Definition of the procedure.
Massage can be defined as soft tissue manipulation using the hands or a mechanical device (Furlan et al 2002). Different techniques can be used, such as: effleurage, petrissage, friction, kneading, or hacking. Either a classical approach is used, or an approach in which the rules of massage from physical medicine are combined with those of acupuncture from neural therapy (treats one unique point with a special vibrating instrument that stimulates the acupuncture point superficially (but not with needle insertion)). In clinical practice, massage is often applied in combination with other therapies such as exercises and other interventions but sometimes also as a sole treatment.
Results of search Systematic reviews
Two SRs were found that dealt with the effects of massage in low back pain patients (Ernst 1999, Furlan et al 2002). One of them was a Cochrane SR, which described the effects of massage in adults with acute, sub-acute and chronic (>12 weeks) low back pain (Furlan et al 2002). The latter SR formed the basis for this evidence review.
Additional trials
Two additional trials were found (Hsieh et al 2004, Walach et al 2003). In one, the effects of massage were compared with standard medical care in a group of patients with chronic pain (Walach et al 2003). However, this study was excluded from the evidence review because it was not clear from the publication what proportion of the study population had low back pain at the start of the study. In the second trial, acupressure was compared with physical therapy (consisting of either infrared light therapy, thermotherapy, electrical stimulation, exercise therapy or pelvic manual traction) (Hsieh et al 2004).
Quality assessment of the evidence
The two SRs were of a high quality.
The Cochrane SR included 7 RCTs that were reported in 8 publications (Cherkin et al 2001, Franke et al 2000, Hernandez-Reif et al 2001, Hoehler et al 1981, Hsieh et al 1992, Melzack et al 1983, Pope et al 1994, Preyde 2000). In these studies massage therapy was compared with a variety of treatments.
The additional trial (Hsieh et al 2004) was high quality.
Effectiveness
Effectiveness of massage versus sham procedure
One high quality RCT (according to the Cochrane Review) showed that massage was significantly better than sham laser therapy with regard to both pain and function up to 1 month after treatment (i.e. disability) (Preyde 2000).
There is limited evidence that massage is more effective than sham procedures in the treatment of chronic low back pain (level C).
Effectiveness of massage versus remedial exercises and posture education
One high-quality study reported that, immediately after treatment, massage therapy led to significantly greater disability and pain improvementscompared with remedial exercise and posture education (Preyde 2000).
Effectiveness of massage versus relaxation therapy
One low quality study reported significantly more pain relief after massage therapy in comparison to progressive relaxation therapy (Hernandez-Reif et al 2001).
There is limited evidence that massage is more effective than relaxation therapy for pain relief (level C).
Effectiveness of massage versus acupuncture
One high quality study compared 10 sessions (over 10 weeks) of either massage or acupuncture (Cherkin et al 2001). Patients in the massage group had better function scores than those in the acupuncture group, at both short-term (10 weeks) and long- term (52 weeks) follow-ups. Differences in pain scores in favour of massage were found only at the longer-term follow-up.
There is limited evidence that massage is more effective than acupuncture in reducing pain (long-term) and improving function (short-term and long-term) (level C).
Effectiveness of massage versus self-care education
One high quality study compared 10 sessions (over 10 weeks) of massage therapy with self-care education (Cherkin et al 2001). Patients in the massage group had more pain relief and better function scores at the short-term follow-up (i.e. 10 weeks). These differences were not maintained at long-term follow-up (i.e. 52 weeks). There is limited evidence that massage is better than self-care education in reducing pain and improving function in the short term but not the longer term (level C).
Effectiveness of massage versus spinal manipulation
In one low quality study, the effectiveness of spinal manipulation was compared with that of massage therapy, where the latter was serving as a control
treatment (Hoehler et al 1981). The manipulation group had better results in relation to pain reduction immediately after the first session, but the difference was not maintained at the longer term. One high quality trial (reported in two papers (Hsieh et al 1992, Pope et al 1994)) showed that spinal manipulation resulted in greater improvements in function compared with massage; there were no differences in pain improvements between the groups.
There is limited evidence that spinal manipulation and massage are equally effective in pain relief, and that spinal manipulation results in better function than massage (each level C).
Effectiveness of massage versus general physical therapies
One high quality study found that acupressure had a significant effect on pain compared with various physical therapies up to 6 months after treatment.
There is limited evidence that acupressure massage is more effective than general physical therapies for mid-term pain relief (level C).
Effectiveness of massage versus electrical stimulation
One high quality RCT showed no differences in pain and function scores between a massage group and a group receiving transcutaneous muscle stimulation (Hsieh et al 1992, Pope et al 1994).
