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Massage for Pain and Anxiety in Cancer Patients
By Dónal P. O'Mathúna, PhD. Dr. O'Mathúna is Senior Lecturer in Ethics, Decision- Making & Evidence, School of Nursing, Dublin City University, Ireland; he reports no financial relationship to this field of study.
This article is a continuation of last month's examination of reflexology for cancer patients. Massage is one of the most commonly used non-pharmacological interventions for managing cancer pain.1 In the often-cited surveys conducted by David Eisenberg and colleagues, after prayer for healing was excluded, massage was the third most commonly used complementary therapy in the United States in 1997 and 1990.2 In his survey conducted in 2002, massage had fallen to sixth in popularity, having been used by 5% of the U.S. population in the previous year compared to 11.1% in 1997.3 Reasons for this change were not proposed but the numbers remain significant.
For cancer patients, massage is said to reduce anxiety, stress, pain, muscle tension, and fatigue.4 Such benefits would be of great value to many cancer patients. About one in five U.S. cancer patients seek massage, and approximately 70% of hospices in the U.K. provide massage.5 Clinicians may expect to be asked by patients with cancer whether massage is likely to be beneficial for them. The evidence available to address such questions will be reviewed here.
Massage is an ancient therapy that has long been valued. Hippocrates wrote that, "The physician must be experienced in many things, but assuredly in rubbing," i.e., massage. Toward the end of the 19th century, massage experienced a resurgence as nurses included it in their care of patients.6 A debate broke out in the British Medical Journal and then the public press alleging that massage had become entwined with prostitution and did not belong in medical establishments. A professional organization was born from this debate that developed standards for massage and went on to become the forerunner of the physical therapy profession. However, the link with medical care had been severed, which only recently has begun to be re-established.
Many different types of massage are practiced. Common to all forms is manipulation of the body's soft tissues by the massage therapist's hands to affect the vascular, muscular, and nervous systems.4 The most widely used form of massage used in health care settings is Swedish massage in which the hands move over the skin in long, gliding strokes (also called "effleurage").7 The muscles may be kneaded and light friction may be applied to the skin. Oil or lotion is often applied as a lubricant and to provide aromatherapy. Rolfing is a form of deep tissue massage where additional pressure is applied to the fascia to promote full range of motion and restore elasticity to connective tissue.8 Shiatsu massage is another deep form of massage which developed in Japan under the influence of traditional Chinese medicine. Various acupoints are massaged using the practitioners' fingers, thumbs, palms, or elbows, even knees or feet.
Mechanism of Action
The precise mechanism of action by which massage may have physical or psychological benefits has not been established. One proposal is that massage triggers a generalized positive reaction to human touch that is essential for health and well-being.5 It may directly relieve muscular aches and tension. Massage can also increase the temperature and blood flow to tissues being manipulated, which is said to promote healing. Little research has been conducted to establish whether any or all of these mechanisms are involved in any beneficial effects.
Much of the evidence available for using massage with cancer patients is anecdotal. A systematic review of research on massage with cancer patients was conducted using the Cochrane Collaboration approach in 2003 and updated in 2006.4 Ten randomized controlled trials (RCTs) were identified. A meta-analysis was not possible because of differences in the type of massage used and the design of the studies. The results were inconsistent, with some finding improvements in pain, nausea, anxiety, and other symptoms, but other studies failing to find significant improvements. Overall, the methodological quality was rated as generally poor according to the CONSORT criteria. Outcome assessors were blinded in only four of the trials. Allocation concealment was assessed as adequate in one trial and only two had adequate randomization methods. Sample sizes ranged from six to 87 participants. The reviewers determined that definitive conclusions on the effectiveness of massage for cancer patients could not be drawn from these studies. However, they noted that there was limited evidence of improvement in pain symptoms and short-term psychological well-being.
Another systematic review included studies which did not include control groups.1 An additional five quasi-experimental studies were located. This review carried out retrospective power calculations on all the studies reviewed. An acceptable level of power is generally 0.80 or higher, indicating an 80% probability of the correct conclusion. In many of the studies reviewed, the power was in the range 0.1-0.4, indicating inadequate sample sizes. For example, one study enrolled 28 participants, yet to detect a significant difference between the two groups they would have needed 326 participants in each group to achieve a power of 0.80. Another study needed 160 participants, but only recruited 29. This systematic review concluded that "the methodological flaws prevent conclusions about the efficacy of massage in cancer patients."
