Massage/Aromatherapy Massage

To evaluate the effectiveness of massage and aromatherapy for symptom relief in patients with cancer

The search used the following sources from 1966–2002: MEDLINE, CINAHL, British Nursing Index, EMBASE, AMED, PsycINFO, and CancerLit.

• A total of 1,322 references were initially retrieved.
• Two reviewers independently assessed trials for inclusion in the review, assessing study quality and extracted data.

Ten reports met the inclusion criteria; eight randomized controlled trials that included 357 patients were reviewed.

• The most consistently found effect of massage or aromatherapy massage was on anxiety.
• Four trials (207 patients total) detected a reduction in anxiety postintervention.
• There was no reported decrease in anxiety with the addition of aromatherapy.

While there is sufficient evidence to support the effectiveness of massage in decreasing anxiety in patients with cancer, there is insufficient evidence to draw conclusions about the effectiveness of aromatherapy massage for patients with cancer. Further research is needed.

• 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.

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.

• FINAL NUMBER STUDIES INCLUDED =  12
• TOTAL PATIENTS INCLUDED IN REVIEW = 358
• KEY SAMPLE CHARACTERISTICS:  Mean age of 8.4 years, age ranged from 1–19 years; 55% male participants; 120 participants from Greece; 62% Caucasian; majority had hematologic cancer; many studies were conducted during painful procedures such as lumbar puncture and venipuncture.

PHASE OF CARE: Multiple phases of care

APPLICATIONS: Pediatrics

Integrative interventions may be very effective for pain and anxiety in children undergoing cancer treatment. Integrative modalities, however, warrant further study with larger sample sizes to better determine their effectiveness in this population.

• No description existed of the time window during which data were extracted.
• Various interventions were combined and analyzed as a unit.
• Only included randomized controlled trials and thus reduced literature sample size
• The sample size for each intervention was small.
• The effect of each intervention is not clear.

This study provided some evidence that complementary modalities can help children undergoing cancer treatment or painful procedures. The usefulness of a particular method should be further examined.

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

• 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.

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.

• 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.

• 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.

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

• 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.

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.

To assess the impact of massage therapy on intermediate-term anxiety in patients undergoing radiation therapy

Patients were randomized to massage therapy and control groups. Patients in the massage therapy group rated anxiety before and after massage sessions, and control patients rated their anxiety 15 minutes before radiation treatment. All massage sessions took place before the radiation treatment over 10 consecutive days. Massage consisted of a 15-minute chair massage with a combination of effleurage and petrissage. Patients did not disrobe for the therapy, and no lotion was used. Massage therapists participated in a training course specifically targeting the care of patients with cancer. All therapy was standardized, but was adapted as necessary to avoid any massage to the treatment field. The massage therapist assessed anxiety in all patients using a visual analog scale (VAS) every day during the study.

• The sample included 100 participants.
• Mean age in the control group was 58 years; mean age in the massage group was 60 years (range = 35–85 years).
• The sample was 68% females and 32% male.
• Most participants had breast or head and neck cancers.

• Single site
• Outpatient setting
• Montreal, Quebec, Canada

Active treatment phase

A randomized controlled trial design was used.

• Visual Analog Scale (VAS): Ranges from 0 (not anxious at all) to 10 (the most anxious I have ever been), using a 10 cm ruler with a slide bar
• Spielberger State-Trait Anxiety Inventory (STAI)

The mean VAS score before massage was 4.0 and after massage was 2.2, which was a 45% decrease in anxiety (p < 0.001). Patients in the massage group showed a 15% decrease in anxiety scores from the first to the last session, and patients in the control group experienced a 19% decrease over the same time interval. Both groups had similar scores for state and trait anxiety at baseline. There were no differences in state anxiety between groups at the last session, indicating no intermediate effects on anxiety. VAS scores declined over time for both groups.

Massage therapy as used in this study was associated with a significant immediate reduction in anxiety, but appears to have little or no effect on intermediate-term anxiety. Anxiety over the course of radiation treatment declined for both groups.

• The study had no appropriate control group.
• The type of massage given was limited (only 15-minute chair massage), which could have influenced results.
• The control group met with the massage therapist for anxiety assessment, but it is not clear whether this provided an adequate attentional control.
• Bias may have been present since the massage therapist was the person who administered the VAS assessment to all patients.
• The study concluded after a 10-day period.
• The duration of therapy for participants was not described, so it is not clear how this reflected an intermediate point in therapy.
• The sample size was not sufficient to allow for subgroup analysis to determine potential differences in effect by diagnosis or other subject groups.
• Baseline VAS scores were relatively low on average in both study groups and was lower in the control group (3.2), which likely influenced effect sizes that could be seen.

