Complementary Therapies in Clinical Practice 18 (2012) 227e234

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Complementary Therapies in Clinical Practice

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The effectiveness of Swedish massage and traditional Thai massage in treating

chronic low back pain: A review of the literature
Sritoomma Netchanok a, *, Moyle Wendy a, b, c, Cooke Marie a, b, d, O’Dwyer Siobhan b, e
a
School of Nursing and Midwifery, Research Centre for Clinical & Community Practice Innovation, Griffith Health Institute, Griffith University, 170 Kessels Road,
Nathan Campus, Nathan/QLD 4111, Australia
b
Research Centre for Clinical & Community Practice Innovation, Griffith Health Institute, Griffith University, 170 Kessels Road, Nathan/QLD 4111, Australia

a b s t r a c t
Keywords: Aim: To review the effectiveness of Swedish and traditional Thai massage in treating chronic low back
Chronic back pain pain.
Swedish massage
Background: Thai and Swedish massage both appear to relieve lower back pain but their relative effec-
Thai massage
Literature review
tiveness has not been clearly established.
Design and method: A literature review of nine databases were searched and 13 papers found.
Results: Six papers meet the inclusion criteria and were summarised and reviewed. Both Thai and
Swedish massages are reported to relieve chronic low back pain by enhancing physical functions;
providing pain relief, improving disability and range of motion, improving psychological functions;
reducing anxiety and improving mood. Although based on different theoretical frameworks, they appear
to be equally effective in relieving chronic low back pain.
Conclusion: Despite some evidence for the use of massage to relieve low back pain, methodological
limitations highlight the need for further studies that compare Thai massage and Swedish massage.
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction several complementary and therapeutic alternatives have been

Chronic low back pain is a common and major health issue, with
70e85% of people suffering low back pain at sometime in their
lives,1,14 and more than 50% of adults suffer from this condition each
year.30 Approximately 90% of patients with low back pain recover
within a few months of onset.15 However, about 10% develop
chronic low back pain and this account for more than 90% of social
costs for back incapacity.14,32 Recurrences of low back pain are
common, with the percentage of subsequent low back pain
episodes ranging from 20% to 44% within 1 year for working pop-
ulations to lifetime recurrence of up to 85%.15,31 Chronic low back
pain is defined as a chronic condition of lower back pain lasting for
at least three months or longer.2,23 It is difficult to treat, impairs
quality of life, restricts physical activity and reduces psychosocial
wellbeing,6,28 and therefore is costly for society.34 As a result,
* Corresponding author. Tel.: þ61 737355273; fax: þ61 737355431.
E-mail addresses: n.sritoomma@griffith.edu.au (S. Netchanok), w.moyle@
griffith.edu.au (M. Wendy), m.cooke@griffith.edu.au (C. Marie), s.odwyer@
griffith.edu.au (O’Dwyer Siobhan).
c
Tel.: þ61 737355526; fax: þ61 737355431.
d
Tel.: þ61 737357985; fax: þ61 737355431.
e
Tel.: þ61 737356619; fax: þ61 737353560.
employed to manage low back pain.
Complementary and alternative medicine (CAM) consists of five
major areas: (1) minddbody interventions (e.g. meditation); (2)
biologically based interventions (i.e. vitamins, minerals, herbal
medicines and nutritional supplements); (3) body-based inter-
ventions (e.g. massage); (4) energy-based interventions (e.g. Reiki);
and, (5) alternative medical systems (e.g. Chinese medicine).26 CAM
is most commonly used for chronic conditions including back
pain.8,36 Among prior users of specific CAM modalities for back
pain, massage was rated most helpful in relieving their current pain
whereas users of chiropractic care reported treatment-related
significant discomfort, pain or harm.30
Massage has been defined as a systematic manipulation of the
soft tissues of the body with rhythmical pressure and stroking for
the purpose of obtaining or maintaining health.33,35 Essentially,
massage is a simple means of providing pain relief through physical
and mental relaxation. It is thought to relieve pain through several
pathways, including increasing the pain threshold by releasing
endorphins,10 and closing the gate of pain at the spinal cord level.22
It also promotes a feeling of wellbeing and a sense of receiving good
care.20,33
Different massage styles, such as acupressure (e.g. traditional
Thai massage) and classic massage (e.g. Swedish massage) use

