MASSAGE THERAPY FOR CANCER PATIENTS

We are happy to share with our readers an important review of medical literature that analyzes scientific data on the impact of massage therapy on the level of pain, depression and anxiety in cancer patients.

We would like to suggest to our readers the best way of using the information presented in this article. If you work with cancer patients or are considering extending your practice in this direction, you should use the information in this article as an important reference source. By using scientific data, you will find it much easier to communicate with physicians, nurses, patients and members of patients’ families about the clinical benefits of massage therapy for cancer patients. By using the information from this and similar sources, you may compose your own short brochure and present it to your target audience.

By Editorial Board of JMS

MASSAGE THERAPY FOR CANCER PATIENTS

LITERATURE REVIEW

By Majd Hussein, RN
Jordan

INTRODUCTION

Cancer patients and their health providers face many important issues and decisions regarding the treatment of such a complex disease as cancer. The first and most essential is to cure the cancer or place it into stable remission; the next is to eliminate secondary complications of the cancer or of the applied treatment (e.g., peripheral edema after chemotherapy).

Many patients are asymptomatic at the early stages of cancer. If cancer isn’t detected accidentally, pain during the later stages of cancer is the most common symptom. It affects 50-90% of cancer patients (Schrijvers, 2007). Despite the fact that some authors (Fallon et al., 2006) think that accurate patient’s assessment and appropriate use of the WHO analgesic ladder allow us to control 80% of cancer-related pain, clinical reality has proved otherwise. Cancer-related pain is still one of the critical problems of modern oncology.

All cancer patients use conventional medical treatment offered by modern oncology to fight cancer. At the same time, more and more patients are using complementary and alternative medicine (CAM) alone or in combination with traditional treatment in order to improve their quality of life and relieve secondary symptoms. Massage therapy (MT) is one form of CAM, and it is widely used by cancer patients.

Very frequently, patients receive conflicting information about MT from the medical community. While some health care providers promote MT, others consider MT to be contraindicated (Corbin, 2005). Despite the absence of a unified view on the clinical benefits of MT, it was reported that 26% of American cancer patients received regular MT at cancer centers (Richardson et al., 2000).

As concluded by L. Corbin, who analyzed a modern database of studies examining the impact of massage on cancer patients:

“The oncologist should feel comfortable discussing massage therapy with patients and be able to refer patients to a qualified massage therapist as appropriate.”

Generally speaking, massage is defined as the manipulation of soft tissues by hand to generate positive effects on the function of various systems of the body (Ernst et al., 2006). According to Sagar et al. (2007), MT has been beneficial to cancer patients because it helps control pain by closing ‘gates’ in the posterior horns of the spinal cord and blocking the further passage of noxious (i.e., pain) stimuli into the CNS. MT also has a positive impact on patients’ mood by elevating the dopamine level, therefore decreasing anxiety and stress level (Corbin, 2005).

The goal of this review is to provide scientifically based information to physicians, nurses, health care management, massage practitioners, etc., about the effectiveness and safety of MT as part of an integrative approach to the treatment of such a debilitating pathology as cancer.

MATERIAL AND METHODS

A literature review was conducted by searching the “Science Direct”, “MEDLINE”, and “High Wire” databases in April 2010 using the key words “Massage Therapy”, “Therapeutic Massage”, “Cancer”, “Oncology”, “Reflexology”, “Pain”, and “Nursing”. The search was limited to the English language, human subjects, adults, research-based articles, integrative literature reviews, and studies that were conducted between 2000 and 2010. We examined only recently published studies in order to present comprehensive information. However, some earlier publications were examined as well if their findings were important to the discussed subject. Overall, 50 articles were found, but only the 20 articles that met the inclusion criteria were examined.

Articles that examined the effect of MT on pain in general without a direct correlation with cancer or cancer treatment were excluded. Because pain is a highly subjective symptom, we examined articles that exhibited significant levels of scientific expertise. This is why we excluded any study with P>0.05. Finally, the review is based on studies conducted in different countries (USA, Spain, South Korea, Taiwan), which excludes cultural effects on the obtained data.

Effect of Massage Therapy on Pain, Anxiety and Depression

Using Nuclear Magnetic Resonance, Sagar et al. (2007) were able to register dynamic responses to biochemical signals. The authors consider MT an important factor that enhances the reciprocal relationship between the body and mind. It has been reported that MT can help cancer patients with a wide range of symptoms, including pain, anxiety, depression, anger, stress, and fatigue (Ernst, 2009). Based on an experimental and cross-sectional analysis of 100 cancer patients, Cambron et al. (2007) concluded that MT can be seen as a safe, non-invasive intervention without major side effects.

A quasi-experimental, pre-post crossover study examined the effectiveness of Reflexology on the level of pain and anxiety in 23 subjects with lung or breast cancer. Each patient received 30 minutes of Reflexology. All subjects reported a reduction in anxiety and pain score with p>0.005 (Stephenson et al., 2000).

