counteract the core pathology of PTSD symptoms. Specific Aims The goal of this DNP project is to increase health care providers' understanding about the benefits of massage therapy, resulting in an increased use of massage in PTSD treatment plans. Increased awareness and use of massage will be achieved by providing more education to providers treating PTSD regarding mental health benefits and proper implementation of massage MASSAGE THERAPY AND PTSD 9 therapy for PTSD and associated comorbidities, with the goal of increasing referral of veterans for massage therapy to reduce PTSD symptoms. Methods Context The George E. Wahlen Department of Veterans Affairs Medical Center (VA) is an urban outpatient mental health clinic treating veterans who have served in the military and are suffering from mental health ailments. This clinic consists of clinical providers who treat veterans suffering from PTSD (as well as other mental health conditions), including psychiatrists (6), nurse practitioners (14), social workers (14), and psychologists (8). Teams are created for continuity of care and consist of a combination of providers. In 2018, this clinic treated over 7,000 veterans suffering from PTSD, of which 1,305 received individual therapy and 560 joined PTSD groups (VA, 2018). Intervention(s) In order to correctly identify mental health providers' awareness of and confidence in massage therapy in helping treat PTSD, a pre-education survey was administered to all mental health providers in this Outpatient Mental Health Clinic (OPMHC). This survey provided information about their perceived barriers to massage therapy referrals, focusing particularly on their attitudes. PowerPoints and handouts were used as educational tools aimed at improving mental health providers' attitudes about making referrals for massage therapy. Educational training sessions were delivered at a team meeting and a prescriber meeting. Providers received a post-education survey to determine the effectiveness of the training program. Further, they received another survey two months after training to ask if they had increased their referrals to MASSAGE THERAPY AND PTSD 10 massage therapy. Per the feedback from the training program, we developed an educational module and referral protocol that could be submitted to stake holders. Study of the Intervention(s) The effect of using massage therapy as a treatment option in treating PTSD was determined by the change in referrals for massage therapy. Also, increasing providers' level of self-reported knowledge increased the validity and acceptability of massage therapy as a treatment modality. Comparing the number of referrals for massage therapy two months before the education module (0) to the number of self-reported referrals sent after the education module (4) provided a basic understanding of providers' attitude toward and belief in the efficacy of massage therapy for an adjunct treatment option. Measures Descriptive statistics were used to describe mental health providers' attitudes toward referring veterans to massage therapy for PTSD using surveys. A training program was delivered during APRN and team meetings and is likely to be supported by standard VA referral protocol and clinical guidelines. The executive report of findings from objectives 1 and 2 (Figure 1), demonstrates the evidence of mental health providers' increased willingness to refer their patients to massage therapy, and how likely they are to refer the next veteran to massage therapy. Data collected from the electronic health recording, tracking "Massage therapy" referrals and administering a survey of self-reported referrals three months post education demonstrated an improvement in massage therapy referral rates from mental health providers. Analysis MASSAGE THERAPY AND PTSD 11 The Wilcoxon signed rank test was used to measure the change in massage therapy referrals and provider self-reported knowledge level regarding the validity and acceptance of massage as a treatment modality and how willing providers are to make a referral for massage therapy pre- versus post-education. Quantitative data were collected using a Likert scale indicating the degree of agreement to each of the survey questions. We collected basic descriptive data about the referring providers (age, gender, race, years of employment, highest degree, role in treatment). A chart audit was conducted to obtain pre-education massage therapy referrals from the outpatient mental health clinic (zero veterans), and a post-education selfreported survey was administered to determine the number of veterans referred to massage therapy by mental health providers. Ethical Considerations The University of Utah and Veterans Affairs Institutional Review Board determined this study to be nonhuman subjects research. No conflicts of interest are claimed for this research. An experienced massage therapist will ensure that each veteran's unique boundaries of what they feel is appropriate during the massage are not crossed, the veterans receiving massage are in control of their treatment, excessive vulnerabilities are not exposed, and trust and safety are achieved. Further, the therapy will be done in conjunction with psychotherapy, so the veterans can effectively process their trauma. The massage therapist must ensure that the Code of Ethics, which defines the standard of care for massage therapists, is never compromised, thus protecting the client. Results Two education sessions were provided in a team meeting and a prescriber meeting to 28 mental health care providers: advanced practice nurses (53.6%), licensed social workers (3%), MASSAGE THERAPY AND PTSD 12 psychiatrists (2%), psychologists (7.1%) PhD/MSW interns (2%), registered nurses (3%), and a vocation rehabilitation provider (1%) (Table 4). Their ages ranged from 28-65, with an mean age of 43.8 (Table 4). They had worked in mental health for less than one year to 42 years, with a mean of 11.48 years (Table 4). The surveys were completed by primarily Caucasian (70%) females (66.7%) (Tables 4). Their educational background ranged from bachelor's degree to doctoral degree, with most (14) having a degree in Master of Science in Nursing (Table 4). The pre-education survey was given immediately before the training session, with the post-education survey administered immediately after the training session on the same day. Each survey had nine questions, with a final question allowing for additional comments. The pre- and post-survey were measured on a 1-4 Likert scale reflecting "completely disagree" to "completely agree," with 0 reflecting undecided. The survey response rate was 100% for the pre-education survey and 96% for the post education survey. Statistical significance was determined using the Wilcoxon Signed Rank Test. The pre-education survey demonstrated an overall awareness that PTSD is not adequately treated with current treatment options (mean 1.89 ±1.286). Additionally, the majority of the mental health providers did not find long-term psychopharmacology treatments for PTSD to be superior to mind-body-based intervention (Pre-mean 1.39± 0.956, post-mean 1.70 8±1.644). The pre-education survey also demonstrated an undecided opinion regarding the effectiveness of massage therapy in treating PTSD (mean 0.75 ±1.236), along with whether, or not health care professionals should include massage therapy in treatment plans (mean 1.18 ± 1.307). Interestingly, the pre-survey showed a desire for advancements in the use of massage therapy as a treatment option for PTSD (mean 2.32±1.416) (Tables 1 and 1.2). MASSAGE THERAPY AND PTSD 13 The post-education survey demonstrated a statistically significant difference in provider knowledge of massage therapy as an effective treatment option for PTSD (0.001) (Table 2). Providers demonstrated increased knowledge about how massage therapy can alleviate symptoms of PTSD (0.000) (Table 2), an increased belief they should include massage therapy among treatment recommendations (0.024) (Table 2), a desire for further advancements in the use of massage therapy as a treatment option for PTSD (0.007) (Table 2), and a willingness to refer veterans suffering from PTSD to a properly trained massage therapist (0.030) (Table 2). A concern and comment section were provided in both pre- and post-education surveys for an increased understanding of the beliefs and attitudes toward massage therapy. The presurvey comments concerned the veterans' potential apprehension to touch, hypervigilance and discomfort with proximity, efficacy of massage therapy (particularly as monotherapy), how an emotional release would be handled during the massage session, research supporting this modality, as well as whether, or not massage would treat other diagnoses. The post-education survey demonstrated that providers wanted veterans to have more access to massage therapy in the VA system, a referral system, and more user-friendly consultations. Also, they noted that research did not demonstrate how long the effects from massage would last. The second training presentation was modified to share PowerPoint notes with providers that included detailed instructions about how massage therapy referrals can be placed within the VA system. The clinic has a massage therapy referral system in place, although most referrals are sent out into the community versus receiving treatment within the VA, which could potentially decrease the number of appropriately trained massage