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  Sunday 29th August, 2021

Is massage better than anti-inflammatory drugs (NSAIDS)

Doctor promoting NSAIDS
Despite the smiling face you will be shocked how ineffective and dangerous NSAIDS are

Introduction

If you have low back pain likely the first thing doctors will do is prescribe over the counter medications, especially Non-Steroidal Anti-inflammatory Drugs (NSAIDS)(1)⁠. However, the actual scientific evidence shows that these are not safe or effective, and that you would be much better off getting a massage.

In the one clinical trial that directly compared massage and anti-inflammatory drugs (NSAIDS) for back pain, massage gave the far superior results. If we compare the scientific evidence for each alone we find that:

  • massage is very safe and supported by reasonable clinical trial results, whereas
  • NSAIDS have performed poorly in clinical trials and have a horrendous record of causing serious side effects and death.

So you are properly informed about your back pain options we will:

  1. show you the trial where NSAIDS and massage went head to head
  2. summarise the safety and effectiveness of massage
  3. summarise the safety and effectiveness of NSAIDS

You will clearly see that the medical guidelines recommending that doctors prescribe NSAIDS are written for the benefit of the drug companies rather than for the public. One of the arguments they make for taking their drugs rather than having safe effective massages is the expense and availability of professional massage therapists. However, we’ll show you effective self massage options that are convenient with no ongoing cost.

The trial where massage and NSAIDS were directly compared.

What the trial did

In this trial (2)⁠ 60 people with long standing upper back pain were given 5 days of either:

  • 400mg of the NSAID Iboprufen three times daily, or
  • daily self application of self massage using a tool called a Wilai Stick. We cover this in the section of self massage options below.

The researchers measured pain, plus functional things such as muscle tightness and head/neck movement.

What the trial found

Those receiving the massages had a good reduction in pain, and improvement in the the functional things such as head/neck movement. On the other hand those receiving the Iboprufen only had a slight improvement in pain and no improvement in the functional things

Summary of clinical trial results and safety for massage

Back massage by a professional therapist
Massage for back pain has been shown to be safe and effective

According to these reviews (3–5) of the clinical trial results of massage therapy for back pain massage, there have been several clinical trials and they have shown massage to give a moderate improvement. Massage therapy has also been shown to be incredibly safe.

Summary: should you get a massage if you have back pain

According to several clinical trials massage is an effective therapy for back pain, and is also very safe. The expense and availability of professional therapists can be an issue, but there is the option of all or some being done using self massage.

There can also be other issues causing pain that need to be addressed. We discuss these in our article on causes of spinal pain

Summary of the clinical trial results and safety for NSAIDS

Clinical trial results

According to the following reviews (1,6,7)⁠ of the clinical trials of the use of NSAIDS for back pain the results range from very small and not clinically significant, to small to moderate short term relief.

Safety of NSAIDS

As well as there being practically no evidence of being effective NSAIDS have a horrendous record of causing serious medical side effects and death. Let’s look at look at what NSAIDS do.

  • NSAIDS are responsible for 100,000 hospitisations a year. The medical cost of treating NSAID side effects is $4 billion per year. 16,500 people die each year from these side effects. (8)⁠
  • According to the USA FDA, 2-4% of those taking NSAIDS for a year will develop a symptomatic ulcer which may be life threatening. (9)⁠
  • 1-2% of NSAIDS users will become hospitalised, and the annual death rate is 0.08-0.22% (9)⁠
  • 50% of those taking NSAIDS will develop mucosal lesions which cause bleeding, ulcers and perforations. Patients can eventually die from these complications. (10)⁠
  • the newer “safer” NSAIDS are killing people too (11)⁠

Why ulcers caused by NSAIDS are so dangerous

Several of the reviews of NSAIDS recommend that to improves safety doctors be diligent in assessing patients receiving NSAIDS (12,13)⁠ The big problem is that while if you have a bleeding ulcer in your skin you can see the blood, but if a gastro intestinal ulcer bleeds though the blood stays inside you and is digested. You don’t see that you are bleeding to death. A doctor will only realise if you have invasive scopes or it is noticed that you are becoming anaemic. Often the first sign is that you are either dead or being rushed to the emergency room. Despite the encouragement for doctors to be vigilant the facts speak for themselves.

