According to the review, the most common outcome measure in these studies was weight gain among the preterm infants.
Other outcome measures assessed in the published research included sleep, calorie consumption, bilirubin levels, vagal activity, number of stools, heart rate variability, pain and length of hospital stay, among others.
As for the interventions used in these studies, the authors of the review state that, in most cases, the preterm infants were assigned to either a preterm infant massage group or a standard-care control group.
However, several of the studies compared other touch-based interventions, such as massage with and without oil or massage versus light, still touch.
Although there was some variation in the type of massage used during these interventions, the analysis showed that most of the studies involved tactile-kinesthetic stimulation (TKS) for the preterm infants, as well as modified versions of TKS.
“Modifications of TKS included shorter or longer duration of massage, as well as elimination of kinesthetic range of movement exercise with only tactile stimulation provided,” the authors report.
“Other massage types evaluated include oil massage combined with either TKS or other standardized technique, Vimala massage, and acupressure and meridian massage.”
In terms of the specific effects of massage on preterm infants, analysis of the 34 studies revealed a positive effect on weight gain, as well as an increase in vagal tone.
The authors of the review point to the increase in vagal tone as a potential driving force behind the beneficial weight gain associated with massage for preterm infants.
“More studies are needed on the underlying mechanism of the effects of massage therapy on weight gain in preterm infants,” state the authors of the review.
“While some trials suggest improvements in developmental scores, decreased stress behavior, positive effects on immune system, improved pain tolerance and earlier discharge from the hospital, the number of such studies is small and further evidence is needed.”
Author: Anna-Kaisa Niemi
Sources: Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University, Palo Alto, California. Originally published online in April 2017 in Children, 4(21).
The University of Miami's Touch Research Institute has studied workplace massage.
A study published in a 1996 International Journal of Neuroscience for example.
That research showed that massaged adults exhibited enhanced mental alertness.
They also completed math problems in significantly less time and with more accuracy.
They actually exhibited lower job stress levels even after a five-week period.
Add that to a 2004 study.
Again this science was published in the International Journal of Neuroscience.
Anxiety scores decreased for all groups who received moderate massage as well as several other types.
The subjects receiving moderate pressure experienced the greatest decrease in stress.
"We found that moderate pressure was the key,"
That statement is from Tiffany Field, PhD, director of the University of Miami's Tough Research Institute.
Dr. Field says this of the 2004 study.
"You don't get those brain-waves changes and the heart-rate slowing and people being in a more relaxed state in light-pressure massage."
Dr. Field adds that these studies didn't compare the length of massage-therapy sessions.
"All I can say is that you won't get the effects unless you use moderate pressure,"
"I don't think the routine is as much of an issue as moderate pressure."
"We've done 10 minutes, a half hour, 15 minutes. That doesn't seem to be a factor."
The New Coffee Break
By: Pete Reinwald
Marilyn Kier knew the stresses of the workplace. As a business consultant for 15 years, she knew the aches in the fingers, the tightness in the shoulders, the pain in the neck. She knew she needed to bring wellness to the workplace.
She joined the chamber of commerce in Northbrook, Illinois, with the idea of sitting chamber members down and showing them what they'd been missing.
"I went there with my massage chair, and everybody looked at me like, 'Is she serious?'" Kier says. You bet she was. She still is. About 10 years later, Kier maintains a core group of about 12 companies, and others seasonally, with which she maintains relationships in the art and income of workplace- or corporate- massage.
"I had no trouble getting into any corporation from large companies like Motorola to smaller privately owned companies," Kier says. No formal studies have been done on trends, but some say corporate massage has leveled off since its 1980s mainstream introduction by TouchPro Institute founder David Palmer, known by some as the father of contemporary chair massage.
Others say it continues to boom. They cite an increasing number of therapists offering workplace massage and an increasing number of companies welcoming it with open and aching arms. "There's so much potential business out there," says Denver therapist Julie Wallace. "I get very excited when I see it becoming accepted as a mainstream idea as a wellness practice."
Says therapist Linda Dumbrigue of Novi, Michigan: "I think there is a huge untapped market, and that's why it's an interest to me." Dumbrigue is among the therapists looking for ways to tap into it. Therapists who have had success securing relationships with companies say it usually comes down to a lot of hard work, homework and creativity-and sometimes, a little luck.
Gary Jones of Austin, Texas, says he once was doing chair massage at a public event-and the CEO of a local company sat down in his chair. "She said, 'Can you come to my company?' I happened to be in the right place at the right time."
Hard work and Homework
Kier sent out flyers to all members of the Northbrook, Illinois Chamber of Commerce. She also joined a local group called the Worksite Wellness Council of Illinois, in which businesses would vie for an annual wellness award. The businesses would attend meetings on wellness in the workplace-and Kier made sure she attended as well. Before she knew it, Kier was bidding on contracts for seated massage.
"I'd determine what their goals and needs were, and I would come back with a proposal on how I could help them achieve that," Kier says.
