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Purpose: This trial was designed to evaluate the optimal dose of massage for individuals with chronic neck pain. Methods: We recruited 228 individuals with chronic nonspecific neck pain from an integrated health care system and the general population, and randomized them to 5 groups receiving various doses of massage (a 4-week course consisting of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times weekly) or to a single control group (a 4-week period on a wait list). We assessed neck-related dysfunction with the Neck Disability Index (range, 0-50 points) and pain intensity with a numerical rating scale (range, 0-10 points) at baseline and 5 weeks. We used log-linear regression to assess the likelihood of clinically meaningful improvement in neck-related dysfunction (≥5 points on Neck Disability Index) or pain intensity (≥30% improvement) by treatment group. Results: After adjustment for baseline age, outcome measures, and imbalanced covariates, 30-minute treatments were not significantly better than the wait list control condition in terms of achieving a clinically meaningful improvement in neck dysfunction or pain, regardless of the frequency of treatments. In contrast, 60-minute treatments 2 and 3 times weekly significantly increased the likelihood of such improvement compared with the control condition in terms of both neck dysfunction (relative risk = 3.41 and 4.98, P = .04 and .005, respectively) and pain intensity (relative risk = 2.30 and 2.73; P = .007 and .001, respectively). Conclusions: After 4 weeks of treatment, we found multiple 60-minute massages per week more effective than fewer or shorter sessions for individuals with chronic neck pain. Clinicians recommending massage and researchers studying this therapy should ensure that patients receive a likely effective dose of treatment.
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Five-Week Outcomes From a Dosing Trial of Therapeu-
tic Massage for Chronic Neck Pain
ABSTRACT
PURPOSE This trial was designed to evaluate the optimal dose of massage for
individuals with chronic neck pain.
METHODS We recruited 228 individuals with chronic nonspecic neck pain from
an integrated health care system and the general population, and randomized
them to 5 groups receiving various doses of massage (a 4-week course consist-
ing of 30-minute visits 2 or 3 times weekly or 60-minute visits 1, 2, or 3 times
weekly) or to a single control group (a 4-week period on a wait list). We assessed
neck-related dysfunction with the Neck Disability Index (range, 0-50 points) and
pain intensity with a numerical rating scale (range, 0-10 points) at baseline and 5
weeks. We used log-linear regression to assess the likelihood of clinically mean-
ingful improvement in neck-related dysfunction (≥5 points on Neck Disability
Index) or pain intensity (≥30% improvement) by treatment group.
RESULTS After adjustment for baseline age, outcome measures, and imbalanced
covariates, 30-minute treatments were not signicantly better than the wait list
control condition in terms of achieving a clinically meaningful improvement in
neck dysfunction or pain, regardless of the frequency of treatments. In contrast,
60-minute treatments 2 and 3 times weekly signicantly increased the likelihood
of such improvement compared with the control condition in terms of both neck
dysfunction (relative risk = 3.41 and 4.98, P = .04 and .005, respectively) and
pain intensity (relative risk = 2.30 and 2.73; P = .007 and .001, respectively).
CONCLUSIONS After 4 weeks of treatment, we found multiple 60-minute massages
per week more effective than fewer or shorter sessions for individuals with chronic
neck pain. Clinicians recommending massage and researchers studying this therapy
should ensure that patients receive a likely effective dose of treatment.
Ann Fam Med 2014;112-120. doi: 10.1370/afm.1602.
INTRODUCTION
Neck pain is a common condition, with a 12-month prevalence of
30% to 50% and rates of activity-limiting pain of 1.7% to 11.5%,1
and it accounts for more than 10 million ambulatory medical
care visits per year in the United States.2 At least one-half of persons with
neck pain report persistent or recurrent neck problems at 1 to 5 years
of follow-up.3,4 Neck pain is the eighth leading cause of disability in the
United States5 and fourth worldwide.6 It is the second leading reason for
use of complementary and alternative medicine (CAM),7 with chiropractic
and massage most commonly used.8 In a national sur vey, 61% of persons
with neck pain who used both CAM and conventional therapies perceived
CAM therapies to be more helpful for this condition, whereas just 6% per-
ceived conventional treatments to be better.9
Massage is the second most commonly used CAM therapy for neck
pain.10, 11 Although it is often used as a stand-alone treatment for chronic
neck pain in the United States, reviews of research on massage for neck
pain draw inconsistent conclusions. Furlan et al12,13 found massage supe-
rior to various controls, Brosseau et al14 found it effective immediately
posttreatment with further follow-up data lacking, and Patel et al15 were
Karen J. Sherman, PhD, M PH1,2
Andrea J. Cook, PhD1,3
Robert D. Wellman, MS1
Rene J. Hawkes, BS1
Janet R. Kahn, PhD4
Richard A. Deyo, MD, M PH5
Daniel C. Cherkin, PhD1,6
1Group Health Research Instit ute, Seat tle,
Washington
2Department of Epidemiology, University
of Washington, Seattle, Washington
3Department of Biostatistics, University
of Washington, Seattle, Washington
4Department of Psychiatry, University of
Vermont College of Medicine, Burlington,
Ver mont
5Department of Family Medicine, Oregon
Health and S cience University, Portland,
Oregon
6Departments of Family Medicine and
Health Services, University of Washington,
Seattle, Washington
Conflic ts of interest: authors report none.
CORRESPONDING AUTHOR
Karen J. Sherman, PhD, MPH
Group Health Research Institute
1730 Minor Ave, Ste 1600
Seat tle, WA 98101
sherman.k@ghc.org
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unable to draw conclusions because of the poor qual-
ity of mostly clinically irrelevant studies. An earlier
Cochrane review16 noted that studies have used such
different types and doses of massage that the optimum
dose for practice and clinical trials is unknown. We
therefore designed a study to evaluate the optimal
combination of frequency and length of sessions with
therapeutic massage in persons with chronic neck pain.
This article describes outcomes 1 week after the end of
a 4-week treatment period, our primary endpoint.
METHODS
Design
We conducted a 6-arm trial with 5 dosing schedules of
massage. The trial protocol and all study procedures
were approved by the Group Health Research Institute
institutional review board. Before being screened for
eligibility by telephone, prospective participants gave
oral consent. Those still eligible gave written consent
before an in-person examination and study enroll-
ment. The study protocol, which has been published in
detail,17 is summarized below.
Participants
Study participants were recruited from Group Health, an
integrated health care system serving about 500,00 0 per-
sons, and from the general population of greater Seattle.
Adults aged 20 to 64 years with chronic nonspecific neck
pain lasting at least 3 months who were able and willing
to attend treatments at our clinic and give informed con-
sent were potentially eligible. From June 2010 through
August 2011, we recruited prospective participants using
mailed invitations to Group Health members with neck
pain–related visits to primary care clinicians, advertise-
ments in the health plan’s magazine, posters, a study
website, neighborhood blogs, and direct-mail postcards.