Example: the UK record of NSAIDS carnage

The following chart sums up the safety problems of NSAIDS (15)⁠ For every person who gets killed in a car accident NSAIDS kills 1.4 people and sends 6.5 to the emergency rooms.

Summary: are NSAIDS good for back pain

Although they are the first medical treatment option for back pain the evidence clearly shows that NSAIDS:

  1. at best only give moderate short term pain relief
  2. they have a horrendous safety record, causing large numbers of hospitalisations and deaths
  3. in a head to head comparison a simple home massage was shown to be far more effectiveness

Summary

If you are suffering from back pain and NSAIDS are not helping this is because scientific studies have shown them to have a horrendous safety record while only being only marginally effective at receiving pain. The reason these results are so bad is because the fundamental cause of back pain is usually tissues being damaged or over-stressed. NSAIDS act to reduce the pain caused by this, but do absolutely nothing to address the actual damage or stress. For more information please see our article on causes of back pain.

Your self massage options

You’ve seen that massage is totally superior to taking NSAIDS for back pain. Professional therapists can provide this excellent care but ongoing regular massages can be expensive. Does massaging your own back help, and if so what can you use and what is the best way? Lets look at your options. There are two main types: massage that mimics the manual therapy of a professional therapist, and those that use vibration.

Massage that mimics professional manual massage

  • Balls and rollers
  • Thai self massage
  • Chairs and cushions
Foam rolling for back pain
Although heavily marketed the clinical trial results for foam rolling are poor, with the results of unsupervised usage likely worse

Balls and rollers

Although balls and foam rollers are heavily marketed as self massage substitutes for professional massage, as we discussed in our article on foam rollers the clinical trial results of supervised roller use are way inferior to those for professional massage, while the results of unsupervised use are likely to be even worse. Because of this we do not recommend these.

Self massage tool: Wilai stick

Thai self massage

This is the massage that proved to be far superior to NSAIDS in the clinical trial. It is a traditional Thai self massage technique using a tool called a wilia stick. This tool was used to apply moderate pressure to the tender spots in the back muscles. For each spot this pressure as applied for five seconds then released. This was repeated five times. We discuss this technique further in our article on self massage for back pain

Massage cushion

Chairs and cushions

These are massagers such as chairs, cushions and some feet massagers. In general, good quality versions can provide some reasonable therapy. Without the skill and knowledge of a professional therapist these are unlikely to be as effective and professionally applied therapy, but they do allow practically unlimited therapy.

Vibration massagers (recommended)

These are devices that use vibration to penetrate rather than physically pressing in like manual massage. Genuine professional standard vibration massagers are often used by professional therapists, but because they do not need any special massage skills to use they can be used to apply very effective self massage.

The benefits and effectiveness

Please see our article The scientifically proven effects of vibration massage- with clinical applications

Choosing a vibration massager

There are some excellent vibration massagers, but great number of vibration massagers marketed for self massage are either ineffective consumer machines and/or less effective and more dangerous percussion massagers. So you do not buy yourself something that doesn’t work or will hurt you please check out our article on how to choose a massager

How to use a vibration massager

Please see our article on how to use a vibration massager

Massaging back with quad head massager
Using our quad head massager to massage back. You can easily reach because unlike massage guns these have proper handles
Our massagers

Years ago in our chiropractic practice we were struggling to find a self massager that we were happy to recommend patients so we had our own built. Since them we’ve shared them with colleagues who use them and recommend them to patients/clients. We built our General Purpose Massager about 10 years ago. They have proved to be very effective, however with just a single head they can only massage a limited area at a time, so we’ve more recently developed our Ultimate Quad Head Massager that delivers highly effective massage through four heads at once. These are available through a large network of fellow professionals, or direct from us. For details please see our order page.

