Massage/Aromatherapy Massage

STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in children and adolescents with cancer

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, CINAHL, PsycINFO, Ovid, MEDLINE, ProQuest Dissertations and Theses, the Electronic Theses and Dissertations System, the Index to Taiwan Periodical Literature, Electronic Thesis and Dissertation System (Chinese)

KEYWORDS: experimental study, random study, quasi-experimental study, children, adolescents, pediatric, cancer, oncology, nonpharmacological interventions, massage, exercise, fitness, physical activity, cognitive-behavioral, stress management, energy conservation, sleep therapy, relaxation, distraction, psychoeducation, fatigue, cancer-related fatigue, loss of energy, levels of tiredness, tired, side effect, symptoms

INCLUSION CRITERIA: RCT or quasi-experimental studies; 1–18 years of age, experiencing cancer-related fatigue; maintenance stage or survivor stage; hospitalized or home; acute lymphoblastic leukemia (ALL)/acute myeloid leukemia (AML)/lymphoma/solid tumor; interventions with descriptions of length, frequency setting, and provider, and including activity enhancement, psychosocial interventions, cognitive behavioral therapy, stress management, relaxation, nutrition consultation, massage, or educational interventions; use of validated scales for cancer-related fatigue in outcomes

EXCLUSION CRITERIA: Written in languages other than English or Chinese

TOTAL REFERENCES RETRIEVED = 76

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Retrieved papers reviewed by two independent reviewers with a third for disagreements about methodologic validity

• FINAL NUMBER STUDIES INCLUDED =  6, 3 in meta-analysis
• SAMPLE RANGE ACROSS STUDIES: 9–60
• TOTAL PATIENTS INCLUDED IN REVIEW = 149
• KEY SAMPLE CHARACTERISTICS: Outpatient and hospitalized children; ALL, solid tumor, AML, and lymphoma; ALL most common; varied disease stage; range from first cycle of chemo to survivor; five studies in the United States, one in Taiwan; home, community, and hospital setting; interventions of exercise-training, physical activity, massage, health education, and exercise training

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Pediatrics

Two studies showed no significance in decreasing total fatigue with exercise. Two studies suggested exercise reduced general fatigue (p < .01). No significance was found for sleep/rest fatigue or cognitive fatigue. Study of massage showed no effect on fatigue. Final study used nurse education session on fatigue versus UC with reports that interventions were “effective.”

No study reduced total fatigue in any population. General fatigue was the only fatigue measure with significant improvement in some studies.

The phases of care, tumor type, and age varied. Children may not have had an ability to differentiate fatigue and relaxation, making fatigue perhaps difficult to measure.

Exercise may be a safe intervention for improving general fatigue in children and adolescents experiencing cancer-related fatigue.

• 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: Multiple phases of care

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).

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.

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.

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.

The intervention was a Swedish/Esalen massage of shoulders, neck, and scalp lasting 20 minutes up to three times per week. Prior to hospitalization, patients were randomly assigned to massage or standard medical care conditions.

• Thirty-five adult patients with varying diagnoses admitted for autologous bone marrow transplantation were included.
• Mean age was 41 years, and the sample was predominantly female.
• Race and ethnicity were not reported.

All participants were inpatients in the bone marrow transplantation unit of a cancer center.

Patients were undergoing the active treatment phase of care. 

The study was a randomized trial comparing massage (n = 16) with a quiet time control condition (n = 18).

Fatigue was measured by a zero to 10 Numerical Rating Scale.

• Borderline significant decreases were observed in fatigue (p = 0.06) over time, although significant decreases were seen during week 1 (pretreatment) and prior to discharge.
• The most robust effects were found during the first week of treatment.

• The study had a small sample size and a lack of control for covariates.
• The analysis of time by group interaction was confusing.
• Effects may not be as great during the posttreatment phase when patients are most ill.
• Massage was performed by a trained healing arts specialist.

• Massage therapy (i.e., Swedish, light touch, foot); manipulation of soft tissue
• Average time: 20 minutes for inpatients and 60 minutes for outpatients
• Tactile stimulation is essential to development and survival.

• N = 1,290 patients
• No demographics were provided.
• KEY SAMPLE CHARACTERISTICS: Fatigue was a presenting symptom in 312 patients.

