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J Acupunct Meridian Stud 2022; 15(3): 163-173

Published online June 30, 2022 https://doi.org/10.51507/j.jams.2022.15.3.163

Copyright © Medical Association of Pharmacopuncture Institute.

Comparison of an Iranian Traditional Massage (Fateh Method) with Physiotherapy and Acupuncture for Patients with Chronic Low Back Pain: a Randomized Controlled Trial

Parva Namiranian1 , Mehrdad Karimi1 , Seyede Zahra Emami Razavi2 , Ahmad Fateh Garoos1 , Mohammad Hossein Ayati1,*

1Department of Traditional Medicine, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran
2Department of Physical Medicine and Rehabilitation, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Correspondence to:Mohammad Hossein Ayati
Department of Traditional Medicine, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran
E-mail Mh-ayati@tums.ac.ir

Received: May 11, 2021; Revised: February 4, 2022; Accepted: March 8, 2022

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Low back pain (LBP) is currently a major reason for disability worldwide. Therapeutic massage is one of the most popular non-pharmacological methods for managing chronic LBP (CLBP), and the Fateh method is a massage technique based on Iranian Traditional Medicine.
Objectives: The current study aimed to compare the effects of Fateh massage with those of acupuncture and physiotherapy on relieving pain and disability in CLBP.
Methods: Eighty-four patients with CLBP were categorized into groups that received Fateh massage, acupuncture, or physiotherapy. Each group included 28 randomly assigned patients who completed 10 sessions of therapy. Visual analogue scale (VAS) scores and Roland–Morris disability scores were evaluated at baseline, after intervention, and four weeks later. The findings were analyzed with SPSS software.
Results: The baseline VAS and Roland–Morris scores of the three study groups did not indicate significant differences (p > 0.05). All three groups showed significant pre-post improvements in both scores (p < 0.05). At the end of the treatment sessions, the three groups showed no significant difference in the reductions in pain intensity and disability score (p > 0.05). Improvements in disability and pain between the first and third time points were significant in all three groups (p < 0.05 for each group). In addition, the results of massage, physiotherapy, and acupuncture groups were not significantly different (p > 0.05). No adverse events occurred in the patients.
Conclusion: The effects of Fateh massage were comparable to those of acupuncture and physiotherapy in reducing pain and disability in patients with CLBP.

Keywords: Persian medicine, Lumbago, Musculoskeletal manipulations, Complementary therapies, Rehabilitation

INTRODUCTION

Low back pain (LBP) is currently the primary reason for disability worldwide [1]. Because of its high prevalence [2], LBP accounts for a substantial proportion of healthcare-related expenses [3] and is one of the most common reasons for seeking medical care [4]. Globally, LBP was among the top ten reasons for the most years lived with disability (YLDs) from adolescence into old age in the Global Burden of Disease Study 2019 [5]. LBP refers to the pain between the lower rib margins and the buttock creases [6]. Most episodes of LBP last merely six to eight weeks; however, 7% to 10% of cases progress to chronic LBP (CLBP) continuing for more than twelve weeks [7]. LBP is multifactorial and has a clear cause in only 15% of the cases [8], which includes serious causes that require specific management protocols, such as vertebral fracture, malignancy, inflammatory disorders, and infection [9]. In the remaining 85% of patients with LBP, a specific nociceptive source is not identifiable; thus, affected individuals are categorized as having nonspecific LBP [10].

Some previous guidelines have suggested short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) as analgesics for management of CLBP [11]. However, NSAID treatment is associated with adverse reactions [12-15]; therefore, more recent guidelines for the treatment of CLBP have emphasized self-management, psychological and physical treatments, and some kinds of complementary therapies. In fact, pharmacological and surgical therapies are being generally de-emphasized in the context of CLBP [16]. For example, the US guideline recommends non-pharmacological therapy as the first treatment option, while the UK [17], Denmark [18], and USA [19] guidelines have also certified the use of exercise (UK, US, and Danish guidelines) as well as some other non-pharmacological treatments such as acupuncture (US), massage (UK and US), and spinal manipulation (UK, US, and Danish). In addition, physiotherapy, as another conservative method, has been commonly used in rehabilitation programs for CLBP [20] and includes a variety of interventions [21]. Numerous systematic reviews and meta-analysis studies [22-28] and several randomized controlled trials [29-32] have also supported the use of acupuncture as an evidence-based, favorable, and effective CLBP treatment.

