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Randomized Trial Comparing Traditional Chinese Medical Acupuncture, Therapeutic Massage, and Self-care Education for Chronic Low Back Pain
Daniel C. Cherkin, PhD;
David Eisenberg, MD;
Karen J. Sherman, PhD;
William Barlow, PhD;
Ted J. Kaptchuk, OMD;
Janet Street, RN, MN, PNP;
Richard A. Deyo, MD, MPH
Arch Intern Med. 2001;161:1081-1088.
ABSTRACT
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Background Because the value of popular forms of alternative care for chronic back
pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic
massage, and self-care education for persistent back pain.
Methods We randomized 262 patients aged 20 to 70 years who had persistent back
pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic
massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage
or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale)
and dysfunction (0-23 scale) were assessed by telephone interviewers masked
to treatment group. Follow-up was available for 95% of patients after 4, 10,
and 52 weeks, and none withdrew for adverse effects.
Results Treatment groups were compared after adjustment for prerandomization
covariates using an intent-to-treat analysis. At 10 weeks, massage was superior
to self-care on the symptom scale (3.41 vs 4.71, respectively; P = .01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on
the disability scale (5.89 vs 8.25, respectively; P
= .01). After 1 year, massage was not better than self-care but was better
than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P = .002; dysfunction scale: 6.29 vs 8.21, respectively; P = .05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care.
Conclusions Therapeutic massage was effective for persistent low back pain, apparently
providing long-lasting benefits. Traditional Chinese Medical acupuncture was
relatively ineffective. Massage might be an effective alternative to conventional
medical care for persistent back pain.
INTRODUCTION
BACK PROBLEMS are among the most prevalent conditions afflicting Americans
and one of the most common reasons for using complementary and alternative
medical (CAM) therapies. In 1997, one third of US adults with low back pain
visited a CAM provider for this problem, most commonly chiropractors, massage
therapists, and acupuncturists.1-2
Ernst3 identified only 4 randomized trials
evaluating therapeutic massage, and these reached conflicting conclusions;
all were judged to be of poor quality and included massage only as a "control"
therapy. Studies4-6
of acupuncture for back pain have also been inconclusive because of poor methodological
quality and treatment protocols that do not reflect common practice. Because
of the lack of rigorous efficacy studies, national evidence-based guidelines
for acute low back pain have not recommended the use of either acupuncture
or massage.7 We compared the effectiveness
and cost of acupuncture, therapeutic massage, and educational materials emphasizing
self-management techniques for chronic low back pain.
PATIENTS AND METHODS
STUDY SITE
This study was conducted at Group Health Cooperative, a large staff-model
health maintenance organization (HMO) in Washington State. Treatments were
provided in the offices of licensed acupuncturists and massage therapists
who were members of a CAM practitioner network used by the HMO. The study
protocol was approved by the Group Health Cooperative institutional review
board, and all participants gave written informed consent.
PATIENTS
Individuals aged 20 to 70 years who visited a primary care physician
for low back pain were identified from automated visit data. Six weeks after
such visits, we mailed these patients letters describing the study, specifying
inclusion and exclusion criteria, and asking those interested to return a
signed consent form. A research assistant telephoned respondents to answer
questions, confirm eligibility, collect baseline data, and randomize those
remaining eligible.
Exclusion criteria were symptoms of sciatica, acupuncture or massage
for back pain within the past year, back care from a specialist or CAM provider,
severe clotting disorders or anticoagulant therapy, cardiac pacemakers, underlying
systemic or visceral disease, pregnancy, involvement with litigation or compensation
claims for back pain, inability to speak English, severe or progressive neurologic
deficits, lumbar surgery within the past 3 years, recent vertebral fracture,
serious comorbid conditions, and bothersomeness of back pain rated as less
than 4 on a scale from 0 to 10.
