ARTICLE IN PRESS

Journal of Bodywork and Movement Therapies (2007) 11, 141145

Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt

RESEARCH

Lower back pain and sleep disturbance are reduced

following massage therapy
Tiffany Fielda,b,, Maria Hernandez-Reifa, Miguel Diegoa, Monica Fraserc
a

Touch Research Institutes, University of Miami School of Medicine, P.O. Box 016820 (D-820),
Miami, FL 33101, USA
b
Fielding Graduate University, USA
c
Biotone, USA
Received 26 January 2006; received in revised form 13 March 2006; accepted 13 March 2006

KEYWORDS
Massage;
Relaxation therapy;
Back pain;
Sleep disturbance;
Anxiety

Summary A randomized between-groups design was used to evaluate massage

therapy versus relaxation therapy effects on chronic low back pain. Treatment
effects were evaluated for reducing pain, depression, anxiety and sleep disturbances, for improving trunk range of motion (ROM) and for reducing job absenteeism
and increasing job productivity. Thirty adults (M age 41 years) with low back pain
with a duration of at least 6 months participated in the study. The groups did not
differ on age, socioeconomic status, ethnicity or gender. Sessions were 30 min long
twice a week for 5 weeks. On the rst and last day of the 5-week study participants
completed questionnaires and were assessed for ROM. By the end of the study, the
massage therapy group, as compared to the relaxation group, reported experiencing
less pain, depression, anxiety and sleep disturbance. They also showed improved
trunk and pain exion performance.
& 2006 Elsevier Ltd. All rights reserved.

Introduction
Back pain is the second leading chronic pain
condition for physician visits, and the morbidity
associated with back pain is the most frequent
cause of work absenteeism (Kaaria et al., 2005).
Corresponding author. Touch Research Institutes, University
of Miami School of Medicine, P.O. Box 016820 (D-820), Miami, FL
33101, USA. Tel.: +1 305 975 5029; fax: +1 305 243 6488.
E-mail address: teld@med.miami.edu (T. Field).

Psychological variables thought to inuence the

pain experience include depression, anxiety, sleeplessness, distress and cognitive functioning.
Relaxation therapy has been used for lower back
pain (Linton et al., 1985; Nicholas et al., 1992).
Massage therapy may effectively treat lower back
pain as it has been shown to reduce pain in other
painful syndromes. For example, massage therapy
has been shown to decrease pain associated
with juvenile rheumatoid arthritis (Field et al.,
1997a), bromyalgia (Sunshine et al., 1996),

1360-8592/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2006.03.001

ARTICLE IN PRESS
142
chronic fatigue syndrome (Field et al., 1997b) and
migraine headaches (Hernandez-Reif et al., 1998).
Moreover, massage therapy has also been shown to
reduce anxiety and depression (Field et al., 1992).
In a recent study comparing massage therapy and
relaxation therapy effects on lower back pain, trunk
and pain exion performance were improved by
massage therapy and self-reported pain depression,
anxiety and sleep disturbance were decreased
(Hernandez-Reif et al., 2001). In addition, dopamine
and serotonin levels increased following a 5-week
period of two 30-min massages per week. The lesser
sleep disturbance that accompanied massage therapy
could relate to the lesser pain, as sleep disturbances
are noted to increase pain and pain-associated substances such as substance P (Field et al., 2004). The
present replication study examined massage therapy
and relaxation therapy effects for reducing chronic
low back pain, depression, anxiety, and sleep disturbance, for improving range of motion (ROM) and nally
for reducing job absenteeism and increase productivity, which were not assessed in the previous study.

