Complementary Therapies in Medicine (2015) 23, 1—6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Chinese massage combined with core stability exercises for nonspecific low back pain: A randomized controlled trial Yingjie Zhang a, Shujie Tang b,∗, Guangmin Chen c, Yuanmei Liu d a
Pain Department, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China b Department of Traditional Chinese Medicine, Medical School, Jinan University, Guangzhou 510632, China c Department of Orthopaedics, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China d Department of Internal Medicine, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China Available online 3 January 2015
KEYWORDS Visual analog scale (VAS); Oswestry disability index (ODI); Nonspecific low back pain (NSLBP); Core stability exercises; Chinese massage
∗
Summary Objective: To determine the effect of Chinese massage combined with core stability exercises on nonspecific low back pain. Methods: In the prospective study, ninety-two participants with nonspecific low back pain were divided into experimental and control group at random, and 46 in each. The experimental group were treated using Chinese massage combined with core stability exercises, while the control group were treated using Chinese massage alone. The two groups were evaluated using visual analog scale and Oswestry disability index at baseline, immediately after two and eight weeks. In addition, the recurrence rate of nonspecific low back pain was evaluated one year after the last intervention. Results: Two weeks after treatment, both VAS and ODI scores decreased significantly in two groups (p < 0.05), when compared with the values before treatment, but no difference between the two groups (p > 0.05). Eight weeks later, the VAS and ODI scores decreased significantly in both groups (p < 0.05); at the same time, both VAS and ODI scores were significantly lower (p < 0.05) in the experimental group than those in the control group. At the final follow-up, five cases recurred in the experimental group and nineteen cases in the control group, the control group has a significantly higher recurrence rate (p < 0.05). Conclusion: Core stability exercises can improve the therapeutic effect of Chinese massage in treating nonspecific low back pain. © 2014 Elsevier Ltd. All rights reserved.
Corresponding author at: 601 Huangpu dadao Road, Guangzhou City, Guangdong Province 510632, China. Tel.: +86 020 85223269. E-mail address: [email protected] (S. Tang).
http://dx.doi.org/10.1016/j.ctim.2014.12.005 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
2
Introduction Low back pain (LBP) is one of the most common musculoskeletal disorders,1 and in USA about 80% of adults had an LBP episode at least once in their lives. LBP is usually regarded as self-limiting, but approximately 16—62% of acute cases may develop chronic pain,2 and its recurrence rate is as high as 85%.3 LBP is the primary cause of absenteeism and disability in industrialized societies,4 exerting a large burden on the health care system. The cause of low back pain is not clear in almost 85% of LBP patients, and these LBP were called nonspecific low back pain (NSLBP). NSLBP is reported to be closely correlated to poor lumbar stability, and clinical trials showed that training muscles could stabilize the trunk and reduce short and long term symptoms of LBP.5 Lumbar exercise can improve the support and stabilization of lumbar spine, avoiding the pain and improving the proprioception related to the dysfunction.6 In recent years, core stability exercises have been carried out widely in rehabilitation of LBP, which has a positive effect on reducing pain7 and elevating the trunk stability to facilitate skilled motor behavior.8 In a meta-analysis, Wang and colleagues found compared to general exercise, core stability exercise was more effective in decreasing pain and improving physical function in patients with LBP.9 In addition, massage is also a common nonsurgical method widely used to treat LBP. In a systematic review, Kumar concluded that massage was an effective treatment option for NSLBP, when compared to placebo and some other active treatment options.10 Chinese massage, as one of the complementary and alternative therapies, has a long history in China, which is popular for various diseases including neck pain, LBP, dysmenorrhea, pediatric torticollis, and cibophobia.11 Some clinical reports from Pang, Zhang, Cai and Liu have confirmed the effectiveness of Chinese massage on LBP.12—15 As core stabilities exercises can stabilize the lumbar structures, we assume that it may improve the effectiveness of Chinese massage and decreasing the recurrence rate of NSLBP when it was performed combined with Chinese massage. Although some studies have confirmed the effectiveness of Chinese massage or core stabilities exercises on NSLBP, no trials have been reported on the effect of Chinese massage combined with core stability exercises for improving the symptoms and decreasing the recurrence rate in patients with NSLBP. Therefore, the objective of this randomized controlled trial was to determine whether Chinese massage combined with core stability exercises may exert greater improvement on NSLBP than massage therapy alone, and help physicians’ better make strategies.
