Massage/Aromatherapy Massage

Massage/Aromatherapy Massage

PEP Topic 
Chronic Pain
Description 

Massage therapy involves the manipulation of the soft-tissue with various hand movements (e.g., rubbing, kneading, pressing, rolling, slapping, tapping). Massage therapy can elicit a relaxation response as measured by decreases in heart rate, blood pressure, and respiration. Often, massage is complemented with aromatherapy (i.e., essential oils combined with a carrier cream or oil to manipulate the soft tissues). Aromatherapy has been used together with massage in some studies. An aromatherapy massage is massage therapy delivered by a therapist while aromatherapy oils are administered by inhalation. Massage with or without aromatherapy has been studied in patients with cancer for management of anxiety, caregiver strain and burden, constipation, chemotherapy-induced nausea and vomiting, depression, lymphedema, pain, sleep-wake disturbances, and fatigue.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Chen, T.H., Tung, T.H., Chen, P.S., Wang, S.H., Chao, C.M., Hsiung, N.H., & Chi, C.C. (2016). The clinical effects of aromatherapy massage on reducing pain for the cancer patients: Meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine, 2016, 9147974.

doi: 10.1155/2016/9147974
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Purpose:

STUDY PURPOSE: To investigate the effectiveness of massage in reducing cancer-related pain

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: PubMed and Cochrane Collaboration
 
INCLUSION CRITERIA: Randomized, controlled trial, comparison of massage with essential oils to a no-massage control group.
 
EXCLUSION CRITERIA: None specified

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 63
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane collaboration risk of bias assessment. Mixed findings for risk of bias

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 3
  • TOTAL PATIENTS INCLUDED IN REVIEW = 278
  • SAMPLE RANGE ACROSS STUDIES: 14–115 patients
  • KEY SAMPLE CHARACTERISTICS: No details were provided.

Phase of Care and Clinical Applications:

PHASE OF CARE: Not specified or not applicable
 
APPLICATIONS: Palliative care 

Results:

The pooled standard mean difference was 0.01, showing no effect of aromatherapy massage compared to usual care for reduction in pain.

Conclusions:

Findings do not show that aromatherapy massage is effective in reducing pain.

Limitations:

  • Limited search
  • Limited number of studies included
  • Low sample sizes

Nursing Implications:

Overall, mixed evidence existed regarding effects of massage therapies for pain management among patients with cancer. This analysis did not show effectiveness of aromatherapy massage, but was very limited by the small number of studies included and small study samples. Massage is a low-risk intervention that may be beneficial for some patients.

Hökkä, M., Kaakinen, P., & Pölkki, T. (2014). A systematic review: Non-pharmacological interventions in treating pain in patients with advanced cancer. Journal of Advanced Nursing, 70, 1954–1969. 

doi: 10.1111/jan.12424
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Purpose:

STUDY PURPOSE: To provide information on the benefits and safety on nonpharmacologic interventions in managing pain for patients with advanced cancer 
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: CINAHL, MEDIC, MEDLINE, and PsycINFO
 
KEYWORDS: Palliative care, hospice care, terminally ill, complementary therapies or nonpharmacological, and neoplasms or cancer and pain or pain management
 
INCLUSION CRITERIA: Main focus on nonpharmacologic interventions for treating pain; palliative, hospice, or end-of-life patients with cancer; adults; English, Swedish, or Finnish language
 
EXCLUSION CRITERIA: Those not meeting inclusion criteria

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 444
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration risk of bias assessment tool

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 11 (nine randomized, controlled trials and two quasiexperimental designs)
  • TOTAL PATIENTS INCLUDED IN REVIEW = 1,033
  • SAMPLE RANGE ACROSS STUDIES: 9–385 patients
  • KEY SAMPLE CHARACTERISTICS: All had advanced cancer

Phase of Care and Clinical Applications:

PHASE OF CARE: End of life care
 
APPLICATIONS: Palliative care 

Results:

Interventions included massage or aromatherapy massage (five studies), physical therapy and massage (one study), transcutaneous electrical nerve stimulation (TENS, one study), acupuncture (one study), reflexology (one study), warm water footbath (one study), biofeedback-assisted relaxation (one study), and varied strategies of relaxation and imagery with nature sounds (one study). The effectiveness of massage was mixed, TENS had the potential to reduce pain on movement, acupuncture reduced pain immediately after the intervention but the benefit was transient, reflexology showed no effect, relaxation with biofeedback was beneficial, and psychoeducational and behavior strategies had only a short-term effect. Most studies were found to have a relatively high risk of bias.

Conclusions:

There was insufficient evidence to draw firm conclusions about the effectiveness of nonpharmacologic interventions to reduce pain among patients with advanced cancer.

