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Research: Summer 2006

Those of us who write about massage therapy have become accustomed, when we do literature searches, to finding only a small number of citations on our subjects of interest. Certainly when I began researching massage therapy and cancer topics in the mid-’90s, I felt lucky to find 10 or so useful references. The studies were all tiny, usually done by nurses, and some were questionable, but after eliminating various pieces about topics nominally called massage, I was happy to find there were still some I could work with.

These days things are beginning to change, and it is easier to find citations on many massage therapy related subjects; nonetheless my expectations were quite modest when I returned to U. of T.’s Gerstein Library to start researching the next edition of Massage Therapy & Cancer.

Was I surprised to see the new level of research into massage therapy efficacy in cancer care! It seemed that, beginning in 2000, the number and calibre of studies had just exploded. I was finding hundreds of citations – I actually had to learn how to do proper limited searches. Even with that newfound skill, I am being put to work sorting through a truly interesting, diverse set of findings and ideas. In this article I would like to give you a taste of what the literature says about our role in this expanding area of massage therapy practice.

Attitudes Are Shifting
Reading a body of literature (not just studies, but also case and program reports, analyses, letters to the editor, commentaries), I start to feel that I am listening in on a dialogue among the expert voices in a field of interest. Circling back to the dialogue over time, you notice trends in how the thinking is developing. When I started out, observations about massage therapy for cancer patients were occasional comments from the periphery, rarely heard or responded to. Now, the subject area is a busy chat room with big names and big institutions weighing in.

The context has shifted, perhaps in cancer care especially, because mainstream medicine is acknowledging the huge toll both the disease and medical treatments have on the patient.

An early voice, Dr. M. Bard, wrote in 1970: “The cancer patient is a person under a special and severe form of stress … all too many individuals are technically cured of their disease but left with an incapacitating psychological injury.” 3

Understanding there is a need to focus on the whole person and not just the disease is more evident in current oncological thinking, partly perhaps because of the amount of suffering involved, but also because of the contradiction between  healthy survivorship and relentless discomfort and stress.

There is growing interest in the role massage therapy can play, but the larger context is complementary and alternative medicine (CAM) in general. The cancer world is starting to embrace integrative medicine – CAM modalities are gaining value because of their capacity to support cancer patients in these four generally recognized areas: symptom management, stress and anxiety reduction, pain control, and enhanced feelings of well-being.

It is interesting to observe new streams of discussion in the literature. Hospitals and other medical services are surveying their staffs’ CAM knowledge and sharing ideas about how to provide in-service education. Members of various disciplines, including pharmacy, are talking about the importance of understanding how CAM practices interact with their fields of treatment and how best to advise patients. Nurses are increasingly viewing their role as information conduits between doctors, patients and services in the community, and are dialoguing about the need to foster good referrals, to be able to answer questions, and to relay case information to CAM practitioners in a useful way. Also very engaging are the reports out of major cancer centres in Canada, the U.S. and the U.K. about their new CAM services and how popular they are with their patients.

There is a combination of bragging and astonishment seeping through their restrained language. To give one quick example, at Stanford’s Cancer Supportive Care Program patient utilization numbers jumped from 421 in 1999 to 6319 in 2002.10 They indicate that massage therapy, yoga, and qigong had the most partakers.
It is a pretty consistent element of this type of service that massage therapy is found in the top three modalities of choice. The existence of these centres also means that more CAM practitioners are joining the staffs of major hospitals, especially in the United States. For example, Memorial Sloan Kettering, a world-renowned cancer hospital in New York City, employs 12 full-time massage therapists.

