Massage for low-back pain

107 Pages·2008·1.17 MB·English

Massage for low-back pain (Review)
Furlan AD, Imamura M, Dryden T, Irvin E
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2008,Issue4
http://www.thecochranelibrary.com
Massageforlow-backpain(Review)
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Analysis1.1. Comparison1Massageversusshamtreatment,Outcome1Painintensity(highervaluesmeanmorepain). 54
Analysis1.2. Comparison1Massageversusshamtreatment,Outcome2Painquality. . . . . . . . . . . . 56
Analysis1.3. Comparison1Massageversusshamtreatment,Outcome3Back-specificfunctionalstatus(higherscores 57
meanmoredisability). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis2.1. Comparison2Massageversusmanipulation/mobilization,Outcome1Painintensity(highervaluesmean 59
morepain). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis3.1. Comparison3Massageversusexercises,Outcome1Painintensity(0:nopain;5:excruciatingpain). . 60
Analysis3.2. Comparison3Massageversusexercises,Outcome2Painquality. . . . . . . . . . . . . . 61
Analysis3.3. Comparison3Massageversusexercises,Outcome3Back-specificfunctionalstatus(RDQ,0-24,scores 63
>14indicatepooroutcomes). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis4.1. Comparison4Massageversusrelaxation,Outcome1Painintensity(VITAS:presentpainwithaVAS 64
rangingfrom0to10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis4.2. Comparison4Massageversusrelaxation,Outcome2Painquality. . . . . . . . . . . . . . 65
Analysis5.1. Comparison5Massageversusacupuncture,Outcome1Painintensity/symptombothersomeness. . 66
Analysis5.2. Comparison5Massageversusacupuncture,Outcome2Function. . . . . . . . . . . . . . 67
Analysis6.1. Comparison6Massageversusself-careeducation,Outcome1Painintensity/symptombothersomeness. 69
Analysis6.2. Comparison6Massageversusself-careeducation,Outcome2Function. . . . . . . . . . . . 70
Analysis7.1. Comparison7Acupuncturemassageversusphysicaltherapy,Outcome1Painintensity. . . . . . 72
Analysis7.2. Comparison7Acupuncturemassageversusphysicaltherapy,Outcome2Function(RolandandMorris 73
disabilityquestionnaire). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis8.1. Comparison8Acupuncturemassageversusclassicmassage,Outcome1Painintensity. . . . . . . 74
Analysis8.2. Comparison8Acupuncturemassageversusclassicmassage,Outcome2Function(valueslessthan70% 76
indicatepoorfunctionalstatus,rangefrom0to100%). . . . . . . . . . . . . . . . . . . .
Analysis9.1. Comparison9ThaimassageversusSwedishmassage,Outcome1Painintensity. . . . . . . . . 77
Analysis9.2. Comparison9ThaimassageversusSwedishmassage,Outcome2Function(OswestryDisabilityIndex). 79
Analysis10.1. Comparison10Massage+exercise+educationversusmassagealone,Outcome1Painintensity(0:no 80
pain;5:excruciatingpain). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis10.2. Comparison10Massage+exercise+educationversusmassagealone,Outcome2Painquality. . . 82
Analysis10.3. Comparison10Massage+exercise+educationversusmassagealone,Outcome3Back-specificfunctional 83
status(RMDQ,0-24,scores>14indicatepooroutcomes). . . . . . . . . . . . . . . . . . .
Massageforlow-backpain(Review) i
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis11.1. Comparison11Massage+exercise+educationversusshamtreatment,Outcome1Painintensity(0:no 85
pain;5:excruciatingpain). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis11.2. Comparison11Massage+exercise+educationversusshamtreatment,Outcome2Painquality. . . 86
Analysis11.3. Comparison11Massage +exercise+educationversusshamtreatment,Outcome3Back-specific 88
functionalstatus(RMDQ,0-24,scores>14indicatepooroutcomes). . . . . . . . . . . . . . .