Method
Participants
The sample included 30 adults (14 women) with low
back pain of a duration of at least 6-months. Power
analyzes based on our previous low back pain study
(Hernandez-Reif et al., 2001), suggested that 30
participants would be sufcient to provide for 70%
power to detect the effects massage therapy on
anxiety, mood, pain, ROM and sleep disturbance. The
participants were cleared by their primary physician
to participate in the study. Exclusion criteria were
back pain due to fractured vertebrae, herniated or
degenerated disks, patients who had undergone
surgery for their back pain, (i.e. laminectomies or
fusions) and patients with sciatic nerve involvement
or legal action pending, such as workmens compensation. The participants averaged 41 years of age and
were middle class (M 2:5 on the Hollingshead
Index), were 67% Caucasian, 9% Hispanic, 16% African
American and 8% Asian. The groups did not differ on
age, socioeconomic status, ethnicity or gender.
Participants were randomly assigned to a massage
therapy or relaxation therapy group.

T. Field et al.
massage therapists, who used Biotone Spa Replenishing Light Body Oil (Biotone, San Diego, CA, USA)
each session starting with the participant in the
prone position, resting the ankles on a small
cushion. The massage consisted of the following
techniques applied to the entire back: (1) moving
the ats of the hands across the back; (2) kneading
and pressing the muscles; and (3) short back and
forth rubbing movements on the muscles next to
the spine and the muscles that attach to the hip
bone. The following techniques were administered
to the legs: (1) long gliding strokes toward the
torso, to the entire leg; (2) kneading and moving
the skin in the thigh area; (3) pressing and
releasing, and back and forth rubbing movements
on the area between the hip and the knee on the
back of the thigh; and (4) short rubbing movements
to the small muscles around the knees. In the
supine position with a bolster under the knee, the
participants received: (1) long gliding strokes and
kneading of the neck muscles; (2) moving the ats
of the hands across the abdomen; (3) pinching and
moving the skin on the abdomen in all directions;
and (4) kneading with mixed wringing the muscles
that bend the trunk forward (rectus and oblique
muscles). Then, to the entire leg: (1) stroking; (2)
kneading followed by pressing and releasing the
anterior thigh region; (3) exing of the thigh and
knee; and (4) pulling of both legs at the same time
using direct longitudinal traction.

Relaxation therapy
A relaxation therapy group, which was included to
control for potential placebo and increased attention effects, was shown how to use progressive
muscle relaxation exercises including tensing and
relaxing large muscle groups starting with the feet
and progressing to the calves, thighs, hands, arms,
back and face. The participants were asked to
conduct these 30-min sessions at home twice a
week for 5 weeks and to keep a log on the times
they spent in relaxation therapy. They were also
called weekly to monitor their compliance.

Prepost session assessments (immediate

effects)

Procedures
Massage therapy
The massage group received two 30-min massage
therapy sessions per week over 5 weeks by trained

The following assessments were made before and

after the sessions on the rst and last days of the
5-week study. These measures were used to assess
stress, pain and ROM.

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Low back pain reduced by massage therapy
Prole of Mood States Depression Scale (POMS-D,
McNair et al., 1971)
The POMS consists of 19 adjectives rating depressed
mood using the words such as blue, sad, and
lively on a 5-point scale ranging from not at
all to extremely. The scale has adequate
concurrent validity and good internal consistency
(r :95; McNair et al., 1971) quate measure of
intervention effects (Pugatch, Haskell & McNair,
1969).
State Anxiety Inventory (STAI; Spielberger et al.,
1970)
The STAI includes 20 anxiety statements assessing
how the participant feels at that moment in terms
of severity (not at all to very much so). Characteristic items include I feel nervous and I feel
calm. The STAI scores increase in response to
stress and decrease under relaxing conditions
(Spielberger et al., 1970). The STAI has adequate
concurrent validity and internal consistency
(r :83, Spielberger, 1972).
VITAS (VITAS Healthcare Corporation, 1993)
Present pain was assessed by a Visual analog Scale
ranging from 0 (happy face) to 10 (frowning/
sad face), which represented no pain to worst
possible pain.

143
assessed for reliability prior to the start of the
study.

