Lower back pain and sleep disturbance are reduced following massage therapy
Lower back pain and sleep disturbance are reduced following massage therapy
Journal of Bodywork and Movement Therapies (2007) 11, 141–145 Bodywork and Journal of Movement Therapies RESEARCH Lower back pain and sleep disturbance are reduced following massage therapy Tiffany Fielda,b,, Maria Hernandez-Reifa , Miguel Diegoa , Monica Fraserc a Touch Research Institutes, University of Miami School of Medicine, P.O. Box 016820 (D-820), Miami, FL 33101, USA b Fielding Graduate University, USA c Biotone, USA Received 26 January 2006; received in revised form 13 March 2006; accepted 13 March 2006 KEYWORDS Massage; Relaxation therapy; Back pain; Sleep disturbance; Anxiety Summary A randomized between-groups design was used to evaluate massage therapy versus relaxation therapy effects on chronic low back pain.
Treatment effects were evaluated for reducing pain, depression, anxiety and sleep distur- bances, for improving trunk range of motion (ROM) and for reducing job absenteeism and increasing job productivity. Thirty adults (M age ¼ 41 years) with low back pain 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 Back pain is the second leading chronic pain condition for physician visits, and the morbidity associated with back pain is the most frequent cause of work absenteeism (Kaaria et al., 2005). Psychological variables thought to inﬂuence the pain experience include depression, anxiety, sleep- lessness, distress and cognitive functioning. Relaxation therapy has been used for lower back pain (Linton et al., 1985; Nicholas et al., 1992). Massage therapy may effectively treat lower back pain as it has been shown to reduce pain in other painful syndromes.
For example, massage therapy has been shown to decrease pain associated with juvenile rheumatoid arthritis (Field et al., 1997a), ﬁbromyalgia (Sunshine et al., 1996), ARTICLE IN PRESS www.intl.elsevierhealth.com/journals/jbmt 1360-8592/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2006.03.001 Corresponding author. Touch Research Institutes, University of Miami School of Medicine, P.O. Box 016820 (D-820), Miami, FL 33101, USA. Tel.: +1 305 975 5029; fax: +1 305 243 6488. E-mail address: tﬁeld@med.miami.edu (T. Field).
chronic fatigue syndrome (Field et al., 1997b) and migraine headaches (Hernandez-Reif et al., 1998). Moreover, massage therapy has also been shown to reduce anxiety and depression (Field et al., 1992). In a recent study comparing massage therapy and relaxation therapy effects on lower back pain, trunk and pain ﬂexion performance were improved by massage therapy and self-reported pain depression, anxiety and sleep disturbance were decreased (Hernandez-Reif et al., 2001). In addition, dopamine and serotonin levels increased following a 5-week period of two 30-min massages per week. The lesser sleep disturbance that accompanied massage therapy could relate to the lesser pain, as sleep disturbances are noted to increase pain and pain-associated sub- stances such as substance P (Field et al., 2004).
The present replication study examined massage therapy and relaxation therapy effects for reducing chronic low back pain, depression, anxiety, and sleep disturb- ance, for improving range of motion (ROM) and ﬁnally for reducing job absenteeism and increase producti- vity, which were not assessed in the previous study. Method Participants The sample included 30 adults (14 women) with low 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% power to detect the effects massage therapy on anxiety, mood, pain, ROM and sleep disturbance.
The participants were cleared by their primary physician to participate in the study. Exclusion criteria were back pain due to fractured vertebrae, herniated or degenerated disks, patients who had undergone surgery for their back pain, (i.e. laminectomies or fusions) and patients with sciatic nerve involvement or legal action pending, such as workmen’s compen- sation. The participants averaged 41 years of age and were middle class (M ¼ 2:5 on the Hollingshead Index), were 67% Caucasian, 9% Hispanic, 16% African 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. Procedures Massage therapy The massage group received two 30-min massage therapy sessions per week over 5 weeks by trained massage therapists, who used Biotone Spa Replen- ishing Light Body Oil (Biotone, San Diego, CA, USA) each session starting with the participant in the prone position, resting the ankles on a small cushion. The massage consisted of the following techniques applied to the entire back: (1) moving the ﬂats of the hands across the back; (2) kneading and pressing the muscles; and (3) short back and forth rubbing movements on the muscles next to the spine and the muscles that attach to the hip bone.
