Massage/Aromatherapy Massage

DATABASES USED: MEDLINE, CINAHL, British Nursing Index, EMBASE, AMED, PsycINFO, SIGLE, and CancerLit were searched, as well as Dissertation Abstracts International.

COMMENTS ON LITERATURE USED: From 1966–2002

FINAL NUMBER STUDIES INCLUDED = 8 RCTs, 10 reports

The most consistent effect was on anxiety. Only one reported an effect on depression.

Insufficient evidence

STUDY PURPOSE: To evaluate the effects of massage and aromatherapy massage on symptoms in people with cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 19, 5 in meta-analysis
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,274
• SAMPLE RANGE ACROSS STUDIES: 20–144
• KEY SAMPLE CHARACTERISTICS: Varied tumor types, varied settings and phases of care

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

Results of the meta-analysis showed no significant differences between massage and no massage for pain, depression, fatigue, or nausea. A meta-analysis of three studies showed significantly lower state anxiety with massage (MD = 18.6, p = 0.0003); however, all studies had very small samples and a high risk of bias. At longer follow-up, no differences were reported between groups in anxiety.

Insufficient evidence exists to show a benefit of massage therapy with or without aromatherapy for the relief of multiple symptoms in people with cancer.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• Low sample sizes

Evidence regarding the effects of massage and aromatherapy massage on various patient symptoms did not show substantial clinical benefit, and evidence is insufficient. However, massage is generally a very low-risk intervention that may provide very short-term benefits for some patients. Additional well-designed research is needed to determine the role of this type of intervention as part of symptom management among patients with cancer at various times in the cancer trajectory.

To complete a systematic review of the effects of aromatherapy on patients with symptoms of depression

• Databases searched were CINAHL, PubMed, MEDLINE, PsyInfo, and Cochrane Library.
• Search keywords were aromatherapy, scent, fragrance, essential oil, depression, depressive disorder, and depressive symptoms. All retrieved reports were of peer-reviewed studies, in English, published 2000–2008.
• A study was included if it referred to the clinical application of aromatherapy as the treatment of patients with some kind of clinical condition or patients suffering from symptoms of depression.
• A study was excluded if it referred to the chemistry of essential oils or if it was published as a dissertation.
   

• The total number of studies retrieved was 48.
• Two studies were of patients with depression; one, of postnatal mothers; three, of patients with cancer.
• Two studies were randomized controlled trials (RCTs), three were not RCTs, and one was quasiexperimental.
• The evaluation method consisted of a systematic review by two graduate students in a master’s degree program in occupational therapy. The graduate students extracted the data.

• The final number of studies included was six.
• The total sample size was 387. The sample range across studies was 5–288.
• Two studies evaluated the effectiveness of aromatherapy on patients with depression, three studied secondary depressive symptoms in patients with cancer, and one focused on postnatal depression. All studies discussed the effectiveness of aromatherapy massage on depressive symptoms.
   

Authors did not mention the phase of care.

Aromatherapy has an alleviation effect on the mood of patients with depressive symptoms; however, there is a notable lack of studies on the use of aromatherapy by people with depression. Almost all the studies use aromatherapy massage and not aromatherapy alone, so whether the effects are from the aroma intervention, the massage intervention, or a combination of the two remains unclear.

Of the six studies, the sample size of three included eight participants or fewer. The size of the others was 36, 42 and 288, respectively. In addition to being small, the samples did not necessarily include cancer patients. These studies were inconsistent and used various oils for the aromatherapy.

The evidence is insufficient to support recommendations for the use of aromatherapy for the treatment of depression. Aromatherapy may, however, be used as complementary and alternative therapy for depression and be considered as a treatment for depression in patients with secondary depression arising from chronic medical conditions.

Patients received one of three types of massage therapy and were asked to report their symptoms posttherapy. Massages were provided by 12 licensed massage therapists. Patients were referred by physicians, nurses, or self. Patients received Swedish, light touch, or foot massage according to their preference. On average, sessions lasted 20 minutes for inpatients and 60 minutes for outpatients.

In total, 1,290 patients were included. 

Inpatient and outpatient

Patients reported the level of symptom distress (0–10) on a card prior to and following massage therapy. Comparisons were analyzed by analysis of covariance, with the baseline score as the covariate.

The effect of massage on symptom relief was demonstrated as a positive response with respect to depression.

• Participants were not randomized.
• The information about the study demographics or participants did not include enough detail.
• There was no standard procedure for length of massage or specific type of session. Patients had a choice of three techniques.
• Patients were referred to massage therapy, including self-referral. Self-referral may skew the posttherapy reports because patients expect a benefit.
• No standardized assessment tool was used to measure the results because symptoms were rated on a card.
• There was no way to differentiate which of the massage techniques was the most beneficial.

Patients were randomized to receive massage therapy or standard treatment. The massage therapy group received 15 massages that were 3–30 minutes long per week by a trained massage therapist for four weeks. The control group received standard medical care alone.

• N = 34
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Stage I or II breast cancer
• OTHER KEY SAMPLE CHRACTERISTICS: At least three months post-treatment

• Randomized

• Participants were assessed for anxiety.
• Mood scales used three standardized assessment tools: State-Trait Anxiety Inventory (STAI), Profile of Mood States (POMS), and Symptom Checklists-90-R (SCL-90-R).
• Immune and neuroendocrine functions were monitored using blood levels of specific immune system markers.

