Lower back pain and sleep disturbance are reduced following massage therapy
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ARTICLE IN PRESS Journal of Bodywork and Movement Therapies (2007) 11, 141–145 Journal of Bodywork and Movement Therapies www.intl.elsevierhealth.com/journals/jbmt 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 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. doi:10.1016/j.jbmt.2006.03.001
ARTICLE IN PRESS 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 effects) Procedures 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.
ARTICLE IN PRESS 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) 1969). 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. Results 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;
ARTICLE IN PRESS 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
ARTICLE IN PRESS 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 References patterns of change associated with the course of time-limited psychotherapy. Mimeo Report. Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., Snyder-Halpern, Verran, J.A., 1987. Instrumentation to describe Schanberg, S., 1992. Massage reduces anxiety in child subjective sleep characteristics in healthy subjects. Research and adolescent psychiatric patients. Journal of the in Nursing & Health 10, 155–163. American Academy of Child and Adolescent Psychiatry 31, Spielberger, C.D., 1972. Anxiety as an emotional state. In: 125–131. Spielberger, C.D. (Ed.), Anxiety: Current Trends in Theory Field, T., Hernandez-Reif, M., Seligman, S., Krasnegor, J., Rivas- and Research. Academic Press, New York. Chacon, R., 1997a. Juvenile rheumatoid arthritis beneﬁts Spielberger, C.D., Gorusch, R.C., Lushene, R.E., 1970. The State from massage therapy. Journal of Pediatric Psychology 22, Trait Anxiety Inventory. Consulting Psychologists Press, Palo 607–617. Alto, CA. Field, T., Sunshine, W., Hernandez-Reif, M., Quintino, O., Sunshine, W., Field, T., Quintino, O., Fierro, K., Kuhn, C., Schanberg, S., Kuhn, C., Burman, I., 1997b. Massage therapy Burman, I., Schanberg, S., 1996. Massage therapy and effects on depression and somatic symptoms in chronic transcutaneous electrical stimulation effects on ﬁbromyal- fatigue immunodeﬁciency syndrome. Journal of Chronic gia. Journal of Clinical Rheumatology 2, 18–22. Fatigue Immunodeﬁciency Syndrome 3, 43–51. Verran, J., Snyder-Halperin, R., 1988. Do patients sleep in the Field, T., Diego, M., Cullen, C., Hernandez-Reif, M., Sunshine, hospital? Applied Nursing Research 1, 95. W., Douglas, S., 2002. Fibromyalgia pain and substance P VITAS Healthcare Corporation, 1993.
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