1744-3881/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctcp.2012.07.001
228 S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234
different techniques and approaches.4 Swedish massage is
considered to be rehabilitative and uses techniques to address
symptoms associated with medical conditions. The emphasis in
Swedish massage is on physical symptoms. Swedish massage is
classified as superficial massage, and consists of five main stroking
actions to stimulate the circulation of blood through the soft tissues
of the body-effleurage, petrissage, friction, tapotement and vibra-
tion.9,29 On the other hand, Thai massage techniques are based on
the energy balance theory of health and healing using deep tissue
massage with acupressure that focuses on the field of energy lines
flowing in the body called ‘Sen Sib’. Palming and thumbing are used
to move energy along pathways.5 Traditional Thai massage is
considered to be curative massage for illness and aims for energetic
balance.9 Both styles of massage however have been used widely to
relieve low back pain, but their relative effectiveness in adults has
not been clearly established.
2. Objectives and methods
This paper presents a review of randomised controlled trials
that focus on the effectiveness of traditional Thai and
Swedish massage in treating chronic low back pain either through
a comparison to each other, a usual care group or other therapies
such as relaxation therapy or joint mobilisation. In addition,
secondary outcomes related to physical and psychosocial functions
investigated in studies will be reviewed. A systematic review of the
literature was conducted according to the PRISMA 2009 checklist
and flow diagram for systematic reviews.24
2.1. Search methods
An appraisal of selected systematic reviews, and research
papers published in English in peer reviewed journals between
2000 and 2011 was undertaken. As there were no published
trials evaluating the effectiveness of any types of massage for
back pain prior to 2000, this was determined to be an appro-
priate starting date for this review.7 The major electronic data-
bases e CINAHL, EBSCOhost, MEDLINE, ProQuest, Google scholar,
ScienceDirect, MEDSCAPE, PubMed, ProQuest Dissertations and
Theses, Australia Digital Theses Program e were searched using
the same search strategy. The search terms included the MeSH
terms and all databases were searched using a combination of
the following key words: Thai massage, Swedish massage, low
back pain, chronic low back pain. Reference lists of all relevant
articles obtained were checked and additional relevant articles
were retrieved.
2.2. Study selection
2.2.1. Inclusion criteria
Studies were included if they met the following criteria:
 Type of participants: adult patients (18 years and older) with
chronic low back pain.
 Type of studies: randomised controlled trials (RCTs).
 Outcome measures: the primary outcome of interest was back
pain intensity; secondary outcomes were any types of physical
and/or psychological function.
 Type of interventions: Thai massage and/or Swedish massage
compared to each other, usual care or other treatments such as
relaxation therapy and joint mobilization.
2.2.2. Exclusion criteria
Studies were excluded when the specific types of Thai or
Swedish massage were not detailed.
2.3. Search outcome
Fig. 1 details the process of the literature search and review.
Thirteen articles were retrieved from the initial searches. Six arti-
cles reported RCT studies of Thai or Swedish massage. Seven articles
were excluded from the review because either they were not
specific trials on Thai or Swedish massage,11,17,18,37 or the partici-
pants did not have back pain,9 or the article reported only a study
protocol,7 or the article was not published in English.13
2.4. Data extraction
The final sample included six research studies. The studies were
further analysed using data extracted under the following head-
ings: author and date of publication, objectives of study, sample,
settings, study designs, interventions, outcome measurements,
findings, and limitations of study (see Table 1).
3. Results
3.1. Traditional Thai and Swedish massage effectiveness on low
back pain
Six papers on the effect of Thai or Swedish massage on lower
back pain were reviewed. All of them were randomised controlled
trials. Five trials tested traditional Thai or Swedish massage
compared with other types of therapies (see Table 1),3,12,16,21,27 and
one trial compared traditional Thai and Swedish massage.5
The primary outcome of pain was mostly measured by pain
intensity using a 10-point Visual Analogue Scale (VAS). Another
pain scale commonly used was the McGill Pain Questionnaire
(MPQ), which consists of two indexes, the Present Pain Index (PPI)
and the Pain Rating Index (PRI), to measure pain intensity and
quality of pain. The secondary outcome measures are grouped into
two major areas: physical function measurement and psychological
measurement. Physical functions included Blood Pressure (BP),
Heart Rate Variability (HRV), disability as measured by the
Oswestry Disability Questionnaire (ODQ, 0e100), back perfor-
mance as measured by the Thoracolumbar spine range of motion
(ROM) or lumbar range of motion as measured by the Modified
Records identified through Additional records identified
database searching (n=12) through other sources (n=1)
Records after duplicates removed (n=13)
Records screened Records excluded
(n=13) (n=6)
Full-text articles assessed Full-text articles excluded,
for eligibility (n=7) with reasons (n=1)
Studies included in
qualitative synthesis (n=6)
Fig. 1. PRISMA 2009 flow diagram.24
Table 1
Traditional Thai and Swedish massage effectiveness on low back pain.

