Feasibility and effectiveness of massage therapy for symptom relief in cardiac catheter laboratory staff: A pilot study

Article Outline

• Abstract
• 1. Introduction
• 2. Methods
  • 2.1. Setting
  • 2.2. Study design
  • 2.3. Instruments used
  • 2.4. Intervention
  • 2.5. Statistical analysis
• 3. Results
  • 3.1. Baseline characteristics
  • 3.2. Feasibility assessment
  • 3.3. Between-group comparisons
  • 3.4. Within-group comparison
• 4. Discussion
• 5. Conclusion
• Conflict of interest statement
• Acknowledgment
• References
• Copyright

Abstract 

A pilot study was conducted to assess the feasibility and efficacy of massage therapy for cardiac catheterization laboratory staff. Staff members (N = 50) were randomly assigned to 5 or 10 weekly 30-min massages, followed by outcomes assessment. A control group (n = 10) receiving no massage therapy underwent comparable assessment. Visual analog scales, the t test, and the repeated measures model evaluated fatigue, pain, relaxation, stress/anxiety, tension/discomfort, and scheduling ease at baseline, 5 weeks, and 10 weeks. The Aickin separation test was used to assess feasibility of further research. Overall, 90% (337/375) of massage appointments were used. No significant effects were observed, but the Aickin separation test supported further research on massage therapy for fatigue, pain, relaxation, and tension/discomfort. Conducting massage therapy in the workplace is logistically feasible. Larger, longitudinal trials are warranted to better evaluate its effects on staff.

Keywords: Fatigue, Heart catheterization, Massage, Pain, Stress, physiological

Abbreviations: CCL, cardiac catheterization laboratory, CMT, certified massage therapist, MT, massage therapy, SDE, standard deviation of the effect estimate, VAS, visual analog scales

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1. Introduction 

There is growing interest in and recognition of the impact of work-related stress on health care employees.¹ Working in an interventional radiology setting such as a cardiac catheterization laboratory (CCL) can be mentally and physically demanding.², ³ In addition to dealing with the stressful atmosphere of the CCL, workers there must care for patients in what has been called an “ergonomically challenging environment.”⁴ Subsequently, staff can experience muscle tension from repetitive activities that incur strain on muscles, joints, ligaments, or tendons. Chronic muscle tension and misalignment of body posture are aggravated by the mandatory use of heavy protective lead aprons that reduce radiation exposure during radiologic procedures. These can weigh between 10 and 15 pounds and may be worn for several hours at a time. Indeed, prolonged use of lead aprons has been linked to increased rates of absenteeism due to new-onset back pain.⁵ Decreased well-being may also be associated with poor performance, increased clinical error, and employment turnover.⁶, ⁷

Massage therapy (MT) is an effective therapy for reducing muscle tension and helping realign body posture. It also raises awareness of musculoskeletal balance in employees and facilitates posture correction. Regular use of MT can improve muscle tension and tonic contraction, alleviate fatigue, and reduce anxiety.⁸, ⁹ However, there is a paucity of data analyzing the impact of MT to reduce musculoskeletal strain experienced by employees in radiology settings. Therefore, a pilot study was undertaken to evaluate the use of MT in the CCL.

Businesses are greatly affected by employee turnover, illness, and injury. MT is a low-cost intervention that may help to manage or reduce current financial burdens associated with lead apron wear and chronic musculoskeletal injury. MT may also enhance job satisfaction.¹⁰, ¹¹ It has been postulated that an increasing acceptance of complementary medicine therapies¹² makes MT attractive to staff.

This pilot study sought to assess the feasibility of providing table MT sessions in a busy radiology work setting during working hours and to evaluate the effectiveness of MT in alleviating chronic musculoskeletal discomfort in staff participants.

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2. Methods 

2.1. Setting 

The study was conducted in the CCL of a tertiary care academic medical center. This laboratory performs more than 7000 cardiac catheterizations annually, with approximately 2000 leading to interventional procedures. Six procedural rooms are available for both diagnostic and interventional procedures.

2.2. Study design 

The study was approved by the Mayo Clinic Institutional Review Board and registered in the US National Institutes of Health clinical trials registry (ClinicalTrials.gov [NCT0148164]).