Materials and methods Design We used a pragmatic randomized controlled trial to evaluate the effectiveness of Chinese massage combined with core stability exercises on NSLBP. The study was approved by the Ethics Committee of Qingzhou hospital of traditional Chinese
Y. Zhang et al. medicine, and an informed consent form was signed by all the participants. The included participants were randomly assigned into experimental or control group. The experimental group received Chinese massage combined with core stabilization exercises, while the control group experienced Chinese massage therapy alone. After the baseline assessment, an independent physician took a sealed opaque envelope for each participant, from a box following a numerical sequence generated by computer, which contained a piece of paper indicating whether the subject belonged to the experimental or control group. The sample size was calculated according to the formula, i.e., n = 2(˛ + ˇ )2 2 /ı2 . In the formula, ˛ and ˇ are the probability of type-1 and 2 error, is standard deviation in standard-therapy group, ı is the difference of means between standard-therapy and experimental group.16 An ˛ level of 0.05 and power of 0.90 and allowing for 10% loss to follow-up were set, the estimation of and ı were performed according to our previous preliminary experiment as well as some published literatures.17,18
Subjects Participants were recruited from patients with NSLBP in Qingzhou hospital of traditional Chinese medicine between March 2011 and June 2012. The inclusion and exclusion criteria were based on the published literature.11 Inclusion criteria: (1) age < 55 years; (2) having NSLBP without any relevant ongoing pathologies such as disc prolapse, fractures, spondylolisthesis, tumor, osteoporosis, or infection; (3) willing to participate in this study and signing informed consent.11 Exclusion criteria: (1) other pain syndromes; (2) spinal surgery in the past 6 months or having to undergo surgery or invasive examinations during the study; (3) neurological disease; (4) psychiatric disease; (5) serious chronic disease that could interfere with the outcomes (e.g., cardiovascular disease, rheumatoid arthritis, epilepsy, or other disqualifying conditions); (6) pregnant or planning to become pregnant during the study.11
Treatment The treatment including Chinese massage and core stability exercises was carried out in Qingzhou hospital of traditional Chinese medicine. In experimental group, the participants received Chinese massage including rolling, rubbing, pushing, oblique-pulling, stroking and tapotement, which was performed in the low back for 40 min, once daily for eight weeks, by professional therapists. In addition, the participants performed core stability exercises including plank, side plank, bridge, straight leg raise and modified push-up, each movement was performed ten times for one arm/leg, once daily for eight weeks. Before the beginning of the treatment, the participants in the experimental group were given an individual specific core stability exercises instruction by the researchers, and at time point, the participants in the experimental group were asked to demonstrate the exercises to ensure that they had mastered the train. In control group, the participants received the same treatment of Chinese massage as the experimental group, but didn’t receive the core stability exercises.
Chinese massage combined with core stability exercises for nonspecific low back pain
Outcomes assessment Demographic characteristics including age, gender, weight, height, level of education, and employment status were collected before treatment. The clinical outcomes of two groups were assessed using visual analog scale (VAS) and Oswestry disability index (ODI) by a surgeon unaware of the grouping, at baseline, immediately after two and eight weeks. The VAS was used to assess the pain intensity. The participants subjectively recorded their pain on a sheet of 10-cm long paper divided by 10 lines. Pain was rated on a scale of 0—10, in which 0 correspond to no pain, while 10 correspond to the severest pain which the participant could not stand.19 The ODI was used to evaluate the functional status of participants, i.e. the influence of NSLBP on daily function. ODI consists of items addressing different aspects of daily living skills; each of them is scored from 0 to 5, and a higher value represents greater disability. The total score is multiplied by two and expressed as a percentage.20 0—10 scores (ODI, 0—20%) mean that patients can cope with most activities of daily living, and no treatment may be indicated, while a score of 41—50 suggests high level of disability (ODI, 80—100%) and these patients may be bed bound. A one-year follow-up was performed after the last intervention to determine the recurrence rate of NSLBP. Recurrence rate is difficult to estimate, as its definition is not standardized across different studies.21 In the current study, recurrence was defined as a return of LBP lasting at least 24 h with a pain intensity of >20 mm on a 100 mm VAS following a period of at least 30 days pain free.22 During the follow-up, a telephone questionnaire, administered by a physician who was blind to the previous treatment and group allocation of the study, was selected as the assessment tool. Using the questionnaires, the episodes, length and severity of LBP were recorded, then the recurrence or not was determined.23 The recurrence rate was defined as the percentage between the number of participants suffering from recurrence and those recovering from pain after the treatment, we use the term recovery from pain when the participants had a pain-free period for at least 30 days during follow-up.
