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The Influence of Classical Massage Therapy on Stress Perception, Mood Disturbances, Body Image, Cortisol and Oxytocin Levels

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ORIGINAL ARTICLE
The efficacy of classical massage on stress perception
and cortisol following primary treatment of breast cancer
Miriam Listing &Michaela Krohn &
Christiane Liezmann &Ina Kim &Anett Reisshauer &
Eva Peters &Burghard F. Klapp &Martina Rauchfuss
Received: 8 June 2009 / Accepted: 28 December 2009 / Published online: 19 February 2010
#Springer-Verlag 2010
Abstract To investigate the efficacy of classical massage
on stress perception and mood disturbances, 34 women
diagnosed with primary breast cancer were randomized into
an intervention or control group. For a period of 5 weeks,
the intervention group (n=17) received biweekly 30-min
classical massages. The control group (n= 17) received no
additional treatment to their routine health care. The Per-
ceived Stress Questionnaire (PSQ) and the Berlin Mood
Questionnaire (BSF) were used and the patientsblood was
collected at baseline (T1), at the end of the intervention
period (T2), and 6 weeks after T2 (T3). Compared with
control group, women in the intervention group reported
significantly lower mood disturbances, especially for anger
(p=0.048), anxious depression (p=0.03) at T2, and tired-
ness at T3 (p=0.01). No group differences were found in
PSQ scales, cortisol and serotonin concentrations at T2 and
T3. However, perceived stress and cortisol serum levels
(p=0.03) were significantly reduced after massage therapy
(T2) compared with baseline in the intervention group.
Further research is needed to validate our findings.
Keywords Breast cancer .Cortisol .Serotonin .
Mood disturbances
Introduction
The evidence of most complementary and alternative
medicine treatments in cancer therapy is inconclusive, and
the impact on the psychological and physical state of the
patients is unclear. Though, there is an increasing aware-
ness regarding the relevance of complementary treatments
such as massage in breast cancer patients. These therapies
are used by the patients as an adjunct to orthodox medicine
for the management of symptoms and to improve quality of
life.
Unquestionably, breast cancer patients undergo the
change of life after breast cancer diagnosis as a stressful,
exhausting life experience (Sehlen et al. 2003). The
patientshigh level of stress perception is associated with
a loss of cognitive and affective flexibility (Gold and
Chrousos 2002) and with an inhibition of several vegetative
processes such as sleep (Swaab et al. 2005; Palesh et al.
2007) and sexual activity (Fobair et al. 2006). Furthermore,
depression and anxiety are the most pronounced comorbid-
ities (Mehnert and Koch 2007; Burgess et al. 2005; Alder
and Bitzer 2003) during the first 1 to 3 months post-
surgery, and may persist for more than 16 months. An
affected psychological state seems to be associated with
worse disease outcome and an impaired immune and
cortisol response (Reiche et al. 2004; Chida and Steptoe
2009). For this reason, improving the psychological state
and the quality of life of breast cancer patients is an
important goal in psycho-oncological care.
Massage therapy may interrupt the cycle of distress and
induce a relaxation response in cancer patients (Corner et
al. 1995; Ahles et al. 1999; Smith et al. 2002; Grealish et al.
2000). However, previous studies did not clearly answer the
question if this stress-reducing effect of massage leads to a
decrease in cortisol levels or not (Moyer et al. 2004). In
M. Listing (*)
Center for Internal Medicine and Dermatology,
Department of Psychosomatics and Psychotherapy Berlin,
Charité-Universitätsmedizin Berlin,
Luisenstr. 13a,
10117 Berlin, Germany
e-mail: miriam.listing@charite.de
M. Krohn :C. Liezmann :I. Kim :A. Reisshauer :E. Peters :
B. F. Klapp :M. Rauchfuss
Center for Internal Medicine and Dermatology,
Charité-Universitätsmedizin Berlin,
Berlin, Germany
Arch Womens Ment Health (2010) 13:165173
DOI 10.1007/s00737-009-0143-9
breast cancer patients in particular (Hernandez-Reif et al.
2004,2005), no significant cortisol changes were found in
urine after massage.
