College of Massage Therapists of Ontario - Ottawa Panel evidence-based clinical ... ·...

Journal of Bodywork & Movement Therapies (2012) 16, 424e455

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/jbmt

SYSTEMATIC REVIEW MASSAGE: LOW BACK PAIN

Ottawa Panel evidence-based clinical practiceguidelines on therapeutic massage for low back pain

Lucie Brosseau, PhD b,c,q,*,1,2, George A. Wells, PhD a,b,1,2, Stephane Poitras,PhD c,1,2, Peter Tugwell, MD, MSc a,b,d,1,2, Lynn Casimiro, PhD c,1,2,Michael Novikov, MScS c,1,2, Laurianne Loew, MScS, PhD(c) c,1,2,Danijel Sredic, BSc c,1,2, Sarah Clement, BSc c,1,2, Amelie Gravelle, BSc c,1,2,Daniel Kresic, BSc c,1,2, Kevin Hua, BSc c,1,2, Ana Lakic, BSc c,1,2,Gabrielle Menard, BSc c,1,2, Stephanie Sabourin, MScS c,1,2,Marie-Andre Bolduc, MScS c,1,2, Isabelle Ratte, MScS c,1,2, Jessica McEwan,MLIS e,1,2, Andrea D. Furlan, MD, PhD f,1,3, Anita Gross, MSc. PT g,1,3,Simon Dagenais, DC h,1,3, Trish Dryden, M.Ed., RMT i,1,3, Ron Muckenheim,RMT j,1,3, Raynald Cote, RMT l,1,3, Veronique Pare, RMT l,1,3,Alexandre Rouhani, RMT m,1,3, Guillaume Leonard, PhD k,1,3,Hillel M. Finestone, MD n,1,3, Lucie Laferriere, MHA o,1,3,Angela Haines-Wangda, MSc p,1,3, Marion Russell-Doreleyers, MSc e,1,3,5,Gino De Angelis, MSc b,c,1,4, Courtney Cohoon, MA b,c,1,4

aClinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, CanadabDepartment of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canadac School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, CanadadCentre for Global Health, Institute of Population Health, Ottawa, Ontario, CanadaeThe Ontario Arthritis Society, Ottawa & Toronto, Ontario, Canadaf Institute for Work & Health, Toronto, Ontario, CanadagMcMaster University, Hamilton, Ontario, CanadahWest Seneca, New York, USAiResearch and Corporate Planning Centennial College, Toronto, Ontario, Canadaj Everest College, Ottawa East, Ontario, Canadak Sherbrooke University, Physiotherapy program, Sherbrooke, Quebec, CanadalAcademy of Massage and Orthotherapy, Gatineau, Quebec, CanadamCentre de Massotherapie et Soins Corporels l’Orchidee, Gatineau, Quebec, Canadan SCO Health Services, Elisabeth Bruyere Health Centre, Ottawa, Ontario, Canada

1360-8592/$ - see front matter ª 2012 Published by Elsevier Ltd.doi:10.1016/j.jbmt.2012.04.002

http://dx.doi.org/10.1016/j.jbmt.2012.04.002

www.sciencedirect.com/science/journal/13608592

http://www.elsevier.com/jbmt



Ottawa Panel evidence-based massage and low back pain clinical practice guidelines 425

oDirectorate Force Health Protection, Canadian Forces Health Services Group Headquarters, National Defense, Ottawa,Ontario, CanadapThe Ottawa Hospital, General Campus, Ottawa, Ontario, CanadaqMontfort Hospital Research Institute, Ottawa, Ontario, Canada

Received 22 November 2011; received in revised form 30 March 2012; accepted 5 April 2012

KEYWORDSClinical practiceguidelines;Low back pain;Massage therapy;Randomizedcontrolled trial;Systematic review

1 Ottawa Panel Members.2 Ottawa Methods Group.3 External Experts.4 Assistant Manuscript Writer.5 Consumer with low back pain.* Corresponding author. Roger Guind

5800#8015; fax: þ1 613 562 5428.E-mail address: Lucie.Brosseau@uo

Summary Objective: To update evidence-based clinical practice guidelines (EBCPG) onmassage therapy compared to control or other treatment for adults (>18 years) suffering fromacute, sub-acute and chronic low back pain (LBP).Methods: A literature search was performed for relevant articles between January 1, 1948 andDecember 31, 2010. Eligibility criteria were then applied focussing on participants, interven-tions, controls, and outcomes, as well as methodological quality. Recommendations basedon this evidence were then assigned a grade (A, B, C, Cþ, D, Dþ, D�) based on their strength.Results: A total of 100 recommendations were formulated from 11 eligible articles, including37 positive recommendations (25 grade A and 12 grade Cþ) and 63 neutral recommendations(49 grade C, 12 grade D, and 2 grade Dþ).Discussion: These guidelines indicate that massage therapy is effective at providing pain reliefand improving functional status.Conclusion: The Ottawa Panel was able to demonstrate that massage interventions are effec-tive to provide short term improvement of sub-acute and chronic LBP symptoms anddecreasing disability at immediate post treatment and short term relief when massage therapyis combined with therapeutic exercise and education.ª 2012 Published by Elsevier Ltd.

Introduction

Low back pain (LBP) is a common condition among theNorth American population, as nearly 80% will experience itat some point in their lives (Frymoyer, 1988). Pain can beacute, lasting from a few days to a few weeks, or maypersist and become chronic if it lasts for more than threemonths (Wilk, 2004; The Philadelphia Panel, 2001). Symp-toms of LBP may include a sharp, stabbing sensation in thelumbosacral region, limited flexibility, range of motion andan inability to stand completely upright without pain(Borkan et al., 1995).

Massage therapy is defined as soft tissue and jointmanipulation using the hands or a handheld device (Imm2010) (Massage Therapy Act, 1991, c. 27, s. 3). An exami-nation of systematic reviews (SRs) and clinical practiceguidelines (CPGs), published within the last five yearssuggests promising outcomes for massage therapy in rela-tion to LBP (Middelkoop et al., 2011; Furlan et al., 2009,2008; Graham et al., 2008; Hettinga et al., 2008; Chou and

on Hall, University of Ottawa, 45

ttawa.ca (L. Brosseau).

Huffman, 2007; Chou et al., 2007; Louw et al., 2007;Luijsterburg et al., 2007; The Philadelphia Panel, 2001).Articles summarizing CPGs for LBP have stated thatmassage therapy is generally recommended, but thatavailable studies are of moderate or weak methodologicalquality, often due to randomization and blinding(Bouwmeester et al., 2009; Dagenais et al., 2010; Pillastriniet al., 2011). Previous SRs and CPGs related to massagetherapy for LBP did not always impose requirements formethodological quality in the studies considered, and didnot indicate if a quantitative methodology was employed toformulate recommendations.

CPGs based on SRs are considered to be solid sources ofevidence to help clinical decision making (Jonas, 2001). Thegoal of this study was to develop recommendations basedon the most recent scientific literature that incorporatesthe graded strength of evidence, and utilizes expert opinionto assess the clinical applicability of the selected trials. It isour aim to give family physicians, physiotherapists, occu-pational therapists, massage therapists, and other

1 Smyth Road, Ottawa, Ontario K1H 8M5, Canada. Tel.: þ1 613 568

mailto:[email protected]

426 L. Brosseau et al.

clinicians the latest knowledge regarding the most appro-priate use of massage therapy.

Methodology

Protocols and registration

The development process of the evidence-based clinicalpractice guidelines (EBCPGs) was similar to that of thePhiladelphia Panel (The Philadelphia Panel, 2001) and otherEBCPGs created by the Ottawa Panel (The Ottawa Panel,2005, 2006, 2008). The methodology of this project fol-lowed the Ottawa Expert Panel methods and used a quan-titative approach consistent with the CochraneCollaboration (www.cochrane.org) and the Ottawa Panelevidence grading system (The Ottawa Panel, 2011).

Ottawa Panel experts

The Ottawa Methods Group (OMG), consisting of a panel ofnine methodologists, sought out professional Canadianassociations whose members treat patients with LBP. Apanel of nine specialists with clinical experience in:biostatistics, massage therapy, occupational therapy, andphysiotherapy were then chosen. The OMG and selectedexperts then created the Ottawa Panel, which wasresponsible for the EBCPGs in this report. The OMG alsoassembled a research team with expertise in meta-analysis,research methods, and the development and evaluation ofEBCPGs. Clinical experts were also included as Panelmembers such as massage therapists, physiotherapists,chiropractor, physiatrists and physicians.

Quantitative grading system

In conjunction with the methodology of previous OttawaPanel publications (The Ottawa Panel, 2005, 2006, 2008,2011), the construction of EBCPGs was developed usingthe Appraisal of Guidelines Research and Evaluation

Table 1 Combined grading recommendations.

Grade Clinical importance Statis

*Grade A (**Stronglyrecommended)

�20% p < 0

*Grade B �20% p < 0

*Grade Cþ(**Suggested use)

�20% Not s

*Grade C (**Neutral) <20% Not s*Grade D (**Neutral) <20% (favours control) Not s*Grade Dþ (**Suggestedno use)

<20% (favours control) Not s

*Grade D� (**Strongly notrecommended)

�20% (favours control) p < 0(favo

RCT, randomized controlled trial; CCT, clinical controlled trial (Taccording to *Ottawa Panel (The Ottawa Panel, 2008) for alphabetcochrane.org) for international nominal grading system. “Reprinted2008 American Physical Therapy Association.”

(AGREE) criteria (http://www.agreetrust.org). Therecommendations from the Ottawa Panel are first gradedLevel I if they represent evidence from at least onerandomized controlled trial (RCT) or level II if based onevidence from non-randomized studies. The strength ofthe evidence of the recommendations is then graded as:A, B, Cþ, C, D, Dþ, or D�, corresponding to each level ofthe Ottawa Panel grading system, which considers clinicalimportance, statistical significance and study design (seeTable 1).

Type of participants (P)

To be considered, studies had to include participants overthe age of 18 years, with acute (less than 4 weeks), sub-acute (4e12 weeks) or chronic (longer than 12 weeks) (ThePhiladelphia Panel, 2001) LBP categorized as: mechanicallower back disorders and/or lower back disorders withradicular findings.

Type of interventions (I)

Interventions considered included specific massage therapytechniques (Swedish, fascial or connective tissue releasetechniques, cross fibre friction, and myofascial triggerpoint techniques), either alone or combined with manipu-lation, mobilization, other manual therapy interventions,or other concurrent interventions (ice, heat, TENS, ultra-sound, and combinations thereof).