Findings suggest that a brief chair massage can be effective for immediate reduction in anxiety, and this may be helpful for certain patients who are very anxious in beginning treatments. Because anxiety in all patients declined over time, and all subjects were seen by a massage therapist prior to each treatment, it may suggest that regular attention to anxiety in interaction with patients may be helpful for anxiety reduction over the course of treatment. This is an area that could be studied. The length and type of massage could influence findings, suggesting that further research in this area should incorporate evaluation of various types and duration of massage.

The intervention was five weeks of massage therapy sessions for 30 minutes per session. Massages were given three times per week, for a total of 15 massages (control group).

• The sample had 34 participants.
• Both groups were comprised of women who had received surgery for breast cancer.
• The women had stage I or II breast cancer, diagnosed within the past three years, and were at least three months post any treatment.

A longitudinal randomized controlled trial design was used.

• State-Trait Anxiety Inventory (STAI) 
• Profile of Mood States (POMS)
• Symptom Checklist–90–Revised (SCL-90-R)
• Natural killer cell numbers and assays (blood) measured immediate- and long-term effects.

Anxiety was reduced in the massage group on STAI (p < 0.05) after the first and last sessions (decreased by 25%).

• Random assignment by flip of coin could have introduced bias; a random-number table could have been used to avoid this bias.
• The study had a small sample.

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

• 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.

• 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.

• Single site
• Inpatient setting
• Five hospital oncology units

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

The study was a randomized, controlled clinical trial.

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

• 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.

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.

• 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.

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

To investigate the effectiveness of integrative medicine therapies on pain and anxiety among patients with cancer

The integrative medicine (IM) therapies included in this study were in three different categories, (a) bodywork, which included craniosacral therapy, medical massage, and reflexology, (b) mind-body and energy (MBE) therapies, which were further divided into separate categories, and (c) traditional Chinese medicine, which included acupressure, acupuncture, and Korean hand therapy. Patients could receive therapy from one category or from more than one in combination therapy.

• N = 1,833  
• MEDIAN AGE = 59 years (range = 44–74 years)
• MALES: 35.8%, FEMALES: 64.2%
• KEY DISEASE CHARACTERISTICS: Primary malignancy sites included female breast, bronchus, lung, trachea, colorectal area, hematopoietic or lymph area, and prostate. Patients with all other primary malignancies who were not included in any of these categories were grouped together into an “other” cancer site designation.

• SITE: Single site
• SETTING TYPE: Inpatient hospital
• LOCATION: Midwest United States

• PHASE OF CARE: Acute, chronic, and palliative  
• APPLICATIONS: Elder care and palliative care 

This retrospective, observational study collected data from electronic medical records.

• Pain and anxiety scores were taken by practitioners directly before and after each session using an 11-point scale on which 0 indicated no pain and 10 the worst pain imaginable.

The results of this study indicated that IM therapies need more extensive research to validate findings, suggesting a correlation between improved self-reported pain and anxiety scores and use of these therapies alone or in combination.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)

Nurses in the oncology inpatient and outpatient settings are instrumental in research evaluating pain management techniques such as IM therapies. Nurses conduct, lead, and participate in every aspect of these studies evaluating patient outcomes from pain management interventions for patients with cancer. Observational studies and qualitative research will be instrumental in developing future evidence-based guidelines.

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

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. Most frequently massaged areas were neck and upper back, 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.

• The study had 348 participants.
• Mean participant age was 65.2 ±14.4 in the experimental group and 64.2 ±14.4 in the control group.
• The sample was 61% female and 39% male.
• The most common diagnoses were breast and lung cancers; 100% had metastatic disease, and 27% had bone metastasis.
• Fifty-four percent had constant pain, and 26% of participants’ pain was neuropathic.
• Forty-four percent were married or in a committed relationship, 39%–42% had a college education level or higher, and 86% were non-Hispanic white.
• In the experimental group, 77% were receiving care at home; in the control group, 81% were receiving care at home.
• Mean worst pain in 24 hours in both groups was 6.4 or greater at baseline.

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

• End-of-life care phase
• End of life and palliative care

A randomized, single-blind, controlled trial design was used.

• Memorial Pain Assessment Card (MPAC): 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

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.

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.

• 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.

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.

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

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.

• 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.

• Single site
• Outpatient setting

Patients were undergoing the active treatment phase of care.