One of the goals of the WHO Traditional Medicine Strategy 2014-2023 is encouraging the effective and safe use of Traditional Medicine via research and integration of Traditional Medicine practice and practitioners into health systems where relevant and applicable [33]. Mohammad Fateh was an Iranian practitioner who created an effective and clinically applicable form of deep tissue massage based on Iranian Traditional Medicine (ITM) approximately 40 years ago [34]. This folk Iranian method includes various techniques that are used for musculoskeletal problems such as nonspecific pain of the upper and lower extremities, neck pain, and back pain. Some properties distinguish it from other massage methods, including rapid execution, the ability to be performed on patients in seated and supine positions, tangible signs of immediate efficacy, and a high rate of patient satisfaction [34,35]. This effective rehabilitation method for CLBP involves three stages: deep tissue friction of the gluteal region, manipulation of the sub-popliteal fossa, and squeezing of the calves [34,35].

Although various studies have evaluated CLBP management [7,8], very few studies have compared the outcomes of the most common therapies for CLBP rehabilitation [25,32]. Therefore, in this study, we aimed to examine and compare the effectiveness of acupuncture, deep tissue massage with the Fateh technique, and physiotherapy on pain and disability in patients with nonspecific CLBP.

MATERIALS AND METHODS

1. Study design and participants

The present study was a controlled clinical trial study conducted on patients with CLBP who were referred to the physical medicine & rehabilitation department of Tehran University of Medical Sciences (TUMS) in Imam Khomeini hospital as well as the Tooba, Valiasr, and Khark clinics of TUMS, Tehran, Iran from September 2019 to February 2020. Patients were selected according to inclusion criteria and examined by a physician. After elimination of patients who met any of the exclusion criteria, the research was explained to the participants, and those who consented to participate in the study were included and categorized into massage, acupuncture, and physiotherapy groups. The study protocol for each group is shown in Fig. 1.

Figure 1. Study flowchart.

2. Inclusion and exclusion criteria

Patients with LBP who attended the abovementioned outpatient clinics during the study period were included on the basis of the following criteria: age, 20-70 years; willingness to participate in the research project; CLBP without paresthesia and radicular pain and any specific pathology; a history of pain for more than 3 months; visual analogue scale (VAS) pain score of 4-9 on a 10-point scale; body mass index (BMI) of 17-30 kg/m2; confirmation of LBP and clinical examination by a specialist to exclude other pathologies; ability to read and write Persian.

The exclusion criteria were as follows: pregnancy; history of surgery due to LBP; presence of red flags that indicated the need for more investigations or surgery; ankylosing spondylitis; neuropathy or neurologic problems in the physical examination; severe untreated scoliosis; infection in low back or spinal cord; acute radiculopathy; mental problems; acute trauma; rheumatoid inflammatory disorders; uncontrolled hypertension or diabetes mellitus; digestive system problems, including stomach pain or ulcer; inflammatory bowel disease; LBP related to menstruation; use of digoxin, warfarin, or heparin; addiction to alcohol or drugs; history of epidural or transforaminal injection of anesthetics; or corticosteroid use within 4 weeks prior to the start of treatment.

3. Randomization and blinding

This study was conducted over a definite and limited duration from September 2019 to February 2020. Thus, patients who were referred to each clinic in this time period were eligible for inclusion in this study. In addition, sample randomization was performed in each group by using an online randomization method. Because the nature and method of therapy was specific in each group and different from the other two groups, blinding of patients and the medical practitioner was impractical. However, the data analyst was blinded to the group assignment of the patients.

4. Interventions

All patients in the three study groups received recommendations for lifestyle modifications. Additionally, all participants were educated to perform a set of strengthening exercises for lumbar muscles at home every day. Diclofenac (100 mg tablets; Najo Pharmacy Company, Iran) was also given to patients to use if they needed it for pain relief, and patients were asked to record the exact number of tablets they took. In addition to these instructions, patients of the intervention group received massage therapy while those of the two control groups received acupuncture and physiotherapy, which have been shown to be effective in treating CLBP.