RANDOMIZATION
After baseline data were collected using computer-assisted telephone
interviewing, patients were randomly allocated without stratification using
a computer-generated random sequence. Immediately after randomization, initial
appointments were arranged for those allocated to acupuncture or massage,
and self-care materials were mailed to patients allocated to that group. Patients
retained access to their usual medical care.
TREATMENTS
Acupuncturists and massage therapists were allowed to schedule up to
10 visits over 10 weeks for each patient and were informed that treatment
cost and effectiveness would be measured. Providers recorded details of treatments,
including whether they felt constrained by the protocol.
Acupuncture
We studied Traditional Chinese Medical (TCM) acupuncture because it
is the most common form of acupuncture used in Washington State. We invited
58 licensed acupuncturists in the CAM provider network with at least 3 years
of experience to participate; 18 applied and 7 were selected, including 3
who were trained in China and 2 who received their clinical training in China.
These acupuncturists and our consultants established a treatment protocol
that they considered clinically reasonable. This protocol permitted basic
TCM needling techniques, electrical stimulation and manual manipulation of
the needles, indirect moxibustion, infrared heat, cupping, and exercise recommendations.
Moxibustion is the combustion of plant material to warm specific points at
or near the surface of the body, and cupping involves placing a small heated
cup on the body to create a vacuum. The protocol proscribed the use of massage
(including acupressure), herbs, and treatments not considered common TCM practice
(eg, Japanese meridian therapy). Decisions about the number and location of
needles were left to the provider.
Massage
We invited 122 licensed massage therapists in the provider network with
at least 3 years of experience to participate; 20 therapists applied and 12
were selected. With the guidance of our study therapists and consultants,
we developed a protocol that focused on manipulation of soft tissues (ie,
muscle and fascia). Thus, we permitted commonly used therapies such as Swedish,
deep-tissue, neuromuscular, and trigger and pressure point techniques but
specifically prohibited so-called energy techniques (eg, Reiki and therapeutic
touch) that do not involve physical contact. We also proscribed meridian therapies
(eg, acupressure and shiatsu) because of the possibility that they would have
effects similar to acupuncture and approaches deemed too specialized (eg,
craniosacral and a system of bodywork called Rolfing).
Self-care Education
Patients allocated to usual care alone might believe that they had been
denied useful therapies, resulting in dissatisfaction and worse outcomes.
Therefore, this comparison group received high-quality and relatively inexpensive
educational materials designed for persons with chronic back pain: a book8 and 2 professionally produced videotapes9:
a 40-minute videotape on self-management of back pain and a 25-minute videotape
demonstrating exercises. These unpublished materials included information
about back pain and its treatment, techniques for controlling and preventing
pain and for improving quality of life, and suggestions for coping with the
emotional and interpersonal problems often accompanying chronic illness. The
content of the book has been published in a slightly modified form.10
OUTCOME MEASURES
Interviewers masked to treatment group used computer-assisted telephone
interviews to assess outcomes 4, 10, and 52 weeks after randomization. Questions
pertaining to specific interventions (eg, "Did you read the book?") were asked
only after outcomes data had been collected. The outcomes of primary interest
were symptoms and dysfunction. At baseline and at all follow-up interviews,
patients rated how "bothersome" back pain, leg pain, and numbness or tingling
had been during the preceding week, each on a scale from 0 to 10. The score
for the most bothersome symptom was used. This question has demonstrated substantial
construct validity.11-12
A modified Roland Disability Scale11, 13-14
was used to measure patients' dysfunction. The score is the number of positive
answers to 23 questions on limitation of daily activities attributable to
back pain. This instrument is reliable, valid, and sensitive.11, 15
Several secondary outcomes, including disability, utilization, and cost,
were also examined. Disability was measured using National Health Interview
Survey questions about numbers of days spent in bed, home from work or school,
or with reduced activity16; the questions were
modified to refer specifically to back-related restrictions.
