Massage therapy for symptom control: Outcome study at a major cancer center

Article (PDF Available)inJournal of Pain and Symptom Management 28(3):244-9 · October 2004with635 Reads
DOI: 10.1016/j.jpainsymman.2003.12.016 · Source: PubMed
Abstract
Massage is increasingly applied to relieve symptoms in patients with cancer. This practice is supported by evidence from small randomized trials. No study has examined massage therapy outcome in a large group of patients. At Memorial Sloan-Kettering Cancer Center, patients report symptom severity pre- and post-massage therapy using 0-10 rating scales of pain, fatigue, stress/anxiety, nausea, depression and "other." Changes in symptom scores and the modifying effects of patient status (in- or outpatient) and type of massage were analyzed. Over a three-year period, 1,290 patients were treated. Symptom scores were reduced by approximately 50%, even for patients reporting high baseline scores. Outpatients improved about 10% more than inpatients. Benefits persisted, with outpatients experiencing no return toward baseline scores throughout the duration of 48-hour follow-up. These data indicate that massage therapy is associated with substantive improvement in cancer patients' symptom scores.

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Available from: Barrie R Cassileth
244 Journal of Pain and Symptom Management Vol. 28 No. 3 September 2004
Original Article
Massage Therapy for Symptom Control:
Outcome Study at a Major Cancer Center
Barrie R. Cassileth, PhD and Andrew J. Vickers, PhD
Integrative Medicine Service (B.R.C., A.J.V.) and Biostatistics Service (A.J.V.), Memorial
Sloan-Kettering Cancer Center, New York, New York, USA
Abstract
Massage is increasingly applied to relieve symptoms in patients with cancer. This practice
is supported by evidence from small randomized trials. No study has examined massage
therapy outcome in a large group of patients. At Memorial Sloan-Kettering Cancer Center,
patients report symptom severity pre- and post-massage therapy using 0–10 rating scales of
pain, fatigue, stress/anxiety, nausea, depression and “other.” Changes in symptom scores
and the modifying effects of patient status (in- or outpatient) and type of massage were
analyzed. Over a three-year period, 1,290 patients were treated. Symptom scores were
reduced by approximately 50%, even for patients reporting high baseline scores.
Outpatients improved about 10% more than inpatients. Benefits persisted, with
outpatients experiencing no return toward baseline scores throughout the duration of 48-
hour follow-up. These data indicate that massage therapy is associated with substantive
improvement in cancer patients’ symptom scores. J Pain Symptom Manage
2004;28:244–249.
2004 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc.
All rights reserved.
Key Words
Massage, cancer, pain, anxiety, depression, nausea, fatigue, clinical trials
Introduction
In the 1940s, Rene A. Spitz learned that
foundling home infants, well fed and warm
but not held or touched, tended to wither away
and die. Of 91 such babies he observed, 27 died
in their first year of life, followed by seven
more in their second year; in other homes, up
to 90 percent died in early infancy. Babies who
survived in the institutions were classified as
hopeless.
1,2
Harlow’s studies of monkeys that
had been removed from their mothers showed
Address reprint requests to: Barrie R. Cassileth, PhD,
Memorial Sloan-Kettering Cancer Center, 1275 York
Avenue, H13, New York, NY 10021, USA.
Accepted for publication: December 23, 2003.
2004 U.S. Cancer Pain Relief Committee 0885-3924/04/$–see front matter
Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2003.12.016
similar results, plus major dysfunctions as they
developed and when they themselves became
mothers.
3
His major work, “Touching: The
Human Significance of the Skin,”
4
clarified a
major message: tactile stimulation is essential
to normal development and even to survival.
The use of human touch as an intervention
against pain and other problems has great
appeal. If effective, it could provide a non-inva-
sive, inexpensive adjunct to the management
of pain and other symptoms experienced by
patients with major chronic illnesses. Data
from related, difficult to control clinical circum-
stances are promising. Massage therapy, de-
fined as manipulation of soft tissue areas of
the body, is offered in clinical settings to assist
relaxation, facilitate sleep, and relieve muscular
Vol. 28 No. 3 September 2004 245Massage for Cancer-Related Symptoms
aches and pains.