From April 7, 2008, through June 16, 2008, a 10-week partial-crossover, randomized pilot study was conducted and stratified by occupation. This design was chosen for several reasons. First, it allowed across-group comparison (massage vs no massage). Second, within-group comparisons were monitored (before-and-after evaluations), with subjects acting as their own controls. The design also offered all participants an opportunity to receive massage at some point during the study period.

All 70 CCL employees (including cardiologists, cardiology fellows, nurses, technical staff, and nurse anesthetists) who wear lead aprons while caring for patients were invited, via a mass e-mail announcement, to participate in the study. The criterion for participation in the 2 interventional groups was a willingness to schedule the MT sessions during working hours. Exclusion criteria were acute sprains with swelling, malignancies with lymph node involvement, fever, varicose veins, phlebitis, pregnancy, trapped or pinched nerve (radicular symptoms), skin abrasions, open wounds, and melanoma.

A convenience sample included the first 50 CCL staff members who responded to the invitation to participate. Participants were randomly assigned by computer to either group 1 (5 weeks without MT), followed by 5 weeks of weekly 30-min MT sessions (averaging 25 min of hands-on massage per session) or group 2 (a 30-min massage once a week for 10 weeks, also averaging 25 min of hands-on massage per session) (Fig. 1). Enrollment was achieved within 48 h.

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• Fig. 1 

  Study accrual flowchart. Sixty of 70 staff members in the cardiac catheterization laboratory (CCL) were eligible for a 10 week partial-crossover randomized massage therapy (MT) trial conducted in the workplace. Of these 60 participants, 50 were randomly assigned to either the 5 week MT arm (n = 25) or the 10 week MT arm (n = 25). A control group of 10 nonrandomized participants declined MT but agreed to complete function questionnaires.

Questionnaires were distributed to all participants at the beginning of the study, at 5 weeks, and at the conclusion of the study. A nonrandomized control group consisted of 10 staff members who declined MT and agreed to complete the same questionnaires that study participants completed (Fig. 1).

A certified massage therapist (CMT) was available during the working week and was located in an area close to the CCL. Records of compliance with the protocol were maintained by the study coordinator.

Available MT times were 2:00 pm–4:30 pm during weeks 1–5 and 11:30 am–5:00 pm during weeks 6–10. Times were based on room and space availability. Participants were asked to use their scheduled break times or to arrange for cross-coverage. Participants were allowed to trade scheduled massage times, if necessary.

2.3. Instruments used 

Demographic data and information about work-related and lifestyle issues were collected at commencement of the study. Questionnaires included state trait anxiety scales and visual analog scales (VAS) to measure fatigue, pain, relaxation, stress/anxiety, and tension/discomfort. The questionnaires were hand delivered at baseline, 5 weeks, and 10 weeks.

Feasibility data on scheduled appointments and missed appointments were tracked throughout the study.

2.4. Intervention 

MT sessions were provided on a massage table, in a quiet, private room near the CCL. Each participant disrobed to the level of his or her own comfort. In massage practices, manual therapy is thought to be most effective when the CMT adjusts the technique, pace, and pressure, on the basis of the CMT’s assessment and on participant feedback throughout the session. The applied massage sessions were therefore individualized and adjusted on the basis of the CMT’s initial visual and verbal assessment, with ongoing palpation assessment during each session. Flexibility, strength, soft-tissue status, and the participants’ verbal responses were part of the assessment. The CMT, who had 750 instruction hours and 3 years of MT experience, used specific primary techniques during each session: sports massage, deep tissue massage, acupressure, myofascial release, and neuromuscular techniques. At the end of each session, the CMT used gentle stretching and stimulation strokes to optimize the participant’s alertness before a return to work.

2.5. Statistical analysis 

Continuous variables were summarized using mean (SD); discrete variables were summarized with frequency (%). Differences within-groups in VAS scores at 5 weeks from baseline and at 10 weeks from baseline were analyzed using the paired t test with intent-to-treat analysis. The 2-sample t test was used to test for differences in the changes in VAS scores across treatment groups. A repeated measures model was also used to analyze VAS responses. The independent variables were survey time (baseline, 5 weeks, and 10 weeks) and treatment (no massage, first 5 weeks of massage, and second 5 weeks of massage). An autoregressive correlation matrix was used to account for the repeated measures correlation within unique subjects.

