Established in 1927 by the American College of Physicians


5 July 2011 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at

1. Massage More Effective Than Usual Care for Treating Chronic Low Back Pain

(subject of a video news release)

Low back pain is one of the most common reasons patients see a physician. Massage therapy is frequently used as an alternative treatment for chronic low back pain, but there is limited evidence as to its effectiveness. According to a new study, massage may be more effective than usual medical interventions for improving pain and function in patients with chronic low back pain.

Researchers studied 401 patients aged 20 to 65 years with nonspecific chronic low back pain to compare the effectiveness of either relaxation or structural massage versus usual care. Patients were surveyed about their symptoms and ability to perform daily activities and then randomly assigned to receive relaxation massage, structure massage (a massage focused on correcting soft-tissue abnormalities), or usual treatment with no massage. Participants in the massage groups had a one-hour massage once a week for 10 weeks, while patients in the usual care group received therapy such as painkillers, anti-inflammatory drugs, muscle relaxants, or physical therapy. After 10 weeks, the researchers re-measured the participants' symptoms and mobility, and then re-measured again at six months and one year. They found that patients in both of the massage groups fared much better than those receiving usual care.

"We found that patients receiving massage were twice as likely as those receiving usual care to report significant improvements in both their pain and function," said Dr. Daniel Cherkin, Director of Group Health Research Institute and lead author of the study. "After 10 weeks, about two-thirds of those receiving massage improved substantially, versus only about one-third in the usual care group."

In addition to improvements in pain and mobility, patients also reported a reduction in the use of non-steroidal anti-inflammatory medications after massage.

While both relaxation and structural massage provided relief and restored function, the researchers suggest that relaxation massage may have a slight advantage over structural massage because it is taught in almost all massage schools, making it more readily accessible and slightly less expensive than structural or other specialized forms of massage.

2. In Screening for Breast Cancer, One Guideline Not Appropriate for All Women

Mammography Screening Increments Should be Based on Individual Risk Factors

Experts disagree on the optimal screening intervals for mammography. Some guidelines recommend annual mammography screening for all women 40 and over, while others recommend biennial screening for women between the ages of 50 and 74, with no firm recommendation for women younger than 50. According to study authors, these guidelines do not consider the influence of common breast cancer risk factors other than age. For example, women with denser breast tissue are at greater risk for breast cancer. In addition, family history of breast cancer and a previous breast biopsy also increase risk. Researchers sought to determine the health benefits and cost effectiveness of mammography performed every three to four years, biennially, or annually in women in different risk categories. They found that mammography every two years was cost-effective for women aged 40 to 49 years with relatively high breast density or additional breast cancer risk factors. Mammography every three to four years was cost-effective for women aged 50 to 79 years with low breast density and no other risk factors. The researchers conclude that recommendations about the frequency of mammography should be personalized based on a woman's age, breast density, history of breast biopsy, and family history of breast cancer, as well as the effect of mammography on her quality of life.

3. Pocket Mobile Echocardiography Shows Promise for Assessing Cardiac Patients

Transthoracic echocardiography (TTE) is a type of ultrasonography used to examine the heart. Recently, a cell phone-sized device called a pocket mobile echocardiography device (PME) became available for clinical use and is designed to do the same job as TTE. However, data on the accuracy of the device is limited. Researchers studied a convenience sample of 97 patients who were consecutively referred for echocardiography at a single setting. The evaluation of the device found that it produced images accurate for assessing ejection fraction and some but not all cardiac structures when compared with standard echocardiography. Less-experienced physicians had difficulty forming a consensus about what the images showed. The findings are promising but suggest the device is not ready for general use by clinicians untrained in obtaining and interpreting its images.