5
It is increasingly used for
symptom relief in patients with cancer. Approxi-
mately 20% of U.S. cancer patients seek mas-
sage therapy,
6,7
and approximately 70% of U.K.
hospices offer it.
8
Massage is included in treat-
ment guidelines such as those of the National
Comprehensive Cancer Network, which recom-
mends consideration of massage for refractory
cancer pain.
9
Research supports such recommendations.
Several trials suggest that massage can reduce
pain in cancer patients at varying stages of dis-
ease.
10,11
In the largest study to date, 87 hospital-
ized cancer patients were randomized to
massage therapy or to control on a crossover
basis. Pain and anxiety scores fell by approxi-
mately 40% during massage compared with
little or no change during control sessions.
12
Massage therapy was superior to control against
anxiety, nausea, fatigue and general well-being
in a randomized study of patients awaiting bone
marrow transplantation.
13
Massage has been available systematically at
Memorial Sloan-Kettering Cancer Center
(MSKCC) since establishment of the Integrative
Medicine Service in 1999. Twelve licensed mas-
sage therapists treat inpatients and also provide
massage therapy at our outpatient facility. Pa-
tients who receive integrative medicine ther-
apies record symptom scores before and after
treatment as a routine part of clinical manage-
ment. To avoid bias, staff not associated with
the evaluation, rather than therapists, provide
cards on which patients complete symptom
rating scales. These cards are placed privately
by patients in a closed box. Only research staff
work with the completed cards. Data from these
scores, reported here, shed important light on
the management of common and often refrac-
tory symptoms experienced by patients with
cancer.
Methods
Patients at MSKCC may self-refer to massage
therapy or may be referred by a health profes-
sional responsible for their care. About 50% of
inpatient referrals come from MSKCC nurses;
self- and family referrals account for a further
20% and 10%, respectively. Physicians and
other health professionals account for the re-
maining approximately 20%. Outpatient mas-
sage therapy is self-referred.
Three variations of massage therapy are avail-
able to patients at MSKCC: standard (“Swed-
ish”) massage,
5
light touch massage, and foot
massage. A specific type of massage is requested
for almost all referrals. Patients receive the re-
quested type of massage approximately three
times out of four. The majority of the remaining
cases are requests for regular massage in which
either light touch or foot massage was given,
typically because the practitioner felt that a
weak or late-stage patient could not tolerate
a regular massage or because the patient was
too ill to move into a comfortable position to
receive standard massage therapy.
Massage sessions average 20 minutes in
length for inpatients and 60 minutes for outpa-
tients. Before and 5–15 minutes after massage
therapy, patients are given a 5 8 inch card
with numerical rating scales for common symp-
toms: pain, fatigue, stress/anxiety, nausea, de-
pression, and “other.” Patients rate each on a
0 (“Not at all bothersome”) to 10 (“Extremely
bothersome”) scale.
Data from symptom cards for massage ther-
apy from April, 2000, when use of the rating
scales was initiated, to March, 2003 were ana-
lyzed. Combinations of interventions, such as
massage and a simultaneous relaxation therapy,
were excluded. Comparisons between different
types of massage or symptoms were conducted
by ANCOVA of the presenting symptom, with
baseline score as a covariate. The presenting
symptom was defined as that with the highest
baseline score. If more than one symptom was
scored equally high, the presenting symptom
was chosen in the following priority order: pain,
depression, anxiety, nausea, fatigue, other. The
main analyses concern the initial episode of
care. This ensures that each patient is included
in the analysis only once. Analyses were con-
ducted by AV using Stata 7 statistical software
(Stata Corp., College Station, Texas).
Ethical approval for this retrospective review
of clinical data was given by the MSKCC IRB.
