Massage and Related Bodywork Detailed Scientific Review

Overview

Background

Massage has not been recommended for the treatment of cancer, itself. It has, however, been recommended as an aid in relieving disease- and treatment-related side effects and enhancing the quality of life of those who are facing the challenges of cancer.

Massage is an ancient preventative and restorative therapy that continues to evolve. Specialized forms can be enjoyed for their gentle or vigorous effects or used for specific therapeutic goals. Therapeutic massage involves specific pressures and/or manipulation of the soft tissue structures of the body to prevent and alleviate discomfort from muscle spasms and other effects of physical or emotional stress. The essence of all massage therapies is touch.

The forms and mechanisms of action of massage are varied and include:

• Swedish

Known as “Swedish” in the U. S. and “massage” in Sweden, this is a basic form that addresses the superficial layers of skin and muscle. It includes long relaxing strokes known as “effleurage”, kneading or “petrissage”, and more invigorating friction or “percussive” strokes. Pain and tension may be relieved through kneading actions that enhance circulation in constricted tissues or through gentle strokes that communicate calmness to touch receptors in the skin¹.

• Deep tissue massage

These forms of massage address the deeper underlying layers of muscle and fascia (connective tissue that “wraps” the muscles and organs). They require a thorough understanding of anatomy in order to access these layers without irritating the more superficial layers.

• Pressure point, myotherapy, trigger point, Rolfing and neuromuscular therapies

These are forms of superficial to deep tissue massage that seek the “structural integration” of the body by releasing tension in the muscles, tendons and fascia (connective tissue that “wraps” the muscles and organs) so that the body is more beneficially aligned with gravity.

Structural integration and pressure point therapies begin with an analysis of current postural distortions and use finely regulated pressure on acutely sensitive spots within taut bands of muscles to ease these distortions. These hypersensitive spots are known as “trigger points” and the intent is to desensitize them so that they no longer “trigger” reactions in local or distant body sites². Trigger points may be calmed by moderate pressure that sends newer more positive messages into the central nervous system (“gate theory of pain”)^3,4.* These types of massage are very specific and it is wise for clients to only seek them from therapists with specialized training (e.g. myofascial release, neuromuscular therapy, Rolfing, etc.)^3-6.

• Shiatsu or acupressure

This form is similar to other pressure point therapies, but differs in that pressure is applied to specific points along the meridians traditionally employed in acupuncture and oriental medicine⁷.

• Sports massage

This form focuses upon maintenance of muscular efficiency, prevention of injuries and loss of mobility, boosting of athletic performance and endurance, curing and restoration of mobility to injured muscles and extension of the health and overall professional life of an athlete. Specific areas massaged and methods used are those that are the most relevant to a particular sport. Two basic approaches used for any athlete are squeezing actions to release the build up of lactic acid and other toxins in over-worked muscles and cross fiber friction to soften stiff tendons⁸.

• Manual Lymphatic Drainage (MLD)

“Manual Lymphatic Drainage” is a copyrighted name that refers to the original Dr. Vodder method of relieving lymphedema. Lymphedema is the retention of proteins and water in the tissues under the surface layer of the skin. Similar techniques from other sources may be referred to as “manual lymphatic therapy (MLT)” or just “special massage”. Very light pressure is ordinarily applied in gentle rhythmic directional motions on the superficial skin and subcutaneous tissues to increase the flow of lymph fluid out of swollen tissues^9,10. Reduction of edema through MLD has been demonstrated to affect lymph reabsorption from the connective tissue by stimulating the remaining lymphatic vessels/channels to reabsorb the stagnating proteins (at a faster rate) and/or move the lymph to other adjacent healthy lymph pathways^10,11,12. The anatomical principles of lymphedema treatment are discussed by Casley-Smith⁹. MLD is part of the Rehabilitation Services standards of care for lymphedema as practiced at The University of Texas MD Anderson Cancer Center.

