In the United States, 80 percent of adults will experience back pain at some point in their lives. Most back pain episodes occur between the ages of 25 and 45, and interfere with home, work, and personal life. The cost to employers for back pain in workers aged 40–65 is estimated to be $7.4 billion per year.1 Even with such a heavy social and financial burden, we still do not understand the etiology of back pain and, therefore, diagnose most back pain cases as “nonspecific low-back pain.” Without knowing the reason for the pain, health-care providers struggle to determine the best form of care.

Swedish Massage vs. Physical Therapy
In a recent comparative effectiveness study, Fahimeh Kamali and a team of researchers at Shiraz University of Medical Sciences compared two of the most common treatments for back pain: Swedish massage therapy and routine physical therapy.2 Women with subacute or chronic nonspecific low-back pain who were referred to a physical therapy center were assessed for eligibility. Subjects were excluded if they had acute disc herniation, fracture, malignancy, pain due to surgery, pain lasting for more than one year, pain medication use for more than one month, pregnancy, radicular pain, spondylolysis, spondylolisthesis, or trauma.
Thirty women agreed to participate in the study and signed an informed consent document. Of these, 15 subjects were randomized to a Swedish massage group where they received 15 minutes of low-back massage including “deep stroking, pulling, friction, rolling, and wringing.” After the massage, the hamstring and paravertebral muscles were stretched and stabilizing exercises were prescribed. The remaining 15 subjects were randomized to routine physical therapy where they received several electrical modalities, including ultrasound for three minutes, TENS for 20 minutes, and vibration for three minutes. The subjects then did the same stabilizing exercises as the massage group. Subjects in both groups received 10 treatment sessions.
Three measures were used to determine the outcome of the study protocols. Pain was assessed using the Numerical Rating Scale (NRS), functional disability was measured by the Oswestry Disability Index, and trunk flexion was measured by the modified Schober range of motion (ROM) test.
Both massage therapy and physical therapy groups demonstrated improvements in all three outcome measures after the 10 visits. However, when the groups were compared with one another, the massage therapy group demonstrated a significantly greater decrease in pain and increase in function, with no difference in trunk flexion. To demonstrate the change in pain, average NRS measures (out of 10) dropped from 6.0 to 1.8 in the massage group, and from 7.3 to 4.1 in the physical therapy group. Overall, both low-back pain groups improved, but the massage group had significantly less pain and dysfunction compared to the physical therapy group.
There were several limitations of this study, including the small sample size (n=30) and the lack of male subjects. Also, there was no long-term follow-up to determine continued improvement beyond the last treatment session. Following the subjects for a longer time period may have given a better view of how long the treatment benefits lasted. Finally, this study was performed in Iran, so the participants might have other factors associated with low-back pain and disability when compared to back pain patients in the United States, leading to possible questions about generalizability of results.

Chinese Massage vs. Chinese Massage Plus Core Stability
Recently, another comparative effectiveness trial was published that compared Chinese massage with a group who received Chinese massage plus performed core stability exercises for nonspecific chronic low-back pain.3 The types of outcome measures were similar to the Kamali study, with pain assessed via the Visual Analog Scale and disability via the Oswestry Disability Index.
In this study, subjects were recruited from a hospital of traditional Chinese medicine and were included if they were less than 55 years old; had nonspecific chronic low-back pain without any relevant ongoing pathologies such as disc prolapse, fractures, infection, osteoporosis, spondylolisthesis, or tumor; and were willing to participate in this study and sign an informed consent. The exclusion criteria for this study included other pain syndromes; spinal surgery in the past six months or having to undergo surgery or invasive examinations during the study; neurological disease; psychiatric disease; serious chronic disease that could interfere with the outcomes (e.g., cardiovascular disease, epilepsy, rheumatoid arthritis, or other disqualifying conditions); or pregnancy or planning to become pregnant during the study.  
Of the 92 subjects enrolled in the study, 46 were randomized to the Chinese massage group, which included “rolling, rubbing, pushing, oblique-pulling, stroking, and tapotement” on the low back for 40 minutes, once daily, for eight weeks by professional therapists. The 46 subjects randomized to the Chinese massage plus exercise group received the same treatment in addition to core stability exercises including “plank, side plank, bridge, straight leg raise, and modified push-up,” performed 10 times for one arm or leg, once daily for eight weeks.
The results demonstrated that after two weeks of care, both groups significantly improved in terms of pain and disability, with no differences between the groups. After eight weeks of treatment, both groups continued to demonstrate significantly improved pain and disability scores. However, pain and disability scores were significantly lower in the Chinese massage plus core stability exercise group than in the Chinese massage alone group, showing average reductions in pain (out of 10) from 7.5 to 1.5 in the massage plus exercise group, and from 7.6 to 2.9 in the massage alone group.
Follow-up occurred in this study for one year posttreatment. A pain-free period for at least 30 days after treatment was confirmed by all of the participants who were screened. Furthermore, 19 subjects (43.2 percent) in the massage-only group experienced a recurrence of back pain, whereas only five subjects (11.6 percent) in the massage plus exercise group experienced such a recurrence.
This study had fewer limitations than the previous trial in that both males and females were recruited and there was a higher sample size (n=92). However, this study was performed in China, again leading to possible questions about generalizability of results to American clients.

Conclusion
1. Short-term outcomes indicate that subacute or chronic nonspecific back pain and disability are significantly improved with Swedish or Chinese massage therapy.
2. When compared to routine physical therapy, Swedish massage was significantly more beneficial in reducing pain and disability for nonspecific low-back pain in women.
3. Core stabilizing exercises, in addition to massage, provide further benefit, with the massage-only group being 6.5 times more likely to experience a long-term back-pain recurrence than the massage plus core-stabilizing exercise group.
4. Comparative effectiveness trials are a good way to compare one beneficial treatment to another in order to determine which form of care is significantly better. However, all clients are different. You and your client’s health-care team will need to determine the best form of care for your client’s specific condition.  

Notes
1. J. A. Ricci et al., “Back Pain Exacerbations and Lost Productive Time Costs in United States Workers,” Spine 31, no. 26 (December 15, 2006): 3,052–60.
2. Fahimeh Kamali et al., “Comparison Between Massage and Routine Physical Therapy in Women with Subacute and Chronic Nonspecific Low Back Pain,” Journal of Back and Musculoskeletal Rehabilitation 27, no. 4 (2014): 475–80.
3. Yingjie Zhang et al., “Chinese Massage Combined With Core Stability Exercises for Nonspecific Low Back Pain: A Randomized Controlled Trial,” Complementary Therapies in Medicine 23, no. 1 (February 2015): 1–6.

Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at jcambron@nuhs.edu.