• SETTING TYPE: Inpatient and outpatient settings
• LOCATION: A large, specialized cancer center

• PHASE OF CARE: Active treatment, long-term follow-up

• Retrospective review of clinical data from first massage episode

• Numeric rating scale (0–10) of extent to which fatigue was experienced as bothersome (0 = not at all bothersome; 10 = extremely bothersome) on a 5\" x 8\" card
• Other measures: Pain, nausea, anxiety

• Mean fatigue improved from 4.7–2.7, which is a 40.7% reduction.
• When patients with a fatigue score of more than 4 were included, fatigue decreased from a mean of 6.6 (SD = 1.8) to a mean of 3.8 (SD = 2.6).
• Effects were smaller and less persistent in inpatients.

• No control or randomization was included.
• The sample was not described.
• Fatigue change scores were reported for the total sample at baseline and post-treatment only; however, in a subgroup followed at 12-, 24-, and 48-hours post-massage, the effects of massage on symptom distress were sustained in outpatients. The effects of massage were smaller and less persistent for inpatients, but the researchers noted that inpatients tended to receive shorter massage treatments in less comfortable settings than did outpatients. The relationship between the length of massage treatment and the size and duration of effects is worthy of further study.   
• Weak or cachectic patients may only tolerate foot massage.
• A licensed massage therapist is needed; otherwise, the intervention is inexpensive.

Promising results warrant a controlled trial.

Massage therapists who were specially trained in massage therapy for patients with cancer discussed the massage intervention process with patients and asked them which parts of their body they would like to have massaged. Massage sessions lasted 10 to 15 minutes, using Swedish massage. The most common areas for massage chosen by patients were the feet and leg or back, neck, and shoulder areas. Once patients were enrolled in the study, oncology social workers met with patients to perform a baseline assessment of pretreatment outcomes. After the massage intervention, the oncology social worker met with the patient to assess posttreatment outcomes.

• The study reported 251 patients with cancer (70% female, 30% male).
• Mean patient age was 54.96 years.
• Of the participants, 68.9% were Caucasian, 29.1% were Black, 1.2% were Asian, 0.4% were Hispanic, and 0.4% were Indian.
• Multiple cancer types were included, but the most common type was gynecologic (25%).
• Patients were recruited during a three-year period and were determined to be eligible for the study by their primary nurse.

Patients were hospitalized at a major university hospital in southeastern Georgia.

Patients were undergoing the active treatment phase of care.

The study used a nonrandomized, single-group, pre-/posttest, repeated-measures design.

A modified version of MacDonald’s Patient Evaluation of Massage Experience Scale was used.

The massage therapy intervention resulted in a statistically significant decline in fatigue mean scores (p <  0.001), which was observed between pre- and posttest treatment evaluations.

• The study was not a randomized controlled trial; therefore, no neutral comparison group existed to test for baseline similarities or postintervention differences between groups.
• A substantial number of patients refused to participate, particularly men. This may be a result of preconceived notions regarding massage and human touch. Changing massage nomenclature to “back rub” may be more broadly acceptable in future investigations.
• The study was not a longitudinal design; therefore, it could not be determined how long the observed benefits lasted.

To determine efficacy of back massage on fatigue and anxiety in patients receiving chemotherapy

Before chemotherapy infusions were started, patients completed study data collection in face-to-face interviews. During chemotherapy administrations, patients in the intervention group received a back massage for 15 minutes before the infusions and between 25–40 minutes of each one-hour period of chemotherapy administration. Data collection was repeated immediately after the massage intervention, and patients were interviewed by phone 24 hours after the chemotherapy treatment for the completion of postintervention data collection. Patients were not randomly assigned to treatment and control groups.

• N = 40  
• MEAN AGE = 49.94 years (SD = 11.31 years)
• MALES: 45% (intervention group); 50% (control group), FEMALES: 55% (intervention group); 50% (control group)
• KEY DISEASE CHARACTERISTICS: Breast and lung cancers were the most frequent diagnoses.
• OTHER KEY SAMPLE CHARACTERISTICS: All patients were receiving single-day chemotherapy. Massage interventions were done during the third or fourth chemotherapy treatment. None of the patients were actively working at the time.

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: Turkey

• PHASE OF CARE: Active antitumor treatment

Quasi-experimental, cross-sectional cohort study

• Spielberger State-Trait Anxiety Inventory (STAI)
• Brief Fatigue Inventory (BFI)

Fatigue scores were significantly different between groups at baseline and higher in the control group the day after chemotherapy. There were no significant differences between groups in the change of fatigue pre- and postintervention. Mean anxiety scores in the control group increased after chemotherapy while those in the intervention group declined. Differences between groups were not statistically significant.

Findings provide limited evidence that back massages may be helpful in reducing anxiety and fatigue experienced during treatment with chemotherapy.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)  
• Other limitations/explanation: Completion of data collection forms by investigators increases potential bias. Only very short-term effects were measured.