Limitations:

  • Very few studies included for most of the specific interventions
  • High risk of bias of studies were included

Nursing Implications:

Treating pain is a high priority among patients with advanced cancer receiving palliative care. The effectiveness of many nonpharmacologic interventions is unclear and warrants additional well-designed research. Most of the evidence involved studies in inpatient settings. Additional research among outpatients and those receiving palliative care in the home is needed. Nonpharmacologic interventions are generally low-risk. The identification of approaches than can facilitate reductions in pain would be beneficial for patients with cancer-related pain.

Lee, S.H., Kim, J.Y., Yeo, S., Kim, S.H., & Lim, S. (2015). Meta-analysis of massage therapy on cancer pain. Integrative Cancer Therapies, 14, 297–304. 

doi: 10.1177/1534735415572885
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Purpose:

STUDY PURPOSE: To investigate the effects of massage therapy on cancer pain

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, China Academic Journal, Korean medical databases
 
INCLUSION CRITERIA: Randomized, controlled trial and nonrandomized controlled trials, no massage as control

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 265
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: PEDro scale and Cochrane Risk of Bias tools were used to evaluate study quality.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 12  
  • TOTAL PATIENTS INCLUDED IN REVIEW = 559
  • SAMPLE RANGE ACROSS STUDIES: Not evaluable
  • KEY SAMPLE CHARACTERISTICS: Varied types of cancer and cancer treatments

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Palliative care 

Results:

Massage was associated with lower pain (SMD = –1.25, p = 0.0001). Subgroup analysis according to type of intervention, massage, aromatherapy massage, or foot reflexology showed positive effect of each type, though few studies in each subgroup existed. PEDro scores indicated that only three studies were low quality, and the rest were high quality; however, risk of bias evaluation varied widely and showed that most studies had moderate to high risk of bias. Effects of massage were more positive in those studies with higher risk of bias.

Conclusions:

Findings show that massage therapy has positive benefits for cancer-related pain.

Limitations:

  • High heterogeneity
  • Sample sizes within studies werenot provided
  • Given total patients across 12 studies, some of these must have been small. 
  • No differentiation between acute or chronic pain

Nursing Implications:

Massage therapy is effective in reducing pain among patients with cancer. This low-risk intervention can be helpful in pain management.

Pan, Y.Q., Yang, K.H., Wang, Y.L., Zhang, L.P., & Liang, H.Q. (2014). Massage interventions and treatment-related side effects of breast cancer: A systematic review and meta-analysis. International Journal of Clinical Oncology, 19, 829–841. 

doi: 10.1007/s10147-013-0635-5
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Purpose:

STUDY PURPOSE: To examine the measurable benefits of massage therapy in people with breast cancer-related symptoms
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: PubMed, EMBASE, Cochrane Library, and Web of Science till November 2012
 
KEYWORDS: Breast neoplasms and massage and clinical trial
 
INCLUSION CRITERIA: Women with breast cancer receiving active cancer treatment
 
EXCLUSION CRITERIA: Not specified

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 120
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias approach

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 8
  • TOTAL PATIENTS INCLUDED IN REVIEW = 950
  • SAMPLE RANGE ACROSS STUDIES: 14–134 patients
  • KEY SAMPLE CHARACTERISTICS: All received surgery; studies were done at various phases of care

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care 

Results:

Studies included those with combined exercise and massage, support and massage for lymphedema, reflexology, foot massage, and aquatherapy. Eight randomized, controlled trials (RCTs) assessed effects on anxiety, and a meta-analysis showed no significant effect of massage on anxiety. Three RCTs looked at effects on fatigue, and a meta-analysis showed improvements in fatigue (SMD = -0.61, p = 0.01). Four RCTs looked at pain, and a meta-analysis showed improvement in pain (SMD = -0.33, p = 0.07, 95% CI -0.69,-0.03).

Conclusions:

The evidence from this meta-analysis suggested that massage interventions may be beneficial in the management of fatigue and pain for women with breast cancer. The results did not suggest effectiveness for anxiety.

Limitations:

The specific effects of massage alone were difficult to identify because most studies included other interventions along with massage. The types of massages used were different, and there was no accommodation for the use of medications. There was high heterogeneity among the studies that examined effects on fatigue. The studies included had multiple methodologic flaws. Several studies were counted twice or more in the meta-analysis. Although different outcomes were reported, it was clear from the data that the study sample was the same in different publications.

Nursing Implications:

Massage is a low-risk intervention that may be beneficial in combating fatigue among patients with cancer. This analysis provided evidence in support of massage; however, this was particularly strong given the study design flaws, the variability in types of massage, and the other interventions that were included in the analysis at various phases of cancer care. Additional well-designed research on massage would be helpful to clarify clinical applicability.