therapists and access to them. Provider comments identified that it is difficult to refer veterans for massage therapy based on mental health ailments versus physical ailments. Further, comments identified a MASSAGE THERAPY AND PTSD 14 dissatisfaction with the referral process and how daunting it felt. However, post-education, the number of providers knowing how to enter referrals in the VA system increased (sig 0.011) (Table 2). One post-education questionnaire was not completed. EHR data demonstrate 0 massage therapy referrals three months prior to the education. Three months later, the post-education survey indicated six providers had included massage therapy in their treatment recommendation, 10 providers thought about including massage therapy in their treatment recommendation, and four mental health providers reported they put in a VA referral for their veteran (Table 6). Discussion Summary The results demonstrate the education sessions were effective in increasing mental health providers' knowledge of how massage therapy may be a beneficial treatment option for PTSD, with a statistically significant change in six of the nine survey questions regarding massage therapy. Only 3.6 % (compared to 10.7% pre-education) of the providers did not agree that massage therapy is an effective treatment option for PTSD post-education. Further, this project was effective in boosting mental health providers' desire for more education and research supporting massage therapy as an adjunct treatment modality for mental health ailments. The education session ultimately increased referrals during the determined the three-month follow-up period, demonstrating providers' willingness to refer patients for massage therapy. However, the follow-up referral survey comments demonstrated that one provider forgot about massage therapy, the daunting referral process, and the delay in getting the veterans access to a massage therapist as barriers to referring veterans to massage therapy. Despite this, there was a noted MASSAGE THERAPY AND PTSD 15 increase in self-reported referrals to massage therapy; from zero to four in the three-month follow up survey. Therefore, implementing the education training sessions during Team 2 and APRN prescriber meetings was an effective method to increase knowledge about the benefits of massage therapy in treating PTSD, along with other mental health conditions. However, the frequency of education sessions may need to be increased to sustain awareness. Despite the daunting referral process and decreased access for properly trained massage therapists within the VA system, 78.6% (compared to 57.2% pre-education) of the mental health providers were willing to refer veterans to massage therapy. To address the access issue, the VA is offering community referrals for massage therapy to contracted outside facilities. This project is unique in assessing a variety of practicing mental health provider- doctors, nurse practitioners, psychologists, and social workers-and their knowledge and willingness to refer veterans to massage therapy. Additionally, it is unique in representing mental health providers desire for increased research regarding the benefits of massage therapy, particularly for PTSD, as well as other mental health conditions. This project directly demonstrates the need for more empirical research about massage therapy and the benefits it may have for mental health conditions. Interpretation The training modules were an effective approach to increasing knowledge about and acceptance of massage therapy in treating PTSD, which increased providers' willingness to refer veterans for treatment. It was expected to see a higher rate of referrals for PTSD following the education sessions. To follow up on this project, additional education sessions with the different teams and continued monitoring of increased referrals for massage therapy may provide further MASSAGE THERAPY AND PTSD 16 referrals and heightened knowledge, related to increased acceptance of massage therapy as a treatment option for PTSD and other mental health conditions. It is possible that awareness and referrals will continue to increase over time, with increased veteran willingness, increased access, and a noted improvement of PTSD outcomes. The findings of this VA study were consistent with those from the cross-sectional study by Alzahrani, Bashawri, Salawati, and Bakarman. (2016) and identified the desire for increased knowledge about the benefits of massage therapy as an adjunct treatment option for mental health conditions. The Alzahrani et al. study (2016) was conducted at the Faculty of Medicine, King Abdulaziz University in Saudi Arabia, to evaluate the knowledge and attitudes regarding