We excluded individuals whose neck pain had a
pathologically identifiable cause (eg, vertebral fracture,
metastatic cancer), was complex (eg, cervical radicu-
lopathy, recent automobile accident), or was too mild,
defined as scoring less than 4 on a pain intensity scale
ranging from 0 to 10 and less than 5 on the Neck Dis-
ability Index (NDI) ranging from 0 to 50. We also
excluded those with potential contraindications for
massage (eg, hypersensitivity to touch), any massage
within the last 3 months, massage for neck pain within
the last year, or an inability to give informed consent
or speak English. Finally, we excluded persons with
medicolegal issues related to neck or back pain.
Randomization
At the end of the baseline interview, a research assis-
tant electronically randomized each participant to 1 of
the 6 treatment groups. Treatment assignments were
generated by a statistician (A.J.C.) using the freely
available R software (version 2.11.0, R-Project for Sta-
tistical Computing), with random block sizes of 6 and
12 within 2 strata, based on NDI scores (5-14 and ≥15).
They were embedded in the computer-assisted tele-
phone interviewing program and inaccessible to study
staff before randomization.
Treatments
For the 4-week primary treatment period, participants
were randomized to a wait list control group or to 5
different dosing schedules of massage: 30-minute treat-
ments either 2 or 3 times per week, or 60-minute treat-
ments 1, 2, or 3 times per week. We defined adherence as
completion of at least 75% of the visits in each protocol.
On the basis of an earlier study,18 we defined dis-
tinct treatment protocols for both 30- and 60-minute
treatments, which included range of motion assessment,
hands-on check-in, massage applied directly to the
neck, addressing compensatory patterns, and integra-
tion (reestablishment within a patient of being in a uni-
fied body after having received intensive isolated work).
Therapists were given time limits for each part of the
massage and permitted to use a broad range of massage
techniques. No self-care recommendations were per-
mitted. Eight licensed massage therapists with at least 5
years of experience were trained in the study protocol
and provided massage treatments in the research clinic
at Group Health. Treatment fidelity was monitored by a
research assistant who was also a massage therapist and
who observed a treatment for all therapists and 34% of
those randomized to massage (4% of all treatments).
Outcomes and Follow-up
Outcomes were assessed at baseline and again at 5
weeks (a week after treatment completion) by tele-
phone interviewers who were unaware of treatment
assignment. Our prespecified primary outcomes were
clinically important improvements in neck pain–related
dysfunction and pain intensity. We attempted to obtain
follow-up data from all trial participants.
The 10-item, 51-point NDI was used to measure
neck pain–related dysfunction; higher scores indi-
cate greater disability. The index shows high internal
consistency and test-retest reliability, is responsive
to change, and correlates well with the McGill Pain
Questionnaire.19,20 The 11-point numerical rating
scale was used to measure neck pain intensity; higher
scores indicate more intense pain. This scale has dem-
onstrated sensitivity to change and is correlated with
other measures of pain intensity.21 Secondary outcomes
included mean NDI and neck pain intensity; 3 types
of activity limitation22; perceived stress, measured
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by the 10-item Perceived Stress Scale (higher scores
indicate greater stress)22; a single-item, 7-point patient
global rating of improvement (higher scores indicate
less improvement); and a single question about overall
patient satisfaction.23
Sample Size and Power
Details of our sample size calculations and all assump-
tions have been provided previously17 but are sum-
marized briefly. Because this was a 6-arm dosing study,
the calculation of sample size was inherently more
complicated. Our sample size was chosen to ensure
adequate power to detect a significant difference
between at least 2 of the 5 massage treatment groups
(and not just adequate power to find a difference
between 1 or more of the treatment groups and the
control group). We powered our study for the primary
binary outcome of a clinically meaningful improve-
ment in neck-related dysfunction (≥5 points on NDI).
With 34 participants per group, we have 97% power
to find a significant difference between at least 2 of the
6 groups (assuming that the control group had a 7%
improvement and the massage groups had an improve-
ment of 35%-70%) and 80% power to find a significant
difference between 2 active massage groups. Assuming
10% loss to follow-up, we recruited 38 participants per
group, for a total sample size of 228 in the trial.
Statistical Analysis
We calculated summary statistics (frequencies, means,
and standard deviations) for baseline study participant
characteristics by treatment group to identify any
important baseline differences across groups. Following
the a priori primar y analysis plan, differences across
treatment groups in the primary outcomes, a clinically
meaningful improvement in neck-related dysfunction
(≥5 points on NDI)24 or in pain (≥30% reduction on
neck pain intensity scale)25 measured at 5 weeks after
randomization, were evaluated using modified Pois-
son regression fitting a Poisson log-link regression
model with generalized estimating equations (GEE)
and robust standard errors.26 To avoid the pitfall of
multiple comparisons related to having 6 treatment
groups, we used the Fisher protected least-significant
difference approach.27 This approach makes pairwise
comparisons among the 6 treatment groups only if
the overall omnibus Wald test statistic is significant.
Prespecified secondary analyses using linear regression
models with GEE and robust standard errors were used
to estimate differences in mean changes from baseline
across treatment groups for the 5-week NDI and neck
pain intensity outcomes. All adjusted models included
baseline NDI and neck pain intensity, age, sex, neck
pain longer than 5 years in duration, use of medica-
tions for neck pain, and race (white non-Hispanic vs
other). All adjusted variables were prespecified except
for race, which was shown at baseline to have larger
than expected differences across groups and met the
adjustment criteria of not being related to any other
prespecified adjustment variable and may be predictive
of outcome response, drop-out, or both.
We used similar adjusted models to analyze the
secondary outcomes. For the binar y outcomes—more
than 7 days in the past week that normal activities
were cut by at least one-half due to neck pain, at least
1 day in the past 4 weeks that neck pain kept you in
bed or lying down for most of the day, and at least 1
day in the past 4 weeks neck pain kept you out of work
or school—we adjusted for only baseline NDI and
neck pain intensity because of model-fitting issues for
these uncommon outcomes. Further, for the secondary
continuous outcome, perceived stress scale, we also
adjusted for baseline perceived stress scale response.
All analyses were conducted according to intention
to treat (ie, comparing participants in the groups to
which they were originally randomly assigned). Analy-
ses were performed using SAS statistical software (ver-
sion 9.2; SAS Institute Inc). All P values are 2 sided and
Wald based, with statistical significance at the P = .05
level.
RESULTS
Recruitment and Follow-up
Among the 1,027 people successfully assessed for eli-
gibility between July 2010 and August 2011, we found
728 to be ineligible and 91 declined (Figure 1). Of the
remaining 228 who were randomized, 37 to 39 persons
were allocated to each of the 5 dosing groups or to the
single wait list control group. The large majority of
participants (86%) were recruited from Group Health.
Overall, follow-up was 97%, with group-specific rates
ranging from 93% to 100%.