• Reflexology

Reflexology is an approach that focuses pressure upon specific points on the soles of the feet or palms of the hands. Practitioners base this practice on the theory that congestion or tension in any part of the foot mirrors congestion or tension in a corresponding part of the body. Thus, treating these areas is theorized to have a related effect elsewhere in the body¹³. (Sometimes classified as a separate therapy rather than a type of massage.)

• Craniosacral therapy

Craniosacral or cranial-sacral therapy employs light, still pressures on areas of the head and sacrum believed to affect the proposed rhythm of the fluid that bathes the brain and spinal cord¹⁴. (Sometimes classified as a separate therapy rather than a type of massage.)

• Traeger

Traeger uses gentle, non-intrusive, natural movements (e.g. rocking) to help release deep-seated physical and mental patterns and facilitate deep relaxation and increased physical mobility¹⁵. (Sometimes classified as a separate bodywork therapy rather than a type of massage.)

Note: Reiki, Healing Touch and Therapeutic Touch are forms of energy therapy that do not involve handling of the soft tissues so they are not included in this review of massage.

Regulation of the Practice of Massage

Legal registration and regulation of massage therapists in this state are provided by the State of Texas Department of Health. Professional accreditation of schools of massage and other professional development in the U. S. is provided by the American Massage Therapy Association. National certification is available through the National Certification Board for Therapeutic Massage and Bodywork. Licensure for physical therapists in this state is provided by The Texas Board of Physical Therapy Examiners. Professional development in physical therapy practices, education and research is provided by the American Physical Therapy Association.

This current review of massage therapies is limited to research concerning the effects of massage for patients with cancer. Not included is research concerning low back pain; however, massage for chronic low back has been systematically reviewed and found to be effective by the Cochrane Review Organization.

Citations of additional research documenting the effects of massage on reduction of heart rate and blood pressure, increased blood circulation and lymph flow, relaxation of muscles, improved range of motion and increased release of enzymes such as serotonin and endorphins may be accessed through The American Massage Therapy Association.

Risks and Adverse Effects

General contraindications for massage include infection, fractures and torn ligaments or tendons, pressure on tissues of patients taking blood-thinners such as Coumadin and direct pressure on the carotid or other major arteries because of the danger of inducing fainting or strokes.

The application of extreme pressure by an inexperienced or inappropriately trained massage therapist can cause bruising and aggravation of existing problems. Fainting or strokes may occur when massaging the carotid sinuses (intersection of the internal and external carotid arteries) especially in people who have head and neck cancers¹⁶ or other physiological reasons for vulnerability¹⁷.

Specific contraindications for patients with cancer include any post-surgical or radiation massage until cleared by a physician as even the lightest pressure in these situations is highly likely to irritate tissues. For patient experiencing nausea, rocking or jostling motions should be avoided. Swollen tissues should not be massaged unless the therapist has special training.

Massage should never be done in the region of obvious tumors, enlarged lymph nodes or masses of an unknown nature because of the risk of dispersing cells as has been demonstrated in one study of sentinal node mapping with and without post-injection massage¹⁷.

Therapists should only consider massage for patients with cancer if they have had specific training. For more in-depth discussion of precautions and opportunities for training, visit the website of the American Massage Therapy Association and search for “cancer”. Also, consult the references “Medicine Hands: Massage for People with Cancer”¹⁸ and "Supportive Cancer Care"¹⁹.

Published research concerning the effects of massage for people with cancer is reviewed in the Summary of Research.

*The "gate control theory of pain" proposes that a mechanism in the dorsal horns of the spinal cord acts like a gate which inhibits or facilitates transmission of pleasant or unpleasant sensations from the body to the brain². [ed. For example, the pleasure sensations of touch in massage are theorized to override the chronic transmission of unpleasant sensations of chronic pain.]

