The authors are Jacqueline Tibbett, PhD, LMT and Jolie Haun, PhD, EdS, LMT.

Low Back, Massage, and Guidelines for Practice

Massage therapists are central to delivering massage as an integrative health care team member. The Massage Therapy Foundation and other massage organizations have supported and published research concluding that massage is effective for treating symptoms of many conditions, pain being a key symptom of interest.

This review presents national clinical guidelines on massage therapy in pain management, focusing on low back pain. We’ll highlight recent recommendations from major national organizations, such as The American College of Physicians (ACP), and The Centers for Disease Control (CDC), so massage therapists and clients can benefit from this information.

As massage therapists, we see many clients with low back pain. Back pain was the most common reason people sought complementary medicine, according to the National Health Interview 2012 Survey. To improve quality of care for patients with musculoskeletal pain, the medical community is prioritizing non-pharmacological treatments—including exercise, education, acupuncture, and massage therapy—as part of a multidisciplinary patient-centered approach.

National Guidelines Related to Massage and Low Back Pain and How They Were Determined

The American College of Physicians (ACP), the second-largest physician group in the United States, released clinical guidelines in 2017 recommending non-invasive, non-pharmacological treatments for low back pain (Qaseem et al 2017). To formulate these guidelines, the ACP and other national health care agencies sponsored extensive systematic reviews on both pharmacological (anti-inflammatories, opioids, etc.) and non-pharmacological therapies for low back pain. A systematic review is a rigorous and structured way of compiling and evaluating research evidence. Massage, other types of manual therapy, acupuncture, exercise, and ultrasound were among the non-pharmacological therapies evaluated in the reviews. An important definition used in the ACP guidelines was that “Acute back pain is defined as lasting less than four weeks, subacute back pain lasts four to 12 weeks, and chronic back pain lasts more than 12 weeks.” The final recommendation for massage was stated as: “Massage is strongly recommended as one of several non-pharmacological treatments for acute or subacute low back pain.” Pause for a moment and take this in: One of the largest physician organizations in the U.S. recommends massage for a prevalent and expensive pain condition. This indicates that massage therapy has gained credibility through the research efforts over the last decades. However, note that the ACP did NOT recommend massage for chronic low back pain due to lack of research evidence. Additionally, The Centers for Disease Control mentioned massage therapy in its March 2016 recommendations for chronic back pain (Dowell et al 2016).

The report noted: “Although there are perceptions that opioid therapy for chronic pain is less expensive than more time-intensive non-pharmacologic management approaches, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy.” In addition to these guidelines relevant to back pain, major national organizations such as the Federation of State Medical Boards, The Joint Commission, and the Department of Health and Human Services recommend multidisciplinary approaches that include massage for treating chronic pain in general. For example, the Veterans Health Association has been implementing non-pharmacological approaches to chronic musculoskeletal pain management including massage in a new health care delivery model called “Whole Health.”

Why is Massage Only Sometimes Endorsed by Major Health Organization for Pain Management?

Even though guidelines are now advocating for non-invasive, non-pharmacological approaches to pain management, massage isn’t strongly recommended by all major health organizations. The main reason massage is not recommended for chronic low back pain by the ACP guidelines (as noted previously in this article) was lack of high-quality research evidence. Clinical guidelines are based primarily on published research evidence. Grading systems exist for quality of research evidence—for example, a study without a control group will not meet criteria for high-quality research, even if massage had a positive impact on the participants.

The nature of bodywork work presents a challenge to meeting high-quality research standards. For example, it is difficult to conduct double-blinded studies in which both participants and therapists don’t know whether the participant is receiving massage or a control treatment. Another barrier to consistency in research is that “massage” is defined differently between research studies and between systematic reviews. However, research quality is improving and continues to advance to meet research review guidelines. Using massage research guidelines is crucial to improving quality of research and gaining acceptance in health care and health insurance coverage. Checklists and guidelines for conducting massage therapy research are outlined in Crawford et al 2016. Future massage research needs rigor, larger sample sizes, and effective use of established research guidelines.

Why is Information About Massage Therapy Guidelines Important for Massage Therapists?

Clinical guidelines will only have impact if they are implemented effectively. Massage therapists play a central role in clinical guideline implementation. When we know and share the recommendations for use of massage, this can give our profession and our clients power. Massage therapists can be advocates for clients and informants for allied health professionals.

What We Can Do:

1.  Get informed about massage therapy research guidelines and the research that drives recommendations.

2.  Share statistics and infographics with clients and on social media pages. E- books and infographics can be found at massagetherapyfoundation.org/ resources/

3.  Share this article or the source articles with physicians and allied health professionals.

4.  Get involved with research-start with a case study or by contacting authors who have conducted randomized controlled trials of massage.

5.  Apply for LMT positions in medical facilities.

6.  Get involved with AMTA efforts for massage coverage by insurance.

7.  Volunteer with the MTF and promote the field of massage.

References

Crawford, C., Boyd, C., Paat, C. F., Price, A., Xenakis, L., Yang, E., … Evidence for Massage Therapy (EMT) Working Group (2016). The Impact of Massage Therapy on Function in Pain Popula- tions-A Systematic Review and Meta- Analysis of Randomized Controlled Tri- als: Part I, Patients Experiencing Pain in the General Population. Pain Medicine (Malden, Mass.), 17(7), 1353. doi.org/10.1093/pm/pnw099 Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescrib- ing Opioids for Chronic Pain — United States, 2016. MMWR. Recommenda- tions and Reports, 65(1), 1–49. doi.org/10.15585/mmwr.rr6501e1er