Wilkinson, S., Barnes, K., & Storey, L. (2008). Massage for symptom relief in patients with cancer: Systematic review. Journal of Advanced Nursing, 63, 430–439.

doi: 10.1111/j.1365-2648.2008.04712.x
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Purpose:

To assess the evidence regarding massage as a means of improving the physical and psychological well-being of patients with cancer

Search Strategy:

  • Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE, Allied and Complementary Medicine (AMED), System for Information on Grey Literature (SIGLE), PsycINFO, and CancerLIT. Investigators also searched dissertation abstracts.
  • Year of publication, as defined by the search strategy, varied by database. The most recent date was September 2006.
  • Search keywords were massage, aromatherapy, therapeutic touch, essential oil, volatile oil and cancer or neoplasm or oncolog* or palliate* or terminal or hospice.
  • Studies were included in the review if they
    • Were randomized controlled trials (RCTs)
    • Involved adult patients with cancer who were receiving care in any healthcare setting
    • Included any type of massage, with a systemic goal, provided by a therapist with a recognized qualification
    • Produced patient-reported outcomes, reported by means of reliable and valid assessment tools, of physical or psychological symptoms and quality of life
    • Included the means by which the reliability and validity of assessment tools were evaluated.
  • Studies were excluded if the purpose of the massage was a specific localized physical effect without a specific systemic aim. For example, a study involving prostatic massage to obtain a semen sample was excluded.

Literature Evaluated:

After elimination of duplicates from the initial search, investigators considered 1,321 references. Of these, investigators chose 10 studies for analysis, using the Jadad scoring approach and CONSORT Statement to appraise study quality. Investigators also used sample size and duration of follow-up to evaluate studies. Given the range of massage techniques and patients, meta-analysis was impossible. Three investigators reviewed studies independently.

Sample Characteristics:

  • The review reported on 386 patients from nine studies.
  • One of the initial references was a duplicate report of a single study.
  • One study was based on personal communication, rather than a final published report.
  • Study samples included more females than males.
  • Various cancer diagnoses were represented.
  • Sample sizes ranged from 6 to 87 participants.
  • Samples included patients receiving surgery, radiotherapy, chemotherapy, and combined treatments.

Results:

  • Patients were assessed 4–16 times, with all patients assessed before and after the intervention or control period.
  • Follow-up was limited. One study assessed patients three weeks after the last massage.
  • Five trials assessed psychological outcomes, including outcomes related to anxiety and depression.
  • Seven trials assessed physical symptoms and quality of life.
  • One study found a significant post-massage decrease in pain for males only. One study found a significant reduction in pain after massage but not after the control period. One study showed pain reduction after the first and third massage, but not after the second and fourth, and a nonsignificant trend of greater pain improvement in the massage group than in the group that did not receive massage.
  • One study showed significant reduction of depression with massage, and one study showed no change.
  • Three studies demonstrated significant post-massage improvement in anxiety.
  • One study associated massage with short-term reduction in nausea.
  • One study associated massage with reduction in fatigue.
  • One study associated massage with improvement in quality of life.
  • Most studies reported decreases in anxiety and other psychological benefits; however, results relating to depression were equivocal across studies.
  • Adverse effects included a single case of skin rash in one trial and, in another trial that involved the use of essential oils, a higher incidence of digestive problems.

Conclusions:

The authors stated that results were inconclusive; however, reported results showed that massage had a preponderantly positive effect in regard to anxiety reduction.

Limitations:

  • This review did not discuss the patients' treatment phase, so effects relating to specific groups of patients were unspecified.
  • Authors did not know how and if variations in massage style affected outcomes.
  • Trials that included the use of oils used different oils, so the authors could draw no conclusions regarding the effect of aromatherapy.
  • No evidence was available to assess long-term effects of massage. Authors found that research of long-term effects, as reported in the studies, was of low quality.
  • Although inclusion criteria demanded that all studies be RCTs, results suggest that one study did not include a separate control group.

Nursing Implications:

Two studies included in the review used a crossover design, and one of these showed significant results after massage but not after the control period. This suggests that crossover design may be particularly applicable to this area of research and that the effects of massage are immediate and time sensitive.