Firstlast day sessions (longer term effects)

On the rst and last day of the 5-week study, the
following assessments were conducted.
Sleep Scale (Verran and Snyder-Halperin, 1988)
This visual analog scale is anchored at one end
with ineffective sleep responses (e.g., Did not
awaken, Had no trouble sleeping) and at the
opposite end with ineffective responses (e.g., Was
awake 10 h, Had a lot of trouble falling asleep).
The participants were asked to place a mark across
the answer line at the point that best reected
their last nights sleep. The scale yields subcategories of sleep disturbance score. A reliability
coefcient of .82 has been reported for this scale
(Snyder-Halpern and Verran, 1987).

Job productivity and absenteeism

Participants were asked how many days they missed
at work and to rate their level of job productivity
on a scale of 0 (not at all productive) to 5 (very
productive) for the rst and last week of the study.

Results
ROM measures
While standing straight with feet placed shoulder
width apart in a normal position, the length of the
spine was measured using a tape measure. One
magic marker mark was made on the skin at the
most prominent bone at the base of the neck
(cervical vertebra bone 7) and a second mark was
made on the skin at the round bony prominence of
the backbone (lumbar vertebra 1). The distance
between these two marks was recorded in centimeters. A trunk exion ROM measure (touch toes
without pain) was then recorded, again from the
base of the neck (cervical vertebra bone 7) to the
round bony prominence of the backbone (lumbar
vertebra 1), asking the person to reach forward to
touch the toes. The trunk exion measure minus
the standing up baseline measure served as the
trunk exion ROM. A pain exion ROM measure
(touch toes to the point of pain) was then obtained,
as above, but the person was asked to reach toward
the toes or ex the trunk as far as possible, even
with pain. This measure was also subtracted from
the baseline standing up measure. All physical
measurements were collected by MHR who was

Repeated measures ANOVAs were conducted to

determine the effects of massage therapy versus
relaxation therapy on lower back pain. The
repeated measures were pre and post therapy
sessions and rst and last days of the study.
Signicant interaction effects were followed by
Bonferroni t-tests.
Group by prepost session and group by prepost
session by day interaction effects were revealed for
the massage group benets for mood and for pain.
Post Bonferroni t-tests indicated the following
(see Table 1): (1) mood as assessed by the POMS
improved following the rst session (t 2:92,
Po.009; Z2 :31) and by the end of the study
(t 2:02, Po.05; Z2 :18) and (2) pain as reported
on the VITAS decreased following each session
(t 4:98, po.001; Z2 :55 for the rst session
and t 6:01, Po.001; Z2 :64 for the second
session) and by the end of the study (t 2:29,
Po.03; Z2 :22).
Group by pre/post session interaction effects
(see Table 1) and Post Bonferroni t-tests revealed
the following: (1) state anxiety decreased for the
massage group on both days (t 4:52, Po.001;

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144

T. Field et al.

Table 1 Means (and standard deviations under means, in italics) for pre/post session measures for the rst and
last days for the massage and relaxation groups.
Measures

Massage therapy
First day
Pre

Relaxation
Last day

Post

Post

Pre

5.7aa
6.1

4.9a
5.6

7.2a
4.4

25.83b
8.3

33.9a
8.8

26.94b
9.1

36.1a
11.5

5.1a
2.9

2.7b
2.1

3.9a
2.5

1.4b
1.6

Trunk exion (cm)*

(touch toes without pain)

58.9a
7.5

62.13b
8.7

60.6a
8.4

Pain exion (cm)*

(touch toes with pain)

61.6a
8.1

63.63b
8.8

62.4a
8.1

Sleep disturbance

40.5a
24.6

Mood (POMS)

10.0a
12.9

Anxiety (STAI)

36.5a
13.3

Pain (VITAS)