People with cancer utilize CAM therapies more often than the general population does. Numerous sources peg utilization in various parts of Canada, the U.S. and Europe in the 20-50 per cent range. Allowing that urban populations show higher numbers than rural ones, these statistics still represent a huge across-the-board demand. With respect to massage therapy specifically, a 2002 survey of breast cancer patients in Vermont indicated 20 per cent used massage 2, and in 2004 it
was estimated that 20 per cent of U.S. cancer patients seek massage therapy. 6 About 70 per cent of U.K. hospices offer inpatient massage. 6

Selecting The Studies
In choosing a group of nine studies to present, I considered these criteria:

Are they superior quality? 
Most of us have already heard that the gold standard of research is the randomized controlled trial or RCT. The high value placed on this type of study comes from the presence of a control group (a comparison group that does not receive the intervention), and from the randomized placement of study participants into intervention and control groups so that the subjects and personnel interacting with them do not know who is receiving what. RCTs are actually the gold standard of quantitative research, meaning studies in which the findings are recorded and analyzed as numerical data (statistics).

There are more RCTs in massage therapy research these days, but the researchers have to find creative ways to design the control group experience – people tend to know if they are being massaged or not!  Seven of our nine studies are quantitative and most are RCTs.

The other division of research, called qualitative research, investigates experience, for example what the experience of receiving massage therapy is like for women who have had mastectomies. 5 Qualitative studies typically involve in-depth interviews with a small group of similar subjects, often over a period of time, to discern the complexities and the trends in what it means to be in their situation.

Qualitative research plays an important role in health care because it shows what it is like to be a patient and to experience various types of illness and/or treatment.

It has been very valuable in promoting investigation into and acceptance of CAM disciplines like massage therapy. We will look at two qualitative studies that illuminate what massage can mean to people who are very ill with cancer.

I am not expert in analyzing research, so I also focused on whether the studies were positively remarked on by colleagues, or frequently referenced in high quality reviews or analyses by other experts.

Do they reflect massage therapy practice? 
A downside of research about massage therapy has been studies that purport to investigate massage but have no massage therapist input in their designs and do not use qualified practitioners. While it is still true that massage therapists are not in the forefront of conducting studies – as a profession we do not yet have the money, training or connectedness to be major players – the best researchers realize that profession-specific expertise and involvement are essential to evaluate ‘real life’ massage therapy. In our group of studies all had credible massage intervention protocols, three used credentialed massage practitioners, and three others had cross-trained nurse/MTs.

The other important question is whether the studies are useful to practitioners. Given the origins of most of the research, my selected group is skewed to medical settings – of the nine, four are conducted in hospitals and one in a hospice – but I believe you will appreciate their relevance for massage therapists working both in and outside these settings. You may want to locate them and peruse their findings in more depth.

Reaching new levels

Study #1: Massage therapy for symptom control: outcome study at a major cancer center 6
This is one of the new breed of larger, highly credible studies. It is a retrospective analysis of 1290 massage treatments given to Memorial Sloan-Kettering Cancer Center (MSKCC) patients over a three year period. The treatments were provided by their twelve staff massage therapists.  There were three treatment options based on the patient’s need: Swedish, ‘light’ or foot massage. Sessions were 20 minutes for inpatients and 60 minutes in their outpatient spa-like facility.

Recipients scored their pre-treatment and post-treatment symptoms on a 0-10 scale in the following categories: pain, fatigue, anxiety, nausea, depression and ‘other.’ Overall, symptom scores were reduced by about 50%, even in patients with high baselines.  More specifically, after one treatment results ranged from 52% improvement in anxiety (highest) to 21% in nausea (lowest). When the data was viewed for baseline scores rated moderate or above before treatment, improvements ranged from 60% for anxiety to 43% for fatigue. Repeat treatment (treatments 2 through 5) for the same patients produced consistent scores and also “suggest that the effects of massage therapy increase for each additional treatment.” They noted that outcomes were sustained longer in outpatients and assumed this was probably because of the shorter treatments and the greater number of inpatient medical procedures and other stressors. Foot massage was the least effective of the three options. The report authors, who are MSKCC researchers, enthused about the tremendous efficacy of the hospital’s massage therapy program: “Major, clinically relevant, immediate improvements in symptom scores were reported following massage therapy.”  “Massage therapy appears to be an uncommonly non-invasive and inexpensive means of symptom control … implementation of a high volume massage therapy service is feasible at a major cancer centre.”

