Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group

Furlan, AD; Imamura, M; Dryden, T; Irvin, E

Abstract

Study Design. Systematic Review.

Objectives. To assess the effects of massage therapy for nonspecific low back pain.

Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.

Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.

Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.

Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.

Spine: 15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684 - abstract

doi: 10.1097/BRS.0b013e3181ad7bd6

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Exercise therapy, Lumbar spine, Massage, Patient education, Topic review , Low back, Lumbar spine, massage therapy, nonspecific low back pain, pain, Systematic review

Insoles for prevention and treatment of back pain

Tali Sahar, Matan J Cohen, Vered Ne’eman et al

Background

There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.

Objectives

To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Search strategy

We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL to October 2008; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.

Selection criteria

We included randomised controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.

Data collection and analysis

One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.

Main results

Six randomised controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

Limitations
This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.

Authors’ conclusions

There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.

High quality trials are required for stronger conclusions.

Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005275.- full text

DOI: 10.1002/14651858.CD005275.pub2.

Filed under: Lumbar spine, Spine, Topic review

Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical practice guideline

Chou R, Atlas SJ, Stanos SP, et al

STUDY DESIGN: Systematic review.
OBJECTIVE: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

SUMMARY OF BACKGROUND DATA: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

RESULTS: For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.

CONCLUSION: Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Spine. 2009 May 1;34(10):1078-93  – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Lumbar spine, Topic review, therapies , interventional, Low back, nonsurgical, radicular pain, therapies

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline

R Chou,L Hoyt Huffman

Background: Many nonpharmacologic therapies are available for treatment of low back pain.

Purpose: To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

Data Sources: English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.

Study Selection: Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.

Data Extraction: We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.

Data Synthesis: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks’ duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland–Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks’ duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.

Limitations: Our primary source of data was systematic reviews. We included non–English-language trials onl

Annals of Internal Medicine. 2007;147:492-504. – full text

Filed under: Conservative therapies, Lumbar spine, Spine, Treatment guidelines

Management of Symptomatic Lumbar Degenerative Disk Disease

L Madigan, AR Vaccaro, LR Spector, R Alden Milam

Symptomatic lumbar degenerative disk disease, or discogenic back pain, is difficult to treat. Patients often report transverse low back pain that radiates into the sacroiliac joints. Radicularor claudicatory symptoms are generally absent unless there is concomitant nerve compression. Physical examination findings are often unremarkable. Radiographic examination may revealdisk space narrowing, end-plate sclerosis, or vacuum phenomenon in the disk; magnetic resonance imaging is useful for revealing hydration of the disk, annular bulging, or lumbar spine end-plate (Modic) changes in the adjacent vertebral bodies. The use of diskography as a confirmatory study remains controversial. Recent prospective, randomized trials and meta-analyses of the literature have helped expand what is known about degenerative disk disease. In most patients with low back pain, symptoms resolve without surgical intervention; physical therapy and nonsteroidal anti-inflammatory drugs are the cornerstones of nonsurgical treatment. Intradiskal electrothermal treatment has not been shown to be effective, and arthrodesis remains controversial for the treatment of discogenic back pain. Nucleus replacement and motion-sparing technology are too new to have demonstrated long-term data regarding their efficacy.

Approximately 70% to 85% of adults will be affected by low back pain (LBP) at some point during their lifetimes.1,2 Numerous anatomic sites can be responsible for the pain, and accurate diagnosis is often difficult. Degenerative disk disease (DDD), internal disk disruption, lumbar disk herniation, and facet joint arthritis, as well as intra-abdominal pathology, are allpotential causes of LBP. Patients with DDD or discogenic back pain can present with aconstellation of symptoms that range from benign LBP to excruciating back pain with lower extremity symptoms. Risk factors for LBP, such as jobs requiring heavy lifting, use of a jackhammer or machine tools, or the operation of motor vehicles, have been identified in the literature.3 Continued degeneration of the affected disk can lead to secondary problems such as degenerative spondylolisthesis, lumbar stenosis, and facet arthrosis.

Journal of the American Academy of Orthopaedic Surgeons, 2009;17:102-111 – abstract

Filed under: Conservative therapies, Lumbar spine, Surgery, Topic review

Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?

Daniel DM

Background

Traction therapy has been utilized in the treatment of low back pain for decades. The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer. The purpose of this paper is to initiate a debate pertaining to the relationship between marketing claims and the scientific literature on non-surgical spinal decompression.

Discussion

Only one small randomized controlled trial and several lower level efficacy studies have been performed on spinal decompression therapy. In general the quality of these studies is questionable. Many of the studies were performed using the VAX-D^® unit which places the patient in a prone position. Often companies utilize this research for their marketing although their units place the patient in the supine position.

Summary

Only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.

Chiropractic & Osteopathy 2007, 15:7 doi:10.1186/1746-1340-15-7

Full text PDF

Filed under: Lumbar spine, Spine, Traction , decompression, Lumbar spine, Traction

Management of chronic low back pain in 2007-2008.

Raspe H.

PURPOSE OF REVIEW: To report and critically appraise the current state of managing chronic (and subacute) low back pain as reflected in recently published guidelines and results from latest trials.

SUMMARY: At present, an individualized clinical approach seems most appropriate. Patients and doctors are free to choose, according to their experiences and preferences, from recommended treatments.

Current Opinion in Rheumatology. 2008 May

DOI:10.1097/BOR.0b013e3282f94256

Link to abstract

Filed under: Lumbar spine