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Research-Based Massage Therapy for Low Back Pain (2 CE Hours)

This course is approved by the Texas Department of State Health Services DSHS for Continuing Education for Massage Therapists CE0009 and by the NCBTMB for Nationally Certified Massage Therapists for 2 CE Hours.

This article reviews the latest clinical research that has reported the effectiveness of massage therapy for the treatment of chronic Low Back Pain and compares massage therapy with other treatments.  We will also review research that compared different types of massage therapy in the treatment of Low Back Pain.

Learning Objectives: After reading this course, you will...

  1. be able to identify the current statistics describing the prevalence and the etiology of LBP.
  2. be able to list "red flags" associated with other serious pathologies in Low Back Pain.
  3. be able to explain the efficacy of massage therapy in the treatment of Low Back Pain.
  4. be able to describe what type of massage is best in the treatment of Low Back Pain.


Introduction to Massage for Low Back Pain
Low Back Pain (LBP) is one of the most prevalent and costly musculoskeletal health problems in modern society.  Research reports that 70-85% of all people will experience LBP at some point in their lives.(1)   Every year, 5 - 10% of the workforce does not work due to LBP.  The majority of people (90%) with acute LBP recover within 2-3 weeks regardless of what they do.  70-80% of these people will have a recurrence in LBP within 1 year and are at risk of developing chronic LBP and disability.  It is this group of patients with non-specific idiopathic episodic LBP that accounts for more than 90% of the total social costs for LBP.(2)  The total economic cost for LBP has been estimated as high as 480 million annually.

Back pain is often a complex phenomenon.  There are several potential sources and causes of back pain, however, the specific cause is often idiopathic.  This is because different spinal tissues can cause similar symptoms and it is difficult to differentiate the underlying cause.  One potential source of back pain is the skeletal muscles of the back, especially the erector spinae, multifidi and transversospinalis muscles.  Potential causes of back pain in muscle tissue include muscle strains (pulled muscles), muscle spasms, and muscle imbalances.  However, imaging studies do not support the notion of muscle tissue damage in many back pain cases and the neurophysiology of muscle spasms and muscle imbalances are not well understood.  Another potential source of low back pain are the synovial joints of the spine (zygapophysial joints, aka facet joints).  These have been identified as the primary source of the pain in approximately one third of people with chronic LBP. (6)  However, the cause of facet joint pain is not fully understood.  There are several common other potential sources and causes of back pain:  these include spinal disc herniation and degenerative disc disease, spondylolisthesis, osteoarthritis (degenerative joint disease), spinal stenosis, trauma, cancer, infection, fractures, and inflammatory diseases.  With all of these potential causes, it is important to rule out the more serious causes that would benefit from specific medical intervention.  This is why it is important that the primary care physician acts as a gateway to other healthcare practitioners.    During the initial consultation, massage therapists should look for “red flags” that might indicate more serious pathologies and contraindicate massage.
“Red Flags” for possible serious pathology in patients with LBP:

  1. Constant pain for more than one month. 
  2. Night pain (especially with a history of cancer).
  3. Referred pain or other radicular symptoms below the knee indicative of nerve root impingement.  These could include tingling, numbness, sensation of hot/cold, or weakness.
  4. Bowel or bladder dysfunction, indicative of cauda equina or serious nerve root impingement.
  5. Back trauma, like a fall or Motor Vehicle Accident.
  6. Diagnosis of disc damage, like a herniated or ruptured disc.

Once more serious causes are ruled out, the patient may benefit from a less invasive intervention like massage therapy.  The type of patients who will more likely benefit from massage therapy are patients with non-specific idiopathic episodic LBP. That is the back pain is not defined to a specific site or tissue, no specific cause of the pain is known, and the pain comes and goes and may be variable in intensity. In these patients, massage may provide pain relief, improved function and provide general relaxation.

Often people with LBP look for some type of therapy to relieve their symptoms and to help heal their back pain.  There are more than 50 potential therapies that promise to relieve LBP and improve function.   However, there is very little sound evidence for most of these therapies.  When we experience pain or discomfort, our natural reaction is to rub the affected area to reduce the sensation.  In essence, this is one way that massage is able to ease LBP.  The gate-control theory explains how massage stimulates the firing of large diameter nerve fibers (alpha), which have an inhibitory effect on the pain fibers (gamma). (3)  Massage also promotes relaxation and a feeling of well being, which lessens our perception of pain.  It has been suggested that deep massage activates the parasympathetic division of the autonomic nervous system thereby creating a “relaxation response.” (5)  In this way, massage increases our pain threshold and causes the release of endorphins, the body’s natural pain relievers.(4)
Massage is used to help relieve LBP extensively throughout the world.  In eastern cultures, acupressure massage is used as part of Traditional Chinese Medicine to relieve physical pain and promote healing.  In a study conducted in Canada, 17% of the population consulted an alternative healthcare practitioner for their pain in the previous year.(7)  A study conducted in an urban New York outpatient rehabilitation clinic reported that 29% of LBP patients used alternative therapies within the past year with massage therapy cited as the most common therapy.(8)  Fifty-three percent of the patients who used alternative therapies reported some degree of improvement in their condition. 

Massage is considered a safe therapeutic modality, associated with few risks or adverse effects. Massage has been researched for pain management in a variety of studies.  In 2004, Moyer et al reported in a meta-analysis of 37 randomized trials (1802 participants) for many different health conditions that massage therapy is effective.  All thirty-seven studies yielded a statistically significant overall effect as well as six specific effects out of nine that were examined.  Massage was shown to be effective in pain relief and improved function and significant results were found within the single-dose and multiple-dose categories, and for both physiological and psychological outcome variables.(9)  Two previous systematic reviews have concluded that massage therapy is effective in the treatment of chronic LBP. (10, 11)  In a more current review, new clinical studies have continued to support the effectiveness of massage in the treatment of LBP and have also compared the efficacy of different types of massage therapy. (12)

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