Massage therapy for chronic low back pain: what the evidence shows

If you live with chronic low back pain, you know how much it can affect your daily life. Many people look for ways to manage this pain, and massage therapy is one option often considered. Low back pain is a very common issue, affecting 70% to 80% of adults at some point [1].

This article looks at what scientific studies and clinical guidelines say about using massage therapy for chronic low back pain. We'll explore a major review of the evidence and how leading medical groups view massage as part of a treatment plan.

What is chronic low back back pain?

Low back pain can be described in different ways. Acute low back pain is usually new and lasts a short time. Sub-acute pain lasts a bit longer. When pain continues for an extended period, it's called chronic low back pain. The way pain is classified can be important because treatments that work for acute pain might not be as effective for chronic pain.

What a major review found about massage for low back pain

A group called Cochrane conducts systematic reviews, which are detailed summaries of research studies on a specific topic. A Cochrane review from 2015 looked at massage therapy for low back pain [1].

This review included 25 trials with 3096 participants in total. Most of these trials focused on people with sub-acute or chronic low back pain.

Here's what the review found:

• Quality of Evidence: The researchers judged the overall quality of the evidence as "low" to "very low." This was mainly because of a risk of bias in the studies and imprecision in the results.
• Acute Low Back Pain: For people with acute low back pain, massage was found to be better than inactive controls (like sham therapy or no treatment) for reducing pain in the short-term. However, it did not show improvement for function in the short-term. This finding came from one study with 51 participants [1].
• Sub-acute and Chronic Low Back Pain:
  • Compared to inactive controls: Massage was better for reducing pain and improving function in the short-term. These findings came from 7 studies (for pain, 761 participants) and 6 studies (for function, 725 participants). However, these benefits did not last into the long-term [1].
  • Compared to active controls: Active controls included treatments like exercise, physical therapy, or spinal manipulation. When massage was compared to these, it was found to be better for reducing pain in both the short-term (12 studies, 964 participants) and long-term (5 studies, 757 participants). However, there were no differences found for function in either the short or long-term when compared to active controls [1].
• Safety: The review reported no serious adverse events in any of the trials. The most common minor side effect was increased pain intensity, which was reported by 1.5% to 25% of participants [1].

The authors of the Cochrane review stated they had "very little confidence that massage is an effective treatment for LBP." They concluded that improvements in pain with massage were seen only in the short-term for acute, sub-acute, and chronic low back pain. Functional improvement was observed in people with sub-acute and chronic low back pain only in the short-term, and only when compared to inactive controls [1].

Why studying massage therapy can be challenging

Researching treatments like massage therapy can be difficult. The Cochrane review noted that a common type of bias in these studies was "performance and measurement bias" [1]. This happens because it's hard to keep participants, massage therapists, and those measuring the results unaware of who is receiving massage and who isn't.

Other challenges in studying massage include:

• Blinding: It's hard for someone to receive a massage without knowing it, or for a therapist to give a massage without knowing if it's the "real" treatment or a comparison.
• Dose: How long should a massage session be? How many sessions are needed? These details can vary between studies and affect the results.
• Type of massage: There are many different types of massage. Studies may not always specify the exact techniques used, making it hard to compare them.
• Comparator choice: Studies compare massage to either inactive controls (like a waiting list or a very light touch) or active controls (like exercise or other therapies). The type of comparison can influence how effective massage appears.

These factors can make it difficult to get a clear and certain picture of massage therapy's effects.

How massage fits into treatment guidelines

The American College of Physicians (ACP) published a clinical practice guideline in 2017 on noninvasive treatments for low back pain [2]. This guideline helps doctors and patients make informed decisions about care.

Here's what the ACP guideline recommends:

• For acute or sub-acute low back pain: The ACP suggests that clinicians and patients can choose nonpharmacologic treatments like superficial heat, massage, acupuncture, or spinal manipulation. The evidence for massage, acupuncture, and spinal manipulation was considered "low-quality evidence" [2].
• For chronic low back pain: The ACP strongly recommends that patients initially choose nonpharmacologic treatments. However, for chronic low back pain, massage is not listed as a first-line nonpharmacologic option. Instead, the guideline recommends options such as:
  • Exercise
  • Multidisciplinary rehabilitation
  • Acupuncture (moderate-quality evidence)
  • Mindfulness-based stress reduction (moderate-quality evidence)
  • Tai chi
  • Yoga
  • Motor control exercise
  • Progressive relaxation
  • Electromyography biofeedback
  • Low-level laser therapy
  • Operant therapy
  • Cognitive behavioral therapy
  • Spinal manipulation (low-quality evidence) [2]

If these nonpharmacologic therapies don't provide enough relief for chronic low back pain, the ACP guideline suggests considering medications like NSAIDs (nonsteroidal anti-inflammatory drugs) first, followed by tramadol or duloxetine. Opioids are considered only as a last resort if other treatments have failed and if the potential benefits outweigh the risks [2].

This shows that while massage is considered for short-term low back pain, other nonpharmacologic approaches are prioritized for chronic low back pain in these guidelines.

Understanding the role of a massage therapist

In several Canadian provinces, massage therapists are regulated health professionals with a statutory college behind the "registered massage therapist" (RMT) title; in others — including Alberta — the title is not backed by a statutory college, so it is worth checking how the profession works where you live and asking about a therapist's training. Massage therapists are skilled in assessing soft tissues and joints, and in applying various massage techniques to help with pain, muscle tension, and other physical issues.

When you see an RMT, they will typically:

• Assess your condition: They will ask about your health history and perform physical tests to understand your specific low back pain.
• Create a treatment plan: Based on their assessment, they will develop a plan that may include specific massage techniques.
• Provide education: They can offer advice on exercises, stretching, and posture to support your recovery and prevent future pain.

An RMT can help you understand if massage therapy is appropriate for your situation and how it might fit into your overall care plan. For more practical information, you can read our guide on massage for lower back pain.

The bottom line

The evidence suggests that massage therapy may offer short-term pain relief for people with sub-acute and chronic low back pain, especially when compared to inactive treatments. It may also help with short-term function compared to inactive controls. When compared to active treatments like exercise, massage might offer short-term and long-term pain relief, but not necessarily better function [1]. The certainty of this evidence is low to very low, and serious side effects are rare [1].

Leading guidelines, like those from the American College of Physicians, recommend nonpharmacologic treatments as a first step for chronic low back pain. While massage is suggested for acute or sub-acute pain, other therapies like exercise, acupuncture, and mindfulness are listed for chronic low back pain [2].

If you are dealing with chronic low back pain, it's important to remember that a comprehensive approach often works best. Massage therapy can be one tool in your pain management strategy, alongside other active therapies. A licensed or registered health professional, such as your doctor, a physiotherapist, or a registered massage therapist, can assess your specific situation and help you decide if massage therapy is a suitable option for you and how it can be sequenced with other care.

For information on another non-pharmacologic treatment, you can read our review on spinal manipulation for chronic low back pain.