Statistical analysis Statistical analysis was performed using SPSS17.0 (SPSS Inc., Chicago, IL, USA). Between-group difference of demographic characteristics at baseline, including age, gender, weight, height, level of education and employment status, was analyzed using Independent-samples t-test or Chi-square test. The comparison of VAS and ODI score at baseline, two weeks and eight weeks after treatment were carried out using analysis of variance (ANOVA), and the comparison of recurrence rate between two groups at the final follow-up was performed by Chi-square test. A two-sided P value of less than 0.05 indicated statistical significance.
Results Between March 2011 and June 2012, 236 patients chose Chinese massage or core stability exercises for NSLBP. 117 were
3
rejected for the sake of exclusion criterion, and 27 patients could not participate in the random assignment because of scheduling conflicts. Therefore, 92 eligible participants were at random assigned in equal number to either experimental or control group. During the trial, five participants withdrew from the study two weeks after treatment for lack of time: three from the experimental group and two from the control group. The trial flowchart is presented in Fig. 1. The baseline characteristics of the participants was listed in Table 1. There was no significant difference in age, gender, height, weight, duration of pain, level of education, and marital status between the experimental and control group (Table 1). In addition, the scores of VAS and ODI before therapy were also well balanced between the two groups (Table 2). The results listed in Table 2 showed that, two weeks after treatment, the VAS (p < 0.05) and ODI (p < 0.05) score decreased significantly when compared to the baseline in both groups, but no significant difference was found between the two groups (p > 0.05). Similarly, eight weeks after treatment, the VAS (p < 0.05) and ODI (p < 0.05) score were significantly reduced in both groups, when compared to the baseline. However, both the VAS (p < 0.05) and ODI (p < 0.05) scores were significantly lower in the experimental group than those in the control group. The five participants who did not complete the eight weeks treatment were considered not to have any changes in VAS and ODI scores. At the final follow-up, a pain-free period for at least 30 days after treatment was confirmed by all the participants accepting telephone questionnaire. However, two participants in the control group were lost because of inability to contact. We assume the two lost participants didn’t suffer from the recurrence. In addition, five cases recurred in the experimental group and nineteen recurred in the control group, then the recurrence rate in the control group was 43.2%, and the experimental group was 11.6%. The control group has a significantly higher recurrence rate (X2 = 5.19, p = 0.036), compared with experimental group. The patients in the control group were 6.5 times more likely to experience recurrences of NSLBP than those in the experimental group
Discussion According to the basic theory of traditional Chinese medicine, low back pain was attributed to kidney deficiency. In the current study, Chinese massage was performed along governor vessel and bladder meridian, which can dredge the meridian and collaterals, reduce the excess and tonify the deficiency of kidney. In addition, Chinese massage can release the spasm, improve the circulation, decrease the edema and aseptic inflammation of the local tissues, relieve the compression of nervous tissue24 and subsequently, Chinese massage can improve the symptoms of NSLBP. In the current study, we found in the control group, compared to the baseline, both the VAS and ODI scores were significantly reduced after treatment, indicating Chinese massage can improve the symptoms of NSLBP, and this is consistent with the viewpoints of previous literatures.12,14,15 Although the exact cause of NSLBP is unclear, many authors suggested that it was closely correlated to the
4
Y. Zhang et al.
Fig. 1
Flow of the participants through the trial.
lumbar instability. The declined lumbar stability and muscle strength play an important role in the occurrence of LBP. However, belonging to a passive physical therapy, massage can’t improve the muscle strength and stabilize the lumbar spine. Consequently, Chinese massage, from a long run, may not decrease the recurrence rate of NSLBP. In the current study, the recurrence rate is 43.2% in the control group, which is consistent with the reported rate2 and confirmed the abovementioned viewpoints. Similarly, Kumar’s study
highlighted the same viewpoints, in a systematic review, he and colleagues concluded that massage is effective for LBP in improving short-term pain and disability, but no evidence was found for the long-term (beyond 6 months) effectiveness.10 In addition, the trial showed the core stability exercises combined with Chinese massage was more effective for NSLBP than massage alone, which was evident in VAS and ODI score eight weeks after treatment. Also, the
Chinese massage combined with core stability exercises for nonspecific low back pain Table 1
The baseline characteristics of the two groups.
Age Gender Male Female Height (cm) Weight (kg) Duration of pain 12 weeks or less 12 weeks or more Education Primary school Secondary school University/college Marrital status Single Married Divorced Working status Working full-time Working part-time Not working
Table 2
5
Experimental group (n = 46)
Control group (n = 46)
p value
48.71 ± 3.89
51.62 ± 4.03
0.71 0.66
29 17 166.9 70.2
31 15 168.1 73.4
26 20
29 17
8 14 24
10 12 24
0.60 0.64 1.00
3 39 4
5 38 3
0.46 0.78 0.69
39 4 3
37 5 4
0.58 0.73 0.69
0.56 0.73 0.52
The comparison of Oswestry disability index and visual analog scale between groups.