Type of comparisons (C)

Studies had to compare massage to a control group thatreceived no intervention, placebo (sham laser treatment),usual care, self-care education, relaxation therapy, shammanual therapy or exercise. Studies with head to headcomparisons of different clinical protocols were includedonly if they were comparing two different types of massage(see Table 3).

tical significance Study design

.05 RCT (single or meta-analysis)

.05 CCT or observational(single of meta-analysis)

ignificant RCT/CCT or observational(single or meta-analysis)

ignificant Any study designignificant Any study designignificant RCT/CCT or observational

(single or meta-analysis).05urs control)

Well-designed RCT with >100 patients(if <100 patients becomes a Grade D)

he Ottawa Panel, 2008). Combined Grading Recommendationsical grading system and to the **Cochrane Collaboration (www.with permission Physical Therapy (2011;91:843e61). Copyright

http://www.cochrane.org

http://www.agreetrust.org



Table 2 Inclusion and exclusion criteria.

Inclusion Exclusion

Study designsRandomized controlled trialQuasi Randomized controlled trialControlled clinical trialCohort studyCase-control studyEnglish and French articles only

Study designsCase-series/case reportUncontrolled cohort studiesData (graphic) without a mean and SDSample size of less than 5 patients per treatment groupStudies with more than 20% drop out rate

PopulationOut/InpatientsAge groups >18 y orAdults who suffered from acute (less than 30 days),sub-acute (30 dayse90 days)or chronic (longer than 90 days) neck disorderscategorized as:- mechanical low back pain- lower back disorders with radicular findings

PopulationCancer (and other Oncologic conditions)Cardiac conditionsDermatologic conditionsHealthy normalJuvenile ArthritisMixed population (other than OA and/or RA).Multiple conditionsNeurologic conditionsPaediatric conditions (no juvenile arthritis)Psychiatric conditionsPulmonary conditionsScoliosisDefinite or possible long tract signsNeck pain caused by other pathological entitiesHeadache not of cervical originCo-existing headacheMixed headache.

InterventionEligible control groups:- placebo,- untreated, sham,- active physiotherapy treatments,- active treatment control,- inactive treatment uncontrolled.

Chiropractic interventions (manipulation, mobilization,manual therapy)

Eligible interventions:- Massage techniques:- Swedish, fascial or connective tissue release techniques,cross fibre friction, and myofascial trigger pointtechniques.

- Multiple interventions (physiotherapy includingice, heat, massage, TENS, ultrasound, combinations)

Intervention- Bilateral interventions (if systemiceffects)

- Multidisciplinary, functional restoration programs.- Surgery of shoulder, knee, neck and low back(i.e. not the effect of the surgery, but theeffect of post-surgery physiotherapy interventionis eligible, e.g. CPM, exercises, thermotherapy, etc.)

- Medication (e.g. phonophoresis with meds)- Thermal biofeedback.- Subtle energy manipulations technique.

Outcomes- Absenteeism, sick leave, returnto work (if available)

- Balance status- Cardio-pulmonary functions- Coordination status- Costs (economics)- Disease Activity- Disability- Oedema- EMG activity- Erythrocyte Sedimentation Rate (ESR)

Outcomes

- Biochemical measures- Patient compliance to medication- Psychosocial measures (depression, home andcommunity activities, leisure, social roles, sexualfunctions)

- Serum markers (except ESR)

(continued on next page)


Table 2 (continued )

Inclusion Exclusion

- Flexibility- Functional status, activities of daily living(self-care activities)

- Gait status- Girth, volume- Global perceived effect- Inflammation- Joint imaging- Medication intake (if reported)- Muscle strength, endurance and power- Pain- Patient satisfaction- Postural assessment- Quality of life- Range of motion, flexibility, mobility- Side effects (if reported)- Swelling- Weight loss


Type of outcomes (O)

Outcomes of primary interests in the primary studies includeddisability (Roland Morris Disability Questionnaire (RMDQ)),functional status (Oswestry Disability Index (ODI), Quebecback pain disability scale, physical function (SF-36)), pres-ence of pain (short-form McGill questionnaire, system both-ersomeness score, visual analogue scale (VAS), Pain PressureIndex, Pain Rating Index, bodily pain (SF-36), and quality oflife (SF-36)). Trials were excluded if the means and standarddeviations for their primary outcomes were not reported.

Type of study designs

Comparative controlled studies (CCSs) such as randomizedcontrolled trials (RCTs), controlledclinical trials (CCTs), cohortstudies, and case-control studies were eligible for inclusion.Studies were excluded if they did not compare the interven-tions of interest to a control group (e.g. uncontrolled cohorttrials), if the study design was a case-series or a case report, ifthere were more than 20% of withdrawals by participants, orhad a sample size of less than 5 subjects per group.

Information sources

The library scientist (JME) performed a systematic search ofEnglish and French literature using a search strategyproposedby theCochraneCollaboration fromJanuary 1, 1948to December, 2010. Studies were extracted from thefollowing databases: EMBASE,MEDLINE, HealthStar, PUBMED,CINAHL, PEDro Psycinfo Rehabdata, SUMsearch, Dissertatino,Abstracts International databases, and Cochrane Library.

Data collection process

Study selectionTwo independent reviewers selected studies from theresults of the literature search based on the inclusion and

exclusion criteria outlined in Table 2, noting the reason ifstudies were excluded (see Table 4). The principal assessor(LB) was consulted whenever uncertainty was presented,who also consulted with the rest of the Ottawa Panelexperts (The Ottawa Panel, 2011).

Data extraction and methodological qualityTwo reviewers independently extracted information fromeach included study using standardized data extractionforms focussing on characteristics of the participants,treatment protocols, study design, allocation concealment,comparative results, and the period of data collection.

The Jadad scale (Jadad et al., 1996) was used to assessthe methodological quality of each selected study. Eachstudy was awarded a maximum of five points: 2 points forthe randomization method, 2 points for double blinding,and 1 point for a description of dropouts.

A study assessed with a Jadad scale score of 3 or morepoints (Jadad et al., 1996) is generally considered as beingof high methodological quality. Points for double-blindnesswere rarely givephysical nature of the interventions and thedifficulties in blinding both therapists and participants;greater emphasis was placed on the randomization andwithdrawals categories.

Data analysis

The Cochrane Collaboration methods were used to performstatistical analysis (www.cochrane.org). Weighted meandifferences (WMDs), absolute benefit, and relative differ-ences were calculated for continuous data. Both the Phil-adelphia Panel (The Philadelphia Panel, 2001) and OttawaPanel agreed that improvement was considered clinicallymeaningful if it was 20% or more relative to a control group,which is consistent with the American College of Rheuma-tology having stated that a 20% improvement was clinicallyimportant (Felson et al., 1995), and also with previousstudies on minimum clinically important differences (MCID)


Table 3 Results of the relative difference of high methodological quality studies.

Study Treatmentgroup

Outcome No. ofpatients

Baselinemean

End ofstudymean

Absolutebenefit

Relativedifferencein changefrombaseline

Weighted meandifference (WMD)95% confidenceinterval (CI)

Cherkinet al., 2011

Structuralmassage

Disability (RolandMorris DisabilityQuestionnaire)Lower betterEnd tx 10 weeks

132 10.1 6.5 �2.10 �20% WMD: �2.50CI low: �3.56CI high: �1.44

Usual care 133 10.5 9.0Cherkinet al., 2011

Structuralmassage

Disability (RolandMorris DisabilityQuestionnaire)Lower betterFU 16 weeks

132 10.1 6.7 �1.10 �11% WMD: �1.50CI low: �2.63CI high: �0.37


Structuralmassage


132 10.1 7.2 0.20 2% WMD: �0.20CI low: �1.33CI high: 0.93


Structuralmassage

Symptoms(Symptombothersomenessscore)Lower betterEnd tx 10 weeks

132 5.6 3.8 �1.20 �21% WMD: �1.4CI low: �1.94CI high: �0.86


Structuralmassage

Symptoms(Symptombothersomenessscore)Lower betterFU 16 weeks

132 5.6 4.2 �0.20 �4% WMD: �0.40CI low: �0.91CI high: 0.11


Structuralmassage


132 5.6 4.6 0.60 11% WMD: 0.40CI low: �0.17CI high: 0.97


Relaxationmassage


136 11.6 6.0 �4.10 �37% WMD: �3.00CI low: �4.10CI high: �1.90


Relaxationmassage


136 11.6 6.0 �3.30 �30% WMD: �1.80CI low: �2.89CI high: �0.71


Relaxationmassage


136 11.6 6.0 �2.50 �23% WMD: �1.40CI low: �2.61CI high: �0.19



Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit




Relaxationmassage

Symptoms(Symptombothersomenessscore)Lower betterEnd tx 10 weeks

136 5.6 3.5 �1.50 �26% WMD: �1.70CI low: �2.24CI high: �1.16


Relaxationmassage


136 5.6 4.3 �0.10 �2% WMD: �0.30CI low: �0.87CI high: 0.27


Relaxationmassage


136 5.6 3.9 �0.10 �2% WMD: �0.30CI low: �0.88CI high: 0.28

Usual care 133 5.8 4.2Littleet al., 2008

Therapeuticmassage

Disability (RolandMorris DisabilityQuestionnaire)Lower betterEnd of tx 12 weeks

147 11.3 7.38 �2.46 �22% WMD: �1.96CI low: �3.33CI high: �0.59

Control(Normal care)

144 10.8 9.34

Littleet al., 2008

Therapeuticmassage


147 11.3 8.78 �0.95 �9% WMD: �0.45CI low: �2.49CI high: 1.59

Control(Normal care)

144 10.8 9.23

Preyde, 2000 Comprehensivemassagetherapy

Pain intensity(Presentpain index)Lower betterEnd of tx 4 weeks

25 2.4 0.44 �1.4 �61% WMD: �1.2CI low: �1.61CI high: �0.79

Remedialexerciseand postureeducation

22 2.2 1.64


Pain intensity(Present painindex)Lower betterFU 4 weeks

25 2.4 0.42 �1.11 �48% WMD: �0.91CI low: �1.33CI high: �0.49


22 2.2 1.33





Baselinemean

End ofstudymean

Absolutebenefit




Pain quality(Pain ratingindex)Lower betterEnd tx 4 weeks

25 12.3 2.92 �7.09 �63% WMD: �4.99CI low: �7.87CI high: �2.11


22 10.2 7.91


Pain quality(Pain ratingindex)Lower betterFU 4 weeks

25 12.3 2.29 �5.00 �44% WMD: �2.9CI low: �5.39CI high: �0.41

Remedialexercise andpostureeducation

22 10.2 5.19



25 8.3 2.36 �5.56 �71% WMD: �4.46CI low: �7.04CI high: �1.88


22 7.2 6.82



25 8.3 1.54 �5.27 �68% WMD: �4.17CI low: �6.37CI high: �1.97

Remedialexercise andpostureeducation

22 7.2 5.71

Preyde, 2000 Soft tissuemanipulation

Pain intensity(Present painindex)Lower betterEnd of tx 4 weeks

25 2.2 1.04 �0.81 �39% WMD: �0.80CI low: �1.37CI high: �0.23

Placebo (shamlasertreatment)