Results
Cards were returned for 3,609 episodes of
care; post-therapy data were available for 3,359
(93%). Of these, 2,465 (73%) involved care of
an MSKCC patient, with smaller numbers for
cancer patients from other hospitals (94, 3%),
246 Vol. 28 No. 3 September 2004Cassileth and Vickers
Table 1
Types of Massage Therapy Received
Inpatients Outpatients Total
Therapy n (%) n (%) n (%)
Massage 316 (33) 244 (74) 560 (43)
Light touch 69 (7) 21 (6) 90 (7)
massage
Foot massage 536 (56) 49 (15) 585 (45)
More than 40 (4) 15 (5) 55 (4)
one therapy
Total 961 (74) 329 (26) 1290 (100)
family members (78, 2%), staff (345, 10%) and
members of the public (377, 11%). Data re-
ported below reflect the initial episode of
care for the 1,290 different MSKCC patients
who provided post-treatment data.
As indicated in Table 1, the most commonly
administered touch therapies were standard
(Swedish) massage or foot massage, with far
fewer patients receiving light touch massage.
Fifty-five patients received more than one type of
touch therapy during the same session, i.e.,
some foot massage and some Swedish mas-
sage during a single session. Foot massage
was predominantly used for inpatients; stan-
dard and light touch massage was more equally
balanced between in- and outpatients. The most
common presenting symptom was anxiety (397,
31%), followed by pain (366, 28%) and fatigue
(312, 24%). Fewer than 10% of patients
reported greatest distress from depression,
nausea or another symptom.
The immediate effects of massage therapy
on symptoms are shown in Table 2. Although
major improvements in symptom scores are ap-
parent—severity of the presenting symptom was
reduced by a mean of 54% (95% C.I. 52%,
56%)—Table 2 may actually underestimate
massage effects. Patients did not necessarily ex-
perience high levels of all symptoms. Therefore,
Table 2
Improvements in Symptom Scores Following Massage Therapy
Symptom n Baseline Post-treatment Change Improvement
Presenting
a
1290 6.6 (2.5) 3.2 (2.7) 3.4 (2.6) 54.1% (34.1)
Pain 1284 3.6 (2.9) 1.9 (2.2) 1.7 (2) 40.2% (40.9)
Fatigue 1263 4.7 (2.9) 2.7 (2.7) 2.1 (2.2) 40.7% (39.1)
Anxiety 1273 4.6 (3.1) 1.8 (2.2) 2.8 (2.5) 52.2% (39.5)
Nausea 1255 1.4 (2.4) 0.7 (1.6) 0.7 (1.6) 21.2% (38.3)
Depression 1254 2.4 (2.8) 1.2 (2) 1.2 (1.9) 30.6% (41.0)
Other 105 6.5 (2.5) 3.4 (2.8) 3.1 (2.8) 46.6% (36.9)
Figures are given as mean (standard deviation).
a
Defined as the symptom with the highest score at baseline.
the data for each symptom includes a significant
number of zero or near zero scores. A patient
presenting with depression, for example, may
have reported no pain or nausea. For such
a patient, no improvement in pain and nausea
would be possible, thus diluting the apparent
effects of treatment on these symptoms at the
group level.
Accordingly, Table 3 includes only data for
symptoms rated four or higher at baseline, the
traditional threshold for considering a symp-
tom of at least “moderate” severity. The strong-
est effects were seen for anxiety and the smallest
changes for fatigue, although a 43% reduction
in fatigue is clinically relevant. There was no
evidence of an attenuation of effect at high
baseline scores. For example, an approximate
45% improvement in pain scores was seen even
in the 244 patients with baseline scores of
seven or above, and in the case of anxiety, im-
provements were always close to 60%, regard-
less of baseline score.