Research Evidence Summaries

Currin, J., & Meister, E.A. (2008). A hospital-based intervention using massage to reduce distress among oncology patients. Cancer Nursing, 31(3), 214–221.

doi: 10.1097/01.NCC.0000305725.65345.f3
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Study Purpose:

To determine if 15 minutes of therapeutic massage is associated with reduction in patient-expressed levels of pain, fatigue, and emotional and physical distress during hospitalization

Intervention Characteristics/Basic Study Process:

Patients were recruited over a three-year period. The same social worker assessed the four domains of distress evaluated; assessments were done pre- and postmassage. All patients served as their own controls. Before the massage, the massage therapist asked the patient which parts of the body to massage. The most frequently chosen area was feet and legs or back, neck, and shoulders. The massage therapist provided each patient with a 10–15 minute Swedish massage. A CD player provided the same music to all patients.

Sample Characteristics:

  • The sample was composed of 251 patients.
  • Mean patient age was 59.4 years. The age range was 20–80 years.
  • The percentage of male patients was 30.3%. The percentage of female patients was 69.7%.
  • The sample included a broad distribution of cancer sites.
  • Of all patients, 68.9% were white, 29.1% were Black; 2% self-identified as belonging to an ethnic group.

Setting:

  • Single site
  • Inpatient
  • University hospital in Georgia, United States

Study Design:

Observational

Measurement Instruments/Methods:

The study used MacDonald’s scale, modified, for patient evaluation of massage therapy (rating on a 1–5 point Likert scale, Cronbach's alpha = 0.850).

Results:

Authors found significant reductions relating to each of the four dimensions measured. Mean pain scores declined (p = 0.000, effect size = 0.7270), fatigue scores declined (p = 0.000, effect size = 0.714), physical distress declined (p =.000, effect size = 0.756), and emotional distress declined (p = 0.000, effect size = 0.6810). Posthoc analysis did not reveal that the main effect was affected by interactions with possible covariates.

Conclusions:

Results demonstrated that massage therapy was associated with reduction of physical and emotional distress, pain, and fatigue in a broad range of hospitalized patients.

Limitations:

  • The study did not have an appropriate control group.
  • The authors noted that a large proportion of patients refused to participate. Males were more likely to refuse participation than females. This suggests that some patients have preconceptions about massage or privacy concerns regarding human touch. The study may have a risk of bias due to selection bias.
  • Postintervention assessments were performed immediately after the intervention. They do not reflect how long perceived benefits lasted.
  • The sample consisted of hospitalized patients, but authors provided no information about phase of care or whether patients were hospitalized for comorbid conditions.

Nursing Implications:

Nurses must consider the possibility that patients have preconceptions or privacy concerns regarding massage therapy. Authors suggested that some patients might be more comfortable with the intervention if it were called a back rub rather than a massage. Nurses in settings that offer massage should incorporate information about the intervention and allow patients to discuss their preconceptions and concerns. Findings suggest that a brief massage can relieve distress during hospitalization. Nurses should consider reinstituting the back rub as a standard nursing intervention.

Jane, S.W., Chen, S.L., Wilkie, D.J., Lin, Y.C., Foreman, S.W., Beaton, R.D., . . . Liao, M.N. (2011). Effects of massage on pain, mood status, relaxation, and sleep in Taiwanese patients with metastatic bone pain: A randomized clinical trial. Pain, 152, 2432–2442.

doi: 10.1016/j.pain.2011.06.021
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Study Purpose:

To compare the efficacy of massage therapy to a social attention condition in Taiwanese patients with cancer with bone metastases

Intervention Characteristics/Basic Study Process:

  • A five-day, two-group trial with a pre/post-test design was used.
  • The experimental intervention was 45 minutes of massage; condition control was caring therapist for a comparable amount of time.

Sample Characteristics:

  • The sample was 72 patients with cancer with bone metastasis.
  • Mean patient age was 50 years.
  • The sample was 42% male and 58% female.
  • The sample was Taiwanese, age 18 or older, oriented x3 (alert and normal), Chinese-speaking and reading, radiologically diagnosed with bone metastasis via bone scan, and reporting moderate bone pain of at least 4 on a 0–10 scale.
  • Patients were excluded if they were regularly receiving massage therapy, were undergoing surgeries or procedures during admission, or had allodynia, thrombocytopenia, spinal cord compression syndrome, deep vein thrombosis, or other contraindications to massage therapy.

Setting:

  • Single site
  • Inpatient setting
  • Five hospital oncology units

Phase of Care and Clinical Applications:

  • Patients were undergoing the active treatment phase of care.
  • The study has clinical applicability for end-of-life and palliative care.

Study Design:

The study was a randomized, controlled clinical trial.

