Effects of Massage Therapy on the Relief of Cancer Pain
3.4.2 Results
3.4.2.2 Characteristics of Study Massage Interventions
The comparison of intervention effects across studies becomes problematic because of considerable variation in the intervention protocols, including types of massage techniques used, body area massaged, the total dose of massage, the time of day of massage delivered, and the number of massage therapists. The most commonly cited massage was light Swedish massage, followed by full-body massage with diverse stroking techniques (i.e. petrissage, friction, and compression) (massage protocol used in Jane et al.’s work in 2010 and 2011 was shown below), aromather- apy, back massage, hand or foot massage, foot re fl exology, myofascial release, and lymphatic draining – all delivered with licensed massage therapists or trained nurses.
The intensity and duration of massages ranged from one session of 3–60 min to 15 sessions over three weeks and the total intervention time varied from 6 to 495 min.
For studies with a series of massage sessions, the interval between massages ranged from one to three days up to a week. Most studies initiated interventions without respect to time of day, whereas nine studies delivered interventions during the evening hours or the morning time period. To ensure fi delity of delivering the MT, nine investigators either used single therapist or developed a standardized massage protocol to enhance the integrity of intervention administration. In consideration of the safety issues of massage in patients with cancer, authors of fi ve studies suggested avoiding sites of tumor, edema, medical devices, deep vein thrombosis, and open lesions.
Table 3.3 Summary of reviewed studies on massage therapy in patients with cancer References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Ahles et al. ( 1999 ) 34 BMT Experimental repeated measures with pre- and post-test Massage vs control Swedish massage: neck, face, scalp, shoulders 20 min × 9 for three weeks (9 sessions) Licensed therapist: 1 Pain, fatigue, nausea, anxiety, depression, mood, emotional distress Immediate effect Pain: 0.13 Anxiety: 3.1 Fatigue: 1.84 Nausea: 1.84
↓depression, ↓emotional distress, ↓anxiety, ↓nausea Cassileth and Vickers ( 2004 )
1,290 (3-year period) Quasi-experimental with pre- and post-test (one group) Swedish massage, light touch massage, foot massage Pain, fatigue, nausea, anxiety, depression Immediate effect: 5–15 min Pain: 0.66 Anxiety: 1.04 Fatigue: 0.71 Nausea: 0.34 Depression: 0.49
Immediate effect: ↓pain, ↓anxiety, ↓fatigue Length of massage effects: last for 24–48 h 20–60 min Licensed therapist: 12 Long-term effect: 2–5 h; 24–48 h Swedish and light touch massage were superior to foot massage Corner et al. ( 1995 ) 52 40% had metastatic disease
Quasi-experimental repeated measure with pre- and post-test Massage vs aromatherapy or control group Back massage: NA Weekly 30 min × 8 weeks (8 sessions) Licensed therapist: 1 Anxiety and depression, symptom distress, QoL NA No mean and SD Aromatherapy and massage had effects on ↓anxiety ↓symptom distress Cumulative effect on ↓anxiety at massage 3 Aromatherapy was superior to massage
24-h duration Currin and Meister ( 2008 )
251 (3-year period) Quasi-experimental with pre- and post-test Swedish massage on feet and leg or back neck and shoulder 10–15 min*1 Licensed therapist: 2 Pain, physical discomfort, emotional discomfort, fatigue Pain: 0.74 Physical: 0.76 Emotional: 0.69 Fatigue: 0.88 ↓pain, ↓physical and emotional discomfort, ↓fatigue Massage effects were no relation with gender, age, ethnicity, cancer type (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Downey et al. ( 2009a ) 167 RCT Light back massage Pain, QoL Pain: NA Massage vs control: NS Median survival time: 149 days Massage vs guided imagery or control (friendly visit) 35-min × 2/weeks × 11 treatment QoL: NA Guided imagery vs control: NS Over 10-week period Licensed therapist: NA Fernández-Lao et al. ( 2012 )