complementary and alternative medicine (CAM) and assess the views on incorporating CAM into future studies. Alzahrani et al. administered a validated and reliable self-administered questionnaire to 273 senior medical students, with 242 students responding. (The survey used in this project was adapted from this same questionnaire.) Alzahrani et al. (2016) found a limited awareness of CAM principles and benefits. Despite the limited awareness, a positive attitude and desire for more knowledge was encouraged by the students. A large percentage of students demonstrated an awareness that "CAM in combination with conventional therapy is beneficial in treating unusual cases, but the choice of CAM should be based on evidence" (p. 17). Interestingly, and consistent with my findings, "medical students are still reluctant to have CAM practitioners in their referral network" (p. 17). Massage therapy is currently considered to be a CAM, but evidence suggests that it directly addresses the stored memories of physical and emotional pain. As previously discussed, massage therapy modulates the amygdala, hypothalamus, and anterior cingulate cortex; decreases cortisol; and increases serotonin and dopamine (Field, 2014). This modulation results MASSAGE THERAPY AND PTSD 17 in stress relief, improved mood, and reduced aggression (Gonçalves, Voos, de Almeida, & Caromano, 2017). Therefore, massage therapy may be superior to other CAM in treating the core pathology of PTSD. Providing education regarding the benefits of massage therapy as a treatment option for PTSD is inexpensive and cost effective, and the participants in this study were receptive to this education. Further, the study showed a statistically significant response among participants for more information regarding massage therapy within the VA system, which demonstrated a desire for alternative treatment options for PTSD beyond the traditional cognitive and pharmacology options. Only a small portion of the mental health providers were involved in these training sessions. Perhaps reaching all mental health providers in this clinic would change the outcomes and referrals. Also, having a massage therapist onsite would likely increase referrals. The VA currently offers massage therapy as a treatment modality, as well as having multiple reputable facilities that provide massage therapy in the surrounding area. Therefore, referring veterans to massage therapy can be done with the current efforts of mental health provider assessments and referrals to VA massage therapists or community care therapists and quarterly education sessions. Access to appropriately trained massage therapists could be increased by working with the major massage therapy schools to enhance education regarding managing PTSD and other mental health symptoms, or the VA could provide training for a massage therapist. Limitations Limitations to the generalizability of this project include having a relatively small sample size (n=28), the relative homogeneity of the sample, the small number of education sessions, and the short duration for follow up. The providers represented in this sample were a small portion of MASSAGE THERAPY AND PTSD 18 the VA mental health providers, again primarily supported by APRNs. Currently, the VA will allow only one alternative treatment option at a time (chiropractic care, acupuncture, or massage therapy), which could drastically decrease referrals if a veteran was already enrolled in one of these other treatment modalities. The education sessions were not mandatory, and thus providers might have been less engaged in the education sessions and less likely to provide thoughtful feedback. Further, the EHR data were retrieved only prior to education and not post-education, thus I was unable to compare pre- and post-education referrals. Personal bias against massage therapy or bias against touch may have confounded the providers' response or willingness to accept massage therapy as a treatment option. Further, presentation style and lack of visual PowerPoints may have altered their ability to listen or remain engaged. In order to minimize bias toward the presentation, the order of the questions on the preand post-education survey was scrambled. Further, the survey was provided to the same providers to correctly measure their specific response to the education. Despite this, the findings contributed relevant information about the beliefs and attitudes surrounding mind-body-based treatment for PTSD and increased willingness to use massage therapy as an adjunct treatment option. Conclusions Awareness of the therapeutic benefits of massage therapy is increasing in the health care industry. Results from this study provide preliminary evidence regarding