2. Melzack R. Pain: past, present and future. Canadian J of Experimental Psychology 1993 Dec;47(4):615-29.

Summary of Research

Amount and Type of Research

Based on our searches of the Medline and CINAHL databases  and other sources between October 1 and February 28, 2006, we have identified 121 unique articles with terms relating to massage and cancer of which 31 had direct relevance to patients with cancer; however, one of these articles²⁰ reported a study that had previously been reported in another journal²¹ and previously reviewed on this website. Thus, we identified 30 relevant articles reporting new information.

On a previous search of the literature between April 1, 2002, and September 30, 2004, we identified 141 unique references in English to “massage”, “reflexology” or “Manual Lymph Drainage”, of which 97 had some direct or indirect applicability to massage for patients with cancer, and 44 of these were most relevant for patients with cancer. We also identified an additional article that had been missed on the initial search.

The initial search between January 1, 1966, and March 31, 2002, identified 165 unique references in English to “massage”, “reflexology” or “Manual Lymph Drainage”.  Of these articles, 58 (35%) were applicable for patients with cancer. (One article that described mechanical rather than manual massage was not included within these applicable articles.) 

Of these 133 applicable references, we retrieved 108 (81.2%) as complete articles and the remainder (25) as abstracts.

We have classified these 133 applicable references into the following types of information:

*Includes guidelines, commentaries about individual studies and surveys of use.

For the human related articles (n=53), we coded the studies that evaluated massage as an intervention (n=54)* by the following study designs:

*The National Cancer Institute and other research design authorities consider this to be the strongest type of study design. For descriptions of study designs, see About Complementary / Integrative Medicine.

**Parentheses indicate the number of studies in which massage could be evaluated because it was not combined with other treatments or, if combined, was compared with treatments lacking the massage component.

***Totals for studies are greater than the number of articles because one article²² reported two studies. 

Summary of Human Research

As of March 1, 2006, 54 human studies have been identified, but only 45 of these studies were designed to evaluate the separate contribution of massage. 

Effects of Massage on Edema after Surgery or Radiation

Specific forms of massage known as “Manual Lymphatic Drainage” (MLD), or other specific forms of lymphatic massage were evaluated in 16 studies of treatments for edema, but 10 of the 16 studies of MLD evaluated combinations of treatments that included MLD along with pneumatic compression, exercise, elastic bandages^12,27-34 and/or non-steroidal anti-inflammatories³⁵. Just 11 studies were designed to evaluate the separate contribution of Manual Lymphatic types of massage in three randomized controlled trials (RCT)^11,36,37, two non-randomized prospective controlled studies^38,39, four non-controlled clinical series^23-25,40 and one retrospective review²⁶.

One of three RCTs was single-blinded (assessors of response were blinded). With 25 subjects in each group (MLD and compression bandaging versus compression bandaging alone), the study had the power to detect differences in swelling of 20% or more. No significant differences in swelling were found between the two groups although subjects with mild lymphedema who had both MLD and compression bandaging had a significantly greater reduction in swelling than all other sub-groups³⁶.

One of the two non-blinded RCTs compared compression by bandages, exercises and skin care for one group of patients with this same combination plus the Manual Lymphatic Drainage (one hour per session for eight sessions over two weeks) for the other group. Both groups obtained a significant reduction in edema with no significant differences between them in the amount of reduced edema¹¹. The other non-blinded RCT compared women who received medication plus a 10-minute massage on request from their spouse or significant other with women who received medication alone. Participants in the massage group gave positive feedback about the experience, but felt that it was not long enough. After 10 to 14 days, no significant differences were evident in pain control, shoulder function or range-of-motion³⁷.

One of two non-randomized prospective controlled studies compared MLD with pneumatic massage using uniform versus differentiated pressure. Significant reductions in edema occurred in the MLD and uniform pneumatic pressure groups³⁸. The second non-randomized controlled study compared compression bandaging with compression bandaging plus MLD and found a significantly greater percent reduction in fluid volume with the addition of MLD (11% versus 4%, P<.0.04)³⁹.