Summary

Yes you can use self massage for back pain. The two best ways to do this and the best equipment to use are:

  1. use a wilai stick or a similar tool to do multiple short duration applications of moderate pressure to the tender spots, or
  2. apply vibration massage using a genuine professional standard vibration massager (not a massage gun).
Professional at desk
Professionals: click the image to find out more and possibly trial vibration massage

Professionals

DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.

Appendix: how clinical trials can mislead

In this section I'll show you how drug companies use clincal trials to produce "evidence" that their drugs are worthwhile. The drug companies then use these trial results to "educate" doctors so the push them onto the public.

Overheating car
Clinical trials could show it was a good idea to duct the cold air from the airconditioner

The problem

To show how this works let me share with you an analogy between back pain and an over heating car engine. We know that the sensible way to fix an overheating car is for the mechanic to investigate the problem and fix what’s wrong. However, let's have a look at what would happen if the “clinical trials” methods were used to find a solution.

The opportunity

Because the problem is overheating the researchers would find a therapy to test and measure the temperature. A company that made ducts that redirected the air conditioner onto the motor would see to opportunity and fund a clinical trial of redirecting the air conditioner onto the motor. The trial would find that redirecting the air conditioner onto the motor lowered the temperature of the motors by 5 degrees.

Using the results to sell stupidity

The research would be published in the International Journal of Automobile Mechanics, then the Duct company would send an army of “advisers” to visit the mechanics and tell them about their wonderful overheating solution. The mechanics might even get an all expenses paid trip to a seminar (sale pitch) on overheating at a nice holiday destination. This all sounds completely ridiculous, except it’s the exact same technique drug companies do to produce favorable clinical trial results and educate doctors to recommend drugs

References

  1. Peck J, Urits I, Peoples S, Foster L, Malla A, Berger AA, et al. A Comprehensive Review of Over the Counter Treatment for Chronic Low Back Pain. Pain Ther. 2021;10(1):69–80.
  2. Wamontree P, Kanchanakhan N, Eungpinichpong W, Jeensawek A. Effects of traditional Thai self-massage using a Wilai massage stickTM versus ibuprofen in patients with upper back pain associated with myofascial trigger points: a randomized controlled trial. J Phys Ther Sci. 2015;27(11):3493–7.
  3. 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.
  4. Cherkin D et. al. A Review of the Evidence for the Effectiveness , Safety , and Cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003;38:898–906.
  5. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2002;27(17):1896–910.
  6. Enthoven WTM, Roelofs PDDM, Deyo RA, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for chronic low back pain. Vol. 2016, Cochrane Database of Systematic Reviews. 2016.
  7. Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, et al. Systemic pharmacologic therapies for low back pain: A systematic review for an American College of physicians clinical practice guideline. Ann Intern Med. 2017;166(7):480–92.
  8. Fine M. Quantifying the impact of NSAID-associated adverse events. Am J Manag Care. 2013;19(14 SUPPL.):267–72.
  9. Lazzaroni M, Bianchi Porro G. Gastrointestinal side-effects of traditional non-steroidal anti-inflammatory drugs and new formulations. Aliment Pharmacol Ther. 2004;20(SUPPL.2):48–58.
  10. Patrignani P et. al. Managing the adverse effects of nonsteroidal anti-infalmmatory drugs. Expert Rev Clin Pharmacol. 2011;4(5):605–21.
  11. Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage. Arthritis Res Ther. 2013;15(SUPPL 3):1–8.
  12. Cryer B. NSAID-associated deaths: The rise and fall of NSAID-associated GI mortality. Am J Gastroenterol. 2005;100(8):1694–5.
  13. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Vol. 147, Annals of Internal Medicine. 2007. 492–504 p.
  14. Blower AL, Brooks A, Fenn GC, Hill A, Pearce MY, Morant S, et al. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharmacol Ther. 1997;11(2):283–91.
  15. Reported road casualties in Great Britain: provisional estimates year ending 2020. UK Dep Transp Stat release

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Dr Graeme

About Dr Graeme

Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more