26 2 1.65


Pain intensity(Present painindex)Lower betterFU 4 weeks

22 2.2 1.18 �0.77 �37% WMD: �0.51CI low: �1.08CI high: 0.07


24 2 1.75



Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit




Pain quality(Pain ratingindex)Lower betterEnd tx 4 weeks

25 10.6 5.24 �21 �193% WMD: �3.07CI low: �6.12CI high: �0.02


26 11.1 8.31


Pain quality (Painrating index)Lower betterFU 4 weeks

22 10.6 4.55 �21 �193% WMD: �3.16CI low: �6.54CI high: 0.16


24 11.1 7.71



25 8.6 3.44 �4.81 �61% WMD: �1.06CI low: �1.65CI high: �0.47

Placebo (shamlaser treatment)

26 7.2 6.85



22 8.6 2.86 �5.04 �64% WMD: �0.96CI low: �1.58CI high: �0.35

Placebo (shamaser treatment)

24 7.2 6.5

Quinnet al., 2008

Reflexology Pain intensity (Visualanalogue scale)Lower betterEnd of tx 6 weeks

7 4.93 3.27 �2.26 �54% WMD: �0.87CI low: �1.62CI high: �0.12

Sham 8 3.53 4.13Quinnet al., 2008

Reflexologytreatment

Pain Intensity (Visualanalogue scale)Lower betterFU 6 weeks

7 4.93 2.83 �2.54 �61% WMD: �1.13CI low: �2.64CI high: 0.38

Sham 8 3.53 3.97Quinnet al., 2008


Pain Intensity(Visual analoguescale)Lower betterFU 12 weeks

7 4.93 2.33 �2.54 �61% WMD: �1.14CI low: �2.05CI high: �0.23

Sham 8 3.53 3.47Quinnet al., 2008


Pain (McGill PainQuestionnaire)Lower betterEnd of tx 6 weeks

7 24.83 12.67 �6.39 �30% WMD: 0.57CI low: �2.93CI high: 4.07

Sham 8 17.87 12.1Quinnet al., 2008


Pain (McGill PainQuestionnaire)Lower betterFU 6 weeks

7 24.83 11.33 �3.80 �18% WMD: 3.16CI low: �1.76CI high: 8.09

Sham 8 17.87 8.17





Baselinemean

End ofstudymean

Absolutebenefit



Quinnet al., 2008


Pain (McGill PainQuestionnaire)Lower betterFU 12 weeks

7 24.83 7.67 �6.32 �30% WMD: 0.64CI low: �3.29CI high: 4.57

Sham 8 17.87 7.03Quinnet al., 2008


Disability (RolandMorrisQuestionnaire)Lower betterEnd of tx 6 weeks

7 5.87 5.5 2.20 35% WMD: 1.47CI low: �0.06CI high: 2.99

Sham 8 6.6 4.03Quinnet al., 2008


Disability (RolandMorrisQuestionnaire)Lower betterFU 6 weeks

7 5.87 3.83 0.39 6% WMD: �0.34CI low: �2.49CI high: 1.81



Disability (RolandMorrisQuestionnaire)Lower betterFU 12 weeks

7 5.87 3.67 1.03 16% WMD: 0.30CI low: �1.22CI high: 1.82



Quality of life(Physicalfunctioning)Higher betterEnd of tx 6 weeks

7 48.2 48.53 �1.33 �3% WMD: �2.20CI low: �5.84CI high: 1.44

Sham 8 44.47 46.13Quinnet al., 2008


Quality of life(Physicalfunctioning)Higher betterFU 6 weeks

7 48.2 48.57 �1.66 �4% WMD: �2.06CI low: �5.18CI high: 1.06

Sham 8 44.47 46.5Quinnet al., 2008


Quality of life(Physicalfunctioning)Higher betterFU 12 weeks

7 48.2 49.2 0 0% WMD: �3.74CI low: �5.52CI high: �1.96

Sham 8 44.47 45.47Quinnet al., 2008


Quality of life(Role physical)Higher betterEnd of tx 6 weeks

7 41.07 49.83 6.69 15% WMD: �1.67CI low: �6.41CI high: 3.07

Sham 8 46.1 48.17Quinnet al., 2008


Quality of life(Role physical)Higher betterFU 6 weeks

7 41.07 48.5 8.66 20% WMD: �3.64CI low: �9.21CI high: 1.93

Sham 8 46.1 44.87Quinnet al., 2008


Quality of life(Role physical)Higher betterFU 12 weeks

7 41.07 49.5 7.03 16% WMD: �2.0CI low: �5.97CI high: 1.97



Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit



Sham 8 46.1 47.5Quinnet al., 2008


Quality of life(Bodily pain)Higher betterEnd of tx 6 weeks

7 40.13 45.03 6.50 15% WMD: �2.10CI low: �7.30CI high: 3.10

Sham 8 44.53 42.93Quinnet al., 2008


Quality of life(Bodily pain)Higher betterFU 6 weeks

7 40.13 50.03 9.53 22% WMD: �5.13CI low: �9.74CI high: �0.52

Sham 8 44.53 44.9Quinnet al., 2008


Quality of life(Bodily pain)Higher betterFU 12 weeks

7 40.13 49.37 7.40 17% WMD: �3.00CI low: �6.35CI high: 0.35

Sham 8 44.53 46.37Quinnet al., 2008


Quality of life(General health)Higher betterEnd of tx 6 weeks

7 48.73 51.97 �1.56 �3% WMD: �5.90CI low: �10.14CI high: �1.66

Sham 8 41.27 46.07Quinnet al., 2008


Quality of life(General health)Higher betterFU 6 weeks

7 48.73 48.73 �4.73 �11% WMD: �2.73CI low: �8.38CI high: 2.92

Sham 8 41.27 46Quinnet al., 2008


Quality of life(General health)Higher betterFU 12 weeks

7 48.73 49.83 �1.83 �4% WMD: �5.63CI low: �10.54CI high: �0.72

Sham 8 41.27 44.2Quinnet al., 2008


Quality of life(Vitality)Higher betterEnd of tx 6 weeks

7 43.6 52.37 2.64 6% WMD: �4.36CI low: �8.29CI high: �0.43

Sham 8 41.87 48Quinnet al., 2008


Quality of life(Vitality)Higher betterFU 6 weeks

7 43.6 49.7 3.20 7% WMD: �4.94CI low: �9.75CI high: �0.13

Sham 8 41.87 44.77Quinnet al., 2008


Quality of life(Vitality)Higher betterFU 12 weeks

7 43.6 50.03 �1.03 �2% WMD: �0.70CI low: �5.11CI high: 3.71

Sham 8 41.87 49.33Quinnet al., 2008


Quality of life(Social functioning)Higher betterEnd of tx 6 weeks

7 37.67 46.97 12.33 30% WMD: �5.36CI low: �17.07CI high: 6.35

Sham 8 44.63 41.6Quinnet al., 2008


Quality of life(Social functioning)Higher betterFU 6 weeks

7 37.67 46.63 2.22 5% WMD: 4.73CI low: �0.95CI high: 10.41





Baselinemean

End ofstudymean

Absolutebenefit



Sham 8 44.63 51.37Quinnet al., 2008


Quality of life(Social functioning)Higher betterFU 12 weeks

7 37.67 50.47 7.86 19% WMD: �0.89CI low: �6.23CI high: 4.45

Sham 8 44.63 49.57Quinnet al., 2008


Quality of life(Role emotional)Higher betterEnd of tx 6 weeks

7 38.43 45.37 9.94 23% WMD: �0.66CI low: �11.44CI high: 10.12

Sham 8 47.7 44.7Quinnet al., 2008


Quality of life(Role emotional)Higher betterFU 6 weeks

7 38.43 46.03 4.03 9% WMD: 5.24CI low: �3.01CI high: 13.49

Sham 8 47.7 51.27Quinnet al., 2008


Quality of life(Role emotional)Higher betterFU 12 weeks

7 38.43 48.37 2.67 6% WMD: 6.60CI low: 3.11CI high: 10.09

Sham 8 47.7 54.97Quinnet al., 2008


Quality of life(Mental health)Higher betterEnd of tx 6 weeks

7 42.8 48.73 3.66 8% WMD: �1.33CI low: �7.47CI high: 4.81

Sham 8 45.13 47.4Quinnet al., 2008


Quality of life(Mental health)Higher betterFU 6 weeks

7 42.8 48.27 2.73 6% WMD: �0.40CI low: �6.12CI high: 5.32

Sham 8 45.13 47.87Quinnet al., 2008


Quality of life(Mental health)Higher betterFU 12 weeks

7 42.8 49 2.00 5% WMD: 0.33CI low: �3.79CI high: 4.45

Sham 8 45.13 49.33Quinnet al., 2008


Quality of life(Physicalsummary)Higher betterEnd of tx 6 weeks

7 43.7 47.43 2.86 7% WMD: �5.06CI low: �7.86CI high: �2.26

Sham 8 41.5 42.37Quinnet al., 2008


Quality of life(Physicalsummary)Higher betterFU 6 weeks

7 43.7 47.03 2.73 6% WMD: �4.93CI low: �8.70CI high: �1.16

Sham 8 41.5 42.1Quinnet al., 2008


Quality of life(Physicalsummary)Higher betterFU 12 weeks

7 43.7 48.87 4.64 11% WMD: �4.84CI low: �6.90CI high: �2.78

Sham 8 41.5 42.03(continued on next page)


Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit



Quinnet al., 2008


Quality of life(Mental summary)Higher betterEnd of tx 6 weeks

7 37.03 45.93 8.50 21% WMD: �2.16CI low: �12.03CI high: 7.71

Sham 8 43.37 43.77Quinnet al., 2008


Quality of life(Mental summary)Higher betterFU 6 weeks

7 37.03 44.93 2.77 7% WMD: 3.57CI low: �3.37CI high: 10.51

Sham 8 43.37 48.5Quinnet al., 2008


Quality of life(Mental summary)Higher betterFU 12 weeks

7 37.03 47.37 2.41 6% WMD: 3.93CI low: �1.14CI high: 9.00

Sham 8 43.37 51.3


for common outcome measures used to assess LBP [RMDQ(MCID: 20%), ODI (MCID: 11%), bodily pain (SF-36) (MCID:29%), physical function (SF-36) (MCID: 17%) and 11 pointnumeric rating scale for pain (MCID: 10%)] (Lauridsen et al.,2006). For dichotomous variables, the clinical improvementis calculated was the difference between the percentimproved in the experimental and control groups (relativerisks). For more details about the statistical analysis, seethe previous publications of the Ottawa Panel (The OttawaPanel, 2005, 2006, 2008, 2011).

