When it comes to treating chronic lower back pain, a new U.S. government funded study suggests that massage therapy may be better than medication or exercise for easing discomfort and improving function — at least in the short term. However, the type of massage that is best, duration of therapy, and who might benefit most need further consideration.
At an integrated healthcare delivery system in the Seattle Washington area, 401 persons with nonspecific chronic lower back pain were enrolled in a parallel-group, randomized, controlled trial to test 2 types of massage therapy compared with usual care [Cherkin et al. 2011]. Participants were blinded to massage type — either structural massage (n = 132) or relaxation massage (n = 136) — while the rest were randomly assigned to usual care (n = 133). Those in the massage groups were given approximately 60-minute massage treatments once-weekly for 10 weeks by one of 27 therapists. Usual medical care included opioid analgesics, anti-inflammatory drugs (NSAIDs), and/or muscle relaxants/sedatives. Average age was 47 years and most participants were female, white, employed, married, and had back pain for at least 1 year.
Outcome measurements included the Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcomes) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful. A battery of other questions assessed such factors as global improvement, satisfaction with treatment, adverse experiences during treatment, and others.
Writing in the Annals of Internal Medicine, the researchers report that both massage groups had statistically significant and equivalent outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation-massage group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural-massage group than in the usual-care group. Adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. Some of the improvements persisted at 26 weeks; however, by 52 weeks, outcomes in the 3 group were statistically comparable.
More specifically, at 10 weeks, more than one-third of those who received either type of massage said their back pain was much better or gone, compared with only 1 in 25 patients (4%) who received usual care. Those in the massage groups were also twice as likely in that period to have spent fewer days in bed, used less anti-inflammatory medication, and engaged in more activity than the usual care group.
The researchers conclude that massage therapy may be effective for treatment of chronic back pain, with some of the benefits lasting up to 6 months. Although, no clinically meaningful differences between relaxation massage and structural massage were observed in terms of relieving disability or symptoms.
COMMENTARY: This was essentially a well-designed study, funded by the U.S. National Center for Complementary and Alternative Medicine (NCCAM). However, there were some limiting factors to consider and certain questions remain incompletely answered, for example:
1. What patients with lower back pain would benefit most from massage?
The current trial enrolled only patients with nonspecific low back pain and excluded those with a specifically diagnosed cause such as fracture, spinal stenosis, cancer, disk herniation, or those with complicated cases involving sciatica or failed back surgery. Patients with severe fibromyalgia or rheumatoid arthritis also were excluded. Additionally, subjects were primarily middle-aged white females, so generalization to a broader population cannot be made on the bases of this trial.
2. Which is best, structural massage or relaxation/spa massage?
Structural massage, which manipulates specific pain-related back muscles and ligaments, might be expected to be superior to the less rigorous relaxation massage (also called Swedish or spa massage), which aims to promote a feeling of body-wide restfulness. Structural massage also requires more training and is more likely to be paid for by health insurance plans, since it is often considered a form of prescribed physical therapy.
Both types of massage are relatively safe but structural massage is more dependent on therapist skills. Variations in technique might account for its lack of superiority in this trial, since there were 27 different massage therapists involved who sometimes customized sessions to patient needs and also recommended different exercises for at-home care between visits. Therefore, on the basis of this particular study’s outcomes, it is difficult to recommend one form of massage over the other.
3. Might there be a strong placebo effect accounting for improvements with massage?
At baseline, all subjects had ranked massage roughly 7 on a 10-point scale of expected helpfulness (10 being highest). It is interesting to observe in the data that all 3 groups (even those who had not received massage) showed improved function and decreased back symptoms from baseline to 10 weeks (at which time massage treatments ended), although such improvements were significantly less in the usual-care control group. Therefore, the mere fact of being in a clinical trial may have exerted some positive placebo effects in all groups. Also, since massage is an active albeit noninvasive form of treatment, and there were high expectations of benefit, there could have been significant placebo effects associated with it.
4. How long should massage be continued for best results?
In this trial, beyond the 10-week active therapy period, there appeared to be a regression toward the mean; that is, beneficial outcomes for all 3 groups diminished and converged — at 52 weeks, measures of improvement were better than at the beginning but not as good as at the 10-week point. Therefore, ongoing massage therapy might be required for maintenance and/or continued improvement but this study does not define the optimum length of massage therapy or its frequency.
There also were a number of complicating, possibly confounding, factors in this trial. For example, some patients in all groups visited healthcare providers for back pain during the trial, some massage-group subjects continued on various medications, 13% of usual-care-group subjects had massages between the 10 and 26 week assessments, and various percentages of subjects in all groups reported having massages between the 26 and 52 week assessments. So, the trial was not as tightly controlled as would have been optimal for achieving highly reliable and internally valid results.
Perhaps the most important message of this trial, as the researchers also suggest, is that treatment by a qualified massage therapist can be a reasonable and beneficial option for persons with nonspecific chronic low back pain. The type of massage and duration/frequency of therapy probably need to be customized to individual patient needs; however, massage should not be viewed as a “quick fix” and it might be considered as an adjunct to rather than a replacement for other standard approaches recommended in current guidelines.
REFERENCE: Cherkin DC, Sherman KJ, Kahn J, et al. A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial. Ann Intern Med. 2011(Jul);155(1):1-9 [article PDF here; abstract here].
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3 comments:
I have been in medicine for 30 years and I still amazed how effective a critique of an article can be to analytical. Add in time of day and temperature of the massage room to be complete. Massage works, acupuncture works, PT works, aerobics work, heat works ... Add all of them at the same time and repeat until the patient is back to normal. Surgery does no work in all cases!
Stephen S. Rodrigues, MD Dallas, TX.
Dr. Rodriques is close. ALL research on back pain, unless otherwise stated, is performed on heterogeneous groups. "Non specific back pain" means as much as "non specific throat pain"--ie, it doesn't mean much. As a physical therapist, I was appalled that PTs started talking about classifying patients with back pain in to more homogenous groups in the mid to late 1990s--I was trained to do this in the 1980s so that this was news was shocking. But, to the point of massage, the question should be, what part of the problem of low back pain does it treat? Massage only treats trigger points. Similar with dry needling (and probably the benefit of acupuncture, though massage is more specific than acupuncture and dry needling is more specific than massage). There are at least two other components of non specific low back pain--muscle inhibition which in my opinion comes from hypomobility in facet joints (similar problems of muscle inhibition occur around the shoulder, neck and knee). So, if you don't treat the joints/facets, your muscle techniques (massage, dry needling) will not be as effective, or maybe not effective at all. I regularly tell my patients it doesn't matter so much to me if you don't let me treat muscles with needles or massage but I can't treat a facet problem which leads to muscle problems without treating the joints. In summary, I wish we would get rid of these studies on non-specific low back pain and researchers would start incorporating evaluation techniques that classify patients. Early models for this exist in the PT literature but we have a long way to go.
Thank you, Dr. Silver, for your comments above. I would agree that "nonspecific" may be overused in the pain literature to mean "there doesn't seem to be any cause of the pain but the patient still says it hurts." This hardly lends itself to robust scientific investigation, wherever the pain occurs and whether it is acute or chronic.
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