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Massage efficacy downgraded by major meta-analysis

PainSci » bibliography » Furlan et al 2015
Tags: treatment, massage, back pain, muscle pain, neck, bad news, manual therapy, modalities, pain problems, spine, muscle, head/neck

Six pages on PainSci cite Furlan 2015: 1. Does Massage Therapy Work?2. The Complete Guide to Trigger Points & Myofascial Pain3. The Complete Guide to Low Back Pain4. The Complete Guide to Neck Pain & Cricks5. Manual Therapy: What is it, and does it work?6. Massage for back pain: an interesting scientific flip-flop

PainSci notes on Furlan 2015:

Previous versions of this meta-analysis of massage therapy for back pain (Furlan 2002 and Furlan 2008) are among the most cited scientific papers about massage therapy. This one is unlikely to wear that crown, because it has a pessimistic conclusion — a change of tune from the optimism of the previous versions. In 2008, the authors concluded that “massage might be beneficial.” In 2015, based on 25 studies instead of a thirteen, they wrote, “We have very little confidence that massage is an effective treatment.” This is a reasonable change, considering that the evidence available is that they “judged the quality of the evidence to be ‘low’ to ‘very low’, and the main reasons for downgrading the evidence were risk of bias and imprecision.” Every study of this topic has serious flaws, even the biggest and most rigorous (eg Cherkin). The evidence is inconclusive at best.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: Low-back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. It is experienced by 70% to 80% of adults at some time in their lives. Massage therapy has the potential to minimize pain and speed return to normal function.

OBJECTIVES: To assess the effects of massage therapy for people with non-specific LBP.

SEARCH METHODS: We searched PubMed to August 2014, and the following databases to July 2014: MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Index to Chiropractic Literature, and Proquest Dissertation Abstracts. We also checked reference lists. There were no language restrictions used.

SELECTION CRITERIA: We included only randomized controlled trials of adults with non-specific LBP classified as acute, sub-acute or chronic. Massage was defined as soft-tissue manipulation using the hands or a mechanical device. We grouped the comparison groups into two types: inactive controls (sham therapy, waiting list, or no treatment), and active controls (manipulation, mobilization, TENS, acupuncture, traction, relaxation, physical therapy, exercises or self-care education).

DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures and followed CBN guidelines. Two independent authors performed article selection, data extraction and critical appraisal.

MAIN RESULTS: In total we included 25 trials (3096 participants) in this review update. The majority was funded by not-for-profit organizations. One trial included participants with acute LBP, and the remaining trials included people with sub-acute or chronic LBP (CLBP). In three trials massage was done with a mechanical device, and the remaining trials used only the hands. The most common type of bias in these studies was performance and measurement bias because it is difficult to blind participants, massage therapists and the measuring outcomes. We judged the quality of the evidence to be "low" to "very low", and the main reasons for downgrading the evidence were risk of bias and imprecision. There was no suggestion of publication bias. For acute LBP, massage was found to be better than inactive controls for pain ((SMD -1.24, 95% CI -1.85 to -0.64; participants = 51; studies = 1)) in the short-term, but not for function ((SMD -0.50, 95% CI -1.06 to 0.06; participants = 51; studies = 1)). For sub-acute and chronic LBP, massage was better than inactive controls for pain ((SMD -0.75, 95% CI -0.90 to -0.60; participants = 761; studies = 7)) and function (SMD -0.72, 95% CI -1.05 to -0.39; 725 participants; 6 studies; ) in the short-term, but not in the long-term; however, when compared to active controls, massage was better for pain, both in the short ((SMD -0.37, 95% CI -0.62 to -0.13; participants = 964; studies = 12)) and long-term follow-up ((SMD -0.40, 95% CI -0.80 to -0.01; participants = 757; studies = 5)), but no differences were found for function (both in the short and long-term). There were no reports of serious adverse events in any of these trials. Increased pain intensity was the most common adverse event reported in 1.5% to 25% of the participants.

AUTHORS’ CONCLUSIONS: We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up. There were only minor adverse effects with massage.

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