Baseline Characteristics
Baseline characteristics were well balanced across
groups, except for the percent of participants of white,
non-Hispanic race/ethnicity and the percent having
more than 7 days of usual activity restricted because
of neck pain (Table 1). Study participants typically had
moderately severe neck pain, but relatively few reported
substantial activity limitations due to their pain.
Treatment Adherence
Treatment adherence, defined as attending at least 75%
of the assigned dose, was at least 95% in 4 massage
dosing groups and 84% in the fifth group (30 minutes
3 times weekly). Because self-care recommendations
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were proscribed, it was not surprising that only 6 of
184 participants (3.3%) in the massage groups reported
doing self-care activities they claimed were recom-
mended by the study massage therapists, with those
recommendations spread evenly among the groups.
Nonstudy Treatments
The use of medication as a nonstudy treatment varied
across groups. Among those randomized to 60 minutes
3 times weekly treatments, medication use in the prior
week dropped from 71.8% at baseline to 34.2%, and in
the 30 minutes 3 times weekly group, medication use
increased from 48.7% to 67.7%. In all other treatment
groups, the absolute percentage change in medication
use varied between –13.2% and 2.6%. Medication use
in the control group increased slightly from 56.8%
to 62.9%. Approximately one-third of participants
reported doing neck exercises at least 3 times per week
at both baseline and 5 weeks. Overall, 11% of partici-
pants made visits to health care professionals during
the 5 weeks of treatment, mostly primary care physi-
cians and chiropractors, with the highest percentage
seen in the wait list control group (17%).
Neck Dysfunction and Neck Pain Intensity
A higher proportion of participants randomized to any
dose of massage reported clinically important improve-
ments in both the NDI and neck pain intensity relative
to those randomized to the wait list control condition
(Table 2). These differences were statistically signifi-
cant only for the more frequent 60-minute treatment
groups, however: the adjusted likelihood of improve-
ment in NDI score for the 2 times weekly and 3 times
weekly groups relative to the control group was 3.41
(95% CI, 1.05-11.08; P = .04) and 4.98 (95% CI, 1.64-
15 .17; P = .005), respectively. The adjusted likelihood
of improvement in neck pain intensity was 2.30 (95%
CI, 1.26-4.18; P = .007) and 2.73 (95% CI, 1.52-4.91;
P = .001), resp ectively.
Although the adjusted mean NDI scores wors-
ened in the wait list control group after 5 weeks, they
improved in all the massage groups (Table 3). Mean
Figure 1. Trial ow.
a Most common r easons for in eligibility: 237 (32.6%) insuf cient neck p ain; 176 (24.6%) neck p ain too complex ; 74 (10.2%) prior massage; 140 (19.2%) could not
attend treatment clinics.
1,047 Assessed for eligibility
228 Randomized
819 Excluded
728 Ineligiblea
91 Declined
38 Allocated
to massage:
1 × 60 min/wk
38 Attended
at least 1
session
38 Attended
at least 3
of 4 (75%)
sessions
38 Analyzed 38 Analyzed
38 Allocated
to massage:
2 × 30 min/wk
38 Attended
at least 1
session
36 Attended
at least 6
of 8 (75%)
sessions
37 Allocated
to wait list
control
35 Analyzed
2 Excluded
from
analysis
1 Withdrew
1 Lost to
follow-up
39 Allocated
to massage:
2 × 60 min/wk
38 Attended
at least 1
session
36 Attended
at least 6
of 8 (75%)
sessions
38 Analyzed
1 Excluded
from analysis
1 Lost to
follow-up
37 Allocated
to massage:
3 × 30 min/wk
36 Attended
at least 1
session
31 At tended at
least 9 of
12 (75%)
sessions
34 Analyzed
3 Excluded
from analysis
2 Withdrew
1 Lost to
follow-up
38 Analyzed
1 Excluded
from analysis
1 Lost to
follow-up
39 Allocated
to massage:
3 × 60 min/wk
39 Attended
at least 1
session
39 Attended at
least 9 of
12 (75%)
sessions
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reductions in NDI from baseline were significantly
greater in the massage groups than in the control group
except for the 30-minute 3 times weekly dose. Improve-
ments in adjusted mean neck pain intensity were signifi-
cantly greater than that in the control group only in the
60-minute treatment 2 and 3 times weekly and in the
30-minute treatment 2 times weekly groups.
We performed linear tests for trend in the outcomes
based on the number of 60-minute treatments per week
(0 to 3 massages per week).These tests showed a signifi-
cant dose-dependent benefit for both the adjusted NDI
and neck pain intensity. For each additional weekly
massage, there was an estimated –1.81-point improve-
ment in NDI (95% CI, –2.52 to –1.10; P <.001) and an
Table 1. Baseline Demographics and Measures Related to Neck Pain
Variable
Control
(n = 37)
1 x 60
Min/wk
(n = 38)
2 x 30
Min/wk
(n = 38)
2 x 60
Min/wk
(n = 39)
3 x 30
Min/wk
(n = 37)
3 x 60
Min/wk
(n = 39)
Demographics
Age, mean (SD), y 44.4 (12.2 ) 50.2 (10.9) 42.3 (11.3) 48.7 (11.5) 4 5. 7 (11 .5 ) 49.0 (9.9)
Women, No. (%) 26 (70.3) 30 (78.9) 28 (73.7) 28 (71.8) 25 ( 67.6 ) 27 (69.2)
College graduate, No. (%) 27 (73.0) 22 (5 7.9 ) 26 (68.4) 25 (6 4 .1) 27 (73) 28 (78.1)
White non-Hispanic, No. (%) 30 (81.1) 30 (78.9) 2 7 ( 7 1.1) 32 (84.2) 20 ( 54 .1) 29 (76.3)
Married, No. (%) 22 (59.5) 2 2 (57.9) 27 ( 71.1) 23 ( 59.0) 26 (70.3) 24 ( 61.5 )
Family income >$45,000/y, No. (%) 27 (73.0) 25 (65.8) 21 (55.3) 29 ( 74.4) 27 (73.0) 23 (59.0)