Reference Objectives Methodology Findings Limitation

Design & sample Settings Interventions Outcome measures Timing of

follow-up
Buttagat To investigate the Randomized The Department Group 1 (treatment): one 30-min - Heart rate variability (HRV) Immediate TTM was associated This study only
et al.3 immediate effects control trial (RCT) of Physiotherapy session of TTM onto the back - Pain intensity and muscle following with significant evaluated the
of traditional Thai 36 patients with at Khon Kaen muscles while lying in the prone tension: 10 cm visual treatment increases in HRV, immediate effect
massage (TTM) chronic low University, position during the period analogue scales (VAS) pressure pain of TTM, which
on heart rate back pain with Thailand between 10.00 h and 13.00 h on - Pressure pain threshold threshold (PPT) and may not correlate
variability and myofascial trigger the day of the study. (PPT): three times for body flexibility with a longer
stress-related points Group 2 (Control): lying prone point and then average (P < 0.05) and term effect
parameters in Average age: quietly in the same environment score (kg/cm2) significant decreases
patients with back 22.6  2.9 yr and for the same period of time - State trait anxiety in pain intensity,
pain associated Female: 55.56 % as the treatment group inventory (STAI): a anxiety and muscle

S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234

with myofascial Pain duration: Groups: 20-item. Tension (P < 0.001).
trigger points 3 months G1: TTM, n ¼ 18 - Body flexibility: A Conclusion:
G2: lying prone, n ¼ 18 sit-and-reach box traditional Thai
massage can increase
heart rate variability,
reduce pain and
improve stress-related
parameters in patients
with back pain
associated with
myofascial trigger points
Chatchawan To verify the Prospective, parallel The Department Traditional Thai massage (TTM) Patient-rated outcome Short-term effect No statistically Participants were
et al.5 effectiveness of group, randomized of Physiotherapy or Swedish massage (SM) for six measures: before and after significant not blinded to
traditional Thai clinical trial (RCT) at Khon Kaen sessions during a 3e4 week period, treatment differences across their treatment
massage among 180 Patients with University, with follow-up 1 month later  Pain intensity by visual  On day 1 all outcomes between groups A ‘no-
patients with back spontaneous back Thailand Group 1: the TTM group received analogue scale (VAS)  Second the TTM and SM treatment’ control
pain associated pain with at least treatment to specific massage  Disability by Oswestry week treatments group
with myofascial one trigger point points. Each point was pressed disability questionnaire  Third week Both groups showed
trigger points in either the upper with the thumb, finger, palm and (ODQ, 0e100) over 50% reduction
or lower torso elbow beginning with gentle  Patient satisfaction with Long-term effect in pain intensity
Age: average pressure and increasing pressure their treatment (4-point  One month after 3 weeks of
36  9 yrs until the patient reached their scale) after the last treatment
Female: 63% pain threshold. Pressure was  Side-effects and treatment Conclusion: TTM or
Pain duration: maintained for 5e10 seconds medication used SM treatment can
>1 months Group 2: comparison group Back performance: be used, with equal
received SM treatments. The  Thoracolumbar spine expected effectiveness,
pressure held was deep enough range of motion in the treatment of
to reach into the subcutaneous  Body flexibility: A back pain associated
tissue but not so deep as to reach sit-and-reach box with myofascial
the patient’s pain threshold.  Pressure pain threshold trigger points
Both the TTM and SM treatments l Recommendation:
asted for 30 min, followed by TTM and SM are
10 min of passive stretching. more widely
Groups: promoted as
G1: TTM, n ¼ 90 alternative primary
G2: SM, n ¼ 90 health care
treatments for back
pain
(continued on next page)