Jason Miller of Enfield, Connecticut, and his partner, Kevin Zorda, spent $1,500 on newspaper ads trying to attract corporate interest to chair massage. They didn't get one call back. They knew they had to try something different. That's when they started thinking outside the box-literally.
They got a four-inch-by-four-inch box. They decorated each side with either words or illustrations that trumpeted their service. One side had an illustration of somebody receiving a chair massage. Another side showed a testimonial from a previous client. Another side included research on employee and company benefits. The top featured just four words: Think outside the box.
"It helped us stand out from the crowd," Miller says. "And it showed a little uniqueness. We'd get a call: 'That's kind of funny. You think outside the box.'"
They'd not only get a call, Miller says. They'd get a client. Miller and other massage therapists-who have been successful in workplace massage-say they can't emphasize enough the importance of the planning and work that go into securing and maintaining corporate accounts. They say therapists should be aware of the time involved in each account, some of which can take up to a half a day or a full day of work, including travel and setting up. That doesn't include communication and coordination leading up to each corporate visit and administrative duties such as billing and collections.
Successful therapists also point out that expanding into corporate massage can mean hiring and training additional therapists.
"You have to decide whether you want to be the business owner or the massage therapist," Kier says. Kier, owner of Wellness At Work, says she wants to remain a therapist. She says she scaled back on her corporate business, which "kind of runs itself now" on the strength of independent contractors whom she trained. "I personally am focusing on orthopedic massage and pain management," she says.
Kier says her background as a corporate consultant helped her to understand "all the stresses that might occur" within the workplace. Her company website (www.wellnessatwork.net) cleverly reads: "Kier, a nationally certified massage therapist who has a BA in psychology, spent 15 years working in employee benefits consulting before she switched gears and became an employee benefit."
But if a business background is helpful, a business plan is essential. Therapists should know the market, the time and money involved in winning a share of it, the resources involved in maintaining it, and the financial results therein. Kier says she uses the same business plan she wrote in massage school-a 60-page paper that features her ethics, policies, principles, operations and more. Once their financial plans are in order, therapists are ready to go after a piece of this vast and seemingly growing corporate pie.
Going for It
Therapists agree on the need for an "inside advocate," somebody inside the company who sees a need for company-wide massage therapy. Wallace, the Denver therapist, says she introduces herself to companies at which she knows somebody, so her foot is in the door and the ice is broken. She sometimes offers her contact a free 20-minute massage as another ice-breaker.
Miller says he and Zorda have their own method: they go straight to the top. "We seek the head honcho of the company," he says. Firstly, he says, it saves time by eliminating red tape. Secondly, it helps the therapist to better educate the company on corporate chair massage. "We found that many of the CEOs were war veterans and were used to the type of massage they got overseas," Miller says. As a result, he says, many corporate executives continue to perceive massage only as "dim lighting, soft music, on a table, sedated." His company, Connecticut Chair Massage, had to break the "corporate massage myth," he says. "We had to educate the clients." Massage schools are doing their part, too. Zorda, director of the massage therapy program at the Windsor, Connecticut, campus at the Branford Hall Career Institute, says his program offers a 30-hour course that focuses exclusively on seated massage. The course covers marketing, networking, price-setting and more.
"We often tell [students] that there's networking groups that they can get involved with," says Zorda, also a massage therapy evaluator for the Accrediting Council for Independent Colleges and Schools. "We're close to Hartford, and we have a lot of insurance companies and a lot of banks," he says. Therefore, they emphasize network groups that might be connected to those types of industries.
Once inside the company door, Denver's Wallace produces a one-page sheet that explains what employees can get from her 20-minute chair massage, that employees keep their clothes on and that they won't be coated with oil or lotion, since neither are used. More importantly, Miller says, therapists must emphasize to prospective clients the ultimate advantage of workplace massage. "They don't care about how it's going to increase blood flow," Miller says. "They care how it's going to improve the bottom line, how it's going to enhance productivity."
Miller says he makes sure he's familiar with studies on workplace massage, such as those done by the University of Miami's Touch Research Institute, which show a correlation between massage, alertness and lower anxiety. "We show them studies," Miller says. "There's just limited research out there on workplace massage," he adds.
Kier points out, though, that much more is being written about massage in general-that more doctors are prescribing it, that people are using it not only as a luxury but to manage pain and that more insurance companies are beginning to pay for hour-long massages. Therapists who arm themselves with such articles can enhance their sales pitch. Kier says she is quick to speak at organizations about the benefits of massage.
She once was asked to be a massage spokeswoman of sorts at a Northwestern University conference on holistic health. "The more you can align yourself with other professionals who look at massage as a credible health benefit," she says, "the more I think that credibility and professionalism will generate corporate arrangements."
Therapists say they use a $1-per minute rule of thumb as a basis for corporate deals. Jones says he uses a tiered pricing system by which he charges $60 per hour if he's providing massages at the company for 3½ hours or more. If he's at the company for fewer than 3½ hours, he charges $70 per hour. "I charge a higher rate for less time," Jones says. "It's expensive getting out there and setting up." He requests a gratuity on one-time arrangements. "I've found that whenever I've charged it, people don't balk," he says. He waives the gratuity as an incentive to establish a regular relationship with the company.