Unemployed, No. (%) 6 (16.2) 9 (23.7) 6 (15.8) 8 (20.5) 8 (21.6 ) 7 ( 17.9)
Work that requires lifting and car rying, No. (%) 8 (21.6) 7 (18.4) 13 ( 3 4. 2) 8 (20.5) 7 (18.9) 10 (25.6)
Measures of neck pain impact
Neck Disability Index, mean (SD) 13.4 (4. 8) 14 (4.6) 13.4 (3.8) 13.7 (5 .1) 13.1 (5.6) 14 .3 ( 5.5)
Neck pain intensity, mean (SD) 5.6 (1.3) 5.9 (1.5) 5.8 ( 1.4) 5.6 (1.1) 6.1 (1.5) 5.7 ( 1.2)
Duration of neck pain >5 y, No. (%) 11 ( 29 . 7) 15 (3 9.5) 19 (50.0 ) 16 (41.0) 12 ( 32.4) 17 (43 .6 )
>7 Days usual activity restricted due to neck pain in
the past 3 mo, No. (%)
9 (24.3) 6 (15.8) 4 (10.5) 8 (20.5) 6 (16. 2) 11 (28.2)
>3 Days of neck exercise in past week, No. (%) 13 ( 35 .0 ) 14 (36 .8) 8 ( 21.1) 14 (35 .9) 11 ( 29 . 7) 15 (38.5)
Any medications for neck pain in past week, No. (%) 21 (56.8) 22 (57.9) 23 ( 60.5) 25 ( 64.1) 18 (48.7) 28 (71.8)
NSAID use for neck pain, No. (%) 19 ( 51.4) 15 (3 9.5) 17 (4 4. 7) 20 ( 51.3) 11 ( 29. 7 ) 15 (38.5)
Opioid use for neck pain, No. (%) 1 (2.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Measures of quality of life
SF-36 General health very good or excellent, No. (%) 25 ( 67.6 ) 25 (65.8) 22.0 (57.9) 26 (66.7) 23 (62.2) 29 ( 74.4)
SF-36 Mental health,a mean (SD) 75.8 (15.2) 76.3 (16.0) 78.4 (14.3) 7 7.1 (1 6.8 ) 78.3 (11.7) 78.9 (13.1)
SF-36 Physical health, mean (SD) 80.2 (13.7) 76.6 (19.6) 81 .1 ( 15.4) 73.8 (17.8) 79.6 ( 20.2) 78.5 (16.4)
Miscellaneous measures
Worry, mean (SD) 4.6 (1.9) 4.3 ( 2.6) 3.6 (2.6) 4.1 ( 2.2 ) 4.2 (2.4) 4 (2.4)
Perceived Stress Scale, mean (SD) 16.9 (6.9) 15 .9 ( 7. 2 ) 16.1 (5.6) 17 ( 6.5) 17.1 (4 .9) 15. 8 ( 6.9)
Very satised with overall care for neck pain No. (%) 1 (4.0) 2 ( 7. 4) 1 (3.2) 5 ( 17. 9) 1 ( 3.0) 2 ( 6 .1)
Expec tation of massage helpfulness, mean (SD) 7.7 (1.4 ) 7.4 (2.3) 7.4 ( 1. 9) 7.4 (1.8 ) 7.2 ( 2.0 ) 7.7 ( 2.3)
Expec t neck pain to be much better or completely
gone in 1 year, No. (%)
13 ( 35 .1) 11 (28.9) 10 (26.3) 13 ( 33 .3) 12 (33.3) 11 (28.2)
Top treatment choice was massage, No. (%) 26 (76.5) 25 (69.4) 17 (48.6) 22 (62.9) 24 (68.6) 2 5 (6 7.6)
Had prior mass age for back or neck pain, No. (%) 25 ( 67. 6 ) 28 (73.7 ) 21 (55 .3) 22 (56.4) 2 0 (5 4.1) 25 ( 64.1)
Neck-related disability days
>7 Days in past 4 weeks that normal activities were
cut by half a day or more because of neck pain,
No. ( %)
5 ( 13.5) 4 (10.5) 1 (2.6) 2 (5 .1) 4 (10.8) 6 ( 15.4)
≥1 Day in the past 4 weeks that neck pain kept you
in bed or lying down for all or most of the day,
No. ( %)
3 (8.1) 4 (10.5) 2 (5.3) 0 (0.0) 5 ( 13. 5) 2 ( 5 .1)
≥1 Day in past 4 weeks that neck pain kept you out
of work or school, No. (%)
2 (5.7) 3 (8.6) 1 (2.7) 2 (5.4) 1 (2.9) 3 (8.1)
NSAID = nonsteroidal anti-inammatory drug; SF-36 = 36-Item S hort For m Health Survey.
Notes: NDI is a 0 to 50 s cale; higher s cores indica te worse function. Ne ck pain intensit y is a 0 to 10 scale; highe r scores indi cate more pain . SF-36 scales are all s caled
to a 0 to 100 scale; hig her scores in dicate bet ter funct ion. Perceive d Stress Sc ale is a 0 to 40 scale; higher score s indicate mor e stress. Worry and ex pectations are both
0 to 10 scales; high er scores indicate more wor ry or highe r expec tations, re specti vely.
a On the 5-it em Mental Health Inventory.
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estimated –0.75-point improvement in neck pain inten-
sity (95% CI, –1.01 to –0.47; P <. 0 01).
Other Outcomes
There were no statistically significant differences
between groups for any secondary outcomes except
for the proportion of participants who reported their
neck pain was much better or completely gone (omni-
bus P <.001) (Table 4). Three massage groups were
significantly more likely to report this level of improve-
ment than the control group: benefit was evident the
30 minutes 3 times weekly group (20.4%; 95% CI,
10.2%-40.6%); the 60 minutes 2 times weekly group
(18.9%; 95% CI, 10.0%-35.8%), and the 60 minutes 3
Table 3. Secondary Outcomes: Mean Improvements in Neck Pain Measures
Outcome
by Massage
Dose
Unadjusted Adjusteda
Mean Change
(95% CI)
Mean Difference
(95% CI)
P
Valu e
Overall
P Valu e
Mean Difference
(95% CI)
P
Valu e
Overall
P Valu e
Neck Disability Index
Control 1.45 (–0.20 to 3.10) Ref <.0 01 Ref <.0 01
1 x 60 min/wk –0.86 (–2.09 to 0.36) –2.31 (–4.37 to –0.26) .03 –2.31 (–4.29 to –0.32) .02
2 x 30 min/wk –0.89 (–2.33 to 0.54) –2.34 (–4.53 to –0.16) .04 –2.35 (–4.51 to –0.18) .03
2 x 60 min/wk –2.06 (–3.51 to –0.62) 3.52 (–5.71 to –1.32) .002 –3.44 (–5.53 to –1.35) .001
3 x 30 min/wk 0.05 (–1.26 to 1.35) 1.41 (–3.51 to 0.70) .19 –1.73 (–3.78 to 0.33) .10
3 x 60 min/wk –4.36 (–6.25 to –2.47) –5.81 (–8.32 to –3.30) <.0 0 1 –5.63 (–7.94 to –3.32) <.0 01
Neck pain intensity
Control –0.51 (–1.35 to 0.32) Ref <.0 01 Ref <. 0 01
1 x 60 min/wk 1.21 (–1.84 to –0.58) –0.70 (–1.74 to 0.35) .19 –0.43 (–1.36 to 0.50) .37
2 x 30 min/wk 1.66 (–2.29 to –1.03) 1.14 (–2.19 to –0.10) .03 –1.02 (–1.93 to –0.12) .03
2 x 60 min/wk –2.21 (–2.81 to –1.61) 1.70 (–2.72 to –0.67) .001 –1.56 (–2.46 to –0.66) .001
3 x 30 min/wk 1.62 (–2.19 to –1.05) –1.10 (–2.12 to 0.09) .03 –0.83 (–1.73 to 0.07) .07
3 x 60 min/wk –2.74 (–3.22 to –2.25) –2.22 (–3.19 to –1.26) <.0 01 –2.07 (–2.94 to –1.20) <. 0 01
Ref = reference group.
a Adjusted fo r baseline Neck Disabilit y Index and ne ck pain intensi ty, age, sex, dura tion of neck pain of more than 5 years, use of me dications fo r neck pain, an d race/
ethnicit y (white non-Hispanic vs oth er).