229
Table 1 (continued )

230
Reference Objectives Methodology Findings Limitation

Design & sample Settings Interventions Outcome measures Timing of

follow-up
Field et al.12 To evaluate A randomized Touch Research Group 1: Massage therapy Preepost session assessments After the sessions At the end of The control
massage between-groups Institutes, University (immediate effects) on the last days of the study, the participants
therapy versus design of Miami School of - received two 30 min massage  Profile of mood states the 5-week study massage therapy actually practiced
relaxation therapy 30 with low back Medicine Miami, USA therapy sessions per week over depression scale group, as compared muscle relaxation
effects on chronic pain 5 weeks by trained massage (POMS-D) to the relaxation The small sample
low back pain Average age: 41 therapists  State-trait anxiety group, reported size
years and middle inventory (STAI) experiencing less Lack of a
class Group 2: Relaxation therapy (control  Pain-visual analogue pain (P ¼ 0.03), long-term
Female: 46.67% for potential placebo) scale (VAS) depression, anxiety follow-up
Pain duration: - showed how to use progressive  ROM-trunk and pain and sleep assessment
6 months muscle relaxation exercises flexion disturbance

S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234

Firstelast day sessions (P < 0.01), improved
(longer term effects) trunk and pain
Conducted these 30 min sessions at
 Sleep scale flexion performance
home twice a week for 5 weeks and
(P < 0.01)
kept a log on the times they spent
in relaxation therapy Job productivity and
Groups: absenteeism
G1: SM technique, n ¼ 15
G2: Relaxation therapy, n ¼ 15
Hernandez To evaluate massage A randomized Touch Research Group 1: Massage therapy Preepost session assessments After the sessions The massage therapy Difficult to ensure
et al.16 therapy for reducing between-groups Institutes, University - received two 30-min massage (immediate effects) on the last days of group, as compared that the control
pain, depression, design. of Miami School of therapy sessions per week  Profile of mood states the 5-week study to the relaxation participants
anxiety and stress 24 Adults with low Medicine Miami, USA over 5 weeks by trained depression scale group, reported actually complied
hormones, and back pain massage therapists (POMS-D) experiencing less with the at-home
sleeplessness and for Average age:  State-trait anxiety pain (P ¼ 0.01), instructions
improving trunk range 39.6 years and Group 2: Relaxation therapy inventory (STAI) depression, anxiety Small sample size
of motion associated middle class (control for potential placebo)  Pain-visual analogue and improved sleep Lack of a
with chronic low Female: 54.17% - was shown how to use scale (VAS) (P ¼ 0.05) long-term
back pain Pain duration: progressive muscle relaxation  ROM-trunk and pain They also showed follow-up
6 months exercises including tensing, flexion improved trunk assessment
relaxing muscle. (P ¼ 0.01) and pain
- conducted these 30 min Firstelast day sessions flexion performance
sessions at home twice a week (longer term effects) (P ¼ 0.02) and their
for 5 weeks and kept a log on  Sleep scale serotonin and
the times they spent in  Symptom checklist-90 dopamine levels
relaxation therapy revised were higher (P ¼ 0.05)
 Urine samples-cortisol,
catecholamine,
serotonin levels
Mackawan To examine the Randomized control The Department Group 1: TTM on lower  The levels of substance Before and after There was no significant Lack of a control
et al.21 immediate effects of comparative study. of Physiotherapy P in saliva 5 min after each difference in the level group due to
TTM versus joint 67Adults with at Khon Kaen - back muscles  Visual analogue treatment of substance P after ethical concerns
mobilization on non-specific LBP University, between L2 and L5 scale (VAS) treatment between This study only
substance P and pain Average age: Thailand the two groups evaluated the
perception in patients 38.97  7.85 yr Group 2: joint mobilization There was a marked short-term effect
with non-specific low Female: 61.19% on spinous process of L2eL5 decrease in VAS after of TTM
back pain Pain duration: by experienced physiotherapist treatment in both TTM
 3 months - The duration of each (P ¼ 0.000) and joint
treatment was 10 min mobilization (P ¼ 0.002)
TTM yields slightly more
beneficial effects than
Groups:
joint mobilization
G1: TTM, n ¼ 35
(P ¼ 0.017)
G2: Joint mobilization,
n ¼ 32
 S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234 231