Before treatment Two weeks after treatment Eight weeks after treatment
Oswestry disability index (ODI)
Visual analog scale (VAS)
E group
C group
E group
C group
29.65 ± 8.76a 21.58 ± 6.34a,b 13.20 ± 2.42c,b
27.89 ± 9.03 23.41 ± 7.43b 18.39 ± 3.67b
7.51 ± 1.56a 3.88 ± 1.31a,b 1.46 ± 0.76c,b
7.58 ± 1.54 4.12 ± 1.33b 2.85 ± 1.58b
E group, experimental group; C group, control group. a Denotes p > 0.05 when compared to control group. b Denotes p < 0.05 in intragroup comparison before and after treatment. c Denotes p < 0.05 when compared to control group.
recurrence rate in the experimental group is significantly lower than that in the control group at the final followup. The better effectiveness of experimental group can be contributed to the core stability exercises. Different from Chinese massage, core stability exercises can improve the activation of deep fibers and the cross-sectional area of the lumbar multifidus,25,26 subsequently it can improve the lumbar stability and decrease the recurrence rate of NSLBP. In a study of systemic review, Choi and colleagues27 concluded that there is moderate quality evidence that post-treatment exercise programs can prevent recurrences of LBP. In the current study, our clinical results confirmed the viewpoint further. In addition, no adverse events were observed during the interventions, indicating that Chinese massage combined with core stability exercises may be a safe, effective therapy for NSLBP. However, the current study has some limitations. First, blinding therapists was difficult in this trial, and the therapist could find the difference between the groups. It might
influence the result of the trial, but we thought its impact might be limited, because the assessors of clinical outcomes were unaware of the grouping and the detailed therapy in the two groups. Second, in the current study, we evaluated the clinical results using self-reported measures of function, not an objective measurement of function or physical activity, which may have some influence on the final result. Even so, the current randomized controlled trial made a significant contribution to the evidence on the effectiveness of Chinese massage combined with core stability exercises in patients with NSLBP. Our findings suggested that core stability exercises can improve the therapeutic effect of Chinese massage in treating NSLBP.
Conflict of interest There is no conflict of interest to declare.
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Sources of funding None.
References 1. Miyamoto GC, Costa LO, Galvanin T, Cabral CM. The efficacy of the addition of the Pilates method over a minimal intervention in the treatment of chronic nonspecific low back pain: a study protocol of a randomized controlled trial. J Chiropr Med 2011;10:248—54. 2. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003;12:149—65. 3. Feng C, Zhang T. Clinical orthopaedics. Beijing: People’s Medical Publishing House; 2004. 4. Lehtola V, Luomajoki H, Leinonen V, Gibbons S, Airaksinen O. Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a subgroup of patients with movement control dysfunction. Protocol of a randomized controlled trial. BMC Musculoskelet Disord 2012;13:55. 5. Adorno ML, Brasil-Neto JP. Assessment of the quality of life through the SF-36 questionnaire in patients with chronic nonspecific low back pain. Acta Ortop Bras 2013;21:202—7. 6. Maul I, Laubli T, Oliveri M, Krueger H. Long-term effects of supervised physical training in secondary prevention of low back pain. Eur Spine J 2005;14:599—611. 7. Bliss LS, Teeple P. Core stability: the centerpiece of any training program. Curr Sports Med Rep 2005;4:179—83. 8. Miyake Y, Kobayashi R, Kelepecz D, Nakajima M. Core exercises elevate trunk stability to facilitate skilled motor behavior of the upper extremities. J Bodyw Mov Ther 2013;17:259—65. 9. Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS ONE 2012;7:e52082. 10. Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. Int J Gen Med 2013;6:733—41. 11. Kong LJ, Fang M, Zhan HS, et al. Chinese massage combined with herbal ointment for athletes with nonspecific low back pain: a randomized controlled trial. Evid Based Complement Alternat Med 2012;2012:695726. 12. Pang RC, Zhang AR, Hu B, Zhao JN, Yang HP, Wang HG. Treating lumbar spinal stenosis using kinesitherapy and Tuina. China Rehabil 2006;21:397.