One study has been conducted with a large number of participants (n = 1,290); however, this study did not have a control group.5 Patients in a large cancer center could refer themselves or be referred by health care professionals for three types of massage: Swedish massage, light touch massage, or foot massage. Before and after massage, patients scored themselves on visual analog scales for six separate symptoms. After adjusting for baseline scores, all symptoms were improved: stress/anxiety, by 52%; fatigue, 41%; pain, 40%; depression, 31%; nausea, 21%; and "other", 47%. The improvements were particularly pronounced for those who had more severe symptoms at baseline. Improvements like these have been found in a small number of similar studies.9 However, the lack of control groups in these studies makes it impossible to attribute causation to the massage or other potential confounding factors.
The results of the largest RCT to date of massage with cancer patients were published recently.10 The trial enrolled 380 patients with advanced cancer at 15 U.S. hospices. Patients received either individualized Swedish massage or a control intervention where the researcher's hands were placed for 3 minutes each on several sites around the body. Touch was light, with no movement of the hands. Pain, mood, and quality of life were measured before intervention, immediately after intervention, and weekly for three weeks. Statistically significant improvements in pain and mood were found after both massage and control intervention, but the changes might not be clinically significant. Massage was statistically superior to control (P < 0.001). The improvements were not sustained as no significant differences were found on any of the measurements made subsequent to those collected immediately post-intervention. Quality of life did not differ significantly between groups.
Massage usually does not elicit adverse effects, but this has rarely been studied. When cancer patients are given massage, some authors recommend avoiding the sites of tumors, bone metastases, medical devices, deep vein thrombosis, and open lesions.1 However, in the recent large RCT with advanced cancer patients, no differences in adverse events or deaths were found between the massage and control groups.10
The evidence available to support the use of massage for the relief of pain and anxiety in cancer patients is weak. Relatively few controlled trials have been conducted, their quality is generally low, and the results are contradictory. However, studies without comparison groups have found that patients report significant benefits immediately after receiving massage. While those benefits are usually not sustained, they can be very important for cancer patients, especially those with advanced cancer. Those with the highest pain and anxiety scores tend to improve the most. While existing studies cannot show if the benefits are due to massage itself, or are a generalized feature of human touch and presence, massage may be of benefit for some cancer patients.
Massage may be a useful means of relieving pain and anxiety in some cancer patients. While the evidence from controlled trials is not strong, the potential for benefit, with little risk of adverse effects, makes massage a suitable complementary therapy for some cancer patients. However, while some patients may be interested in massage, many are not. Researchers in one clinical trial found that many cancer patients refused massage, particularly male patients.9 This may reflect a lack of familiarity with massage, or a concern for privacy, but should be taken into consideration when discussing massage. More research is needed to understand whether certain types or durations of massage may have more benefit than others.
1. Jane SW, et al. Systematic review of massage intervention for adult patients with cancer: A methodological perspective. Cancer Nurs 2008;31:E24-E35.
2. Eisenberg DM, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575.
3. Tindle HA, et al. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005;11:42-49.
4. Wilkinson S, et al. Massage for symptom relief in patients with cancer: Systematic review. J Adv Nurs 2008;63:430-439.
5. Cassileth B, Vickers AJ. Massage therapy for symptom control: Outcome study at a major cancer center. J Pain Symptom Manage 2004;28:244-249.
6. Nicholls DA, Cheek J. Physiotherapy and the shadow of prostitution: The Society of Trained Masseuses and the massage scandals of 1894. Soc Sci Med 2006;62: 2336-2348.
7. Myers CD, et al. Massage modalities and symptoms reported by cancer patients: Narrative review. J Soc Integr Oncol 2008;6:19-28.
8. Cassileth BR. The Alternative Medicine Handbook. New York: W. W. Norton; 1998.
9. Currin J, Meister EA. A hospital-based intervention using massage to reduce distress among oncology patients. Cancer Nurs 2008;31:214-221.
10. Kutner JS, et al. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: A randomized trial. Ann Intern Med 2008; 149:369-379.