Examination of the effect of massage on depression in
cancer patients is sparse (Listing et al. 2007). Hernandez-
Reif et al. (2005) showed a significant reduction in de-
pressive mood, whereas three other studies found no
significant changes (Corner et al. 1995; Ahles et al. 1999;
Soden et al. 2004). Based on their findings, Hernandez-Reif
et al. (2005) corroborated the hypothesis that the improved
mood was associated with an increase of serotonin after
massage therapy.
We therefore designed a randomized controlled trial to
evaluate the short- and longer term effects of a standardized
classical massage on stress perception and mood disturban-
ces as well as on serotonin and cortisol serum levels as
physiological indicators.
Our hypotheses are as follows: classical massage in
breast cancer patients leads to (H1) a reduction of stress
perception and cortisol levels at the end of intervention
period and at 6 weeks after treatment and (H2) an im-
provement of mood disturbances and serotonin levels at the
end of intervention period and at 6 weeks after treatment.
Methods
Participants
This present study was an important part of the larger
randomized controlled trial (Listing et al. 2009), which was
carried out in six subsequent cycles between February 2005
and December 2006. Thirty-four women of the cycles five
and six with primary breast cancer (mean age 59.7, SD =
11.6, range 3682 years) participated in this study.
Participants of these cycles were additionally asked to
provide blood samples. All women gave written informed
consent. The eligible patients were formerly treated at
the Breast Cancer Center of the Charité University
Hospital Berlin, and they were recruited between June
and September 2006 by letter of request through the
psychosomatic department of Charité University Hospital
Berlin, Germany. The study was conducted according to
the Declaration of Helsinki, approved by the ethics
committee of the Charité University Hospital and was
performed without external funds.
Participations were screened for eligibility by electronic
patient records and hand-written medical reports, which
included information on surgical notes, tumor size, histol-
ogy grading, axillary node involvement, hormone receptor
status, and after-treatments. In addition, information on the
patientsmedication was collected, and a psychological
interview and physical examination with each patient were
conducted. The inclusion criteria (in dependence on
(Hernandez-Reif et al. 2005)) were as follows: tumor size
T2 (5 cm), nodal state N2 (9 axillary positive
nodes), no distant metastases, primary breast cancer
diagnosis within the past 4 years, and at least 3 months
after primary treatment with operation, chemotherapy, and/
or radiation therapy. Exclusion criteria were lymphedema of
the arms and breast, inflamed skin in the area of therapy,
treatment with anticoagulants, antidepressants, corticoste-
roids, opioids and cytostatic drugs, limited German language
skills, alcohol and illicit drug abuse, and psychotic disorders.
Study design
The women were randomly assigned to a massage therapy
group (n=17) or a standard treatment control group (n=17)
by a study nurse not involved in the conduction of the study
by a simple randomization list. At baseline (T1), at the end
of the 5-week-intervention period (T2) and at the 6-week
follow-up after the intervention period (T3), participants
completed self-reported questionnaires and provided blood
samples. The women assigned to the massage therapy
group received a 30-min classical massage of the back,
neck, and head, twice a week. Each massage was conducted
in a quiet and private room on a massage table by the same
licensed, trained female massage therapist. The control
group members did not receive any additional therapy
during the study period of 11 weeks. They were informed
to receive progressive muscle relaxation according to
Jacobson after completion of the study (Fig. 1).
Classical massage
The 30-min massage session consisted of Swedish tech-
niques. The massage procedure followed a standardized
protocol (Listing et al. 2009). The subsequent techniques
were applied to the participants covered in a prone position:
stroking (two hands, one hand, edge of hand, palm, thumbs,
fingertips); kneading (one hand, two hand); friction (thumbs,
fingertips). The following muscles (m.) were massaged:
autochthonal back muscles, m. latissimi dorsi, m. trapezii, m.
sternocleidomastoidei, m. rhomboidei, m. supraspinati, m.
teres majores, m. levatores scapulae, compendiously neck
muscles, m. pectorales majores.
Assessments
Psychometric measures
Perceived Stress Questionnaire Perceived Stress Question-
naire (PSQ) is a self-rating instrument developed to assess
perceived stressful situations and reactions on a cognitive
and emotional level during the last month (Levenstein et al.
166 M. Listing et al.
1993). We used the 20-item German version of the PSQ
validated by Fliege et al. (2005) in a sample of 2,458
patients. Respondents rate how often an item occurs on a
4-point Likert scale during the last month. The question-
naire consists of four subscales: subscale 1 (worries) covers
worries, anxious concern for the future, feelings of
desperation and frustration; subscale 2 (tension) explores
tense disquietude, exhaustion, and lack of relaxation;
subscale 3 (joy) is concerned with positive feelings of
challenge, joy, energy, and security; and subscale 4
(demands) covers perceived environmental demands, such
as lack of time, pressure, and overload. The four subscales
were transformed to standardized scales ranging from 0 to
100. PSQ was available for all participants and time points.
Berlin Mood Questionnaire
The validated and well-established German questionnaire
(Hörhold and Klapp 1993; Rose et al. 1998) is a shortened
and rescaled form of the multidimensional mood question-
naire of Hecheltjen and Mertensdorf (1973), which is itself
a translation of the mood adjective list of Nowlis (1965).
The 30-item Berlin Mood Questionnaire (BSF) measures
six different mood dimensions in a way that is analogous to
the profile of mood states (Lorr et al. 1982). Respondents
rate how often an item occurs to them on a 5-point Likert
scale. Five of the scales showed good stability (Cronbach
α=0.80 to 0.93) and one scale (listlessness) showed a
Cronbach αof 0.60. The six subscales (anxious depression,
anger, tiredness, listlessness, elevated mood, involvement)
were transformed to standardized scales ranging from 0 to
100.
Complete data on the BSF was available in 26 patients
(n=14 massage group, n=12 controls).
Endocrine measures
Each patientsblood samples were collected at the same
time in the morning at baseline (10 min before the
questionnaires were administrated), at the end of the
intervention (10 min after intervention), and at the end of
follow-up (10 min before the questionnaires were adminis-
trated). A commercial sample device (Monovette; Sarstedt,
Nürmbrecht, Germany) containing the protease inhibitor
aprotinin (Trasylol; 500 KIU/ml blood) was used. The
serum tubes were refrigerated and centrifuged for 10 min
(2,500× per minute). The supernatants were extracted and
filled into aliquots at 500 µl. The aliquots were stored in
the laboratory at 80°C until required for biochemical
analyses.
The quantitative measurement of cortisol in serum was
performed using a commercially available competitive
binding enzymimmunoassay (ELISA) according to the
manufacturer's instructions (R&D Systems, Minneapolis,
MN, USA). Intra- and interassay coefficients of variations
were 6.3% and 10.4%, respectively.
Before assaying serotonin concentrations, sample were
thawed and acylated. The N-acetylserotonin concentration
was measured by an ELISA manufactured by IBL-Hamburg
(Germany) with 3.26.2% intra-assay and 6.914.9% inter-
assay coefficients of variations. Cortisol and serotonin
measures were available for all subjects and time points.
Data analysis
A per-protocol analysis was performed. All 29 patients who
completed the study period were included in the efficacy
analysis. Patients who dropped out were compared with the
completers concerning their baseline characteristics. To
compare groups at baseline, Pearsons chi-square test for
categorical data and ttest for independent variables were
applied.
The hypotheses (H1-H2) of this study were tested as
secondary outcomes of the larger randomized controlled
trial (Listing et al. 2009). Therefore, an adjustment for
multiple testing was not performed for these secondary
outcomes but only for the primary ones (reduction of
physical discomfort at T2 and T3) in the larger trial.
Fig. 1 Study design
The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer 167
To investigate the effect of massage on stress perception
and mood disturbances in this study, the PSQ and BSF
subscales were compared between the intervention and
control group at T2 and T3 by means of an analysis of
covariance (ANCOVA) with baseline status as a covariable.
Because of a skewed non-normal distribution of the labo-
ratory data, the cortisol and serotonin levels were logarith-
mic transformed and ANCOVA was used to compare both
groups. In addition, paired ttests were applied to
investigate the changes in the questionnaires subscales
and laboratory data over time. Data analyses were con-
ducted using the SPSS (14.0) statistical software package.