The following techniques were administered to the legs: (1) long gliding strokes toward the torso, to the entire leg; (2) kneading and moving the skin in the thigh area; (3) pressing and releasing, and back and forth rubbing movements on the area between the hip and the knee on the back of the thigh; and (4) short rubbing movements to the small muscles around the knees. In the supine position with a bolster under the knee, the participants received: (1) long gliding strokes and kneading of the neck muscles; (2) moving the ﬂats 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 muscles).
Then, to the entire leg: (1) stroking; (2) kneading followed by pressing and releasing the anterior thigh region; (3) ﬂexing of the thigh and knee; and (4) pulling of both legs at the same time using direct longitudinal traction.
Relaxation therapy A relaxation therapy group, which was included to control for potential placebo and increased atten- tion effects, was shown how to use progressive muscle relaxation exercises including tensing and relaxing large muscle groups starting with the feet and progressing to the calves, thighs, hands, arms, back and face. The participants were asked to conduct these 30-min sessions at home twice a week for 5 weeks and to keep a log on the times they spent in relaxation therapy. They were also called weekly to monitor their compliance. Pre–post session assessments (immediate effects) The following assessments were made before and after the sessions on the ﬁrst and last days of the 5-week study.
These measures were used to assess stress, pain and ROM.
ARTICLE IN PRESS T. Field et al. 142
Proﬁle of Mood States Depression Scale (POMS-D, McNair et al., 1971) The POMS consists of 19 adjectives rating depressed mood using the words such as ‘‘blue ‘ ‘ sad’’, and ‘‘lively’’ on a 5-point scale ranging from ‘‘not at all’’ to ‘‘extremely’’. The scale has adequate concurrent validity and good internal consistency (r ¼ :95; McNair et al., 1971) quate measure of intervention effects (Pugatch, Haskell & McNair, 1969).
State Anxiety Inventory (STAI; Spielberger et al., 1970) The STAI includes 20 anxiety statements assessing how the participant feels at that moment in terms of severity (not at all to very much so).
Character- istic items include ‘‘I feel nervous’’ and ‘‘I feel calm.’’ The STAI scores increase in response to stress and decrease under relaxing conditions (Spielberger et al., 1970). The STAI has adequate concurrent validity and internal consistency (r ¼ :83, Spielberger, 1972). VITAS (VITAS Healthcare Corporation, 1993) Present pain was assessed by a Visual analog Scale ranging from 0 (‘‘happy face’’) to 10 (‘‘frowning/ sad face’’), which represented no pain to worst possible pain.
ROM measures While standing straight with feet placed shoulder width apart in a normal position, the length of the spine was measured using a tape measure. One magic marker mark was made on the skin at the most prominent bone at the base of the neck (cervical vertebra bone 7) and a second mark was made on the skin at the round bony prominence of the backbone (lumbar vertebra 1). The distance between these two marks was recorded in cen- timeters. A trunk ﬂexion ROM measure (touch toes without pain) was then recorded, again from the base of the neck (cervical vertebra bone 7) to the round bony prominence of the backbone (lumbar vertebra 1), asking the person to reach forward to touch the toes.
The trunk ﬂexion measure minus the standing up baseline measure served as the trunk ﬂexion ROM. A pain ﬂexion ROM measure (touch toes to the point of pain) was then obtained, as above, but the person was asked to reach toward the toes or ﬂex the trunk as far as possible, even with pain. This measure was also subtracted from the baseline standing up measure. All physical measurements were collected by MHR who was assessed for reliability prior to the start of the study.
First–last day sessions (longer term effects) On the ﬁrst and last day of the 5-week study, the following assessments were conducted. Sleep Scale (Verran and Snyder-Halperin, 1988) This visual analog scale is anchored at one end with ineffective sleep responses (e.g., ‘‘Did not awaken ‘ ‘ Had no trouble sleeping’’) and at the opposite end with ineffective responses (e.g., ‘‘Was awake 10 h ‘ ‘ Had a lot of trouble falling asleep’’). The participants were asked to place a mark across the answer line at the point that best reﬂected their last night’s sleep. The scale yields subcate- gories of sleep disturbance score.
A reliability coefﬁcient of .82 has been reported for this scale (Snyder-Halpern and Verran, 1987).
Job productivity and absenteeism Participants were asked how many days they missed at work and to rate their level of job productivity on a scale of 0 (not at all productive) to 5 (very productive) for the ﬁrst and last week of the study. Results Repeated measures ANOVAs were conducted to determine the effects of massage therapy versus relaxation therapy on lower back pain. The repeated measures were pre and post therapy sessions and ﬁrst and last days of the study. Signiﬁcant interaction effects were followed by Bonferroni t-tests.
Group by pre–post session and group by pre–post session by day interaction effects were revealed for the massage group beneﬁts for mood and for pain.