Results

Literature search

A literature search was performed in December 2010 andfound 359 articles related to massage therapy and LBP, ofwhich 44 were deemed potentially relevant. Thirty-threestudieswere excluded (see Table 2) for the following reasons:asymmetrical population randomization (Dishman andBulbulian, 2001), difficult to isolate the effects of massage(Eisenberg et al., 2007; Hsieh et al., 2002; Skillgate et al.,2007; Zaproudina et al., 2009), no control group (Farasynand Meeusen, 2007; Koes et al., 1992; Melzack et al., 1980;Werners et al., 1999; Wilkinson, 1997), combination ofinterventions (Ferrell et al., 1997; Franke et al., 2000;Kankaanpaa et al., 1999; Koes et al., 1993; Konrad et al.,1992; Lidstrom and Zachrisson, 1970; Manniche et al., 1988,1991, 1989), no massage intervention (Ginsberg and Famaey,1987; Godfrey et al., 1984; Hoehler et al., 1981), head tohead comparison of multiple therapies (Hsieh et al., 2004,2006; Mackawan et al., 2007), missing data (Kalauokalaniet al., 2001), healthy study subjects (Kolich et al., 2000),contained only an abstract (Mandala et al., 2001), notrandomized (MelanconandMiller, 2005),massagewasnot theprimary intervention of the study (Pope et al., 1994), hada mixed populations (Skillgate et al., 2007; Walach et al.,

2003), and did not report standard deviations for outcomesof interest (Yip and Tse, 2004). The Ottawa Panel and theresearch assistant teamdetermined that 11 RCTarticleswereeligible; no other type of studies were found that met eligi-bility criteria (Chatchawan et al., 2005; Cherkin et al., 2001,2011; Farasyn et al., 2006; Field et al., 2007; Geisser et al.,2005; Hernandez-Reif et al., 2001; Little et al., 2008; Pooleet al., 2007; Preyde, 2000; Quinn et al., 2008).

Methodological quality

Four out of the 11 included articles received a score of“high quality” (�3): (Cherkin et al., 2011; Little et al.,2008; Preyde, 2000; Quinn et al., 2008); the remainder ofthe articles (7) were of low quality (<3): (Chatchawanet al., 2005; Cherkin et al., 2001; Farasyn et al., 2006;Field et al., 2007; Geisser et al., 2005; Hernandez-Reifet al., 2001; Poole et al., 2007) (see Appendix A and B).

Effectiveness of massage for LBP

The primary focus of this review was to develop recom-mendations based on RCTs with high methodological quality(�3) according to the Jadad scale (Cherkin et al., 2011;Little et al., 2008; Preyde, 2000; Quinn et al., 2008).

Cherkin et al. (2011) (see Appendix A), investigatedstructural massage versus control (usual care) and demon-strated clinically important benefits for decreaseddisability (RMDQ) (see Fig. 1) and symptoms (symptombothersomeness score) (see Fig. 2). When relaxationmassage was compared to control (usual care), clinicallyimportant benefits were demonstrated for improvedsymptoms (symptom bothersomeness score) (see Fig. 4) anddecreased disability (RMDQ) (see Fig. 3).

Little et al. (2008) (see Appendix A) investigated thera-peutic massage versus control (normal care) and demon-strated clinically important benefits for decreaseddisability (RMDQ) (see Fig. 5).

Table 4 Table of excluded studies.

Studies Reason for exclusion

Dishman and Bulbulian, 2001 Asymmetrical population randomizationEisenberg et al., 2007 Impossible to isolate the effect of massage from

all the other therapies evaluated in this study.Farasyn and Meeusen, 2007 No controlFerrell et al., 1997 Combination of interventionsFranke et al., 2000 Combination of interventionsFraser and Kerr, 1993 No massage interventionGinsberg and Famaey, 1987 No controlGodfrey et al., 1984 No controlHoehler et al., 1981 No controlHsieh et al., 2002 Impossible to isolate the effect of massage

from all the other therapies evaluated in this study.Hsieh et al., 2004 Head to head e multiple therapyHsieh et al., 2006 Head to head e multiple therapyKalauokalani et al., 2001 Missing dataKankaanpaa et al., 1999 Combination of interventionsKoes et al., 1993 Combination of interventionsKoes et al., 1992 No controlKolich et al., 2000 Study subjects were healthyKonrad et al., 1992 Combination of interventionsLidstrom and Zachrisson, 1970 Combination of interventionsMackawan et al., 2007 Head to headMandala et al., 2001 Abstract onlyManniche et al., 1988 Combination of interventionManniche et al., 1991 Combination of interventionManniche et al., 1989 Combination of interventionMelancon and Miller, 2005 Not randomizedMelzack et al., 1980 No controlPope et al., 1994 Effect of massage itself is not the main

purpose of this studySkillgate et al., 2007 Mixed population and massage not isolatedWalach et al., 2003 Mixed populationWerners et al., 1999 No controlWilkinson, 1997 No controlYip and Tse, 2004 RatioZaproudina et al., 2009 Impossible to isolate the effect of massage from

all the other therapies evaluated in this study.


Preyde (2000) (see Appendix A), measured soft-tissuemanipulation versus placebo (sham laser treatment).There were clinically important benefits demonstrated forthe improvement of pain intensity (Present pain index)(see Fig. 6), pain quality (Pain rating index) (see Fig. 8),and decreased disability (RMDQ) (see Fig. 7). Clinicallyimportant benefits were demonstrated but statisticallysignificant for improvement in pain intensity (Present painindex) (see Fig. 6) and pain quality (Pain rating index) (seeFig. 8). This study also compared comprehensive massagetherapy (massage, remedial exercise and posture educa-tion) versus remedial exercise and posture education.There were clinically important benefits demonstrated forthe improvement of pain intensity (Present pain index)(see Fig. 9), pain quality (Pain rating index) (see Fig. 11),and decreased disability (RMDQ) (see Fig. 10).

Quinn et al. (2008) (see Appendix A), measured reflex-ology treatment versus sham. Clinically important benefitswere demonstrated for improved pain intensity (VAS) at (see

Fig. 12) and quality of life e bodily pain (SF-36) (see Fig. 17).Clinically important benefits were demonstrated but notstatistically significant for improvements in pain (McGill painquestionnaire) (see Fig. 13), disability (RMDQ) (see Fig. 14),quality of life e physical functioning (see Fig. 15) quality oflife e role physical (SF-36) (see Fig. 16), quality of life egeneral health (see Fig. 18), quality of life e vitality (seeFig. 19), quality of life e social functioning (SF-36) (seeFig. 20), quality of lifee emotional role (SF-36) (see Fig. 21),quality of life e mental health (see Fig. 22), quality of life ephysical summary (see Fig. 23), and quality of life e mentalsummary (SF-36) (see Fig. 24).

Discussion

The Ottawa Panel was able to demonstrate that massagetherapy seems to be promising and yielded beneficialresults for mechanical LBP when compared to acupuncture,

Figure 3 Relaxation massage versus control (usual care):Dysfunction.

Figure 1 Structural massage versus control (usual care):Dysfunction.

Figure 2 Structural massage versus control (usual care):Symptoms.

Figure 4 Relaxation massage versus control (usual care):Symptoms.


Figure 7 Soft tissue manipulation versus Placebo (Sham lasertreatment): Disability.

Figure 5 Therapeutic massage versus Control (Normal care):Disability.

Figure 6 Soft tissue manipulation versus Placebo (Sham lasertreatment): Pain intensity.


self-care/education, relaxation therapies, conventionalphysiotherapy, and placebo controls. A total of 37 positiverecommendations were formulated (25 grade A and 12grade Cþ), as were 63 neutral recommendations (49 gradeC and 12 grade D), and 2 negative recommendations (2grade Dþ). Massage therapy should be recommended whenmanaging sub-acute and chronic LBP for immediate posttreatment improvement in pain and disability and shortterm relief when combined with therapeutic exercise andeducation.

Comparisons with previous guidelines

Previously published CPGs recommended massage therapybut did not review supporting evidence in-depth and oftenviewed it as an optional intervention for LBP (Middelkoopet al., 2011; Furlan et al., 2009, 2008; Graham et al.,2008; Chou and Huffman, 2007; Chou et al., 2007;Pillastrini et al., 2011). The conflicting evidence tosupport clear recommendations for massage therapy forLBP might have been due to a lack of a quantitativegrading system and a lack of high quality RCTs. Anotherrecent and updated overview of CPGs on LPB treatmentssuggests that massage therapy has unclear benefits due toinconclusive or conflicting evidence (Pillastrini et al.,2011). In the present study, we found that long termeffects of massage therapy still present conflicting

Figure 11 Comprehensive massage therapy versus Remedialexercise and posture education: Pain quality.

Figure 8 Soft tissue manipulation versus Placebo (Sham lasertreatment): Pain quality.

Figure 10 Comprehensive massage therapy versus Remedialexercise and posture education: Disability.

Figure 9 Comprehensive massage therapy versus Remedialexercise and posture education: Pain intensity.


Figure 14 Reflexology versus sham: Disability.

Figure 12 Reflexology versus sham: Pain.

Figure 13 Reflexology versus sham: Pain. Figure 15 Reflexology versus sham: Quality of life.


Figure 18 Reflexology versus sham: Quality of life.Figure 16 Reflexology versus sham: Quality of life.

Figure 17 Reflexology versus sham: Quality of life. Figure 19 Reflexology versus sham: Quality of life.


Figure 22 Reflexology versus sham: Quality of life.







evidence, but short term effects seems to suggest thatmassage therapy may relieve symptoms of LBP anddecrease associated disability.