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

• 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

• 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).

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.

• 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.

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.

To evaluate the effects of yoga, massage, and Reiki therapies on stress, pain, anxiety, mood, overall health, and quality of life (QOL)

Data were collected from patients who self-enrolled in yoga, Reiki, and massage services during a six-month period. Patients completed study questionnaires before and after participating in one of these services, within one to three minutes before and after participation.

• N = 150   
• AGE = Not provided
• MALES: 9%, FEMALES: 91%
• CURRENT TREATMENT: Chemotherapy, radiation therapy, other
• KEY DISEASE CHARACTERISTICS: Patients involved were at varied points in the care trajectory, and 75% were either newly diagnosed or had completed initial treatment. Disease types were not reported.

• SITE: Single site   
• SETTING TYPE: Other    
• LOCATION: Community center in Illinois

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

• Quasi-experimental

• 10-point rating scales for all outcome measures

The time patients had been participating in the service ranges from one month to more than three years. Significant changes in pain levels pre- and postservice provision were reported (p < 0.001). Individuals receiving Reiki had higher preservice pain levels. Center staff encouraged patients with pain to enroll in Reiki. No significant postservice differences in pain across the intervention types were reported. All patients reported lower anxiety scores after receiving the service (p < 0.001) with no differences between groups.

Integrative therapies such as Reiki, massage, and yoga may be helpful for management of symptoms such as pain and anxiety.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Author states that this was a repeated measures design and used repeated measures ANOVA, but description of methods looks as if each patient completed study assessment only immediately pre and post a single service. 
• Measurements were at a time point immediately before and after a service—it is unclear how meaningful this timing is in terms of looking at ongoing symptom management.
• Validity of the instrument for measurement and interpretation of anxiety and mood is questionable.
• Pain levels overall were low,suggesting potential floor effects in measurement in non-Reiki patients.
• No information is provided about chronicity, type, etc., for pain, or any other interventions being used for pain.

This study has numerous limitations and high risk of bias, so no firm conclusions can be drawn about the actual efficacy of the interventions being evaluated.

To pilot a randomized trial examining the effectiveness of cognitive behavioral therapy (CBT) and aromatherapy massage (AM) in reducing emotional distress in patients with cancer and to compare the differences in effectiveness between the CBT and AM groups

Participants were randomized to one of two treatment groups: CBT or AM. The study did not explain how the CBT intervention was actually implemented, except to note that trained and accredited therapists delivered the therapy. The study listed the topics covered in the CBT sessions but did not describe the procedures, group-session format, etc. AM was described as standard massage with 20 essential oils, delivered by a trained aromatherapist, in a quiet room with minimal talking. Each group received one of these interventions along with “treatment as usual” (standard care). Both groups were offered, after study entry, up to eight one-hour sessions delivered over 10 weeks. Time interval between treatments was not delineated.

• The study reported on a sample of 36 patients (39 enrolled; 3 dropped out before postintervention assessment).
• Mean patient age was 52.5 years.
• The sample was 79% female (n = 31) and 21% male (n = 8).
• The sample was composed mostly of patients with breast and colorectal cancer but also included patients with lung or prostate cancer, lymphoma, and myeloma.
• The stage of disease and other characteristics, such as type of treatment, was unspecified. Also unspecified was whether participants were receiving pharmacologic treatment for emotional distress (anxiety or depression) or some other psychological support. Study participants were screened, by means of the Hospital Anxiety and Depression Scale (HADS), for anxiety and depression. The initial cut score was 8. (An initial cut score of 8–10 is considered borderline for anxiety or depression.) Four months after study initiation, the cut score was increased to 11. (A cut score of 11 or higher is considered clinically significant.) The demographics of the CBT and AM groups were similar except in regard to gender: The CBT group contained only one male; seven males were in the AM group. In both groups, the total sample size was too small to allow researchers to detect significance differences.

• Single site
• Outpatient setting
• An urban teaching hospital, recruited from outpatient oncology clinics, in London, England

Patients were undergoing multiple phases of care.

The study, a pilot, was a randomized, single-blind, prospective, repeated-measure clinical trial with no control group. Measures were collected at baseline and at three and six months postintervention.