Automated utilization data provided complete information on provider
visits, radiologic procedures, operations, and hospitalizations covered by
the HMO. All analgesic agents, nonsteroidal anti-inflammatory drugs, and muscle
relaxant medications dispensed from HMO pharmacies were recorded, although
some were undoubtedly prescribed for problems other than back pain. Visits
to nonstudy acupuncturists, massage practitioners, and other providers not
covered by the HMO were identified at the 10-week and 1-year interviews.
Other secondary outcome measures were use of medications, satisfaction
with overall care for the back problem, SF-12 Physical and Mental Health summary
scales,17 and numbers of days of aerobic exercise
and back exercise performed (asked only at 1 year) in the previous week.
COSTS OF CARE
The study paid $25 for each acupuncture and massage visit (about 50%
of typical insurance reimbursement in Washington). Nonstudy treatments were
covered (within contract limitations) by patients' health insurance. Eighty-seven
percent of HMO enrollees had coverage for acupuncture and massage for chronic
low back pain on a physician's referral. The HMO's cost accounting system
provided information on costs of back pain–related services. Out-of-pocket
expenses were not captured. We used the fee schedule used by major insurers
in Washington State who cover massage and acupuncture to estimate the costs
of the intervention visits: $48 per massage visit and $60 per initial and
$45 per follow-up acupuncture visit.
STATISTICAL ANALYSIS
The study was designed to have 80% power to detect a 2.5-point difference
on the Roland Disability Scale and a 1.5-point difference on the symptom bothersomeness
scale for the comparison of acupuncture and massage. These are consistent
with the smallest clinically important differences.11
These measures were analyzed as continuous variables within the context of
an intent-to-treat analysis using analysis of covariance (ANCOVA) with adjustment
for baseline values. Overall 2-sided significance of .05 was used when comparing
all 3 treatments. Pairwise comparisons were made using the Sidak adjustment
for multiple comparisons.18 Simple analysis
of variance and nonparametric Kruskal-Wallis analyses were performed to confirm
the ANCOVA.
We did not use repeated-measures analysis because differences among
treatments were not constant over time. We therefore analyzed main effects
at each point adjusting for the baseline values with ANCOVA. The final models
included baseline covariates predictive of the primary outcomes at 10 weeks
(baseline Roland Disability Scale score, baseline symptom bothersomeness scale
score, pain traveling below the knee but not meeting criteria for sciatica,
more than 90 days of back pain in the past 6 months, and satisfaction with
previous back care) and sex and age. We tested interactions of the covariates
with treatment to assess effect modification. Logistic regression adjusted
for baseline values was used for dichotomous outcomes.
RESULTS
RECRUITMENT AND FOLLOW-UP OF PATIENTS
Between May 30, 1997, and October 21, 1997, 3996 letters were mailed
to HMO enrollees 6 weeks after a primary care visit for back pain. It is not
known how many of these patients were eligible (eg, still had significant
low back pain). Consent forms were returned by 693 enrollees (17%) (Figure 1). The first 262 enrollees confirmed
eligible were randomized to receive acupuncture (n = 94), massage (n = 78),
or self-care education (n = 90). Ninety-five percent of all patients were
successfully interviewed at each follow-up.
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Figure 1. Trial profile. None of the 262
randomized patients withdrew because of adverse events.
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BASELINE CHARACTERISTICS
The typical patient was approximately 45 years old, white, well educated,
and employed (Table 1). Mean scores
on the SF-12 Mental Health Scale were close to the national norms (49 vs 50),
but mean scores on the SF-12 Physical Health Scale were substantially worse
(37 vs 50).17 Most patients had first received
treatment for back problems more than 1 year earlier, and most had experienced
pain continuously for the past year. On average, patients reported moderately
severe symptoms (bothersomeness scale score, 6.2) and dysfunction (Roland
Disability Scale score, 12.2). Most were using pain medication (primarily
nonsteroidal anti-inflammatory drugs). Three percent of patients had previous
experience with acupuncture for back pain, and 16% had previously tried massage.
Baseline characteristics were similar across the 3 treatment groups.