Massage is a low-risk intervention that may be helpful to some patients during active chemotherapy treatment to reduce anxiety or fatigue. This study, however, does not provide strong supportive evidence due to multiple study design limitations.

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

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.

• 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)

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

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

• Single-blind, randomized, controlled trial

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

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.

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

• 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

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.

To examine the efficacy of polarity therapy (PT) for reducing cancer-related fatigue and improving health-related quality of life (HRQOL) in women receiving radiation treatments for breast cancer.

Patients were treated with one of three arms: standard clinical care, standard clinical care plus three modified massages, or standard clinical care plus 3 PT treatments. Patients were asked to lie on their back and stomach, and treatments lasted about 75 minutes. For the PT treatments, the therapist used hand positions to examine energy flow, discover trigger points, and restore homeostatic energy flow. For the modified massage treatments, therapists used a modified Swedish massage applied over the clothing, and areas to be massaged were left to the discretion of the patients. Information was collected through daily diaries and weekly questionnaires completed by the patients. Participants were recruited by a clinical research coordinator with a referral from their treating oncologist.

• Final sample size used for the analysis was 43 female participants.
• Mean age was 52.9 years. 
• All participants were diagnosed with breast cancer (stage 0–IV).
• Thirty-eight of 43 patients were Caucasian.

This was a randomized, controlled trial.

• The Brief Fatigue Inventory (BFI) was used for the primary outcome measure. 
• Daily fatigue diaries were used to assess fatigue at its worst during the day and were completed at bedtime.
• HRQOL was assessed using the Functional Assessment of Chronic Illness Therapy (FACIT)–Fatigue.

The baseline BFI showed a significant difference in baseline fatigue scores. The standard care group had a mean of 1.8, the massage mean was 3.0, and the PT mean was 3.7.  BFI scores, fatigue diaries, and HRQOL measures across the three intervention weeks showed no significant differences between the three groups.

This study did not show a significant improvement in fatigue scores between the groups. The interventions were well received by participants, and no adverse effects were reported, suggesting that this intervention could be further studied with a larger sample size.

• The study had a control group that received less attention due to a lack of therapeutic interventions compared to the other two groups, but the massage arm seemed to suggest an effective method to control for attention.
• The study group was comprised of one diagnosis and gender.

All participants received four weekly 45-minute sessions of therapeutic massage (MT), healing touch (HT), or presence (P) and four weekly sessions of a standard care control. Credentialed practitioners who were also registered nurses delivered MT and HT. The three interventions all included music, a centering message, and a message to focus on breathing and letting go of extraneous thoughts. The order of the conditions was randomized. MT included a written Swedish massage protocol using massage gel. For HT, the protocol developed by Healing Touch International was used, and touch and nontouch techniques were used. Energy techniques used included centering, unruffling, magnetic unruffling, full-body connection, mind clearing, chelation, and lymphatic drain to modulate the energy field. For P, participants lied on a table listening to relaxing music. An MT or HT therapist sat with the participant during the session. The purpose was to be attentive and caring but to avoid therapy or physical intervention. In the control group, symptoms and vital signs were assessed.

• Of the 230 adults who consented to participate, 164 completed all eight sessions.
• Of those who completed the study, mean age was 54.7 years, 87% were female, 98% were Caucasian, and 68% were married.
• The majority had stage III or IV disease, and 52% had breast cancer.
• Mean time since diagnosis was 17.4 months.
• All participants rated fatigue, pain, anxiety, or nausea as greater than 3 on a scale of 0 to 10.

Patients were from two outpatient chemotherapy clinics in the Midwest.

Patients were undergoing the active treatment phase of care.

This was a randomized, two-period crossover (between one of the interventions and standard care) study.

• Profile of Mood States (POMS) for fatigue
• Blood pressure
• Heart rate
• Respiratory rate
• Pain
• Nausea
• Medication use
• Anxiety
• Mood disturbance
• Satisfaction

Compared to the control group, there was no effect of presence on fatigue. When comparing individual interventions to their matched control periods, the effect of MT on fatigue was close to significance (p = 0.057). HT was found to reduce fatigue (p = 0.028).

There was no clear evidence that one intervention was superior to the other, but MT and HT seemed to be more effective than presence alone or standard care in improving fatigue.

• Interventions also included centering, breathing, and music, which may confound the results.
• The commitment to complete the study was great, and the dropout rate was high.
• Cross-over designs may be more appropriate for healthy participants or those with earlier stage disease.
• The study design was complex. There was no blinding, there was variability in the research assistant and practitioners collecting assessments, and there was variation in the intervention technique.
• A greater number of participants assigned to the presence group dropped out due to treatment preference.
• A registered nurse certified in massage or healing touch therapy is required.