Company arrangements vary from once or twice a week, to once a month to once a year, to whenever the mood and the money strike the company. Sometimes the employees pay for the massages; sometimes the company pays for them, and some-times the employees and company share the costs.
Of 18 corporate accounts maintained by his company, Miller says, 11 are paid entirely by employees, two are paid entirely by the companies and five are partially paid for by the companies. When employees are paying for all or part of the massages, therapists say, it's a good idea to have the employees pay in advance. The therapists thereby know they have a commitment and know how many therapists to send to the job. When the company pays all the costs, the therapist generally knows the frequency of company-wide sessions (once a week, once a month, etc.). In such cases, some therapists ask the company to let them know ahead of time how much time will be needed on the coming visit, and they bill the company in advance.
As with most chair massage sessions, workplace-massage sessions generally last 15 to 20 minutes, focusing on the neck, head, back, shoulders, arms, hands and fingers. Most therapists prefer to customize each session, as if to say to the employee: "I care about you, not just your company." Many ask the client whether they have any areas that need special attention. They ask new clients about health history, recent injuries and whether they've had chair massage.
Kier says she trains her independent contractors to focus on individual needs. "Our goal is to really customize the on-site massage on what each employee needs on any given day that we're there," she says. "It's not just a routine. These are skilled therapists who can ask questions and tailor the session accordingly."
"We encourage all of our staff to individualize each session," Miller says. "If you're doing the same routine over and over again, you're really not helping anyone." Jones says his teacher required all of his therapists to execute at least a variation of the same chair-massage routine, adapted from an Eastern style of therapy called shiatsu that emphasizes energy channels and pressure points.
"Everybody has his or her own interpretation of that routine," Jones says. "They kind of make it their own. The routine that I use has a certain flow to it. I might leave out some things and just focus on the things that people like, if somebody requests something specific."
The key is for the company and employees to feel comfortable with the therapist. Take it from Briefing.com, a Chicago-based company that provides financial news and analysis. The company sought a massage therapist "driven by a sense of ergonomics and keeping employees healthy," says Pat O'Hare, manager of investor content at Briefing.com.
The company started with one visit a week from a therapist. It's now up to two visits a week. The company and employees share the costs. Employees there feel good about their therapist, O'Hare says. More importantly, they just feel good.
"She's become kind of like one of us at Briefing.com," O'Hare says of the company's therapist. "She's a friendly face-and a nice face to see twice a week. We're glad that she understands that we put in a lot of hours and do a lot of sitting and staring at a computer."
A few Things to Know
Your chair. "We did a large event one time in conjunction with about 40 other therapists…and many were not trained in how to perform chair massage or even how to adjust the chair. That had a huge impact on clients who had never had a chair massage before." -Jason Miller
Your client. "I think what makes any therapist successful is to be able to establish that rapport on a nonverbal basis. They get an impression of you in a matter of seconds. If you don't connect with them, you might not get another chance. You have to do everything you can to establish that rapport quickly and do everything you can to make them feel comfortable." -Marilyn Kier
Your boundaries. "When things change, what are you willing to do and not willing to do? The owner of a company, at the last minute, called to cancel the chair massage gig. I said, 'OK, I do expect payment,' even though I didn't work. I had blocked out that time, and I wasn't going to fill that time on short notice." -Gary Jones
Your business arrangements. Companies that pay 100 percent of the massage costs make for convenient and seemingly stable, but not necessarily long-term, business arrangements. When the employee pays all or part of the cost of the massage, "they seem to see more value in the massage. Those who do it because the company pays for it don't always see the value right away." Also, "when companies are trying to cut the budget, that's the program that gets hit relatively quickly." -Kevin Zorda
Your business potential: "It's a very rare occasion that somebody receives a chair massage and doesn't become a repeat customer." -Julie Wallace
Studies: Moderate Pressure is the Key
Studies by the University of Miami's Touch Research Institute underscored the power of workplace massage.
A 1996 study published in the International Journal of Neuroscience showed that massaged adults exhibited enhanced mental alertness, completed math problems in significantly less time and with more accuracy, and exhibited lower job stress levels after a five-week period.
A 2004 study, also published in the International Journal of Neuroscience, showed that anxiety scores decreased for all groups who received moderate massage (an indentation in the skin), light massage (light stroking) and vibratory stimulation-but that the group receiving the moderate pressure displayed the greatest decrease in stress.
"We found that moderate pressure was the key," Tiffany Field, PhD, one of the leaders of both studies, says of the 2004 study. "You don't get those brain-waves changes and the heart-rate slowing and people being in a more relaxed state in light-pressure massage."
Field says the studies didn't compare the length of massage-therapy sessions. "All I can say is that you won't get the effects unless you use moderate pressure," she says. "I don't think the routine is as much of an issue as moderate pressure. We've done 10 minutes, a half hour, 15 minutes. That doesn't seem to be a factor."