1) Fateh technique massage

Patients in the massage group received ten 15-minute massage sessions performed using the special Fateh technique. This technique is based on ITM and requires client cooperation in performing home exercises, including “knee-to-chest stretch” and “standing leg lift.” In the first exercise, the patient assumes a supine position and gently pulls one knee toward the chest with the hand, maintains the position for approximately 10 s, goes back to the starting condition, and then repeats the exercise with the other leg. For the “standing leg lift,” the patient stands while holding onto a wall with both hands and lifts one leg off the floor with flexion of the hip and knee. After maintaining the position for 3 s, the patient goes back to the starting condition and then repeats the exercise with the other leg.

According to the Fateh method for deep tissue massage, each patient underwent a massage session once a week (for the first four weeks), followed by a session every other week (for the next four sessions), and then one session per month. Details of the Fateh technique are shown in Fig. 2.

Figure 2. Details of Fateh technique for low back pain. In the first step gluteal region is manipulated and secondly sub-popliteal area, calf and foot are massaged. each step is done in three manoeuvres. (A) Transverse friction is applied horizontally by the thumb over gluteal muscles. While very little motion occurs at the fingertips overlying the skin, the tissues are massaged by thumb from superficial to deep. Then, in the next manoeuvres, kneading (as a form of petrissage) on gluteal region with palmar thenar is done. Skin and subcutaneous tissues are moved in a circular way on the underlying structures (picture is not shown). (B) Muscle rolling (as a form of petrissage) of gluteal muscles with both hands followed by kneading with thumbs from inside to outside is done. (C) In the second step, sub-popliteal area, calf and foot are manipulated. As picture shows, kneading on sub-popliteal area is done with finger pads. (D) The previous manoeuvre continues with a single-handed V-shape movement from proximal to distal of calf. (E) Friction is applied over the ligament and myofascial junctions of foot.

2) Acupuncture

Patients in the acupuncture group received 10 treatment sessions, which were conducted twice a week by a specialized acupuncture physician. The standard needling method was applied, and the acupoints included GV3, BL23, BL40, KI3, and the low back Ashi point. These points were needled by a sterile one-time disposable stainless-steel needle to a depth of 20 mm. Stimulation was performed by twirling the needles. The needles were removed after 20 min and after a final twirl.

3) Physiotherapy

Patients in the physiotherapy group received 10 consecutive one-hour sessions of physiotherapy three times a week; each session consisted of hotpack therapy (heated to 71℃-74℃ for 20 min), transcutaneous electrical nerve stimulation (TENS; at a frequency of 100 Hz for a total of 20 min, intensity adjusted according to the patient’s tolerability), and ultrasound (1 MHz, 1.5 W/cm2 for a total of 10 min) applied to the lumbar area.

5. Data collection

Demographic data of all individuals, including age, sex, weight, height, BMI, and occupation, were recorded. Baseline demographic characteristics of the studied participants are shown in Table 1. Pain level and disability due to LBP were evaluated three times in each group: before beginning treatment, after completing the intervention, and one month after finishing the therapy. These evaluations were performed using the VAS with scores between 0 and 10 and the Roland–Morris Disability Questionnaire (RMDQ) with scores of 0-24. Patients in the acupuncture group underwent 10 treatment sessions performed twice a week, while those in the physiotherapy group underwent 10 sessions performed three times a week. For the patients who received deep tissue massage with the Fateh method, the 10 treatment sessions included four massage sessions performed once a week, followed by four sessions performed every alternate week, and then two sessions performed with an interval of a month. The number of diclofenac tablets taken was recorded on the basis of the patients’ self-reported data. Adverse events were evaluated during and at the final point of each treatment. These evaluations were based on direct observations and self-reports by the patients.

*There were no significant differences among the 3 treatment groups for any of the characteristics (p > 0.05)..

BMI = body mass index; LBP = low back pain; n = number..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Baseline demographic characteristics of studied patients according to treatment group*.