20 Breast cancer survivors
Randomized single- blind, placebo- controlled crossover Myofascial release vs education (placebo) Myofascial release followed by barners approach 40-min × 1 (washout period: three weeks) Licensed therapist: NA Salivary fl ow rate, cortisol, IgA, a -amylase Salivary: −0.60 Cortisol: 0.00 IgA: 0.233 a -amylase: 0.455
Myofascial release: ↑salivavry fl ow rate (parasympathetic effect) Cortisol, IgA, a -amylase: NS Immune function (IgA) was modulated by patient’ positive attitude toward massage Ferrell-Torry and Glick ( 1992)
9 56% had metastatic disease Quasi-experimental with pre- and post-test (one group) Swedish along with myofascial trigger points therapy 30 min × 2 consecutive nights Licensed therapist: 1 Pain, anxiety, SR (immediate effect) Physiologic indicators: HR, RR, MAP (10-min interval) Pain: 1.13 Anxiety: 1.08 SR: 1.26 HR: 0.19 RR: 0.25 SBP: 0.59 DBP: 0.47 ↓pain, ↓anxiety, ↓HR, ↓RR, ↓BP, ↑SR Grealish et al. ( 2000 ) 103 Experimental design with crossover
Foot massage 10 min × 2 consecutive nights Licensed therapist: 2 Pain intensity, SR, HR, nausea Pain: 0.25 SR: 0.61 Nausea: 0.32 ↓pain, ↓nausea, ↓HR, ↑SR No gender effect 10–20 min interval
Table 3.3(continued)
(contin
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Hernandez- Reif et al. ( 2005 ) 58 Women with breast cancer Experimental design with pre- and post-test Massage vs control Relaxation vs control Massage on neck/face, shoulders, arms, legs/ft, back 30-min × 3/per week × 5 weeks (15 sessions) Licensed therapist: NA Pain intensity, depressed mood, anxiety (immediate effect)
Pain: 0.35 Mood: 0.39 Anxiety: 0.79 Dopamine: NA NK cells: NA Lymphocytes: NA Massage and relaxation group: ↓pain, ↓anxiety ↓depressed mood (week 1) Massage group: ↓depressed mood, ↓anger, ↑vigor (week 5) Massage group: ↑dopamine, ↑NK cells, ↑lymphocytes
Dopamine, NK cells, lymphocytes (long- term effect): week 1 from week 5 Jane et al. ( 2009 ) 30 Patients with metastatic bone pain
Quasi-experimental repeated measures with pre- and post- test (one group) Swedish full-body massage on head, face, neck, arms, back, legs, and feet 45-min × 1 (evening time) Pain intensity, anxiety, relaxation: HR, MAP Immediate, inter- immediate, long-term effects (16–18 h after MT) Pain: 1.83 Anxiety: 1.64 HR: 0.01 MAP: 0.11
↓pain, ↓anxiety HR and MAP: NS No patients reported any adverse effects as a result of MT Therapist: 1 (trained RN) Jane et al. ( 2011 ) 72 Patients with metastatic bone pain
RCT with repeated measure Massage vs social attention Swedish full-body massage on head and neck, face, arms, back, legs and feet Pain intensity, mood, SR, sleep quality 20-min interval D1-D2-D3 ES: D1 Pain: 0.706 Mood: 0.55 Relaxation: 0.54 Sleep: 0.08 Massage group: ↓pain intensity, ↑mood and SR (D1-D3); ↑sleep quality (D1) 45-min × 3 consecutive nights Group effects: ↓pain Intensity ↑mood and SR, sleep quality (NS) Therapist: 4 (trained RN)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Kite et al. ( 1998 ) 58 Quasi-experimental pre- and post-test (one group) Aromatherapy: scalp, hands, feet, face, legs with 20 kinds of oils 15–60 min (median 45-min)/ week × 6 weeks Psychological distress, physical distress, global bene fi ts Interval: before and after (6th session)
NA ↓anxiety and ↑depression: 50–94% of patients reported improv tension, stress, depression, pain, insomnia, tiredness, global bene fi ts No subgroup effect on gender and types of treatment Kutner et al. ( 2008 ) 380 Advanced cancer
RCT Massage vs simple touch Swedish massage on neck and back, arms, legs and feet 30-min × 3/per week × 2 weeks (6 sessions) Licensed therapist: NA Pain intensity and mood (immediate effect) Pain interference, symptom distress, QoL, and analgesic use (sustained effect)