Analysis12.1. Comparison12Acupuncturemassage+conventionaltreatmentversusconventionaltreatmentalone, 89
Outcome1Painintensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis12.2. Comparison12Acupuncturemassage+conventionaltreatmentversusconventionaltreatmentalone, 90
Outcome2Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis13.1. Comparison13Massage+exerciseversusShamMassage+exercise,Outcome1Painintensity. . . 91
Analysis13.2. Comparison13Massage+exerciseversusShamMassage+exercise,Outcome2Function. . . . . 92
Analysis14.1. Comparison14Footreflexologyversusrelaxation,Outcome1Painintensity. . . . . . . . . 93
Analysis14.2. Comparison14Footreflexologyversusrelaxation,Outcome2Function. . . . . . . . . . . 94
Analysis15.1. Comparison15Footreflexology+usualcareversususualcarealone,Outcome1Painintensity. . . 96
Analysis15.2. Comparison15Footreflexology+usualcareversususualcarealone,Outcome2Function. . . . . 97
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Massageforlow-backpain(Review) ii
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[Interventionreview]
Massage for low-back pain
AndreaDFurlan1,MartaImamura2,TrishDryden3,EmmaIrvin1
1InstituteforWork&Health,Toronto,Canada.2DivisionofPhysicalMedicineandRehabilitation,DepartmentofOrthopaedicsand
Traumatology,UniversityofSãoPauloSchoolofMedicine,SãoPaolo,Brazil.3AppliedResearchCentre,CentennialCollege,Toronto,
Canada
Contactaddress:AndreaDFurlan,InstituteforWork&Health,481UniversityAvenue,Suite800,Toronto,ON,M5G2E9,Canada.
[email protected].(Editorialgroup:CochraneBackGroup.)
CochraneDatabaseofSystematicReviews,Issue4,2008(Statusinthisissue:Newsearchforstudiescompleted,conclusionsnotchanged)
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
DOI:10.1002/14651858.CD001929.pub2
Thisversionfirstpublishedonline:8October2008inIssue4,2008.
Lastassessedasup-to-date: 9July2008.(Datesandstatuses?)
This record should be cited as: Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database of
SystematicReviews2008,Issue4.Art.No.:CD001929.DOI:10.1002/14651858.CD001929.pub2.
ABSTRACT
Background
Low-backpainisoneofthemostcommonandcostlymusculoskeletalproblemsinmodernsociety.Proponentsofmassagetherapy
claimitcanminimizepainanddisability,andspeedreturntonormalfunction.
Objectives
Toassesstheeffectsofmassagetherapyfornon-specificlow-backpain.
Searchstrategy
WesearchedMEDLINE,EMBASE,CINAHLfromtheirbeginningtoMay2008.WealsosearchedtheCochraneCentralRegisterof
ControlledTrials(TheCochraneLibrary2006,issue3),HealthSTARandDissertationabstractsupto2006.Therewerenolanguage
restrictions.Referencesintheincludedstudiesandinreviewsoftheliteraturewerescreened.
Selectioncriteria
The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a
mechanicaldevice)asatreatmentfornon-specificlow-backpain.
Datacollectionandanalysis
Tworeviewauthorsselectedthestudies,assessedtheriskofbiasusingthecriteriarecommendedbytheCochraneBackReviewGroup,
andextractedthedatausingstandardizedforms.Bothqualitativeandmeta-analyseswereperformed.
Mainresults
Thirteenrandomizedtrialswereincluded.Eighthadahighriskandfivehadalowriskofbias.OnestudywaspublishedinGermanand
therestinEnglish.Massagewascomparedtoaninerttherapy(shamtreatment)intwostudiesthatshowedthatmassagewassuperior
forpainand functiononboth shortandlong-termfollow-ups. Ineightstudies, massage was comparedtootheractive treatments.
Theyshowedthatmassagewassimilartoexercises,andmassagewassuperiortojointmobilization,relaxationtherapy,physicaltherapy,
acupuncture and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The
beneficialeffectsofmassageinpatientswithchroniclow-backpainlastedatleastoneyearaftertheendofthetreatment.Twostudies
Massageforlow-backpain(Review) 1
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
comparedtwodifferenttechniquesofmassage.Oneconcludedthatacupuncturemassageproducesbetterresultsthanclassic(Swedish)
massageandanotherconcludedthatThaimassageproducessimilarresultstoclassic(Swedish)massage.