One randomized controlled trial compared manual lymph drainage provided by professional therapists with simple lymphatic techniques (SLD) taught to patients by therapists. No significant changes were associated with SLD, but therapist delivered MLD was associated with significant reduction in limb volume (P=.013), reduced dermal thickness at the deltoid site (P=.03), improved emotional function (P=.006), and reduced sleep disturbance (P=.03). MLD was also significantly more likely than SLD to improve pain (P=.01), discomfort (P=.002), heaviness (P=.003), fullness (P<.001), bursting (P=.008) and hardness (P<.001)⁴¹.

Additional non-controlled prospective and retrospective studies are described in the Annotated Bibliography^{23-26,32-34,40,42}.

Published Reviews

Three groups have reviewed the evidence concerning manual lymph drainage with other interventions for reduction of edema. The National Cancer Institute⁴³ concluded that massage has been shown to be an effective therapy for lymphedema, although the Canadian Medical Association concluded that the addition of MLD to other treatments provided no significant benefit⁴⁴. The most recent review by Cancer Care Ontario’s Program in Evidence-based Care concluded that compression therapy and manual lymphatic drainage (MLD) may improve established lymphedema, but that further studies were needed⁴⁵.

Conclusions concerning treatment of postsurgical edema with Manual Lymphatic Drainage based upon three randomized controlled trials and reviews by other groups are that manual lymph drainage massage may add benefit, but must be combined with other treatments for edema such as compression bandaging and therapeutic exercises.

Professional massage appears to be more effective than simple lymphatic drainage techniques performed by patients themselves based upon one randomized controlled cross-over trial.

Effects of Massage on Nausea

One of two randomized controlled trials evaluated the effect of massage upon nausea in 16 patients undergoing bone marrow transplants compared with 17 control patients. Significant immediate decreases in numerical nausea scales were associated with the massage group⁴⁶. The other randomized controlled trial had a cross-over design and it evaluated the effect on nausea of two 10-minute foot massage (not foot reflexology) sessions for 87 subjects. Mean nausea scores decreased significantly at the end of the massage sessions, but not at the end of the control sessions^47a. Two other larger randomized controlled trials with enough power to detect significant differences found no significant effects on nausea^48,49. One large prospective non-randomized cohort study found significant effects on nausea with Swedish massage, light touch massage and/or foot massage⁵⁰.

Conclusions based upon the four randomized and one non-randomized controlled studies are that massage alone may provide some temporary relief of nausea, but the evidence is mixed and weak.

Effects of Massage Upon Immune and Neuroendocrine Substances and Functions

Two studies have investigated the effects of massage upon immune system and nervous system transporters and related mood effects. One study was a randomized controlled trial of massage compared with usual care that reported significant decreases in anxiety, depression and hostility, but no decreases in the levels of the cortisol stress hormones, norepinephrine and epinephrine⁵¹.  Data from the patients in this study was later added to data from patients in a subsequent non-randomized controlled trial of massage, relaxation training and usual care. Significant increases in dopamine and serotonin were reported along with significant positive effects upon the moods of depression, anxiety, pain and vigor. Natural killer cell levels increased with massage and with relaxation, but the increase was only significant with massage and the levels actually declined in the standard care group. Nevertheless, the authors stated that these distributions were uneven and there were large variances and not enough subjects to do between group analyses⁵².

Conclusions based upon these two combined studies are that massage may affect neuroendocrine substances, associated moods, natural killer cells and lymphocyte levels, but the evidence is weak. Replication is needed in larger randomize studies that are at least blinded to the evaluators. Their estimated sample sizes should be based on large expected variances. 

Effect of Massage Upon Body Image

The effect of massage upon body image following mastectomy was examined in a clinical series⁵³ and a case report⁵⁴. The clinical series was a pilot study of three women who were having significant problems adapting to the loss of their breasts. They received six massages with their choice of the part of the body to be massaged. The women reported that the massage sessions helped them to relax, sleep better and regain their ability to look at or touch themselves. One woman experienced feeling “low” and it was theorized that this may have been associated with the release of pent-up feelings, and she continued the massage sessions⁵³. The case report illustrated the threats to sexuality in the excerpts of a dialogue between the patient and the therapist during massage sessions and compared these with the dialogue of a male client with concerns about general control rather than sexuality⁵⁴.