NA Massage and simple touch: ↓pain intensity, (massage was superior to simple touch for pain and mood) No group effect on pain interference, symptom, QoL, analgesic medication Meek ( 1993 ) 30 Exclude bone metastases
Quasi-experimental repeated measures with pre- and post-test (one group) Slow stroke back massage 3 min × 2 consecutive nights Licensed therapist: NA SBP, DBP, HR, ST SBP: 0.27 ↓4.2/min (HR) Immediate: 5-min interval DBP: −0.2 ↓9.17 mmHg (SBP) HR: −0.23 ↓6.4 mmHg (DBP) ST: 0.14 ↓1.45 F (ST)
Table 3.3 (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Mehling et al. ( 2007 ) 180 Post-operative cancer RCT with repeated measures Massage + acupun cture ( n = 93) vs control ( n = 45) Swedish massage (applying kneading and stroke) + acupressure-type foot massage + acupuncture (for pain, anxiety, nausea) Pain, depressive mood, nausea, vomiting, cost for post-operative stay 3-h interval for measur ement (D1-D2-D3) Pain: 0.68 (D1) Mood: NA Vomiting: 0.36 Nausea: NA Cost: NA Massage + acupuncture: ↑mood (D1-D3), ↓nausea and ↓vomiting (D1) Cost: NS Moderate-to-severe pain and mild depression at baseline reported signi fi cant improvement
10–30 min (mean = 20 min) × 2 Licensed therapist: NA Patients receiving massage only reported greater pain improvement in pain than in control group Subgroup effect: abdominal (ES: 0.98), prostate (ES: 0.97), and breast (ES: 0.66) Osaka et al. ( 2009 ) 34 Terminal ill cancer patients (median survival time: 38 days)
Quasi-experimental with pre- and post-test design (one group) Hand massage on upper extremity of one hand (immediate effect) 5-min × 1 Licensed therapist: 1 Anxiety-state CgA (stress biomarker) Satisfaction ES: with-in subjects Anxiety: 0.71 CgA: 0.68 Satisfaction: NA
↓anxiety (STAI-state) and CgA, ↑Satisfaction with hand massage Group effect: normal group (STAI and CgA signi fi cant) Anxious group (STAI signi fi cant and CgA NS), satis fi ed group reported more signi fi cant effects (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Post-White et al. ( 2003 ) 164 Patients under chemo- therapy Experimental design with crossover (pre- and post-test) Swedish massage with relaxing music played 45-min × 4 weekly Licensed therapist: 8 Pain, anxiety, fatigue, mood, nausea, HR, RR, SBP, and DBP
Pain index: 0.33 Pain interference: −0.45 Mood: 0.53 Anxiety: 0.58 Fatigue: 0.33 MT and HT: ↓pain, ↓ ↓RR, ↓SBP, ↓DBP ↑mood, ↓medication use Nausea and satisfaction (NS) MT: ↓anxiety HT: ↓fatigue
MT, HT, presence groups vs control
Medication use, satisfaction Immediate effect Smith et al. ( 2002 ) 41 Bone metastases included
Quasi-experimental repeated measures with pre- and post-test massage vs attention (20-min) Swedish massage 15–30 min × 3 times during 1-week (each session with 24 h apart) Therapist: 1 Pain intensity, pain distress, anxiety, symptom distress, sleep pattern Interval (four-day apart) Pain: 0.43 Anxiety: 0.71 Symptom distress scale: −0.61 Sleep: 0.62
↓pain, ↓symptom distress and stable sleep pattern Soden et al. ( 2004 ) 42 Palliative care unit
Experimental design with repeated measure (pre- and post-test) Massage ( n = 13) vs aromatherapy ( n = 16) or control ( n = 13) Swedish massage 30-min per week × 4 weeks (4 sessions) Interval: 1 week after last massage Licensed therapist: 1 Pain intensity, pain descriptor, sleep quality, mood (anxiety/ depression), symptom distress
NA Massage or combined massage (MT + aromatherap ↓pain intensity, ↑ ↑anxiety/ depression (within-subjects) Pain descriptor, symptom distress (NS) No cumulative effect on pain and mood Stephenson et al. ( 2000 ) 23 Breast ( n = 13) and lung ( n = 10) cancers
Experimental design with crossover (pre- and post-test) Foot re fl exology: areas corresponding pain and cancer site 30-min × 1 Licensed therapist: 1 Pain, anxiety Immediate effect Pain: 0.65 Anxiety: 0.54 ↓pain and ↓anxiety Foot re fl exology vs control