Schober test. Psychological measures were patient satisfaction with

physical measures
outcomes was by
provided by only
back care (5-point Likert scale), State Trait Anxiety Inventory (STAI),
massage therapy

only short-term
specific form of

Assessment of
5-item Mental Health Index of the SF-36 in Quality of Life
two massage
The use of a

measurement.
therapists

follow-up
3.2. Traditional Thai massage versus Swedish massage on back pain
relief
(P ¼ 0.006) compared
in the quality of pain
(P < 0.001), decrease
group had improved
function (P < 0.001),

* 63% of CMT group

* 27% of SMT group
The comprehensive

* 14% of RM group
All of the six trials reported that the massage used as the

* 0% of the control
follow-up, no pain
massage therapy

less intense pain

with the other 3

intervention (traditional Thai massage, Swedish massage, struc-

tural massage, relaxation massage) significantly reduced pain
reported in:
At 1-month

intensity.3,5,12,16,21,27
group
groups

3.2.1. Traditional Thai massage versus Swedish massage

The study of Chatchawan et al.5 (n ¼ 180) showed that tradi-
tional Thai massage or acupuncture massage, which is the practice
treatment and
Baseline, after

at 1-month

of applying pressure and tension with manual aids to specific

follow-up

points on the body, was equally effective at reducing lower back

pain compared with Swedish massage. Chatchawan et al.5 found
that pain intensity among back pain patients with myofascial
 The State Anxiety Index
Primary outcomes: functional

trigger points, as measured by the Visual Analogue Scale was

Secondary outcomes: anxiety
and lumbar range of motion

 The Modified Schober

 The Roland Disability
Questionnaire (RDQ)

reduced by over 50% (P < 0.05) after only three weeks of treatment
test (lumbar range
Questionnaire (PPI

with either traditional Thai massage or Swedish massage. Myo-

 The McGill Pain

fascial trigger points are hyperirritablespots in skeletal muscle that

of motion)

are associated with palpable nodules, which are small contraction

and pain relief

and PRI)

knots (a number of individual muscle fibres maximally contracted),

and a common cause of pain.19 In terms of short-term effectiveness,
the Chatchawan et al.5 study showed that the Swedish massage
group had a slightly larger improvement in pain intensity
compared to the traditional Thai massage group (P ¼ 0.05) imme-
diately after the specific massage. In terms of long-term effective-
ness, the study showed no significant difference in the degree of
Group 4: a placebo of sham
Group 3: remedial exercise

G4: Control group, n ¼ 26

manipulation only (STM)

reduction in pain intensity between the groups at the end of three

Group 1: comprehensive

approximately 1 month
massage therapy (CMT)

Each subject received 6

with posture education

weeks of treatment. However, there was a statistically significant

Group 2: soft-tissue

treatments within

difference in the degree of improvement in the pressure pain

G1: CMT, n ¼ 25
G2: STM, n ¼ 25

threshold between treatment groups (P < 0.05), with patients in

G3: RE, n ¼ 22
laser therapy

the traditional Thai massage group showing a greater increase in

only (RE)

Groups:

pressure pain threshold than patients in the Swedish massage

group (difference between groups 0.4 kg/cm2, 95% confidence
interval 0.2e0.7 kg/cm2), although it was not clinically significant.
However, Chatchawan et al.5 concluded that both treatments had
of Guelph, Ontario
Centre, University

equal therapeutic effectiveness in the treatment of clients with

The Health and

back pain associated with myofascial trigger points, however both

Performance

the difference between group and the 95% confidence interval was
Canada

too small (less than 1) to conclude that the difference was clinically
significant.
Average age: 46 yrs
107 Subjects with