Physiological effects

We have concluded that massage therapy is an effectiveintervention to relieve LBP. However, the mechanismunderlying its effectiveness is still unclear. The pressurestimulation associated with touch may increase vagalactivity, which in turn lowers physiological arousal and stresshormones (cortisol levels) (Field, 1998). In a recent study onthe physiological effects of massage, it was confirmed thatphysiological arousal and stress hormones are loweredfollowing massage therapy (Rapaport et al., 2010). Theeffect on pain of pressure stimulus generated by touch is alsoexplained by the gate-control theory (Melzack and Wall,1965), which stipulates that pressure stimulus reaches thespinal cord faster by travelling through large myelinatednerve fibres (Ab fibres) and therefore inhibits nociceptivesignals travelling by slower, less insulated nerve fibres (Adand C fibres). By reaching the spinal cord faster, the pressurestimulus prevents nociceptive signals from reaching thesupra-spinal structures implicated in pain processing. It wasalso observed that massage therapy enhanced immunefunction: Swedish Massage Therapy increased the number ofcirculating lymphocytes, CD 25þ lymphocytes, CD 56þlymphocytes, CD4þlymphocytes, and CD8þlymphocytes(effect sizes from 0.14 to 0.43) (Rapaport et al., 2010).

However, it is important to mention that environmentalfactors may also influence reported pain and functionalimprovements. The relaxing setting, the therapeutic effectsof touch and patient education may also contribute to theefficacy of massage therapy (Cherkin et al., 2011). Acombination of massage therapy and exercise can provide ananalgesic-like effect (Hoffman et al., 2005). Moyer et al.(2004) proposed a psychotherapeutic model that can beextended to massage therapy. It is reported that somepsychological benefits from a therapy may come from all thefactors that form the therapy rather that the treatment itself(Wampold, 2001). “In this model, factors such as a client whohas positive expectations for treatment, a therapist who iswarm and has positive regard for the client, and the devel-opment of an alliance between the therapist and client areconsidered to be more important than adherence toa specific modality of psychotherapy.” (Moyer et al., 2004)

Limitations

Even though this CPG employed a rigorous selectioncriteria and a meticulous methodology, several weak-nesses can be identified. A total of 16 relevant RCTs hadto be excluded because they could not isolate the effectsof massage therapy or because participants also usedmedication or surgery (see Table 4). This reduced thenumber of studies available to support the specific effectof massage therapy. Additionally, it was difficult todetermine the effects of type and dosage of massagebecause the RCTs employed different techniques, dura-tions, and treatment protocols. Most studies of massagetherapy combined various techniques, which were likelyapplied differently by each therapist. Another limitationof this study is the broad definition of massage, which mayexplain why the reflexology study of Quinn et al. (2008)reported conflicting results for disability compared tothe lower back massage study of Cherkin et al. (2011),Little et al. (2008) and Preyde (2000). Finally, only Englishand French articles were selected, which may haveexcluded important information published in otherlanguages.

Clinical implication

Massage therapy should be used as an effective treatmentto relieve sub-acute and chronic LBP symptoms anddecrease disability at immediate post treatment and theeffects may be maintained in the short term if combinedwith remedial exercises and education. Therefore massagetherapy should be part of the treatment options for LBP.

Conclusion

The Ottawa Panel CPGs recommends massage therapy as aneffective intervention to reduce sub-acute and chronic LBPsymptoms and decrease disability at immediate posttreatment and short term relief when combined withtherapeutic exercise and education. Further research isneeded to examine the effects of dosage and technique.Replication of long term effects would allow for greaterconfidence in this treatment.


Acknowledgement

The authors are indebted to Lucie Poulin MA (ExternalExpert) for her valuable comments.

This systematic review was financially supported byHolistic Health Research Funds, The University of OttawaResearch University Chair Award and the Ministry of HumanResources, Summer Students Program (Canada).

Appendix A

Grading recommendationsTraditional Thai Massage (increasing pressure along

two lines on each side of the back and passive stretching)versus Swedish massage (stroking, kneading, stripping, towarm muscles before applying greater pressure andpassive stretching), Level 1 (RCT, N Z 177, low quality),(Chatchawan et al., 2005) Grade C for pain intensity (VAS)at end of treatment (3 weeks) and at follow up (4 weeks),for functional status (Oswestry Disability Index) at end oftreatment (3weeks) and at follow up (4 weeks) (no benefitdemonstrated). Patients with persistent back pain, eithersub-acute (lasting for 4e12 weeks) or chronic (lasting forover 12 weeks) and at least one trigger point in the upperand lower torso region.

Massage (Swedish, deep tissue, neuromuscular, triggerand pressure point technique {acupressure and shiatsu})versus Control (Self-care) (book and video material),Level 1 (1 RCT, N Z 168, low quality). (Cherkin et al.,2001) Grade C for pain intensity (system bothersomenessscale) at end of treatment (10 weeks) and follow up (42weeks) and disability (Roland Morris Disability Question-naire) at end of treatment (10 weeks) (no benefit demon-strated). Grade D for disability (Roland Morris DisabilityQuestionnaire) at follow up (42 weeks) (no benefitdemonstrated but favouring control). Patients with non-specific sub-acute to chronic low back pain (�6 weeks61% more than a year).

Structural massage (myofascial, neuromuscular andother soft-tissue techniques) versus Control (Usual care)(no special care), Level 1 (1 RCT, N Z 265, high quality).(Cherkin et al., 2011) Grade A for disability (Roland MorrisDisability Questionnaire) and symptoms (symptom bother-someness score) at end of treatment (10 weeks) (clinicallyimportant benefit demonstrated). Grade C for disability(Roland Morris Disability Questionnaire) and symptoms(symptom bothersomeness scale) at follow up (16 weeks)(no benefit demonstrated). Grade D for disability (RolandMorris Disability Questionnaire) and symptoms (symptombothersomeness score) at follow up (42 weeks) (no benefitdemonstrated but favouring control). Patients with non-radicular chronic low back pain of mechanical origins (�3months).

Relaxation massage (effleurage, petrissage, circularfriction, vibration, rocking and jostling, and holding)versus Control (Usual care) (no special care), Level 1 (1RCT, N Z 269, high quality). (Cherkin et al., 2011)Grade A for symptoms (symptom bothersomeness score)at end of treatment (10 weeks) and disability (RolandMorris Disability Questionnaire) at end of treatment (10

weeks) and at follow up (16 and 42 weeks) (clinicallyimportant benefit demonstrated). Grade C for symptoms(symptom bothersomeness score) at follow up (16 and 42weeks) (no benefit demonstrated). Patients with non-radicular chronic low back pain of mechanical origins(�3 months).

Roptrotherapy (deep cross friction massage techniquewith aid of a myofascial bar) versus Placebo (Ender-mology) (30-min session of endermology to account forthe touching effects of massage, a device with a suctionhead was adjusted to a minimal but continuous sectionpower and applied across the middle and lower back (T6-L3) and buttocks.), Level 1 (1 RCT, N Z 40, low quality).(Farasyn et al., 2006) Grade A for pain intensity (VAS) anddisability (Oswestry disability index) at end of treatment (1week) (clinically important benefit demonstrated).Patients with non-specific sub-acute low back pain (3e12weeks).

Roptrotherapy (deep cross friction massage techniquewith aid of a myofascial bar) versus Control (No treat-ment), Level 1 (1 RCT N Z 40, low quality). (Farasynet al., 2006) Grade A for pain intensity (VAS) anddisability (Oswestry disability index) at end of treatment(1 week) (clinically important benefit demonstrated).Patients with non-specific sub-acute low back pain (3e12weeks).

Massage therapy (effleurage, petrissage and othermassage technics) versus Relaxation (progressive musclerelaxation), Level 1 (1 RCT, N Z 30, low quality). (Fieldet al., 2007) Grade CD for pain intensity (VAS) at end oftreatment (5 weeks) (clinically important benefit demon-strated without statistical significance). Patients with non-specific chronic low back pain (�6 months).

Manual therapy (muscle energy technique) andspecific exercises (Sahrman and Bokhout self-correctionexercises, stretches and strengthening exercises) versusSham manual therapy and specific exercises (Sahrmanand Bokhout self-correction exercises, stretches andstrengthening exercises). Level 1 (1 RCT, N Z 39, lowquality) (Geisser et al., 2005) Grade CD for pain intensity(VAS) at end of treatment (6 weeks) (clinically importantbenefit demonstrated without statistical significance).Grade C for functional status (Quebec back pain disabilityscale) at end of treatment (6 weeks) (no benefit demon-strated). Patients with non-specific chronic low back pain(�3 months).

Manual therapy (muscle energy technique) and non-specific exercises (exercises were not designed to treatspecific musculoskeletal dysfunction) versus Shammanual therapy and non-specific exercises (exerciseswere not designed to treat specific musculoskeletaldysfunction). Level 1 (RCT, N Z 33, low quality), (Geisseret al., 2005) Grade D for pain intensity (VAS) and functionalstatus (Quebec back pain disability scale) at end of treat-ment (6 weeks) (no benefit demonstrated but favouringcontrol). Patients with non-specific chronic low back pain(�3 months).

Massage (effleurage, petrissage and other massagetechnics) (30 min therapy sessions over 5 weeks) versusRelaxation (Progressive muscle relaxation) (30 minsessions, twice a week for 5 weeks and to keep a dog),Level 1 (1 RCT, N Z 24, low quality). (Hernandez-Reif


et al., 2001). Grade CD for pain intensity (VAS) at end oftreatment (5 weeks) (clinically important benefit demon-strated without statistical significance). Grade C for painintensity (short-form McGill questionnaire) at end oftreatment (5 weeks) (no benefit demonstrated). Patientswith non-specific chronic low back pain (�6 months).

Therapeutic massage (classic massage: Therapistsdrew on techniques as appropriate from: 1 e classicalSwedish Massage: such as effleurage, kneeding, pet-rissage and percussion. 2 e Soft tissue release: includingneuromuscular trigger point release. 3 e Passive andactive stretching, including proprioceptive neuromus-cular facilitation.) versus Control (Normal care), Level 1(1 RCT, N Z 291, high quality). (Little et al., 2008) GradeA for disability (Roland Morris Disability Questionnaire) atend of treatment (12 weeks) (Clinically important benefitdemonstrated). Grade C for disability (Roland MorrisDisability Questionnaire) at follow up (40 weeks) (no benefitdemonstrated). Patients with non-specific chronic low backpain (�3 months).

Reflexology (Morell Technique: this involves theapplication of firm but gentle compression by the ther-apist’s hands to points of the feet thought to correspondto other parts of the body) versus Relaxation (Progres-sive muscle relaxation), Level 1 (1 RCT, N Z 122, lowquality). (Poole et al., 2007) Grade CD for bodily pain (SF-36) at end of treatment (6e8 weeks) (clinically importantbenefit demonstrated without statistical significance).Grade C for pain intensity (VAS) at end of treatment (6e8weeks) and at follow up (6 months) and bodily pain (SF-36)at follow up (6 months) and physical function (SF-36) anddisability (Oswestry disability index) at end of treatment(6e8 weeks) and follow up (6 months) (no benefit demon-strated). Patients with benign chronic low back pain (�12weeks).