Authors’conclusions
Massagemightbebeneficialforpatientswithsubacuteandchronicnon-specificlow-backpain,especiallywhencombinedwithexercises
andeducation.Theevidencesuggeststhatacupuncturemassageismoreeffectivethanclassicmassage,butthisneedconfirmation.More
studiesareneededtoconfirmtheseconclusions,toassesstheimpactofmassageonreturn-to-work,andtodeterminecost-effectiveness
ofmassageasaninterventionforlow-backpain.
Massageforlow-backpain(Review) 2
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
PLAIN LANGUAGE SUMMARY
Massageforlow-backpain
Low-back pain(LBP)isone ofthemostcommonandcostlymusculoskeletalproblemsinmodernsociety. Seventyto85% ofthe
populationwillexperienceLBPatsometimeintheirlives.Proponentsofmassagetherapyclaimitcanminimizepainanddisability,
andspeedreturntonormalfunction.
Massage in this review is defined as soft-tissue manipulation using hands or a mechanical device on any body part. Non-specific
LBPindicatesthatnospecificcauseisdetectable,suchasinfection,neoplasm,metastasis,osteoporosis,rheumatoidarthritis,fracture,
inflammatoryprocessorradicularsyndrome(pain,tinglingornumbnnessspreadingdowntheleg.
Thirteen randomized trials (1596 participants) assessing various types of massage therapy for low-back pain were included in this
review. Eighthadahighriskandfivehadalowriskofbias. Massagewasmorelikelytoworkwhencombinedwithexercises(usually
stretching)andeducation.Theamountofbenefitwasmorethanthatachievedbyjointmobilization,relaxation,physicaltherapy,self-
careeducationoracupuncture.Itseemsthatacupressureorpressurepointmassagetechniquesprovidemorereliefthanclassic(Swedish)
massage,althoughmoreresearchisneededtoconfirmthis.
Noseriousadverseeventswerereportedbyanypatientintheincludedstudies. However,somepatientsreportedsorenessduringor
shortlyafterthetreatment.Somepatientsalsoreportedanallergicreaction(e.g.rashorpimples)tothemassageoil.
Insummary,massage mightbebeneficialforpatientswithsubacute (lastingfourto12weeks)andchronic(lastinglonger than12
weeks)non-specificlow-backpain,especiallywhencombinedwithexercisesandeducation.
BACKGROUND projectintothecentralnervoussystemwithinthespinalcord).T-
cellactivityisdepressed(whereas,conversely,smalldiameternerve
Low-backpain(LBP)isamajorhealthprobleminmodernsociety.
fibres(nociceptivefibres)haveanexcitatoryinput)andpainrelief
Seventyto85% of thepopulation will experience LBPat some
follows(Melzack1996).Massagetherapymayprovideitsbenefits
timeintheirlives(Andersson 1999).Eachyear,5%to10% of
byshiftingtheautonomicnervoussystemfromastateofsympa-
theworkforceisoffworkbecauseoftheirLBP,themajorityfor
theticresponsetoastateofparasympatheticresponse.However,
lessthansevendays.Almost90%ofallpatientswithacuteLBP
supportforthistheoryisnotuniversal,andithasevenbeensug-
getbetterquiterapidly,regardlessoftherapy.Theremaining10%
gestedthatmassagetherapymaypromoteasympatheticresponse
areatriskofdevelopingchronicpainanddisability,andaccount
oftheautonomicnervoussystem(Moyer2004).Themechanis-
for more than90% of social costs for backincapacity (Waddell
ticlinksbetweenmanipulationofbodytissuesandcorresponding
1998).
relieffromabroadrangeofsymptomsarenotfullyunderstood.