I had three good reasons for getting a chair massage:
I was getting ready to write an article about it;
I had $18 in my pocket-enough for a $15, 15-minute massage and a small tip;
I was getting nagged by my back and shoulders, which were telling me: "If we don't start feeling better soon, you're in big trouble." So I visited a therapist after work one day in downtown Chicago. The therapist took my coat and my glasses and told me to have a seat on the chair. I sat down on the chair but wasn't quite sure what else to do. I gingerly rested my chin on the doughnut-looking pad at the top. My eyes looked inquisitively toward the ceiling. My feet were on the floor, my arms at my sides. I felt uncomfortable. And I felt goofy. Said my back and shoulders: "You're killing us."The therapist, who apparently had assumed that I knew what to do with my head, hands, feet, knees, back and chin, gently and patiently directed me into position, and we were ready to go.She started by touching my back lightly, sweeping both hands in what felt like figure-eights. It relaxed me, and I liked it. She then really went to work, applying moderate pressure to my back, neck and shoulders. It wasn't doing much for me. It felt as though her hands and my relief were slipping away.After a few minutes, the therapist told me that she couldn't seem to work through my dress shirt. It was 60 percent cotton and 40 percent polyester-apparently great for killing both wrinkles and massages. I took off my overshirt, and the therapist quickly found what she told me was a trigger point in the upper left side of my back. It was a sign of some sort of repeat activity, she said. I thought about it, and she was right: For months, I'd been carrying a heavy work bag-always on my left shoulder-to and from my commuter train.Her revelation prompted me to adjust the load in my bag and to occasionally switch shoulders, and her work made the pain go away. I also liked the attention she gave my arms and fingers.I knew the session was coming to a sad, but soothing, end when she reverted to light touches and figure-eights. She concluded with a couple of light, little taps as if to say: "Atta boy. You finally listened to your body."Attribution: https://www.amtamassage.org/articles/3/MTJ/detail/1654/the-new-coffee-break
Cathryn Jakobson Ramin’s back pain started when she was 16, on the day she flew off her horse and landed on her right hip.
For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.
By 2008, after Ramin had exhausted what seemed like all her options, she elected to have a “minimally invasive” nerve decompression procedure. But the $8,000 operation didn’t fix her back, either. The same pain remained, along with new neck aches.
The big takeaway: Millions of back patients like Ramin are floundering in a medical system that isn’t equipped to help them.They’re pushed toward intrusive, addictive, expensive interventions that often fail or can even harm them, and away from things like yoga or psychotherapy, which actually seem to help. Meanwhile, Americans and their doctors have come to expect cures for everything — and back pain is one of those nearly universal ailments with no cure. Patients and taxpayers wind up paying the price for this failure, both in dollars and in health.
Thankfully, Ramin finally discovered an exercise program that has eased her discomfort. And to this day, no matter how busy her life gets, she does a series of exercises every morning called “the McGill Big Three” (more on them later). “With very rare exceptions,” she says, “I find time to exercise, even when I’m on the road.”
More and more people like Ramin are seeking out conservative therapies for back pain. While yoga, massage, and psychotherapy have been around for a long time, there was little high-quality research out there to understand their effects on back pain, and doctors sometimes looked down on these practices. But over the past decade, that’s changed.
To learn more, I searched the medical literature on treatments for lower back pain (the most common type) and read through more than 80 studies (mainly reviews of the research that summarized the findings of hundreds more studies) about both “active” approaches (yoga, Pilates, tai chi, etc.) and passive therapies (massage, chiropractics, acupuncture, and so on). I also talked to nine experts and researchers in this field. (For more detail on our methods, scroll to the end.)
What I found surprised me: Many of these approaches really do seem to help, though often with modest effects. But when you compare even those small benefits with the harm we’re currently doing while medically “treating” back pain, the horror of the status quo becomes clear. “No one dies of low back pain,” one back pain expert, University of Amsterdam assistant professor Sidney Rubinstein, summed up, “but people are now dying from the treatment.”
Mainstream medicine has failed people with chronic back pain
Lower back pain is one of the top reasons people go to the doctor in the US, and it affects 29 percent of adult Americans, according to surveys. It’s also the leading reason for missing work anywhere in the world. The US spends approximately $90 billion a year on back pain— more than the annual expenditures on high blood pressure, pregnancy and postpartum care, and depression — and that doesn’t include the estimated $10 to $20 billion in lost productivity related to back pain.
Doctors talk about back pain in a few different ways, but the kind most people (about 85 percent) suffer from is what they call "nonspecific low back pain." This means the persistent pain has no detectable cause — like a tumor, pinched nerve, infection, orcauda equina syndrome.
About 90 percent of the time, low back pain is short-lived (or in medical lingo, “acute”) and goes away within a few days or weeks without much fuss. A minority of patients, though, go on to have subacute back pain (lasting between four and 12 weeks) or chronic back pain (lasting 12 or more weeks).
