A Comparison of the Effects

of 2 Types of Massage and

Usual Care on Chronic Low
Back Pain
A Randomized Controlled Trial

AGUILAN, ALLAN
AGUILAR, JOY
ANGELES, ANNA
BADERA, RHEA
BAUTISTA, REYNALYN

Discussion
I. Introduction
II. Methodology
III. Results
IV. Conclusion

Introduction

Chronic Low Back Pain

Low back pain or lumbago is a common
disorder involving the muscles and bones of
the back.
Muscle,Nerve or Bone pain
Stress, Trauma or Injury
40% of people
Longer than 3 months

Massage
A mechanical stimulation of the tissues through
rhythmically applied pressure or stretching.
Swedish Massage warm up the muscle tissue,
releasing tension and gradually breaking up
muscle "knots" or adhered tissues
Neuromuscular therapy alternating levels of
concentrated pressure (10-30 seconds) on the
areas of muscle spasm
Shiatsu acupressure with stretching, breathing and
rotating

Objectives:
To compare the effectiveness of 2 types of
massage and usual care for chronic back pain.
Relaxation Massage
Structural Massage

 Patients: 401 persons 20 to 65 years of age with nonspecific

chronic low back pain.
Limitation: Participants were not blinded to treatment.
Exclusion criteria
1) specific causes of back pain (for example, cancer, fractures,
or spinal stenosis)
2) complicated back problems (for example,
sciatica, back surgery in the past 3 years, or medicolegal issues)
3) conditions making treatment difficult(for example, paralysis
or psychoses),
4) conditions that might confound treatment effects or
interpretation of results
(for example, severe fibromyalgia or rheumatoid arthritis),
5) inability to speak English,
6) massage within the past year

Methodology

Methodology

Study Design
Randomization and Interventions
Study Treatments
Outcomes and Follow-up
Statistical Analysis
Role of the Funding Source

Study Design
aged 20 to 65 years
had outpatient visit diagnoses suggesting
nonspecific
chronic low back pain
3 to 12 months after visits
low back pain lasting at least 3 months
at least 3 on a scale of 0 to 10

Randomization & Intervention

Randomization schedule was created by a
biostatistician and was blocked on massage
therapist; allocation was centrally generated and
concealed.
Participants:
randomly allocated in a 1:1:1 ratio to receive usual care,
relaxation massage, and structural massage
knew whether they received massage but were blinded to
type; usual care recipients were aware that they had enrolled
in a trial of massage.

 Therapist were not blinded to the type of

massage that they provided.
Study personnel assessing trial outcomes were
blinded to study assignment.

Study Treatments
Therapists

n=27
with at least 5 years experience
received protocol training
treatment fidelity

Massage Techniques
treatment at no cost
provided for 10 weekly
treatments and followup visits after
adherence
completion of at least 8
follow-up visits
home exercises were
recommended for
participants in massage

Structural massage

Relaxation massage

Structural Massage
to identify and alleviate
musculoskeletal
contributors to back
pain
myofascial,
neuromuscular, and
other soft-tissue
techniques
varied body areas
for home exercisepsoas stretch

Relaxation Massage
to induce a sense of
relaxation
effleurage, petrissage,
circular friction,
vibration, rocking and
jostling and holding
7-20 mins on back and
buttocks
for home exercise- 2.5
minute relaxation
exercise

Outcomes and Follow-up

Outcomes were measured at 10, 26 and 52 weeks
by masked interviewers
Primary Outcomes: 10 wks
> Dysfunction was measured using the
modified RDQ
>Symptoms were assessed by the Symptom
Bothersomeness

 Secondary outcomes: 26 and 52 wks

> percentage of participants with significant
level of reduction in dysfunction based on RDQ
and symptom bothersomeness scores.
> Short Form 12 Physical and Mental Health
Survey.
> Effects on occupational activities

> Improvement in back pain related

dysfunction
>Satisfaction Rate(very satisfied- not very
satisfied) :Using the Likert Scale
> Total Cost of back pain-related visits, imaging
studies and medications during follow-up year .