Study #2: Aromatherapy and massage for symptom relief in patients with cancer 7
This is another example of massage therapy’s new level of credibility. It is one of the Cochrane Collaboration’s highly regarded meta-analyses (Cochrane Database of Systematic Reviews). In a study like this, the investigators review a large collection of available studies on a specific subject, pick those that meet their exacting criteria, and merge the results to see what this increased data pool reveals. In this review, of 1322 identified references 10 met their criteria of RCT/controlled before and after series/interrupted time series studies.

In scrutinizing their selected studies, they found that the most consistent effect of treatment was anxiety reduction, followed by beneficial effects on depression, nausea and pain. Interestingly, they could not determine whether there were significant additional outcomes added by the aromatherapy component.

Some interesting clinical trials and pilot studies

Study #3: Therapeutic massage and healing touch improve symptoms in cancer 9
In this study of outpatients in chemotherapy protocols, therapeutic massage (MT), healing touch (HT), and time interacting with a caring nurse (presence) were compared to each other and to standard medical care alone. There were a total of 230 subjects who each received four weekly 45-minute sessions of one of the interventions plus four weeks of no intervention (standard care). The 68-subject MT group received full body Swedish treatments. The researchers found that MT and HT were more effective than presence in inducing relaxation and improving mood (only MT lowered anxiety), demonstrating that therapeutic touch adds something beyond the effects of contact with a caring professional. MT and HT provided pain relief, but only MT reduced morphine doses and NSAID use. HT was more
effective in reducing fatigue.

Nausea scores showed some improvement with both, but like at MSKCC, this group of subjects appeared to have good medication control so the nausea-reducing effects of MT were not as apparent as in older studies. MT achieved the best results in lowering blood pressure and heart and respiration rates. While this is a study that observed autonomic indicators quite closely, it is noteworthy that most similar studies report significant shifts in vital signs with massage therapy. It would be interesting to see a depth analysis of how reducing sympathetic activation and increasing time spent in parasympathetic might influence not just symptom control but also healing and cancer survival.

Study #4: Outcomes of therapeutic massage for hospitalized cancer patients 11
This is another study that used pre-massage and post-massage symptom ratings. I was really interested in their stated purpose, to “examine the effects of therapeutic massage on perception of pain, subjective sleep quality, symptom distress and anxiety” in their subjects, who were hospitalized for about a week to have chemotherapy/radiation.

Of the 41 participants, 20 received three 15 to 30-minute treatments of light Swedish massage (effleurage and petrissage) and 21 had 20 minutes of “focused nurse interaction” (NI).

Pain perception, symptom distress and anxiety were found to improve significantly in the MT group and only anxiety improved (slightly) in the NI group; sleep quality was unchanged in the MT group but dropped significantly in the NI group; NI group scores worsened for pain and symptom distress.

This study represents an interesting new trend in understanding massage therapy efficacy – while many studies point to evidence of symptom reduction, studies like this one are showing that massage may be particularly powerful at offsetting symptom distress, in other words, in helping people separate their discomforts from related feelings of upset, fear, or inability to cope.

This is also one of the newer studies focusing on sleep, perhaps a bigger pre-occupation in hospitals where sleep disturbances are common. Quality sleep is such an important background factor in physical and mental resilience that if massage therapy can consistently promote better sleep it is an efficacy that deserves more of our focus.

Study #5:  Massage therapy for patients undergoing autologous bone marrow transplantation 1
This is an RCT of massage versus no massage for patients undergoing bone marrow transplants, an experience at the zenith of treatment-induced illness. There were 34 participants, 16 in the MT group and 18 in the control group (who had quiet time in their rooms). This highly regarded study, despite being a few years older and having a less well explained massage protocol, pioneered examining massage therapy for treating very ill cancer patients, something oncologists were often reluctant to consider. The researchers found that the massaged group immediately had significantly better scores versus control on symptom distress, nausea and anxiety, and by final assessment, fatigue also showed significant improvement compared to the control group. More studies using massage with the very frail or ill are starting to emerge, a benefit since sometimes more medication is not possible or inconsistent with quality of life, and massage may prove to be a most useful treatment modality in such cases.

