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in the study with regard to infant sleep outcomes is likely due to the combined impact of the short study duration and minimal parent preparation, training, and support for the intervention's application. This leads me to speculate that infant sleep outcomes could potentially be magnified or further improved if a massage-based bedtime routine was continued beyond just two weeks and/or if mothers or other caregivers are given more instructional resources or follow-up support. For instance, I imagine a mother, particularly a first-time mother or caregiver, would value being able to watch a professional infant massage provided to their child, and then have an opportunity to demonstrate and practice observed and learned techniques on their child with the therapist there to supervise, guide, reinforce, and encourage the work. This one-on-one instruction and supportive approach is used and is very successful with regard to related health behaviors and skills acquisition such as breastfeeding education. Mothers or caregivers providing massage as part of a bedtime routine is appropriate, and massage therapists can have a role in helping clients feel confident in providing this for their children to help with sleep issues or to support a healthy bedtime routine. THREE STRONG INDICATORS Though relatively small, the positive results from this study can be seen as a good indication that even in bare minimum situations there is a signal of massage's benefit for infant and maternal sleep outcomes. The next question is how to optimize and improve that benefit signal through a more enhanced training and delivery approach. For me, regular massage over an extended time period was what supported my development of healthy sleep ability, but to my knowledge, no massage- related sleep research has examined the effect of regular massage over an extended period of time on infants or otherwise. Mindell and colleagues did publish one- year follow-up data on a similar study in 2011 for which an internet training delivery approach was used to prepare mothers to incorporate a bath, massage, and cuddle routine into bedtime practices. 7 In this study, similar infant and maternal sleep benefit occurred using the same three-week study design, but at one-year follow-up, 50 percent of participants indicated they still used the routine "most of the time" or "always" with continued benefit. Another 36 percent indicated they continued using the routine "about half the time," suggesting massage can be incorporated by the mother long-term for infants and toddlers to the benefit of both. It is a practice I promote and share with others, and the work of Mindell and others support it. I imagine all massage therapists can site anecdotal evidence from their practice and experiences similar to mine about how massage therapy is beneficial for sleep and promoting healthy sleep habits. Such evidence is an important part of the three- legged evidence-based practice "stool" as clinical experience. Just as with sitting on a stool, the other two stool legs for evidence- based practice, research and patient values, are just as important. Just as it is important to sit on a stool with three strong legs, massage therapists should have three strong indicators to inform their evidence-based practice. "Massage-Based Bedtime Routine: Impact of Sleep and Mood in Infants and Mothers" provides another strengthening component to the research leg of the evidence-based practice stool when infant and maternal sleep promotion are wanted and valued by the massage client. Notes 1. Tiffany Field, "Massage Therapy Research Review," Complementary Therapies in Clinical Practice 24 (2016): 19–31. 2. Tiffany Field and Maria Hernandez‐Reif, "Sleep Problems in Infants Decrease Following Massage Therapy," Early Child Development and Care 168, no. 1 (2001): 95–104. 3. Tiffany Field, Gladys Gonzalez, Miguel Diego, and Jodi Mindell, "Mothers Massaging Their Newborns with Lotion Versus No Lotion Enhances Mothers' and Newborns' Sleep," Infant Behavior and Development 45 (2016): 31–7. 4. Charlotte C. Yates et al., "The Effects of Massage Therapy to Induce Sleep in Infants Born Preterm," Pediatric Physical Therapy: The Official Publication of the Section on Pediatrics of the American Physical Therapy Association 26, no. 4 (2014): 405. 5. Cathy Bennett, Angela Underdown, and Jane Barlow, "Massage for Promoting Mental and Physical Health in Typically Developing Infants Under the Age of Six Months," Cochrane Database of Systematic Reviews 4 (2013). 6. Jodi A. Mindell et al., "Massage-Based Bedtime Routine: Impact on Sleep and Mood in Infants and Mothers," Sleep Medicine 41 (2018): 51–7. 7. Jodi A. Mindell et al., "Long-Term Efficacy of an Internet-Based Intervention for Infant and Toddler Sleep Disturbances: One Year Follow-up," Journal of Clinical Sleep Medicine 7, no. 5 (2011): 507–11. Niki Munk, PhD, LMT, is an assistant professor of health sciences at Indiana University, a Kentucky-licensed massage therapist, a visiting fellow with the Australian Research Centre in Complementary and Integrative Medicine, and mother of two young daughter-scientists. Munk's research explores real-world massage therapy for chronic pain, trigger point self-care, massage for amputation-related sequelae, and the reporting and impact of massage-related case reports. Contact her at SOMATIC RESE ARCH Yo u r M & B i s w o r t h 2 C E s ! G o t o w w w. a b m p . c o m / c e t o l e a r n m o r e . 55

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