Massage Therapy for Low Back Pain

According to medical experts, low back pain is the second most common reason why people visit their physician, only after visits for cold and flu. If you've ever suffered a backache, you know how difficult life can be when simple things like chores, sitting at a desk or even finding a comfortable sleeping position seem impossible. Unfortunately, conventional treatments are not always helpful.

A doctor may prescribe pain medications and anti-inflammatory drugs for your lower back pain or even recommend invasive surgery. Other treatments may involve physical therapy or weight reduction as many cases of lower back pain are attributed to excessive abdominal weight and improper compensation when bending or lifting. It's imperative that you learn proper lifting methods and perform exercises to strengthen the abdominals thereby reducing the stress on your lower back.

However, even with the proper care and prevention, some people continue to suffer from pain and their quality of life quickly diminishes. Fortunately, massage therapy has been found to be an extremely effective method for dealing with lower back pain. A study published in the International Journal of Neuroscience concluded that "lower back pain is reduced and range of motion was increased after massage therapy" in a group of lower back pain sufferers.¹ The group was compared to a group of similar patients that underwent progressive muscle relaxation.

The group that underwent 30-minute massage therapy sessions twice a week for five weeks reported less pain, depression, anxiety and improvements in sleep. Greater trunk movement was reported and their serotonin and dopamine levels were higher. Serotonin and dopamine are responsible for feelings of calm and euphoria.

For more information on how massage therapy can reduce your lower back pain and improve the quality of YOUR life, please give our office a call.

1. Hernandez-Reif M, Field T, Krasnegor J, Theakston H. Lower back pain is reduced and range of motion increased after massage therapy. International Journal of Neuroscience 2001;106(3-4):131-145.

Muscle Relaxants Ineffective for Acute Low Back Pain

Low back pain is a common condition in the US. A current study from the journal Spine sums up the scope of the problem:

“[Low back pain] accounts for 15 million physician visits per year and an estimated cost of $192 million in 1990. Low back problems are the second most common cause for office visits to primary care physicians, and back pain is the most common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational medicine physicians. It ranks third among indications for surgery. The content of the care provided by these allopathic physicians consists of evaluation, reassurance, advice regarding activities, physical methods, medications, and surgery.”

The goal of this study was to evaluate the effectiveness of muscle relaxant use in patients with acute low back pain. The authors prospectively collected data on 1,633 patients from a wide range of health care providers: primary care, chiropractic, orthopedic, and HMO patients.

The individual practitioners treated the study subjects as they would treat any other patient. Each subject was given the Roland-Morris survey to assess loss of function. The authors of the study then contacted the patients at 2, 4, 8, 12 and 24 weeks after the baseline interview to see if they were “completely better.”

• The patients taking muscle relaxants had higher Roland-Morris scores.
• 49% of the patients received muscle relaxants at some point during the study.
• The researchers found that patients receiving muscle relaxants had a significantly longer recovery period than did those who did not receive the drugs:

“[The findings] indicate that patients taking muscle relaxants, after controlling for baseline status, return to self-assessed ability to perform their daily activities more slowly than patients who do not take muscle relaxants.”

The authors then wondered if perhaps the delayed recovery was due to an initially higher score on the Roland test. The authors then looked at just those patients with Roland scores higher than 12. The authors found that the high-scoring patients who were prescribed muscle relaxants took 19% longer to reach functional recovery than patients who were not given muscle relaxants.

An additional area of concern is the adverse affects that can be experienced with these medications:

“Muscle relaxants can be sedating, may increase fall risk, and impair the ability to drive automobiles or operate machinery. There is also some concern relating to possible risk of dependency for benzodiazepine medications.”

The authors conclude:

“This large cohort study showed no evidence of benefit and even a delay in functional recovery for severely affected patients who take muscle relaxants in the setting of acute back pain.”

Bernstein E, Carey TS, Garrett JM. The use of muscle relaxant medications in acute low back pain. Spine 2004;29(12):1346-1351.