Table 3.3 (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Stephenson et al. ( 2003 ) 36 Metastatic cancer Experimental design with repeated measure (pre- and post-test) Foot re fl exology: areas corresponding pain and cancer site 30-min × 2 (24 h apart) Licensed therapist: 1
Pain Immediate effect, 3 h, 24-h NA ↓pain (immediate effect) Pain at 3 h and 24 h (NS) Foot re fl exology ( n = 19) vs control ( n = 17) Stephenson et al. ( 2007 )
86 (dyads) Metastatic cancer Experimental design with pre- and post-test Foot re fl exology vs control (30-min readings by family) Foot re fl exology: nurse-led 15–30 min train- ing + 15–30 min for partner Pain (brief pain inventory)/ short-form McGill pain questionnaire Anxiety
NA ↓pain and ↓anxiety Subgroup effect: patients with moderate-to-severe pain (eta squared: 0.23) or anxiety (eta squared: 0.15) had more signi fi cant ef 30-min × 2 delivered by family Sturgeon et al. ( 2009 ) 51 Breast cancer under treatment
Quasi-experimental with pre- and post-test (one group) Swedish full-body massage 30-min per week × 3 weeks Pain, anxiety, nausea and vomiting, symptom distress, sleep, QoL Interval: one week after the last massage Pain: 0.20 Anxiety: 0.31 Distress: 0.20 Sleep: 0.07 QoL: 0.30
↓anxiety, ↑QoL, ↑ sleep (time to fall asleep, soundness of sleep, sleep satisfaction, quality, and disturbance) Pain, overall sleep quality symptom distress (NS) Weinrich and Weinrich ( 1990 )
28 Experimental repeated measures (pre- and post-test) Swedish massage: back 10 min × 1 (9:00 am – 12:00 noon) Pain intensity Immediate and 1-h interval × 2 Pain: 0.04 (immediate effect)
No time effect on pain Subgroup effect: a signi fi immediate effect in male Massage vs control (10-min visit) 0.08 (1 h) 0.22 (2 h) (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Wilkie et al. ( 2000 ) 29 Experimental design with pre- and post-test Massage vs control Full-body massage 30–45 min × bi-weekly × 2 week (4 sessions) Licensed therapist: 5 Pain intensity, emotional distress, relaxation: pulse rate and RR (immediate effect) Pain: 0.14 Morphine: −0.57 QoL: 0.66 (global)
↓HR, ↓RR Pain intensity, QoL, and analgesic intake (NS) No gender effect Longevity, analgesic dose (convert intramuscular morphine-equivalent doses) (1–2 week) Wikinson ( 1995 ) 51 76% had metastatic disease
Experimental repeated measure Massage vs aromatherapy Full-body massage Duration: weekly × 3 week (evening time) Trained nurses: 3 Anxiety (immediate effect) QoL (physical, psycho logical symptom, global QoL) (long-term effect: 3-week) Physical: 0.78 QoL: 0.94 Psychological: 0.39
Massage: ↓psychological symptom and ↓state anxiety Aromatherapy: ↓psychological symptom, ↓state anxiety ↑QoL and physical scales Wilkinson et al. ( 1999 ) 87 Experimental repeated measure with pre- and post-test
Full-body massage Duration: 3 times (over 3 consecutive week, evening time) Trained nurses: 4 Anxiety (immediate effect) QoL (physical, psycho logical symptom, global QoL) (long- term effect: 3-week) STAI: 0.35 Trait anxiety inventory: 0.12 Physical: 0.50 Psycho: 0.02 QoL: 0.06 Massage: ↓STAI Aromatherapy: ↓STAI, physical and psychological symptom Massage vs aromatherapy
Table 3.3 (continued)
References Sample ( n ) Research design Massage protocol Measurement Effect size (d) Massage effects signi fi cance Wilkinson et al. ( 2007 ) 288 Early and advanced cancer RCT Aromatherapy vs control Aromatherapy 60-min/session per week × 4 (evening time) Therapist: 12 Anxiety/depression, QoL (pain, fatigue, nausea, global QoL)
Anxiety: 4.07 Depress: 1.72 Pain: 0.43 Fatigue: 2.51 Nausea: 0.63 QoL: 1.04
↓anxiety and depression at week 6 6 and 10 weeks after randomization Anxiety and depression at week 10 (NS) ES: at 6-week ↓self-report anxiety at week 6 and 10 Self-reported depression at week 6 or 10 (NS) Pain, fatigue, nausea, global QoL (NS) No carryover or long-term effects, only last for tw weeks after intervention Williams et al. ( 2002 ) 29 Breast cancer- related lympho- edema
