Massage therapy and non-specific low back pain

Back pain - A global health burden

Non-specific low back pain is a difficult to treat global health burden, one of the reasons for this is that like the name suggests, there is often no clear identifiable cause. There is much debate about the best way to manage low back pain, some of the strongest reviews support the need for a  multi-modal therapeutic approach. A multi-modal approach can involve a number of management strategies that include but is not limited to education, reassurance, analgesic medicines and a number of non pharmacological therapies.

Non-specific low back pain & inflammation

The diagnosis of non-specific low back pain implies no known pathoanatomical cause, however there is still a lot of discussion around the idea that the thoracolumbar fascia may be a contributor to this type of low back pain. (see Corey 2011, Willard 2012, Schilder 2014, Klinger 2014, Stecco 2016). Siegfried Mense one of the world leading researchers on muscle pain suggest that inflammation (chronic and acute) of the thoracolumbar fascia has the ability to stimulate neurogenesis of free nerve endings and sensitize nerves. 

With this in mind, it is worth noting that low back pain is a complex problem that should not be looked at in isolation. It may very well be that inflammation driven changes may contribute to the initial development of non-specific low back pain. However, in chronic low back issues central sensitization is often the primary driver of persistent symptoms. 

Manual therapy & low back pain

In the past one the primary management strategies was a pharmacological approach, but over time some of these treatments evolve into a health care crisis of their own. The Center for Disease Control and a recent article on non-specific low back pain published in The Lancet, expressed the need to move beyond a pharmacological approaches for symptom management and a called for the use of a number of non-pharmacological approaches. 

With the many documented biological and psychosocial benefits to a massage therapy, we are uniquely suited to help those who suffer from low back pain. One speed bump still in the way is the lack of systematic reviews and randomized control trials of massage therapy. There has been some movement it the last couple of years, but because because of the lack of a research culture in the profession these things take time.

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Links & References

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Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet.

Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., . . . Langevin, H. M. (2015). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of Cellular Physiology.

Best, T., Gharaibeh, B., & Huard, J. (2012). Stem cells, angiogenesis and muscle healing: A potential role in massage therapies? British Journal of Sports Medicine.

Bouffard, N. A., Cutroneo, K. R., Badger, G. J., White, S. L., Buttolph, T. R., Ehrlich, H. P., . . . Langevin, H. M. (2007). Tissue stretch decreases soluble TGF-β1 and type-1 procollagen in mouse subcutaneous connective tissue: Evidence from ex vivo and in vivo models. Journal of Cellular Physiology.

Cherkin, D. C., Sherman, K. J., Kahn, J., Wellman, R., Cook, A. J., Johnson, E., . . . Deyo, R. A. (2011). A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain. Annals of Internal Medicine.

Corey, S. M., Vizzard, M. A., Badger, G. J., & Langevin, H. M. (2011). Sensory Innervation of the Nonspecialized Connective Tissues in the Low Back of the Rat. Cells Tissues Organs.

Corey, S. M., Vizzard, M. A., Bouffard, N. A., Badger, G. J., & Langevin, H. M. (2012). Stretching of the Back Improves Gait, Mechanical Sensitivity and Connective Tissue Inflammation in a Rodent Model. PLoS ONE.

Fisher, P., Zhao, Y., Rico, M., Massicotte, V., Wade, C., Litvin, J., . . . Barbe, M. (2015). Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury. Journal of Cell Communication and Signaling.

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Hoheisel, U., & Mense, S. (2015). Inflammation of the thoracolumbar fascia excites and sensitizes rat dorsal horn neurons. European Journal of Pain.

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Kumar, S., Beaton, K., & Hughes, T. (2013). The effectiveness of massage therapy for the treatment of nonspecific low back pain: A systematic review of systematic reviews. International Journal of General Medicine.

Kregel, J., Meeus, M., Malfliet, A., Dolphens, M., Danneels, L., Nijs, J., & Cagnie, B. (2015). Structural and functional brain abnormalities in chronic low back pain: A systematic review. Seminars in Arthritis and Rheumatism.

Langevin, H. M., Stevens-Tuttle, D., Fox, J. R., Badger, G. J., Bouffard, N. A., Krag, M. H., . . . Henry, S. M. (2009). Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskeletal Disorders.

Maher, C., Underwood, M., & Buchbinder, R. (2016). Non-specific low back pain. The Lancet.

Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., & Weber, W. J. (2016). Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clinic Proceedings.

Schilder, A., Hoheisel, U., Magerl, W., Benrath, J., Klein, T., & Treede, R. (2014). Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain.

Schilder, A., Magerl, W., Hoheisel, U., Klein, T., & Treede, R. (2016). Electrical high-frequency stimulation of the human thoracolumbar fascia evokes long-term potentiation-like pain amplification. Pain.

Stecco, A., Stern, R., Fantoni, I., Caro, R., & Stecco, C. (2016). Fascial Disorders: Implications for Treatment. Pm&r.

Steffens, D., Maher, C. G., Pereira, L. S., Stevens, M. L., Oliveira, V. C., Chapple, M., . . . Hancock, M. J. (2016). Prevention of Low Back Pain. JAMA Internal Medicine.

Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the Mechanisms of Massage Efficacy: The Role of Mechanical Immunomodulation. Journal of Athletic Training.

Willard, F., Vleeming, A., Schuenke, M., Danneels, L., & Schleip, R. (2012). The thoracolumbar fascia: Anatomy, function and clinical considerations. Journal of Anatomy.

Wong, J., Côté, P., Sutton, D., Randhawa, K., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. (2016). Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain.