Cancer and Massage: What Does the Research Say?
Tracy Walton
AMTA National Convention,
Saturday, September 25, 2010
Topic / PageQuestions / 2
Common Mistakes in Using Massage Research / 2
Foundations of Clinical Research / 3
What Do Research Reviews Tell Us? / 9
Another Relevant Review / 11
Highlights and Comparisons of Individual Studies / 12
Other Studies on Cancer and Massage / 19
Related Studies / 20
So…What Do We Say? / 23
Studies on Massage for Caregivers / 23
How to Find Research / 26
References / 27
Contact Information / 30
Description
Research and interest in massage therapy is growing, and there is special interest in the role of massage in cancer care. In this lively seminar, we will take a look at the best evidence supporting massage therapy for people with cancer. In a clear, easy-to-understand format we will review and evaluate current research.
Questions
Who could benefit?
How could they benefit from massage?
How do we know that massage could help?
What are the qualities of massage therapy and massage therapists that are helpful?
What do we know about massage therapy and cancer from our clinical observations, from our own experiences? In our hearts?
How do we evaluate and use the research on massage and cancer?
Common Mistakes in Using Massage Research
1. Making statements about massage that are based on mechanistic theories about massage, clinical observations, speculation, wishful thinking, or what we learned in school, rather than conclusive research data.
Example: “Massage increases circulation”
Reality: Only a few studies on massage and circulation exist, all are small, and the results are mixed, not conclusive. Older studies from the early days of Swedish massage suggest massage might increase blood and lymph circulation, but back then the measurements were unsophisticated. In more recent studies, information is inconclusive.
Example: “Massage releases endorphins”
Reality: I know of only two studies on massage and endorphins, from the late 80’s. One, using Swedish techniques (Kaada and Torsteinbo), found no change in endorphin levels. Another small study, using a form of connective tissue massage (CTM) (Day et al.), suggested some change in endorphin levels.
Example: “Massage boosts immunity”
Reality: Only a handful of small studies report this claim, and there is no body of conclusive evidence that supports the view that massage enhances immune function.
Overall, we sometimes confuse the types of outcomes we are seeing: clinical, mechanistic, and others
2. Overstating Results of Small or Poorly Designed Studies
Pilot studies, with 10 or 30 subjects, studies without control groups, studies that don’t control/manage bias, etc.
3. Drawing Conclusions from a Single Study vs. a Body of Research
The first or only research study on a topic does not typically qualify as definitive, nor does a set of studies from a single source or
lab. For conclusive data, a body of research includes studies by varying groups, similar enough to be compared (apples and
apples), different enough to provide some diversity in perspectives and approaches.
Foundations of Clinical Research
Levels of Evidence. The ranking of evidence available to answer a question. In general, the strongest level of evidence is a systematic review of the body of research on a topic, and the weakest level of evidence is a single anecdote. An anecdote is a single clinical story or patient experience. A case report is a formal, structured write-up of a single clinical story. A case series is a formal write-up of a collection of clinical stories. Other levels of evidence are defined below.
(From Walton, T., “Massage Research in Massage Practice (Chapter 6),” Medical Conditions and Massage Therapy, Philadelphia: Lippincott Williams & Wilkins, 2011.)
The Research Review. A review of the research literature on a given topic.
Narrative Review. A compilation and summary of research literature on a topic, describing the body
of research in narrative form, without quantitative analysis of the study outcomes.
Systematic Review/Meta-Analysis. A review of research that includes methodical search appropriate studies, explicit search criteria, and quantitative methods to determine the effectiveness of a therapy. Statistical (“meta-analytical”) methods used to evaluate a body of research literature on a topic, in order to determine whether a treatment convincingly produces an outcome.
The Randomized, Controlled Clinical Trial (RCT or RCCT)
A planned clinical trial that tests a therapeutic intervention by including a control group or control condition, then randomizing study subjects to either group. The therapeutic intervention is also called the active treatment.
The RCT is: Prospective, not Retrospective. It looks forward, not back.
The RCT includes: a control group or control condition. A control condition is a research condition, such as usual medical care, experienced by members of a control group, to provide a comparison to the active treatment being tested.
A control group is a group of people in a research study who do not receive the experimental or active treatment being tested; they undergo the same measurements from researchers to provide a comparison for the effects of the active treatment.
The RCT includes: randomization. In clinical research, the random assignment of study subjects to different “arms” of a study (active treatment, control, or other comparison groups). The randomization is typically done by a computer generated “flip of a coin.”
The RCT can take several forms, including a parallel design, crossover design, and a wait-list control.
RCT: Parallel Design.
(From Walton, T., “Massage Research in Massage Practice (Chapter 6),” Medical Conditions and Massage Therapy, Philadelphia: Lippincott Williams & Wilkins, 2011.)
RCT: Crossover Design.
(From Walton, T., “Massage Research in Massage Practice (Chapter 6),” Medical Conditions and Massage Therapy, Philadelphia: Lippincott Williams & Wilkins, 2011.)
RCT: Wait-List Control.
(From Walton, T., “Massage Research in Massage Practice (Chapter 6),” Medical Conditions and Massage Therapy, Philadelphia: Lippincott Williams & Wilkins, 2011.)
Sample Size. The number of research subjects enrolled in a study.
Confounding. Any influence on a research study that obscures the true relationship between an intervention and an outcome. Confounding variables accentuate or reduce the apparent size of a treatment effect.
Bias. Any type of influence in a research study that leads to error, favoring one research outcome over another.
Placebo effect. A positive response to a “sham” treatment or inactive substance, possibly reflecting a research subject’s beliefs or expectations of benefit from the intervention. A “sham control” procedure is designed to isolate the placebo effect.
Attention control. A control procedure that is designed to isolate the effects of simply giving someone attention. Sometimes a friendly visit, or simply the presence of someone, or conversation, can bring about a therapeutic effect.
What do Research Reviews Tell Us?
/ Ernst E., 2009 / Jane SW et al., 2008 / Myers C et al., 2008 / Corbin L., 2005 /Type of Review / Quantitative / Quantitative / Narrative / Narrative
# Studies Reviewed / 14 RCTs identified in 6 databases up through November 2008 / 15 studies identified in 6 databases in time period 1986-2006 / 22 studies identified in 2 databases up through April 2007 / Unspecified number of studies identified primarily in 2 databases up through January 3, 2005.
Findings / “Collectively, they suggest that massage can alleviate a wide range of symptoms: pain, nausea, anxiety, depression, anger, stress and fatigue. However, the methodological quality of the included studies was poor, a fact that prevents definitive conclusions. CONCLUSION: The evidence is, therefore, encouraging but not compelling. The subject seems to warrant further investigations which avoid the limitations of previous studies.” / “Methodological issues that potentially account for discrepancies across studies included less rigorous inclusion criteria, failure to consider potential confounding variables, less than rigorous research designs, inconsistent massage doses and protocols, measurement errors related to sensitivity of instruments and timing of measurements, and inadequate statistical power.”
Future studies should use equal massage doses, standard protocols, look at massage effects over time, large sample sizes, etc. / “Collectively, the available data support the view that massage, modified appropriately, offers potential beneficial effects for cancer patients in terms of reducing anxiety and pain and other symptoms. Replication of preliminary studies with larger, more homogeneous patient samples and rigorous study designs will help to clarify which massage modalities have the most potential benefit for which patients before, during, and after specific types of cancer treatment.” / “Conventional care for patients with cancer can safely incorporate massage therapy, although cancer patients may be at higher risk of rare adverse events. The strongest evidence for benefits of massage is for stress and anxiety reduction, although research for pain control and management of other symptoms common to patients with cancer, including pain, is promising.”
Found few safety concerns but urged investigating MT qualifications, and MTs should understand massage adjustments for common cancer presentations.
Another Relevant Review
A Meta-Analysis of General Massage Therapy Research (not Focused on Cancer).
Moyer, CA, Rounds J, Hannum, JW. A Meta-Analysis of massage therapy research. Psychological Bulletin 2004 130(1):3-18.
Massage therapy (MT) is an ancient form of treatment that is now gaining popularity as part of the complementary and alternative medical therapy movement. A meta-analysis was conducted of studies that used random assignment to test the effectiveness of MT. Mean effect sizes were calculated from 37 studies for 9 dependent variables. Single applications of MT reduced state anxiety, blood pressure, and heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were MT's largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy. No moderators were statistically significant, though continued testing is needed. The limitations of a medical model of MT are discussed, and it is proposed that new MT theories and research use a psychotherapy perspective.
