This study suggests that therapeutic massage has clinically important benefits at least in the short term for persons with chronic neck pain. Our findings are unlikely to be due to other treatments for neck pain, as other treatments were used infrequently in both groups. Nor can the results be attributed to greater medication use in the massage group, because this did not occur. Furthermore, these findings are unlikely due to baseline differences between the groups as the groups were quite similar across a broad range of measures. In this study, the Neck Disability Index was more sensitive to change than the Copenhagen Scale, a finding that has been reported previously.20
published a systematic review of 19 trials of massage for mechanical neck disorders. However, 13 of these included massage as part of a multimodal physiotherapy intervention and were unable to tease apart the relative contribution of massage. Moreover, these trials did not describe how much massage was actually administered. Of the 6 “massage-only” trials reviewed, 2 involved only one treatment session and 1 each studied self-administered massage, persons with headache of “cervicogenic origin,” Chinese massage, and Swedish massage. In this last trial, Irnich22
found that compared to acupuncture or sham laser treatment, massage was less likely to result in improvements in motion-related pain. Dysfunction due to neck pain was not measured. The “dose” of massage used in that study (five 30-minute treatments) was substantially less than in the present study. Furthermore, the massage given in the Irnich study does not resemble conventional massage practice in the US, where therapy sessions would be twice as long, provided by a licensed massage therapist, and include a wider range of massage techniques as well as self-care recommendations.10
Thus, none of these previous studies of massage shed light on the usefulness of the type and dose of massage used in this study or included the type of massage received by the general public seeking therapeutic massage for neck pain.
Our findings raise the question of the most clinically useful way to present a study’s results. Typically, studies of treatments for spine pain display results as mean differences between groups (or from baseline). However, such data do not always highlight important clinical differences between groups.23
For example, our dichotomized results for the primary outcomes measures showed stronger benefit for massage than the mean change between groups. Clinicians often characterize patients as having benefited or not from the treatments. Displaying study outcomes as the proportion receiving each treatment who have benefited to a clinically meaningful extent will make the study results easier for clinicians to interpret. One downside of this approach is that if the main study outcomes are dichotomized as improved (to an important extent) or not, the required sample sizes to detect a 10 – 20% difference in the proportion who have improved would usually be larger than that required to detect a mean change equal to the minimum clinically important difference.
Our trial evaluating massage for neck pain was not designed to tease apart the specific effects of soft-tissue manipulation from those attributable to the patient-provider interaction, the home practice recommendations, or expectations of the patient. Thus, our trial cannot shed light on which aspects of the massage experience might have been responsible for the benefits seen. Rather we conducted a more pragmatic trial to evaluate massage for neck pain. There were clearly differences between the two groups regarding patient provider interactions as everyone in the massage group, but only about 1 in 5 persons in the self-care group visited at least one type of health care provider during the intervention period. However, this design is most appropriate for answering clinical questions regarding the benefits of massage therapy for patients with chronic neck pain seen by primary care providers. Reassuringly, the mean scores on the Neck Disability Index were comparable to those of primary care neck pain patients in other therapeutic trials.15,24,25
Nevertheless, our study includes some important methodological strengths, notably a treatment protocol that reflected common practice, a rigorous randomization procedure, good adherence to treatment recommendations, high follow-up rates, and the use of recommended outcome measures administered by interviewers unaware of treatment group. Limitations of this study include modest size, the impossibility of masking people to study treatment (as is generally true of studies of physical treatments), follow-up of less than one year, and the absence of participants with severe neck pain. Despite these limitations, our data suggest that therapeutic massage is helpful in relieving neck pain and dysfunction for a substantial fraction of individuals, at least in the short term. Because some of the exclusion criteria for this study (e.g. exclusion of participants with cervical radiculopathy, prior neck surgery, litigation for neck pain, motor vehicle accident within the past three months, and currently receiving treatments for neck pain apart from medications) may well have eliminated some people who would seek massage therapy for their neck pain in the community, future studies would be required to evaluate the effectiveness of massage in such individuals.
Future studies should investigate the optimal dose of massage including the number of treatments, the frequency of treatments and the length of the treatment period as well as the usefulness of “booster” sessions or self-massaging devices, in extending the time frame for these benefits. Once the treatment is optimized, larger studies should be conducted that include at least one year or longer follow-up period and patients with more severe neck pain. Such studies should include multiple outcome measures, including global rating of improvement, which we found to show an important difference between treatment groups at all follow-up interviews.