Experimental design with crossover MLD vs simple SLD
MLD: Vodder method to treat neck, trunk, and arms 45 min × 5 days × 3 weeks (15 times) SLD: 20 min × 5 days × 3 weeks Therapist: 3 (MLD) Excess limb volume, caliper creep, dermal thickness, QoL
Excess limb volume: 0.76 (2 groups)
MLD effects: ↓limb volume, ↓caliper readings, ↓dermal thickness, ↓QoL (emotion), ↓pain Caliper creep: 0. 89 (MLD) Dermal thickness: 0.44 Modi fi ed from Jane et al. ( 2008 ) BMT bone marrow transplant, CgA salivary chromogranin, D day, DBP diastolic blood pressure, ELV excess limb volume, ES effect sizes, HR heart rate, HT healing touch, MAP mean arterial pressure, MLD manual lymphatic drainage, MT massage therapy, NA non-applied due to the omission of related information or mean and standard de from reviewed studies, NK natural killer, NS no signi fi cance, QoL quality of life, RA registered nurse, RCT randomized clinical trial, RN registered nurse, RR respiratory rate, SBP subacute back pain, SLD simple lymphatic drainage, SR subjective relaxation, ST skin temperature, STAI state-trait anxiety inventory
Massage Protocol
The primary goal of this full-body massage was to decrease pain intensity and anxiety, and improved physiological relaxation for patients with metastatic bone pain during an in-patient hospitalization. To maximize therapeutic effects, this inter- vention should include the following protocol (Field et al. 1996 ; Wilkie et al. 2000 ; Smith et al. 2002 ; Price et al. 2007 ; Jane et al. 2009 ) .
Pre-massage Preparation
1. The subject was instructed to have the evening meal at least 1 h prior to the interven- tion or to have the meal after the intervention, remain in bed for at least for 10 min immediately before the intervention, wear loose clothes, and empty his/her bladder.
2. Each massage was performed between 4:00 and 5:00 pm in his/her unit with the door closed and curtain drawn.
3. Prior to the intervention, the subject was instructed to lie fi rst side-lying or prone position, then face-up, close their eyes, take three deep breaths, and refrain any conversation during the entire intervention.
4. Each massage session included unscented massage lotion as a skin lubricant.
5. The subject was asked about their comfort with the room temperature. The appli- cation of fan or heater based on the individual’s comfort.
6. The massage therapist assesses sites of metastases and any local skin conditions which would be a contraindication to massage intervention.
During Massage Intervention
1. Each massage must be a direct hand-on and skin-to-skin manipulation of the soft tissue of the backside of the body and must last for 45 min, if possible.
2. Each massage should include selected strokes with certain amount of time to eight different body areas, including head and neck , back , gluteus muscles , and four extremities .
3. Selected strokes included:
• Ef fl eurage : rhythmic, long, fi rm and gliding stroke conforming to the con- tours of the body using the therapist’s whole palm of the hand or the tips of the middle fi ngers with 5–10 times.
• Light petrissage : rolling, squeezing, and kneading movement of the fi ngers and thumb done slowly and lightly using the therapist’s tips of thumbs or three middle fi ngers with fi ve to ten times.
• Nerve stroke : very light brushing of the skin with the therapist’s fi ngers or full hand with three to fi ve times.
• Light compression : fi ngertips are used to lightly compress selected areas of tension using only mild to moderate pressure to the plantar surfaces, shoulders, palms, and possibly to the sacral area with 0–15 s duration.
4. Modi fi cation of massage: administration of very light and gentle pressure with Ef fl eurage stroke in the bone metastatic sites and avoidance of sites of super fi cial tumors, infection, hyperestuesias, wounds, edema, and intravenous catheters.