After adjusting for baseline score, outpatients
reported symptom scores 0.56 points lower
(95% C.I. 0.27, 0.85; P 0.0002) than inpa-
tients, equivalent to an approximate 10%
greater improvement. Effects by type of mas-
sage are shown in Table 4. Adjusting for in- or
outpatient and baseline score, patients receiv-
ing Swedish and light touch massage had supe-
rior outcomes to those receiving foot massage
(0.32 points; 95% C.I. 0.03, 0.60 P 0.03). Pa-
tients receiving Swedish or light touch massage
had an average 58% improvement in severity of
their presenting symptom compared to a 50%
improvement in patients receiving foot mas-
sage. There was no significant difference be-
tween Swedish and light touch massage (0.41
points better response for light touch; 95% C.I.
0.11, 0.13; P 0.12).
Vol. 28 No. 3 September 2004 247Massage for Cancer-Related Symptoms
Table 3
Improvements in Symptom Scores After Massage Therapy
Symptom n Baseline Post-treatment Change Improvement
Presenting
a
1131 7.3 (1.9) 3.5 (2.7) 3.7 (2.6) 52.0% (33)
Pain 625 6.1 (1.8) 3.3 (2.3) 2.9 (2.2) 47.8% (32.2)
Fatigue 819 6.6 (1.8) 3.8 (2.6) 2.8 (2.4) 42.9% (35.4)
Anxiety 786 6.7 (1.9) 2.7 (2.3) 4 (2.4) 59.9% (30.2)
Nausea 222 6 (1.9) 3 (2.5) 3.1 (2.4) 51.4% (37.4)
Depression 378 6.2 (1.9) 3.2 (2.5) 3 (2.3) 48.9% (35.7)
Other 94 7.1 (2) 3.7 (2.8) 3.4 (2.8) 48.3% (35.5)
Data include only baseline scores of four or higher. Figures are given as mean (standard deviation).
a
Defined as the symptom with the highest score at baseline.
Similar effects appear for additional massage
therapy interventions. Percent improvement in
presenting symptoms for episodes two to five
for the same individuals are, respectively: 53%
(n 450; 95% C.I. 50%, 56%); 58% (n 203;
95% C.I. 54%, 63%); 56% (n 118; 95% C.I.
49%, 62%) and 61% (n 73, 95% C.I. 53%,
69%). Indeed, in a general linear model ad-
justed for baseline score and clustered by pa-
tient, the coefficient for each treatment was
negat iv e and statistically signi fic ant (P 0.001),
suggesting that the effects of massage therapy
proba bly incre ase for each additi on al treatmen t.
We attempted to follow about one in four
patients (83 outpatients and 247 inpatients)
for up to two days to obtain data in addition to
their immediate post-treatment scores. Inpa-
tients and outpatients were assessed typically
two to five hours after treatment; outpatients
were additionally assessed approximately 24
and 48 hours after treatment. Data were ob-
tained from 74 outpatients (89%) and 237 inpa-
tients (96%). These patients versus those we
did not attempt to follow beyond 48 hours
received similar therapies: 43%, 53%, 9% vs.
48%, 47%, 8% received regular, foot or light
massage, respectively. The two groups also had
comparable immediate responses to therapy
(53% vs. 54% improvement, P 0.6) and simi-
lar proportions of inpatients (78% v. 73%).
Baseline scores were slightly lower in patients
followed longer (6.3 vs. 6.7), suggesting that
patients followed beyond 48 hours were reason-
Table 4
Differences in Effect by Type of Massage Therapy
Type of massage n Baseline Post-treatment Change Improvement
Swedish 550 6.7 (2.5) 3.1 (2.7) 3.1 (2.7) 57% (32)
Light touch 88 6.7 (2.5) 2.7 (2.7) 2.7 (2.7) 62% (35)
Foot 574 6.5 (2.5) 3.4 (2.8) 3.4 (2.8) 50% (36)
Figures are given as mean (standard deviation).
ably representative of the whole sample. As
shown in Table 5, the effects of touch therapy
for inpatients did not persist in the longer term.
Two to five hours after treatment, scores were
approximately 0.5 points higher than immedi-
ately after treatment. This suggests that inpa-
tient severity scores returned to baseline within
a day or so.
