Lower back pain and sleep disturbance are reduced following massage therapy

Journal of Bodywork and Movement Therapies (2007) 11, 141–145

                                                                                                Journal of
                                                                                                Bodywork and
                                                                                                Movement Therapies


Lower back pain and sleep disturbance are reduced
following massage therapy
Tiffany Fielda,b,, Maria Hernandez-Reifa, Miguel Diegoa, Monica Fraserc

  Touch Research Institutes, University of Miami School of Medicine, P.O. Box 016820 (D-820),
Miami, FL 33101, USA
  Fielding Graduate University, USA
  Biotone, USA

Received 26 January 2006; received in revised form 13 March 2006; accepted 13 March 2006

    KEYWORDS                          Summary A randomized between-groups design was used to evaluate massage
    Massage;                          therapy versus relaxation therapy effects on chronic low back pain. Treatment
    Relaxation therapy;               effects were evaluated for reducing pain, depression, anxiety and sleep distur-
    Back pain;                        bances, for improving trunk range of motion (ROM) and for reducing job absenteeism
    Sleep disturbance;                and increasing job productivity. Thirty adults (M age ¼ 41 years) with low back pain
    Anxiety                           with a duration of at least 6 months participated in the study. The groups did not
                                      differ on age, socioeconomic status, ethnicity or gender. Sessions were 30 min long
                                      twice a week for 5 weeks. On the first and last day of the 5-week study participants
                                      completed questionnaires and were assessed for ROM. By the end of the study, the
                                      massage therapy group, as compared to the relaxation group, reported experiencing
                                      less pain, depression, anxiety and sleep disturbance. They also showed improved
                                      trunk and pain flexion performance.
                                      & 2006 Elsevier Ltd. All rights reserved.

Introduction                                                         Psychological variables thought to influence the
                                                                     pain experience include depression, anxiety, sleep-
Back pain is the second leading chronic pain                         lessness, distress and cognitive functioning.
condition for physician visits, and the morbidity                      Relaxation therapy has been used for lower back
associated with back pain is the most frequent                       pain (Linton et al., 1985; Nicholas et al., 1992).
cause of work absenteeism (Kaaria et al., 2005).                     Massage therapy may effectively treat lower back
                                                                     pain as it has been shown to reduce pain in other
  Corresponding author. Touch Research Institutes, University       painful syndromes. For example, massage therapy
of Miami School of Medicine, P.O. Box 016820 (D-820), Miami, FL
                                                                     has been shown to decrease pain associated
33101, USA. Tel.: +1 305 975 5029; fax: +1 305 243 6488.             with juvenile rheumatoid arthritis (Field et al.,
   E-mail address: tfield@med.miami.edu (T. Field).                   1997a), fibromyalgia (Sunshine et al., 1996),

1360-8592/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
142                                                                                            T. Field et al.