Reflexology (Morell Technique: this involves theapplication of firm but gentle compression by the ther-apist’s hands to points of the feet thought to correspondto other parts of the body) versus Control (non-inter-vention), Level 1 (1 RCT, N Z 108, low quality). (Pooleet al., 2007) Grade A for pain intensity (VAS) at end oftreatment (6e8 weeks) (clinically important benefitdemonstrated). Grade CD (clinically important benefitdemonstrated without statistical significance). Grade C forpain intensity (VAS) at follow up (6 months), for disability(Oswestry disability index) and physical function (SF-36) atend of treatment (6e8 weeks) and follow up (6 months)and for bodily pain (SF-36) at end of treatment (6e8weeks) and at follow up (6 months) (no benefit demon-strated). Patients with benign chronic low back pain (�12weeks).

Soft tissue manipulation (Friction, trigger point andneuromuscular therapy) versus Placebo (Sham lasertreatment), Level 1 (1 RCT, N Z 51, high quality).(Preyde, 2000) Grade A for pain intensity (Present painindex), pain quality (Pain rating index) and disability(Roland Morris Disability Questionnaire) at end of treat-ment (4 weeks) (clinically important benefit demon-strated). Grade CD for pain intensity (Present pain index)and pain quality (Pain rating index) at follow up (4 weeks)(clinically important benefit demonstrated without statis-tical significance). Grade D for back specific functional

status (Roland Morris Disability Questionnaire) at follow up(4 weeks) (no benefit demonstrated but favouring control).Patients with non-specific chronic low back pain (�3months).

Comprehensive massage therapy (Massage, remedialexercise and postural reeducation) versus Remedialexercise and postural reeducation, Level 1 (1 RCT,N Z 47, high quality). (Preyde, 2000) Grade A for painintensity (Present pain index), pain quality (Pain ratingindex) and disability (Roland Morris Disability Question-naire) at end of treatment (4 weeks) and follow up (4weeks) (clinically important benefit demonstrated).Patients with non-specific chronic low back pain (�3months).

Reflexology treatment (pressure massage along theinner edge of the feet to stimulate specific reflex points)versus sham (simple foot massage treatment using lesspressure and avoiding points which are representative ofthe vertebrae of the spine), Level 1 (1 RCT, N Z 15, highquality). (Quinn et al., 2008) Grade A for pain intensity(Visual analogue scale) at end of treatment (6 weeks) andfollow up (6 and 12 weeks) and quality of life e bodily pain(SF-36) at follow up (6 weeks) (clinically important benefitdemonstrated). Grade CD for pain (McGill pain question-naire) at end of treatment (6 weeks) and follow up (12weeks), quality of life -physical role (SF-36) at follow up (6weeks), quality of life -social functioning (SF-36) at end oftreatment (6 weeks), quality of life- emotional role (SF-36)at end of treatment (6 weeks) and quality of life- mentalsummary (SF-36) at end of treatment (6 weeks) (clinicallyimportant benefit demonstrated without statisticalsignificance).

Grade C for pain (McGill pain questionnaire) at followup (6 weeks), for quality of life -physical role (SF-36) atend of treatment (6 weeks) and follow up (12 weeks),for quality of life e bodily pain (SF-36) at end oftreatment (6 weeks) and follow up (12 weeks) for qualityof life e general health (SF-36) at end of treatment (6weeks), quality of life vitality (SF-36) at end of treat-ment (6 weeks) and follow up (6 weeks), quality of life emental health (SF-36) at end of treatment (6 weeks) andfollow up (6 and 12 weeks), quality of life e physicalsummary (SF-36) at end of treatment (6 weeks) andfollow up (6 and 12 weeks), quality of life e socialfunctioning (SF-36) at follow up (6 and 12 weeks), qualityof life e mental summary (SF-36) at follow up (6 and 12weeks) and quality of life e physical functioning (SF-36)at follow up (12 weeks) and quality of life e emotionalrole (SF-36) at follow up (6 and 12 weeks) (no benefitdemonstrated).

Grade DD for disability (Roland Morris disability ques-tionnaire) at end of treatment (6 weeks) and follow up (12weeks) (clinically important benefit demonstrated favour-ing control without statistical significance)

Grade D for disability (Roland Morris questionnaire) atfollow up (6 weeks), quality of life e physical functioning(SF-36) at end of treatment (6 weeks) and follow up (6weeks), quality of life e general health (SF-36) at follow up(6 and 12 weeks) and quality of life e vitality (SF-36) atfollow up (12 weeks) (no benefit demonstrated butfavouring control). Patients with non-specific chronic lowback pain (�3 months).

Appendix B Table of included studies.

Author/Year Samplesize

Populationdetails

Symptomduration

Age(Mean, SD)

Treatment Comparison group Concurrenttherapy

Session/weekNo. ofweeks

Follow upduration

Quality(R, B, W)

Cherkinet al.,2011

Parallel-groupRCTTotal: 401Gr1: 132Gr2: 136Gr3: 133

Inclusion criteria:(1) Patients with

non-radicularchronic lowback pain ofmechanicalorigins

(2) Presenting pain�3/10 on backpain bothersomescale

(3) Age 20e65 andlives within 45 mintravel time froma study massagetherapist.

Exclusion criteria:(1) Structural or

neurologiccauses or potentialcauses of lowback pain

(2) Inappropriatecandidate formassage

(3) Characteristicscomplicatingthe interpretationof findings

(4) Characteristicsrelated to ability tocomplete thestudy protocol

(5) Had massagein previousyear.

At least3 months

Gr1: X Z 46SD Z 12Gr2: X Z 47SD Z 11Gr3: X Z 48SD Z 11

Gr1: Structuralmassage:Intended to identifyand alleviatemusculoskeletalcontributors toback pain, comprisedmyofascial,neuromuscular, andother soft-tissuetechniques. Myofascialtechniques are intendedto engage and releaseidentified restrictionsin myofascial tissues.Neuromusculartechniques are used toresolve soft-tissueabnormalities bymobilizing restrictedjoints, lengtheningconstricted musclesand fascia, balancingagonist and antagonistmuscles, and reducinghypertonicity. The areasof the body that weretreated varied acrosspatients and treatmentsessions. Therapistscould recommenda home exerciseconsisting of psoasstretch to enhance andprolong any benefitsof structural massage.Gr2: Relaxationmassage: Intended

Gr3: Usual care:participants receivedno special care butwere paid $50. Actualcare was determinedfrom medical recordsand interviews.

N/A 10 weeklytreatments

Follow-up at26 and 52weeks

2, 0, 1


Otta

waPanelevid

ence

-basedmassa

geandlow

back

pain

clinica

lpractice

guidelin

es

447

Appendix B (continued )


Populationdetails

Symptomduration

Age(Mean, SD)

Treatment Comparison group Co currentthe apy


Follow upduration

Quality(R, B, W)

to induce a generalizedsense of relaxation,comprised effleurage,petrissage, circularfriction, vibration,rocking and jostling, andholding. Therapists weregiven time limits foreach body region,including 7e20 min onthe back and buttocks.Therapists could providea compact disk of a 2.5-min relaxation exerciseto be done at home toenhance and prolongtreatment benefits.

Littleet al.,2008

RCTTotal: 291Gr1: 147Gr2: 144

Inclusion criteria:(1) Presentation

in primarycare with lowback painmore than 3monthspreviously

(2) Currently scoring4 or moreon the RolandMorris DisabilityQuestionnaire

(3) Current pain for3 or more weeks.

Exclusion criteria:(1) Under 18

and over 65

>3 months Gr1: X Z 46SD Z 10Gr2: X Z 46SD Z 10

Gr1: TherapeuticMassage: The initialconsultation involvedtaking a case-history anddrawing up a treatmentplan between client andtherapist. Therapistsdrew on techniques asappropriate from: 1)classical SwedishMassage: such aseffleurage, kneeding,petrissage andpercussion, 2) Soft tissuerelease: includingneuromuscular triggerpoint release, 3) passiveand active stretching,including proprioceptiveneuromuscularfacilitation.

Gr2: Normal care N/ Gr1: 6sessions

12 weeksand 52weeks

2, 0, 1

448L.

Brosse

auetal.

nr

A

(2) Clinical indicators ofserious spinaldisease

(3) Current nerve rootpain-previous spinalsurgery pendinglitigation

(4) History ofpsychosis or majoralcohol misuse(difficultycompletingoutcomes)

(5) Perceivedinability to walk100 m (exercisedifficult)

Preyde,2000

RCTTotal: 98Gr1: 25Gr2: 25Gr3: 22Gr4: 26

InclusionCriteria:(1) Aged

18e81(2) Existence of

sub-acute(between 1 weekand 8 months)low-back pain

(3) Absence ofsignificantpathology,such as bonefracture, nervedamage or severpsychiatriccondition, includingclinicaldepression asdetermined bya physician

(4) No pregnancy(5) Stable health.

>3 months Gr1:X Z 46.5,SD Z 18.4Gr2:X Z 47.9,SD Z 16.2Gr3:X Z 48.4,SD Z 12.9Gr4:X Z 41.9,SD Z 16.6

Gr1: Soft-Tissuemanipulation (STM).Soft tissue manipulationtechniques such asfriction, triggerpoints andneuromusculartherapy were usedto promote circulationand relaxation ofspasm or tension.The durationwas between 30and 35 min.Gr2: Comprehensive

massage therapy

(CMT). Varioussoft-tissuemanipulation techniquessuch as friction,trigger points andneuromuscular therapywere used to promotecirculation andrelaxation

Gr3: Remedial

Exercises with

posture

education only. Foeachtreatment, stretchexercises forthe trunk, hips andtighs, includingflexion andmodified extensionweretaught and reviewtoensure propermechanics.Stretches were towithin a pain-freerange,help for about 30in a relaxed mannandperformed twice oone occasion per dfor related areas a

/A 6treatmentswithin


Otta

waPanelevid

ence

-basedmassa

geandlow

back

pain

clinica

lpractice

guidelin

es

449

r

ing

,

ed

be

ser,

naynd

N



Populationdetails

Symptomduration

Age(Mean, SD)

Treatment Comparison group Concurrenttherapy


Follow upduration

Quality(R, B, W)

Exclusion Criteria:(1) Low back pain

was beyondthe 8-month sub-acute cut-off

(2) They were notcurrentlyexperiencing low-back pain

(3) They indicateda diagnosis ofcomplexhealth problemssuch as multiplesclerosis.

of spasm or tension.(Duration: 30e35 min)Stretching exercises forthe trunk, hips, andthighs, including flexionand modified extension,were taught andreviewed toensure propermechanics.Stretches were to bewithina pain-free range,held for about 30 sin a relaxed manner,and performed twiceon one occasion per dayfor the relatedareas and morefrequentlyfor the affectedareas. 15e20 minof education on postureand body mechanics,particularly as theyrelatedto work and dailyactivities

morefrequently for theaffectedareas. Subjects wereencouraged to engagein generalstrengtheningor mobility exercisessuch as walking,swimming oraerobics and to buildoverall fitnessprogressively.Education of postureand body mechanics,especiallywhen related to workand daily activities,was provided.Gr4: Placebo(Sham laser

treatment):

Received shamlow-level laser(infrared) therapy.The laser was set uptolook as if it wasfunctioning,but was not. Thesubject was“treated” lying on his

450L.