Highlights and Comparisons of Individual Studies
Author, date / Cassileth & Vickers, 2004 / Kutner et al., 2008 / Post-White et al.,2003 / Jane et al., 2009 /
Title / Massage Therapy for Symptom Control: Outcome Study at a Major Cancer Center. / Massage Therapy versus Simple Touch to Improve Pain and Mood in Patients with Advanced Cancer / Therapeutic Massage and Healing Touch Improve Symptoms in Cancer / Effects of a full-body massage on pain intensity, anxiety, and physiological relaxation in Taiwanese patients with metastatic bone pain: a pilot study
Sample Size / n = 1,290 / n = 380 / n = 164 / n = 30
Study Subjects / Inpatients and outpatients / Patients with advanced cancer at end of life / Chemotherapy outpatients / Patients with metastatic bone disease
Control? / No control group. / Only a comparison treatment group (below).
(Parallel design) / Control group = usual care.
(Crossover design) / No control group.
Were other interventions tested? / No. / YES. Simple-touch sessions. Six 30-minute sessions over 2 weeks, provided by hospice volunteers (lay people). Referred to as “nonmoving touch.” A sequence of hand placements for 3 min. each , bilat., at base of neck, scapulae, low-back, lower legs, heels, clavicles, forearms, hands, knees, feet. / YES. Two others!
1. Healing Touch (well-described in paper), same dose, setting, table, etc.
2. Caring Presence (well-described), conversation, no touch or therapy, same dose, same setting, massage table, etc. Subjects “crossed over” from control to one of three therapies, or vice versa. / No.
Massage Provider / LMTs / LMTs with cancer/hospice experience / RN/MT/Healing Touch practitioners / RN with massage training
Massage
Dose / One session, average time 20’ for inpatients and 60' for outpatients.
Total = 20-60 min. / Six 30-minute sessions scheduled over 2 weeks. Referred to as “moving touch” throughout study.
Total = 180 min. / 45 min./week X 4 weeks
Total = 180 min. / One 45-minute session, actual range 38-50 minutes
Total = 38-50 min.
Massage Technique / Fairly open protocol.
Patient. choice (and LMT determination of appropriateness) of standard Swedish massage, “light touch massage,” and “foot massage.” Some had combinations of more than one therapy.
Body areas not mentioned but implied. / Fairly open protocol with some limits.
Gentle effleurage, petrissage, myofascial trigger point release (concentrated finger pressure to painful localized areas).
Individual MT judgment about frequency of rate, rhythm, stroke, sequence, mix, and body areas massaged. MTs spent 65% of time on effleurage; 35% on petrissage., most frequently neck/upper back (80% of the time), etc. / Standard protocol
Complete Tx description.
Written protocol including effleurage, petrissage, friction/rubbing.
Body areas included upper back, lower back, hips, buttocks, upper chest, neck, face, head, anterior torso, abdomen., legs, feet. / Standard protocol
“Full-body” session
with effleurage, light petrissage, nerve strokes, light compressions for designated time ranges on eight body areas (head, neck, back, gluteal muscles, 4 extremities). Targeted highly innervated areas (head, hands, feet), less innervated areas (back and limbs). 5 patients received modified protocol omitting some techniques such as neck traction or shoulder compression.
Outcomes tested
When? / Survey of symptoms including pain, fatigue, anxiety, nausea, depression.
Pre-post treatment, and 2 days post-treatment for ¼ of subjects. / Symptoms: Immediate and sustained changes in pain.
Mood
Quality of life
Symptom distress
Vital signs: HR, RR
Analgesic medication use
Pre-post treatment, and weekly for 3 weeks. / Vital signs: HR, RR, BP
Symptoms such as pain, nausea, fatigue, anxiety, mood.
Analgesic use.
Antiemetic use.
Satisfaction with care.
Pre-post treatment (vital signs, pain, nausea), other symptom and mood measurements taken before 1st and 4th intervention, other measurements at final session. / Symptoms: pain, anxiety Physiological relaxation (HR, BP (mean arterial pressure, or average BP over a cardiac cycle)).
Pre-treatment, immediate post-treatment, then 5,10,15,20,30,60,90, 150 min., and then 16-18 hrs. post-treatment.
Results / Symptoms:
Between baseline and post-treatment, there were improvements in pain, fatigue, anxiety, nausea, and depression. For whichever symptom was "presenting" (the one the subject scored the highest at baseline), there was significant change, too. The results echo results of some smaller RCT’s on this population.