CharacteristicTreatment group
Acupuncture (n = 28)Massage
(n = 28)
Physiotherapy (n = 28)
Age, mean ± SD, y51.53 ± 8.9050.86 ± 9.0050.68 ± 10.51
Women, %67.8660.7164.29
BMI, mean±SD28.38 ± 1.9428.37 ± 2.4828.08 ± 2.37
Duration of LBP, %
3-6 months8.38.98.2
6-12 months30.729.230.5
1-5 years38.841.140.2
> 5 years22.220.821.1

*There were no significant differences among the 3 treatment groups for any of the characteristics (p > 0.05)..

BMI = body mass index; LBP = low back pain; n = number..



6. Scales

The VAS [36] score and frequency of pain were first evaluated. The meaning of the numbers on the VAS was explained to patients, and each individual was asked to mark his/her perceived pain intensity on a scale bar between 0 and 10, with 0 indicating no pain and 10 representing the highest pain ever experienced [37]. These measurements were followed by evaluations using the RMDQ [38], the Persian translation of which was used in this study [39]. RMDQ is a self-reporting questionnaire and is one of the two most commonly used questionnaires to measure disability in patients with LBP. It consists of 24 questions, with every item evaluating a specific dysfunctional behavior. The patients mark each sentence that correctly reflects their status. The questionnaire mainly evaluates patients’ physical functioning and their status while performing routine activities such as sitting, walking, dressing, lying down, bending over, and self-care. The score range is 0-24; 0 indicates no disability and 24 indicates the highest disability [38].

7. Statistical analysis

The data were analyzed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). In this study, descriptive statistics and appropriate statistical tests, including the Kruskal–Wallis test, F-test, and paired t-test were used to analyze the data. The mean ± standard deviation (mean ± SD) of the VAS and disability (Roland–Morris) scores of each group were calculated three times during the study. Additionally, analysis of variance (ANOVA) was used to evaluate significant differences among the three groups under study. The chi-square test, F-test, and paired t-test were used to examine the differences between variables in each group. The significance level in this study was set at < 0.05.

8. Ethical considerations

This study was conducted in accordance with the World Medical Association Declaration of Helsinki. Ethical approval was received from Tehran University of Medical Sciences in September 2019 (ID: IR.TUMS.VCR.REC.1397.667), after which recruitment was initiated. The protocol was registered in the Iranian registry of Clinical Trials (registration number: IRCT20181225042118N1). The aim of the study was completely explained to the participants, and patients were assured that their information was kept confidential, and the final report will be anonymous. All participants provided written informed consent.

RESULTS

1. Demographic data

Twenty-eight participants completed the follow-up assessments in each group. All groups contained a larger percentage of female patients (67.86%, 60.71%, and 64.29% in the acupuncture, massage, and physiotherapy groups, respectively). The mean ± SD age of participants in the acupuncture, massage, and physiotherapy groups was 51.53 ± 8.90, 50.86 ± 9.00, and 50.68 ± 10.51 years, respectively. The mean ± SD BMI of patients in the acupuncture, massage and physiotherapy groups was 28.38 ± 1.94, 28.37 ± 2.48, and 28.08 ± 2.37 kg/m2, respectively. The mean age and BMI did not differ significantly among the study groups. Likewise, the groups were comparable in terms of sex distribution (p > 0.05). Details are shown in Table 1.

2. Within-group results

1) Pain

The mean baseline pain intensity of patients in the acupuncture group was 7.41 ± 1.70, which decreased to 4.54 ± 1.24 after finishing therapy sessions and 5.03 ± 1.38 four weeks after the end of treatment. The mean VAS score of cases in the massage group was 7.14 ± 1.44, which declined to 3.42 ± 0.92 post-treatment and 3.82 ± 1.27 four weeks after ending therapy. For the physiotherapy group, the mean pain severity, which was 7.77 ± 1.07, diminished to 3.84 ± 0.82 after finishing treatment and then increased to 4.65 ± 1.06 one month post-treatment. These changes were significant in all three groups (p < 0.05).