4.152b
5.81

Pre

First day

26.1b
23.7

Last day
Post

Post

11.6a
13.5

6.3a
7.7

28.8a
6.0

33.4a
11.9

25.8a
5.5

4.4a
2.1

3.6a
2.2

3.1a
2.3

2.7a
2.4

61.91b
8.0

59.1a
7.9

59.7a
8.7

60.4a
4.9

60.7a
4.7

63.53b
8.1

61.1a
7.6

61.3a
8.1

63.2b
4.4

63.6b
4.0

31.8ab
19.9

4.4ab
4.0

Pre

29.6ab
15.2

*Higher score is optimal. All other measures, lower score is optimal. Different letter subscripts indicate different means.
Number superscripts indicate levels of signicance 1P :05, 2P :01, 3P :0001 for the prepost session effects and letter
subscripts indicate levels of signicance (aP :05, bP :01) for the pre session rst day versus last day effects.

Z2 :51 for the rst day and t 4:34, Po.001; Z2

:48 for the last day); (2) trunk exion increased for
the massage group on both days (t 5:18, Po.001;
Z2 :57 for the rst day and t 2:60, Po.02; Z2
:62 for the last day); and (3) trunk exion with pain
increased for the massage group on both days
(t 4:21, Po.001; Z2 :47 for the rst day and
t 4:53, Po.001; Z2 :52 for the last day). A group
by day interaction effect yielded a decrease in
sleep disturbance for the massage therapy group
across the study (t 2:72, Po.01; Z2 :29). No
changes were noted for the job productivity or
absenteeism measures.

Discussion
After the rst session, the massage participants
reported less depressed mood, as they did across
the study. After the rst and last massage therapy
session, they were less anxious. Similarly, pain was
lessened after the rst and last sessions and over
the course of the study for the massage therapy
group. These ndings concur with other massage
studies on depressive pain syndromes including
bromyalgia (Sunshine et al., 1996) and chronic
fatigue syndrome (Field et al., 1997b) and suggest
that massage therapy is more effective than

relaxation therapy for reducing pain and anxiety,

and for improving mood.
The massage therapy group also experienced an
immediate increase in the measures of trunk
exion with and without pain after the rst and
last sessions as they had in our previous massage
therapy study on individuals with lower back pain
(Hernandez-Reif et al., 2001). Increased ROM has
been correlated with signicant pain reduction
following physical therapy (Mooney et al., 1996).
Finally, another effect for the massage therapy
group was less disturbed sleep by the end of the
study. Similar ndings were reported for lower back
pain by Hernandez-Reif et al. (2001) and for other
pain syndromes following massage (Field et al.,
1997a; Sunshine et al., 1996). Sleep recordings and
biochemical assays of substance P might indicate
whether the lower back pain is related to less
restorative sleep and the resultant release of
substance P, as has been noted for other pain
syndromes such as bromyalgia (Field et al., 2002).
Although massage therapy was also expected to
increase job productivity and reduce absenteeism
for individuals with chronic low back problems,
these measures were not affected by massage
therapy in this sample. The lack of effects on job
productivity and absenteeism may relate to the
virtual absence of these problems at baseline. The
sample of individuals working at the medical school

ARTICLE IN PRESS
Low back pain reduced by massage therapy
may have felt that being present and productive
was critical to their jobs despite lower back pain.
One limitation of the study was ensuring that the
control participants actually practiced muscle
relaxation. A future study might have the relaxation participants attend sessions at the clinic to
ensure compliance. Another limitation of the study
was the small sample size and lack of a long-term
follow-up assessment. These data, nonetheless,
suggest that massage therapy effectively reduces
pain, sleep disturbances and the anxiety and
depressed mood states associated with lower
back pain.

Acknowledgements
We would like to thank the individuals who
participated in this study and the therapists who
provided the massage. This research was supported
by an NIMH Senior Research Scientist Award
(#MH00331), an NIMH Research Grant (#MH46586)
to Tiffany Field and funds from Johnson & Johnson
and Biotone to the Touch Research Institutes.

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