AlthoughLBPisabenignandself-limitingcondition,manypa- Mechanistic studies are neededto delineate underlying biologic
tientslookforsometypeoftherapytorelievetheirsymptomsand andpsychologicaleffectsofmassageandtheirrelationshiptoout-
toprovidethemwithhopeforacure.Forthisreason,itispossible comes.
tolistmorethan50potentialtherapiespromisingtorelievethe
pain,lessenthesufferingandofferacureforthisproblem.How-
TheuseofmassageforLBPisverypopular.Ineasterncultures,
ever,thereissoundevidenceforonlyaminorityofthesetherapies
massageisbelievedtohavepowerfulanalgesiceffects,particularly
(VanTulder1997b).
ifappliedtoacupuncture-points,atechniqueknownas“acupres-
Whenexperiencingpainordiscomfort,thenaturalreactionisto sure”.In1998/99,almost17%oftheCanadianpopulationaged
ruborholdtheaffectedareatoreducethesensation.Atitsmost 18orolderreportedtheyhadsoughtthecareofalternativehealth
basic, massage isasimpleway ofeasingpain,whileatthesame carepractitionersinthepreviousyear.Theseincluded:chiroprac-
time aiding relaxation, promoting a feeling of well being and a tors,massagetherapists,acupuncturists, homeopathsandnatur-
senseofreceivinggoodcare.Soft-tissuemassageisthoughttoim- opaths.Themostcommonindicationwaschronicpain,including
provephysiologicalandclinicaloutcomesbyofferingthesymp- back problems (Health Reports 2001). In 1998, Wainapel sur-
tomaticreliefofpainthroughphysicalandmentalrelaxation,and veyedanurbanrehabilitationmedicineoutpatientofficeinNew
increasing thepain thresholdthrough the releaseof endorphins Yorktoaddresstheuseofalternativetherapyandtheirperceived
(Ernst1999).Thegate-controltheorypredictsthatmassaginga effectiveness(Wainapel1998).Theresultsindicatedthat29%of
particularareastimulateslargediameternervefibres.Thesefibres thesubjectsusedoneormorealternativemedicaltherapiesinthe
haveaninhibitoryinputontoT-cells(whicharethefirstcellsthat past 12 months and the most common therapy cited was mas-
Massageforlow-backpain(Review) 3
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
sage.Musculoskeletalpainsyndromesinvolvingthespineandex- 2)assesstheeffectivenessofdifferenttechniquesofmassage.
tremitieswerethemostcommonlyreportedproblems.Fifty-three
percentofthepatientswhousedalternativetreatmentsreported
somedegreeofeffectiveness. METHODS
Massageisrecognizedasasafetherapeuticmodality,withfewrisks
oradverseeffects.However,therearecontraindications, suchas, Criteriaforconsideringstudiesforthisreview
applyingmassageoveranareawithacuteinflammation,skinin-
fection,non-consolidatedfracture,burnarea,deepveinthrombo-
Typesofstudies
sisoroversitesofactivecancertumour(Vickers1999b).Minor
painordiscomfortwasexperiencedby13%ofparticipantsduring Publishedandunpublishedreportsofcompletedrandomizedcon-
orshortlyafterreceivingmassage(Cherkin2001). trolledtrials(RCTs),quasi-randomized,andcontrolledclinicaltri-
als(CCTs)withnolanguagerestrictionswereincluded.Abstracts
Massagehasbeeninvestigatedinthepainmanagementareaforits
ofongoingstudieswereincluded.
efficacyinrelievingheadaches(Jensen1990),post-exercisemuscle
pain(Weber1994),cancerpain(Weinrich1990)andmechanical
Typesofparticipants
neckpain(Gross1999).Thesestudiesshowlittleornoeffectof
massage inrelievingthesepainconditions. In2004 Moyeretal • Adults(olderthan18years)withacute(lessthanfourweeks),
reportedonameta-analysisof37randomizedtrials(1802partic-
sub-acute(fourto12weeks)orchronic(morethan12weeks)
ipants)formanydifferenthealthconditions. Thismeta-analysis
non-specificLBP(Philadelphia2001)
supportsthegeneralconclusionthatmassagetherapyiseffective. • LBP isdefinedaspain localizedfromthecostal margin or
Thirty-sevenstudiesyieldedastatisticallysignificantoveralleffect
12thribtotheinferiorglutealfold(Waddell2000)
aswellassixspecificeffectsoutofninethatwereexamined.Signif- • Non-specific indicates that no specific cause is detectable,
icantresultswerefoundwithinthesingle-doseandmultiple-dose
such as infection, neoplasm, metastasis, osteoporosis,
categories,andforbothphysiologicalandpsychologicaloutcome
rheumatoidarthritis,fracture,inflammatoryprocessorradic-
variables.(Moyer2004)
ular syndrome. RCTs that included subjects with specific
Our previous systematic review (Furlan 2002) concluded that causeofLBPwereexcluded.
