Neck pain is a leading cause of disability that affects workers all over the world and results in high economic costs to individuals, businesses and governments due to absenteeism and productivity losses. Psychosocial factors play a role in its development and resolution, making the clinical management of neck pain challenging.
While earlier research focused on pain relief, more recent research has included patient-centered outcomes as well. This randomized controlled study compared the effectiveness of three active therapies: deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy consisting of exercise followed by massage, with advice to stay active as a control group.
The Study Methods
Six hundred and nineteen adults with subacute or persistent neck pain were recruited using ads in a free daily Stockholm newspaper. Participants were aged 18–70 years, and reported subacute (30–90 days duration) or chronic (more than 90 days duration) non-specific disabling neck pain with or without headache and/or radiating symptoms.
Those with pain intensity less than 2/10 and disability less than 1/10 on a numerical rating scale (NRS) were excluded. Also excluded were those with a history of cancer, severe skin disorders, recent neck surgery, prolapsed disc, spondylolisthesis, fracture, spinal stenosis, arthritis, osteoporosis, recent neck trauma, severe neck pain, steroids use, drug abuse, treatment by a manual therapist for the current complaint, signs of infection, no access to a smartphone with connection to the internet, or inability to communicate in Swedish. Baseline questionnaires were completed prior to randomization, and treatment began immediately following random assignment to a group.
Participants were allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Treatment duration was six weeks, and the number of visits was limited to six for massage, exercise and combined therapy, and three for the advice group.
Treatments were provided by multiple trained and experienced therapists who were not part of the research team and used a manualized protocol. Treatment and protocol fidelity were regularly assessed. Participants allocated to the advice control group received an educational booklet and attended up to three visits with a therapist. The booklet included evidence-based information about back and neck pain, the psychology of the condition, misconceptions about back and neck pain and the importance of returning to normal activities.
Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and work absence. Outcomes were measured at 7, 12, 26 and 52 weeks.
Out of 1,514 individuals screened, 621 participants were enrolled. The average age of the sample was 46 years, and 69 percent were female. Most participants reported pain duration of more than 12 months, and 77 percent used medication for their pain. The average number of visits was 2.4 for advice to stay active, 5.8 for massage, 5.0 for exercise, and 5.5 for massage and exercise combined. The 52-week follow-up rate was highest for massage therapy (94 percent) and lowest for advice to stay active (79 percent).
At 7 and 12 weeks follow-up, participants in the massage and the combined therapy groups had lower mean pain intensity than participants in the advice group. Pain-related disability for combined therapy and exercise were lower compared to advice after 12 weeks. At 26 weeks, massage and exercise were more likely to show a minimal clinically important improvement in pain intensity compared to advice. At 52 weeks, there were no consistent differences among groups in pain intensity or pain-related disability.
In terms of secondary outcomes, the incidence of perceived recovery at 52 weeks was 20 percent in the advice group, 27 percent in the exercise group, 35 percent in the massage group, and 40 percent in the combined therapy group. There was no difference in the number of visits to additional health care providers at 52 weeks across groups. However, 23 percent of the participants in the advice group visited a massage therapist during the first three months compared to 12 percent, 14 percent and 13 percent in the massage, exercise and combined therapy groups, respectively.
Limitations of the Study
In this study, double blinding was not possible, so expectation may explain some of the differences in results among the interventions. The advice group received a maximum of three sessions of therapy compared to six sessions in the other groups, and the reduced frequency of patient-therapist interaction may have affected the results.
Implications for Evidence-Informed Practice
These results show that massage alone or with exercises was more effective in the short term than advice to reach a clinically meaningful improvement in pain intensity, and that massage and exercise alone were more effective in the mid-term.
The authors note that the short- and mid-term improvement and long-term lack of any significant difference among groups are not inconsistent. In individuals with persistent pain, self-perceived recovery may not equal complete resolution of the pain. Instead, it may be that the person has learned to cope with pain, redefined what it means to be healthy or reached an acceptable quality of life as they define it.
Massage, exercise or a combination of both may encourage these kinds of reframing based on mechanisms beyond the immediate effects of deep tissue manipulation. The sense of empathy and care provision offered by massage therapy may increase patient satisfaction, reduce anxiety and distress, and facilitate a sense of self-efficacy.
Massage Therapy Journal
A Real Pain in the Neck
1. Skillgate E, Pico-Espinosa OJ, Côté P, Jensen I, Viklund P, Bottai M, Holm LW. "Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial." Musculoskelet Sci Pract. 2020 Feb;45:102070.