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

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. The evidence clearly shows massage to be way superior to NSAIDS for back pain.

In spite this medical guidelines recommend NSAIDs rather than massage. A reason given is the cost of massage, however the massage that produced the superior results in the direct comparison was self massage. This negates the cost excuse and creates huge opportunities for back pain sufferers.
In this article we will discuss this trial and the other evidence relating to the effectiveness and safety of massage and NSAIDS, then discuss your massage and self massage options.

CONTENTS

The trial where massage and NSAIDS were directly compared
Summary of clinical trial results and safety for massage
Summary of clinical trial results and safety for NSAIDS
Your self massage options
Professionals
Appendix: How clinical trials can mislead
References

Dr Graeme's comments

Graeme’s comments

This article discusses two different therapies for back pain. However, back pain is usually caused by complex musculoskeletal problems. The proper treatment of back pain should consider all these issues rather than apply a single therapy. These results show that massage deserves to be part of the solution though. For back pain we recommend that you consult a professional for proper examination and assessment, then discuss having massage as part of your management plan.

The trial where massage and NSAIDS were directly compared.

What the trial did

In this trial (1)⁠ 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

Dr Graeme's comments

Graeme’s comments

Before we look at the clinical trial results you need to be aware that clinical trials do favour drugs and can easily be used to show stupid and harmful things are good. In spite of that massage still produces the best results. If you want to know how clinical trials can be used to produce misleading results and sell stupid products I’ve discussed this in the appendix.

Summary of clinical trial results and safety for massage

According to these reviews (2–4) 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 of the clinical trial results and safety for NSAIDS

Clinical trial results

According to the following reviews (5–7)⁠ 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. In spite of this they are the most commonly used drug in the world are often seen as the first option for general practitioners to prescribe. 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)⁠ There’s one big problem though. If you have a bleeding ulcer in your skin it’s very obvious: you can see the blood. 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. 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 (14,15)⁠ For every person who gets killed in a car accident NSAIDS kills 1.4 people and sends 6.5 to the emergency rooms.

Your self massage options

Professional massage therapists provide excellent care, but ongoing regular massages can be expensive. Self massage removes most of this ongoing cost, but as discussed in our article on the use of foam rollers a lot of self massage is riskier and a lot less effective than professional massage. Lets look at your safe effective self massage options. There are many forms of self massage, but these fit into two basic categories: massage that mimics the manual therapy of a profession therapist and those that use vibration.

Massage that mimics professional manual massage

  • Balls and rollers
  • Thai self massage
  • Chairs and cushions
Foam roller usage unsupervised

Balls and rollers

As we discuss in our article on foam rollers using these is far less effective and more riskier than professional massage.

Self massage tool: Wilai stick

Thai self massage

The massage that proved to be far superior to NSAIDS is a traditional Thai self massage technique using a tool called a wilia stick. This 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. For more information please see our research summary.

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.

Self massage allows the benefits of quality massage at home for little cost

Vibration massagers (RECOMMENDED)

As we discuss in our article The scientifically proven effects of vibration massage- with clinical applications vibrations delivered by an effective massager penetrate better than manual massage and have excellent benefits. Further, it's application does not require and special massage skill. Therefore, if you follow the correct simple procedure and use an effective machine it should provide excellent benefits.
To find out more about this therapy please see:
How to choose an effective massager
How to use a vibration massager

Please note that as discussed in our article Percussion massage vs vibration massage percussion massagers tend to cliam the benefits of vibration, but they are far less effective and have a much greater risk of causing injury.

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

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, lets 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. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  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



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