massage was beneficial for chronic low-back pain, but itis out-
of-datebecauseofmorerecentlypublishedtrials.Therefore,the Typesofinterventions
needforanupdatedreviewonthistopic.
Massageinthisreviewisdefinedassoft-tissuemanipulationusing
handsoramechanicaldevice.Massagecanbeappliedtoanybody
part,tothelumbarregiononlyortothewholebody.Weusedthe
OBJECTIVES taxonomyofmassagetreatmentsformusculoskeletalpaindevel-
opedbySherman2006toincludestudiesinthisreview.Thetaxon-
The main objective of thisreview was to update our previously
omywasconceptualizedasathree-levelclassificationsystem:goals
publishedsystematicreviewtoassesstheeffectivenessofmassage
oftreatment,styles,andtechniques.Fourcategoriesdescribedthe
therapyinpatientswithnon-specificLBPcomparedto:
principalgoaloftreatment:relaxationmassage,clinicalmassage,
1)Shamorplacebomassage(explanatorytrials) movementre-educationandenergywork.Eachgoaloftreatment
couldbemetusinganumberofdifferentstyles,witheachstyle
2)Othermedicaltreatments(pragmatictrials)
consistingofanumberofspecifictechniques.Atotalof36distinct
3)Notreatment techniques were identified and described, many of which could
beincludedinmultiplestyles(seeTable1).Weexcludedtrialsin
Secondaryobjectiveswereto:
whichmassagewasnotappliedwithanyofthegoalsoftreatment
1)comparetheadditionofmassagetoothertreatments describedabove.
Table1. Taxonomyofmassagepractice(Shermanetal2006)
Goaloftreatment Relaxationmassage Clinicalmassage Movementreeducation Energywork
Intention Relaxmuscles,move Accomplishspecific Inducesenseoffreedom, Hypothesizedtofree
bodyfluids,promote goalssuchasreleasing easeandlightnessin
Massageforlow-backpain(Review) 4
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Table1. Taxonomyofmassagepractice(Shermanetal2006)
(Continued)
wellness musclespasms body energyblockages
Commonlyusedstyles Swedischmassage;Spa Myofascialtrigger Proprioceptive; Acupressure;Reiki;
(examples) massage;Sportsmassage points therapy; Neuromuscular Polarity;Therapeutic
Myofascialrelease; facilitation; Strain touch;Tuina;
Straincounterstrain; counterstrain;Trager
CommonlyTechniques Gliding,kneading, Direct pressure, Contract-relax,passive Directionofenergy,
(examples) friction, holding, skinrolling,resistive stretching,resistive smoothing, direct
percussion,vibration stretching,stretching stretching,rocking pressure,holding,
manual,cross-fibre- rocking,traction
friction,
• HealthSTARfrom1991toAugust2006,usingOVID3.0
Inphysiotherapy,massage isconsideredanadjuncttherapyora • CINAHLfrom1982toMay2008usingOVID(forsearch
complementary treatment to prepare the patient for exercise or
strategy,seeAppendix1).
other interventions; it is rarely the main treatment used. How- • EMBASEfrom1980toMay2008,usingOVID(forsearch
ever,therearepractitioners(e.g.massagetherapists)thatemploy
strategy,seeAppendix1).
massageastheonlyintervention.Inthisreview,weanalyzedmas- • Dissertationabstractsfrom1861toMay1999,usingSilver
sagealonebecauseitisdifficulttoreachdefiniteconclusionswhen
Platter(version3.10).
multipletreatmentsareinvolved. • Contactwithexperts(May1999):AmericanMassageTher-
apy Association, Touch Research Institute (USA), Funda-
Typesofoutcomemeasures cionKovacs(Spain),NationalCenterforComplementary&
Trials were included that used at least one of the five primary AlternativeMedicinefromtheNationalInstituteofHealth
outcomemeasures (USA), National Association of Nurse Massage Therapists
(USA),RolfInstitute(USA).