• Hospital Anxiety and Depression Scale (HADS): For screening and participant eligibility
• At baseline: Treatment preferences and beliefs about effectiveness and satisfaction with either CBT or AM
• Profile of Mood States Short Form (POMS-SF): Total mood disturbance score (TMS), summed from six subscales
• Psychological Outcomes Profiles (PSYCHLOPS): Six-point Likert scale to assess distress, duration, and impact of two patient-derived problem areas
• EuroQol: A health-related quality-of-life measure
• Client event recall: Asking patients about their experience with the therapy
• Consultation and Relational Empathy (CARE) measure: To quantify each patient’s perception of relational empathy with the therapist

The study was drastically underpowered, with too small a sample to allow researchers to draw meaningful conclusions. The study produced no statistically significant findings.

• With low recruitment (8%), a protracted period (two years, but still called a pilot?), and an underpowered design that lacked a strong conceptual grounding and rationale, this study produced no meaningful conclusions and suggested no direct application to practice.
• Both therapies, AM and CBT, were well received and posed no risk of harm.
• To treat the \"whole patient,\" nonpharmacologic interventions should be offered, when possible, to patients with cancer.

• The study had a small sample size, with less than 100 participants.
• The study had risks of bias due to no control group and as the result of sample characteristics.
• Findings are not generalizable.
• The study used nonrandom (convenience) sampling with a low accrual rate.
• Screening criteria changed four months into the trial, but data do not differentiate participants (defined only as patients with HADS greater than 8).
• Rationale for sampling time points is unclear (e.g., why should researchers expect an effect three to six months after AM?).
• Time between last treatment (AM or CBT) and three-month sampling is not noted, so relating outcomes to intervention is difficult.
• Participants were allowed to select the  number of therapy sessions to attend, which is certainly a weakness.
• Whether CBT was delivered in a group format cannot be ascertained.

AM may be beneficial as a treatment for short-term anxiety. This poorly designed and controlled pilot study offers no other immediate nursing implication.

To examine the effects of therapeutic massage on pain, sleep quality, symptom distress, and anxiety in patients hospitalized for treatment of cancer

Patients who received massage had 15–20 minutes of light Swedish massage techniques of effleurage and petrissage three times during one week of hospitalization. Each session was given at least 24 hours apart. The control condition was 20 minutes of deliberate focused communication from a nurse. Discussions involved patient teaching, relaxation techniques, questions about cancer and treatment, life challenges, and stress reduction.

• The sample was 40 hospitalized patients with cancer.
• Mean patient age was 62 years; range was not provided.
• The sample was 95% male and 5% female.
• Various cancer diagnoses were included: lymph, lung, gastrointestinal, genitourinary, head and neck, leukemia, breast, and skin.
• The majority of patients were Caucasian, married or partnered, and not working.

• Single site
• Inpatient setting
• Colorado

Active treatment phase

A quasi-experimental design was used.

• Numeric Pain Rating Scale
• Verran and Snyder-Halpern Sleep Scale
• McCorkle Symptom Distress Scale
• Spielberger State-Trait Anxiety Inventory

• Analysis of variance showed changes in pain and symptom distress in the group receiving massage (p < 0.10), and in sleep in the control group (p < 0.10).
• There was no difference in anxiety.

Provision of therapeutic massage in hospitalized patients with cancer may have a positive effect on pain and symptom distress.

• The study had a small sample, with less than 100 participants.
• Because the study had no random assignment and no blinding, there is associated risk of bias.
• No information was provided on differences in use of pain medication or other interventions to control symptoms and relevant distress.
• The sample was biased, being mostly male and Caucasian.
• No information was provided about severity of illness.
• It is not clear whether the hospitalized patients were currently receiving chemotherapy or radiation therapy during hospitalization.

This study did not provide any strong support for the use of therapeutic massage in hospitalized patients with cancer.

To evaluate the effects of massage and aromatherapy on pain scores (primary aim), and to improve sleep, reduce anxiety and depression, and improve overall quality of life (secondary aims), in patients with advanced cancer

The intervention was a course of massage therapy with and without an essential oil (aromatherapy). Patients were randomly assigned to one of three groups:

1. Massage with lavender oil
2. Massage with inert oil
3. Control group

• The sample included 42 patients receiving palliative cancer care.
• The aromatherapy group had 16 patients, the massage group had 13 patients, and the control group had 13 patients.

Major hospitals and hospices in the United Kingdom

A randomized controlled trial design was used.

Hospital Anxiety and Depression Scale (HADS)

There were no statistically significant differences between the groups—aromatherapy or massage—in anxiety reduction (p = 0.95–1.0).

• Sample sizes were small.
• The trial demonstrated the difficulty of studying this population. Participants were fatigued, had poor performance statuses, and often could not complete the questionnaires. These factors contributed to the high attrition rate.
• The trial had considerable cost implications in terms of training, nursing time, and equipment.