Y. Zhang et al. 13. Zhang Y, Chen P, Ke JL. Treating lumbar spinal stenosis using Tuina and fumigating and washing: report of 112 cases. J Tradit Chin Med Zhejiang 2010:838—9. 14. Cai K. Tuina treating lumbar degenerative spinal stenosis: report of 56 cases. Bone Setting Tradit Chin Med 1999:27—8. 15. Liu HB. Tuina treating lumbar spinal stenosis:report of 38 cases. Modern Rehabil 2000:1051. 16. Deng Wei, He Jia. Design and statistical analysis of clinical trials. Beijing: People’s Medical Publishing House; 2012. 17. Bonetti F1, Curti S, Mattioli S, Mugnai R, Vanti C, Violante FS, Pillastrini P. Effectiveness of a ‘Global Postural Reeducation’ program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord 2010;11:285. 18. Schenkman ML, Jordan S, Akuthota V, Roman M, Kohrt WM, Hearty T, Cleary C, Backstrom KM. Functional movement training for recurrent low back pain: lessons from a pilot randomized controlled trial. PM&R 2009;1:137—46. 19. Lee CW, Hwangbo K, Lee IS. The effects of combination patterns of proprioceptive neuromuscular facilitation and ball exercise on pain and muscle activity of chronic low back pain patients. J Phys Ther Sci 2014;26:93—6. 20. Veresciagina K, Ambrozaitis KV, Spakauskas B. The measurements of health-related quality-of-life and pain assessment in the preoperative patients with low back pain. Medicina (Mex) 2009;45:111—22. 21. Weiner SS, Nordin M. Prevention and management of chronic back pain. Best Pract Res Clin Rheumatol 2010;24: 267—79. 22. Stanton TR, Latimer J, Maher CG, Hancock MJ. A modified Delphi approach to standardize low back pain recurrence terminology. Eur Spine J 2011;20:744—52. 23. Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine (Phila Pa 1976) 2001;26:E243—8. 24. Su CM. Tuina treating lumbar spinal stenosis: review of literatures. Massage Daoyin 2008;24:43—5. 25. Standaert CJ, Weinstein SM, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Spine J 2008;8:114—20. 26. Aluko A, DeSouza L, Peacock J. The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial. J Manipulative Physiol Ther 2013;36, 497.e1—504.e3. 27. Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev 2010:CD006555.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Chinese massage combined with core stability exercises for nonspecific low back pain: A randomized controlled trial Yingjie Zhang a, Shujie Tang b,∗, Guangmin Chen c, Yuanmei Liu d a
Pain Department, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China b Department of Traditional Chinese Medicine, Medical School, Jinan University, Guangzhou 510632, China c Department of Orthopaedics, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China d Department of Internal Medicine, Qingzhou Hospital of Traditional Chinese Medicine, Qingzhou, Shandong Province 262500, China Available online 3 January 2015
KEYWORDS Visual analog scale (VAS); Oswestry disability index (ODI); Nonspecific low back pain (NSLBP); Core stability exercises; Chinese massage
∗
Summary Objective: To determine the effect of Chinese massage combined with core stability exercises on nonspecific low back pain. Methods: In the prospective study, ninety-two participants with nonspecific low back pain were divided into experimental and control group at random, and 46 in each. The experimental group were treated using Chinese massage combined with core stability exercises, while the control group were treated using Chinese massage alone. The two groups were evaluated using visual analog scale and Oswestry disability index at baseline, immediately after two and eight weeks. In addition, the recurrence rate of nonspecific low back pain was evaluated one year after the last intervention. Results: Two weeks after treatment, both VAS and ODI scores decreased significantly in two groups (p < 0.05), when compared with the values before treatment, but no difference between the two groups (p > 0.05). Eight weeks later, the VAS and ODI scores decreased significantly in both groups (p < 0.05); at the same time, both VAS and ODI scores were significantly lower (p < 0.05) in the experimental group than those in the control group. At the final follow-up, five cases recurred in the experimental group and nineteen cases in the control group, the control group has a significantly higher recurrence rate (p < 0.05). Conclusion: Core stability exercises can improve the therapeutic effect of Chinese massage in treating nonspecific low back pain. © 2014 Elsevier Ltd. All rights reserved.
