A small group of patients were treated for low-back pain with 10 massages and more than half received some relief, according to this release from Indiana University-Purdue’s School of Health and Rehabilitation Sciences.
The researchers are to be applauded for seeking evidence for a potential low-cost, non-pharmaceutical and non-invasive public health solution for a very common problem.
Unfortunately, the release omitted some important details such as how many volunteers were involved, how long the study lasted, including any follow-up, and how improvement in back pain was measured. The study itself provides all that information (104 patients were studied for either 12 or 24 weeks) and the release would have been better with that and additional data included.
Although almost everyone will have low back pain at some point in their life, relatively few develop persistent, disabling pain — so-called chronic low back pain. For these individuals, there are many available treatments, but none have been shown to consistently offer a “cure” or a large improvement that is sustained after the treatment is completed.
Treatments often fall into categories of oral medicines, physical and behavioral therapies, and invasive procedures such as injections or surgery. This study examines one physical treatment — massage. This study looked at results over time in less than 100 patients treated by community-based massage therapists.
The study showed that about half had an improvement in pain and function after 3 months, but this decreased to about 40 percent by 6 months. How these results compare to other treatments in usual practice settings is the actual “real world” question. One that is not answered by this study.
We give the release credit for stating that massages are generally not covered by insurance and that patients typically pay out-of-pocket. And the release provided some important context about cost with this statement from the lead author: “Generally, people wonder if it is worth it. Will it pay to provide massage to people for an extended period of time? Will it help avoid back surgeries, for example, that may or may not have great outcomes? These are the types of analyses that we hope will result from this study.”
While massage is now offered in nearly all cities and towns, not all readers know how much they will need to shell out for the 10 sessions used in this study.
A one hour massage averages $60 an hour nationally, so 10 sessions would cost about $600. That’s something people considering this type of therapy would like to know.
The release does not explain the benefit in useful numerical terms. It includes the statement that more than 50 percent of patients received “clinically meaningful improvements.” We need the release to describe a single one of those improvements and define “meaningful” using numbers.
One could argue that “50 percent” is a quantified benefit, however, the use of “more than 50 percent” does not appear accurate since they are claiming improvement in low back pain without telling us that the benefit fell away in time. The number reported in the study for the “bodily pain domain” is 49.4 percent clinical improvement at 12 weeks and 40 percent improvement at 24 weeks — a lessening of the benefits over time.
We hesitate to suggest that any harm could come from a massage. But the release could have included a statement of there being “no evidence of harms” during the study, if that were the case.
Depending on the cause of the back pain, is there a potential risk that some patients might experience a worsening of pain after a massage? The release doesn’t say whether people with injuries should avoid massage and seek help from a back specialist. This is especially important if people are seeking therapy on their own, without seeing a physician.
As we described above in regard to benefit and harm, the release does not provide enough numbers to help readers assess the quality of the evidence. We aren’t told how many volunteers were in the study or the length of time they were followed.
The release should have noted that there was no comparison group, meaning we don’t know how they would have done if they didn’t get massage or sought another treatment, Moreover, we aren’t told which type of massage the volunteers received, what kind of training the therapists had, or whether the volunteers were receiving other treatments at the same time.
Further, the release doesn’t tell us which type of massage was used or how many patients were assigned to each type. One might assume Swedish massage was the style used since it is the best known, but the full study states that therapists “utilized any massage technique within the purview of their training experience,” and noted that the following techniques were employed: “Swedish massage, active isolated stretching, myofascial techniques, lymphatic drainage, movement, trigger point therapy, neuromuscular therapy, cranialsacral therapy, reflexology, Reiki, acupressure, and positional release.”
These are all vastly different alternative treatments. For example, unlike Swedish massage, Reiki involves only light or no touch. The types of massage used needed some clarification in the release.
We do give the release credit for noting some limitations of the research. It states that “much more work needs to be done” and that the study results need to be replicated and a cost-benefit analysis undertaken to show the enefits of massage for back pain.
There was no disease mongering. The release provides context on the numbers of people who experience back pain, but the 15 percent cited is a tad higher than the usual 7-10 percent cited in other research.
The release does not give us any information about who funded the study. We should be told who funded the study and if there are any conflicts of interest for the authors or their institutions.
We would like to give the release credit for mentioning that back pain is very complex, and that surgery is sometimes an option. However, we think the release falls short in not acknowledging that there has been extensive research on a variety of complementary approaches before this study including yoga, massage, acupuncture and exercise. The release could have provided that information about alternatives, as well as make some effort to tell us how massage compares with other non-invasive physical treatments.
The complexity of the problem, the option for surgery and the nature of chronic treatment are all relevant, as the release notes, but that’s no substitute for mentioning other treatment alternatives, some of which, like physical therapy, are covered by insurance.
It’s common knowledge that massage is widely available. We give the release credit for noting that it’s not covered by insurance and therefore not accessible to everyone.
The release claims this is “the first study of its kind” to assess massage for low back pain. Many studies have evaluated outcomes of massage in uncontrolled studies (where there was no comparison to another treatment). A search at the National Library of Medicine resulted in almost 300 results. While some of the studies may not precisely compare to this one — the release does not back up its claim by explaining the novelty.
To further complicate things, the release includes a confusing paragraph about the “real-world” massages given to the research patients:
“Previous studies of the effectiveness of massage were conducted in controlled research situations. In this study, patients were referred by a physician to a massage therapist. The massage therapist designed and provided a series of 10 massages — at no cost to the patient — in a clinical treatment environment, mimicking the experience of people who choose to seek massage therapy in the real world.”
When we read that paragraph, we get the impression that a therapist came to a “clinical environment” to provide the 10 massages. How is that “mimicking the experience” of the real world any better than previous studies?
The release doesn’t include any unjustifiable language. But the headline and opening of the release tend to give the study more credit than is due. It’s in the closing paragraphs that the release notes that the study results need to be replicated and that a cost-benefit analysis should be done to learn the effectiveness of this treatment.
Systematic, Criteria-Driven
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