Measurement Instruments/Methods:

  • Present Pain Intensity (PPI) – Visual Analog Scale (VAS)     
  • Mood VAS
  • Relaxation VAS
  • Sleep VAS
  • Symptom Distress Scale
  • Demographic and medical profiles

Results:

  • Pre- to postintervention effects: No statistical significance was shown in individual patients.
  • Results from MANCOVAs showed statistically significant intervention effects on pain, mood, and relaxation VASs, but not the sleep VAS.
  • There was a significant linear group by time effect on relaxation VAS in both groups: F (1, 69) = 10.39, p = 0.002, indicating a different pattern of change in relaxation VAS change scores between the groups.

Conclusions:

This trial documented therapeutic effects of massage on improving pain intensity, mood status, and muscle relaxation in patients with metastatic bone pain. The study has clinical implications supporting massage therapy and other medical modalities for optimal improvement in patients with cancer with bone metastases.

Limitations:

  • The study had a small sample, with less than 100 participants.
  • The patient population was heterogeneous.
  • The study involved a short course of therapy.
  • The study lacked multidimensional measurement of pain and patient binding.

Nursing Implications:

Massage therapy may play an important role in cancer bone pain, sleep, and, mood.

Kutner, J.S., Smith, M.C., Corbin, L., Hemphill, L., Benton, K., Mellis, B.K., . . . Fairclough, D.L. (2008). Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: A randomized trial. Annals of Internal Medicine, 149, 369–379.

doi: 10.7326/0003-4819-149-6-200809160-00003
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Study Purpose:

To test the hypothesis that massage would decrease pain and analgesic medicine use

To explore effects on quality of life and physical and emotional symptom distress

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to a massage treatment group or to a control group in which patients received simple touch controlled for time and attention. Individual baseline data for disease characteristics, pain, symptom distress, quality of life, functional status, expectations from massage, and concurrent interventions were collected within 72 hours of study inclusion and at three weekly visits over the three to four weeks of study participation, for measurement of sustained effects. Data collectors were blinded to study group assignment. Participants received up to three 30-minute treatments over two weeks with at least 24 hours between treatment sessions, according to a schedule jointly determined by the patient and the treatment provider. Treatment providers obtained immediate outcome data prior to and following each treatment. All participants received routine care in addition to study interventions. Massage intervention included gentle effleurage, petrissage, and myofascial trigger point release. The most frequently massaged areas were neck and upper back and arms, hands, lower legs, and feet. Massages were performed by licensed massage therapists who had at least six months’ experience working with patients with advanced cancer. Control touch included placement of both hands on the participant bilaterally on the neck, shoulder blades, lower back, calves, heels, clavicles, lower arms, hands, patellae, and feet with light and consistent pressure. All treatment providers had standardized hands-on training and were evaluated for competency.

Sample Characteristics:

  • The study reported on 348 patients.
  • Mean patient age was 65.2 years (SD = 14.4) in the experimental group, and 64.2 years (SD = 14.4) in the control group.
  • The sample was 61% female and 39% male.
  • The most common diagnoses were breast and lung cancers.
  • All patients had metastatic disease, 27% had bone metastasis, 54% had constant pain, and 26% had neuropathic pain.
  • Of the sample, 44% were married or in a committed relationship, 39%–42% had a college level or higher education, and 86% were non-Hispanic white.
  • In the experimental group, 77% were receiving care at home, and 81% were receiving care at home in the control group.
  • Mean worst pain in 24 hours in both groups was 6.4 or greater at baseline.

Setting:

  • Multisite
  • 15 U.S. hospices and the University of Colorado Cancer Center

Study Design:

The study was a randomized, single-blind, controlled trial.

Measurement Instruments/Methods:

  • Memorial Pain Assessment Card (MPAC) using a 0–10 point scale for immediate effect
  • Brief Pain Inventory (BPI) for sustained measure
  • MPAC Mood Scale
  • McGill Quality of Life Questionnaire
  • Memorial Symptom Assessment Scale (MSAS)
  • Recording of name, dose, and frequency of medication for symptom management

Results:

Both massage and touch were associated with significant improvements in immediate and sustained pain outcomes. Massage was superior to touch, but the difference was not statistically significant. Both groups demonstrated statistical, but not clinically significant, improvement in BPI scores. Both massage and simple touch were reported to be associated with statistically significant immediate improvement in mood, with massage showing statistically superior effect compared to touch. Confidence intervals were provided, but significance levels were not reported. Both groups demonstrated improvement in physical and emotional symptom distress and quality of life across weekly evaluations, but there were no differences between groups. There were no adverse effects associated with the interventions, and no differences in general adverse events or mortality between groups. Differences in pain medication use were not reported.

Conclusions:

Both massage and simple touch appeared to have immediate beneficial effects on pain and mood in these patients. Both groups experienced slight improvement in pain, quality of life, and symptom distress over time. These changes were minimal, showing statistical significance but not clinical relevance.