Corresponding author at: 601 Huangpu dadao Road, Guangzhou City, Guangdong Province 510632, China. Tel.: +86 020 85223269. E-mail address: [email protected] (S. Tang).
http://dx.doi.org/10.1016/j.ctim.2014.12.005 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
2
Introduction Low back pain (LBP) is one of the most common musculoskeletal disorders,1 and in USA about 80% of adults had an LBP episode at least once in their lives. LBP is usually regarded as self-limiting, but approximately 16—62% of acute cases may develop chronic pain,2 and its recurrence rate is as high as 85%.3 LBP is the primary cause of absenteeism and disability in industrialized societies,4 exerting a large burden on the health care system. The cause of low back pain is not clear in almost 85% of LBP patients, and these LBP were called nonspecific low back pain (NSLBP). NSLBP is reported to be closely correlated to poor lumbar stability, and clinical trials showed that training muscles could stabilize the trunk and reduce short and long term symptoms of LBP.5 Lumbar exercise can improve the support and stabilization of lumbar spine, avoiding the pain and improving the proprioception related to the dysfunction.6 In recent years, core stability exercises have been carried out widely in rehabilitation of LBP, which has a positive effect on reducing pain7 and elevating the trunk stability to facilitate skilled motor behavior.8 In a meta-analysis, Wang and colleagues found compared to general exercise, core stability exercise was more effective in decreasing pain and improving physical function in patients with LBP.9 In addition, massage is also a common nonsurgical method widely used to treat LBP. In a systematic review, Kumar concluded that massage was an effective treatment option for NSLBP, when compared to placebo and some other active treatment options.10 Chinese massage, as one of the complementary and alternative therapies, has a long history in China, which is popular for various diseases including neck pain, LBP, dysmenorrhea, pediatric torticollis, and cibophobia.11 Some clinical reports from Pang, Zhang, Cai and Liu have confirmed the effectiveness of Chinese massage on LBP.12—15 As core stabilities exercises can stabilize the lumbar structures, we assume that it may improve the effectiveness of Chinese massage and decreasing the recurrence rate of NSLBP when it was performed combined with Chinese massage. Although some studies have confirmed the effectiveness of Chinese massage or core stabilities exercises on NSLBP, no trials have been reported on the effect of Chinese massage combined with core stability exercises for improving the symptoms and decreasing the recurrence rate in patients with NSLBP. Therefore, the objective of this randomized controlled trial was to determine whether Chinese massage combined with core stability exercises may exert greater improvement on NSLBP than massage therapy alone, and help physicians’ better make strategies.
Materials and methods Design We used a pragmatic randomized controlled trial to evaluate the effectiveness of Chinese massage combined with core stability exercises on NSLBP. The study was approved by the Ethics Committee of Qingzhou hospital of traditional Chinese
Y. Zhang et al. medicine, and an informed consent form was signed by all the participants. The included participants were randomly assigned into experimental or control group. The experimental group received Chinese massage combined with core stabilization exercises, while the control group experienced Chinese massage therapy alone. After the baseline assessment, an independent physician took a sealed opaque envelope for each participant, from a box following a numerical sequence generated by computer, which contained a piece of paper indicating whether the subject belonged to the experimental or control group. The sample size was calculated according to the formula, i.e., n = 2(˛ + ˇ )2 2 /ı2 . In the formula, ˛ and ˇ are the probability of type-1 and 2 error, is standard deviation in standard-therapy group, ı is the difference of means between standard-therapy and experimental group.16 An ˛ level of 0.05 and power of 0.90 and allowing for 10% loss to follow-up were set, the estimation of and ı were performed according to our previous preliminary experiment as well as some published literatures.17,18
Subjects Participants were recruited from patients with NSLBP in Qingzhou hospital of traditional Chinese medicine between March 2011 and June 2012. The inclusion and exclusion criteria were based on the published literature.11 Inclusion criteria: (1) age < 55 years; (2) having NSLBP without any relevant ongoing pathologies such as disc prolapse, fractures, spondylolisthesis, tumor, osteoporosis, or infection; (3) willing to participate in this study and signing informed consent.11 Exclusion criteria: (1) other pain syndromes; (2) spinal surgery in the past 6 months or having to undergo surgery or invasive examinations during the study; (3) neurological disease; (4) psychiatric disease; (5) serious chronic disease that could interfere with the outcomes (e.g., cardiovascular disease, rheumatoid arthritis, epilepsy, or other disqualifying conditions); (6) pregnant or planning to become pregnant during the study.11
Treatment The treatment including Chinese massage and core stability exercises was carried out in Qingzhou hospital of traditional Chinese medicine. In experimental group, the participants received Chinese massage including rolling, rubbing, pushing, oblique-pulling, stroking and tapotement, which was performed in the low back for 40 min, once daily for eight weeks, by professional therapists. In addition, the participants performed core stability exercises including plank, side plank, bridge, straight leg raise and modified push-up, each movement was performed ten times for one arm/leg, once daily for eight weeks. Before the beginning of the treatment, the participants in the experimental group were given an individual specific core stability exercises instruction by the researchers, and at time point, the participants in the experimental group were asked to demonstrate the exercises to ensure that they had mastered the train. In control group, the participants received the same treatment of Chinese massage as the experimental group, but didn’t receive the core stability exercises.