Table 2. Primary Outcomes: Clinically Relevant Improvements in Neck Pain Measures
Outcome by Massage Dose
Unadjusted Adjusteda
% (95% CI) RR (95% CI)
P
Valu e
Overall
P Valu e RR (95% CI)
P
Valu e
Overall
P Valu e
Clinically relevant improvement
in NDIb
Control 8.6 (2.9-25.3) 1.00 .001 1. 00 . 003
1 x 60 min/wk 18.4 (9.4 -36.0) 2.15 (0.60-7.67) .24 1.9 6 (0. 53 -7.33) .32
2 x 30 min/wk 15.8 (7.6-32.9) 1.84 (0.50-6.81) .36 1.9 0 ( 0.53 -6.8 6) .33
2 x 60 min/wk 31.6 (19.8 -50.4) 3.6 8 (1.13-11.98) .03 3.41 (1.0 5-11.0 8) .04
3 x 30 min/wk 11.8 (4.7-29.5) 1.37 (0.33-5.68) .66 1.61 (0.40 -6.46) .5 0
3 x 60 min/wk 47.4 (33.9-66.2) 5 .53 ( 1. 78-17.15 ) .003 4.98 (1.64 -15.17) .005
Clinically relevant improvement
in neck pain intensityc
Control 25.7 (14.6-45.2) 1.00 <. 0 01 1.00 <. 0 01
1 x 60 min/wk 34.2 (22.0 -53.2) 1.33 (0.65-2.72) .43 1.17 ( 0.58-2. 37 ) .66
2 x 30 min/wk 42.1 ( 29. 0 -61.1) 1.64 (0.83-3.22) .15 1.61 (0. 83 -3 .13) .16
2 x 60 min/wk 63.2 (49.5 -8 0.5) 2.46 (1.33-4.54) .004 2. 30 ( 1. 26 - 4 .18) .007
3 x 30 min/wk 44.1 (30.2-64.4) 1.72 (0.87-3.38) .12 1.61 (0.81-3.18) .17
3 x 60 min/wk 76.3 (63.9 -91.1) 2.97 (1.64-5.36) .000 2.73 (1.5 2-4.91) .001
RR = relative risk.
a Adjusted fo r baseline Neck Disabilit y Index and ne ck pain intensi ty, age, sex, dura tion of neck pain more than 5 yea rs, use of medications for neck pain, and r ace/
ethnicit y (white non-Hispanic vs oth er).
b Improvement of a t least 5 point s from baseline at 5 weeks p ostrandomization.
c Improvement of a t least 30% fr om baseline at 5 weeks pos trandomiz ation.
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times weekly group (40.6%; 95% CI, 27.8%-59.5%).
Moreover, the last group fared significantly better than
all other treatment groups.
Adverse Events
During the 4-week treatment period, 10 participants
(5.2% of the total) reported 14 adverse events (11 mild
and 3 moderately severe) at least possibly related to
massage. All these events were related to pain, primar-
ily spine pain. Adverse event frequencies were similar
in participants attending 30-minute and 60-minute
treatments (4% vs 6%, respectively) and in those
attending 1, 2, or 3 times per week (7.9% vs 2.6% vs
6.7%, respectively).
DISCUSSION
Our findings demonstrate that the beneficial effects of
massage treatments for chronic nonspecific neck pain
increase with dose. Although 30-minute massages,
either 2 or 3 times a week, failed to provide significant
benefits compared with the wait list control condition,
the beneficial effects of 60-minute massages increased
with dose and were especially evident for those receiv-
ing massage 2 or 3 times per week. Compared with
their control counterparts, massage participants were
3 times more likely to have a clinically meaningful
improvement in neck function if they received 60 min-
utes of massage twice a week and 5 times more likely
if they received 60 minutes of massage 3 times a week.
Our results confirm the effectiveness of a 60-minute
massage for persons with chronic neck pain. Changes
in the use of medications for neck pain or visits to clini-
cians could not explain these findings. In addition, we
found few adverse events, most of which were mild.
Our findings are similar to those of our small trial of
massage for chronic neck pain18 and a large trial of mas-
sage for back pain.28 Massage thus appears relatively
safe when provided by appropriately trained therapists,
but can be associated with transient increases in pain.
Our findings also suggest that previously pub-
lished studies of massage for neck pain may have not
administered adequate doses. For example, the newest
Cochrane review of massage for neck pain15 reported
9 trials of massage for subacute or chronic neck pain.
Among the 7 trials with conceivably relevant designs,
4 trials included only a single session of a single mas-
sage technique applied for less than 5 minutes, 1 trial
included only five 30-minute treatments over 2 weeks,
1 included five 45-minute treatments over 1 month,
and the last was a series of weekly 60-minute massages.
In addition, most trials lacked massage resembling
Table 4. Adjusted Secondary Outcomes at 5 Weeks Postrandomization
Outcome
Control
(n = 37)
1 x 60
Min/wk
(n = 38)
2 x 30
Min/wk
(n = 38)
2 x 60
Min/wk
(n = 39)
3 x 30
Min/wk
(n = 37)
3 x 60
Min/wk
(n = 39)
Overall
P
>7 Days in past 4 weeks
that normal ac tivities
were cut by half a day
or more because of
neck pain, % (95% CI)
8.9
(4.0 to 19.8)
5.1
(2.3 to 11.8)
1.9
(0.3 to 12.2)
2.8
(0.8 to 9.2)
4.7
(1.6 to 13.7)
7.9
(3.3 to 18.9)
.35
≥1 Day in the past 4
weeks that neck pain
kept you in bed or lying
down for all or most of
the day, % (95% CI)
6.5
(2.0 to 21.2)
6.9
(2.9 to 16.7)
4.3
(0.9 to 20.3)
0.0a
(n/a)
8.5
(3.8 to 18.7)
3.5
(1.0 to 12.8)
.67
≥1 Day in the past 4
weeks that neck pain
kept you out of work or
school, % (95% CI)
4.6
(1.1 to 19.8)
6.8
(2.4 to 19.1)
2.2
(0.4 to 14.1)
3.6
(0.9 to 14.7)
1.8
(0.4 to 7.8)
4.9
(1.2 to 19.8)
.73
Perceived Stress Scale,
mean (95% CI)
–0.42
(–2.4 to 1.6)
–1.1
(–2.3 to 0.1)
–1.6
(–3.3 to 0.2)
–1.5
(–3.1 to 0.0)
–3.7
(–5.5 to –1.9)
–1.5
(–3.2 to 0.3)
.21
Compared with when you
began the study, neck
pain is much better or
completely gone, %
(95% CI)
2.5
(0.4 to 14.8)
7.1
(2.2 to 18.2)
9.3
(3.6 to 23.9)
18.9
(10.0 to 35.8)
20.4
(10.2 to 40.6)
40.6
(27.8 to 59.5)
<.0 01
Very satised with care for
neck pain, % (95% CI)
22.2
(11.2 to 44.0)
40.0
(27.6 to 57.8)
40.6
(27.8 to 59.2)
54.6
(41.1 to 72.5)
25.9
(16.3 to 44.3)
47. 0
(33.2 to 66.5)
.06
n/a = not a pplicable.