Two-sided pvalues < 0.05 were considered statistically
significant.
Results
Sample characteristics
Thirty-four women with primary breast cancer were
enrolled. Most of the women (44.1%) had stage 1 (tumor
size 2 cm) breast cancer and 79.4% women had a negative
axillary lymph node status. Lumpectomy was undertaken in
25 (73.5%) women and mastectomy in 9 (26.5%). There
were 24 and 10 women who had their surgeries within the
past year and less than two years ago, respectively.
The women in the intervention group and control group
did not differ significantly in sociodemographic and clinical
variables (Table 1), the standardized questionnaires sub-
scales, and concentrations of hormones at baseline.
Five women (only one in the massage group) failed to
meet the visits of the study during the intervention period.
These five drop-outs did not differ from the completers
regarding the baseline status. All 29 patients (n=16
intervention group, n=13 control group) who completed
the whole study were included in the efficacy analysis.
Women of the intervention group (n=16) attended ten
massage sessions in 5 weeks (two per week).
Efficacy of massage treatment
Perceived stress
The analysis of PSQ revealed no significant group differ-
ences (Table 2).
However, in secondary pre/post-comparisons (from T1 to
T2 and from T1 to T3) a significantly reduced perceived
stress was found in the intervention group, but not in the
control group. Worries decreased significantly (t(15)=2.2;
p=0.047) in the intervention group from on average 37.5 (at
T1) to 31.3 (at T2) and remained low at T3 (t(15)=3.5; p=
0.003). Compared with baseline, tension was significantly
reduced at T2 (t(15)= 4.0; p=0.001) and demands were
significantly lower at follow-up (t(15)=2.2; p=0.048).
Mood disturbances
A significant group effect was attained for the reduction of
anger (F(1,23) =4.4; p=0.048) and anxious depression
(F(1,23)=5.2; p= 0.03) at the end of the intervention period
(Table 2). Comparing the two groups, reduction of tiredness
(F(1,23)=4.0; p= 0.056) almost reached statistical signifi-
cance directly after treatment (T2). This reduction of
tiredness was sustained over time and showed a significant
Table 1 Sociodemographic and clinical variables at baseline
Factor Massage
(n= 17)
Control
(n= 17)
p value
Age, mean (SD) 59.5 (12.1) 59.9 (11.5) 0.92
Marital status
Married 7 (41.2%) 12 (70.6%)
Divorced 3 (17.6%) 2 (11.8%)
Widowed 5 (29.4%) 2 (11.8%)
Single 2 (11.8%) 1 (5.9%) 0.37
Stage of breast cancer
Ductal carcinoma in situ 5 (29.4%) 4 (23.5%)
1 (tumor size 2 cm) 6 (35.3%) 9 (52.9%)
2 (tumor size 25 cm) 6 (35.3%) 4 (23.5%) 0.57
Nodal status
N0 13 (76.5%) 14 (82.4%)
N1 (3 tumor positive
axillary nodes)
3 (17.6%) 2 (11.8%)
N2 (9 tumor positive
axillary nodes)
1 (5.9%) 1 (5.9%) 0.89
Histological grading
I 4 (23.5%) 5 (29.4%)
II 4 (23.5%) 7 (41.2%)
III 6 (35.3%) 4 (23.5%)
Unknown 3 (17.6%) 1 (5.9%) 0.51
Type of surgery
Lumpectomy 12 (70.6%) 13 (76.5%)
Mastectomy 5 (29.4%) 4 (23.5%) 0.70
Treatments received
Radiation 11 (64.7%) 12 (70.6%) 0.71
Chemotherapy 5 (29.4%) 8 (47.1%) 0.29
Radiation and
chemotherapy
4 (23.5%) 6 (35.3%)
None 5 (29.4%) 3 (17.6%) 0.73
Medication
Tamoxifen 8 (47.1%) 7 (41.2%)
Goserelin+Tamoxifen 1 (5.9%) 0
Exemestan 1 (5.9%) 1 (5.9%)
Anastrozol 3 (17.6%) 4 (23.5%)
None 4 (23.5%) 5 (29.4%) 0.86
168 M. Listing et al.
Table 2 Perceived stress and mood disturbances at baseline (T1), at the end of the intervention (T2), and at follow-up (T3)
Subscales Group Mean (SD) Adjusted mean difference (M C) [95% CI]
c
ES
at T1 at T2 at T3 at T2 at T3 at T2
PSQ Tension
a
Massage 40.8 (21.3) 30.8 (17.5) 35.4 (17.3) 6.07 [15.19 to 3.06] 4.88 [13.69 to 3.93] 0.52
Control 42.2 (13.4) 37.8 (14.3) 41.1 (12.3)
Demands
a
Massage 34.6 (20.5) 30.0 (19.5) 29.6 (18.0) 3.49 [14.55 to 7.57] 2.73 [10.36 to 4.91] 0.25
Control 28.3 (17.3) 29.4 (16.9) 27.8 (15.0)
Worries
a
Massage 37.5 (20.1) 31.3 (13.9) 28.3 (13.0) 1.29 [9.54 to 6.95] 0.92 [8.42 to 6.58] 0.12
Control 33.9 (10.4) 30.6 (13.5) 27.2 (13.5)
Joy
a
Massage 61.3 (22.1) 65.0 (21.8) 65.8 (24.7) 0.96 [12.07 to 10.15] 1.53 [10.10 to 13.15] 0.07
Control 65.0 (21.9) 68.9 (22.3) 67.2 (18.7)
BSF Anger
b
Massage 17.5 (13.0) 8.2 (9.9) 11.4 (13.1) 9.52* [18.96 to 0.08] 4.90 [13.92 to 4.12] 0.82
Control 12.5 (11.6) 15.4 (15.0) 13.8 (11.5)
Anxious Depression
b
Massage 21.8 (13.1) 13.6 (9.5) 16.8 (13.4) 7.15* [13.61 to 0.68] 4.96 [12.39 to 2.48] 0.90
Control 20.4 (14.2) 20.0 (11.7) 20.8 (11.8)
Listlessness
b
Massage 9.3 (14.1) 6.1 (10.4) 10.4 (13.8) 2.08 [8.02 to 3.87] 1.41 [2.67 to 5.49] 0.28
Control 4.2 (5.1) 5.4 (7.2) 4.2 (7.3)
Tiredness
b
Massage 28.9 (15.7) 18.2 (14.8) 18.9 (14.8) 10.43 [21.15 to 0.30] 15.73* [24.20 to 7.27] 0.79
Control 27.5 (21.3) 27.9 (17.2) 33.8 (16.4)
Elevated mood
b
Massage 49.6 (20.2) 61.8 (20.6) 55.4 (22.4) 9.57 [4.54 to 23.68] 7.42 [5.87 to 20.70] 0.55
Control 55.4 (22.0) 55.4 (20.3) 51.7 (18.9)
Involvement
b
Massage 53.6 (21.3) 59.3 (17.9) 62.5 (21.9) 3.88 [15.53 to 7.78] 3.24 [8.50 to 14.97] 0.27
Control 65.0 (14.9) 70.8 (18.8) 67.9 (16.2)
In healthy subjects (for comparison), the following means (SD) values were reported: PSQtension 34 (21), demands 36 (21), worries 26 (20), and joy 62 (21) (Fliege et al. 2005); and BSF
anger 28.3 (22.3), anxious depression 20.5 (17.8), listlessness 26.8 (20.0), tiredness 44.5 (23.8), elevated mood 42.3 (22.3), and involvement 51.5 (14.5; Rose et al. 1998).
Mmassage group, Ccontrol group, CI 95% confidence interval, ES effect size based on ANCOVA
*p<0.05
a
Lower values indicate less tension, demands and worries. Higher values indicate higher levels of joy
b
Lower values indicate less anger, anxious depression, listlessness, and tiredness. Higher values indicate higher levels of involvement and elevated mood
c
Mean differences were adjusted for baseline
The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer 169
difference compared with controls at follow-up (F(1,23)=
14.8; p=0.01).