the primarily positive beliefs and attitudes about massage therapy and the increased desire for more education and research regarding the benefits of massage therapy. However, observing the beliefs and attitudes from the veterans versus mental health providers might be a useful measure of the benefits of MASSAGE THERAPY AND PTSD 19 massage therapy in treating PTSD. More controlled studies are needed, specifically of PTSD, to adequately demonstrate the outcomes of massage therapy. Implementing referrals to massage therapy for PTSD can be challenging with lack of access to appropriately trained massage therapists, especially those trained in mental health conditions. Further, the daunting referral process may drastically limit the referrals, particularly if providers must refer to only one alternative treatment modality at a time. In order to successfully increase awareness, acceptance, and willingness to refer veterans to massage therapy, education modules need to be offered to all mental health providers and veterans. Additionally, access to appropriately trained massage therapists is essential, to sustain buy-in from mental health providers. A study with a larger sample size with consistent chart reviews is recommended, along with monitoring of referrals and veteran perceptions of the benefits of massage therapy. This project could be further adapted to directly monitor the benefits of massage therapy and PTSD outcomes. Despite limitations and challenges, this project significantly increased awareness about the benefits of massage therapy in treating PTSD as well as increased the willingness of providers to refer veterans for massage therapy. Acknowledgements I would like to thank my project faculty chair and content expert, Michael Johnson PhD, APRN, for his guidance, feedback, and support for my project. I would also like to thank Jamie Levasseur, APRN for her constant support and expertise in mental health and the VA system. I would also like to thank my editors, Christine Pickett and Natalie Taylor, for their assistance in the appropriate formulation of the content. MASSAGE THERAPY AND PTSD 20 References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. Retrieved from https://s3.amazonaws.com/academia.edu.documents/32876859/Ajzen_1991_ Beckham, MASSAGE THERAPY AND PTSD 21 Alzahrani, S. H., Bashawri, J., Salawati, E. M., & Bakarman, M. A. (2016). Knowledge and attitudes towards complementary and alternative medicine among senior medical students in King Abdulaziz University, Saudi Arabia. Evidence-Based Complementary and Alternative Medicine Journal: eCAM, 2016, 9370721. Cartwright, C., Gibson, K., Read, J., Cowan, O., & Dehar T. (2016). Long-term antidepressant use: patient perspectives of benefits and adverse effects. Patient Prefer Adherence,10, 1401-1407. https://doi.org/10.2147/PPA.S110632 Collinge, W., Kahn, J., & Soltysik, R. (2012). Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: A pilot study. Military Medicine, 177(12), 1477-1485. Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., ... Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. doi: 10.1016/j.cpr.2015.10.003 Field, T. (2014). Massage therapy research review. Complementary Therapies in Clinical Practice, 20(4), 224-229. http://doi.org/10.1016/j.ctcp.2014.07.002 Gonçalves, L. L., Voos, M. C., de Almeida, M. H. M., & Caromano, F. A. (2017). Massage and storytelling reduce aggression and improve academic performance in children attending elementary school. Occupational Therapy International, 2017, 1-7. http://doi.org.ezproxy.lib.utah.edu/10.1155/2017/5087145 Hoskins, M., Pearce, J., Bethell, A., Dankova, L., Barbui, C., Tol, W., . . . Bisson, J. (2015). Pharmacotherapy for post-traumatic stress disorder: Systematic review and meta MASSAGE THERAPY AND PTSD 22 analysis. British Journal of Psychiatry, 206(2), 93-100. doi:10.1192/bjp.bp.114.148551 Beckham, J.C., Moore, S.D., Feldman, M.E., Hertzberg, M.A., Kirby, A.C., & Fairbank, J.A. (1998). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry,155(11):1565-1569. DOI:10.1176/ajp.155.11.1565 Lanius, R.A. (2015). Trauma-related dissociation and altered states of consciousness: A call for clinical, treatment, and neuroscience research. European Journal of Psychotraumatology, 6, 1-9. doi:10.3402/ejpt.v6.27905 McCafferty, I. (2016). In Safe Hands: Massage and PTSD. American Massage Therapy Association. Retrieved from https://www.amtamassage.org/articles/3/MTJ/detail/3484/insafe-hands-massage-ptsd Office of Veterans Affairs. (2018). Posttraumatic Stress Disorder (PTSD). Retrieved from https://www.research.va.gov/topics/ptsd.cfm Park, C. L., Finkelstein-Fox, L., Barnes, D. M., Mazure, C. M., & Hoff, R. (2016). CAM Use in Recently-returned