Chronic nonspecific back pain is the kind the medical community is often terrible at treating. Many of the most popular treatments on offer from doctors for chronic nonspecific low back pain — bed rest, spinal surgery, opioid painkillers, steroid injections — have been proven ineffective in the majority of cases, and sometimes downright harmful.
Here’s the outrageous part: All these opioids were being prescribedbefore we actually knew if they helped people with chronic lower back pain. It gets worse: Now high-quality evidence is coming in, and opioids don’t actually help many patients with chronic low back pain.
This soon-to-be-published randomized controlled trial was the first to compare the long-term use of opioids versus non-opioid medications (such as anti-inflammatory drugs and acetaminophen) for low back pain. After a year, the researchers found opioids did not improve patients’ pain or function, and the people on opioids were actually in slightly more pain compared to the non-opioid group (perhaps the result of “opioid-induced hyperalgesia” — heightened pain brought on by these drugs).
As for surgery, only a small minority of patients with chronic low back pain require it, according to UpToDate, a service that synthesizes the best available research for clinicians. In randomized trials, there was no clinically meaningful difference when comparing the outcomes of patients who got spinal fusion (which has become more and more popular in the US over the years) with those who got a nonsurgical treatment.
Steroid injections for back pain, another popular medical treatment, tend to have similarly lackluster results: They improve pain slightly in the short term, but the effects dissipate within a few months. They also don’t improve patients’ long-term health outcomes.
It’s not entirely surprising that the surgeries, injections, and prescription drugs often fail considering what researchers are now learning about back pain.
Historically, the medical community thought back pain (and pain in general) was correlated to the nature and severity of an injury or anatomical issue. But now it’s clear that what’s going on in your brain matters too.
“Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role but psychological and social factors also play a big role," Roger Chou, a back pain expert and professor at Oregon Health and Science University, summarized.
For example, when you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.
The awareness about the role psychological factors play in how people experience pain has grown more widespread with the general shift away from the dualist view of the mind and body toward the more integrated biopsychosocial model. Chronic nonspecific low back pain “should not been considered as a homogenous condition meaning all cases are identical,” researchers in one review of the research on exercise cautioned.
A new understanding of pain called “central sensitization” is also gaining traction. The basic idea is that in some people who have ongoing pain, there are changes that occur between the body and brain that heighten pain sensitivity — to the point where even things that normally don’t hurt are perceived as painful. That means some people with chronic low back pain may actually be suffering from malfunctioning pain signals.
Enter alternative therapies for chronic back pain
Despite the clear risks, doctors have continued to prescribe painkillers, and perform surgeries and injections, sometimes to patients who won’t take no for answer or who can’t afford to try alternatives (which usually aren’t covered by insurance plans).
Slowly, though, the tide is shifting.
Medical societies and public health agencies are now advising doctors to try less invasive options and even alternative therapies such as acupuncture before considering opioids or surgery.
At the same time, research has mounted suggesting active therapies (exercise programs, yoga, tai chi) can really help people work through back pain, and alternative approaches (massage, spinal manipulation) can be effective, too — with the caveat that they’re often no panacea and the effects tend to be short-lived and moderate.
But most of the alternatives also carry little or no harm (except to patients’ pocketbooks) — which makes them all the more appealing amid the historic drug crisis.
“We have a slew of modalities and procedures that the American College of Physicians cannot endorse — such as opioids, fusion surgery, such as injections,” Ramin said, because there’s now so much evidence of ineffectiveness or harm. “So all those things are off the table, and now they are looking for things they can endorse that will not cause harm.”
Moving is probably the most important thing you can do for back pain
When back pain strikes, your first instinct may be to avoid physical activity and retreat to the couch until the pain subsides.
But doctors now think that in most cases, this is probably the worst thing you can do. Studies comparing exercise to no exercise for chronic low back pain are consistently clear: Physical activity can help relieve pain, while being inactive can delay a person’s recovery.
Exercise is helpful for a number of reasons: It can increase muscle strength, which can help support the spine; It can improve flexibility and range of motion in the back, which can help people’s functional movement and get them back to their normal living; it can boost blood flow to the soft tissues in the back, which promotes healing and reduces stiffness. These are just a few reasons why researchers who study back pain suggest opting for exercise before some of the passive therapies like acupuncture or massage (we’ll describe those later).
Researchers in this 2016 review of the research on exercise for chronic nonspecific low back pain summarized exercise’s range of benefits, including these pretty amazing findings:
“Aerobic exercise for 20 min on a cycle ergometer at 70% peak oxygen uptake reduced the pain perception for more than 30 min for patients with [chronic low back pain].”
“Improving the flexibility of the lumbar spine and hamstrings can significantly reduce [chronic low back pain] by 18.5%–58%.”
“Core stabilization programs have been shown to significantly reduce [chronic low back pain] by 39%–76.8%, and a muscular strength program significantly reduced [back pain] by 61.6%.”
Those researchers suggested that a combination of exercises — strength training, aerobic exercise, flexibility training — may be most helpful to patients, and that there seemed to be no clear winners among the different approaches but that each had its own benefits.