Another pre-post study was conducted on two groups of patients (42 subjects and 44 subjects) with various forms of metastatic cancer. The study protocol was designed to examine the effectiveness of foot MT conducted by the patient’s partner on pain and anxiety scores. The intervention included a 15- to 30-minute teaching session on the basic principles of foot massage for patients’ partners. The clinical group received 30 minutes of foot massage, while the control group received 30 minutes of reading from partners. The results indicated an immediate reduction of pain and anxiety in the experimental group (p=0.001) (Stephenson et al., 2001).

Kim et al. (2010) reviewed one randomized controlled trial and three non-randomized controlled trials that examined the effect of Reflexology on the pain level as well as other uncomfortable symptoms like nausea and vomiting associated with chemotherapy. The authors of all reviewed studies concluded that Reflexology has a positive clinical effect of reducing the level of pain, nausea and vomiting. However, the authors of the reviewed studies also concluded that further research is needed because of potential flaws in the study design.

A large experimental pre-post study of 1,290 cancer patients who received regular MT over a period of three years showed a 50% decrease in the intensity of pain, anxiety, fatigue, depression, and nausea in these patients. This significant decrease in symptoms was registered even for patients who initially reported high baseline scores (Cassileth and Vickers, 2004).

Stephenson et al. (2003) reported the results of a pilot study conducted on 36 patients with metastatic cancer who received Reflexology. The obtained data indicated a positive immediate reduction in pain scores, with no statistically significant difference between three and 24 hours after the intervention.

Another randomized controlled trial (Mehling et al., 2007) examined the effect of MT and acupuncture on 138 cancer patients in the postoperative period. In the clinical group (93 patients), MT and acupuncture were added to traditional anti-cancer therapy starting on the first day after surgery, while in the control group (45 patients), only traditional therapy was used. The results showed a decrease in pain intensity of 1.4 points on a 0-10 pain scale, compared to 0.6 in the control group (p=0.038); in the clinical group, the authors also registered a decrease in symptoms of depression of 0.4, compared to 0 in the control group (p=0.003).

Kutner et al. (2008) conducted a randomized clinical study on 380 adult patients with advanced cancer in hospice. The patients in the control group received simple touch, while the clinical group received 30 minutes of MT over a two-week period. The results indicated that MT had an immediate effect on pain reduction (massage, -1.87 points vs control, – 0.97 point) and mood enhancement (massage, -1.58 points vs control, -0.97 point).

A Taiwanese pre- and post-test study examined the effectiveness of MT on pain and anxiety of 30 patients with metastatic bone cancer. MT was applied every 16 to 18 hours, and the authors registered pain reduction (p<0.04) and a decrease in anxiety level (Jane et al., 2009).

Some studies examined the effect of special types of bodywork on the pain intensity associated with cancer. A Korean study (Chang, 2008) investigated the effectiveness of Aroma massage on pain, anxiety and depression among 58 patients with terminal cancer. Twenty-eight patients were assigned to the clinical group, which received the Aroma massage (a blend of Bergamot, Lavender, and Frankincense oils in the ratio of 1:1:1), while 30 patients were assigned to the control group, which received regular massage with almond oil. The authors concluded that subjects from the clinical group showed significant improvements in pain intensity (t=3.52, p=0.001) and depression (t=-8.99, p=0.000).

Jane et al. (2009) examined the effects of MT on pain intensity, anxiety, and physiological relaxation over a 16- to 18-hour period in 30 cancer patients with bone metastases. MT was shown to have immediate [t(29)=16.5, p=0.000; t(29)=8.9, p=0.000], short-term (20-30 minutes) [t(29)=9.3, p=0.000; t(29)=10.1, p=0.000], intermediate (1-2.5 hours) [t(29)=7.9, p=0.000; t(29)=8.9, p=0.000], and long-term benefits (16-18 hours) [t(29)=4.0, p=0.000; t(29)=5.7, p=0.000] on the level of pain and anxiety. The most significant impact occurred 15 minutes after the MT intervention. The authors concluded that MT can assist health care providers in controlling pain and anxiety as an additional tool along with pharmacological treatment.

Post-White et al. (2003) conducted a clinical study on 230 subjects experiencing pain triggered by cancer. For four weeks, the authors registered the daily dosage of NSAIDs (pain and anti-inflammatory medication) consumed by the cancer patients while they received regular massage treatments. The study showed a significant decrease in the daily usage of medication while MT was performed. The authors also registered lowered blood pressure, respiratory rate, and heart rate.

Wilkinson et al. (2008) published a systematic review of 1325 papers that examined the effectiveness of MT for patients with cancer. Based on this extensive analysis, the authors suggested that MT is able to reduce pain and anxiety in the short term.

