By Melissa Quick, DO
Integrative Medicine Fellow, Mount Sinai Beth Israel Medical Center, New York City
Dr. Quick reports no financial relationships relevant to this field of study.
Synopsis: Based on the results of Sherman’s study alongside the conclusions of Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders, it seems that massage is a safe and generally useful modality for grade 1 and 2 neck pain.
Source: Sherman KJ, et al. Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. Ann Fam Med 2014;12:112-120.
This study was performed to assess the optimal amount of time massage should be used to improve neck pain in individuals suffering from chronic (> 3 months), non-specific neck pain. A total of 228 participants were randomized to one of six study groups (approximately 38 participants in each). The participants were between the ages of 20 and 64, both male and female, had to have at least one primary care visit for neck pain in the past 3-12 months, and had non-specific uncomplicated neck pain. Subjects were excluded if they had previous massage for neck pain in the last year or any massage in the last 3 months or complex neck pain (including disk herniation, motor vehicle accident, previous neck surgery, stroke, metastatic cancer, and many others).
This study examined five doses of massage that covered a broad range of feasible frequencies per week (1, 2, or 3 times) and treatment lengths (30 and 60 min). Five study groups received various doses of massage as the primary treatment (weeks 1-4), which consisted of a 4-week course of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times weekly. The control group was randomized to a wait list during the primary treatment period and then received 6 weekly 60-minute massages after the primary treatment period in the secondary treatment period (weeks 5-10).
Study participants in the treatment groups received a total of 4-12 hours of massage and a total of 4-12 treatments, depending on their group assignment. Distinct massage protocols were defined for both the 30- and 60-minute massages to ensure that the massage therapist spent roughly the same proportion of time in each phase of treatment. Eight licensed massage therapists with at least 5 years of experience were trained in the study protocol and provided all massage treatments.
Treatment adherence was high — between 84-95% in all groups. The massage therapists were also specifically asked not to recommend self-care regimens, and at the end of the study, only 3.3% of participants reported doing self-care activities.
Primary outcomes were assessed at baseline and again at 5 weeks (a week after treatment completion) by telephone interviewers who were unaware of treatment assignment. The Neck Disability Index (NDI), a 10-item questionnaire, was used to assess neck pain and dysfunction and participants used a 0 ("no pain") to 10 ("pain as bad as it can be") scale to rate their pain at baseline and at all follow-up interviews.
Secondary outcomes measured days of restricted activity, global rating of improvement of pain, quantification of perceived stress (measured by a 10-item Perceived Stress Scale), and a single question about overall patient satisfaction.
The authors of the study acknowledge the inherent complexity of analyzing a six-arm dosing study, but chose a large sample size that allowed adequate power to detect significant differences between at least two of the five massage treatment groups.
For the primary outcome of the study — clinically relevant improvements in neck pain scores — the results indicate that the beneficial effects of 60-minute massages increased with dose and were especially evident for those receiving massage 2 or 3 times per week (2 x 60 min/wk: odds ratio (OR), 3.68; 95% confidence interval [CI], 1.13-11.98; P = 0.03; and 3 x 60 min/wk: OR, 5.53; 95% CI, 1.78-17.15; P = 0.003). Conversely, 30-minute massages, either 2 or 3 times a week, failed to provide significant benefits compared with the wait list control condition (2 x 30 min/wk: OR, 1.84; 95% CI, 0.5-6.81; P = 0.36; and 3 x 30 min/wk: OR, 1.37; 95% CI, 0.33-5.68; P = 0.66). Despite the differing significance of treatment duration and frequency, mean NDI scores improved in all massage groups compared to the control group after 5 weeks.
The only statistically significant finding for the secondary outcomes was the proportion of participants who reported their neck pain was much better or completely gone (omnibus P < 0.001). Three massage groups were significantly more likely to report this level of improvement than the control group: the 30 min x 3 times weekly group (OR, 20.4; 95% CI, 10.2-40.6); the 60 min x 2 times weekly group (OR, 18.9; 95% CI, 10.0-35.8), and the 60 min x 3 times weekly group (OR, 40.6; 95% CI, 27.8-59.5). Overall, the group with the most massage (60 min x 3 times weekly) had the most improved symptoms compared to every other treatment group.