“My general take,” Chou said, “is that all [exercise types] seem to work.” If people find a program that makes them feel better, he added, they’ll probably see benefits not only with their back but with their overall health and sleep patterns, too.
To be clear, exercise doesn’t always help with those short-lived acute episodes. But if you have chronic back pain, you’ll want to find ways to work through the discomfort and keep active. Next, we’ll turn to some more specific exercises that are popular (and well studied) for back pain.
Yoga, Pilates, and tai chi seem to help — but it’s not clear that they’re any better than other exercise
There’s lots of research on back pain and yoga. Not all of it is high-quality, but taken together, the evidence pretty uniformly suggests yoga can both decrease pain and improve back-related function. (You can read more about yoga’s health benefits — and the difficulties of studying the practice — in this Show Me the Evidence.)
The most recent Cochrane systematic review on yoga and chronic low back pain, published in 2017, sums up the results of the best available studies, which mostly focused on the Iyengar, Hatha, or Viniyoga forms of yoga:
There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance.
So again, this isn’t an end-all treatment — but the evidence we have points in the direction of a benefit.
Importantly, the review authors also noted that it’s not clear whether yoga is better than other exercises, since there were few head-to-head comparisons tracking yoga against other kinds of workouts.
As for tai chi and Pilates, the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions, recently published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain, including these two kinds of exercises. It found tai chi seemed to reduce chronic back pain and help people return to their daily activities when compared with no exercise, and that it was more effective in alleviating pain than backward walking or jogging but not necessarily better than swimming.
For Pilates, the evidence was a little more mixed: It was associated with small or no effects on pain and no effects on function compared with other types of exercise. Again, though, pretty much every back expert I spoke to said any exercise is better than no exercise, so if Pilates is something you enjoy, do it.
Try to find a “back whisperer,” or try these three exercises from one
Ramin, the journalist and author of Crooked, makes a compelling argument for seeking out a specialist who deeply understands the back to tailor an exercise program that targets your specific pain.
These “back whisperers” come from many different backgrounds: doctors of physical therapy with an orthopedic clinical specialist certification, personal trainers with a degree in exercise science, physical therapists.
“They are able to observe how you walk and sit and stand, and grasp what your posture and gait say about your muscles, tendons, and ligaments,” she writes in Crooked. “Generally, they focus on functional training, prescribing exercise regimens that are ‘non-pain-contingent’ (you don’t stop when it hurts, sorry), ‘quantitative’ (you will not be allowed to quit until you hit your ‘number’), and ‘high-dose’ (you will do this routine on a schedule rather than when the spirit moves you).”
One renowned “back whisperer” isspine biomechanics professor Stuart McGill, of the University of Waterloo in Canada, who has treated everyone from Olympic athletes to professional football players. He spends several hours watching his patients move, and identifies the specific motions, postures, and loads that trigger their back pain. He then tailors exercise programs that build a foundation for pain-free activity, so that those triggers no longer result in pain. (He’s also written a popular book, Back Mechanic, which walks readers through his process — an approach based on decades of research at his spine biomechanics lab and clinic at the University of Waterloo.)
McGill has a set of spine-stabilizing exercises — the McGill Big Three, which Ramin does daily — based on research in his lab that are targeted at people with chronic back pain.
It can be difficult to find someone with the expertise of a back whisperer like McGill, and their time can also be costly. There’s also no study that brings together research on these folks, but if you can find a good one who works for you, your back pain could be improved.
We’re learning how much back pain is mental, and that mind-body approaches can help
So where does physical therapy — usually a combination of guided exercises, mobilization, superficial heat or cold, and health advice — fit into the back pain treatment picture?
In AHRQ’s read of the evidence, it didn’t seem to work better than simple advice to remain active when it came to reducing pain and improving function. (The researchers I talked to said this lack of effect may be because of the variability in physiotherapy approaches and programs, and the difficulty in coming to clear conclusions about the variety of programs on offer.)
Nowadays, though, there are also several different kinds of physical therapies that also integrate psychotherapy or cognitive behavioral therapy, often called multidisciplinary rehabilitation.
Multidisciplinary rehab takes the “biopsychosocial” view of back pain — again, that the pain arises from the interplay of physical, psychological, and social factors. It can of course be tricky to disentangle whether mood disorders like anxiety or depression contribute to people’s pain, or whether they arise out of the pain, but either way, the biopsychosocial model views the physical as only one part of the equation. So these practitioners deal with what’s going on inside the head as part of their back pain therapy — helping patients get treatment for their depression or anxiety, or guiding them through cognitive behavioral therapy to improve their coping skills.
Perhaps not surprisingly, multidisciplinary therapy appears to work slightly better thanphysical therapy alone for chronic back pain in both the short and long term. Patients who get these more holistic treatments are also more likely to return to work.