OEF/OIF/OND US Veterans: Demographic and psychosocial predictors. Complementary Therapies in Medicine, 28, 50-56. http://doi.org.ezproxy.lib.utah.edu/10.1016/j. ctim.2016.08.004 Price, C. (2006). Dissociation reduction in body therapy during sexual abuse recovery. Complementary Therapies in Clinical Practice, 13(2), 116-28. Ravn, S. L., Vaegter, H. B., Cardel, T., & Andersen, T. E. (2018). The role of posttraumatic MASSAGE THERAPY AND PTSD stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation. Journal of Pain Research, 11, 527-536. http://doi.org.ezproxy.lib.utah.edu/10.2147/JPR.S155241 Reisman, M. (2016). PTSD Treatment for veterans: What's working, what's new, and what's next. Pharmacy and Therapeutics, 41(10), 623-634. Siqveland, J., Ruud, T., & Hauff, E. (2017). Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain. European Journal of Psychotraumatology, 8(1), Retrieved from: http://doi.org.ezproxy.lib.utah.edu/10.1080/20008198.2017.1375337 Steckler, T., & Risbrough, V. (2012). Pharmacological treatment of PTSD - established and new approaches. Neuropharmacology, 62(2), 617-627. http://doi.org/10.1016/j.neuropharm.2011.06.012 23 MASSAGE THERAPY AND PTSD 24 Figures and Tables Table 1: Descriptive Statistics Std. N Mean Dev 28 1.89 1.286 DESCRIPTIVE STATISTICS PTSD is adequately treated with current treatment options Post Education 27 1.48 Long-term psychopharmacology treatment 28 1.39 for PTSD is superior to treatments relying on mind-body-based interventions Var Min 0 Max 4 1.282 0.956 0 0 3 3 1.644 0.914 1.655 Post Education Massage therapy is an effective treatment option for PTSD Post Education Placebo-controlled studies demonstrate that massage therapy can alleviate symptoms of PTSD 27 1.70 28 0.75 0.953 1.236 0 0 3 3 0.909 1.528 27 2.19 28 0.71 1.495 1.272 0 0 4 3 2.234 1.619 Post Education Health care professionals should always include massage therapy among treatment recommendations for patients suffering from PTSD 27 2.41 28 1.18 1.366 1.307 0 0 4 4 1.866 1.708 Post Education Advancements in the use of massage therapy as a treatment for patients suffering from PTSD should be included in future VA staff meetings 27 2.04 28 2.32 1.427 1.416 0 0 4 4 2.037 2.004 Post Education I know how to contact the properly trained massage therapists for proper referral of my patients with PTSD 27 3.04 28 1.93 1.018 0.766 0 0 4 4 1.037 0.587 Post Education I am aware of the VA's official protocol and recommendations for massage therapy as a treatment modality 27 2.74 28 1.68 1.095 0.819 0 0 4 3 1.199 0.671 Post Education 27 2.37 1.305 0 4 1.704 MASSAGE THERAPY AND PTSD 25 I would refer my patients suffering from PTSD to a properly trained massage therapist for treatment 28 2.04 1.621 0 4 2.628 Post Education 27 2.70 1.235 0 4 1.524 Table 1.2: Mean Frequencies Mean Frequencies I would refer my patients suffering from PTSD to a properly trained massage therapist for treatment I am aware of the VA's official protocol and recommendations for massage therapy as a treatment modality I know how to contact the properly trained massage therapists for proper referral of my patients with PTSD Advancements in the use of massage therapy as a treatment for patients suffering from PTSD should be included in future VA staff meetings Healthcare professionals should always include massage therapy among treatment recommendations for patients suffering from PTSD Placebo-controlled studies demonstrate that massage therapy can alleviate symptoms of PTSD Massage therapy is an effective treatment option for PTSD Long term psychopharmacology treatment for PTSD is superior to treatments relying on mind-body-based interventions PTSD is adequately treated with current treatment options 0 Post Education 0.5 1 Pre-Education 1.5 2 2.5 3 3.5 MASSAGE THERAPY AND PTSD Table 2: Test Statistics Table 3: Test Statistics a 26 MASSAGE THERAPY AND PTSD 27 Table 4 Demographics: Race Valid Asian Black Hispanic White Total Frequency 3 1 1 23 28 Percent 10.7 3.6 3.6 82.2 100.0 Valid Percent 10.7 3.6 3.6 82.2 100.0 Cumulative Percent 10.7 14.3 17.9 100.0 Highest Degree Valid Valid BSN DNP MD MSN PhD Post-Master's Total APRN LCSW MD MSW, intern PhD Frequency 3 5 2 14 1 2 28 Frequency 15 3 2 1 2 Percent 10.7 17.9 7.1 50.0 7.2 7.1 100.0 Percent 53.6 10.7 7.1 3.6 7.1 Valid Percent 10.7 17.9 7.1 50.0 7.2 7.1 100.0 Valid Percent 53.6 10.7 7.1 3.6 7.1 Cumulative Percent 10.7 28.6 35.7 85.7 92.9 100.0 Cumulative Percent 53.6 64.3 71.4 75.0 82.1 MASSAGE THERAPY AND PTSD PhD, intern RN Voc Rehab Total N Valid Missing Mean Median Mode Std. Deviation Variance Range Minimum Maximum 1 3 1 28 Years of Employment 27 1 11.48 9.00 1 10.875 118.259 41 1 42 Age N Valid Missing Mean Median Mode Std. Deviation Variance Range Minimum