Commentary
Approximately 70% of the U.S. population experiences neck pain in their lives, and it often becomes episodic or chronic,1 thereby negatively impacting individuals, their families, communities, businesses, and health care systems.2 Indeed, neck pain is responsible for more than 10 million ambulatory medical care visits annually in the United States3 and is also the eighth leading cause of disability in the United States.4 Though conventional treatment options exist, neck pain is the second leading reason individuals seek out complementary and alternative medicine (CAM) treatments.5 Furthermore, massage therapy is the second most commonly used CAM treatment for neck pain.6
Although many etiologies of neck pain can arise from any of the structures in the neck, the vast majority of neck pain can be classified as "non-specific" — including degenerative changes, muscle spasm, ligamentous strain, etc. — and has no relation to specific disease or trauma.7 In general, non-specific neck pain does not require imaging, and importantly, research shows no correlation between degenerative changes seen on X-ray and pain levels.7
Until recently, defining neck pain and understanding appropriate treatment modalities had been vague, with a considerable amount of heterogeneity in the literature. However, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders recently spent 7 years compiling a comprehensive review of the current state of neck pain research in an effort to elucidate a more clear and concise approach to neck pain. The task force concluded: 1) neck pain is common and frequently recurs; 2) there is typically no single cause and no single effective treatment for neck pain; 3) neck pain (including whiplash injuries) should be classified into four common grades (see Table 1); and 4) there are a variety of options including massage for Grade 1 or 2 neck pain.8
So, using the guidelines above, how should we treat neck pain? Many medical providers may begin with conventional medical recommendations such as rest, medications (especially NSAIDs), and physical therapy, but the evidence for long-term benefit of these modalities is lacking.9 Manual therapy presents as a useful adjunct to conventional treatment.
The task force reviewed more than 350 invasive and noninvasive studies on neck pain and concluded that "therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain,"9 hence validating the focus of Sherman’s study on the benefit of massage, one of the manual therapies. While many versions of manual therapy exist (chiropractic, osteopathic manipulation, etc.) and have their own inherent benefit, discussing modalities beyond massage therapy are beyond the scope of this article.
The word "massage" stems from both Arabic and Greek roots and means "to touch or squeeze softly." Massage therapy has evolved since its origin more than 5000 years ago in India. Massage therapy is known as one of the earliest and most primitive techniques for pain relief and can be defined as a "therapeutic manipulation using the hands or a mechanical device in which numerous specific and general techniques are used in sequence, such as effleurage, petrissage, and percussion."10
A 2012 Cochrane review assessing the effects of massage on mechanical neck disorders found that certain massage techniques (traditional Chinese massage, classical, and modified strain/counterstrain) were more effective than control for improving function and tenderness immediately post-treatment but do not have clinically applicable long-term conclusions.1
One of the goals of Sherman’s study was to identify the optimal dose of massage therapy and, as such, the authors also focused on the feasibility of accessing and adhering to various massage therapy schedules. This study had an impressively high adherence rate: at least 95% in four massage dosing groups and 84% in the fifth group (30 minutes 3 times weekly), which speaks to the tolerability of this modality. The only groups with statistically significant outcomes for the primary variable were the longer, 60-minute massage groups, and even more benefit was seen in those who had hourly massages three times a week compare to just twice a week.
Interestingly, these results suggest a linear, dose-dependent relationship between the frequency and amount of time of a massage: longer, more frequent massages provide greater results. This is most evident in the secondary outcome of the NDI: for each additional weekly massage, there was an estimated -1.81-point improvement in NDI (95% CI, -2.52 to -1.10; P < 0.001) and an estimated -0.75-point improvement in neck pain intensity (95% CI, -1.01 to -0.47; P < 0.001). The authors of the study do not mention why they picked their specific frequencies and durations. A future study may provide more information as to where and when this linearity of frequency and duration ceases to be beneficial.
