We are happy to share with our readers an important review of medical literature which 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 it is much easier to communicate with physicians, nurses, patients and members of patients’ families on clinical benefits of massage therapy for the 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.

Editorial Board



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 to make in regard to treatment of such complex disease as cancer. The first and most essential is to cure cancer or place it into stable remission, the next issue is to eliminate secondary complications of cancer or 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 the pain during the later stages of cancer is the most common symptom. It affects 50-90 % of cancer patients with cancer (Schrijvers, 2007). Despite the fact that some authors (Fallon et al., 2006) think that accurate patient’s assessment and appropriate using of WHO analgesic ladder allows us to control 80% of cancer related pain the clinical reality proved otherwise. The cancer related pain is still one of the critical problems of modern oncology.

All cancer patients are using 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 the traditional treatment in order to improve the 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, the 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 was concluded by L. Cobrin who analyzed modern database of studies examined the impact of massage on the 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 manipulation of soft tissues by hands 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 the cancer patients because it helps control the pain by closing ‘gates’ in the posterior horns of the spinal cord and blocks the further passage of noxious (i.e. pain) stimuli into CNS. MT also has a positive impact on patients’ mood by elevating the dopamine level, therefore decreasing anxiety and stress level (Corbin, 2006).

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

MATERIAL AND METHODS

A literature review was conducted by searching “Science Direct”, “MEDLINE”, and “High Wire” databases in April 2010 through 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 review, and studies which 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 20 articles which met the inclusion criteria were examined.

The articles which examined the effect of MT on pain in general without a direct correlation with cancer or cancer treatment were excluded. Because pain is highly subjective symptom, we examined articles which exhibited significant levels of scientific expertise. This is why we excluded any study with P>0,05. Finally, the review is based on studied conducted in different countries (USA, Spain, South Korea, Taiwan) and it excludes the cultural effects on the obtained data.

Effect of Massage Therapy on Pain, Anxiety and Depression

Using the Nuclear Magnetic Resonance, Sagar et al., (2007) was able to registered dynamic response to biochemical signals. The authors consider MT as an important factor which enhances 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 Jerrilyn et al., (2007) MT can be seen as 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 a 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 the level of pain and anxiety score. The intervention included 15- 30 minutes of teaching session on the basic principles of foot massage for patients’ partners. 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 experimental group p=0.001 (Stephenson et al., 2001).

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

A large experimental pre – post study of 12 900 cancer patients received regular MT conducted over a period of three years showed a 50% decrease of the intensity of pain, anxiety, fatigue, depression, and nausea in these patients. This significant decrease of the symptoms was registered even for patients who initially reported high baseline scores (Cassileth, 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 the positive immediate reduction of pain score with no statistically significant difference between three and 24 hours after intervention.

Other randomized controlled trial (Mehling et al., 2009) examined the effect of MT and acupuncture on138 cancer patients in postoperative period. In a clinical group (93 patients) MT and acupuncture were added to the traditional anti-cancer therapy starting on the first day after the surgery while in control group (45 patients) traditional therapy was used only. The results exhibited decrease of pain intensity by 1.4 points on 0-10 pain scale compared to 0.6 in control group (p=0.038), also in the clinical group authors registered decrease symptoms of depression by 0.4 compared to 0 in the control group (p=0.003).

Kutner et al.,(2008) conducted a randomized clinical study on 380 adult cancer patients with advanced cancer in hospice. The patients in the control group received a simple touch, while the clinical group received 30 minutes of MT over two weeks period. The results indicated that MT exhibited 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 points).

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 to18 hours, and the authors registered pain reduction (p<0.04), and diminution of anxiety level (Sui-Whi et al., 2005).

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. 28 patients were assigned to 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 control group which received regular massage with almond oil. The authors concluded that subjects from clinical group showed significant improvements in pain intensity (t=3.52, p=0.001) and depression (t=-8.99, p=0.000).

Jane, (2005) 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 metastasises. 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 level of pain and anxiety. The most significant impact occurred 15 minutes after the MT intervention. The author concluded that MT can assist health care providers to control 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 a daily dosage of NSAID (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 the 1325 papers which examined the effectiveness of MT for cancer patients with cancer. Based on such extensive analysis, the authors suggested that MT is able to reduces pain and anxiety in the short term.

Currin and Meister, (2008) examined the effectiveness of MT to reduce 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 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 a biochemical effects on CNS function, because it increases the dopamine level, which helps improve mood and decreases anxiety. The authors also pointed out that MT increases the lymphocyte count and stimulates natural killer production which are very important factors in the recovery of cancer patients.

Other Aspects of Massage Therapy

As therapeutic modality MT has its limitations, but frequently patients receive very conflicting information about its health benefits. Some healthcare providers promote MT, while other see it as contraindication (Cambron, et al., 2007). The absence of a unified view contributes greatly to the 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 every day exercise (Kassab & Stevensen, 1996).

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

According to McEachrane-Gross et al., (2006) who conducted a mail survey study of 500 participants, 27.3% 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 repetitive users of MT. The authors examined MT values, which attract repetitive users. The authors identified six valued elements of MT 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 statistically proved a pain reduction effect as well as positive impact on anxiety and depression always associated with various types of cancer. Reviewed studies showed the pain reduction effect of MT is most likely associated with blocking passage of pain stimuli through the gate system in the posterior horns of the spinal cord (Sagar et al., 2007) while mood enhancing and antidepressant effects are the result of increase in dopamine level production in the brain (Corbin, 2006). The antidepressant effect of MT has even more profound impact on the recovery of cancer patient because severe depression is directly linked with suppression of immune system.

In the reviewed literature we found only one conflicting point which is the utilization of MT in cases of bone cancer with metastasises. While Sui-Whi 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 complication 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 the cancer management and treatment.