Maximum 28 28 0 43.86 40.00 34a 11.352 128.868 37 28 65 3.6 10.7 3.6 100.0 3.6 10.7 3.6 100.0 85.7 96.4 100.0 MASSAGE THERAPY AND PTSD 29 Figure 5: Individual Questions Frequencies PTSD is adequately treated with current treatment options 15 10 5 0 Long term psychopharmacology treatment for PTSD is superior to treatments relying on mindbody-based interventions 20 0 Strongly Disagree Disagree Undecided Agree Strongly Agree Pre-Education Post Education Pre-Education Placebo-controlled studies demonstrate that massage therapy can alleviate symptoms of PTSD Massage therapy is an effective treatment option for PTSD 30 20 10 0 Post Education 40 20 0 Strongly Disagree Undecided Disagree Pre-Education Pre-Education Post Education Agree Strongly Agree Post Education Advancements in the use of massage therapy as a treatment for patients suffering from PTSD should be included in future VA staff meetings Healthcare professionals should always include massage therapy among treatment recommendations for patients suffering from… 20 15 10 5 0 10 0 Strongly Disagree Undecided Disagree Pre-Education Post Education Pre-Education Agree Post Education Strongly Agree MASSAGE THERAPY AND PTSD 30 I know how to contact the properly trained massage therapists for proper referral of my patients with PTSD I am aware of the VA's official protocol and recommendations for massage therapy as a treatment modality 20 10 20 10 0 0 Pre-Education Post Education Pre-Education Post Education I would refer my patients suffering from PTSD to a properly trained massage therapist for treatment 18 16 14 12 10 8 6 4 2 0 Strongly Disagree Disagree Undecided Pre-Education Agree Strongly Agree Post Education Table 5: Individual Questions Frequencies PTSD is adequately treated with current treatment options Strongly Disagree Disagree Undecided Agree Strongly Agree Long term psychopharmacology treatment for PTSD is superior to treatments relying on mind-bodybased interventions Strongly Disagree Disagree Undecided PreEducation 1 10 7 8 2 PreEducation Percentag e 3.6 35.7 25 28.6 7.1 Percentag e Post Education 2 7 10 8 0 Post Education Percentage 2 17 8 7.1 60.7 28.6 2 16 5 7.4 59.3 18.5 7.4 25.9 37 29.6 0 Percentage MASSAGE THERAPY AND PTSD Agree Strongly Agree Massage therapy is an effective treatment option for PTSD Strongly Disagree Disagree Undecided Agree Strongly Agree Placebo-controlled studies demonstrate that massage therapy can alleviate symptoms of PTSD Strongly Disagree Disagree Undecided Agree Strongly Agree Health care professionals should always include massage therapy among treatment recommendations for patients suffering from PTSD Strongly Disagree Disagree Undecided Agree Strongly Agree Advancements in the use of massage therapy as a treatment for patients suffering from PTSD should be included in future VA staff meetings Strongly Disagree Disagree Undecided Agree Strongly Agree I know how to contact the properly trained massage therapists for proper referral of my patients with PTSD Strongly Disagree Disagree 31 1 0 PreEducation 0 3 20 5 0 PreEducation 3.6 0 Percentag e 0 10.7 71.4 17.9 0 Percentag e 4 0 Post Education 0 1 8 15 3 Post Education 14.8 0 Percentage 0 1 21 6 0 PreEducation 0 3.6 60.7 21.4 10.7 Percentag e 0 1 6 17 3 Post Education 0 3.7 22.2 63 11.1 Percentage 1 8 14 4 1 PreEducation 3.6 28.6 50 14.3 3.6 Percentag e 0 4 8 13 2 Post Education 0 14.8 29.6 48.1 7.4 Percentage 0 1 7 17 3 PreEducation 0 3.6 25 60.7 10.7 Percentag e 0 1 2 16 8 Post Education 0 3.7 7.4 59.3 29.6 Percentage 5 18 17.9 64.3 0 2 0 7.4 0 3.7 29.6 55.6 11.1 Percentage MASSAGE THERAPY AND PTSD Undecided Agree Strongly Agree I am aware of the VA's official protocol and recommendations for massage therapy as a treatment modality Strongly Disagree Disagree Undecided Agree Strongly Agree I would refer my patients suffering from PTSD to a properly trained massage therapist for treatment Strongly Disagree Disagree Undecided Agree Strongly Agree 32 1 3 1 PreEducation 3.6 10.7 3.6 Percentag e 3 18 4 Post Education 11.1 66.7 14.8 Percentage 6 16 3 3 0 PreEducation 21.4 57.1 10.7 10.7 0 Percentag e 1 3 5 15 3 Post Education 3.7 11.1 18.5 55.6 11.1 Percentage 0 2 10 11 5 0 7.1 35.7 39.3 17.9 0 1 4 17 5 0 3.7 14.8 63 18.5 FIGURE 6: Post Education Post Education Referrals 12 10 8 6 4 2 0 As a healtcare professional, I As a Healthcare professional I I have put in a VA referral for have included massage have thought about including properly trained massage therapy in my treatment massage therapy in my therapist for my veterans recommendations for treatment recommendations with PTSD patients suffering from PTSD for patient's suffering from PTSD Agree Table 6: Post Education Disagree MASSAGE THERAPY AND PTSD 33 MASSAGE THERAPY AND PTSD 34