• Pain • Handsearch of reference lists in review articles, guidelines
• Overallimprovement
andintheretrievedtrials.
• Back-specificfunctionalstatus • Contact with experts in the field of spine disorders (May
• Wellbeing(e.g.qualityoflife)
1999):EditorialBoardoftheCochraneBackReviewGroup
• Disability(e.g.activitiesofdailyliving,workabsenteeism)
andtheCochraneComplementaryMedicineField.
Physicalexaminationmeasuressuchasrangeofmotion(ROM), ThesearchstrategyrecommendedbytheCochraneBackReview
spinal flexibility, degrees of straight leg raising (SLR) or mus- Group (van Tulder 2003)was used to find controlledtrials for
clestrengthwereconsideredsecondaryoutcomes.Theywereex- spinaldiseases.Thesearchstrategieswerereviewedandconducted
tractedonlyifnoprimaryoutcomeswereavailablebecausethey byanexpertlibrarian(EmmaIrvin)andtheCochraneBackRe-
correlatepoorlywiththeclinicalstatusofthepatient(Deyo1998). viewGroupTrialsSearchCoordinator(RachelCourban).
Thetimingoftheoutcomemeasurementsweredividedintotwo
categories:1)short-term:whentheoutcomeassessmentwastaken
Datacollectionandanalysis
fromtheendoftheinterventionperioduptothreemonthsafter
randomization,and2)long-term:whentheoutcomeassessment
wastakenmorethanthreemonthsafterrandomization. Selectionofthepapers
One review author (EI) conducted the electronic searches in
Searchmethodsforidentificationofstudies MEDLINE,HealthSTAR,CINAHLandEMBASE.Theresults
were merged using Reference Manager 9.5 and duplicates were
Thefollowingdatabasesweresearched:
manuallyremoved.Tworeviewauthors(AFandMI),appliedthe
• TheCochraneCentralRegisterofControlledTrials(CEN- inclusioncriteriadescribedabove.Onereviewauthor(AF)con-
TRAL),inTheCochraneLibrary2006,Issue3. ducted the searches in The Cochrane Central Register of Con-
• MEDLINEfrom1966toMay2008usingOVID(forsearch trolledTrialsandDissertationAbstractsandcontactedtheexperts
strategy,seeAppendix1). inthefield.ForarticleswritteninlanguagesotherthanEnglish,
Massageforlow-backpain(Review) 5
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
wesoughthelpfromtheCochraneCollaborationtotranslateand
extractthedata.
Assessingriskofbias
Two review authors(AF,TDor MI)assessed theriskof bias of
each paper.Inthe case of disagreement, review authors triedto
reachconsensusandifnecessary,athirdreviewauthorhelpedto
solvedisagreements.
Theriskofbiasofthearticleswasassessedusingthecriteriarec-
ommendedinthemethodguidelinesforsystematicreviewsinthe
CochraneBackReviewGroup(vanTulder2003),whichareshown
inTable2.Eachcriteriawasscoredas“yes”,“no”or“don’tknow”.
Theriskofbiasassessmentofthestudieswasusedfortwopur-
poses:first,toexcludestudieswithfatalflaws(suchasdropoutrate
higherthan50%,statisticallysignificantandclinicallyimportant
baselinedifferencesthatwerenotaccountedforintheanalyses).
Studiesthatpassedthefirstscreeningforfatalflawswereclassified
intohighorlowriskofbias.Astudywithlowriskofbiaswasde-
finedasatrialfulfillingsixormoreofthe11methodologicquality
criteriaandnothavingafatalflaw.Astudywithhighriskofbias
wasdefinedasfulfillingfewerthansixcriteriaandnothavinga
fatalflaw.Theclassificationintohigh/lowriskofbiaswasusedto
gradethestrengthoftheevidence.