3.2.2. Traditional Thai massage versus other therapies

Pain duration:

Two studies (Buttagat et al. in 2009 and Mackawan et al. in

subacute low
Randomized

Female: 51%

1 wke 8 mt

2005) assessed the effectiveness of traditional Thai massage on

controlled
trial (RCT)

back pain

pain intensity (as measured by the Visual Analogue Scale)

compared with bed rest and joint mobilization. Buttagat et al.3
reported that pain intensity, pressure pain threshold, and muscle
of subacute low-back pain
therapy for the treatment

tension, all showed significant immediate term improvements after

comprehensive massage

components of massage

a placebo of sham laser

posture education) and
remedial exercise with
therapy, two separate

traditional Thai massage for back pain associated with myofascial

therapy (soft-tissue
manipulation and

trigger points compared with the control group (group difference

To compare the
effectiveness of

2.7 [95% confidence interval 1.9e3.4], P < 0.001). Mackawan et al.21

examined the acute effect of traditional Thai massage and joint
mobilization on pain levels and pain perception in non-specific low
back pain. The findings suggested that both treatments could
temporarily relieve pain. Although there was no significant differ-
ence between the two treatments in their substance P levels, the
Preyde27

Visual Analogue Scale in the traditional Thai massage group was

slightly lower than that of the joint mobilization group. This result
supported the view that traditional Thai massage could reduce pain
232 S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234
slightly more than joint mobilization (difference between group
0.88 [95% confidence interval 0.16e1.59], P ¼ 0.017).
3.2.3. Swedish massage versus other therapies
Three studies12,16,27 reported that the Swedish massage
technique was found to be more effective than relaxation
therapy (muscle relaxation exercise) for immediately reducing
lower back pain (P ¼ 0.05).12,16 The massage group had signifi-
cantly less intense pain (mean of the Present Pain Index score
0.42 vs. 1.18e1.75, P < 0.001) and a decrease in the quality of pain
(mean of the Present Rating Index score 2.29 vs. 4.55e7.71,
P ¼ 0.006) compared with soft-tissue manipulation, remedial
exercise and posture education for subacute low back pain.27
Six studies3,5,12,16,21,27 reported that both traditional Thai and
Swedish massage could reduce back pain intensity. Traditional Thai
massage slightly reduced pain compared to joint mobilization
while the Swedish massage group had significantly less intense
pain and a decrease in the quality of pain compared with soft-tissue
manipulation, remedial exercise and posture education for
subacute low back pain. When traditional Thai massage was
compared to Swedish massage, there were no clinically significant
differences between groups.
3.3. Traditional Thai massage versus Swedish massage on physical
functions
Along with examining the primary outcome (pain intensity),
three studies considered other effects as secondary outcomes such
as physical function including functional ability, range of motion of
back and body flexibility.
3.3.1. Traditional Thai massage versus Swedish massage
The Chatchawan et al.5 study compared the effectiveness of
traditional Thai massage and Swedish massage among clients with
back pain associated with myofascial trigger points and reported
that clients in both massage groups reported improvements in
almost all secondary outcome measures: disability measurement,
back performance, body flexibility, side effects and medication use,
at all post-treatment assessment times. Thai massage improved
disability more than Swedish massage immediately and at the end
of the 3-week treatment (P < 0.05). Comparison between groups by
means and 95% confidence interval indicated that there were no
significant differences between the effect of traditional Thai
massage and Swedish massage on disability, back performance and
body flexibility.5
3.3.2. Swedish massage versus other therapies
Two trials16,27 examined the effectiveness of Swedish
massage compared with other therapies including acupuncture
massage, soft-tissue manipulation, exercise posture, education
and sham laser therapy (low-level infrared laser) on low back
pain. The findings showed that Swedish massage technique
significantly improved functional ability both immediately
(P < 0.001) and in the short term (one month) (P < 0.001) for low
back pain compared with soft-tissue manipulation, exercise and
posture education, and sham laser therapy.27 Looking at lumbar
range of motion, there was no difference in range of motion
between the three groups (soft-tissue manipulation, exercise
and posture education, and sham laser therapy).27 In the Her-