Performance Testing of Low Back Pain Patients

This study was designed to evaluate if physical performance tests were reliable and valid in low back pain patients. Using a sample of 44 LBP patients and 48 pain-free subjects, the authors compared the two groups as they performed in multiple tests—such as the "Lumbar Flexion," "Five-Minute Walk," "Sorensen fatigue test," and "Repeated Sit-to-Stand." As well, the subjects took self-report tests to express their perceived levels of pain and disability, as a means of comparison to the physical functioning and endurance tests.

The authors found the battery of tests reliable. Another benefit of these tests is that since they are easily administered, good reliability can be found in a clinical context. And after testing and retesting subjects, scores still were stable—which indicates a patient only has to perform the task/test once, and a reliable score will emerge.

The authors found a moderate correlation between the physical performance tests and the self-report pain questionnaires:

"Further, although physical performance and self-report of disability were moderately correlated, the correlation between disability and lumbar flexion was trivial. This shows that physical performance measures are much better indicators of a patient�s ability to function than the frequently used impairment measure of spinal range of motion. Low back pain is a problem of activity intolerance; therefore, clinical assessments should be activity based."

The authors conclude that the battery of tests are useful indicators of disability. A strong correlation between the self-reports of disability and the tests confirmed an association between a patient�s perception of their disability and their actual physical performance.

Simmonds MJ, Olson SL, Jones S, et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine 1998; 23(22):2412-2421.

Pre-Work Screenings and Low Back Injuries

This study set out to assess if pre-work screening methods with hospital employees reduced the low back injury rate, lost workdays, and medical costs. The screening was intended to match an employee's physical capabilities with the physical demands of a job. The screening consisted of assessing posture, flexibility, strength, and range of motion. Additionally, the session included instruction on lifting techniques and body mechanics.

Over 10 ^1/2 years, 1457 pre-work screening were performed. In that time 177 back sprains and strains occurred. When comparing the rate of back injuries between the screened and unscreened personnel, no significant differences occurred. But, the amount of lost work days and medical costs decreased significantly among the screened employees:

"These findings suggest that though the rate of back sprain or strain injuries do not decrease, the severity of those injuries do decrease significantly over time. Also, the use of the prework functional screen offers the employer the highest degree of protection against rising lost work days and incurred medical costs that occur as the result of back sprain or strain injuries."

�The authors conclude that preventive measures and pre-work screenings will aid an employer in reducing its various costs and help identify the individuals who are not able to perform the physical demands of the job they are being hired for.

Nassau D. The effects of prework functional screening on lowering an employer's injury rate, medical costs and lost work days. Spine 1999;24(3): 269-274.

Prognosis of Low Back Pain in General Practice

This study attempted to identify what factors determined the duration of low back pain (LBP) episodes and recurrence rate in a group of 269 general practice patients. The authors studied a number of variables in their investigation: the duration of LBP before the patient consulted a physician; the type of onset of back pain (sudden or gradual); severity of back pain at initial visit; whether or not the patient had a history of back surgery; whether the patient received physical therapy for LBP symptoms; and the degree of disability from the LBP. The patients were followed for one year after the initial assessment. The study found:

• "The median time to recovery from the index episode was 7 weeks...70% of patients still had low back pain after 4 weeks, 48% after 8 weeks, 35% after 12 weeks, and at the end of the follow-up year 10% of the patients still had low back pain."
• Recovery from LBP was complicated by four factors:

1. A longer history of back pain before the initial visit to a physician.
2. The presence of sciatica.
3. "Maximal lumbal flexion" as determined by Schobers test.
4. Receiving physical therapy. "The results of the present study indicate that patients receiving physical therapy during the first 5 weeks after the initial visit also will take longer to recover from low back pain than those not receiving physical therapy." The study found that "the time to recovery was approximately 4 weeks longer for patients who received physical therapy than for patients who did not receive physical therapy."

The only factor that appeared to influence the rate of relapse was disability as measured by reports of daily functioning. The researchers found that the severity of pain and psychosocial factors were not associated with the patients time to recover. However, other aspects in the patients' history—such as back surgery or chronic LBP—did emerge as risk factors for recurring LBP.

van den Hoogen HJM, Koes BW, Deville W, van Eijk JTM, Bouter LM. The prognosis of low back pain in general practice. Spine 1997;22(13):1515-1521.