Limitations:

  • Findings are limited to patients with very advanced cancer, the majority of whom were in hospice programs, and may not be applicable to other patient groups.
  • There was no usual care control group.
  • Having an appropriate attentional control group was useful, but given the findings that both study groups experienced benefits, the attention itself may be the most relevant factor in changes seen.

Nursing Implications:

Simple touch appeared to have a short-term positive effect on patient mood and pain experience. This is an intervention that should be easy to provide for patients and could be something that caregivers could also be educated to provide. This intervention could be useful for intermittent use as an adjunct to other interventions for pain management. Formal massage did not provide significantly greater effects. Given findings of simple touch in the population studied here, evaluation of this approach in other patient groups can be useful.

Miladinia, M., Baraz, S., Shariati, A., & Malehi, A.S. (2016). Effects of slow-stroke back massage on symptom cluster in adult patients with acute leukemia: Supportive care in cancer nursing. Cancer Nursing. Advance online publication. 

doi: 10.1097/NCC.0000000000000353
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Study Purpose:

To examine the effects of slow-stroke back massage on the symptom cluster of fatigue, pain, and sleep disturbance

Intervention Characteristics/Basic Study Process:

Patients were assigned to massage or usual care control groups according to a fixed approach such that the first three patients entered into the study were assigned to the intervention, the next three to control, and so on. Massage was provided by two oncology nurses who had four months of professional training. The intervention group received 10-minute massage sessions every other day for four weeks in a special room in an outpatient setting. Control patients were given social attention. Data collectors were blinded to the study assignment. Soothing music was provided during the massages.

Sample Characteristics:

  • N = 60   
  • MEAN AGE = 34.5 years
  • MALES: 51.7%, FEMALES: 48.3%
  • CURRENT TREATMENT: Chemotherapy
  • KEY DISEASE CHARACTERISTICS: All had acute leukemia and were between the first and third chemotherapy cycles
  • OTHER KEY SAMPLE CHARACTERISTICS: Intensity of at least 3 on numeric scales for pain, fatigue, and sleep disorders; and a score of at least 5 on the Pittsburgh Sleep Quality Index (PSQI)

Setting:

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Iran

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Palliative care 

Study Design:

  • Single-blind, randomized, controlled trial

Measurement Instruments/Methods:

  • Numeric rating scales for pain, fatigue, and sleep quality
  • Pittsburgh Sleep Quality Index (PSQI)

Results:

Repeated measures ANOVA showed a significant difference in pain, fatigue (p = 0.001), and sleep disorder intensity (p = 0.015) from baseline to the end of week 5. By the end of week 4, PSQI scores showed improvement in the intervention group compared to controls (p = 0.003). Trends showed a consistent decline in pain, fatigue, and sleep disturbance intensity during the four weeks in which massage was done in the intervention group, while in the control group, intensity of these symptoms increased.

Conclusions:

Sessions of slow-stroke back massage were shown to reduce intensity of pain, fatigue, and sleep disturbance.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • The effect of the music component cannot be determined.
  • It is unclear if the attempted attention control provided was similar in amount of time to time spent with intervention patients.
  • Lack of any sample contamination could not be assured. 
  • At the end of the four weeks, increasing symptom intensity was shown in the massage group

Nursing Implications:

Massage was shown to be of benefit in dealing with the symptoms of pain, fatigue, and sleep disturbance during the treatment phase for patients with leukemia. Nurses can apply massage as a low-risk intervention. Trend results in this study suggest that massage likely has only short-term effects as symptom intensity levels began to rise after the four-week intervention. Ongoing research is needed to evaluate the optimum frequency and timing  of massage and duration of effects.

Post-White, J., Kinney, M.E., Savik, K., Gau, J.B., Wilcox, C., & Lerner, I. (2003). Therapeutic massage and healing touch improve symptoms in cancer. Integrative Cancer Therapies, 2, 332–344.

doi: 10.1177/1534735403259064
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Study Purpose:

To determine if massage therapy and healing touch were effective in reducing anxiety, mood disturbance, pain, fatigue, and nausea and in improving the relaxation and satisfaction with care of patients receiving chemotherapy treatment

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups: therapeutic massage, healing touch, or caring presence. All received four weekly 45-minute sessions of the intervention and four weeks of standard care (control). After four weeks, patients were crossed over to another intervention or the control. Order of the intervention and usual-care control were randomized. Pre- and post-assessments of pain, nausea, and vital signs were done at each session. Assessments of intervention effects were done at the beginning and end of each four-week session. Therapeutic massage was provided in a standardized fashion, using a Swedish massage protocol. Healing touch followed a previously developed protocol incorporating centering, unruffling, magnetic unruffling, full-body connection, mind clearing, chelation, and lymphatic drain. Presence consisted of patients lying down for 45 minutes with relaxing music and the presence of a therapist. The therapist asked patients how they were feeling and if they had any questions. Conversation may or may not have occurred, according to the patient’s preference; the purpose of the therapist was to be attentive but to avoid therapy or physical intervention. The control condition consisted of usual care, which the authors did not describe.