nandez et al.16 study, the massage therapy group experienced
immediate changes in trunk flexion and displayed improved
trunk flexion (P ¼ 0.02) for chronic low back pain across the
study period (five weeks) compared with a relaxation muscle
exercise group.
3.4. Adverse events
Only one of the six trials reported adverse reactions. Both
traditional Thai massage and Swedish massage had some side
effects, that is, soreness and skin reaction. The trial conducted by
Chatchawan et al.5 reported that during the treatment period
between 5 and 10 out of 90 patients from each group reported
having a little soreness after each treatment; however, those side
effects disappeared after 5e10 min. Five patients from the Swedish
massage group reported a reaction (rashes and pimples) to the
massage oil, four of them reported this effect after the last treat-
ment, but one of them reported this side effect after receiving the
treatment on day three.
3.5. Traditional Thai massage versus Swedish massage on
psychological functions
Most massage therapy studies for back pain have researched the
effectiveness of massage therapy in the areas of physical or physi-
ological function, but only a few studies have investigated the
psychological effectiveness of massage therapy for back pain. No
study has compared the effectiveness of traditional Thai massage
and Swedish massage in relation to psychosocial wellbeing.
However, three trials measured the effect of traditional Thai or
Swedish massage therapies on anxiety or stress in the immediate-
effect period.3,12,16
3.5.1. Traditional Thai massage versus relaxation therapy
Traditional Thai massage administered onto the back muscle for
30 minutes in the prone position was significantly effective in
reducing sympathetic activity, and stress and anxiety in patients
with back pain associated with myofascial trigger points compared
to the control group (group difference 5.9 [95% confidence interval
0.8e11.1], P ¼ 0.026).3 The result of an increased relaxation
response and an overall reduction in the defence-arousal (stress)
response as a result of traditional Thai massage was possibly
mediated by increased parasympathetic and decreased sympa-
thetic activity.3
3.5.2. Swedish massage versus relaxation therapy
Two trials reported that Swedish massage significantly reduced
anxiety, and improved mood (P ¼ 0.01)12 and sleep (P ¼ 0.03)
compared to relaxation therapy16. Hernandez-Reif et al.16 found
a significant increase in levels of serotonin (5HIAA) and dopamine
for the massage therapy group (P¼0.04), again indicating modu-
lation of the autonomic nervous system and decreased anxiety.12,25
4. Discussion
4.1. Strengths and limitations of studies
This literature review shows that both Thai and Swedish
massage techniques are effective complementary therapies that
can be used in the treatment of adults with chronic low back pain. A
comparison of traditional Thai massage (an Eastern style) and
Swedish massage (a Western technique) suggests that they are
equally effective in treating lower back pain.
All of the reviewed studies were conducted as randomised
controlled trials and half of the studies reported an appropriate
intention-to-treat analysis. The findings indicated that both Thai
and Swedish massage give beneficial effects on back pain relief as
well as a number of physical and psychological functions. All
studies have shown that both traditional Thai massage and Swedish
massage significantly reduced pain intensity and improved the
pressure pain threshold. However, most studies only measured
 S. Netchanok et al. / Complementary Therapies in Clinical Practice 18 (2012) 227e234
immediate and short-term effectiveness (5 weeks only post
completion of intervention), no long-term effectiveness (more than
12 weeks post-completion of intervention) was assessed. Tradi-
tional Thai massage was significantly more effective than Swedish
massage at improving pressure pain threshold (P<0.05). When
Swedish massage is correctly applied with lighter pressure than
traditional Thai massage, the deep stroking and kneading tech-
niques of Swedish massage may break down trigger points and
muscle adhesions similar to traditional Thai massage and as such, it
may have a similar effect on reducing back pain.5 However, in
a comparison of traditional Thai and Swedish massage with other
therapies, Thai massage showed a slight significant reduction of
pain when compared to joint mobilization (P < 0.001) and Swedish
massage was more effective in back pain relief than relaxation
therapy (P < 0.001).
In relation to physical functions, despite some limitations of the
previous studies outlined such as small sample sizes non-blinded
trials for participants and assessment of effectiveness in the short-
term only, traditional Thai massage and Swedish massage may