The effects of massage therapy lasted longer
for outpatients. Indeed, there is no evidence that
symptom scores regress toward baseline values
(Fig. 1). There was no difference between types of
massa ge ther ap y concerning the time course
of symptom improvement.
Discussion
This is the largest study of massage for cancer
patients yet reported. Such studies typically
note sample sizes of six,
14
23
15
and 54.
13
We
found no study of massage therapy with a
sample size greater than 100. This may reflect
that massage therapy services have been avail-
able only rarely until recently, at major cancer
centers. Our first conclusion, therefore, is that
implementation of a high volume massage ther-
apy service is feasible at a major cancer center.
Major, clinically relevant, immediate im-
provements in symptom scores were reported
following massage therapy. Given the observa-
tional nature of this study, we cannot make con-
clusions about the cause of this effect. However,
248 Vol. 28 No. 3 September 2004Cassileth and Vickers
Table 5
Symptom Scores for Longer-Term Follow-Up
Outpatients
Baseline n 74: 5.8 (2.2)
Post-treatment n 73: 2.7 (2.1)
Later same day n 53: 2.9 (2.3)
Next day n 49: 2.7 (2.2)
Two-day follow-up n 38: 2.6 (2.4)
Inpatients
Baseline n 237: 6.2 (2.4)
Post-treatment n 237: 3.1 (2.7)
Later same day n 237: 3.7 (2.9)
Figures are given as mean (standard deviation).
it is notable that the size of the effects found
are highly similar to those reported in prior
randomized trials of massage therapy in
cancer patients. For example, Grealish et al.
reported that pain and anxiety scores improved
during treatment from approximately 2.5 to 1.5
(40%) and from 5.4 to 3.2 (41%), respectively,
with no change in controls.
12
The comparable
figures reported by Stephenson et al. are 2.9 to
1.4 (53%) and 4.7 to 2.4 (50%), again, with
marginal change in controls (15). This suggests
that the results reported in randomized trials
can be achieved in the clinical setting.
The effects of massage were smaller and less
persistent for inpatients. There are two possible
explanations. First, inpatients are more subject
to intervening events than are outpatients. They
may undergo procedures or have medication
changed. Inpatients also tend to receive shorter
massage treatments in less comfortable settings
Fig. 1. Time course of treatment effects for outpa-
tients: symptom scores are given as means with stan-
dard errors.
than do our outpatients. The relationship be-
tween the length of massage treatment and
the size and duration of effects is worthy of
further research.
We found that Swedish and light touch mas-
sage were superior to foot massage, even after
controlling for baseline severity and location of
treatment. It may be that the effects of touch to
the body are more profound than touch given
only to the feet. However, it is also possible that
the apparently lesser effects of foot massage
reflect a case mix inadequately captured by
baseline symptom scores. For example, weak or
cachectic patients often receive massage just to
the feet rather than the whole body. Set against
such an explanation is that such patients also
receive light touch massage.
In conclusion, massage therapies apparently
lead to large, immediate improvements in
symptoms scores in cancer patients, even those
with very high baseline scores indicating sub-
stantial levels of pain, anxiety, or other symp-
toms. Outpatients experienced persisting
benefit across the total of 48 hours studied. We
plan a prospective controlled trial for longer
periods of time to determine the duration of
effect. Meanwhile, it is clear that massage therapy
achieves major reductions in cancer patients’
pain, fatigue, nausea, anxiety and depression.
Massage therapy appears to be an uncommonly
non-invasive and inexpensive means of symp-
tom control for patients with serious chronic
illness. It is non-invasive, inexpensive, comfort-
ing, free of side effects and greatly appreciated
by recipients. This non-randomized study sug-
gests that it is also markedly effective.
Acknowledgments
Anne Seidler collated and entered the data
for this article. The authors also thank the
MSKCC massage therapists, headed by Wendy
Miner, LMT and the staff of the MSKCC Bend-
heim Integrative Medicine Center.