Chinese massage combined with core stability exercises for nonspecific low back pain
Outcomes assessment Demographic characteristics including age, gender, weight, height, level of education, and employment status were collected before treatment. The clinical outcomes of two groups were assessed using visual analog scale (VAS) and Oswestry disability index (ODI) by a surgeon unaware of the grouping, at baseline, immediately after two and eight weeks. The VAS was used to assess the pain intensity. The participants subjectively recorded their pain on a sheet of 10-cm long paper divided by 10 lines. Pain was rated on a scale of 0—10, in which 0 correspond to no pain, while 10 correspond to the severest pain which the participant could not stand.19 The ODI was used to evaluate the functional status of participants, i.e. the influence of NSLBP on daily function. ODI consists of items addressing different aspects of daily living skills; each of them is scored from 0 to 5, and a higher value represents greater disability. The total score is multiplied by two and expressed as a percentage.20 0—10 scores (ODI, 0—20%) mean that patients can cope with most activities of daily living, and no treatment may be indicated, while a score of 41—50 suggests high level of disability (ODI, 80—100%) and these patients may be bed bound. A one-year follow-up was performed after the last intervention to determine the recurrence rate of NSLBP. Recurrence rate is difficult to estimate, as its definition is not standardized across different studies.21 In the current study, recurrence was defined as a return of LBP lasting at least 24 h with a pain intensity of >20 mm on a 100 mm VAS following a period of at least 30 days pain free.22 During the follow-up, a telephone questionnaire, administered by a physician who was blind to the previous treatment and group allocation of the study, was selected as the assessment tool. Using the questionnaires, the episodes, length and severity of LBP were recorded, then the recurrence or not was determined.23 The recurrence rate was defined as the percentage between the number of participants suffering from recurrence and those recovering from pain after the treatment, we use the term recovery from pain when the participants had a pain-free period for at least 30 days during follow-up.
Statistical analysis Statistical analysis was performed using SPSS17.0 (SPSS Inc., Chicago, IL, USA). Between-group difference of demographic characteristics at baseline, including age, gender, weight, height, level of education and employment status, was analyzed using Independent-samples t-test or Chi-square test. The comparison of VAS and ODI score at baseline, two weeks and eight weeks after treatment were carried out using analysis of variance (ANOVA), and the comparison of recurrence rate between two groups at the final follow-up was performed by Chi-square test. A two-sided P value of less than 0.05 indicated statistical significance.
Results Between March 2011 and June 2012, 236 patients chose Chinese massage or core stability exercises for NSLBP. 117 were
3
rejected for the sake of exclusion criterion, and 27 patients could not participate in the random assignment because of scheduling conflicts. Therefore, 92 eligible participants were at random assigned in equal number to either experimental or control group. During the trial, five participants withdrew from the study two weeks after treatment for lack of time: three from the experimental group and two from the control group. The trial flowchart is presented in Fig. 1. The baseline characteristics of the participants was listed in Table 1. There was no significant difference in age, gender, height, weight, duration of pain, level of education, and marital status between the experimental and control group (Table 1). In addition, the scores of VAS and ODI before therapy were also well balanced between the two groups (Table 2). The results listed in Table 2 showed that, two weeks after treatment, the VAS (p < 0.05) and ODI (p < 0.05) score decreased significantly when compared to the baseline in both groups, but no significant difference was found between the two groups (p > 0.05). Similarly, eight weeks after treatment, the VAS (p < 0.05) and ODI (p < 0.05) score were significantly reduced in both groups, when compared to the baseline. However, both the VAS (p < 0.05) and ODI (p < 0.05) scores were significantly lower in the experimental group than those in the control group. The five participants who did not complete the eight weeks treatment were considered not to have any changes in VAS and ODI scores. At the final follow-up, a pain-free period for at least 30 days after treatment was confirmed by all the participants accepting telephone questionnaire. However, two participants in the control group were lost because of inability to contact. We assume the two lost participants didn’t suffer from the recurrence. In addition, five cases recurred in the experimental group and nineteen recurred in the control group, then the recurrence rate in the control group was 43.2%, and the experimental group was 11.6%. The control group has a significantly higher recurrence rate (X2 = 5.19, p = 0.036), compared with experimental group. The patients in the control group were 6.5 times more likely to experience recurrences of NSLBP than those in the experimental group
Discussion According to the basic theory of traditional Chinese medicine, low back pain was attributed to kidney deficiency. In the current study, Chinese massage was performed along governor vessel and bladder meridian, which can dredge the meridian and collaterals, reduce the excess and tonify the deficiency of kidney. In addition, Chinese massage can release the spasm, improve the circulation, decrease the edema and aseptic inflammation of the local tissues, relieve the compression of nervous tissue24 and subsequently, Chinese massage can improve the symptoms of NSLBP. In the current study, we found in the control group, compared to the baseline, both the VAS and ODI scores were significantly reduced after treatment, indicating Chinese massage can improve the symptoms of NSLBP, and this is consistent with the viewpoints of previous literatures.12,14,15 Although the exact cause of NSLBP is unclear, many authors suggested that it was closely correlated to the
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Y. Zhang et al.