Cortisol and serotonin
Serum cortisol level decreased significantly from baseline
to the end of the intervention period in the massage group
(p=0.03) but increased again at follow-up (Fig. 2a). No
significant changes were found in the control group and
between the two groups (Fig. 2a).
For serotonin, we did not find any significant changes,
neither in the massage nor in the control group nor between
the two groups, at the end of the intervention and at follow-
up (Fig. 2b).
Adverse events
After the third massage session, one patient experience
higher back pain which was resolved in the following
sessions. Another patient in the massage group reported an
increase in blood pressure.
Discussion
We investigated the efficacy of classical massage and its
sustained effects in primary breast cancer patients in terms
of perceived stress perception, mood disturbances, cortisol,
and serotonin levels. Our hypotheses could be partly
confirmed because we found a significantly higher im-
provement of mood disturbances at T2 and a significantly
higher reduction of tiredness at T3 in the massage group
compared with controls. There were no statistical signifi-
cant differences in stress perception, cortisol, and serotonin
concentrations at T2 and T3. Nevertheless, a reduction of
stress perception and cortisol levels was observed in the
massage group at the end of intervention period compared
with baseline. This effect sustained for stress perception but
not for cortisol levels.
Our findings in short-term stress reduction are in
accordance with other studies (Corner et al. 1995; Grealish
et al. 2000) that found a decrease of stress perception only
in pre/post-comparisons within the massage group. Beyond
that Ahles et al. (1999) and Smith et al. (2002) showed a
significant superiority of massage treatment compared with
their control groups regarding stress reduction. There are
two possible reasons for the lack of a significant group
difference in our data: the small sample size and the fact
that we applied massage in a less stressful situation
(>3 months after primary treatment) than Ahles et al.
(1999) and Smith et al. (2002) who investigated their
efficacy in patients still receiving chemotherapy. Starting at
a higher level of perceived stress usually leads to a higher
mean improvement than in the case of lower stress levels.
Different from the reduction of cortisol levels in our
results, Hernandez-Reif et al. (2004,2005) did not find any
changes in the cortisol levels in breast cancer patients after
massage therapy, which may trace back to the cortisol
measurement in urine. Regarding urinary cortisol levels,
inconsistent results were reported from other authors
(Ironson et al. 1996; Bost and Wallis 2006; Taylor et al.
2003; Field et al. 2004) which examined the effect of
massage in patients who suffered from different diseases.
Whereas other studies (Ouchi et al. 2006; Stringer et al.
2008; Hart et al. 2001; Field et al. 1998) also showed a
reduction of cortisol in serum and saliva after massage
therapy, which is consistent with our data. Nevertheless, a
comparison of these studies is complicated because of
patients with various diseases, massage techniques, and
different trial profiles.
The stress buffering effect of massage has been shown to
be mediated by the activation of the central nervous system.
Fig. 2 a Median serum cortisol concentrations logarithmic trans-
formed at baseline (T1), at the end of the intervention (T2), and at the
follow-up (T3) in the massage group and the control group. Single star
indicates p<0.05. bMedian serum serotonin concentrations logarith-
mic transformed at baseline (T1), at the end of the intervention (T2),
and at the follow-up (T3) in the massage group and the control group
170 M. Listing et al.
One explanation for stress reduction after massage therapy
could be the activation of brain areas, which are involved in
relaxation processes. Interestingly, Ouchi et al. (2006)
could show a reduction of cortisol in serum and of
chromogranin A in saliva and a reduction in the heart rate
as well as an increase in the blood flow in the parietal and
occipital regions of the brain in positron emission tomog-
raphy after massage therapy. The regional cerebral blood
flow increases in a state of vigilance reduction, which is in
parallel with slow wave activity on electroencephalogram.
In support of this finding, Field et al. (2004) found an
increased incidence of delta waves in EEG. Other studies
postulated a stimulation of parasympathetic activity after
massage therapy. Diego et al. (2005) found an increased
activity of the nervus vagus in premature infants after
massage. Another explanation for stress reduction after
massage therapy could be the inhibitory effect of intrace-
rebral oxytocin on the stress-induced activity of hypothalamic
pituitaryadrenal (HPA) axis, including attenuated secretion
of adrenocorticotropin, catecholamines, and corticoste-
rone (Heinrichs et al. 2003). It have been shown that
(Uvnas-Moberg and Petersson 2005;Wikstrometal.
