The Massage Therapy Guide to Low Back Pain
Low back pain is one of the leading causes of disability and lost productivity in our modern society. It's estimated that over 80% of adults will experience back pain at least once, and about 1 in 3 experience it on a regular basis.
The Problem with Medical Care for Back Pain
Occasionally, back pain is a symptom of a more serious health issue that requires medical attention, but the vast majority of back pain episodes don't require medical care.
Medicine's track record with back pain is not great. For many medical doctors, if there isn't a neurological or spinal problem that shows up on imaging tests, there isn't much they can do to help you get out of pain and heal. The most common treatment for back pain by medical doctors is drug therapy, such as muscle relaxants or "pain killers."
Treatments like medications don't actually work at healing injured tissues, but simply numb the pain sensations we feel. Research also shows that muscle relaxants are ineffective at treating back pain and simply provide symptomatic relief. Drugs also have high risks of negative side effects and addiction, as we've seen with the opiate crisis in the US.
In extreme cases, medical doctors will resort to surgery for some patients with chronic back pain. About 100,000 people have back surgery each year in the US, with little evidence that it's effective. In fact, recurrence of pain and trauma caused by surgery are so common that there's actually a name for it: Failed Back Surgery Syndrome. About 40% of patients who undergo back surgery have pain that returns within two years.
A 2017 book called Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery reports that we spend $100 billion a year on low back pain in the United States, with very poor results.
Medical care is also expensive. An average doctor's visit can easily cost a few hundred dollars and if a doctor orders imaging (x-rays, MRI, or CT scans), the costs can run into the thousands very quickly.
What are the most common causes of back pain?
While there rare instances of organic lesions causing back pain (such as cancer, disk herniations, infection, or fracture), about 90% of back pain has a source that's "unclear." 1
A growing body of scientific literature seems to indicate that the vast majority of back pain cases are due to muscle dysfunction or injury.
How Do Muscles Cause Low Back Pain?
One of the most overlooked causes of back pain is the role of muscle and fascia. While a medical doctor will look for indications of bone, disk, or neurological problems, most doctors aren't adept at dealing with muscular issues.
Research shows that our core muscle strength plays a large role in the development of low back pain. This makes sense: the entire function and movement of our spine, hips, torso, and limbs is controlled by our muscles. Our muscles can create back pain in a variety of ways:
Muscles Can Be Weak
If you don't use your core muscles on a regular basis, they'll lose tone and become weak. Weak muscles can't stabilize your spine as intended, which in turn can make it easier for you to get injured. In fact, one of the key components to recovering from and preventing back pain is to work to build core strength. A 2018 study found that women rowers with poor core strength were more likely to develop back pain.2
Muscles Can Be Imbalanced
It's not uncommon for people to have some core muscle imbalances. This can be caused by postural issues or the tendency to exercise certain muscles more than others. The key to health is balance, and this holds true for our core musculature.
Muscles Can Be Strained by Poor Posture
If we sit or stand incorrectly, this can put tremendous strains on certain muscles in our back and abdomen. These strains can then lead to other issues such as changes in gait or exercise patterns.
Muscles Can Be Injured
This is a common source of back pain. One weekend we're cleaning the garage and we overexert ourselves and "pull a muscle." These types of muscle injuries cause pain that can eventually turn into chronic problems, as they cascade into other muscle dysfunction and tension.
Muscle Spasm Can Be Secondary to Spinal Injury
Our bodies react to trauma or injury by "guarding" the area from further injury. For the low back, that means creating muscle spasm that limit motion in the injured area. If left untreated, these muscle spasms can persist even after the original injury has healed.
Can Massage Therapy Help Treat Back Pain?
Since muscle strength, injury, and health plays such a large role in the development and treatment of back pain, it makes sense that massage therapy will be useful in helping patients recover.
In fact, massage therapy is the most commonly used non-medical therapy for back pain. A 2015 study (Broom et al) found that about 25% of women who suffer from back pain use massage to get relief.
Is massage beneficial for back pain? Let's see what the medical literature has to say.