Study #6:  Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain 13
This pilot study examines massage in the hospice setting, comparing massage therapy to regular hospice care alone. The subject group consisted of 29 terminally ill patients –15 in the massage group and 14 in the control group – none of whom had had prior massage at the hospice. The treatment group each received four 30-50 minute Swedish massage treatments with a protocol that allowed some judgment flexibility by the therapist.  Physical relaxation response indicators, pain intensity, and emotional distress all showed good improvement, with control group beneficial responses consistently rated lower. The authors predicted that a sample size of 80 would produce massage significance on pain intensity, reducing/stabilizing analgesic dosages and quality of life.

Study #7:  Breast cancer patients have improved immune and neuroendocrine functions following massage therapy 8
This is an RCT from the Touch Research Institute that examined psychoemotional factors in women with Stage 1/2 breast cancer diagnoses. They compared the results of receiving 15 massages over 5 weeks in a non-hospital setting to standard medical care alone. There were 34 participants –18 in the massage group and 16 in control group. A specific 30-minute treatment protocol was used. Immediate MT effects included reduced anxiety, depression and anger and results over the protocol included reduced stress, depression and hostility. The control group experienced increased anger and depression over the same period. The researchers examined biochemical data (provided by 27 of the 34 subjects) and reported that MT effects included increased urinary serotonin and dopamine values (improved mood effects) while the control group had increased norepinephrine (stress effects). An interesting element of this study is that they also looked at immune cell values, reporting increased numbers of natural killer (NK) cells and lymphocytes in the MT group. This is a small sample and experts have commented that the observed increase may not be clinically significant; hopefully larger more definitive studies may clarify the answer.

my two favourite qualitative studies

Study #8:  A meaningful relief from suffering: experiences of massage in cancer care 4
This Swedish study started with an analysis of what cancer-
related suffering is, concluding that it is encompassed by these words: uncertainty, vulnerability, isolation, discomfort and re-definition. To explore how massage therapy might influence this suffering, they gave daily massage treatments to eight fairly ill hospitalized female cancer patients for 10 days. The protocol consisted of 20 minutes of light massage, primarily stroking to arms and hands or legs and feet, that was done by “health care workers.” Subjects described the following experiences of these treatments in response to open-ended questioning, leading the researchers to define the results as “meaningful relief”:

• massage provided a feeling of being ‘special’, helping to counteract isolation and anonymity in the hospital setting
• a positive relationship was developed with the practitioner
• providing massage; most interestingly, this was extended to the other hospital personnel, helping neutralize a sense that the hospital staff were too busy to care
• experiences of feeling stronger, of having increased possibilities in their bodies, that perhaps their bodies were not betraying them, and of interest in using self massage
• an increased sense of autonomy and choice
• that massage “feels good”, “natural”, “normal”, “comfortable”

Study #9:  Massaged embodiment of cancer patients 12
I was so fascinated to learn of the existence of this work that I went to some trouble and expense to get a copy. It is part of the doctoral thesis of an Australian nurse/massage therapist who undertook to study “a way of seeing and understanding cancer patients’ complex experience of embodiment.”  In this section of her work, she evaluates how massage can influence the sense of embodiment (or disembodiment) of the person with cancer. The subject group consisted of 18 cancer patients, many of whom were dying, and all of whom had “experienced a great deal of pain and suffering.” They received 1-8 massages and related their feelings about and during the sessions. In the summarized data, massage therapy was found to: free minds of worries and negative thoughts; produce feelings of relaxation, comfort, peace, calmness and being better able to cope; create more energy and a better quality of sleep; reduce pain and edema; open up feelings and reduce disconnection; and promote more acceptance of the new body. The author’s report incorporates many direct quotes from the participants, including this one,