Spinal manipulation by chiropractors works about as well as exercise or over-the-counter drugs — with some big caveats
Passive therapies can also play a role in helping people manage back pain, though there’s no silver bullet among them, and their effects also tend to be modest and short-lived. (Again, active approaches to managing back pain should be your first stop.) The research base for these alternative therapies is also generally weak: There’s a lot of variability among the practice styles and programs on offer, even within one category of treatment like massage. It can be difficult to blind the patients to the treatment they are receiving, and the people who seek out particular therapies — acupuncture, massage — are probably more amenable to them, which may bias the results. With that said, here’s what we know.
Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.
There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.
First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back painfound that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.
The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.
“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”
As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.
“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”
While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.
The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).
The results on massage are mixed — but it’s also pretty harmless
In general, massage therapists work by manipulating the muscle and soft tissue of the back and body. There are many, many different styles of massage: Swedish, deep tissue, sport, myofascial release, Thai, the list goes on. Massages also vary in how long they last, how much pressure is used, and how frequent sessions are, which makes the evidence for massage pretty difficult to interpret.
But there’s good news here: Massage is pretty harmless, and the researchers who study back pain say the approach makes sense from a pain relief perspective. So it may be worth trying.
According to AHRQ, for subacute (lasting between seven and 12 weeks) and chronic low back pain, massage seems to improve symptoms and function in the short term (i.e., one week) — but there’s no evidence that it leads to any long-term change. At best, you’ll get a bit of immediate relief, but nothing lasting.
The Cochrane systematic review on massage for low back pain looked at 25 trials on massage and, like AHRQ, found short-term improvements in pain and function for both subacute and chronic low back pain but a very mixed evidence base.
Acupuncture seems to help too — sort of — though it’s more controversial
One of the oldest approaches to back pain is acupuncture, a core part of traditional Chinese medicine. The philosophical underpinning of acupuncture is that disease or pain in the body is the result of imbalances between the body’s “yin and yang forces.” “Vital energy circulates throughout the body along the so-called meridians, which have either Yin or Yang characteristics,” the Cochrane authors explain. Using needles to stimulate the parts of the body that are located on these meridians can modulate pain or reverse disease, practitioners claim.
A 2005 Cochrane review looked at the evidence for acupuncture and low back pain and came to a few useful conclusions: There was “insufficient evidence” to make any recommendations about acupuncture for acute low back pain — so it may or may not help people. For chronic pain, acupuncture seemed to offer more pain relief when compared with no treatment or sham acupuncture (when practitioners use needles that don’t actually penetrate the skin). The needling also improved function in the short-term when compared with no treatment for chronic pain sufferers. But acupuncture was not more effective than other treatments.
UpToDate looked at more recent research and noted that the studies on acute pain were still limited, and that evidence for acupuncture’s effects on chronic pain is somewhat conflicting. The review also noted it was unclear whether acupuncture’s benefit lies in the needling, or in the placebo effect.
The author of the Cochrane review, Andrea Furlan, pointed to a more recent randomized trial, which came out in 2009 after her review was published: It also found that acupuncture seemed to reduce chronic low back pain — but it didn’t seem to matter where the needles were placed, raising questions about the meridian philosophy guiding the practice.
This is what makes acupuncture controversial. Science suggests it might work — but the squishiness of the findings, combined with the lack of scientific underpinning in acupuncture’s philosophy, leaves room for interpretation. And evidence-based medicine thinkers and skeptics view the results of studies as suggestive of nothing more than acupuncture’s potent placebo effect.
Researchers have found that the more dramatic the medical intervention, the stronger the placebo effect. And getting poked all over the body by needles is a pretty dramatic intervention. (See this classic study comparing water injections with sugar pills for migraines, as well as Vox’s placebo explainer by Brian Resnick.) That’s not to mention you can never run a double-blind placebo — the gold standard in health research — on acupuncture, since that would involve both practitioners and patients not knowing (or being blinded to) what treatment they are giving and receiving.
We need make our default choices more back- (and health-) friendly
There’s a pretty simple adage public health officials stick to: Make it easy for people to stay healthy, and make it hard for them to get sick.
When it comes to back pain in America, we make it easy for people to get sick and hard for them to stay healthy.
There’s a complete disconnect between what insurance providers will cover for people and what actually helps their back pain. It’s still much easier to get your opioids or back surgery paid for by your insurance provider than to get a massage or exercise program reimbursed.
More states need to move in the direction of places like Oregon, where insurance payers are making the default options for people with back pain healthier by expanding access to, and coverage for, non-drug options.
For example, the Oregon Health Plan (the state’s version of Medicaid, federally funded health insurance for the poor) has ensured that alternatives like acupuncture and physical therapy are covered. It’s also expanded access to treatment for the behavioral health factors that are associated with back pain (such as depression and anxiety) by paying primary care clinics extra to be able to hire behavioral health specialists and meet patients who may not have had access to those services. Finally, it’s opened non-medication pain clinics, where people with low back pain can get a range of treatments as well as help to taper off their opioid prescriptions.