While impressive statistically, it is questionable if the general population would be able, both in terms of time and financial constraints, to achieve such dedicated adherence. In fact, though a handful of private insurance companies may cover some types of massage, the majority of insurance services (including Medicaid and Medicare) do not cover massage therapy, which can make this a difficult option for many patients. Perhaps with more studies similar to Sherman’s, policy makers and insurers can move massage therapy into a more accessible modality. For reference, according to the American Massage Therapy Association, the average massage costs $65 an hour.11
Another aspect of Sherman’s study worth mentioning is that the massage therapists were specifically asked to not give advice or education to patients, presumably to ensure the results reflected only the effects of massage therapy. In a real clinical setting, however, Sherman acknowledges that self-care recommendations and education are commonly given to patients and likely serve as an adjunct to massage therapy. In a practical sense, self-care regimens and educational materials are low-cost, so for a patient with financial restraints, this option would be an attractive option to offer a patient.
One possible confounding factor in this study is that the majority of the study participants (55.3-73.7% per group) had prior personal experience with massage, which may have predisposed them to an anticipatory effect. On the other hand, each group had similarly low expectations that massage would be helpful (approximately 18% between all groups), which may indicate the participants did not garner any preconceived expectations from their participation in the study.
Finally, it is important to recognize potential risks in all treatments offered to patients. Thankfully, in general, massage is well-tolerated and quite safe.12 Indeed, only 5.2% of the participants in Sherman’s study had an adverse event, most of which were related to increased spinal pain. Interestingly, the adverse event frequencies were similar between each group, suggesting that the duration or frequency of massage has no direct impact on adverse events.
Sherman’s study used well-trained massage therapists with a minimum of 5 years of experience. Before recommending a massage therapist to a patient, it may be beneficial to ensure your massage therapist has had the appropriate training and licensing. Currently, 43 states and Washington, D.C. regulate massage, and most require a minimum number of hours of training and successful completion of an exam.13
Based on the results of Sherman’s study and the task force conclusions, it seems that massage is a safe and generally useful modality for grade 1 and 2 neck pain. We can also extrapolate from this study that any dose of massage is better than none, based on the results that showed a global increase in mean NDI scores in all massage groups except for the control group after 5 weeks.
Ultimately, when recommending treatment for neck pain, it is crucial to recall that there is no "best" treatment plan and a trial of a variety of therapies or a combination of therapies may be needed to achieve improvement of symptoms. Keeping that in mind, based on this study, it seems that when we recommend massage, longer treatments and greater frequency seem to have the most benefit if this is available to the patient.
References
- Patel KC, et al. Massage for mechanical neck disorders. Cochrane Database Syst Rev 2012;9:CD004871.
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Hogg-Johnson S, et al. The burden and determinants of neck pain in the general population: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
J Manipulative Physiol Ther 2009;32(2 Suppl):S46-60. -
Riddle DL, Schappert SM. Volume and characteristics of inpatient and ambulatory medical care for neck pain in the United States: Data from three national surveys. Spine (Phila Pa 1976) 2007;32:132-140;
discussion 141. - Murray CJ, et al, U.S. Burden of Disease Collaborators. The state of U.S. health, 1990-2010: Burden of diseases, injuries, and risk factors. JAMA 2013;310:1591-608.
- Barnes PM, et al. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;10:1-23.
- Goode AP, et al. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken). 2010;62:1594-1601.
- Borghouts JA, et al. The clinical course and prognostic factors of non-specific neck pain: A systematic review. Pain 1998;77:1-13.
- Haldeman S, et al., Scientific Secretariat of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. A best evidence synthesis on neck pain: Findings from the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(4 Suppl):S1-S220.
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Hurwitz EL, et al. Treatment of neck pain: Noninvasive interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33:
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Haraldsson BG, et al. Massage for mechanical neck disorders.
Cochrane Database Syst Rev 2006;3:CD004871. - American Massage Therapy Association. Industry Fact Sheet. Available at: www.amtamassage.org/infocenter/economic_industry-fact-sheet.html. Accessed Oct. 30, 2014.
- Yin P, et al. Adverse events of massage therapy in pain-related conditions: A systematic review. Evid Based Complement Alternat Med 2014;2014:480956
- American Massage Therapy Association. Government Relations Overview. Available at: www.amtamassage.org/government/gr_overview.html. Accessed Oct. 30, 2014.
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