Massage did show some benefit in patient mood scale assessment tools and immune system function. Specifically, reduced anxiety was found on the STAI after the first and last sessions. Reduced depression was found on the POMS depression score after the first and last sessions and from the first to the last day of the study. The SCL-90-R confirmed a reduction in depression from the first to the last day. Wilcoxon’s matched-pairs signed-ranks tests revealed an increase in dopamine and serotonin levels in the massage group; the control group showed a significant increase in norepinephrine. Natural killer cell cytotoxicity did not attain significance.

• The study only looked at the short-term benefit to patients.
• Long-term effectiveness was not demonstrated.
• Sample size was small; participants had early-stage breast cancer diagnoses.
• Patients were randomized based on a coin toss.

To investigate the short- and long-term effects of classical massage therapy on cytokine responses and the Th1/Th2 ratio, depression, mood, and perceived stress in patients with primary breast cancer; to evaluate the relevance of classical massage therapy in the context of oncologic care  

Authors randomized 34 women into two groups. The massage group received a 30-minute classical massage twice per week for five weeks. The control group received standard medical care only. Time points in the study were before intervention, at the end of the five-week intervention period, and at six weeks after the intervention. At these time points, participants completed several measurement instruments, and investigators took blood samples to determine cytokine concentrations and the Th1/Th2 ratio.

• The sample was composed of 29 participants.
• Mean age of patients in the massage group was 59.5 years; in the control group, 59.9 years.
• Because participants were patients with breast cancer, the assumption is that 100% of participants were female.
• The tumor size of all participants was less than or equal to T2; nodal state, less than or equal to N2. The time since disease onset was less than four years before the study. Participants had completed surgery, chemotherapy, and/or radiation therapy at least three months prior to the beginning of the study.
   

Unspecified

• Phase of care: long-term follow-up
• Clinical applications: late effects and survivorship

Randomized controlled trial

• Perceived Stress Questionnaire (PSQ), to assess the subjective experience of stressful situations on the cognitive and emotional level. Authors used a 20-item German version of the PSQ, a version consisting of four subscales: worries, tension, demands, and joy. These are rated with a four-point Likert scale and subscale values are transformed into scores 0–100. High scores correspond to high levels of stress.    
• Patient Health Questionnaire (PHQ), to screen, diagnose, and evaluate the severity of different psychiatric diseases. Depression score is derived from nine items, and the sum of the scores varies 0–27. The higher the score, the more severe the depression.    
• Berlin Mood Questionnaire, or Berliner Stimmungsfragebogen (BSF), a self-report of mood developed on the basis of the Profile of Mood States (POMS). The 30-item BSF measures six mood states and rates each on a five-point scale. Authors used BSF scales of anxious depression and elevated mood.
• BD Cytometric Bead Array (CBA) kit to measure cytokine concentrations.
   

• Authors noted no significant sociodemographic or clinical differences between participants in the massage group and those in the control group.
• At five weeks, immediately after massage, depression and anxious depression decreased significantly, compared to depression and anxious depression in the control group (p = 0.005, effect size (ES) = 1.39 in PHQ scores).
• Stress and elevated mood did not change significantly after massage therapy.
• Changes of cytokine concentrations and Th1/Th2 ratio were insignificant, although authors noted a slight shift toward Th1 in the massage group over time.

Massage therapy is an efficient treatment for reducing depression in breast cancer patients. Insignificant results concerning immunologic parameters, stress, and mood indicate that further research is needed to determine psychological and immunologic changes associated with massage therapy.

• The study had a small sample size, with fewer than 30 participants.
• The study had a risk of bias due to no attentional control condition.
• Improvement of psychometric parameters may differ with massage therapist.
• Cytokine levels may fluctuate or increase coincident with immunologic processes, such as infections or chronic diseases.
• Authors do not make clear whether, at the five-week time point, measures were taken immediately after the massage. Timing could influence results.
• Authors stated that effect size for depression was 1.39 on a 100-point scale, but they did not state how effect size was calculated.

Massage therapy may be an effective intervention to offer to patients who struggle with depression. Additional studies should evaluate the effectivenss of this intervention as well as its effect on immunologic parameters, stress, and mood.

Participants were randomly allocated to receive weekly massages with either lavender (aromatherapy group), an inert carrier oil (massage group), or no intervention. The two massage groups received a 30-minute back massage weekly for four weeks. Scales were completed the week before the first treatment and in the week after the last massage.

• N = 42
• KEY DISEASE CHARACTERISTICS: Advanced cancer

• SITE: Multi-site
• LOCATION: Palliative care units in the United Kingdom

• A visual analog scale of pain intensity
• A Modified Tursky Pain Descriptors Scale
• The Verran and Snyder-Halpern Sleep Scale
• The Hospital Anxiety and Depression Scale
• The Rotterdam Symptom Checklist

Significant long-term benefits of aromatherapy or massage were not demonstrated for pain, anxiety, or quality of life. A statistically significant reduction in depression scores was present in the massage group.

• RCT but small sample size
• Predominance of women and older age group limit the ability to generalize.
• The measurement interval allows other variables to affect the scores in this population of low performance and fatigued patients.
• Study recruitment took two years.