2003) touch is linked to increased levels of oxytocin,
which has been shown to play an important role in the
social modulation of stress response in various regions of
the limbic system.
We also investigated the effect of massage on mood
disturbances. The improvement for anger, anxious depres-
sion, and tiredness in the intervention group was signifi-
cantly higher than minor changes observed in the control
group. In agreement with our results, Hernandez-Reif et al.
(2005) found an improvement of anger in the massage
group compared to the control group in Profile of Mood
States (POMS) and also an improvement in depressive
mood and vitality in the massage group. Post-White et al.
(2003) found an improvement of mood disturbance in all
three intervention groups (massage, healing touch, and
presence) compared to the control group. In contrast, Ahles
et al. (1999) also used POMS and ascertained no significant
group effect, since both massage group and control group
improved over time.
Unlike other studies (Song and Kim 2006; Hernandez-
Reif et al. 2004,2005), we did not find any rise in the
serotonin levels after massage in the intervention group.
Nevertheless, a post-hoc analysis showed an increase in
serotonin levels of the patients in the massage group, whose
mood disturbances improved over 20% (T2-T1) compared
with the patients in the massage group with no improve-
ment in mood disturbances. Because of the low patient
numbers, we did not show these data. This result may be
useful to encourage further investigations.
What are the putative mediators between physical
contact and mood response?
Other studies suggested that physical contact increases
levels of serotonin, which were shown to correlate with
improvement of mood disturbance. Nevertheless, future
research should support the previous findings of serotonin
rise after massage therapy and the correlation with mood
improvement, and try to answer the question whether it is
mechanical manipulations or therapeutic influence, which
results in an improvement of mood. Another explanation is
the reduction of corticotropin-releasing hormone and
glucocorticoids and the reduced activation of locus coeru-
leus and dorsal raphe, which results in changes in the
sensitization of the 5HT-receptors (Leonard 2005) and a
reduced activity of the sympathetic nervous system.
Increased glucocorticoid levels are known to inhibit the
prefrontal cortex metabolism. In addition, glucocorticoid
receptor dysregulation is found in the neocortex and
hippocampus of patients with depression (Swaab et al.
2005; Pariante and Miller 2001). This is in agreement with
the normalization of glucocorticoid receptor expression
levels found after antidepressant treatments in animal
studies (Yau et al. 2002).
Another theory postulate the benefit of massage origi-
nate in factors such as the therapists personal character-
istics, the interpersonal interactions and communication, the
recipients expectation of a positive outcome, while the
application of a specific massage technique may be less
important. In this model, the effect of massage therapy on
stress perception and mood disturbances is unlikely caused
by the physical effect of manipulation but is due to
interpersonal attention.
Several methodological limitations of our study must be
considered. For feasibility reasons it was not possible to
measure cortisol and serotonin at repeated time points in the
morning to take the circadian rhythm of hormones better
into account and to improve the precision of the analysis.
Nevertheless, blood samples per patient were taken in the
morning at the same time of day. Furthermore, the sample
size was small and our findings need to be replicated in a
larger sample of women with primary breast cancer.
In massage therapy, the pressure should not be applied
on the affected area and massage should not be given to
patients with contraindications such as acute thrombosis,
inflamed skin in the area of therapy. Otherwise, this
treatment is considered to be safe, and side effects such as
hematomas are rare (Ernst 2003; Cambron et al. 2007). At
present, there is no evidence for the spreading of tumor
cells by massage therapy (Corbin 2005).
Conclusion
Our randomized controlled study suggests that women with
breast cancer benefited from a 5-week massage treatment
The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer 171
within the first years after surgery. Our study suggests that
massage therapy may lead to a short-term reduction of
stress perception and cortisol levels. Furthermore, we found
a positive impact of massage on mood disturbances. This
study also raises questions for further investigations that
may help in the understanding of the mechanisms of
massage therapy and its physiological and psychological
effects.
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The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer 173
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