improve physical disability and back performance including range of
motion. Although, traditional Thai massage seems more beneficial
than Swedish massage in functional ability (P < 0.05), both styles of
massage have similar results in lumbar range of motion.
The reported trials showed both Thai and Swedish massage
effect psychological functions by improving mood and anxiety in
chronic low back pain sufferers. However, no trial compared Thai
and Swedish massage to each other in relation to emotions.
Despite some strengths, there are a number of limitations in
design and follow-up assessment in the reported studies. In terms
of methodology limitations, three studies3,5,21 did not have
a control group or placebo controls, no blinding of treatment for
participants and small sample sizes. For example, two studies12,16
had small sample sizes, 30 and 24 respectively. Also, one of
studies27 measured only the physical domain. In relation to limi-
tations of follow-up assessment, five of the six studies were limited
to short-term assessment, three studies only tested the immediate
effects (beforeeafter each massage),3,21 the longest follow-up of
effectiveness was investigated at five-weeks post interven-
tion.5,12,16,27 Clinical trials should monitor and measure adverse
effects and analgesic medication use for studies using an inter-
vention for pain. Only one of the reviewed studies reported side
effects of massage treatment.
There was no study comparing traditional Thai and Swedish
massage to each other in relation to psychological wellbeing. Given
the limitations of methodological strength, further studies are
needed that examine the effectiveness of traditional Thai and/or
Swedish massage compared to each other or other therapies in
respect to chronic low back pain intensity, physical functional
ability and the psychological wellbeing.
4.2. Implication of findings
All of the reviewed trials that explored the effect of Thai and/or
Swedish massage for low back pain reported both types of massage
could reduce pain. Traditional Thai massage may be equally as
effective as Swedish massage on chronic lower back pain. However,
the studies’ limitations support the need for future high-quality
controlled trials to develop the efficacy of traditional Thai
massage and Swedish massage for chronic low back pain in adult
groups.
5. Conclusion
Chronic low back pain is a common symptom in adults and it
can have a serious impact on both the individual and community, in
233
particular in functional and emotional status, cost and health care
utilization, quality of life and self care behaviour. However,
complementary therapies such as traditional Thai massage or
Swedish massage may help tackle this problem. Both traditional
Thai and Swedish massage may relieve chronic low back pain by
enhancing physical functions; providing pain relief, improving
functional abilities and range of motion, improving psychological
functions; reducing anxiety and improving mood. Although, based
on different theories, they are equally effective in relieving low back
pain. However, the existing studies have limitations, including
inappropriate measurements, lack of control groups, small sample
size, and a lack of data on long-term effectiveness.
6. Relevance to clinical practice
Both traditional Thai massage and Swedish massage can relieve
lower back pain and it appears they may be equally effective in
providing back pain relief and improvement in psychological
functioning. Traditional Thai massage seems to be more beneficial
than Swedish massage in functional-ability improvement; both
styles of massage have similar results in lumbar range of motion.
Massage is a relatively low cost treatment that can be readily
incorporated into the care plans of clients at hospital or other
health care settings.
This review improves our understanding of how massage can
influence physical functioning and psychological wellbeing of
adults with chronic low back pain. It also identifies future research
recommendations in relation to designing longer, high-quality,
randomised controlled trials to further test the effectiveness of
the both traditional Thai and Swedish massage techniques.
Contributions
Conception and study design: NS, WM, MC; data collection and
analysis: NS, WM, MC and manuscript preparation: NS, WM, MC,
SOD.
Conflict of interest statement
No conflict of interest declared by the authors.
Acknowledgements
We thank the aging and older people publication syndicate from
the Research Centre for Clinical and Community Practice Innova-
tion (RCCCPI), Griffith University for their comments on the draft
manuscript and the Christian University of Thailand for the PhD
scholarship that made this study possible.
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