Table2. Criteriausedtoassessriskofbias(vanTulder2003)
Criteria/Definitions
Wasthemethodofrandomisationadequate?Arandom(unpredictable)assignmentsequence.Examplesofadequatemethodsare
computer-generatedrandomnumberstableanduseofsealedopaqueenvelopes.Methodsofallocationusingdateofbirth,dateof
admission,hospitalnumbers,oralternationshouldnotberegardedasappropriate.
Wasthetreatmentallocationconcealed?Assignmentgeneratedbyanindependentpersonnotresponsiblefordeterminingthe
eligibilityofthepatients.Thispersonhasnoinformationaboutthepersonsincludedinthetrialandhasnoinfluenceonthe
assignmentsequenceoronthedecisionabouteligibilityofthepatient.
Wasthepatientblindedtotheintervention?Thereviewauthordeterminesifenoughinformationabouttheblindingisgiveninorder
toscorea“yes.”
Wasthecareproviderblindedtotheintervention?Thereviewauthordeterminesifenoughinformationabouttheblindingisgivenin
ordertoscorea“yes.”
Wastheoutcomeassessorblindedtotheintervention?Thereviewauthordeterminesifenoughinformationabouttheblindingis
giveninordertoscorea“yes.”
Wasthedrop-outratedescribedandacceptable?Thenumberofparticipantswhowereincludedinthestudybutdidnotcomplete
theobservationperiodorwerenotincludedintheanalysismustbedescribedandreasonsgiven.Ifthepercentageofwithdrawalsand
drop-outsdoesnotexceed20%forimmediateandshort-termfollow-ups,30%forintermediateandlong-termfollow-upsanddoes
notleadtosubstantialbiasa“yes”isscored.
Didtheanalysisincludeanintention-to-treatanalysis?Allrandomizedpatientsarereported/analyzedinthegrouptowhichthey
wereallocatedbyrandomizationforthemostimportantmomentsofeffectmeasurement(minusmissingvalues),irrespectiveof
noncomplianceandco-interventions.
Werethegroupssimilaratbaselineregardingthemostimportantprognosticindicators?Inordertoreceivea“yes,”groupshaveto
besimilaratbaselineregardingdemographicfactors,durationandseverityofcomplaints,percentageofpatientswithneurological
symptoms,andvalueofmainoutcomemeasure(s).
Massageforlow-backpain(Review) 6
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Table2. Criteriausedtoassessriskofbias(vanTulder2003)
(Continued)
Wereco-interventionsavoidedorsimilar?Co-interventionsshouldeitherbeavoidedinthetrialdesignorbesimilarbetweenthe
indexandcontrolgroups.
Wasthecomplianceacceptableinallgroups?Thereviewauthordeterminesifthecompliancetotheinterventionsisacceptable,based
onthereportedintensity,duration,numberandfrequencyofsessionsforboththeindexinterventionandcontrolintervention(s).
Wasthetimingoftheoutcomeassessmentinallgroupssimilar?Timingofoutcomeassessmentshouldbeidenticalforallintervention
groupsandforallimportantoutcomeassessments.
Descriptionofstudies
Dataextraction
See:Characteristicsofincludedstudies;Characteristicsofexcluded
Tworeviewauthors(AF,TDorMI)extractedthedatafromeach
studies.
trial,usingastandardizedform.Thefollowingdatawereextracted
Inourpreviousreview,wehadidentifiedninepublicationsreport-
fromeachstudyinadditiontothedatafortheriskofbiasassess-
ingoneighttrials.However,wedecidedtoexcludefourofthese
ment: methodsof patient recruitment,age of patients, country,
trialsinthiscurrentupdatebecausethemassagetherapywasnot
numberofpatientsincludedineacharm,lengthofLBPepisode,
judgedtobeappropriate(Godfrey1984;Hoehler1981;Melzack
causesof LBP,previous treatmentsfor LBP(including surgery),
1983;Pope1994).Thereasonsforexclusionoftheseandother
typesofinterventions,numberofsessions,typesofoutcomesmea-
trialsareexplainedintheCharacteristicsofexcludedstudiestable.