Stay-Active Care Versus Manual Therapy + Stay-Active Care

It is well known that staying active is an important way to quickly recover from an episode of low back pain. Other studies have shown that chiropractic care is also effective at helping patients with back pain.

This current study was conducted over a 10-week period in Sweden, and it looked at the effectiveness of traditional stay-active treatment for lower back pain, versus that of stay active-care combined with manual therapy that included stretching and manipulation.

160 study subjects aged 20 to 55 years of age, employed, and with lower back pain of 3 months duration or less and no other significant medical conditions or complications entered the clinical trial. Subjects were randomly assigned to one of two groups, with 45% assigned to the reference (stay-active care) group, and 55% assigned to the experimental (stay-active care + manual therapy) group.

Stay-active treatment was given by 2 orthopedic surgeons and 8 physiotherapists to the reference group. This treatment consisted of:

• Patient education to encourage taking part in physical activities to stay fit.
• Prescribing sick leaves as short as possible, with medications prescribed when indicated.
• Offering muscle stretching and matching home exercises (41% received stretching).

The experimental group (stay-active therapy + manual care) received treatment from 2 GPs and 9 physiotherapists who had previously received 12 days of training in administering manual therapy. They used the stay-active approach noted above, and added manual therapy to their treatment, which included:

• Muscular Energy Technique (MET) diagnostic items included in the physical exam.
• Mobilization for pelvic dysfunction, with a lock maneuver administered gently according to MET procedure.
• Treatment with specific mobilization or lumbar thrust techniques based on exam results.

Steroid injections were allowed in 50% of the patients based on specific findings, with soft tissue stretching after parasacrococcygeal injections (injections to the base of the spine near the rectum). Auto-traction was used when indicated for cases of herniated disc.

Outcomes for both pain and 15 disability variables were measured using visual analog scales that rated pain or disability from none (0 mm) to maximum (100 mm). 12 of the disability items formed the Disability Rating Index, which measured such items as the ability to lift heavy items, to do heavy or light physical work, ability to participate in sports, to run, to get up from a sitting position, to dress (without help), to bend over a sink, to carry a bag, to climb stairs, to make a bed, to walk outdoors. The other 3 disability variables measured the ability to lie still, and to drive or ride in a car. The questionnaire also asked about medications taken.

A baseline measurement was obtained when patients entered the study, and outcomes were measured at 5 weeks and 10 weeks after treatment started. Treatment staff was blinded to the outcomes during the study period.

At the beginning of the study, the baseline results were the same for both groups. Pain scores decreased significantly with treatment over time for both groups. But because the experimental group had a slightly greater degree of baseline pain, when adjustments for herniations, age and sex were made, the experimental group experienced a faster rate in the decrease of pain during the last week of the study. The use of pain medication and nonsteroidal anti-inflammatory medications decreased at a similar rate in both groups over the period of the study.

At baseline, the experimental group tended to have slightly higher initial disability scores for all 15 variables than the reference group. By 5 and 10 weeks, the experimental group tended to have lower scores on all disability variables, and to have experienced a faster rate of improvement in the Disability Rating index, than the reference group.

Stay-active care combined with manual therapy provided greater pain relief during the last week of treatment and improved disability scores at 5 and 10 weeks, when compared with stay-active care alone. These study results are consistent with previous studies that have shown the higher effectiveness of manual treatment when compared with stay-active care treatment. The study authors theorize that this effectiveness is due to extension of the muscle spindles resetting input into the proprioreceptive system within the lower back, although the true mechanism is still unknown and needs further study.

The improved results with manual therapy would indicate that it should become a more generally used treatment option in the treatment of lower back pain than stay-active care alone.

Grunnesjo MI, Bogefeldt JP, Svardsudd KF, Blomberg SIE. A randomized controlled clinical trial of stay-active care versus manual therapy in addition to stay-active care: functional variables and pain. Journal of Manipulative and Physiological Therapeutics 2004;27:431-441.