Statistical Analysis
Sample size was calculated to ensure adequate
power at 10 weeks to detect a clinically
meaningful 2-point mean difference between
structural massage and usual care groups.
Analysis were conducted using generalized
estimating questions(12) w/ an independent
working correlation structure

 Precision Variables
> age, group, sex, baseline RDQ
> symptom bothersomeness scores, SF-12 test,
education level, body mass index, type of work,
original cause of backpain, more than 7 days of
reduced back pain and mediation use in previous week.
Least Significant differnce approach was used to
control multiple comparisons.
Adjusted mixed-effects model to asses effects
Intraclass correlation coefficient was calculated to
quantify the degree of variability

Role of the Funding Source

The research is funded by the National Center
for Complementary and Alternative Medicine

Results

Results

Study Recruitment and Follow-up

Baseline Characteristics
Study Treatments
Primary Outcomes
Secondary Outcomes
Practitioner Effects
Co-interventions and Subsequent Use of Massage
Cost of Back Pain-Related Health Care After
Randomization
Adverse Effects

STUDY RECRUITMENT AND FOLLOW UP

Of 9127 invitations and 1161 responses
402(35% ) were eligible and allocated
Others (Not Randonmly Assigned):
1.) Ineligible: 662
2.) Unable to Contact : 8
3.) Recruitment ended before eligibility was
determined : 26
4.) Declined : 63

 STRUCTURAL MASSAGE (n=132)

> Massage Therapists (Group A): 27
> Participants treated by therapist: median (5)
min : 1
max : 13
RELAXATION MASSAGE (n=136)
> Massage Therapists (Group B) : 27
> Participants treated by therapist : median (5)
min : 0
max : 13
USUAL CARE ( n=133)

BASELINE CHARACTERISTICS

Middle-aged
Female
White
RDQ: 10.8
Symptom Bothersomeness: 5.7

STUDY TREATMENT
STRUCTURAL MASSAGE

88% adhered to treatment

(8-10 visits)
12% did not complete
treatment
(0-7 visits)
PTs recommended 7 home
exercises
Psoas stretch

RELAXATION MASSAGE

93% adhered to treatment

(8-10 visits)
7% did not complete treatment
(0-7 visits)
PTs recommended 7 home
exercises
Conscious relaxation

PRIMARY OUTCOMES
at 10 wks:
Improvement was evident in both types of massage
RDQ scores are lower for the massages than for usual
care

at 26 wks:
Continuous improvement for all treatments, but better
improvement evident in massage
Massage groups RDQ increases

at 52 wks:
Relaxation massage was shown to be slightly more
effective than structural massage (lower RDQ by 1.2 pts)

SECONDARY OUTCOMES
at 10 wks
both physical and mental health scores were better for
the two types of massage than it was for usual care

at 52 wks:
for mental health SF-12 scores decreased for both
massages types and increased for usual care
for physical health SF-12 scores increased for both
massage types and decreased for usual care
concluding overall that massage is better than usual care
based on secondary outcomes

PRACTITIONER EFFECTS
Therapists treatment skills were effective

CO-INTERVENTIONS AND SUBSEQUENT

USE OF MASSAGE
at 10 wks:
more participants from the usual care group visited a
provider for back pain than the massage groups
usual care participants sought out for massage treatment

between 10 26 wks:
lesser participants from the usual care group reported to
have visited a provider for back pain than the massage
groups

at 52 wks:
it was observed from the patients that massage,
particularly relaxation massage, was effective
two participants from the usual care group and one from
the structural underwent back surgery

COST OF BACK PAIN-RELATED HEALTH

CARE AFTER RANDOMIZATION
Average cost: $540
Average cost per treatment session
Usual care cost: $25
Relaxation massage cost: $78
Structural massage cost: $38

ADVERSE EFFECTS
4% of relaxation massage recipients and 7% of
structural massage recipients reported adverse
effects, mostly increased pain
Some experienced nausea, SOB and chest pain
from the structural group but those were
classified to be unrelated to treatment

CONCLUSION

 Massage therapy improved function and decreased

pain more than usual care in pts with uncomplicated
chronic low back pain after 10 weeks.
Relaxation massage has the same effect to those of
structural massage.
No evidence of differential effectiveness among the
massage therapists, and both relaxation and
structural massage had very low rates of adverse
effects.
The study has limitations.

 In summary, results suggest that both relaxation

massage and structural massage are reasonable
treatment options for persons with chronic low
back pain.

A Comparison of the Effects

of 2 Types of Massage and
Usual Care on Chronic Low
Back Pain
A Randomized Controlled Trial
Daniel C. Cherkin, PhD | Karen J. Sherman, PhD, MPH | Janet Kahn, PhD
Robert Wellman, MS | Andrea J. Cook, PhD | Eric Johnson, MS
Janet Erro, RN, MN | Kristin Delaney, MPH | Richard A. Deyo, MD, MPH
-Retrieved on 15 June 2015 from http://annals.org/article.aspx?
&year=2011&volume=155&page=1

PEDRO SCALE
1.) Eligible Criteria

2.)Subject Randomized

3.)Allocation of Data Concealed

4.)Allocation Concealed in Figure 1

5.) Blinding of all subjects

6.)Blinding of all therapists

7.) Blinding of all assessors

8.) At least 85% complete

9.) Intention to Treat

10.) Comparison w/ othe r groups

TOTAL: 8/10