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Table 1. Baseline Characteristics of 262 Patients With Low Back Pain
(LBP) by Treatment Group*
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STUDY TREATMENTS
Ninety-four percent of patients assigned to self-care reported reading
at least some of the book (55% claimed to have read more than two thirds)
and 73% reported watching the videotapes. Ninety-four percent of patients
in the acupuncture group and 95% in the massage group visited their assigned
provider and made a mean (SD) of 8.0 (2.4) and 8.3 (2.3) visits, respectively.
Visits to massage therapists and acupuncturists averaged approximately 1 hour.
All patients who received acupuncture were needled and "de qi," a characteristic
dull ache, numbness, or tingling sensation associated with needling, was reported
for 89%. Other commonly used therapies were infrared or other lamp heat (82%
of patients), cupping (66%), and electrostimulation of the needles (51%).
A mean of 12 needles (range, 5-16) were inserted at each visit, with significant
differences among acupuncturists (P<.001). Acupuncturists
recommended exercise for about half of their patients, usually stretching,
walking, or swimming.
At the first visit, the most commonly used massage techniques were Swedish
(71%), movement reeducation (70%), deep tissue (65%), moist heat or cold (51%),
trigger or pressure point (48%), and neuromuscular (45%). Treatments provided
at follow-up visits were similar. Massage therapists recommended exercise,
typically stretching, at the conclusion of 64% of initial visits. Most massage
therapists (59%) also used "body awareness" techniques to help clients become
more aware of their physical and kinesthetic sensations, including potential
early warning signals of injury.
No serious adverse effects were reported by any study patients. Eleven
percent of patients in the acupuncture group and 13% in the massage group
reported "significant discomfort or pain" during or shortly after treatment.
Mean (SD) intervention costs per randomized patient were $50 for the
group receiving self-care education materials, $352 ($138) for acupuncture
visits, and $377 ($139) for massage visits.
PERCEIVED LIMITATIONS OF TREATMENT PROTOCOLS
Although initially fully satisfied with the treatment protocol, acupuncturists
perceived some level of constraint at 46% of initial visits and for at least
1 visit for 70% of their patients. Proscribed treatments cited most frequently
were herbs (36%) and Chinese massage (20%). Three acupuncturists rarely or
never felt constrained and 2 usually felt constrained. Constraints were rarely
noted by massage therapists.
NONSTUDY TREATMENTS
Ten percent of patients in the massage group vs 18% and 21% in the acupuncture
and self-care groups, respectively, made HMO visits for back pain during the
treatment period (P = .16). The percentages of patients
reporting visits to providers not covered by the HMO was low (0% for massage,
4% for acupuncture, and 10% for self-care; P = .01).
One patient in the acupuncture group and 3 in the self-care group visited
a massage therapist, and only one patient in the massage group and none in
the self-care group visited an acupuncturist.
OUTCOMES AT THE END OF 10 WEEKS OF TREATMENT
Subjective Responses
At 10 weeks, 74% of patients rated massage as very helpful (at least
8 on a scale from 0-10) compared with 46% for acupuncture (P<.001). Of those using self-care materials, only 17% and 26% considered
the book and the videotapes, respectively, very helpful.
Primary Outcomes: Symptoms and Dysfunction
Significant treatment effects favoring massage emerged after 10 weeks
(Table 2, Figure 2, and Figure 3).
After adjustment for baseline scores and prognostic covariates, treatments
differed in their effects on symptom bothersomeness (P
= .02) and dysfunction (P<.001). The massage group
had less severe symptoms than the self-care group (P
= .01) and less dysfunction than the self-care (P<.001)
and acupuncture (P = .01) groups. Analyses using
square root transformations and nonparametric tests yielded similar results.
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Table 2. Symptom Bothersomeness Scale and Roland Disability Scale Scores
at Baseline, 4 Weeks, 10 Weeks, and 1 Year*
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Figure 2. Mean symptom bothersomeness scale
scores adjusted for baseline bothersomeness score (overall mean score, 6.2),
baseline Roland Disability Scale score, pain below the knee, more than 90
days of back pain in the past 6 months, satisfaction with back care, sex,
and age. Higher scores indicate more severe symptoms.