The 2011 Seattle Study
This 2011 study3 done in Seattle started with 400 adults who had back pain lasting at least three months. All of the patients were screened to make sure that none of them had any organic cause of their pain. None of the patients had had massage in the previous year.
The 400 patients were divided into three groups:
- The first group received "Structural Massage," which was intended to identify and alleviate musculoskeletal contributors to back pain, allowed myofascial, neuromuscular, and other soft tissue techniques."
- The second group of patients received relaxation massage.
- The third group acted as the control and they received regular medical care.
The massage patients received a weekly massage for ten weeks and then all of the test subjects were re-evaluated at the end of the study, at six months, and one year later.
At the 10-week mark, all of the massage therapy patients (in both groups) had experienced significantly more improvement in back pain measures: they had improved mental health, used fewer NSAIDs for their pain, had less disability, had overall better improvement, and were much happier with their care than the patients with usual medical care.
The massage patients maintained more improvement at the 26-week follow-up, but there didn't seem to be any difference in groups at the 1-year checkup.
2000 Toronto Study
This was a smaller study4 of 98 people with subacute back pain. The participants were separated into four groups:
- The first group received comprehensive treatment that included massage, exercises, and postural education.
- The second group received massage only, with no additional services.
- The third group received remedial exercise instruction.
- The fourth group received a sham laser therapy treatment. This was the control group.
All of the study subjects received six treatments over the course of a month.
The authors found that both of the massage therapy groups had significant improvements in pain and function when compared to the exercise and sham treatment groups, with the greatest improvements seen in the comprehensive treatment group:
"All subjects' reported levels of pain in the comprehensive massage therapy group decreased in intensity from baseline to post treatment, which did not occur in any other group. At the 1-month follow-up, 63% of the subjects in the comprehensive massage therapy group reported no pain, as compared with 27% in the soft-tissue manipulation group, 14% in the exercise group and 0% in the sham laser group."
Massage Therapy and Multi-Disciplinary Treatment of Back Pain
While massage is a fantastic way of working on the myofascial aspect of low back pain, most research shows that massage therapy works even better when used with other modalities.
As we mentioned earlier, core muscle strength and balance plays an important role in maintaining a healthy, pain-free spine and low back. In a study by British researchers,5 patients with back pain performed core stabilizing activities and some of the patients were then given trigger point therapy. Those patients who received both interventions had better outcomes.
Most back pain patients who use massage therapy for relief also take advantage of chiropractic adjustments, yoga, or Pilates as a way to reduce pain and increase core strength and flexibility.
In 2017, the American College of Physicians published their clinical guidelines for low back pain. They wrote that for acute and subacute pain:
"[C]linicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation…"
While more research needs to be done on the clinical benefits of massage therapy for back pain, avoiding drugs, surgery, and expensive interventions should be the first priority. Massage therapy is an important part of that mission.
- Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Practice & Research: Clinical Rheumatology 2010 Dec;24(6):769-81. doi: 10.1016/j.berh.2010.10.002. Review. PubMed PMID: 21665125.
- Gonzalez SL, Diaz AM, Plummer HA, Michener LA. Musculoskeletal Screening to Identify Female Collegiate Rowers at Risk for Low Back Pain. Journal of Athletic Training. 2018 Dec;53(12):1173-1180. doi: 10.4085/1062-6050-50-17. Epub 2018 Dec 7. PubMed PMID: 30525938; PubMed Central PMCID: PMC6365069.
- Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Annals of Internal Medicine 2011;155(1):1-9.
- Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ. 2000 Jun 27;162(13):1815-20. PubMed PMID: 10906914; PubMed Central PMCID: PMC1231369.
- Trampas A, Mpeneka A, Malliou V, Godolias G, Vlachakis P. Immediate Effects of Core-Stability Exercises and Clinical Massage on Dynamic-Balance Performance of Patients With Chronic Specific Low Back Pain. Journal of Sports Rehabilitation 2015 Nov;24(4):373-83. doi: 10-1123/jsr.2014-0215. Epub 2014 Dec 4.
- Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PubMed PMID: 28192789.