chronic fatigue syndrome (Field et al., 1997b) and       massage therapists, who used Biotone Spa Replen-
migraine headaches (Hernandez-Reif et al., 1998).        ishing Light Body Oil (Biotone, San Diego, CA, USA)
Moreover, massage therapy has also been shown to         each session starting with the participant in the
reduce anxiety and depression (Field et al., 1992).      prone position, resting the ankles on a small
   In a recent study comparing massage therapy and       cushion. The massage consisted of the following
relaxation therapy effects on lower back pain, trunk     techniques applied to the entire back: (1) moving
and pain flexion performance were improved by             the flats of the hands across the back; (2) kneading
massage therapy and self-reported pain depression,       and pressing the muscles; and (3) short back and
anxiety and sleep disturbance were decreased             forth rubbing movements on the muscles next to
(Hernandez-Reif et al., 2001). In addition, dopamine     the spine and the muscles that attach to the hip
and serotonin levels increased following a 5-week        bone. The following techniques were administered
period of two 30-min massages per week. The lesser       to the legs: (1) long gliding strokes toward the
sleep disturbance that accompanied massage therapy       torso, to the entire leg; (2) kneading and moving
could relate to the lesser pain, as sleep disturbances   the skin in the thigh area; (3) pressing and
are noted to increase pain and pain-associated sub-      releasing, and back and forth rubbing movements
stances such as substance P (Field et al., 2004). The    on the area between the hip and the knee on the
present replication study examined massage therapy       back of the thigh; and (4) short rubbing movements
and relaxation therapy effects for reducing chronic      to the small muscles around the knees. In the
low back pain, depression, anxiety, and sleep disturb-   supine position with a bolster under the knee, the
ance, for improving range of motion (ROM) and finally     participants received: (1) long gliding strokes and
for reducing job absenteeism and increase producti-      kneading of the neck muscles; (2) moving the flats
vity, which were not assessed in the previous study.     of the hands across the abdomen; (3) pinching and
                                                         moving the skin on the abdomen in all directions;
                                                         and (4) kneading with mixed wringing the muscles
                                                         that bend the trunk forward (rectus and oblique
Method                                                   muscles). Then, to the entire leg: (1) stroking; (2)
                                                         kneading followed by pressing and releasing the
Participants                                             anterior thigh region; (3) flexing of the thigh and
                                                         knee; and (4) pulling of both legs at the same time
The sample included 30 adults (14 women) with low
                                                         using direct longitudinal traction.
back pain of a duration of at least 6-months. Power
analyzes based on our previous low back pain study
(Hernandez-Reif et al., 2001), suggested that 30
participants would be sufficient to provide for 70%       Relaxation therapy
power to detect the effects massage therapy on
anxiety, mood, pain, ROM and sleep disturbance. The      A relaxation therapy group, which was included to
participants were cleared by their primary physician     control for potential placebo and increased atten-
to participate in the study. Exclusion criteria were     tion effects, was shown how to use progressive
back pain due to fractured vertebrae, herniated or       muscle relaxation exercises including tensing and
degenerated disks, patients who had undergone            relaxing large muscle groups starting with the feet
surgery for their back pain, (i.e. laminectomies or      and progressing to the calves, thighs, hands, arms,
fusions) and patients with sciatic nerve involvement     back and face. The participants were asked to
or legal action pending, such as workmen’s compen-       conduct these 30-min sessions at home twice a
sation. The participants averaged 41 years of age and    week for 5 weeks and to keep a log on the times
were middle class (M ¼ 2:5 on the Hollingshead           they spent in relaxation therapy. They were also
Index), were 67% Caucasian, 9% Hispanic, 16% African     called weekly to monitor their compliance.
American and 8% Asian. The groups did not differ on
age, socioeconomic status, ethnicity or gender.
Participants were randomly assigned to a massage
therapy or relaxation therapy group.                     Pre–post session assessments (immediate
                                                         The following assessments were made before and
Massage therapy                                          after the sessions on the first and last days of the
The massage group received two 30-min massage            5-week study. These measures were used to assess
therapy sessions per week over 5 weeks by trained        stress, pain and ROM.
Low back pain reduced by massage therapy                                                                  143

Profile of Mood States Depression Scale (POMS-D,        assessed for reliability prior to the start of the
McNair et al., 1971)                                   study.
The POMS consists of 19 adjectives rating depressed
mood using the words such as ‘‘blue’’, ‘‘sad’’, and    First–last day sessions (longer term effects)
‘‘lively’’ on a 5-point scale ranging from ‘‘not at
all’’ to ‘‘extremely’’. The scale has adequate         On the first and last day of the 5-week study, the
concurrent validity and good internal consistency      following assessments were conducted.
(r ¼ :95; McNair et al., 1971) quate measure of
intervention effects (Pugatch, Haskell & McNair,       Sleep Scale (Verran and Snyder-Halperin, 1988)
                                                       This visual analog scale is anchored at one end
                                                       with ineffective sleep responses (e.g., ‘‘Did not
State Anxiety Inventory (STAI; Spielberger et al.,     awaken’’, ‘‘Had no trouble sleeping’’) and at the
1970)                                                  opposite end with ineffective responses (e.g., ‘‘Was
The STAI includes 20 anxiety statements assessing      awake 10 h’’, ‘‘Had a lot of trouble falling asleep’’).
how the participant feels at that moment in terms      The participants were asked to place a mark across
of severity (not at all to very much so). Character-   the answer line at the point that best reflected
istic items include ‘‘I feel nervous’’ and ‘‘I feel    their last night’s sleep. The scale yields subcate-
calm.’’ The STAI scores increase in response to        gories of sleep disturbance score. A reliability
stress and decrease under relaxing conditions          coefficient of .82 has been reported for this scale
(Spielberger et al., 1970). The STAI has adequate      (Snyder-Halpern and Verran, 1987).
concurrent validity and internal consistency
(r ¼ :83, Spielberger, 1972).                          Job productivity and absenteeism

                                                       Participants were asked how many days they missed
VITAS (VITAS Healthcare Corporation, 1993)             at work and to rate their level of job productivity
Present pain was assessed by a Visual analog Scale     on a scale of 0 (not at all productive) to 5 (very
ranging from 0 (‘‘happy face’’) to 10 (‘‘frowning/     productive) for the first and last week of the study.
sad face’’), which represented no pain to worst
possible pain.

