MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Researchers from the ‘International Centre for Allied Health Evidence’, University of South Australia in Adelaide wanted to determine whether massage therapy is an effective intervention for back pain. They carried out extensive literature searches to identify all systematic reviews on the subject, analysed them critically and evaluated their methodological quality. Nine systematic reviews were found. Their methodological quality varied from poor to excellent. The primary research informing these systematic reviews was generally considered to be weak quality. The findings indicated that massage may be an effective treatment option when compared to placebo or active treatment options such as relaxation, especially in the short term. There were conflicting and contradictory findings for the effectiveness of massage therapy as a treatment of non-specific low back pain when compared against other manual therapies such as mobilization, standard medical care, and acupuncture.

The authors concluded that there is an emerging body of evidence, albeit small, that supports the effectiveness of massage therapy for the treatment of non-specific low back pain in the short term. Due to common methodological flaws in the primary research, which informed the systematic reviews recommendations arising from this evidence base should be interpreted with caution.

My own systematic review from 1999 (which the authors of this systematic review of systematic reviews seem to have missed) concluded that massage seems to have some potential as a therapy for low back pain. Indeed, there seems to be unanimous agreement that massage therapy is a promising treatment. Why then do massage therapists not finally get their act together and conduct a few more high quality primary studies? Currently, we have about as many reviews as trials! Doing even more reviews will not answer the question about effectiveness!!!

And it is a damn important question. Back pain is extremely common and extremely expensive for us all. At present, we have no optimal treatment. Chiropractors and osteopaths are claiming to have found a good solution, but many experts are not convinced by their evidence and argue that the risks of spinal manipulation might not outweigh its benefits. Massage, by contrast, is almost risk-free. Considering all this, I believe we need more trials with some urgency.

So, why are such trials not forthcoming? I realise that multiple hurdles have to be taken:

  • Clinical studies of that nature are expensive, and there is no obvious funding source.
  • Massage therapists usually do not have enough research expertise to pull off a sound study.
  • There are multiple methodological problems in conduction a definitive massage trial that might convince us all.

However, none of these obstacles are insurmountable. I suggest massage therapists team up with experts who know how to run clinical trials, hammer out a reasonable study design and approach government or other official funders for support. We need a definitive answers and we need them soon: is massage effective? which type of massage? for which patients? at which stage of non-specific low back pain?

10 Responses to Massage for back pain? Why is there still no certainty?

  • Funding should be easy – assuming they are remotely interested, that is.

    Some conservative figures:

    The CNHC have nearly 5,000 massage therapists on their register (and there will be many thousands of others who are not CNHC registrants). However, taking that figure for now. Assume they only have four appointments per day, only work four days a week and for 40 weeks of the year. That gives 640 appointments per practitioner per year. Let’s say they charge £50 an appointment. That gives a total income from those 5,000 of £160 million. Not an insignificant amount.

    How about a 1% levy on all appointments? That’s just 50p each – that could either come from the practitioner’s profit or an additional 50 on what they charge their customers. Not very much individually. But, over even just these 5,000 therapists, this accumulates £1.6 million per year! Now, what research could they do with that? Just think what they could do with a 10% levy!

    Even of my guesses are a bit out, the potential for funding good trials is there – there only has to be a willingness to do it. Or are they too busy treating customers for conditions they don’t have good evidence for?

    Of course, the same calculations can be done for homeopaths, reiki enthusiasts, reflexologists, etc. Lack of funding for altmed trials is a non-argument.

  • Hi
    Do you have the references for the papers you used to write this blog please?

  • In Germany, health insurance companies are cutting down on expenses for massages and other physiotherapeutic treatment. You can get a prescription for six treatments at a time only for twenty minutes each. Sometimes you get only three treatments. If a sound study could prove effectiveness, then the health insurance would have to reconsider this policy. So there might be some financial gain for the therapists involved – and some gain in the wellbeing of their patients too.

  • ”massage therapy as a treatment of non-specific low back pain” sounds like a non-specific treatment for a non-specific ailment. How rigorously can it be evaluated? Personally I have found that it makes my lower back pain worse. I would suggest that back pain in our society is often caused by sedentary occupations resulting in poor posture and lack of muscle tone; massage that relaxes muscles is not addressing the likely cause of the problem, whereas a bit of (properly supervised) regular exercise could work wonders.

    • This is very true. In this instance, massage can only temporarily relieve the symptoms of LBP. If someone sits 7 hrs a day, has weak abdominal muscles, has a gut, does not exercise (by exercising I mean getting the heart rate up and blood moving at least every other day for 30-45 min via, bike, vigorous waliking- doesn’t have to be the iron man competition), well, not much a massage can do for the long term. The responsibility falls on the person, but sometimes it’s just easier to pass it on to someone else for 60 min 😉 you are SO right. Regular exercise and a little strength building is the answer.

      Sorry to hear MT hurts your back. Curious indeed. Sometimes putting a pillow under your hipbones during a session to decrease the arch can prevent that.. Cheers

  • Perhaps the Touch Research Institute will be a helpful resource: http://www6.miami.edu/touch-research/Research.html

  • Good day Prof. Ernst,

    Thank you for your commentary regarding our recent publication “The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews”. We too acquiesce with you regarding the need for high level, better quality primary research studies, an issue which seems to reflect a number of areas in health.

    Just to provide a clarification to your comment “My own systematic review from 1999 (which the authors of this systematic review of systematic reviews seem to have missed)”, our search did not miss your systematic review.

    As indicated in the methods, our search strategy for this systematic review searched for publications published from the time periods of January 2000 to December 2012. Your systematic review was published in 1999 and as such was outside the scope of our systematic review.

    We have read with great interest many of your publications over the years and look forward to reading your continued works.

    Saravana Kumar

  • Dear Edzard,
    Thanks for this post. I do always appreciate your outspoken rougue-ness.
    Short answer: No studies, no certainty. I’m sure that you know, the absence of research has no relationship to whichever modality in question, it has more to do with qualified persons to perform the work and then the almighty funding. A number of therapists have to bite the bullet and get their credentials in research, like chiropractors did a few decades ago, and continue to do. It is imperative that massage therapy be investigated from various perspectives. Human outcome studies are a breeze to design really, they just need doing. But more importantly, compared to many therapies, massage therapy has very tangible hypotheses of mechanism of action. We are in the process of investigating a number of such mechanisms. We are now funded to continue our work on massage for postoperative adhesion prevention, and have already published promising results, including showing attenuating effects on inflammation. Anecdotes and animal research support that massage might increase the rate and quality of reinnervation after nerve injury. Also, is there anything “myofascial” “released” in “myofascial release?” Studies addressing one possibility for this are also underway.

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