2) Disability

The mean disability score in the acupuncture group was 10.64 ± 1.59 at the first visit, which decreased to 7.61 ± 1.93 and 8.22 ± 1.97 in the second and follow-up visits, respectively. The mean Roland–Morris score of patients in the massage group was 10.79 ± 1.58 at first, which changed to 7.44 ± 1.98 after completing the therapy sessions and was 8.14 ± 1.73 in the follow-up evaluation. The mean baseline disability score in the physiotherapy group was 10.36 ± 2.02, which declined to 6.91 ± 1.56 in the second assessment and was 8.52 ± 1.72 in the third evaluation. The changes were significant in all three groups (p < 0.05).

3) Adverse events

None of the study participants reported serious adverse effects. One patient in the massage group discontinued therapy sessions due to pain at the site of manipulation during treatment, but she showed no other sign or symptom.

3. Between-group comparisons

1) Pain

The baseline VAS scores of the three study groups did not differ significantly (p > 0.05). In the second assessment, pain intensity improved significantly in the acupuncture, massage, and physiotherapy groups (2.87 ± 1.30, 3.72 ± 1.21, and 3.94 ± 0.30, respectively), with no significant difference among groups (p > 0.05). However, in assessments performed four weeks after completion of therapy, all groups showed a mean increase in pain score in comparison with that in the second visit. As illustrated in Fig. 3, this increase was the highest in the physiotherapy group, followed by the massage and acupuncture groups.

Figure 3. Effects of three treatment modalities on low back pain at baseline, immediately after completion of treatment, and at the follow-up evaluations after the each treatment. Duration of physiotherapy, massage and acupuncture were 4, 12, and 5 weeks, respectively (see Materials and Methods). (A) Mean VAS scores of three treatment groups. VAS scores at post treatment and one month post treatment were lower than baseline values (*p < 0.05). Note that there were no significant differences among treatment modalities. (B) Mean disability scores (Roland-Morris) of three treatment groups. The scores at post treatment and one month post treatment were lower than baseline values (*p < 0.05). Note that there were no significant differences among treatment modalities.

Regarding the change in VAS scores between the first and third timepoints, the pain improvement was significant in all three groups (p < 0.05 in each group). Massage improved the VAS score by 3.94 ± 0.26, while physiotherapy and acupuncture improved the VAS score by 3.13 ± 0.01 and 2.38 ± 0.27, respectively. However, the improvements in the three groups did not show significant differences (p > 0.05).

2) Disability

The Roland–Morris scores of patients in the three groups did not differ significantly at baseline (p < 0.05). Assessments performed at the end of therapy revealed that massage could decrease the mean disability score by 2.65 ± 0.21. However, the three groups did not show a significant difference in the extent of score reduction, since the mean improvement in the disability score was 2.42 ± 0.22 in the acupuncture group and 1.84 ± 0.70 in the physiotherapy group (p = 0.00). In Fig. 3, all three groups showed a relative increase in the disability score between the second and third assessments, with the highest increase observed in the physiotherapy group and followed by the acupuncture and massage groups. However, the extent of increase in all three groups again did not show any significant differences (p < 0.05).

Fig. 3 also shows the change in disability scores between the first and third timepoints. The massage group showed a reduction of 2.65 ± 0.25, followed by the acupuncture (2.42 ± 0.42; p = 0.00) and physiotherapy (1.84 ± 0.30; p = 0.00) groups. No significant differences were observed among the groups (p > 0.05).

3) Number of diclofenac tablets taken

The mean number of diclofenac tablets taken per day before treatment in the acupuncture, massage, and physiotherapy groups was 2.83 ± 1.41, 2.31 ± 1.03, and 4.40 ± 1.08, respectively. Baseline medication use did not differ significantly in the acupuncture and massage groups (p > 0.05), but was significantly higher in the physiotherapy group (p < 0.05). Between baseline and the end of the treatment period, the mean number of medications taken by patients decreased to 1.32 ± 0.62, 1.06 ± 0.93, and 1.12 ± 1.81 in the acupuncture, massage, and physiotherapy groups, respectively (p < 0.05 in the physiotherapy group). All three groups showed no significant difference between the number of tablets taken in the second and third evaluations (p > 0.05 in all three groups).