We also used the separation test, as described by Aickin,¹³, ¹⁴ to analyze data because of the small sample size, short study duration, and early phase nature of the study. This technique facilitated assessment of the value of further research on MT in this work setting. For this test, we first calculated the standard deviation of the effect estimate (SDE) of the mean difference, then calculated the value of Δ = 1.645∗SDE. Further research is indicated if the mean difference exceeds Δ/2 (in the favorable direction), but not if it is below −Δ/2 (in the unfavorable direction). Other findings would indicate that there is not enough information to make a definitive recommendation for or against further research. All analyses were conducted with SAS version 9 software (SAS Institute, Inc, Cary, North Carolina).

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3. Results 

3.1. Baseline characteristics 

Sixty of the 70 CCL employees were enrolled, and all 60 completed the study, with 100% compliance in returning questionnaires. Participants included 15 physicians, 21 nurses, 5 nurse anesthetists, and 19 technical staff. Demographic and baseline characteristics of study participants are summarized in Table 1. All 3 groups (5 weeks of MT, 10 weeks of MT, and no MT) had similar distributions of age and sex. However, there were some statistically significant differences among the groups. Notably, participants randomized to group 1 (5 weeks of MT) had been wearing lead aprons significantly longer than those randomized to 10 weeks of MT (mean, 7.7 years vs 2.8 years, respectively; P < .001). The nonrandomized control subjects reported significantly less baseline pain (P = .02) and tension/discomfort (P = .002) than the 50 MT participants.

Table 1. Baseline and Demographic Characteristics of MT Study Participants.^a

Characteristic	Group 1: 5 Weeks of MT (n = 25)	Group 2: 10 Weeks of MT (n = 25)	P Valueb	Group 3: Control Group (n = 10)	P Valuec
Male sex, No. (%)	15 (60%)	10 (40%)	.16	8 (80%)	.08
Age, y	43.7 (10.5)	40.5 (8.9)	.25	42.4 (7.0)	.91
Height, in	68.8 (3.3)	67.5 (4.4)	.25	69.8 (2.6)	.19
Weight, lb	172.1 (33.5)	167.8 (32.0)	.66	193.3 (27.2)	.04
Participation in routine physical exercise, No. (%)	21 (84%)	22 (88%)	.68	8 (80%)	.63
Median (Q1, Q3) time spent wearing a lead apron, y	7.7 (5.0, 20.8)	2.8 (1.1, 4.3)	<.001	6.6 (1.7, 14.8)	.92
Time per week wearing a lead apron in past 5 weeks, h	13.1 (8.9)	14.2 (7.7)	.64	10.7 (10.0)	.32
Style of lead apron worn, No. (%)			.54		.41
Two-piece (vest/apron)	20 (80%)	16 (67%)d		9 (90%)
One-piece (full coverage)	3 (12%)	4 (16%)		0 (0%)
One-piece (front coverage)	2 (8%)	4 (16%)		1 (10%)
Occupation, No. (%)			.13		.63
Consultant	6 (24%)	3 (12%)		2 (20%)
Fellow	1 (4%)	3 (12%)		0 (0%)
RN	6 (24%)	10 (40%)		5 (50%)
Technician	11 (44%)	5 (20%)		3 (30%)
CRNA	1 (4%)	4 (16%)		0 (0%)
MT experience, No. (%)			.32		.21
None	11 (44%)	6 (24%)		6 (60%)
<1 Massage per year	7 (28%)	9 (36%)		3 (30%)
≥1 Massage per year	7 (28%)	10 (40%)		1 (10%)
Style of shoes worn in procedure room, No. (%)			.40		.72
Sneakers	14 (56%)	11 (44%)		4 (44%)e
Dress shoes	1 (4%)	4 (16%)		2 (22%)e
Crocs	6 (24%)	4 (16%)		1 (11%)e
Other	4 (16%)	6 (24%)		2 (22%)e
Amount subject would be willing to pay for a 30-minute massage, $	11.60 (9.20)	14.00 (11.20)	.41	9.00 (9.70)	.28

Abbreviations: CRNA, certified registered nurse anesthetist; h, hour; lb, pound; MT, massage therapy; Q1, quartile 1; Q3, quartile 3; RN, registered nurse; SD, standard deviation; y, year.

3.2. Feasibility assessment 

Overall, the study had a 90% utilization rate of the 375 appointments. In the first 5 weeks, 112 of the 125 appointments (90%) were used. In the second 5 weeks, 225 of the 250 appointments (90%) were used. Of 25 missed appointments in the second half, 12 fell during the same week. Only 1 appointment was traded during the first 5 weeks, whereas 4 appointments were traded or given away in the second 5 weeks.