ROM measures
                                                       Repeated measures ANOVAs were conducted to
While standing straight with feet placed shoulder      determine the effects of massage therapy versus
width apart in a normal position, the length of the    relaxation therapy on lower back pain. The
spine was measured using a tape measure. One           repeated measures were pre and post therapy
magic marker mark was made on the skin at the          sessions and first and last days of the study.
most prominent bone at the base of the neck            Significant interaction effects were followed by
(cervical vertebra bone 7) and a second mark was       Bonferroni t-tests.
made on the skin at the round bony prominence of          Group by pre–post session and group by pre–post
the backbone (lumbar vertebra 1). The distance         session by day interaction effects were revealed for
between these two marks was recorded in cen-           the massage group benefits for mood and for pain.
timeters. A trunk flexion ROM measure (touch toes       Post Bonferroni t-tests indicated the following
without pain) was then recorded, again from the        (see Table 1): (1) mood as assessed by the POMS
base of the neck (cervical vertebra bone 7) to the     improved following the first session (t ¼ 2:92,
round bony prominence of the backbone (lumbar          Po.009; Z2 ¼ :31) and by the end of the study
vertebra 1), asking the person to reach forward to     (t ¼ 2:02, Po.05; Z2 ¼ :18) and (2) pain as reported
touch the toes. The trunk flexion measure minus         on the VITAS decreased following each session
the standing up baseline measure served as the         (t ¼ 4:98, po.001; Z2 ¼ :55 for the first session
trunk flexion ROM. A pain flexion ROM measure            and t ¼ 6:01, Po.001; Z2 ¼ :64 for the second
(touch toes to the point of pain) was then obtained,   session) and by the end of the study (t ¼ 2:29,
as above, but the person was asked to reach toward     Po.03; Z2 ¼ :22).
the toes or flex the trunk as far as possible, even        Group by pre/post session interaction effects
with pain. This measure was also subtracted from       (see Table 1) and Post Bonferroni t-tests revealed
the baseline standing up measure. All physical         the following: (1) state anxiety decreased for the
measurements were collected by MHR who was             massage group on both days (t ¼ 4:52, Po.001;
144                                                                                                               T. Field et al.

  Table 1 Means (and standard deviations under means, in italics) for pre/post session measures for the first and
  last days for the massage and relaxation groups.

  Measures                          Massage therapy                                Relaxation

                                    First day               Last day               First day                Last day

                                    Pre         Post        Pre          Post      Pre          Post        Pre          Post

  Mood (POMS)                       10.0a        4.152b      5.7aa        4.9a      7.2a         4.4ab      11.6a         6.3a
                                    12.9         5.81        6.1          5.6       4.4          4.0        13.5          7.7
  Anxiety (STAI)                    36.5a       25.83b      33.9a        26.94b    36.1a        28.8a       33.4a        25.8a
                                    13.3         8.3         8.8          9.1      11.5          6.0        11.9          5.5
  Pain (VITAS)                       5.1a        2.7b        3.9a         1.4b      4.4a         3.6a        3.1a         2.7a
                                     2.9         2.1         2.5          1.6       2.1          2.2         2.3          2.4
  Trunk flexion (cm)*                58.9a       62.13b      60.6a        61.91b    59.1a        59.7a       60.4a        60.7a
  (touch toes without pain)          7.5         8.7         8.4          8.0       7.9          8.7         4.9          4.7
  Pain flexion (cm)*                 61.6a       63.63b      62.4a        63.53b    61.1a        61.3a       63.2b        63.6b
  (touch toes with pain)             8.1         8.8         8.1          8.1       7.6          8.1         4.4          4.0
  Sleep disturbance                 40.5a                   26.1b                  31.8ab                   29.6ab
                                    24.6                    23.7                   19.9                     15.2

  *Higher score is optimal. All other measures, lower score is optimal. Different letter subscripts indicate different means.
  Number superscripts indicate levels of significance 1P ¼ :05, 2P ¼ :01, 3P ¼ :0001 for the pre–post session effects and letter
  subscripts indicate levels of significance (aP ¼ :05, bP ¼ :01) for the pre session first day versus last day effects.