sures,timingofoutcome assessment, statistical analysesandthe
For this updated review, we identified nine additional random-
author’sconclusionsabouttheeffectivenessoftheinterventions.
izedcontrolledtrialsthatwerepublishedafterourpreviousreview
(Chatchawan 2005; Farasyn 2006; Field 2007; Geisser 2005a;
Dataanalysis
Hsieh2004;Hsieh2006;Mackawan2007;Poole2007;Yip2004).
Allquantitative results were enteredinto RevMan Analysis 4.2. Intotal,weincluded13trials(1596participants)inthisupdated
Resultsforcontinuousvariableswerereportedasweightedmean review.FourstudieswereconductedintheUSA(416participants-
difference (WMD) when the outcome measures were identical, Cherkin2001;Field2007;Geisser2005a;Hernandez-Reif2001),
andstandardizedmeandifference(SMD)whentheoutcomemea- twoinTaiwan(275participants-Hsieh2004;Hsieh2006)two
sures were different. Statistical pooling was considered, but be- in Thailand (247 participants - Chatchawan 2005; Mackawan
causeofclinicalheterogeneity,wasnotpossibleforthemajority 2007)one inCanada (104 participants - Preyde2000), one in
ofthecomparisons. HongKong(61participants-Yip2004)oneinGermany(190
AqualitativeanalysiswasperformedusingtheGRADEapproach, participants - Franke 2000) one in the UK (243 participants -
whichusesthefollowingelements:studydesign,riskofbias,con- Poole2007)andoneinBelgium(60participants-Farasyn2006).
sistency ofresults, directness(generalizability), precision ofdata AlltrialswerepublishedinEnglishexceptthetrialconductedin
and reporting bias (GRADE 2004). Only the primary objec- GermanywhichwaspublishedinGerman.
tiveandtheprimaryoutcomemeasuresweresummarizedinthe The population included in the trials was similar regarding the
GRADEtables.Theoverallqualityofevidenceforeachoutcome diagnosis, whichwasnon-specificLBP,butdifferedwithrespect
isdeterminedbycombiningtheassessmentsinalldomains.The tothediagnoses, duration ofpain, previoustreatmentsanddis-
qualitystartsathighwhenRCTswithlowriskofbiasprovidere- tributionsofage.Onetrialincludedparticipantswithacutelow-
sultsfortheoutcome,andreducesbyalevelforeachofthefactors back pain (Yip 2004), three trials included patients with suba-
notmet. cuteandchroniclow-backpain(Hsieh2004;Hsieh2006;Preyde
Highqualityevidence=thereareconsistentfindingsamongat 2000)andfivetrialswerelimitedtopatientswith chronicpain
leasttwoRCTswithlowpotentialforbiasthataregeneralizableto (Chatchawan2005;Cherkin2001;Franke2000;Geisser2005a;
thepopulationinquestion.Therearesufficientdata,withnarrow Hernandez-Reif2001).
confidenceintervals.Therearenoknownorsuspectedreporting Thetypesofmassagetechnique,durationandfrequencyoftreat-
biases. mentsvariedamongthestudies.Intwostudiesmassagewasap-
Moderatequalityevidence=oneofthefactorsisnotmet pliedwithamechanicaldevice(Farasyn2006;Franke2000)while
Lowqualityevidence=twoofthefactorsarenotmet in the remaining studies it was done with hands. Two studies
Verylowqualityevidence=threeofthefactorsarenotmet usedaspecificoil(Field2007;Yip2004).Intwostudiesdistinct
Noevidence=noevidencefromRCTs techniquesofmassagewerecompared(Chatchawan2005;Franke
2000).
With respectto the outcome measures, pain intensity was used
RESULTS in all of the studies. Three studies (Hernandez-Reif 2001 ;
Massageforlow-backpain(Review) 7
Copyright©2008TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.