Traditional medicine relies heavily on the pharmacological aspect of pain management. It is obvious 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 provider should consider all possible scientifically proved tools, including so called non – pharmacological methods of treatment.

This review showed that MT is a safe and effective type of complementary therapy of cancer and also supports the idea of wide integration of MT into the clinical practice of the 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 its combination with other types CAM (e.g. massage with essential oils). Another suggestion is to consider evaluation of the other parameters besides pain, anxiety and depression as a part of the future study of MT effects.

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

REFERENCES

Calenda E. Massage therapy for cancer pain. Current Pain and Headache Reports, 10(4), 270-4, 2006.
Cambron J.A., Dexheimer J., Coe P., Swenson R. Side-Effects of Massage Therapy: A Cross-Sectional Study of 100 Clients. Journal of Complementary and Alternative Medicine, 13(8), 793-796, 2007.
Cassileth B.R., Vickers A.J. Massage therapy for symptoms control: outcomes study at a major cancer center. Journal of Pain and Symptoms Management, 28:244-249, 2004.
Chang S. Y. Effects of aroma hand massage on pain, state anxiety and depression in hospice patients with terminal cancer. Journal of Korean Academy of Nursing, 38(4):493-502, 2008.
Corbin. Safety and Efficacy of Massage Therapy for Patients With Cancer. Journal of Cancer Control, 12(3), 158-164, 2005.
Currin J, Meister EA (2008). A hospital-based intervention using massage to reduce distress among oncology patients. Journal of Cancer Nursing, 31(3): 214-21, 2008.
Ernst E. Massage therapy for cancer population and supportive care. Journal of Supportive Care in Cancer, 17: 333-337, 2009.
Fallon M., Hanks G., Cherny N. Principles of control of cancer pain. BMJ, 332(7548):1022-124, 2006.
Gatlin C.G., Schulmeister L. When medication is not enough: non-pharmacological management of pain. Clinical Journal of Oncology Nursing, 11(5), 699-704, 2007.
Jane S.W. Effects of a full body massage on pain intensity, anxiety and physiological relaxation in Taiwanese Patients with metastatic bone pain. Journal of Pain and Symptom Management, 37(4):754-763, 2005.
Joske DJ, Rao A., Kristjanson L. Critical review of complementary therapies in haemato-oncology. Internal Medicine Journal, 36(9):579-586, 2006.
Kassab H.S., Stevensen R.C. Common misunderstandings about complementary therapies for patients with cancer. Complement Ther. Nurs. Midwifery, 2 (3):62-65 1996.
Kim J-I., Lee M.S., Kang J.W., Choi D.Y., Ernst E. Reflexology for the Symptomatic Treatment of Breast Cancer: A Systematic Review. Journal of integrative cancer therapies, 9 (4) 326-330, 2010.
Kutner, J.S., Smith, M.C., Corbin, L., Hemphill, L., Benton, K., Beaty, B. , Sue Felton, S., Yamashita, T.E., Bryant, L.L., Fairclough, D.L. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer. Ann Internal Med, 149:369-379, 2008.
McEachrane-Gross, F.P., Liebschutz, J.M., Berlowitz. D. Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: across-sectional survey. Complementary and Alternative Medicine, 1472-6882 ,2006.
Mehling, W.E, Jacobs, B., Acree, M., Wilson, L. Bostrom, A., Jeremy West, J., Acquah, B.A.J. Burns, B., Chapman, J., Hecht, F.M. Symptom Management with Massage and Acupuncture in Postoperative Cancer Patients: A Randomized Controlled Trial. Journal of Pain and Symptoms Management, 33(3), 2007.
Post-White J., Kinney M.E., Savik K., Gau J.B. , Lerner I. Therapeutic massage and healing touch improve symptoms of cancer. Integr Cancer Ther, 2(4):332-344, 2003.
Richardson M.A., Sanders T., Palmer J.L. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol, 18:2505-2514, 2000.
Sagar, S.M., Dryden. T., Wong, R.K. Massage therapy for cancer patients: a reciprocal relationship between body and mind. Curr Oncol, 14(2), 45-56, 2007.
Schrijvers D. Pain control in cancer: Recent findings and trends. Ann Oncol, 18(9):37-42, 2007.
Smith J.M., Sullivan. S.J., Baxter G.D. The culture of massage therapy: Valued elements and the role of comfort, contact, connection and caring. Complementary Ther Med, 17:181-189, 2009.
Stephenson, N.L.N, Weinkrich, S.P., Tavakoli, A.S. The Effect of Foot Reflexology on Anxiety and Pain in Patients with Breast and Lung Cancer. Oncology Nursing Forum, 27(1):67-72, 2000.
Stephenson, N., Dalton, J.A., Carlson, J. The effect of foot reflexology on pain in patients with metastatic cancer. Appl. Nurs. Res., 16(4): 284-6, 2003.
Sui Whi J. Effects of a full body massage on pain intensity, anxiety and physiological relaxation in Taiwanese Patients with metastatic bone pain. J. Pain Symptom Manage, 37(4):754-763, 2005.
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Majd Hussein, RN
Majd Hussein is a native Jordanian. In 2009 she graduated from Hashemite University in Azzarqa, Jordan with a Bachelors degree in nursing. Currently she is in the second year of the Masters Degree program in nursing oncology at the same university. While completing her Masters Degree studies Majd currently works as a Senior Pediatric Nurse in Prince Hussein Hospital.
While working on Master Degree, Majd got interested in non-pharmaceutical methods of pain control for cancer patients. She is especially interested in massage therapy, because of its effectiveness, convenience and absence of side effects. Currently Majd lives in Amman, Jordan where she works and finishes her studies. Her major hobby is reading.


Category: Medical Massage

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