Z2 ¼ :51 for the first day and t ¼ 4:34, Po.001; Z2 ¼                 relaxation therapy for reducing pain and anxiety,
:48 for the last day); (2) trunk flexion increased for                and for improving mood.
the massage group on both days (t ¼ 5:18, Po.001;                       The massage therapy group also experienced an
Z2 ¼ :57 for the first day and t ¼ 2:60, Po.02; Z2 ¼                  immediate increase in the measures of trunk
:62 for the last day); and (3) trunk flexion with pain                flexion with and without pain after the first and
increased for the massage group on both days                         last sessions as they had in our previous massage
(t ¼ 4:21, Po.001; Z2 ¼ :47 for the first day and                     therapy study on individuals with lower back pain
t ¼ 4:53, Po.001; Z2 ¼ :52 for the last day). A group                (Hernandez-Reif et al., 2001). Increased ROM has
by day interaction effect yielded a decrease in                      been correlated with significant pain reduction
sleep disturbance for the massage therapy group                      following physical therapy (Mooney et al., 1996).
across the study (t ¼ 2:72, Po.01; Z2 ¼ :29). No                     Finally, another effect for the massage therapy
changes were noted for the job productivity or                       group was less disturbed sleep by the end of the
absenteeism measures.                                                study. Similar findings were reported for lower back
                                                                     pain by Hernandez-Reif et al. (2001) and for other
                                                                     pain syndromes following massage (Field et al.,
                                                                     1997a; Sunshine et al., 1996). Sleep recordings and
Discussion                                                           biochemical assays of substance P might indicate
                                                                     whether the lower back pain is related to less
After the first session, the massage participants                     restorative sleep and the resultant release of
reported less depressed mood, as they did across                     substance P, as has been noted for other pain
the study. After the first and last massage therapy                   syndromes such as fibromyalgia (Field et al., 2002).
session, they were less anxious. Similarly, pain was                    Although massage therapy was also expected to
lessened after the first and last sessions and over                   increase job productivity and reduce absenteeism
the course of the study for the massage therapy                      for individuals with chronic low back problems,
group. These findings concur with other massage                       these measures were not affected by massage
studies on depressive pain syndromes including                       therapy in this sample. The lack of effects on job
fibromyalgia (Sunshine et al., 1996) and chronic                      productivity and absenteeism may relate to the
fatigue syndrome (Field et al., 1997b) and suggest                   virtual absence of these problems at baseline. The
that massage therapy is more effective than                          sample of individuals working at the medical school
Low back pain reduced by massage therapy                                                                                            145

may have felt that being present and productive                          decrease and sleep improves after massage therapy. Journal
was critical to their jobs despite lower back pain.                      of Clinical Rheumatology 8, 72–76.
   One limitation of the study was ensuring that the                 Field, T., Diego, M., Cullen, C., Hartshorn, K., Gruskin, A.,
                                                                         Hernandez-Reif, M., Sunshine, W., 2004. Carpal tunnel
control participants actually practiced muscle                           syndrome symptoms are lessened following massage therapy.
relaxation. A future study might have the relaxa-                        Journal of Bodywork and Movement Therapies 8, 9–14.
tion participants attend sessions at the clinic to                   Hernandez-Reif, M., Dieter, J., Field, T., Swerdlow, B., Diego,
ensure compliance. Another limitation of the study                       M., 1998. Migraine headaches are reduced by massage
                                                                         therapy. International Journal of Neuroscience 96, 1–11.
was the small sample size and lack of a long-term
                                                                     Hernandez-Reif, M., Field, T., Krasnegor, J., Theakson, H., 2001.
follow-up assessment. These data, nonetheless,                           Lower back pain is reduced and range of motion increased
suggest that massage therapy effectively reduces                         after massage therapy. International Journal of Neuroscience
pain, sleep disturbances and the anxiety and                             106, 131–145.
depressed mood states associated with lower                          Kaaria, S., Kaila-Kangas, L., Kirjonen, J., Riihimaki, H.,
back pain.                                                               Luukkonen, R., Leino-arjas, P., 2005. Low back pain, work
                                                                         absenteeism, chronic back disorders, and clinical findings in
                                                                         the low back as predictors of hospitalization due to low back
                                                                         disorders: a 28-year old follow-up of industrial employees.
Acknowledgements                                                         Spine 30, 1211–1218.
                                                                     Linton, S.J., Melin, L., Stjernlof, K., 1985. The effects of applied
                                                                         relaxation and operant activity training on chronic pain.
We would like to thank the individuals who                               Behavioral Psychotherapy 13, 87–100.
participated in this study and the therapists who                    McNair, D.M., Lorr, M., Droppleman, L.F., 1971. POMS—Profile of
provided the massage. This research was supported                        Mood States. Educational and Industrial Testing Service, San
by an NIMH Senior Research Scientist Award                               Diego, CA.
                                                                     Mooney, V., Saal, J.A., Saal, J.S., 1996. Evaluation and
(#MH00331), an NIMH Research Grant (#MH46586)
                                                                         treatment of low back pain. Clinical Symposia 48, 1–32.
to Tiffany Field and funds from Johnson & Johnson                    Nicholas, M.K., Wilson, P.H., Goyen, J., 1992. Comparison of
and Biotone to the Touch Research Institutes.                            cognitive-behavioral group treatment and an alternative
                                                                         non-psychological treatment for chronic low back pain. Pain
                                                                         48, 339–347.
                                                                     Pugatch, D., Haskell, D., McNair, D., 1969. Predictors and
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