Sample Characteristics:

  • The study reported on a sample of 164 patients.
  • Mean patient age was 57.4 years, with a range of 27–83 years.
  • The sample was 87% female and 13% male.
  • The most common cancer types were breast, gynecologic or genitourinary, gastrointestinal, hematologic, and lung.
  • The majority of patients had stage III or IV disease, and 50% were in the first month of chemotherapy treatment.
  • All patients had a score of at least 3 on a 10-point scale of symptom severity. The most frequently reported symptoms were fatigue, pain, anxiety, and nausea.

Setting:

  • Single site
  • Outpatient setting

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized, controlled, parallel-group, crossover design was used.

Measurement Instruments/Methods:

  • Symptom rating scales (0–10)
  • Brief Pain Inventory
  • Brief Nausea Index
  • Profile of Mood States
  • Satisfaction measure according to a four-point Likert-type scale

Results:

  • Of those who initially entered the study, 29% dropped out. Half of the dropouts were due to changes in the cancer treatment protocol; half were because patients wanted an intervention different from the one assigned. Those who dropped out had higher pain, nausea, mood disturbance, and fatigue at baseline (p < 0.05) than those who did not.
  • Massage and healing touch groups showed immediate post-session reduction of respiratory rate, heart rate, and blood pressure (p < 0.01), and these interventions were more effective (p < 0.01) in achieving these reductions than were control and presence conditions. Massage and healing touch were associated with pre- and post-session reduction in current pain (p < 0.001).
  • Over the four-week study period, mood disturbance decreased over time in all patients. Massage therapy, compared to the control condition, was more effective at reducing total mood disturbance (p = 0.004) and anxiety (p = 0.023). Healing touch reduced mood disturbance (p = 0.003) and fatigue (p = 0.028).
  • Mean pain scores in all cases declined over time.
  • There were no differences between groups in nausea or use of antiemetics.
  • There were no differences between groups in overall satisfaction. Massage and healing touch were associated with higher satisfaction with the intervention than was presence (p < 0.0001).

Conclusions:

Massage therapy and healing touch were more effective than presence alone or standard care in improving mood, reducing anxiety, pain, and fatigue and in reducing heart rate, blood pressure, and respiratory rate immediately postintervention.

Limitations:

  • The control condition may not have provided appropriate attentional control.
  • The study had risk of bias due to no blinding.
  • The anxiety measure was not a rigorous, valid tool; it was a 10-point scale.
  • The study had a large drop-out rate.

Nursing Implications:

Massage therapy and therapeutic touch can be beneficial to patients because the interventions induce physical relaxation and reduce pain, fatigue, and anxiety. In this study, these interventions were more effective in this regard than was therapeutic presence alone. Massage therapy and therapeutic touch are complementary therapies that nurses can consider and advocate for on behalf of patients who may benefit from them.

Toth, M., Marcantonio, E.R., Davis, R.B., Walton, T., Kahn, J.R., & Phillips, R.S. (2013). Massage therapy for patients with metastatic cancer: A pilot randomized controlled trial. Journal of Alternative and Complementary Medicine, 19, 650–656. 

doi: 10.1089/acm.2012.0466
Print

Study Purpose:

To determine the feasibility and effects of providing therapeutic massage at home for patients with metastatic cancer

Intervention Characteristics/Basic Study Process:

Massage therapy was the experimental intervention. Professional massage therapists provided the intervention in patients’ homes up to three times during the first week after enrollment. The duration of massage ranged from 15–45 minutes; the duration and amount of pressure was modified based on patients’ comfort. Control groups received either a no-touch intervention or usual care. The no-touch intervention consisted of massage therapists being with patients and holding hands without any healing intervention in their homes. Usual care did not include a home visit. Data were collected at baseline and four times after the intervention during a weekly assessment. 