Note: All variables are adjus ted for baseline Neck Disability Inde x and neck pai n intensity. The outcomes Perceived Stres s Scale, neck p ain is much bet ter/completely
gone, and sa tisfaction with care for n eck pain additionally adju sted for age, s ex, duration of neck pain mor e than 5 years, u se of medica tions for nec k pain, and race
(white non- Hispanic vs other). The Percei ved Stress S cale was fur ther adjusted for baseline score for this scale.
a No partic ipant in this gro up was kept in bed fo r most of the day b ecause of neck pain.
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conventional massage practice in the United States,
where 60-minute treatments administered by licensed
massage therapists are the norm, a wide range of mas-
sage techniques are used in a single session, and self-
care recommendations are provided.29 This review
notes that there is little information regarding optimal
parameters for the massage, including the number of
treatments per week and the length of each session.
We found slightly different results in our controls
and 60-minute weekly massage group than we did in
a previously published study18 comparing weekly mas-
sage with a control condition of receipt of a self-care
book. Participants in both studies reported similar rat-
ings of neck pain and dysfunction before treatment;
however, among the control groups, clinically impor-
tant improvement in that earlier study was worse for
pain (only 10% improved vs 26% in this trial) but simi-
lar for neck dysfunction (approximately 8% improved
in both studies). More participants receiving weekly
60-minute massages in that earlier study reported
clinically relevant improvement in both pain (48%
improved vs 34% in this trial) and dysfunction (35%
improved vs 18% in this trial). Virtually all participants
in the prior study received self-care recommendations,
most commonly pertaining to stretching, but such rec-
ommendations were prohibited in this trial, which may
at least partially explain the difference between study
results. Conceivably, these differences could reflect
variability due to small sample sizes. Potentially, these
combined results may indicate that 60 minutes once a
week may still be an effective treatment relative to a
control condition, but likely less effective relative to 2
to 3 times per week as indicated by this trial.
Our study’s strengths include rigorous randomiza-
tion, assessment of follow-up outcomes by interviewers
unaware of treatment group, high adherence to the
massage dose in each group, high follow-up rates, and
massage protocols that both maximized standardization
of treatment and allowed the study massage therapists’
sufficient latitude to provide treatments they thought
would benefit their patients. Our study’s major limita-
tions include modest sample sizes in each group, inabil-
ity to control for nonspecific effects of attention with
the use of a wait list control design, and inclusion of
patients who had primarily mild to moderate neck pain.
The prohibition of giving self-care recommendations
might be a limitation in the sense that massage thera-
pists typically make such recommendations, but this
prohibition enhances our confidence that the findings
are due to the massage itself. In unpublished data from
a larger study describing the practice of 126 massage
therapists,29 we found that they recommended self-care
for 87% of the 165 visits for chronic neck pain, most
commonly body awareness (49%), hot and/or cold ther-
apy (43%), and exercise (42%). Additional limitations
include only short-term follow-up and our inability to
fully assess how representative our patients are of those
with chronic nonspecific neck pain in primary care.
Few studies of nonpharmacologic CAM therapies
have evaluated the effect of dose on outcomes. In 2
small studies, Haas et al30, 31 found greater improve-
ment for back pain and cervicogenic headache among
patients who received 3 or 4 chiropractic treatments
per week for 3 weeks than among those receiving
fewer treatment per week. In a 5-arm, 8-week trial of
massage for persons with osteoarthritis, Perlman et al32
found that 60 minutes of weekly or twice weekly mas-
sage was clearly superior to usual care and appeared
better than 30 minutes of twice weekly massage.
Our findings have important implications for both
clinical practice and research. At baseline, only about
5% of participants were very satisfied with their overall
care for neck pain, suggesting that new therapeutic
alternatives are needed for family physicians. Outcome
data suggest that patients seeking massage for chronic
neck pain are more likely to benefit if they have multiple
60-minute treatments per week than if they have only 1.
Such a treatment schedule might prove challenging for
many patients because of time and financial constraints.
Our findings also suggest that future trials evaluating
massage for chronic neck pain, which we think would be
important, should include multiple 60-minute treatments
each week for the first 4 weeks of treatment, self-care
recommendations, and longer-term follow-up.
To read or post commentaries in response to this ar ticle, see it
online at www.annfammed.org/content/12/2/112.
Key words: chronic neck pain; pain management; disability; massage;
clinical trial; complementary and alternative medicine; holistic medicine
Submitted March 14, 2013; submitted, revised, August 8, 2013;
accepted September 10, 2013.
Funding support: Our study was funded by grant R01 AT004411
from the National Center for Complementary and Alternative Medicine,
National Institutes of Health.
Prior presentations: International Forum XII for Primary Care Research
on Low Back Pain. Odense, Denmark, October 2012.
Disclaimer: The funders had no role in the interpretation or reporting
of results. The views expressed herein do not necessarily represent the
views of the funders.
Acknowledgments: We thank our research team, including Beth
Lapham, our research assistants (Zoe Bermet, Kevin Filocamo, Melissa
Parson, Kirsten Sullivan), massage therapists (Christine Chmielewski,
Lesely Ernst, Tom Harvey, Michael Jacobus, Maureen McKelvey, Dawn
Schmidt, Carol Tiebout), nurse practitioners (Wendy Robinson, David
Diechert), programmers ( Jane Graf ton and DT Tran), and massage con-
sultant Diana Thompson.
Trial registration: NCT01122836 (ClinicalTrials.gov).