To test hypotheses regarding the effect of massage on anxiety, pain, nausea, sleep, and quality of life (QOL).

Patients were referred by their physicians and were provided a physician order for massage. Patients completed self-administered instruments prior to massage therapy and one week after therapy. Massage treatments lasted 30 minutes and were provided during treatment with chemotherapy and/or radiation therapy (RT) once per week for three weeks.

• The sample was comprised of 51 women with breast cancer.
• Mean age was 53 years.
• All patients were diagnosed with breast cancer; 27% had recurrence.
• The majority (78%) of patients were receiving only chemotherapy, and 61% were either also receiving concurrent RT or had RT planned in the future.
• The sample was 84% Caucasian, with 45% currently working full-time and 88% having at least some college education.

• Single site
• Outpatient
• Kansas

Patients were undergoing the active treatment phase of care.

The study used a pre-/posttest design.

• State-Trait Anxiety Inventory (STAI)
• Visual analog scale (VAS) for pain
• Symptom Distress Scale (SDS)
• Verran and Snyder-Halpern Sleep Scale (VSH)
• Functional Assessment of Cancer Therapy–Breast (FACT-B)

STAI scores were lower after massage therapy (p = 0.03). Sleep scale items that showed improvement with massage were soundness of sleep (p = 0.05), time from settling down to sleeping (p = 0.02), and overall sleep satisfaction (p = 0.01). FACT-B scores also showed improvement in several areas after massage therapy (p < 0.05). Effect sizes in these areas were moderate (≥0.3).

Provision of massage therapy during treatment for breast cancer may reduce anxiety and improve sleep and aspects of QOL.

• The study had a small sample, with less than 100 patients.
• The study lacked a control or comparison group.
• The study lacked blinding, and the massage therapist obtained all self-reported data.
• The study had a short duration of intervention and follow-up.
• The sample was highly educated and overwhelmingly Caucasian, with 52% of patients earning more than $50,000. The findings may not be generalizable to other socioeconomic and ethnic groups.

Massage therapy may assist women undergoing breast cancer treatment to better tolerate the impact of treatment, reduce anxiety, and improve sleep during active treatment.

This intervention was a 30-minute, full-body massage delivered by the first author after completing pre-test. After the intervention, the participant was instructed to lie quietly for 30 minutes before completing the post-test.

• N = 30
• KEY SAMPLE CHARACTERISTICS: Taiwanese hospitalized patients with metastatic bone pain

• Quasi-experimental design

• Pre-test/post-test measures
• Repeated to examine the time effects of massage

Massage was shown to have effective, immediate, short-term (20–30 minutes; a 61% reduction in anxiety), intermediate (1–2.5 hours), and long-term benefits (16–18 hours) on present pain intensity and anxiety. The most significant reduction in anxiety occurred 15–20 minutes after the intervention. The results from ANOVA revealed a time effect of massage on anxiety visual analog score across time at a statistically significant level (F [10, 20] = 10.3, p < 0.001).

• Convenience sampling
• Small sample size
• Quasi-experimental design
• Lack of a control condition and possible response bias
• Well designed but not randomized

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

• 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.

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

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

• Pilot randomized, controlled trial
  • No blinding

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

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.

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

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

The intervention was a four-week course of one-hour aromatherapy massage offered in National Health Service cancer care settings in the United Kingdom. Patients were recruited and randomized to the intervention group or the control group. The primary variable was change in anxiety and/or depression between full case and borderline and noncase at 10 weeks postrandomization. Diagnostic assessments were tape-recorded, and regular consensus meetings were held to ensure consistency of the diagnostic rating. The secondary variable was self-reported anxiety using the State Subscale of the State Anxiety Inventory (SAI).

• The sample was comprised of 288 participants.
• Participants had a diagnosis of cancer, with prognosis of more than three months.

Four cancer centers and one hospice in England (National Health Service cancer care settings)

A longitudinal, randomized controlled trial design was used.

State Anxiety Inventory (SAI)–State Subscale measured at 6 and 10 weeks

Patients receiving aromatherapy massage experienced a significant improvement in anxiety at two weeks after intervention, and this was maintained at six weeks after intervention. The reduction of anxiety (by SAI) in the patients receiving usual care plus aromatherapy massage was at a confidence interval of 95% (p = 0.04) both at 6 weeks and 10 weeks.

The results of this trial suggest that aromatherapy massage is an effective therapeutic option for the short-term management of mild to moderate anxiety in patients with cancer.

The study required specialized training in aromatherapy massage.