Five-week Outcomes From a Dosing Trial of Therapeutic Massage for Chronic Neck Pain

Karen J. Sherman, PhD, MPH; Andrea J. Cook, PhD; Robert D. Wellman, MS; Rene J. Hawkes, BS; Janet R. Kahn, PhD; Richard A. Deyo, MD, MPH; Daniel C. Cherkin, PhD

Disclosures

Ann Fam Med. 2014;12(2):112-120. 

In This Article

Discussion

Our findings demonstrate that the beneficial effects of massage treatments for chronic nonspecific neck pain increase with dose. Although 30-minute massages, either 2 or 3 times a week, failed to provide significant benefits compared with the wait list control condition, the beneficial effects of 60-minute massages increased with dose and were especially evident for those receiving massage 2 or 3 times per week. Compared with their control counterparts, massage participants were 3 times more likely to have a clinically meaningful improvement in neck function if they received 60 minutes of massage twice a week and 5 times more likely if they received 60 minutes of massage 3 times a week. Our results confirm the effectiveness of a 60-minute massage for persons with chronic neck pain. Changes in the use of medications for neck pain or visits to clinicians could not explain these findings. In addition, we found few adverse events, most of which were mild. Our findings are similar to those of our small trial of massage for chronic neck pain[18] and a large trial of massage for back pain.[28] Massage thus appears relatively safe when provided by appropriately trained therapists, but can be associated with transient increases in pain.

Our findings also suggest that previously published studies of massage for neck pain may have not administered adequate doses. For example, the newest Cochrane review of massage for neck pain[15] reported 9 trials of massage for subacute or chronic neck pain. Among the 7 trials with conceivably relevant designs, 4 trials included only a single session of a single massage technique applied for less than 5 minutes, 1 trial included only five 30-minute treatments over 2 weeks, 1 included five 45-minute treatments over 1 month, and the last was a series of weekly 60-minute massages. In addition, most trials lacked massage resembling conventional massage practice in the United States, where 60-minute treatments administered by licensed massage therapists are the norm, a wide range of massage techniques are used in a single session, and self-care recommendations are provided.[29] This review notes that there is little information regarding optimal parameters for the massage, including the number of treatments per week and the length of each session.

We found slightly different results in our controls and 60-minute weekly massage group than we did in a previously published study[18] comparing weekly massage with a control condition of receipt of a self-care book. Participants in both studies reported similar ratings of neck pain and dysfunction before treatment; however, among the control groups, clinically important improvement in that earlier study was worse for pain (only 10% improved vs 26% in this trial) but similar for neck dysfunction (approximately 8% improved in both studies). More participants receiving weekly 60-minute massages in that earlier study reported clinically relevant improvement in both pain (48% improved vs 34% in this trial) and dysfunction (35% improved vs 18% in this trial). Virtually all participants in the prior study received self-care recommendations, most commonly pertaining to stretching, but such recommendations were prohibited in this trial, which may at least partially explain the difference between study results. Conceivably, these differences could reflect variability due to small sample sizes. Potentially, these combined results may indicate that 60 minutes once a week may still be an effective treatment relative to a control condition, but likely less effective relative to 2 to 3 times per week as indicated by this trial.

Our study's strengths include rigorous randomization, assessment of follow-up outcomes by interviewers unaware of treatment group, high adherence to the massage dose in each group, high follow-up rates, and massage protocols that both maximized standardization of treatment and allowed the study massage therapists' sufficient latitude to provide treatments they thought would benefit their patients. Our study's major limitations include modest sample sizes in each group, inability to control for nonspecific effects of attention with the use of a wait list control design, and inclusion of patients who had primarily mild to moderate neck pain. The prohibition of giving self-care recommendations might be a limitation in the sense that massage therapists typically make such recommendations, but this prohibition enhances our confidence that the findings are due to the massage itself. In unpublished data from a larger study describing the practice of 126 massage therapists,[29] we found that they recommended self-care for 87% of the 165 visits for chronic neck pain, most commonly body awareness (49%), hot and/or cold therapy (43%), and exercise (42%). Additional limitations include only short-term follow-up and our inability to fully assess how representative our patients are of those with chronic nonspecific neck pain in primary care.

Few studies of nonpharmacologic CAM therapies have evaluated the effect of dose on outcomes. In 2 small studies, Haas et al[30,31] found greater improvement for back pain and cervicogenic headache among patients who received 3 or 4 chiropractic treatments per week for 3 weeks than among those receiving fewer treatment per week. In a 5-arm, 8-week trial of massage for persons with osteoarthritis, Perlman et al[32] found that 60 minutes of weekly or twice weekly massage was clearly superior to usual care and appeared better than 30 minutes of twice weekly massage.

Our findings have important implications for both clinical practice and research. At baseline, only about 5% of participants were very satisfied with their overall care for neck pain, suggesting that new therapeutic alternatives are needed for family physicians. Outcome data suggest that patients seeking massage for chronic neck pain are more likely to benefit if they have multiple 60-minute treatments per week than if they have only 1. Such a treatment schedule might prove challenging for many patients because of time and financial constraints. Our findings also suggest that future trials evaluating massage for chronic neck pain, which we think would be important, should include multiple 60-minute treatments each week for the first 4 weeks of treatment, self-care recommendations, and longer-term follow-up.

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