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Background: The efficacy of various massage doses in palliative cancer care settings is still debated, and no specific protocol is available. Aim: Evaluating response to various massage doses for symptom cluster of pain-fatigue-sleep. Design: A 7-arm randomized-controlled trial with weekly massage for 4 weeks depending on the prescribed dose (15-, 30-, or 60-min; 2× or 3×/week) and a 4-week follow-up. The intensities of pain, fatigue, and sleep disturbance were measured using a 0-10 scale at nine-timepoint; baseline, weekly during the intervention, and the follow-up period. Then, the mean scores of the three symptoms were calculated as the symptom cluster intensity at each timepoint. IRCT.ir IRCT20150302021307N5. Setting/participants: Adults with cancer (n = 273) who reported all three symptoms at three oncology centers in Iran. Results: The odds of clinical improvement (at least 30% reduction in symptom cluster intensity from baseline) increased with dose-escalation significantly [(OR = 17.37; 95% CI = 3.87-77.90 for 60-min doses); (OR = 11.71; 95% CI = 2.60-52.69, for 30-min doses); (OR = 4.36; 95% CI = 0.94-20.32, for 15-min doses)]. The effect durability was significantly shorter at 15-min doses compared to 30- and 60-min doses. The odds of improvement for doses 3×/week was not significant compared to doses 2×/week (OR = 12.27 vs OR = 8.34); however, the effect durability for doses 3×/week was significantly higher. Conclusions: The findings indicated that dose-escalation increases the efficacy of massage for the pain-fatigue-sleep symptom cluster. Although the 60-min doses were found to be more effective, the 30-min doses can be considered more practical because they are less costly and time-consuming. Our findings can be helpful to develop massage guidelines in palliative care settings. Trial registration: Iranian Registry of Clinical Trials, IRCT20150302021307N5.
Article
Background Chronic neck pain (CNP) is prevalent, and it reduces functional status and quality of life and is associated with deleterious psychological outcomes in affected individuals. Despite the desirability of massage and its demonstrated effectiveness in CNP treatment, multiple accessibility barriers exist. Caregiver-applied massage has demonstrated feasibility in various populations but has not been examined in Veterans with CNP or compared in parallel to therapist-delivered massage. Objective This manuscript described the original study design, lessons learned, and resultant design modifications for the Trial Outcomes for Massage: Care Ally–Assisted Versus Therapist-Treated (TOMCATT) study. Methods TOMCATT began as a 3-arm, randomized controlled trial of 2 massage delivery approaches for Veterans with CNP with measures collected at baseline, 1 and 3 months after intervention, and 6 months (follow-up). Arm I, care ally–assisted massage, consisted of an in-person, 3.5-hour training workshop, an instructional DVD, a printed treatment manual, and three 30-minute at-home care ally–assisted massage sessions weekly for 3 months. Arm II, therapist-treated massage, consisted of two 60-minute sessions tailored to individual pain experiences and treatments per week for 3 months. The treatments followed a standardized Swedish massage approach. Arm III consisted of wait-list control. Results Retention and engagement challenges in the first 30 months were significant in the care ally–assisted massage study arm (63% attrition between randomization and treatment initiation) and prompted modification to a 2-arm trial, that is, removing arm I. Conclusions The modified TOMCATT study successfully launched and exceeded recruitment goals 2.5 months before the necessary COVID-19 pause and is expected to be completed by early 2023. Trial Registration ClinicalTrials.gov NCT03100539; https://clinicaltrials.gov/ct2/show/NCT03100539 International Registered Report Identifier (IRRID) DERR1-10.2196/38950
Chapter
Complementary health approaches include a broad range of practices, interventions, and natural products that are not typically part of conventional medical care. Many complementary and integrative health approaches are multimodal in nature and may contribute to pain relief by impacting several pain‐processing structures simultaneously, and they address the cognitive, emotional, and physical complexities associated with pain. Although complementary approaches vary greatly, it is useful to classify them by their primary therapeutic input, which may be dietary (e.g. special diets, herbs), psychological (e.g. meditation), physical (e.g. massage, acupuncture) or the combination of psychological and physical (e.g. yoga). Complementary health approaches are often used in combination, both in traditional health systems (e.g. traditional Chinese medicine) and in modern integrative practice.
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Myalgia is pain that occurs in the muscles that can interfere with daily activities. Sports massage and meditation is an alternative to reduce the feeling. The purpose of this study was to determine the effect of sports massage on overcoming myalgia disorders. This study uses a quantitative quasi-experimental method with this type of design using the equivalent time series sample design. The population in this study was a total of 36 masseurs who worked in sports injury therapy massage centers on the 4th floor of UNY Plaza. The sample was determined using purposive sampling technique and obtained a number of 15 samples. This type of research is a quasi-experimental, using a pretest-posttest design. Research subjects were given 3 (three) repetitions of treatment, namely the first week, the second week and the third week. The data analysis technique in this study used a t-test (paired t-test), in test I, test II and test III, the overall significance was obtained with a value of 0.000 (sig. < 0.05). The conclusion in this research is sports massage with meditation can reduce myalgia disorders.Pengaruh sports massage dengan meditasi terhadap gangguan myalgiaAbstrakMyalgia merupakan nyeri yang terjadi pada otot yang dapat menganggu aktivitas sehari-hari. Sports massage dan meditasi merupakan salah satu alternatif untuk mengurangi rasa nyeri. Tujuan penelitian ini untuk mengetahui pengaruh sports massage dengan meditasi terhadap gangguan myalgia. Penelitian ini menggunakan metode quasi eksperimen kuantitatif dengan jenis rancangan menggunakan the equivalent time series sample design. Populasi dalam penelitian ini adalah masseur sejumlah total 36 yang bekerja di tempat masase terapi cedera olahraga di Plaza UNY lantai 4. Penentuan sampel menggunakan teknik purposive sampling dan diperoleh sejumlah 15 sampel. Subjek penelitian diberikan 3 (tiga) kali pengulangan perlakuan yaitu minggu ke- I, minggu ke-II dan minggu ke-III. Teknik analisis data dalam penelitian ini menggunakan uji-t (paired t-test). pada uji I diperoleh nilai 0,000 (sig. < 0,05), uji II diperoleh nilai 0,000 (sig. < 0,05) dan uji III diperoleh nilai 0,000 (sig. < 0,05). Kesimpulan dalam penelitan ini adalah sports massage dengan meditasi dapat mengurangi gangguan myalgia
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Objectives Trigger points are thought to be associated with chronic neck pain and can be treated with massage self-care techniques such as trigger point self-care. We sought to examine the feasibility of a developed group training approach for trigger point self-care to inform future efficacy focused clinical trials for chronic neck pain. Methods Self-identified adults with chronic neck pain were recruited to participate in one of two scheduled group training sessions. Data was collected pre- and post-training with follow-up at 1-, 4-, and 8-weeks. Measures included a trigger point self-care training objectives survey, daily self-report logs, and neck disability and pain via the Neck Disability Index. Training included interactive lecture, demonstration, supervised practice, and assessment for an individualized trigger point self-care plan. Handouts and tools were provided for training and home use. Results Five participants (women = 3; ages 22-58; White = 4) enrolled and completed the study. All participants completed each data collection point, attended a post-intervention focus group or interview, submitted their completed daily self-care log, and reported achieving all intended training objectives. All participants felt the downtown university location was convenient and non-clinical environment simulated a real-world educational/training experience. Two participants reported having some discomfort the day after training, most expected the training would help them, and several expressed excitement about learned content and empowerment to manage their own pain. Neck Disability Index scores at week-1 did not change for 1 participant, worsened for 1 participant, and improved for 3 participants. All participants’ Neck Disability Index scores were better than baseline at week-4 and week-8. Conclusions Our trigger point self-care group training approach was acceptable to study participants and is feasible to implement in future clinical trials. Larger studies including participants with more severe neck pain and disability are needed to test the trigger point self-care approach.