In surveys at 5 and 10 weeks, participants were asked how many times they thought the work atmosphere had been positively or negatively affected by the MT pilot study. At 5 weeks, 5 participants (50%) in group 3 (control group) said that work had been negatively affected by the study at least once, compared with 9 of the 50 MT participants (18%) in groups 1 and 2 (P = .02). In regard to the question of whether the study had a positive effect on the work atmosphere, we found no statistically significant difference among the 3 groups; 24 of all 60 participants (40%) reported that work had been positively affected at least once. At 10 weeks, 6 participants (60%) in group 3 (the control group) indicated that the study had had a negative impact on work, compared with 15 of the 50 MT participants (30%) (groups 1 and 2) (P = .03). Overall, 38 of the 60 participants (63%) reported that work had been positively affected at least once. Subjects in the 10-week MT group observed a positive impact more often than did those in the 5-week MT group (median, 3–4 times vs 1–2 times, respectively; P = .04).

3.3. Between-group comparisons 

VAS scores for fatigue, pain, relaxation, stress/anxiety, and tension/discomfort for the 3 groups at 3 time points are summarized in Table 2. In addition, the differences in VAS scores among the groups are compared from baseline to week 5 and from baseline to week 10. None of the 5 measures was statistically significant between the 2 MT groups with regard to changes from baseline. Repeated measures regression models also found no significant effect of MT on VAS measures (data not shown). In many cases, however, the estimated effect of the time period (eg, first 5 weeks, second 5 weeks) was statistically significant (data not shown).

Table 2. Characteristics of Massage Therapy Study Participants at Baseline, 5 Weeks, and 10 Weeks.^a

Variables	Group 1: 5 Weeks of MT (n = 25)	Group 2: 10 Weeks of MT (n = 25)	P Value	Group 3: Control Group (n = 10)	P Value
Fatigue
At baseline (0 = none; 10 = extreme)	3.6 (2.3)	3.4 (2.0)	.85	2.8 (2.9)	.38
After 5 weeks	2.8 (1.8)	3.0 (1.9)	.70	2.2 (2.4)	.27
Change from baseline to week 5	−.7 (1.8)	−.4 (2.0)	.56	−.6 (3.3)	.96
Paired t test P value for change from baseline to week 5	.06	.33		.58
After 10 weeks	2.7 (1.9)	1.7 (1.2)	.04	2.1 (1.8)	.86
Change from baseline to week 10	−.9 (2.0)	−1.7 (1.9)	.14	−.7 (2.2)	.40
Paired t test P value for change from baseline to week 10	.04	<.001		.34
Pain
At baseline (0 = none; 10 = extreme)	2.6 (2.4)	2.0 (1.6)	.37	.7 (1.1)	.02
After 5 weeks	2.2 (1.7)	2.1 (1.5)	.86	1.6 (2.5)	.36
Change from baseline to week 5	−.4 (1.6)	.1 (1.9)	.38	.9 (1.0)	.14
Paired t test P value for change from baseline to week 5	.27	.84		.36
Pain level after 10 weeks	2.0 (1.7)	1.6 (1.2)	.34	1.0 (1.6)	.15
Change from baseline to week 10	−.6 (2.3)	−.5 (1.9)	.84	.3 (2.1)	.25
Paired t test P value for change from baseline to week 10	.20	.21		.66
Relaxation
At baseline (0 = none; 10 = extreme)	4.8 (1.9)	4.1 (2.2)	.20	5.5 (2.8)	.18
After 5 weeks	5.2 (2.0)	4.8 (1.9)	.47	5.1 (2.8)	.85
Change from baseline to week 5	.3 (2.1)	.7 (2.7)	.60	−.4 (1.3)	.26
Paired t test P value for change from baseline to week 5	.46	.22		.34
After 10 weeks	4.3 (2.4)	5.0 (2.4)	.29	6.0 (2.2)	.11
Change from baseline to week 10	−.5 (2.9)	1.0 (3.2)	.09	.5 (2.2)	.79
Paired t test P value for change from baseline to week 10	.37	.14		.49
Stress/anxiety
At baseline (0 = none; 10 = extreme)	3.6 (2.0)	4.0 (2.2)	.62	2.6 (3.0)	.10
After 5 weeks	3.2 (1.7)	3.2 (2.0)	.88	2.0 (2.3)	.07
Change from baseline to week 5	−.5 (1.7)	−.8 (1.5)	.44	−.6 (1.6)	.91
Paired t test P value for change from baseline to week 5	.17	.01		.26
After 10 weeks	2.8 (1.7)	2.7 (2.3)	.84	1.6 (1.8)	.10
Change from baseline to week 10	−.9 (2.1)	−1.3 (2.7)	.56	−1.0 (1.3)	.88
Paired t test P value for change from baseline to week 10	.04	.02		.04
Tension/discomfort
At baseline (0 = none; 10 = extreme)	3.6 (2.3)	3.4 (2.0)	.82	1.4 (1.6)	.002
After 5 weeks	2.9 (1.7)	2.8 (1.5)	.79	1.5 (2.1)	.02
Change from baseline to week 5	−.6 (1.7)	−.6 (1.7)	>.99	.1 (2.8)	.26
Paired t test P value for change from baseline to week 5	.07	.07		.91
After 10 weeks	2.5 (1.7)	2.1 (1.5)	.42	1.3 (1.6)	.07
Change from baseline to week 10	−1.0 (2.2)	−1.3 (2.4)	.71	−.1 (2.3)	.19
Paired t test P value for change from baseline to week 10	.03	.02		.77