Sample Characteristics:

  • N = 39 (final sample); 20 received massage intervention, 10 received no-touch control, 9 received usual-care control
  • MEAN  AGE = 55.1 (SD = 11)
  • MALES: 18%, FEMALES: 82%
  • KEY DISEASE CHARACTERISTICS: Metastatic cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: 56% had breast cancer.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Home    
  • LOCATION: Boston, MA; oncology clinics at a large urban academic medical center

Phase of Care and Clinical Applications:

  • PHASE OF CARE: End-of-life care
  • APPLICATIONS: Palliative care 

Study Design:

  • Pilot randomized, controlled trial
    • No blinding

Measurement Instruments/Methods:

  • State-Trait Anxiety Inventory (STAI)
  • Brief Pain Inventory-Short Form
  • Global measure of perceived stress

Results:

Massage therapy at home was a feasible intervention. The mean number of massage therapy sessions per patient was 2.8. There were no serious adverse events related to the interventions. There were no significant changes in the primary outcomes (i.e., pain, anxiety, and alertness). There were only trends toward improvement in pain and sleep of patients after therapeutic massage but not in patients in the control groups. Researchers identified a significant improvement in the quality of life of patients who received massage therapy after one-week follow-up, but the difference was not sustained at one month. 

Conclusions:

The study shows that therapeutic massage at home is a feasible intervention. However, its effects on anxiety or pain were not conclusive. The small and uneven sample sizes across groups are a major weakness of the study. Although two measures were used for anxiety, the authors did not state which measures were used for the main analysis. Validity of measurements (i.e., alertness, and quality-of-life measure) is also problematic.

Limitations:

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Measurement of validity/reliability questionable

 

Nursing Implications:

The role of nurses for this intervention is not clear. The massage therapy given in the present study was a professional intervention.

Wang, T., Wang, H., Yang, T., Jane, S., Huang, T., Wang, C., & Lin, Y. (2015). The effect of abdominal massage in reducing malignant ascites symptoms. Research in Nursing and Health, 38, 51–59. 

doi: 10.1002/nur.21637
Print

Study Purpose:

To evaluate the effect of abdominal massage on reducing ascites, pain, and other ascites-related symptoms

Intervention Characteristics/Basic Study Process:

Gentle abdominal massage consisting of straight rubbing, point rubbing, and kneading was provided by a trained nurse practitioner (NP) for 15 minutes, twice a day (7–8 am and 4–5 pm) for three consecutive days. Control participants received social attention by the same NP who delivered the massage. The NP followed a script during the interaction exploring the patient’s feelings and thoughts and providing information about treatment. Symptoms and body weight were measured in the morning for four successive days (pre- to post-test).

Sample Characteristics:

  • N = 80
  • MEAN AGE = 59.11 years (SD = 11.05 years)
  • MALES: 66%, FEMALES: 34%
  • KEY DISEASE CHARACTERISTICS: Stage IV cancer; had not received chemotherapy in the preceding month; most common type of cancer was liver followed by colorectal, gastric, and pancreatic
  • OTHER KEY SAMPLE CHARACTERISTICS: 54% of the patients had mild ascites, 28% were moderate, and 18% were severe as defined by the Moore and Aithal grading system

Setting:

  • SITE: Single site
  • SETTING TYPE: Inpatient
  • LOCATION: Northern Taiwan

Phase of Care and Clinical Applications:

  • PHASE OF CARE: End of life care
  • APPLICATIONS: Palliative care 

Study Design:

Randomized, controlled trial using repeated measures

Measurement Instruments/Methods:

  • Symptoms were measured using the Edmonton Symptom Assessment System–Ascites Modification (ESAS-AM).
  • Body weight was measured with a scale.
  • A blinded assessor collected the data.

Results:

There was no significant change in pain, tiredness, nausea, drowsiness, poor appetite, shortness of breath, mobility limitation, or body weight among patients who received massage. The intervention group did experience a significant improvement in depression (p = 0.003), anxiety (p = 0.002), poor well-being (p = 0.001), and perceived abdominal bloating (p < 0.001). These symptoms improved gradually over time for the intervention group, but slightly increased over time for the control group. No massage-related adverse events occurred.

Conclusions:

Abdominal massage did not improve pain in this study; however, this may be related to the low level of pain among patients at baseline. Massage improved depression, anxiety, well-being, and perceived abdominal bloating. Additional study is needed with larger groups of patients with malignant abdominal ascites.

Limitations:

  • Small sample (< 100)
  • Baseline sample/group differences of import
  • Findings not generalizable
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Patients were from one medical center. All the patients were randomized except patients in the same patient room who were assigned to the same group. The intervention group had more multiple-organ metastases, and this was controlled for in the analysis. In addition, the intervention group at baseline had significantly more nausea, poorer appetite, and more shortness of breath, but less drowsiness than the control group.

Nursing Implications:

This non-invasive, inexpensive intervention was not effective in reducing pain for patients with abdominal ascites, but it may provide relief for other symptoms such as abdominal bloating, depression, anxiety, and poor well-being. After additional study, if this intervention is proved to be appropriate for pain management, nurses will need training on proper massage techniques.

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