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Figure 3. Mean Roland Disability Scale scores
adjusted for baseline Roland Disability Scale score (overall mean score, 12.2),
baseline symptom bothersomeness scale scores, pain below the knee, more than
90 days of back pain in the past 6 months, satisfaction with back care, sex,
and age. Higher scores indicate greater disability.
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There were no significant interactions between treatment and baseline
characteristics included as covariates in the final model, suggesting that
there were no subgroups of patients (eg, women) especially likely to benefit
from a particular treatment. There was little difference among the acupuncturists
with respect to effect on patients' symptoms or function, although differences
among massage therapists approached statistical significance.
At 10 weeks, only 5% of patients in the massage group compared with
19% in the acupuncture and self-care groups reported more than a week of restricted
activity (P = .02 after controlling for baseline
values). Similar results were found for the proportions of patients who spent
1 or more days in bed because of back pain (massage group, 3%; acupuncture
group, 13%; and self-care group, 12%; adjusted P
= .04). The proportion of patients who missed work or school was similar in
the 3 groups (8%-14%).
Secondary Outcomes
Differences among the groups on the SF-12 Physical Health Scale were
significant at 10 weeks (P = .006). The only significant
pairwise comparison found massage to be superior to self-care (P = .004). Differences among the treatments on the SF-12 Mental Health
Scale were not significant at 10 weeks, but at 4 weeks the scores for the
massage group were superior to those for the acupuncture (P = .003) and self-care (P = .03) groups.
At baseline, less than 10% of patients in all 3 groups were very satisfied
with the care they had received for their back problem. By 10 weeks, patients
in the massage and acupuncture groups were more likely to be very satisfied
than those in the self-care group (50%, 37%, and 13%, respectively; adjusted P<.001).
Between baseline and 10 weeks, the percentages of patients reporting
medication use decreased substantially in the acupuncture group (from 69%
to 51%) and the massage group (from 73% to 47%) but little in the self-care
group (from 63% to 62%). Controlling for baseline values, medication use by
the acupuncture and massage groups did not differ from each other but was
significantly below that in the self-care group (P<.05).
At the end of the treatment period, approximately 25% of patients in
all 3 groups reported more than 3 days of aerobic exercise in the previous
week.
OUTCOMES AFTER 1 YEAR
Outcomes observed for massage and acupuncture at 10 weeks remained relatively
unchanged at 1 year (Table 2 and Figure 2 and Figure 3). Massage was superior to acupuncture in its effect on
symptoms (P = .002) and function (P = .051). However, there were substantial improvements in the self-care
group during this period such that patients in this group had better outcomes
than those in the acupuncture group, although these differences were not statistically
significant.
By 1 year, differences among groups in disability days, SF-12 Physical
and Mental Health scale scores, and satisfaction were no longer significant.
However, use of medications (primarily nonsteroidal anti-inflammatory drugs)
remained lower in the massage group than in both other groups (adjusted P<.05).
At 1 year, there were no significant differences among the treatment
groups in the proportions of patients (1) with a recurrence or continuation
of back pain in the previous 6 months (almost 80%), (2) seeking back care
(about 40%), or (3) visiting an acupuncturist (about 6%) or a massage therapist
(about 15%). The benefit of massage did not seem to be due to greater exercise
by patients in that group because we found that patients in the massage group
were less likely than those in the acupuncture and self-care groups to report
more than 3 days of regular back exercises in the previous week (18%, 26%,
and 37%, respectively; P = .03) and about equally
likely to report use of aerobic exercise.
During the year after randomization, the mean number of provider visits
(excluding intervention visits), number of filled pain medication prescriptions,
and costs of outpatient HMO back care services were about 40% lower in the
massage group than in other groups (Table
3). However, because of large SDs, these differences were not statistically
significant. Two patients in the self-care group and 1 in the acupuncture
group had back surgery (decompressive lumbar laminectomies for spinal stenosis).