Amit Shah, the chief medical officer at CareOregon (one of the insurance companies administering the Oregon Health Plan), said they decided to move in this direction in the face of the mounting evidence of the harm opioids were causing. “Chronic lower back pain is very prevalent, and we know some people with chronic lower back pain have used opioids for it,” he said. “There’s been a lot of evidence and studies about how opioids are not necessarily the most effective approach, while other medical interventions are effective.”
This knowledge, along with “the continual realization that patients deserve more than a prescription that doesn’t necessarily work,” Shah said, pushed Oregon to experiment with a new benefit structure that might actually help people. “We’re trying to expand the options instead of limiting choice only to opioids.”
Officials in Oregon haven’t yet determined the cost of this new scheme, but opioid prescriptions are already down. Shah also said he’s confident that the measures are bound to reduce the cost burden overall, since alleviating pain can help people can get back to work and bring down the numbers of opioid deaths. If only other states would follow Oregon and take back pain this seriously.
*A note on the methods for this installment of Show Me the Evidence
There’s a mountain of research on low back pain. (Entering the term in the PubMed search engine turned up more than 31,000 results.) So I zeroed in on the highest-quality evidence: systematic reviews. (These are syntheses of the research evidence that bring together all the highest-quality studies to come to more fully supported conclusions.)
I found the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions and had recently (February 2016) published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain. The AHRQ review covered 156 of the best back pain studies from 2008 to April 2015. I then searched for low back pain–related systematic reviews on PubMed Health, the government search engine that specializes in systematic reviews and meta-analyses, to cover the recent period left out of the AHRQ review (from May 2015 to the present, July 2017).
To make sure I wasn’t missing anything, I consulted the chronic and acute low back pain articles on UpToDate, (a service that synthesizes the best available research for clinicians), the Cochrane Library of systematic reviews, and guidelines.gov, and sometimes followed the footnotes in these reviews to other studies. Ramin’s book Crookedwas also an excellent source for thinking on back pain. Finally, I conducted interviews with nine back pain doctors and researchers, including authors of many of the systematic reviews referenced here.
My conclusion agrees with the February 2017, report by the American College of Physicians.
That report advised doctors and patients try “non-drug therapies” such as exercise, tai chi, yoga, and avoid prescription drugs or surgical options wherever possible.
Massage Therapy: Exactly what should somebody expect throughout a massage?
- The massage therapist will certainly ask inquiries about just what motivated you to obtain a massage.
- The massage therapist will desire background information about your physical problem, medical history, lifestyle, anxiety levels and also any type of uncomfortable areas.
- The massage specialist will certainly ask exactly what your wellness goals are as well as will discuss exactly how massage could help you achieve those goals.
- During an individually massage therapy session, you will certainly be asked to remove apparel to your level of convenience. Apparel is not removed during "chair" massage therapies.
Customers additionally must consider the following suggestions in order to help them locate a massage therapist who is trained and certified.
- Are you certified to practice massage therapy? (35 states have actually passed legislation to regulate massage therapy).
- Are you a participant of the American Massage Therapy Association?
- Are you Across the country Qualified in Restorative Massage therapy and Bodywork?
Massage Therapy Could Help Reduce Your Discomfort.
Countless Americans are all as well aware of pain. There can be many trips to the medical professional or chiropractic physician, discomfort medications, sleepless evenings and also the concern of making it via the day while enduring pain.
Have you attempted massage?
A current survey by the American Hospital Association shows that almost 82 percent of healthcare facilities that use some type of corresponding or alternative treatment provide the usage of massage treatment, with 70 percent of those health centers utilizing massage therapy for pain management as well as pain relief.
A consumer study commissioned by the American Massage Therapy Association? (AMTA) reveals that more individuals compared to ever before are looking for massage to manage and eliminate pain. The survey shows that almost half, 47 percent, of those polled have had a massage particularly for discomfort relief.
A 2003 study of 1,998 massage customers revealed that 63 percent thought massage treatment provided them higher discomfort relief compared to chiropractic care, acupuncture, physical treatment or other bodywork.
Scientific research study has actually revealed massage treatment can:.
- Be more effective for persistent neck and back pain than various other corresponding treatments.
- Promote relaxation and relieve the understanding of discomfort and also anxiety in cancer patients.
- Lower post-traumatic frustrations much better than ice bag therapies.
- Decrease discomfort and muscle mass spasms in people that have undertaken heart bypass surgery when part of hospital-based surgery therapy.
- Boost the mind to produce endorphins.
- Improve self-confidence by encouraging people to successfully cope with their pain.
If you have chronic pain, talk with your doctor regarding adding massage by a qualified massage therapist to your pain monitoring program. Locating a trained as well as competent certified massage therapist is essential, so search for a participant of AMTA.
How to back-pain relief with Massage Therapist: A Consumer Reports survey of 3,562 back-pain sufferers. 101 That helped back pain in 2017
That found that more than 80 percent of those who had seen a massage therapist or chiropractor or tried yoga or tai chi said it had helped them. This is supported by a new guideline from the American College of Physicians (ACP) recommending massage therapy for low back pain.
PHOTO-ILLUSTRATION: BRYAN CHRISTIE DESIGN
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