Because this was a pilot study, the separation test was used to assess whether it might be worthwhile to pursue further research on MT in this setting in a larger trial. Using this analysis, we found that group 2 had the greatest beneficial effect in regard to fatigue and relaxation and that further studies using these outcome measures appear reasonable. Compared with controls, group 2 also showed some benefit of MT for fatigue, pain, and tension/discomfort. There was no difference between groups 1 and 2 for the variables of pain, stress/anxiety, and tension/discomfort (Table 3).

Table 3. Aickin Separation Test Results.^a

VAS measure	Group 1: 5 Weeks of MT (n = 25)	Group 2: 10 Weeks of MT (n = 25)	Mean Difference	Δ/2	Separation in Favor of Group
Change from baseline to 5 weeks
Fatigue	−.72	−.40	.32	.45
Pain	−.36	.08	.44	.41	Group 1
Relaxation	.32	.68	.36	.56
Stress/anxiety	−.48	−.84	−.36	.38
Tension/discomfort	−.64	−.64	.00	.39
Change from baseline to 10 weeks
Fatigue	−.88	−1.72	−.84	.46	Group 2
Pain	−.60	−.48	.12	.48
Relaxation	−.52	.96	1.48	.71	Group 2
Stress/anxiety	−.92	−1.32	−.40	.56
Tension/discomfort	−1.04	−1.28	−.24	.54
	Group 3: Control Group (n = 10)	Group 2: 10 Weeks of MT (n = 25)	Mean Difference	Δ/2	Separation in Favor of Group
Change from baseline to 10 weeks
Fatigue	−.70	−1.72	−1.02	.66	Group 2
Pain	−.30	−.48	−.78	.63	Group 2
Relaxation	.50	.96	.46	.77
Stress/anxiety	−1.00	−1.32	−.32	.56
Tension/discomfort	−.10	−1.28	−1.18	.73	Group 2

Abbreviations: MT, massage therapy; SDE, standard deviation of the effect estimate; VAS, visual analog scale.

3.4. Within-group comparison 

We used the paired t test to compare the change in VAS scores (by group) from baseline to 5 weeks or 10 weeks. As can be seen in Table 2, we found no significant improvement in fatigue for group 2 after the first 5 weekly massages; however, after 10 weekly massages, fatigue improved significantly (P < .001). In contrast to group 2, which showed no improvement in fatigue after 5 weekly massages, group 1 reported a significant (P = .04) decrease in fatigue from baseline after 5 weekly massages. Repeated measures modeling analysis indicated that the improvement in fatigue was more significant (P = .02) with the second set of massages than with the first set of massages.

Weekly massages for 5 or 10 weeks had no significant effect on participants’ reported states of pain or relaxation (Table 2).

Five weekly massages decreased the level of stress/anxiety significantly in both groups 1 (P = .04) and group 2 (P = .01) (Table 2). However, group 3 (no intervention) also reported a significant decrease in stress/anxiety at week 10 (P = .04) (Table 2).

