Massage Therapy in an Ambulatory Pain Clinic
Chronic low back pain is one of the most common types of pain experienced by patients. It is defined as pain in the lower back that does not resolve within 3 to 6 months. The most common causes of low back pain are osteoarthritis, muscular pain, herniated disc, fractures, spinal stenosis, scoliosis, and compression fractures.1 Chronic low back pain that results from these conditions interferes with essential activities of daily living such as sleeping, socializing, and doing household chores; furthermore, chronic pain impedes an individual’s ability to exercise.
Opioids, despite potential complications and side effects, are widely used as effective analgesics in the treatment of moderate-to-severe chronic low back pain.2,3 With regard to mild, chronic low back pain, Astin stated that alternative therapies have been proven a safe and effective alternative for pain control and can potentially decrease reliance on opioid prescriptions.4 Massage therapy is an ancient therapy used to mobilize soft tissue. Tissue mobilization is thought to elicit a number of beneficial physiological effects, which might modulate pain. Massage can also relax the body, aid in tissue repair, improve blood flow in superficial vessels, and elevate mood.5 It is believed that pain reduction might occur through activation of segmental inhibitory pain pathways and by the production of endorphins.5 Recently, the use of massage technique for chronic low back pain sufferers has shown promising results in the treatment of chronic low back pain, especially when combined with exercise and education.5
Massage therapy has proven to be a valuable adjunct in pain management, leading to significant benefits with reports of decreasing pain levels. These interventions can also lead to decreased anxiety as an added benefit.1 The main objective of alternative therapies is to reduce chronic low back pain levels, which in turn may help decrease opioid utilization.
Study of Massage Therapy
A review of the literature reveals that the subject of alternative therapy for patients with chronic pain has been receiving more attention from providers; these modalities focus on pain management, primarily as a tool to reduce pain levels, opioid abuse, and addiction.6 The phrases “alternative medicine” and “alternative therapies” lack clear definitions. There are no widely accepted phrases for practices grouped under the terms of alternative, unconventional, unorthodox, or complementary therapies.6 However, any treatment or therapy such as massage therapy that does not fall under the umbrella of conventional medicine would be termed an alternative therapy.6 Furthermore, the number of patients with chronic pain who use alternative therapies is increasing, largely due to the increase in doubts, skepticism, and dissatisfaction with conventional medicine.7
The authors conducted a comparative trial to study the effect of massage therapy on pain. The setting for this study was a pain management clinic in Western New York. The clinic is located in a suburban setting and is directed by one nurse practitioner and ancillary staff. As recommended by the New York State Department of Health for pain providers, the clinic does not take self-referrals; all patients are referred to the clinic by their primary care physicians.
Sixty chronic low back pain patients were included in the study and were randomized into two groups: a treatment group (30 patients) and control group (30 patients). All participants in the study continued to receive their usual care, which included monthly clinic visits focusing on pain and medication management (ie, opioids, non-steroidal anti-inflammatory drugs, muscle relaxants), trigger point injections (muscular injections) as indicated, and nutritional counseling. The treatment group also received the addition of massage therapy.
Pain levels before and after the massage therapy were recorded using a 0-10 numeric pain rating scale. Demographic data was obtained from all participants, and each participant signed an informed consent document. In addition, functional status and disability ratings were obtained from participants before and after treatment. The Oswestry Disability Index, an assessment tool often used to measure a patient’s permanent functional disability, was used in this study.
One licensed massage therapist, employed by the clinic, provided the therapy sessions. Massage interventions consisted of 15-minute therapeutic massage sessions given twice per week for 4 weeks. Treatments included gentle massage in the lower lumbar spine. Levels of pain and disability were assessed before treatment sessions began, and at the completion of the 4-week massage treatment session.
Table 1 illustrates the participants’ demographic characteristics and pain medications. A variety of opioids were used for pain control. Of the control group, 46.7% was taking hydrocodone (Lortab), while 20.0% were using morphine-based products to treat their pain. Of the treatment group, 58.1% of the participants were prescribed hydrocodone or its derivatives, while 19.4% were prescribed oxycodone (Percocet) or its derivative to treat their chronic low back pain. Table 2 illustrates the overall use of alternative therapies. Eighty percent of the control group had considered using alternative therapies in the past to help their chronic low back pain, compared with 74.2% of the treatment group. Interestingly, 83.3% of the control group and 87.1% of the treatment group had at least one health care professional recommend alternative therapies for treatment of chronic low back pain.
Table 3 shows pre- and post-treatment pain scores. There was a significant difference between the pre- and post-treatment pain rating in the treatment group (6.73 vs 5.33—a decrease of 1.4). The control group’s pre-treatment and post-treatment scores remained unchanged. In addition, the control group reported a mean pre-treatment disability rating of 17.67 (moderate disability), which remained unchanged at the end of the study. By comparison, there was a decrease in disability scores for the treatment group (15.40 to 14.45).
As stated earlier, the majority of the participants had at least one health care provider recommend alternative therapies for the treatment of their chronic pain. In addition, >50% of both the treatment and control group had considered using alternative therapies for their treatment of chronic pain. It is unclear as to why there was no follow through with the participants in the utilization of alternative therapy.