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    • "Complementary and alternative medicine (CAM), including acupuncture, homeopathy, naturopathy and special dietary concepts, is gaining more and more interest. Many patients ask for CAM methods, in order to enhance the efficacy of their cancer treatment, to boost their immune system as well as to reduce side effects and increase tolerability of conventional cancer care [1][2][3]. Several methods of Traditional Chinese Medicine (TCM) are sub-classified as CAM, and acupuncture is one of the most frequently requested and offered treatments. Thus, there is a need for solid data on the effects of acupuncture, and therefore, several prospective approaches are currently being defined. "
    [Show abstract] [Hide abstract] ABSTRACT: Several reports have shown that acupuncture is an effective method of complementary medicine. However, only a few of these reports have focused on oncological patients treated with radiation therapy. Most of these studies discuss a benefit of acupuncture for side-effect reduction, however, not all could demonstrate significant improvements. Thus, innovative trial designs are necessary to confirm that acupuncture can alleviate side effects related to radiation therapy. In the present manuscript, we perform a broad review and discuss pitfalls and limitations of acupuncture in parallel with standard radiation therapy, which lead the way to novel treatment concepts.
    Full-text · Article · Aug 2016
    • "The cancer patients who have received planned nursing interventions have shown much lower rate of psychological symptoms like anxiety, depression, and a significant improvement of emotional wellbeing than the counter parts. Cassileth RB and Vickers JA [15]; Herizchi S, Asvadi I, Piri I, Golchin M, Shabanlui R and Sanaat Z [16]; Kashani F, Babaee S, Bahrami M and Valiani M [17] also have noticed that the nursing interventions like massage, Progressive Muscle Relaxation Therapy, breathing exercise, psycho educative care and prayer enhance psychological health status and quality of life. Evidence is accumulating that nursing interventions improve emotional adjustment, and reduces both treatment and disease related distress in cancer patients. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Cancer patient's undergoing chemotherapy experiences a variety of side effects which has influence on prognosis of illness, activity of daily living and the quality of life. There is a need of nursing care interventions for management and prevention of problem among cancer patients. Aim & Objectives: The present study aimed to assess the effectiveness of nursing interventions on physical and psychological outcome among cancer patients undergoing chemotherapy. Material and Methods: A true experimental study, post test only design with control group approach was conducted among 130 cancer patients undergoing chemotherapy at oncology ward of Pravara Rural Hospital, Loni (Bk), Ahmednagar, Maharashtra. Cancer patients who are 18 years old or older were selected with systematic random sampling method. Pre tested semi structured interview schedule was used to gather data. The assessment of health status before start of chemotherapy was carried out, followed by the nursing interventions was implemented based on patient needs and problems, and the post test was conducted after the period of interventions. The collected data was tabulated and analyzed using appropriate statistical methods wherever required. Results: The results revealed that the cancer patients experienced a wide range of physical and psychological problems prior to chemotherapy treatment. Cancer patients who received nursing interventions had improved post test mean scores on chemotherapy symptoms, pain and fatigue; emotional well being, anxiety and depression than the patients who received routine care, notably it was statistically significant at p
    Full-text · Article · Apr 2016
    • "Aghabati and colleagues examined the effects of Therapeutic Touch, placebo, and usual care on the pain and fatigue of the cancer patients undergoing chemotherapy and found that therapeutic touch was more effective in decreasing pain and fatigue than usual care, whereas the placebo group showed a decreasing trend in pain and fatigue scores compared with the usual care group [4]. In a cohort study with 1290 patients, Cassileth and Vickers found that massage therapy was associated with a substantive improvement in cancer patients' symptoms such as pain, fatigue, stress/anxiety, nausea, and depression [5]. Krucoff and colleagues undertook a multicenter, prospective trial with 748 patients undergoing percutaneous coronary intervention or elective catheterisation to determine the effects of music, imagery, and touch therapy (MIT) on in-hospital major adverse cardiovascular events, 6-month readmission or death, 6-month major adverse cardiovascular events, 6- month death or readmission, and 6-month mortality. "
    File · Data · Mar 2016 · Journal of Krishna Institute of Medical Sciences University
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