A significant decrease in tension/discomfort was reported by group 1 after 5 weekly massages (P = .03), whereas there was improvement only after 10 weekly massages in group 2 (P = .02) (Table 1).

Pain levels reported by participants to the therapist at the start of their final session were significantly lower (.76 points lower than at the start of their first session; P = .03).

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4. Discussion 

This pilot study demonstrates the feasibility of delivering an MT program in the workplace, specifically in a CCL, during working hours. The data also suggest that a massage program can be beneficial for staff working in such settings.

Several other studies have demonstrated the benefits of MT in the workplace. In 1996, Shulman and Jones¹⁵ reported on a massage study involving employees of a company that was actively restructuring and reducing its workforce. Eighteen subjects received chair MT for 15 min weekly, for a total of 6 weeks in the workplace, whereas the 15 control subjects were allowed a 15-min break. A significant reduction in anxiety levels was found in the massage group.

When Katz et al. (1999)¹⁰ conducted a pilot study to evaluate the feasibility of a series of 8 workplace-based MT treatments of 15 min each, the subjects included 10 registered nurses and 2 nonmedical ward staff in a large teaching hospital; significant improvement after treatment was found in pain intensity, tension levels, and overall mood state (P < .001). A limitation of this study was its lack of a control group.

In a small Italian study,¹¹ 28 participants were randomly assigned either to a treatment group (n = 14) that received weekly MT at work for 4 weeks or to a control group (n = 14). Reductions in blood pressure and stress were documented in the treatment group.

In our study, no particular time was set for the participants to receive a massage. Participants had to arrange for a treatment whenever their schedule allowed it by using their breaks or finding coverage. Our finding of a 90% utilization rate of available appointments supports the idea that CCL personnel liked incorporating massage into their daily work schedule. However, the missed appointments may have been better utilized if a scheduling coordinator had been assigned to manage appointments in the CCL, with its often emergent nature.

We chose table MT to accommodate hips, legs and feet, and the upper body because CCL staff stand for long periods. Musculoskeletal issues are often found to include tension imbalances, along with fatigue and weakness of the lower and upper body. In addition, we wanted to determine the feasibility of providing table massage sessions vs chair massage sessions in a busy work setting.

The 10 control participants elected to be in the control group and were not selected through a randomized process. This group’s baseline symptoms of pain and tension/discomfort were lower than those of the MT participants. Their decision to defer participation may have been influenced by their lower baseline symptoms. More accurate assessment may have been generated by full randomization.

While the enrollment scheme undoubtedly had a positive impact on accrual and participation rates, it also introduced the potential for selection bias. Selection bias is a lesser concern in regard to the feasibility determination, but it may be a significant confounder in the other measures. Since this was a pilot study with a primary focus on feasibility, we decided that the design of this study was the most prudent approach at this stage of investigation. To more fully address this weakness, we plan to conduct future studies using a randomized design.

Although this was a pilot study, positive effects were noted in fatigue and relaxation in the 10-week MT group (group 2) vs the 5-week MT group (group 1). In addition, group 2 reported improvement in fatigue, pain, and tension/discomfort compared with the control group.

The separation test analysis of the results for the end points of fatigue, pain, and tension/discomfort suggests that a larger-scale trial with a longer time frame is warranted on the basis of these preliminary findings.

The limitation of our study is that this was a pilot study with not enough participants to result in a definitive conclusion. Further studies are needed to explore the optimal frequency and duration of table MT in the workplace. For example, initially offering massages more frequently (eg, 3 times a week) might produce a better response. Determination of optimal maintenance MT would be similarly important. Long-term studies are also needed to assess the benefits and cost-effectiveness of MT for CCL workers. The findings of this pilot study support the need for further exploration of MT in the workplace to promote the health and wellness of CCL workers.

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5. Conclusion 

With a 90% scheduling success rate, this early phase study demonstrates the feasibility of providing table MT to CCL staff in the workplace. Staff members were able to schedule and undergo weekly 30-min table MT sessions in an in-facility setting during working hours.

Our findings also suggest that table massage for 30 min weekly in the workplace may improve fatigue, pain, and tension/discomfort. Future studies utilizing a fully randomized approach are needed to clarify the true effect of MT on clinical outcomes and to determine the optimal frequency and duration of such an intervention.

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Conflict of interest statement 

The authors have no conflicts of interest to disclose.

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Acknowledgment 

The study had no funding support.

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