Similar percentages of patients (15%-20%) in the 3 groups reported use of
non-HMO providers for back care during the previous 6 months, and they averaged
similar numbers of visits (about 2).
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Table 3. Back Pain–Related HMO Services and Costs During the
Year After Randomization*
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CLINICAL SIGNIFICANCE OF FINDINGS
Group differences identified in this study exceeded suggested values
for the smallest clinically relevant differences (2.5 points on the Roland
Disability Scale and 1.5 points on the symptom bothersomeness scale). The
adjusted Roland Disability Scale score for the massage group at 10 weeks was
3.0 points lower than that for the self-care group and 2.4 points below that
for acupuncture. Symptom bothersomeness for the massage group at 1 year was
1.7 points lower than in the acupuncture group. The magnitude of the benefit
of massage in this study (3.0 points on the Roland Disability Scale at 10
weeks) is double that found by other studies using the Roland Disability Scale
and reporting significant effects of exercise19
and cognitive-behavioral interventions20-21
for chronic low back pain.
COMMENT
The results of this study suggest that massage is an effective short-term
treatment for chronic low back pain, with benefits that persist for at least
1 year. Self-care educational materials had little early effect but, by 1
year, were almost as effective as massage. We were unable to identify any
subgroups that were especially likely to benefit from one or both of these
therapies. The persistent effects and substantially lower (but not statistically
significant) utilization and costs of care for the massage group suggest that
the initial costs (approximately $375 in this study) might be offset by reductions
in subsequent care. Although the cost of self-care materials is low, it is
not clear that their use will result in cost savings. However, the combination
of massage and self-care materials might prove to be particularly cost-effective.
Because we did not include a "no treatment" or "standard care only"
control group, the results might underestimate the value of all 3 treatments.
However, if acupuncture has a positive effect, it seems to be concentrated
during the first 4 weeks because there was little improvement thereafter.
During the first 4 weeks, all 3 groups improved by similar amounts, reflecting
either the natural course of back pain, equivalent early effectiveness of
all 3 treatments, or both.
The reasons for superior outcomes in the massage group are unclear but
do not seem attributable to more favorable baseline characteristics or greater
use of back care or exercise. In fact, back care visits, medication use, and
back exercise were lowest in the massage group. The findings of this study
are congruent with those of a recent consumer survey, which found deep-tissue
massage to be the most helpful treatment for back pain and acupuncture to
be among the least helpful.22
Several related aspects of the massage therapy experience could explain
its effectiveness: (1) spending an hour in a relaxed environment, (2) being
touched in a therapeutic context, (3) receiving ongoing attention, (4) specific
effects of soft-tissue manipulations on the structure and/or function of the
tissues and on pain sensation, (5) education about exercise or other lifestyle
changes, and (6) increased body awareness (as described in the "Study Treatments"
subsection). It is unclear which, if any, of these explanations is most important.
Better mental health status in the massage group during the first few weeks
of treatment suggests that massage might enhance mental health independent
of its effect on physical health, as has been reported in previous controlled
studies evaluating the effects of massage for various conditions.23
The relative ineffectiveness of the educational materials in the short
term, coupled with evidence for effectiveness at 1 year, suggests a delayed
benefit of viewing the materials or a benefit of reviewing the materials during
the remainder of the year. Previous studies of educational booklets alone24 or combined with nurse education25-26
showed no significant effect on back pain or function. More sophisticated
educational materials (identical to those used in this study) supplemented
by classes20-21 have modest short-term
effects on function and symptoms compared with a popular book on back pain.27
This study demonstrates that HMO patients with back pain are willing
to participate in trials evaluating CAM therapies and to comply with assigned
treatments. Although only 17% of patients invited to participate returned
consent forms, a large fraction of the nonrespondents were likely ineligible
(eg, no longer experiencing significant pain, workers compensation claimants,
or experiencing sciatica). We previously found that two thirds of patients
seen for back pain by primary care providers no longer had significant pain
or dysfunction 7 weeks after their visits.28
This suggests that a substantial proportion of patients with persisting pain
or dysfunction volunteered to participate in this study. Furthermore, participants
resembled patients with back pain commonly seen in primary care in terms of
their demographic and clinical characteristics and were not persons who normally
visited acupuncturists or massage therapists for their back pain. Finally,
few patients reported significant discomfort or pain associated with the treatments,
and there were no serious adverse effects.