DISCUSSION

According to a recent study, more than half of the physicians in the US recommend at least one complementary and integrative health approach to patients with CLBP, among which massage therapy is the most commonly recommended approach [40]. LBP is a very common health issue that accounts for a substantial proportion of healthcare-related expenses worldwide, and recent guidelines for the management of CLBP have emphasized the importance of self-management, psychological and physical treatments, and some types of complementary therapies such as massage and acupuncture [16]. In this study, an Iranian deep tissue massage technique known as Fateh massage after its founder, Mohammad Fateh, was studied. The effect of this method on pain and disability due to nonspecific CLBP was evaluated and compared with those of acupuncture and physiotherapy.

In the current study, application of acupuncture, Fateh technique massage, and physiotherapy caused significant improvements in the patients’ VAS and Roland–Morris scores in comparison with the baseline values (p < 0.05 in each group). The follow-up assessments showed that all three therapies could significantly improve pain and disability scores in comparison to those reported in the first visit. However, the results of the massage, acupuncture, and physiotherapy groups were not significantly different from each other (p > 0.05).

Massage is defined as a form of soft tissue manipulation with the use of hands or a mechanical device [41]. The use of massages for CLBP is evidence-based [42] and is recommended by the American College of Physicians (ACP) Clinical Practice Guideline [19,43]. The US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) also reported that massage is effective for CLBP [44].

Various techniques of massage are practiced at present, one of which is deep tissue massage. This method involves working with tissues in the layers of the body through release, stretch and soothe holding patterns to reduce patient discomfort [45]. Fateh massage is a deep tissue massage method based on ITM that also requires patient cooperation for doing home exercises. Fateh massage for CLBP employs different techniques for the gluteal and sub-popliteal regions. Details are shown in Fig. 2.

Some previous studies have evaluated different types of massage techniques based on ITM. Sanei et al. [35] studied the Fateh technique and its effect on CLBP with radiculopathy. In their randomized controlled trial, the Fateh method was superior to home exercise in improving pain and disability as well as radiculopathy and paresthesia of patients. Our results are consistent with their study, showing that the Fateh method is effective and safe in decreasing pain and disability in CLBP patients. The Kermanshahi massage is another Iranian massage technique that has been found to be beneficial for CLBP with radiculopathy. According to a non-randomized controlled trial conducted by Hashemi et al. [46], this method decreased pain and disability in patients with lumbar radiculopathy. The Kermanshahi method was also shown to improve physical activity and pain intensity in patients with knee osteoarthritis [47].

The anti-pain effects of Fateh massage may be classified into general and specific categories. Several general mechanisms have been proposed to explain the effects of massage on pain reduction. These effects may be further classified into mechanical, nervous, and physiological (biochemical materials) mechanisms [48].

Analgesic mechanical mechanisms, which are the most well-known, involve emptying of the venous and lymphatic systems from fluid and fluid movement due to the pressure gradient [49]. Deep tissue massage influences the underlying fascia as well as deep connective tissues. Adhesions, scars, and constrictions may occur due to deep tissue damage, potentially restricting fluid movement in the vasculature and reducing muscle activity. The mechanical effect of deep massage may resolve these microscarrings and adhesions, thereby improving fluid stasis and the accumulation of metabolic byproducts [50]. In deep tissue massage, the shearing forces, especially at the interface of two tissue types, such as the dermis-fascia, fascia-muscle, muscle-bone, and scar tissue–bone, also play a role in preventing adhesions or breaking them down and thereby enhancing fascial mobility [49].

Notably, the improvement in blood flow due to vasodilation caused by histamine release and mast cell stimulation [50] during massage can facilitate clearance of metabolic waste products [49]. This washout may reduce muscle spasm and improve muscle endurance. Muscle pain may reduce as a result of the metabolite washout, and the cycle is broken if muscle spasm was principally responsible for metabolite accumulation [49]. Moreover, these metabolites have an osmotic influence on fluid shifts and stimulate pain fibers [50]; thus, their removal can have additional pain-relieving effects.

