Clinical Massage Therapy “Real-World” Study Outcomes

Commentary by Gerard Malanga, MD

Peer Reviewed

When discussing nonsurgical options to manage chronic low back pain with patients, massage should be part of the conversation. In a first-of-its-kind study, clinical massage therapy (CMT) was shown to produce "clinically meaningful improvement" for more than half of patients studied. The research was published online in March 2017 in the journal Pain Medicine.
Woman having a massage treatment on her backWhen discussing nonsurgical options to manage chronic low back pain with patients, massage should be part of the conversation."Existing medical guidelines already recommend CMT for low back pain," says lead researcher and co-first author William G. Elder, PhD, of the Department of Family and Community Medicine at the University of Kentucky.

"However, the recommendation has been at a 'B' level on an 'A-C' scale, as CMT had not been previously demonstrated effective in primary care," Dr. Elder says. "This study suggests CMT is effective when patients are referred by primary care providers and, if we are able to replicate results, may result in guideline authors moving CMT to an 'A' level."

Research in a Real-World Environment
Unlike previous studies on the efficacy of massage for back pain, the authors took a "real-world" approach, as opposed to a controlled research environment.

Following chronic low back pain patients who were referred to the study by their primary care providers (PCP), the researchers connected the subjects to local licensed massage therapists. As opposed to providing the same "standard" massage treatment to all patients, the massage therapists were instructed to tailor the therapy based on the needs of the individual patient.

"This study is so novel in that we took a pragmatic approach and allowed people to go to a massage therapist in their community," says co-first author Niki Munk, PhD, LMT, School of Health and Rehabilitation Sciences at Indiana University-Purdue University Indianapolis.

"Everything about their appointment was as if it would be if they sought it out on their own," she says. "The massage therapist did all the scheduling, developed a therapeutic relationship with the patient, and completed the assessment. The only parameter was that the patient needed to have 10 sessions in 12 weeks."

Older Patients Reaped the Most Benefits
The research team collaborated with PCPs in Kentucky who referred patients for 10 complimentary CMT sessions with licensed massage therapists in the community over a 12-week period. Chronic low back pain patients qualified for the study solely based on a referral from their PCP-patients were not excluded based on age, comorbidities, or medication use.  

The participants were measured at baseline using Oswestry Disability Index and SF-36v2 tests, and researchers used mixed linear models and Tukey's tests to measure improvement at the completion of the 12-week massage program and at 24 weeks after the start of the program.

Of 104 enrolled patients, 85 completed the program through 12 weeks and 76 completed the full 24-week program. At 12 weeks, 54.1 percent showed clinically meaningful improvement in their chronic low back pain. At 24 weeks, 75 percent of patients showing improvement at 12 weeks retained clinically meaningful change.

For SF-36v2 Physical and Mental Component Summaries, 55.4 percent and 43.4 percent, respectively showed clinically meaningful improvement at 12 weeks, and 46.1 percent and 30.3 percent at 24 weeks. For Bodily Pain, 49.4 percent were clinically improved at 12 weeks and 40 percent were improved at 24 weeks.

The researchers discovered some key insights related to patients' age, weight, and medication regimen:

  • Adults age 50 and over were 3.75 times more likely to have clinically meaningful improvement in their chronic pain and disability from CMT. Seventy percent of adults age 50 and older had clinically significant improvement compared with 38 percent of younger adults.
  • Obese patients reported low back pain relief from CMT at 12 weeks, but the benefits weren't retained at 24 weeks.
  • Patients who reported taking opioid pain medication did report reduced pain as a result of CMT, but they were two times less likely to have clinically meaningful change when compared to patients not taking opioids.

The opioid findings may be of particular interest to physicians who want a different nonsurgical treatment option for people with chronic back and neck pain.

"Further research could explore if massage might help people get off opioids," Dr. Munk says.

What Providers Can Do with This Information
Lead researcher Dr. Elder says he was happy to discover massage was successful for a wide spectrum of people, something providers can take advantage of when considering it as a treatment with their chronic low back pain patients.

"[I was] pleased to find that CMT helped patients previously not included in studies, such as patients on multiple medications, significantly overweight, or over 65," he says. "This means that providers do not have to be highly considerate of patient characteristics when recommending CMT."

Referring patients to massage therapist begins with building a network, says Dr. Munk. She suggests providers seek out partnerships in the massage community. To secure a quality referral network, doctors should ask massage therapists about their education, experience, if they have condition-specific interests or training, and whether they work with other health care professionals.

One important point physicians should recognize is that massage is not covered under most health insurance plans, so it may be cost-prohibitive for some patients. Despite the financial drawback, patients should understand massage's potential for reducing their chronic low back pain.

Commentary

Gerard Malanga, MD
Professor, Department of Physical Medicine and Rehabilitation
Rutger's University-New Jersey Medical School
Newark, NJ

Chronic low back pain remains costly and difficult to manage process. Depending on the etiology in the potential source of pain, various treatment options are offered to patients and include exercise programs, chiropractic treatment, medications, various injections, and interventional pain procedures. Unfortunately, many patients are left with chronic persistent low back pain refractory to these various treatments.

In addition, over the past two decades, there has been increased use of patients who have been treated with opioid medications. This has demonstrated a positive pain and functional improvement in a small number of patients and has been associated with many side effects ranging from constipation to addiction. In addition, we are now faced with what is been called the “opioid epidemic,” and an increasing rate of overdose and death from opiates. Therefore, there is been a renewed interest in nonpharmacologic pain management.

The use of manual therapies ranging from manipulation to soft tissue mobilization has long been considered a viable treatment option with associated health benefits. Among these manual therapies is massage therapy, which has demonstrated benefit in prior studies.

In this study by Elder et al, it has more clearly shown the benefits of massage therapy in a study performed using a real-world, pragmatic approach with various therapists within a specific community referred by the primary care physicians. Clinically meaningful improvements were noted in multiple areas ranging from bodily pain to Oswestry Disability Index, which is commonly used in studies on low back pain. After 10 simple massage therapy sessions, a significant percentage of patients had improvement lasting for up to 24 weeks.

This simple intervention is without side effects, can be provided simply, and is a much lower cost than most of the other interventions that are tried. Unfortunately, until researchers are able to show that massage results in lower costs (which is highly likely), most insurance carriers will not pay for this treatment. And, for many patients, that will force them into using treatments that are covered by insurance, though they often come at a higher cost and with significant potential side effects. This is another example of one of the many flaws of our current health care system.

Updated on: 03/20/18
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Mobilization, Manipulation, and Clinical Massage Are Effective Treatments for Neck Pain
Niki Munk, PhD, LMT
Assistant Professor and Director of Research
Department of Health Sciences
Indiana University
Gerard Malanga, MD
Physiatrist
New Jersey Sports Medicine, LLC
Cedar Knolls, NJ
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