Currin and Meister (2008) examined the effectiveness of MT in reducing distress among cancer patients. The authors described distress as a combination of four main factors: pain, physical discomfort, emotional discomfort, and fatigue. A total of 251 patients were allocated to a non-randomized single pre-post study over a three-year period. The analysis of the data showed a statistically significant reduction in patient-reported distress for all four measures: pain (F = 638.208, p = .000), physical discomfort (F = 742.575, p = .000), emotional discomfort (F = 512.000, p = .000), and fatigue (F = 597.976, p = .000). This reduction in patient distress was observed regardless of gender, age, ethnicity, or cancer type.

Corbin (2005) and Calenda (2006) considered that MT has biochemical effects on CNS function because it increases the dopamine level, which helps improve mood and decrease anxiety. The authors also pointed out that MT increases the lymphocyte count and stimulates natural killer cell production, which are very important factors in the recovery of cancer patients.

Other Aspects of Massage Therapy

As a therapeutic modality, MT has its limitations, but frequently patients receive very conflicting information about its health benefits. Some healthcare providers promote MT, while others see it as contraindicated (Cambron et al., 2007). The absence of a unified view contributes greatly to misunderstanding among patients and within the medical community, as well as between patients and healthcare providers.

The most common myth about MT is that it helps cancer spread (Joske et al., 2006). Some authors think that stimulation of the circulation and lymphatic system by MT is similar to everyday exercise (Kassab and Stevensen, 1996).

Ernst et al. (2006) enumerate the following contraindications for MT in cases of cancer: severe osteoporosis, bone fractures, burns, vein thrombosis, open wounds and skin infection. Also, MT is contraindicated if patients have bone metastases. Deep tissue massage should be avoided in cases of abnormalities of the coagulation system (Corbin, 2005).

According to McEachrane-Gross et al. (2006), who conducted a mail survey study of 500 participants, 27.3% of cancer patients reported using various forms of CAM, including MT. Average CAM users are more educated (P=0.02), have higher income (p=0.006), and they are not veterans (p=0.003).

Smith et al. (2009) conducted a study based on a telephone survey of 19 repeat users of MT. The authors examined the values of MT that attract repeat users. The authors identified six elements of MT that the patients valued the most: time for care and personal attention, engaging and competent therapists, trust partnership, holism and empowerment, effective touch, and enhancing relaxation.

DISCUSSION

As reported by Richardson et al. (2000), 26% of American cancer patients use MT as a treatment option. Analysis of the literature used in this review clearly showed that MT has a statistically proven pain reduction effect as well as a positive impact on the anxiety and depression always associated with various types of cancer. The reviewed studies showed that the pain reduction effect of MT is most likely associated with blocking the passage of pain stimuli through the gate system in the posterior horns of the spinal cord (Sagar et al., 2007), while the mood-enhancing and antidepressant effects are the result of increased dopamine production in the brain (Corbin, 2005). The antidepressant effect of MT has an even more profound impact on the recovery of cancer patients because severe depression is directly linked with suppression of the immune system.

In the reviewed literature, we found only one conflicting point, which is the utilization of MT in cases of bone cancer with metastases. While Jane et al. (2009) concluded that pain and anxiety are significantly decreased among patients with metastatic bone cancer after MT, Corbin (2005) sees metastatic cancer as a contraindication for MT.

CONCLUSION AND RECOMMENDATIONS

Treatment of cancer and its complications is a very difficult task. This is why any statistically confirmed method or technique must be used for the patients’ health benefits. In cases of terminal cancer, maintaining the quality of life to the very end is an equally important task. This is why MT should be included in the integrative approach to cancer management and treatment.

Traditional medicine relies heavily on the pharmacological aspect of pain management. It is obvious that this one-sided approach is insufficient. Also, there are ethical, social and religious issues associated with pharmacological methods used to control pain associated with cancer. Thus, the complex nature of cancer requires an integrative approach to its management and healthcare providers should consider all possible scientifically proven tools, including so-called non-pharmacological methods of treatment.

This review showed that MT is a safe and effective type of complementary therapy for cancer and also supports the idea of wide integration of MT into the clinical practice of oncology hospitals and centers.

Future researchers who consider further evaluation of MT effects on cancer patients should concentrate on the examination of the clinical value of various types of massage techniques and methods as well as their combination with other types of CAM (e.g., massage with essential oils). Another suggestion is to consider evaluating other parameters besides pain, anxiety and depression as a part of the future study of MT effects.

An equally important task is educating physicians and nurses about the clinical effectiveness of MT in reducing pain, anxiety and depression. MT must be considered as part of the curriculum in medical and nursing schools as well as continuing education courses. The media also must highlight the effectiveness of MT for cancer patients.

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Category: Medical Massage

Tags: JMS 2011 Issue #2