Brosse

auetal.

or herside with propersupport to permitrelaxation.The instrument washeld on the area ofcomplaint by thetreatment provider,sothe subjectwas attended for theduration of thesession(20 min) to controlfor the effects ofinterpersonal contactand support. Thecontrol groupreceived 20 minof sham low-levellaser (infrared)therapy (SLL). Thelaser wasset up to look as ifit was functioningbut was not. Thesubject was“treated” lying on hisor herside with propersupport to permitrelaxation. Theinstrument was heldon the area ofcomplaint by thetreatment provider


Otta

waPanelevid

ence

-basedmassa

geandlow

back

pain

clinica

lpractice

guidelin

es

451



Populationdetails

Symptomduration

Age(Mean, SD)

Treatment Comparison group urrentapy


Follow upduration

Quality(R, B, W)

Quinnet al.,2008

RCTTotal: 15Gr1: 7Gr2: 8

Inclusion criteria:(1) Diagnosed with

non-specific LBP(2) Physiotherapy-medi-

cationor other treatmentfor LBP had beenstabilized forat least 3 months

(3) No involvement inother researchproject within thepast 3 months

(4) Not pregnant.

N/A Gr1:X Z 42SD Z 24Gr2:X Z 45SD Z 20

Gr1: Reflexologytreatment: involves asequence of pressuremassage whichallowed stimulationof the numerous specificreflex points on the feetassociated with organsthroughout the body.Included key pointsof the feetthat arerepresentativeof the vertebraeof the spine andthe surroundingmusculature.

Gr2: Sham: Simplefoot massagetreatment using thesamesequence as in thereflexologytreatment group.Used lesspressure (lower leveofstimulation to allreflex points)and include themajority of thereflex areas on thefeet. The pointswhich arerepresentativeof the vertebrae ofthe spineand surroundingmusculaturewere specificallyavoided.

Once perweekfor sixconsecutiveweeks

6 and 12weeksfollow-up

2, 1, 0

452L.

Brosse

auetal.

Concther

l

N/A


References

Borkan, J., Reis, S., Hermoni, D., Biderman, A., 1995. Talkingabout the pain: a patient-centered study of low back pain inprimary care. Social Science & Medicine 40 (7), 977e988.

Bouwmeester, W., Enst, A., Tulder, M., 2009. Quality of low backpain guidelines improved. Spine 34 (23), 2562e2567.

Chatchawan, U., Thinkhamrop, B., Kharmwan, S., Knowles, J.,Eungpinichpong, W., 2005. Effectiveness of traditional Thaimassage versus Swedish massage among patients with back painassociated with myofascial trigger points. Journal of Bodyworkand Movement Therapies 9 (4), 298e309.

Cherkin, D.C., Eisenberg, D., Sherman, K.J., Barlow, W.,Kaptchuk, T.J., Street, J., Deyo, R.A., 2001. Randomized trialcomparing traditional Chinese medical acupuncture, thera-peutic massage, and self-care education for chronic low backpain. Archives of Internal Medicine 161 (8), 1081e1088.

Cherkin, D.C., Sherman, K.J., Kahn, J., Wellman, R., Cook, A.J.,Johnson, E., et al., 2011. A comparison of the effects of 2 typesof massage and usual care on chronic low back pain:a randomized, controlled trial. Annals of Internal Medicine 155(1), 1e9.

Chou, R., Huffman, L.H., 2007. Nonpharmacologic therapies foracute and chronic low back pain: a review of the evidence foran American Pain Society/American College of Physicians clin-ical practice guideline. Annals of Internal Medicine 147 (7),492e504.

Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J.T., Shekelle, P.,Owens, D.K., 2007. Diagnosis and treatment of low back pain:a joint clinical practice guideline from the American College ofPhysicians and the American Pain Society. Annals of InternalMedicine 147 (7), 478e491.

Dagenais, S., Tricco, A., Haldeman, S., 2010. Synthesis of recom-mendations for the assessment and management of low backpain from recent clinical practice guidelines. The Spine Journal10, 514e529.

Dishman, J.D., Bulbulian, R., 2001. Comparison of effects of spinalmanipulation and massage on motoneuron excitability. Elec-tromyography and Clinical Neurophysiology 41 (2), 97e106.

Eisenberg, D.M., Post, D.E., Davis, R.B., Connelly, M.T.,Legedza, A.T., Hrbek, A.L., Prosser, L.A., Buring, J.E.,Inui, T.S., Cherkin, D.C., 2007. Addition of choice of comple-mentary therapies to usual care for acute low back pain:a randomized controlled trial. Spine 32 (2), 151e158.

Farasyn, A., Meeusen, R., Nijs, J., 2006. A pilot randomizedplacebo-controlled trial of roptrotherapy in patients withsubacute non-specific low back pain. Journal of Back andMusculoskeletal Rehabilitation 19, 111e117.

Farasyn, A., Meeusen, R., 2007. Effect of roptrotherapy onpressure-pain thresholds in patients with subacute nonspecificlow back pain. Journal of Musculoskeletal Pain 15 (1), 41e53.

Felson, D.T., Anderson, J.J., Boers, M., et al., 1995. Preliminarydefinition of improvement in rheumatoid arthritis (AmericanCollege of Rheumatology). Arthritis and Rheumatism 38,727e735.

Ferrell, B.A., Josephson, K.R., Pollan, A.M., Loy, S., Ferrell, B.R.,1997. A randomized trial of walking versus physical methods forchronic pain management. Aging (Milano) 9 (1e2), 99e105.

Field, T.M., 1998. Massage therapy effects. American Psychologist53 (12), 1270e1281.

Field, T., Hernandez-Reif, M., Diego, M., Fraser, M., 2007. Lowerback pain and sleep disturbance are reduced following massagetherapy. Journal of Bodywork and Movement Therapies 11,141e145.

Franke, A., Gebauer, S., Franke, K., Brockow, T., 2000. Acupunc-ture massage vs Swedish massage and individual exercise vsgroup exercise in low back pain sufferers e a randomized

controlled clinical trial in a 2 � 2 factorial design. ForschKomplementarmed Klass Naturheilkd 7 (6), 286e293.

Fraser, J., Kerr, J.R., 1993. Psychophysiological effects of backmassage on elderly institutionalized patients. Journal ofAdvanced Nursing 18 (2), 238e245.

Frymoyer, J.W., 1988. Back pain and sciatica. New England Journalof Medicine 318, 291e300.

Furlan, A., Imamura, M., Dryden, T., Irvin, E., 2009. Massage forlow back pain; an updated systematic review within theframework of the Cochrane back review group. Spine 34 (16),1669e1684.

Furlan, A.D., Imamura, M., Dryden, T., Irvin, E., 2008. Massage for lowback pain (Cochrane Review). The Cochrane Library Issue 4, 1e80.

Geisser, M.E., Wiggert, E.A., Haig, A.J., Colwell, M.O., 2005. Arandomized, controlled trial of manual therapy and specificadjuvant exercise for chronic low back pain. The ClinicalJournal of Pain 21 (6), 463e470.

Ginsberg, F., Famaey, J.P., 1987. A double-blind study of topicalmassage with Rado-Salil ointment in mechanical low-back pain.Journal of International Medical Research 15 (3), 148e153.

Godfrey, C.M., Morgan, P.P., Schatzker, J., 1984. A randomizedtrial of manipulation for low-back pain in a medical setting.Spine 9 (3), 301e304.

Graham, N., Gross, A., Goldsmith, C.H., Klaber Moffett, J.,Haines, T., Burnie, S.J., Peloso, P.M.J., 2008. Mechanical trac-tion for neck pain with or without radiculopathy (Cochranereview). Cochrane Database of Systematic Reviews 3, 1e41.

Hernandez-Reif, M., Field, T., Krasnegor, J., Theakston, H., 2001.Lower back pain is reduced and range of motion increased aftermassage therapy. International Journal of Neuroscience 106(3e4), 131e145.

Hettinga, D.M., Hurley, D.A., Jackson, A., May, S., Mercer, C.,Roberts, L., 2008. Assessing the effect of sample size, meth-odological quality and statistical rigour on outcomes of rando-mised controlled trials on mobilisation, manipulation andmassage for low back pain of at least 6 weeks duration. Phys-iotherapy 94, 97e104.

Hoehler, F.K., Tobis, J.S., Buerger, A.A., 1981. Spinal manipulationfor low back pain. Journal of the American Medical Association245 (18), 1835e1838.

Hoffman, M., Shepanski, M., Mackenzie, S., Clifford, P., 2005.Experimentally induced pain perception is acutely reduced byaerobic exercise in people with chronic low back pain. Journalof Rehabilitation Research and Development 42 (2), 183e190.

Hsieh, C.Y.J., Adams, A.H., Tobis, J., Hong, C.Z., Danielson, C.,Platt, K., Hoehler, F., Reinsch, S., Rubel, A., 2002. Effective-ness of four conservative treatments for subacute low backpain: a randomized clinical trial. Spine 27 (11), 1142e1148.

Hsieh, L.L., Kuo, C.H., Yen, M.F., Chen, T.H., 2004. A randomizedcontrolled clinical trial for low back pain treated by acupressureand physical therapy. Preventive Medicine 39 (1), 168e176.

Hsieh, L.L., Kuo, C.H., Lee, L.H., Yen, A.M., Chien, K.L.,Chen, T.H., 2006. Treatment of low back pain by acupressureand physical therapy: randomised controlled trial. BritishMedical Journal 332 (7543), 696e700.

Jadad, A.R., Moore, R.A., Carroll, D., et al., 1996. Assessing thequality of reports of randomized clinical trials: is blindingnecessary? Controlled Clinical Trials 17, 1e12.

Jonas, W.B., 2001. The evidence house: how to build an inclusivebase for complementary medicine. Western Journal of Medicine175, 79e80.

Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D.,Deyo, R.A., 2001. Lessons from a trial of acupuncture andmassage for low back pain. Spine 26 (13), 1418e1424.

Kankaanpaa, M., Taimela, S., Airaksinen, O., Hanninen, O., 1999.The efficacy of active rehabilitation in chronic low back pain.Effect on pain intensity, self-experienced disability, and lumbarfatigability. Spine 24 (10), 1034e1042.


Koes, B.W., Bouter, L.M., Van Mameren, H., Essers, A.H.M.,Verstegen, G.J., Hofhuizen, D.M., Houben, J.P., Knipschild, P.G.,1993. A randomized clinical trial of manual therapy and physio-therapy for persistent back and neck complaints: subgroupanalysis and relationship between outcome measures. Journal ofManipulative & Physiological Therapeutics 16 (4), 211e219.

Koes, B.W., Bouter, L.M., Van Mameren, H., Essers, A.H.M.,Verstegen, G.M.J.R., Hofhuizen, D.M., Houben, J.P.,Knipschild, P.G., 1992. Randomized clinical trial of manipula-tive therapy and physiotherapy for persistent back and neckcomplaints: results of one year follow-up. British MedicalJournal 304 (6827), 601e605.

Kolich, M., Taboun, S.M., Mohamed, A.I., 2000. Low back muscleactivity in an automobile seat with a lumbar massage system.International Journal of Occupational Safety and Ergonomics 6(1), 113e128.

Konrad, K., Tatrai, T., Hunka, A., Vereckei, E., Korondi, I., 1992.Controlled trial of balneotherapy in treatment of low back pain.Annals of the Rheumatic Diseases 51, 820e822.

Lauridsen, H.H., Hartvigsen, J., Manniiche, C., Korsholm, L.,Grunnet-Nilsson, N., 2006. Responsiveness and minimal clini-cally important difference for pain and disability instruments inlow back pain patients. BMC Musculoskeletal Disorders 7, 82.doi:10.1186/1471-2474-7-82.

Lidstrom, A., Zachrisson, M., 1970. Physical therapy on low backpain and sciatica: an attempt at evaluation. ScandinavianJournal of Rehabilitation Medicine 2 (1), 37e42.

Little, P., Lewith, G., Webley, F., Evans, M., Beattie, A.,Middleton, K., Barnett, J., Ballard, K., Oxford, F., Smith, P.,Yardley, L., Hollinghurst, S., Sharp, D., 2008. Randomisedcontrolled trial of Alexander technique lessons, exercise, andmassage (ATEAM) for chronic and recurrent back pain. BritishJournal of Sport Medicine 42 (12), 965e968.

Louw, Q., Morris, L., Sklaar, J., 2007. Evidence of physiother-apeutic interventions for acute LBP patients. South AfricanJournal of Physiotherapy 63, 7e14.

Luijsterburg, P.A.J., Verhagen, A.P., Ostelo, R.W.J.G., vanOs, T.A.G., Peul, W.C., Koes, B.W., 2007. Effectiveness ofconservative treatments for the lumbosacral radicular syndrome:a systematic review. European Spine Journal 16, 881e899.

Mackawan, S., Eungpinichpong, W., Pantumethakul, R.,Chatchawan, U., Hunsawong, T., Arayawichanon, P., 2007.Effects of traditional Thai massage versus joint mobilization onsubstance P and pain perception in patients with non-specificlow back pain. Journal of Bodywork and Movement Therapies11, 9e16.

Mandala, G., Bordonato, R., DiGangi, A., Marino, V., Negrini, S.,2001. Effectiveness of back school or shiatsu massage reflextherapy in chronic low back pain: a prospective, randomizedcontrolled blind trial. In: First World Congress of InternationalSociety of Physical and Rehabilitation Medicine, vol. 76.

Manniche, C., Hesselsoe, G., Bentzen, L., Christensen, I.,Lundberg, E., 1988. Clinical trial of intensive muscle training forchronic low back pain. The Lancet 2 (8626e8627), 1473e1476.

Manniche, C., Lundberg, E., Christensen, I., Bentzen, L.,Hesselsoe, G., 1991. Intensive dynamic back exercises forchronic low back pain: a clinical trial. Pain 47 (1), 53e63.

Manniche, C., Lundberg, E., Christensen, I., Hesselsoe, G.,Bentzen, L., 1989. Intensive dynamic back exercises forpatients with chronic low back pain: a controlled study. Uge-skrift for Laeger 151 (32), 2030e2034.

Massage Therapy Act, 1991. Retrieved September 26, 2011, from:http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91m27_e.htm.

Melancon, B., Miller, L.H., 2005. Massage therapy versus traditionaltherapy for low back pain relief: implications for holistic nursingpractice. Holistic Nursing Practice 19 (3), 116e121.

Melzack, R., Jeans, M.E., Stratford, J.G., Monks, R.C., 1980. Icemassage and transcutaneous electrical stimulation: comparisonof treatment for low-back pain. Pain 9 (2), 209e217.

Melzack, R., Wall, P.D., 1965. Pain mechanisms: a new theory.Science 150, 971e979.

Middelkoop, M., Rubinstein, S.M., Kuijpers, T., Verhagen, A.P.,Ostelo, R., Koes, B.W., Tulder, M.W., 2011. A systematic reviewon the effectiveness of physical and rehabilitation interventionsfor chronic non-specific low back pain. European Spine Journal20, 19e39.

Moyer, C.A., Rounds, J., Hannum, J.W., 2004. A meta-analysis ofmassage therapy research. Psychological Bulletin 130 (1), 3e18.

Pillastrini, P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A.,Mugnai, R., Violante, F., 2011. An updated overview of clinicalguidelines for chronic low back pain management in primarycare. Joint Bone Spine, 1e10.

Poole, H., Glenn, S., Murphy, P., 2007. A randomised controlledstudy of reflexology for the management of chronic low backpain. European Journal of Pain 11, 878e887.

Pope, M.H., Philips, R.B., Haugh, L.D., Hsieh, C.Y.J.,MacDonald, L., Haldeman, S., 1994. A prospective randomizedthree-week trial of spinal manipulation, transcutaneous musclestimulation, massage and corset in the treatment of subacutelow back pain. Spine 19 (22), 2571e2577.

Preyde, M., 2000. Effectiveness of massage therapy for subacutelow-back pain: a randomized controlled trial. Canadian MedicalAssociation Journal 162 (13), 1815e1820.

Quinn, F., Hughes, C.M., Baxter, G.D., 2008. Reflexology in themanagement of low back pain: a pilot randomised controlledtrial. Complementary Therapies in Medicine 16, 3e8.

Rapaport, M.H., Schettler, P., Bresee, C., 2010. A preliminary studyof the effects of a single session of Swedish massage onhypothalamic-pituitary-adrenal and immune function in normalindividuals. Journal of Alternative and Complementary Medi-cine. doi:10.1089/acm.2009.0634.

Skillgate, E., Vingard, E., Alfredsson, L., 2007. Naprapathic manualtherapy or evidence-based care for back and neck pain: a random-ized, controlled trial. The Clinical Journal of Pain 23 (5), 431e439.

The Ottawa Panel (Brosseau, L., Wells, G., Tugwell, P., Egan, M.,Dubouloz, C.J., Casimiro, L., Robinson, V., Pelland, L., McGo-wan, K., Lamb, B.), 2005. Ottawa Panel evidence-based clinicalpractice guidelines for therapeutic exercises and manualtherapy in the treatment of osteoarthritis. Journal of AmericanPhysical Therapy Association 85, 907e971.

The Ottawa Panel (Brosseau L, Wells GA, Finestone HM, Graham I,Egan M, Dubouloz CJ, Bilodeau M, Robinson V, Casimiro L,McGowan J), 2006. Ottawa Panel evidence-based clinicalpractice guidelines for post-stroke physical rehabilitationintervention. Topics in Stroke Rehabilitation 13, 1e202.

The Ottawa Panel (Brosseau, L., (PI), Wells, G., Tugwell, P., Egan,M., Dubouloz, C.J., Casimiro, L., Robinson, V., Wilson, K.,McGowan, J.), 2008. Ottawa Panel evidence-based clinicalpractice guidelines for strengthening exercises in the treatmentof fibromyalgia. Part 1. Journal of American Physical TherapyAssociation 88, 857e871.

The Ottawa Panel (Brosseau, L., (PI), Wells, G.A., Tugwell, P., Egan,M., Dubouloz, C.J., Casimiro, L., Welch, V., McEwan, J., et al.),2011. Ottawa Panel evidence-based clinical practice guidelinesfor weightmanagement in obese and overweight individuals withosteoarthritis. American Journal of Physical Therapy 91, 1e19.

The Philadelphia Panel (Ottawa Methods Group: Wells, G., Tugwell,P., Brosseau, L. (Co-PI), et al.), 2001. Philadelphia Panelevidence-based clinical practice guidelines on selected reha-bilitation interventions: over and methodology. Journal of theAmerican Physical Therapy Association 81, 1629e1640.

Walach, H., Guthlin, C., Konig, M., 2003. Efficacy of massagetherapy in chronic pain: a pragmatic randomized trial. The

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91m27_e.htm

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91m27_e.htm


Journal of Alternative and Complementary Medicine 9 (6),837e846.

Wampold, B.E., 2001. Contextualizing psychotherapy as a healingpractice: culture, history, and methods. Applied & PreventivePsychology 10, 69e86.

Werners, R., Pynsent, P.B., Bulstrode, C.J., 1999. Randomized trialcomparing interferential therapy with motorized lumbar trac-tion and massage in the management of low back pain ina primary care setting. Spine 24 (15), 1579e1584.

Wilk, V., 2004. Acute low back pain: assessment and management.Australian Family Physician 33 (6), 403e407.

Wilkinson, T.L., 1997. The effect of therapeutic touch on theexperience of acute pain in postoperative laminectomypatients. Dissertation, Bellarmine College, Louisville, KY.

Yip, Y.B., Tse, S.H.M., 2004. The effectiveness of relaxation acupointstimulation and acupressure with aromatic lavender essential oilfor non-specific low back pain in Hong Kong: a randomisedcontrolled trial. Complementary Therapies in Medicine 12, 28e37.

Zaproudina, N., Hietikko, T., Hanninen, O.O.P., Airaksinen, O.,2009. Effectiveness of traditional bone setting in treatingchronic low back pain: a randomised pilot trial. ComplementaryTherapies in Medicine 17 (1), 23e28.

College of Massage Therapists of Ontario - Ottawa Panel evidence-based clinical ... ·...

Documents

Transcript of College of Massage Therapists of Ontario - Ottawa Panel evidence-based clinical ... ·...