Among nervous mechanisms, the gate control theory of pain may be involved in the effects of massage therapy. Aδ and C nerve fibers conduct pain and terminate in the substantia gelatinosa (laminae II and III of the dorsal horns of spinal cord), while C fibers also transmit slow-chronic pain (which is the predominant type of pain in CLBP) to the spinal cord [51]. In addition to many other probable stimulants, TrPs are also causes of nociceptive input [52]. Thus, the sensory afferent neuron reaches the substantia gelatinosa which is a key region containing synaptic connections of neurons as well as interneurons [52]. The interneurons prevent transmission of signals to the brain. Excitation of the Aβ sensory fibers from tactile receptors can prevent transmission of pain signals. This phenomenon is probably a result of local lateral inhibition in the spinal cord [51]. Thus, as an effective maneuver, massage improves pain by stimulating mechanoreceptors.

Concerning the role of biochemical materials in massage, the release of endogenous endorphins is a key concept [49]. Enkephalin is released when nerve fibers of the raphe magnus nucleus (a midline nucleus situated in the lower pons and upper medulla) are stimulated. Enkephalin suppresses presynaptic and postsynaptic pain fibers of type C and type Aδ in their synapses in the dorsal horns, thereby blocking pain at this stage. Fibers that originate in the raphe magnus nucleus transmit signals to the nerves of spinal cord dorsal horns to produce serotonin at their endings, and serotonin induces the secretion of enkephalin by local cord neurons. Serotonin inhibits pain pathways in the spinal cord [51]. Another important mediator is substance P, which has been suggested to be the neurotransmitter of type C nerve endings [51]. Endorphins can prevent the secretion of substance P [53], thereby preventing the transmission of a pain stimulus.

Among the specific effects of Fateh massage, one notable aspect is the effect of techniques involving gluteal muscles. One viewpoint related to the efficacy of such techniques is related to the idea of trigger points (TrPs). TrPs may be disabling and can prevent people from performing their daily activities. Iglesias-Gonzalez et al. found that patients with LBP frequently showed gluteus medius TrPs, and the TrPs of gluteal and low back muscles in these patients were associated with each other. Additionally, the number of active TrPs was correlated with LBP intensity [54]. TrPs in the quadratus lumborum muscle are a common source of LBP. The gluteus minimus and gluteus medius muscles are located in the referred pain zones of the quadratus lumborum and frequently develop associated TrPs. In addition, other back muscles such as the multifidi and longissimus thoracis muscles can also cause pain in low back and buttock regions [52].

The other specific mechanism involves the sub-popliteal area, the calves and foot. TrPs play an important role in this region as well. TrPs in the hamstring muscle can also cause LBP with myofascial origin. From the clinical point of view, even if the quadratus lumborum or iliopsoas are involved, release of hamstring muscles at first can improve the outcomes because TrPs of the hamstring muscles are usually associated with active TrPs of the proximal muscles. Additionally, TrPs commonly develop in the gastrocnemius muscle in connection with TrPs of the hamstring muscle [52]. Moreover, soleus muscle TrPs can increase the potential for LBP since these TrPs restrict ankle dorsiflexion when the person leans over and lifts unsuitably or inappropriately [52]. The Fateh method is effective for the abovementioned muscles or their tendons.

Another point related to the manipulation of sub-popliteal area is the increase in oxygenation. Iwamoto et al. studied the effects of friction massage of the popliteal fossa on muscle oxygenation by using near-infrared spectroscopy. They found that the amount of oxygenated hemoglobin significantly increased after manipulation due to improvements in leg venous return [55]. The clinical importance of muscular oxygenation is related to removal of substances that are responsible for pain, spasm, and fatigue in muscles and the reduced range of motion in joints [55].

The exact therapeutic mechanism underlying massage remains to be fully understood, and may involve a combination of the abovementioned mechanisms. The effectiveness of massage depends on the type of techniques used [56]. For chronic nonspecific LBP, manual therapies have been associated with high levels of patient satisfaction, decreased pain, and improved functional conditions [56]. The same is true for the Fateh method, and a combination of mechanical, neurologic, reflexive, biochemical and psychological effects mediated by this method may be responsible for the symptom improvement in patients with CLBP.