To ensure that all cancer patients with fatigue were identified and treated promptly and effectively.  These guidelines included recommended standards of care for assessment and management of fatigue in children, adolescents, and adults with cancer.

The guidelines were evidence- and consensus-based. The guidelines were multidisciplinary, and all recommendations were category 2A unless otherwise stated.

The guidelines provided several algorithms for assessment and management based on age group, level of self-reported fatigue, and phase of treatment.

Screening

• All patients with cancer should be screened for the presence or absence of fatigue at regular intervals as a vital sign.
  • Age older than 12 years:  Screen on a 0-to-10 scale or as none, mild, moderate, or severe.
  • Age 7 to 12 years:   Use 1-to-5 scale (1 = no fatigue and 5 = worst).
  • Age 5 to 6 years:  Screen using “tired” or “not tired.”

Focused Evaluation of Fatigue

• A focused history and assessment of contributing factors should be performed when screening indicates moderate to severe fatigue.
  • Age older than 12 years:  score of 4 to 10
  • Age 7 to 12 years:  score of 3 to 5
  • Age 5 to 6 years:  “tired”
• Focused history should
  • Rule out recurrence or progression of cancer
  • Include a review of systems
  • Include an in depth fatigue history, including onset and patterns, associated/alleviating factors, and interference with function.
• Assessment of treatable contributing factors, such as
  • Other related symptoms
  • Anemia
  • Sleep disturbance
  • Medication and side effects
  • Comorbidities
  • Activity and fitness level.

Management and Interventions

• Active Treatment
  • Education and counseling regarding known patterns of fatigue and reassurance that treatment-related fatigue is not necessarily indicative of progression of disease.
  • General management strategies to include self-monitoring, energy conservation techniques, and use of distraction
  • Nonpharmacologic interventions to include activity enhancement, physically based therapies (such as massage), psychosocial interventions, nutritional consultation, and cognitive behavioral therapy for sleep
  • Pharmacologic interventions to include consider psychostimulants, treatment of anemia as indicated, and consideration of mediation for sleep
• Posttreatment
  • Education and counseling about known fatigue patterns and self-monitoring of fatigue levels
  • General management and nonpharmacological and pharmacological interventions as for active treatment above
• End of Life
  • Education and counseling about known fatigue patterns and as an expected end of life symptom
  • General strategies as per active treatment and post treatment
  • Nonpharmacologic interventions to include activity enhancement, psychosocial interventions, and nutrition consultation
  • Pharmacologic interventions as per active and post treatment

Within activity enhancement information, the guideline cites several synthesized reviews regarding the use of exercise and concludes that

• Improvement in fatigue was not noted with all diagnoses.
• It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment.
• Referral to exercise specialists or physical therapy should be triggered by
  • Patients with comorbid conditions, such as chronic obstructive pulmonary disease or cardiac disease
  • Recent major surgery
  • Specific functional or anatomical deficits
  • Substantial deconditioning.
• Exercise should be used with caution in patients with
  • Bone metastases
  • Immunosuppression or neutropenia
  • Thrombocytopenia
  • Anemia
  • Fever or active infection
  • Limitations due to other illnesses.

Because fatigue is a subjective experience, it was recommended that assessment should use patient self-reports and other sources of data.

Several barriers were identified related to effective treatment for fatigue.  Due to barriers, it was stated that screening for fatigue needs to be emphasized.  Rescreening was emphasized because fatigue may exist beyond the period of active treatment.

Factors identified as potential causative agents that should be specifically assessed were outlined.  These factors were pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, medication side effects, and other comorbidities.

It was noted that fatigue often occurs as part of a symptom cluster, often with sleep disturbance, emotional distress, or pain, so that assessment of these problems and institution of effective treatment is essential.

The importance of comprehensive assessment, including review of all current medications and noncancer comorbidities, was identified.  For example, it was noted that there can be thyroid dysfunction after radiation therapy for various cancers or use of biological and that hypogonadism can be associated with fatigue.

• The majority of studies regarding the impact of exercise on fatigue were performed in patients with limited types of cancer, and findings may not be applicable to all types of patients.  In addition, the timing and amount of exercise for various groups are not clear.  There are also few longitudinal studies examining fatigue in long-term disease-free survivors, although fatigue can be a long-term or late effect.
• Although the guideline was structured according to phase of treatment, recommended interventions did not vary according to phase of treatment.  There were minimal differences in recommended content of education and counseling.
• There was little evidence regarding effective management of fatigue in end of life care.
• There was no discussion of prevention related to fatigue.