Massage for low‐back pain

Andrea D Furlan; Marta Imamura; Trish Dryden; Emma Irvin

doi:10.1002/14651858.CD001929.pub2

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Figure 1

Summary of risks of bias

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Figure 2

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Figure 3

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Figure 4

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Figure 5

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Figure 7

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Analysis 1.1

Comparison 1 Massage versus sham treatment, Outcome 1 Pain intensity (higher values mean more pain).

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Analysis 1.2

Comparison 1 Massage versus sham treatment, Outcome 2 Pain quality.

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Analysis 1.3

Comparison 1 Massage versus sham treatment, Outcome 3 Back‐specific functional status (higher scores mean more disability).

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Analysis 2.1

Comparison 2 Massage versus manipulation/mobilization, Outcome 1 Pain intensity (higher values mean more pain).

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Analysis 3.1

Comparison 3 Massage versus exercises, Outcome 1 Pain intensity (0: no pain; 5: excruciating pain).

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Analysis 3.2

Comparison 3 Massage versus exercises, Outcome 2 Pain quality.

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Analysis 3.3

Comparison 3 Massage versus exercises, Outcome 3 Back‐specific functional status (RDQ, 0‐24, scores >14 indicate poor outcomes).

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Analysis 4.1

Comparison 4 Massage versus relaxation, Outcome 1 Pain intensity (VITAS: present pain with a VAS ranging from 0 to 10).

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Analysis 4.2

Comparison 4 Massage versus relaxation, Outcome 2 Pain quality.

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Analysis 5.1

Comparison 5 Massage versus acupuncture, Outcome 1 Pain intensity / symptom bothersomeness.

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Analysis 5.2

Comparison 5 Massage versus acupuncture, Outcome 2 Function.

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Analysis 6.1

Comparison 6 Massage versus self‐care education, Outcome 1 Pain intensity / symptom bothersomeness.

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Analysis 6.2

Comparison 6 Massage versus self‐care education, Outcome 2 Function.

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Analysis 7.1

Comparison 7 Acupuncture massage versus physical therapy, Outcome 1 Pain intensity.

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Analysis 7.2

Comparison 7 Acupuncture massage versus physical therapy, Outcome 2 Function (Roland and Morris disability questionnaire).

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Analysis 8.1

Comparison 8 Acupuncture massage versus classic massage, Outcome 1 Pain intensity.

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Analysis 8.2

Comparison 8 Acupuncture massage versus classic massage, Outcome 2 Function (values less than 70% indicate poor functional status, range from 0 to 100%).

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Analysis 9.1

Comparison 9 Thai massage versus Swedish massage, Outcome 1 Pain intensity.

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Analysis 9.2

Comparison 9 Thai massage versus Swedish massage, Outcome 2 Function (Oswestry Disability Index).

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Analysis 10.1

Comparison 10 Massage + exercise + education versus massage alone, Outcome 1 Pain intensity (0: no pain; 5: excruciating pain).

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Analysis 10.2

Comparison 10 Massage + exercise + education versus massage alone, Outcome 2 Pain quality.

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Analysis 10.3

Comparison 10 Massage + exercise + education versus massage alone, Outcome 3 Back‐specific functional status (RMDQ, 0‐24, scores >14 indicate poor outcomes).

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Analysis 11.1

Comparison 11 Massage + exercise + education versus sham treatment, Outcome 1 Pain intensity (0: no pain; 5: excruciating pain).

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Analysis 11.2

Comparison 11 Massage + exercise + education versus sham treatment, Outcome 2 Pain quality.

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Analysis 11.3

Comparison 11 Massage + exercise + education versus sham treatment, Outcome 3 Back‐specific functional status (RMDQ, 0‐24, scores >14 indicate poor outcomes).

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Analysis 12.1

Comparison 12 Acupuncture massage + conventional treatment versus conventional treatment alone, Outcome 1 Pain intensity.

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Analysis 12.2

Comparison 12 Acupuncture massage + conventional treatment versus conventional treatment alone, Outcome 2 Function.

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Analysis 13.1

Comparison 13 Massage + exercise versus Sham Massage + exercise, Outcome 1 Pain intensity.

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Analysis 13.2

Comparison 13 Massage + exercise versus Sham Massage + exercise, Outcome 2 Function.

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Analysis 14.1

Comparison 14 Foot reflexology versus relaxation, Outcome 1 Pain intensity.

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Analysis 14.2

Comparison 14 Foot reflexology versus relaxation, Outcome 2 Function.

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Analysis 15.1

Comparison 15 Foot reflexology + usual care versus usual care alone, Outcome 1 Pain intensity.

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Analysis 15.2

Comparison 15 Foot reflexology + usual care versus usual care alone, Outcome 2 Function.

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Table 1. Taxonomy of massage practice (Sherman et al 2006)

Goal of treatment	Relaxation massage	Clinical massage	Movement reeducation	Energy work
Intention	Relax muscles, move body fluids, promote wellness	Accomplish specific goals such as releasing muscle spasms	Induce sense of freedom, ease and lightness in body	Hypothesized to free energy blockages
Commonly used styles (examples)	Swedisch massage; Spa massage; Sports massage	Myofascial trigger points therapy; Myofascial release; Strain counterstrain;	Proprioceptive; Neuromuscular facilitation; Strain counterstrain; Trager	Acupressure; Reiki; Polarity; Therapeutic touch; Tuina;
Commonly Techniques (examples)	Gliding, kneading, friction, holding, percussion, vibration	Direct pressure, skin rolling, resistive stretching, stretching manual, cross‐fibre‐friction,	Contract‐relax, passive stretching, resistive stretching, rocking	Direction of energy, smoothing, direct pressure, holding, rocking, traction

Table 1. Taxonomy of massage practice (Sherman et al 2006)

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Table 2. Criteria used to assess risk of bias (van Tulder 2003)

Criteria/Definitions

Was the method of randomisation adequate? A random (unpredictable) assignment sequence. Examples of adequate methods are computer‐generated random numbers table and use of sealed opaque envelopes. Methods of allocation using date of birth, date of admission, hospital numbers, or alternation should not be regarded as appropriate.