Fig. 1
Flow of the participants through the trial.
lumbar instability. The declined lumbar stability and muscle strength play an important role in the occurrence of LBP. However, belonging to a passive physical therapy, massage can’t improve the muscle strength and stabilize the lumbar spine. Consequently, Chinese massage, from a long run, may not decrease the recurrence rate of NSLBP. In the current study, the recurrence rate is 43.2% in the control group, which is consistent with the reported rate2 and confirmed the abovementioned viewpoints. Similarly, Kumar’s study
highlighted the same viewpoints, in a systematic review, he and colleagues concluded that massage is effective for LBP in improving short-term pain and disability, but no evidence was found for the long-term (beyond 6 months) effectiveness.10 In addition, the trial showed the core stability exercises combined with Chinese massage was more effective for NSLBP than massage alone, which was evident in VAS and ODI score eight weeks after treatment. Also, the
Chinese massage combined with core stability exercises for nonspecific low back pain Table 1
The baseline characteristics of the two groups.
Age Gender Male Female Height (cm) Weight (kg) Duration of pain 12 weeks or less 12 weeks or more Education Primary school Secondary school University/college Marrital status Single Married Divorced Working status Working full-time Working part-time Not working
Table 2
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Experimental group (n = 46)
Control group (n = 46)
p value
48.71 ± 3.89
51.62 ± 4.03
0.71 0.66
29 17 166.9 70.2
31 15 168.1 73.4
26 20
29 17
8 14 24
10 12 24
0.60 0.64 1.00
3 39 4
5 38 3
0.46 0.78 0.69
39 4 3
37 5 4
0.58 0.73 0.69
0.56 0.73 0.52
The comparison of Oswestry disability index and visual analog scale between groups.
Before treatment Two weeks after treatment Eight weeks after treatment
Oswestry disability index (ODI)
Visual analog scale (VAS)
E group
C group
E group
C group
29.65 ± 8.76a 21.58 ± 6.34a,b 13.20 ± 2.42c,b
27.89 ± 9.03 23.41 ± 7.43b 18.39 ± 3.67b
7.51 ± 1.56a 3.88 ± 1.31a,b 1.46 ± 0.76c,b
7.58 ± 1.54 4.12 ± 1.33b 2.85 ± 1.58b
E group, experimental group; C group, control group. a Denotes p > 0.05 when compared to control group. b Denotes p < 0.05 in intragroup comparison before and after treatment. c Denotes p < 0.05 when compared to control group.
recurrence rate in the experimental group is significantly lower than that in the control group at the final followup. The better effectiveness of experimental group can be contributed to the core stability exercises. Different from Chinese massage, core stability exercises can improve the activation of deep fibers and the cross-sectional area of the lumbar multifidus,25,26 subsequently it can improve the lumbar stability and decrease the recurrence rate of NSLBP. In a study of systemic review, Choi and colleagues27 concluded that there is moderate quality evidence that post-treatment exercise programs can prevent recurrences of LBP. In the current study, our clinical results confirmed the viewpoint further. In addition, no adverse events were observed during the interventions, indicating that Chinese massage combined with core stability exercises may be a safe, effective therapy for NSLBP. However, the current study has some limitations. First, blinding therapists was difficult in this trial, and the therapist could find the difference between the groups. It might
influence the result of the trial, but we thought its impact might be limited, because the assessors of clinical outcomes were unaware of the grouping and the detailed therapy in the two groups. Second, in the current study, we evaluated the clinical results using self-reported measures of function, not an objective measurement of function or physical activity, which may have some influence on the final result. Even so, the current randomized controlled trial made a significant contribution to the evidence on the effectiveness of Chinese massage combined with core stability exercises in patients with NSLBP. Our findings suggested that core stability exercises can improve the therapeutic effect of Chinese massage in treating NSLBP.
Conflict of interest There is no conflict of interest to declare.
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Sources of funding None.
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