“You feel that the cancer was a violation, the surgery was a violation, the chemo, the tests, the radiotherapy … they’re all just attacking your body. Then you have to go home and live with the side effects and the repercussions of all that. So you detach yourself and try to cope with it, maybe I just keep thinking this isn’t the body I had before and where has it gone and why? Later, reflecting on her massage experience: Very relaxed. I feel like you have done something good for your body, just a sense that your body belongs to you a bit if you know what I mean. I have been totally disconnected. It’s not the body I had before… It’s a strange thing I suppose, it is connecting with it again. You are owning it again or something. The first massage, I walked out of here and I felt I had a spring in my step and I thought, this is me again.” How moving is that? And how profound is it as a component of survivorship, or of peaceful death? As yet we can only guess at the answer, but it is an important inquiry. If massage helps people struggling with cancer to reconnect with their sense of core self, what contribution does this make to their quest for health?

The Dialogue Continues
As the dialogue in the literature proceeds, needless to say it is not all good – there are still mixed feelings about massage therapy and the other CAM modalities. Opinions on lymph drainage are still confusing to interpret, and there is as yet very little investigation of massage therapy’s role in key areas like scar treatment and rehabilitation work. Nonetheless, acknowledgement and appreciation of massage therapy’s efficacies are moving forward quite quickly in the cancer care world. As well, identified names in our profession are starting to show up on search citations.

Massage therapy is coming to be seen as offering an integrated emotional and physical support to cancer patients that is clearly very potent in creating beneficial changes. These benefits can help sustain them through their journey of illness and treatment and may in time be demonstrated to play a meaningful role in helping them survive.

references
1. Ahles TA, Tope DM, Pinkson B. (1999). Massage therapy for patients undergoing autologous bone marrow transplantation. Journal of Pain and Symptom Management 18(3):157-63
2. Ashikaga T, et al. (2002). Use of complementary and alternative medicine by breast cancer patients: prevalence, patterns and communication with physicians. Supportive Care in Cancer 10(7):542-8
3. Bard M (1970). Where Medicine Fails, quoted by Krant, M, Psychological aspects of cancer diagnosis, Klastersky J & Staguet M, eds: Medical Complications in Cancer Patients. New York, Raven Press 1981
4. Billhult A, Dahlberg K.  (2001). A meaningful relief from suffering: experiences of massage in cancer care. Cancer Nursing 24(3):180-4
5. Bredin M (1999). Mastectomy, body image and therapeutic massage: a qualitative study of women’s experience. Journal of Advanced Nursing 29(5):1113-20
6. Cassileth B, Vickers A (2004).  Massage therapy for symptom control: outcome study at a major cancer center. Journal of Pain and Symptom Management 28(3):244-49
7. Fellowes D, Barnes K, Wilkinson S. (2004). Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database of Systematic Reviews, Cochrane Collaboration
8. Hernandez-Reif H, Ironson B, Field T, Hurley J, Katz G, Diego M, Weiss S, Fletcher MA, Schanberg S, Kuhn C, Burman I. (2004). Breast cancer patients have improved immune and neuroscience functions following massage therapy. Journal of Psychosomatic Research 57:45-52
9. Post-White J, Kinney ME, Savik K, Gau JB, Wilcox C, Lerner I.  (2003). Therapeutic massage and healing touch improve symptoms in cancer. Integrative Cancer Therapies 2(4):332-44
10. Rosenbaum E, Gautier H, Fobair P, Neri E, Festa B, Hawn M, Andrews A, Hirshberger N, Selim S, Spiegel D (2004). Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report. Supportive Care in Cancer, 12(5):293-301
11. Smith MC, Kemp J et al. (2002). Outcomes of therapeutic massage for hospitalized cancer patients. Journal of Nursing Scholarship 34(3):257-62
12. Van der Riet P. (1999). Massaged embodiment of cancer patients. Australian Journal of Holistic Nursing 6(1):4-13
13. Wilkie DJ, Kampbell J, Cutshall S, Halabisky H, Harmon H, Johnson LP, Weinacht L, Rake-Marona M. (2000). Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain. Hospice Journal 15(3) 2000