Was the treatment allocation concealed? Assignment generated by an independent person not responsible for determining the eligibility of the patients. This person has no information about the persons included in the trial and has no influence on the assignment sequence or on the decision about eligibility of the patient.

Was the patient blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."

Was the care provider blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."

Was the outcome assessor blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."

Was the drop‐out rate described and acceptable? The number of participants who were included in the study but did not complete the observation period or were not included in the analysis must be described and reasons given. If the percentage of withdrawals and drop‐outs does not exceed 20% for immediate and short‐term follow‐ups, 30% for intermediate and long‐term follow‐ups and does not lead to substantial bias a "yes" is scored.

Did the analysis include an intention‐to‐treat analysis? All randomized patients are reported/analyzed in the group to which they were allocated by randomization for the most important moments of effect measurement (minus missing values), irrespective of noncompliance and co‐interventions.

Were the groups similar at baseline regarding the most important prognostic indicators? In order to receive a "yes," groups have to be similar at baseline regarding demographic factors, duration and severity of complaints, percentage of patients with neurological symptoms, and value of main outcome measure(s).

Were co‐interventions avoided or similar? Co‐interventions should either be avoided in the trial design or be similar between the index and control groups.

Was the compliance acceptable in all groups? The review author determines if the compliance to the interventions is acceptable, based on the reported intensity, duration, number and frequency of sessions for both the index intervention and control intervention(s).

Was the timing of the outcome assessment in all groups similar? Timing of outcome assessment should be identical for all intervention groups and for all important outcome assessments.

Table 2. Criteria used to assess risk of bias (van Tulder 2003)

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Comparison 1. Massage versus sham treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (higher values mean more pain) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Short‐term follow‐up	2	91	Std. Mean Difference (IV, Random, 95% CI)	‐0.92 [‐1.35, ‐0.48]
1.2 Long‐term follow‐up	1	51	Std. Mean Difference (IV, Random, 95% CI)	‐0.49 [‐1.05, 0.06]
2 Pain quality Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Back‐specific functional status (higher scores mean more disability) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Short‐term follow‐up	2	91	Std. Mean Difference (IV, Random, 95% CI)	‐1.76 [‐3.19, ‐0.32]
3.2 Long‐term follow‐up	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.96 [‐1.58, ‐0.35]

Comparison 1. Massage versus sham treatment

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Comparison 2. Massage versus manipulation/mobilization

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (higher values mean more pain) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Massage versus manipulation/mobilization

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Comparison 3. Massage versus exercises

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (0: no pain; 5: excruciating pain) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain quality Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Back‐specific functional status (RDQ, 0‐24, scores >14 indicate poor outcomes) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Massage versus exercises

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Comparison 4. Massage versus relaxation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (VITAS: present pain with a VAS ranging from 0 to 10) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Short‐term follow‐up	2	54	Mean Difference (IV, Random, 95% CI)	‐1.27 [‐2.46, ‐0.08]
2 Pain quality Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Massage versus relaxation

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Comparison 5. Massage versus acupuncture

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity / symptom bothersomeness Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up (10 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up (52 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up (10 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up (52 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Massage versus acupuncture

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Comparison 6. Massage versus self‐care education

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity / symptom bothersomeness Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up (10 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up (52 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up (10 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up (52 weeks after randomization)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. Massage versus self‐care education

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Comparison 7. Acupuncture massage versus physical therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Short‐term follow‐up	2	266	Std. Mean Difference (IV, Random, 95% CI)	‐0.72 [‐0.96, ‐0.47]
1.2 Long‐term follow‐up	2	250	Std. Mean Difference (IV, Random, 95% CI)	‐0.95 [‐1.39, ‐0.51]
2 Function (Roland and Morris disability questionnaire) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 7. Acupuncture massage versus physical therapy

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Comparison 8. Acupuncture massage versus classic massage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Massage plus individual exercise. Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Massage plus group exercise. Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function (values less than 70% indicate poor functional status, range from 0 to 100%) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Massage plus individual exercise. Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Massage plus group exercise. Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Acupuncture massage versus classic massage

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Comparison 9. Thai massage versus Swedish massage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function (Oswestry Disability Index) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 9. Thai massage versus Swedish massage

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Comparison 10. Massage + exercise + education versus massage alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (0: no pain; 5: excruciating pain) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain quality Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Back‐specific functional status (RMDQ, 0‐24, scores >14 indicate poor outcomes) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 10. Massage + exercise + education versus massage alone

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Comparison 11. Massage + exercise + education versus sham treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity (0: no pain; 5: excruciating pain) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Pain quality Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Back‐specific functional status (RMDQ, 0‐24, scores >14 indicate poor outcomes) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 11. Massage + exercise + education versus sham treatment

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Comparison 12. Acupuncture massage + conventional treatment versus conventional treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short ‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 12. Acupuncture massage + conventional treatment versus conventional treatment alone

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Comparison 13. Massage + exercise versus Sham Massage + exercise

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	0		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	0		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 13. Massage + exercise versus Sham Massage + exercise

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Comparison 14. Foot reflexology versus relaxation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 14. Foot reflexology versus relaxation

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Comparison 15. Foot reflexology + usual care versus usual care alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Function Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Short‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Long‐term follow‐up	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 15. Foot reflexology + usual care versus usual care alone

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