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The decline in circulatory function with aging may be alleviated by a combination of gingival massage (physical stimulation) and mechanical cleaning. Several studies have reported the systemic effect of physical stimulation on various parts of the body, including its therapeutic effect on pain in the neck and shoulders that becomes evident with age, and improvement in blood circulation. In contrast, few studies have reported on the changes in gingival microcirculation induced by gingival massage, while no previous study has evaluated the effect of gingival microcirculation on age-related changes in the hemodynamics of the oral cavity. This study aimed to investigate how gingival massage affects age-related changes in gingival microcirculation. Male Wistar rats (7-week, 6-month and 1-year old) were prepared for a gingival massage group and a control group. Mechanical stimulation was applied on the maxillary molar gingiva for 5 seconds twice a week for 4 weeks. Subsequently, gingival reactive hyperemia was measured using a laser Doppler flowmeter. In addition, morphological analyses were also performed by hematoxylin and eosin and Indian ink staining and a vascular resin cast model. Base Flow, maximum response (Peak), and time required for the maximum response to halve (T1/2) were reduced in 1-year-old rats compared with the other age groups. In the mechanical stimulated group, T1/2 was increased in 7-week, 6-month, and 1-year-old rats, and total blood flow (Mass) was increased in 6-month and 1-year-old rats. In addition, clear blood vessel networks and loop-like revascularization were only observed in the mechanical stimulated group. Changes in age-related decline in gingival microcirculatory function and vascular construction were reported in this study, and the results suggested that gingival massage activates both the functional and morphological aspects of gingival microcirculation and may be effective for maintaining oral health.
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Importance: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. Objectives: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. Design: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. Results: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. Conclusions and Relevance: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.
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A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990. To document trends in alternative medicine use in the United States between 1990 and 1997. Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively. A total of 1539 adults in 1991 and 2055 in 1997. Prevalence, estimated costs, and disclosure of alternative therapies to physicians. Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services. Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
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This is the protocol for a review and there is no abstract. The objectives are as follows: This systematic review will assess the effect of massage, either alone or in combination with other treatments, on pain, function/disability, patient satisfaction and global perceived effect, in adults with mechanical neck disorders.
Article
Study Design. A systematic review was conducted. Objective. To identify, evaluate, and compare standard scales for assessing neck pain or dysfunction. Summary of Background Data. The degree of a patients neck pain or dysfunction can be evaluated using standardized scales at the time of a clinical encounter or during the performance of clinical research protocols. The choice of a scale with the most appropriate characteristics, however, is always a challenge to clinicians and researchers. Methods. Articles concerning scales for functional evaluation of neck pain or dysfunction were identified by computer searching of MEDLINE (January 1966 to June 1999) and CINAHL (1985 to 2000), citation tracking using the Citation Index, hand searching of relevant journals, and correspondence with experts. Results. Five standard scales were found. Three scales were remarkably similar in terms of structure and psychometric properties: the Neck Disability Index, the Copenhagen Neck Functional Disability Scale, and the Northwick Park Scale. However, only the first instrument has been revalidated in different study populations. The Neck Pain and Disability Scale provides a visual template for collection of information, but its usefulness is limited if the questionnaire must be read to the patient. The Patient-Specific Functional Scale is very sensitive to functional changes in individual patients, but comparisons between patients are virtually impossible. Conclusions. The five scales identified in this study have similar characteristics. The Neck Disability Index, however, has been revalidated more times for evaluation of patient groups. For individual patient follow-up evaluation, the Patient-Specific Functional Scale has high sensitivity to change, and thus represents a good choice for clinical use. The final choice should be tailored according to the target population and the purpose of the evaluation.
Article
Background: Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both. Objective: To document perceptions about CAM therapies among persons who use CAM and conventional therapies. Design: Nationally representative, random-household telephone survey. Setting: The 48 contiguous U.S. states. Participants: 831 adults who saw a medical doctor and used CAM therapies in 1997. Measurements: Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies. Results: Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were "It wasn't important for the doctor to know" (61%), "The doctor never asked" (60%), "It was none of the doctor's business" (31%), and "The doctor would not understand" (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension. Conclusions: National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.
Article
Study Design. Best evidence synthesis. Objective. To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. Summary of Background Data. Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. Results. We found 226 articles on the course and prog-nostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psy-chosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prog-nostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. Conclusion. The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.
Article
Background: Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both. Objective: To document perceptions about CAM therapies among persons who use CAM and conventional therapies. Design: Nationally representative, random-household telephone survey. Setting: The 48 contiguous U.S. states. Participants: 831 adults who saw a medical doctor and used CAM therapies in 1997. Measurements: Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies. Results: Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were It wasn't important for the doctor to know (61%), The doctor never asked (60%), It was none of the doctor's business (31%), and The doctor would not understand (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension. Conclusions: National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.
Article
Background: The prevalence of mechanical neck disorders (MND) is known to be both a hindrance to individuals and costly to society. As such, massage is widely used as a form of treatment for MND. Objectives: To assess the effects of massage on pain, function, patient satisfaction, global perceived effect, adverse effects and cost of care in adults with neck pain versus any comparison at immediate post-treatment to long-term follow-up. Search methods: We searched The Cochrane Library (CENTRAL), MEDLINE, EMBASE, MANTIS, CINAHL, and ICL databases from date of inception to 4 Feburary 2012. Selection criteria: Studies using random assignment were included. Data collection and analysis: Two review authors independently conducted citation identification, study selection, data abstraction and methodological quality assessment. Using a random-effects model, we calculated the risk ratio and standardised mean difference. Main results: Fifteen trials met the inclusion criteria. The overall methodology of all the trials assessed was either low or very low GRADE level. None of the trials were of strong to moderate GRADE level. The results showed very low level evidence that certain massage techniques (traditional Chinese massage, classical and modified strain/counter strain technique) may have been more effective than control or placebo treatment in improving function and tenderness. There was very low level evidence that massage may have been more beneficial than education in the short term for pain bothersomeness. Along with that, there was low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction. The clinical applicability assessment showed that only 4/15 trials adequately described the massage technique. The majority of the trials assessed outcomes at immediate post-treatment, which is not an adequate time to assess clinical change. Due to the limitations in the quality of existing studies, we were unable to make any firm statement to guide clinical practice. We noted that only four of the 15 studies reported side effects. All four studies reported post-treatment pain as a side effect and one study (Irnich 2001) showed that 22% of the participants experienced low blood pressure following treatment. Authors' conclusions: No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.As a stand-alone treatment, massage for MND was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.