1. Limitations

The sample size was not very large, which is a limitation of the current study. However, this could be addressed in future studies. In addition, a longer follow-up period is recommended. Moreover, we recommend including joint range of motion measurements in future studies of the Fateh technique since some patients showed immediate and considerable improvements after the massage therapy. We also suggest the inclusion of an additional control group with only lumbar muscle strengthening exercises in future studies to determine the efficacy of exercise and its interaction with the massage.

CONCLUSIONS

Fateh massage showed positive effects in reducing pain and disability in patients with CLBP. Therefore, it can be considered to be an applicable and safe method for management of CLBP.

ACKNOWLEDGEMENTS

We thank the personnel of physical medicine and rehabilitation clinic in Imam Khomeini hospital, Tooba, Valiasr and Khark clinics, Tehran, Iran who helped us in executing this study.

FUNDING

This study was based on the Ph.D. thesis of Dr. Parva Namiranian in the School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran.

AUTHORS' CONTRIBUTIONS

MK and MHA designed the study. SZE, AFG, and MHA performed interviews and physical examinations. PN and SZER performed the analysis with feedback from MK. PN wrote the first draft of the manuscript based on a draft version of her PhD thesis. MHA supervised the manuscript and did the project administration. All authors contributed to the critical revision of the draft manuscript, read and approved the final version of the manuscript.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Fig 1.

Figure 1.Study flowchart.
Journal of Acupuncture and Meridian Studies 2022; 15: 163-173https://doi.org/10.51507/j.jams.2022.15.3.163

Fig 2.

Figure 2.Details of Fateh technique for low back pain. In the first step gluteal region is manipulated and secondly sub-popliteal area, calf and foot are massaged. each step is done in three manoeuvres. (A) Transverse friction is applied horizontally by the thumb over gluteal muscles. While very little motion occurs at the fingertips overlying the skin, the tissues are massaged by thumb from superficial to deep. Then, in the next manoeuvres, kneading (as a form of petrissage) on gluteal region with palmar thenar is done. Skin and subcutaneous tissues are moved in a circular way on the underlying structures (picture is not shown). (B) Muscle rolling (as a form of petrissage) of gluteal muscles with both hands followed by kneading with thumbs from inside to outside is done. (C) In the second step, sub-popliteal area, calf and foot are manipulated. As picture shows, kneading on sub-popliteal area is done with finger pads. (D) The previous manoeuvre continues with a single-handed V-shape movement from proximal to distal of calf. (E) Friction is applied over the ligament and myofascial junctions of foot.
Journal of Acupuncture and Meridian Studies 2022; 15: 163-173https://doi.org/10.51507/j.jams.2022.15.3.163

Fig 3.

Figure 3.Effects of three treatment modalities on low back pain at baseline, immediately after completion of treatment, and at the follow-up evaluations after the each treatment. Duration of physiotherapy, massage and acupuncture were 4, 12, and 5 weeks, respectively (see Materials and Methods). (A) Mean VAS scores of three treatment groups. VAS scores at post treatment and one month post treatment were lower than baseline values (*p < 0.05). Note that there were no significant differences among treatment modalities. (B) Mean disability scores (Roland-Morris) of three treatment groups. The scores at post treatment and one month post treatment were lower than baseline values (*p < 0.05). Note that there were no significant differences among treatment modalities.
Journal of Acupuncture and Meridian Studies 2022; 15: 163-173https://doi.org/10.51507/j.jams.2022.15.3.163

Table 1 . Baseline demographic characteristics of studied patients according to treatment group*.

CharacteristicTreatment group
Acupuncture (n = 28)Massage
(n = 28)
Physiotherapy (n = 28)
Age, mean ± SD, y51.53 ± 8.9050.86 ± 9.0050.68 ± 10.51
Women, %67.8660.7164.29
BMI, mean±SD28.38 ± 1.9428.37 ± 2.4828.08 ± 2.37
Duration of LBP, %
3-6 months8.38.98.2
6-12 months30.729.230.5
1-5 years38.841.140.2
> 5 years22.220.821.1

*There were no significant differences among the 3 treatment groups for any of the characteristics (p > 0.05)..

BMI = body mass index; LBP = low back pain; n = number..


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