Major strengths of this study were the randomized design, involvement
of massage therapists and acupuncturists in developing treatment protocols,
minimal "contamination" or "co-interventions," high compliance rates, adequate
sample size, high follow-up rates, and short- and long-term follow-up. The
study's primary limitations are use of a single study site, the absence of
a "no treatment" or "usual care" control group, restriction of the study to
a single form of acupuncture (TCM), the possibility that acupuncturists and
massage therapists were atypical, and use of protocols that excluded treatments
often used by some TCM acupuncturists (eg, herbs and oriental massage).
Few conventional or CAM treatments have been found by rigorous randomized
trials to be effective treatments for chronic low back pain. The results of
this study suggest that therapeutic massage is effective for chronic or subacute
low back pain and raise doubts about the effectiveness of TCM acupuncture.
It remains unclear whether a more comprehensive TCM approach including herbs
and oriental massage would be effective for persistent back pain. Studies
of the effectiveness of other forms of acupuncture are also needed because
these vary in the location and depth of needling. The finding that benefits
of massage persist well beyond the last treatment and the suggestion of possible
reductions in subsequent health care utilization make massage a high priority
for further study. Finally, future research should attempt to determine which
components of the massage therapy experience contribute to its effectiveness.
AUTHOR INFORMATION
Accepted for publication November 7, 2000.
This project was supported by grants from Group Health Cooperative,
The Group Health Foundation, Seattle, Wash, and the John E. Fetzer Institute,
Kalamazoo, Mich; and by grant HS09351 from the Agency for Healthcare Research
and Quality, Rockville, Md.
We are indebted to the many people who contributed to the successful
completion of this study, in particular our project team (Floradean Bousman,
Russ Bradley, Kristin Delaney, Dakota Duncan, Letitia Hodgkinson, Eapen Leubner,
Nancy Monroe, and Jane Steetle); Linda Shultz, Cheri Anderson, Julia Anderson,
and the rest of the Center for Health Studies Survey Group; our acupuncturist
consultants (Karen Boyd and Pat Flood); our massage therapist consultants
(Lori Bielinski, Janet Kahn, E. Houston LeBrun, and Diana L. Thompson); the
participating acupuncturists (Hoy Ping Yee Chan, Amy Zhuan Ying Chen, John
Fenoli, Tom Glynn, Peter White, and Haifeng Wu); and our participating massage
therapists (Lucy Baker, Nancy Emory, Daphne Godejohn, Karen Lucas, Jillian
Orton, Robert Regan-Hughes, Pamela Reinhardt, Susan Rosen, Cheri Schell, Tatiana
Shiyan, and Ann Marie Taylor Ruff).
Corresponding author and reprints: Daniel C. Cherkin, PhD, Center
for Health Studies, Group Health Cooperative, 1730 Minor Ave, Suite 1600,
Seattle, WA 98101.
From the Center for Health Studies, Group Health Cooperative, Seattle,
Wash (Drs Cherkin and Barlow and Ms Street); Beth Israel–Deaconess Center
for Alternative Medicine Research and Education, Department of Medicine, Harvard
Medical School, Boston, Mass (Drs Eisenberg and Kaptchuk); Northwest Institute
of Acupuncture and Oriental Medicine, Seattle (Dr Sherman); and the Departments
of Medicine and Health Services, University of Washington, Seattle (Dr Deyo).
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