Post Bonferroni t-tests indicated the following (see Table 1): (1) mood as assessed by the POMS improved following the ﬁrst session (t ¼ 2:92, Po.009; Z2 ¼ :31) and by the end of the study (t ¼ 2:02, Po.05; Z2 ¼ :18) and (2) pain as reported on the VITAS decreased following each session (t ¼ 4:98, po.001; Z2 ¼ :55 for the ﬁrst session and t ¼ 6:01, Po.001; Z2 ¼ :64 for the second session) and by the end of the study (t ¼ 2:29, Po.03; Z2 ¼ :22). Group by pre/post session interaction effects (see Table 1) and Post Bonferroni t-tests revealed the following: (1) state anxiety decreased for the massage group on both days (t ¼ 4:52, Po.001; ARTICLE IN PRESS Low back pain reduced by massage therapy 143
Z2 ¼ :51 for the ﬁrst day and t ¼ 4:34, Po.001; Z2 ¼ :48 for the last day); (2) trunk ﬂexion increased for the massage group on both days (t ¼ 5:18, Po.001; Z2 ¼ :57 for the ﬁrst day and t ¼ 2:60, Po.02; Z2 ¼ :62 for the last day); and (3) trunk ﬂexion with pain increased for the massage group on both days (t ¼ 4:21, Po.001; Z2 ¼ :47 for the ﬁrst day and t ¼ 4:53, Po.001; Z2 ¼ :52 for the last day). A group by day interaction effect yielded a decrease in sleep disturbance for the massage therapy group across the study (t ¼ 2:72, Po.01; Z2 ¼ :29). No changes were noted for the job productivity or absenteeism measures.
Discussion After the ﬁrst session, the massage participants reported less depressed mood, as they did across the study. After the ﬁrst and last massage therapy session, they were less anxious. Similarly, pain was lessened after the ﬁrst and last sessions and over the course of the study for the massage therapy group. These ﬁndings concur with other massage studies on depressive pain syndromes including ﬁbromyalgia (Sunshine et al., 1996) and chronic fatigue syndrome (Field et al., 1997b) and suggest that massage therapy is more effective than relaxation therapy for reducing pain and anxiety, and for improving mood.
The massage therapy group also experienced an immediate increase in the measures of trunk ﬂexion with and without pain after the ﬁrst and last sessions as they had in our previous massage therapy study on individuals with lower back pain (Hernandez-Reif et al., 2001). Increased ROM has been correlated with signiﬁcant pain reduction following physical therapy (Mooney et al., 1996). Finally, another effect for the massage therapy group was less disturbed sleep by the end of the 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 biochemical assays of substance P might indicate whether the lower back pain is related to less restorative sleep and the resultant release of substance P, as has been noted for other pain syndromes such as ﬁbromyalgia (Field et al., 2002). Although massage therapy was also expected to increase job productivity and reduce absenteeism for individuals with chronic low back problems, these measures were not affected by massage therapy in this sample. The lack of effects on job productivity and absenteeism may relate to the virtual absence of these problems at baseline. The sample of individuals working at the medical school ARTICLE IN PRESS 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 4.15b 2 5.7a a 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 25.8b 3 33.9a 26.9b 4 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 62.1b 3 60.6a 61.9b 1 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 63.6b 3 62.4a 63.5b 3 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 1 P ¼ :05, 2 P ¼ :01, 3 P ¼ :0001 for the pre–post session effects and letter subscripts indicate levels of signiﬁcance (a P ¼ :05, b P ¼ :01) for the pre session ﬁrst day versus last day effects. T. Field et al.
may have felt that being present and productive was critical to their jobs despite lower back pain. One limitation of the study was ensuring that the control participants actually practiced muscle relaxation. A future study might have the relaxa- tion participants attend sessions at the clinic to ensure compliance. Another limitation of the study was the small sample size and lack of a long-term follow-up assessment. These data, nonetheless, suggest that massage therapy effectively reduces pain, sleep disturbances and the anxiety and depressed mood states associated with lower back pain.
Acknowledgements We would like to thank the individuals who participated in this study and the therapists who provided the massage. This research was supported by an NIMH Senior Research Scientist Award (#MH00331), an NIMH Research Grant (#MH46586) to Tiffany Field and funds from Johnson & Johnson and Biotone to the Touch Research Institutes. References Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., Schanberg, S., 1992. Massage reduces anxiety in child and adolescent psychiatric patients. Journal of the American Academy of Child and Adolescent Psychiatry 31, 125–131.
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