Another high quality RCT showed that massage resulted in significantly less pain relief compared with TENS (Melzack et al 1983).
There is limited evidence that there is no difference between massage and transcutaneous muscle stimulation with regard to improvements in either pain or function (level C). There is limited evidence that massage is less effective than TENS in relieving pain (level C).
Effectiveness of massage versus corset
One high quality RCT, reported in two papers, compared massage to the wearing of a corset (Hsieh et al 1992, Pope et al 1994). No differences between the treatments were found for function or pain.
There is limited evidence that there is no difference in the effectiveness of massage and the wearing of a corset (level C).
Effectiveness of massage as a component of combined therapy
One high quality studyshowed that massage in combination with remedial exercises and education was better for pain relief than massage alone, immediately after treatment (Preyde 2000). The combination therapy was also better than remedial exercises only or sham laser therapy, in terms of both pain relief and improvement of function up to 1 month after treatment (Preyde 2000).
There is limited evidence that massage in combination with remedial exercises and education is better than massage alone, remedial exercises alone or sham laser therapy for short-term pain relief and improved function (level C).
Effectiveness of different types of massage vs each other
One high quality study compared the effectiveness of therapeutic acupuncture massage with classical massage (each combined with either individual medical exercises or group exercises) (Franke et al 2000).
Immediately after therapy, acupuncture massage showed significantly better effects for both disability and pain compared with classical massage.
There is limited evidence that therapeutic acupuncture massage is more effective than classical massage (level C).
Cost-effectiveness
Unknown (no studies were found on this issue)
Safety
Unknown (no studies were found on this issue)
Subjects (indications)
Not having shown evidence of effectiveness, it is not possible to define indications for massage.
Comments
None
Summary of evidence
• There is limited evidence in each case that massage is more effective than: sham procedures; remedial exercise and posture education; relaxation therapy (for pain relief); acupuncture (long-term pain relief and function); self-care education (for short-term pain relief and improvement of function); and general physical therapies (for mid-term pain relief (each, level C)).
• There is limited evidence that massage and spinal manipulation are equally effective for pain relief, but that massage results in less functional improvement than spinal manipulation (each level C).
• There is limited evidence that there is no difference between massage and transcutaneous muscle stimulation with regard to improvements in either pain or function (level C). There is limited evidence that massage is less effective than TENS in relieving pain (level C).
• There is limited evidence that there is no difference in the effectiveness of massage and the wearing of a corset (level C).
• There is limited evidence that a combined treatment of massage with remedial exercises and education is better than massage alone, remedial exercises alone or sham laser therapy for short-term pain relief and improved function (level C).
• There is limited evidence that therapeutic acupuncture massage is more effective than classical massage (level C).
Recommendation
We cannot recommend massage therapy as a treatment for chronic low back pain.
References
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2. Ernst E (1999) Massage therapy for low back pain: A systematic review. J Pain Symptom Manage, 17: 65-9.
3. Franke A, Gebauer S, Franke K, Brockow T (2000) [Acupuncture massage vs Swedish massage and individual exercise vs group exercise in low back pain sufferers--a randomized controlled clinical trial in a 2 x 2 factorial design]. Forsch Komplementarmed Klass Naturheilkd, 7(6): 286-93.
4. Furlan AD, Brosseau L, Imamura M, Irvin E (2002) Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine, 27(17): 1896-910.
5. Hernandez-Reif M, Field T, Krasnegor J, Theakston H (2001) Lower back pain is reduced and range of motion increased after massage therapy. Int J Neurosci, 106(3-4): 131-45.
6. Hoehler FK, Tobis JS, Buerger AA (1981) Spinal manipulation for low back pain. Jama, 245(18): 1835-8.
7. Hsieh CY, Phillips RB, Adams AH, Pope MH (1992) Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther, 15(1): 4-9.
8. Hsieh LL, Kuo CH, Yen MF, Chen TH (2004) A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy. Prev Med, 39(1): 168-76.
9. Melzack R, Vetere P, Finch L (1983) Transcutaneous electrical nerve stimulation for low back pain. A comparison of TENS and massage for pain and range of motion. Phys Ther, 63(4): 489-93.
10. Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S (1994) A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine, 19(22): 2571-7.
11. Preyde M (2000) Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Cmaj, 162(13): 1815-20.
12. Walach H, Guthlin C, Konig M (2003) Efficacy of massage therapy in chronic pain: a pragmatic randomized trial. J Altern Complement Med, 9(6): 837-46.