Conclusions concerning the effect of massage upon body image in patients with cancer would not be reasonable due to the preliminary nature of this pilot study and limitations of case reports.

Effects of Massage on Pain, Anxiety, Relaxation and Other Quality of Life Components

Three randomized and blinded controlled trials examined effects of massage or foot reflexology upon pain and general quality of life (mood, anxiety, depression, sleep quality). One trial of 42 patients compared massage with and without aromatherapy to a control group receiving standard care alone. Massage alone had significant effects upon sleep quality and depression, massage plus aromatherapy had significant immediate effects upon pain and the two massage groups combined had immediate effects upon pain and sleep quality⁵⁵. A pilot study examined the effects of four sessions of 30-45 minute massages by five licensed massage therapists among 29 hospice patients. Significant reductions occurred in pulse, respiratory rates and pain intensity after some massage sessions (P<0.05); however, long term intermittent pain escalated to constant pain in 7% of patients receiving massage and none of the controls and massage was not a significant predictor of Global Well Being per multiple regression analysis⁵⁶. The third blinded trial enrolled 17 patients in a palliative care setting compared foot reflexology to basic foot massage and reported approximately equal negative and positive responses to these therapies; however this last trial was just a pilot study and did not have the power to detect significant differences⁵⁷.

Six randomized, but unblinded controlled trials included pain among the outcomes examined^{21,47,48,58-60}. The largest of these trials assessed pain and other outcomes for 230 patients with various cancers who were receiving chemotherapy. Three interventions were evaluated: therapeutic massage, Healing Touch and a caring presence with calming music. Patients received four weekly sessions of their assigned intervention and four weekly sessions of standard care. Intervention or standard care was started on the day before their next chemotherapy cycle with the order of intervention and standard care randomized in a cross-over design. Both the massage and Healing Touch groups had immediate significant reductions in pain post-session compared to standard care. Massage sessions over four weeks were associated with significant reductions in analgesic use compared to standard care. Other significant effects associated with massage included reductions of mood disturbance and anxiety compared with standard care⁴⁸.

Another large unblinded trial compared massage versus low-frequency inaudible vibrations or usual care among 105 women with suspected malignant lesions who were scheduled for laparotomies. Massage was associated with significantly reduced affective and sensory pain and distress. However, when controlling for multiple comparisons and outcomes, these significant differences were not evident. (Although this was the largest trial, it had not satisfied the initial estimated power requirements of 130 patients due to various patients dropping out.)⁵⁹.

One unblinded trial evaluated 50 children who had undergone bone marrow transplants and were recovering and waiting for engraftment. Children were randomized to receive massage given by certified and experienced professional therapists or massage given by parents or standard care. Among children in both massage groups combined, positive trends in reduced use of narcotics were observed, but did not reach significance. In the professional massage group, both the children and the parents reported immediate reductions of anxiety and parents reported observing reduced discomfort in the children. For the parent administered massage group and for both massage groups combined, significantly shortened time to engraftment occurred. An interaction occurred between professional and parent administered massage in that children in the professional massage group received a greater frequency of parent-administered massage than those in the standard care group. (Parents in all groups had not been invited to give massages, but were asked to report any that were given.)²¹.

The fourth non-blinded RCT matched patients based upon frequency of medications taken and then randomly assigned them to a ten-minute back massage or visit with a nurse for ten minutes. Pain levels significantly decreased immediately after massage for males (F(5, 13) = 8.24, p=0.01), but not for females. Medication taken one to four hours prior to the massage was only significantly associated with decreased pain two hours after the intervention and only for females (F(3, 7) =29.37, 29.37, P=0.002)⁵⁸. In another trial, 36 patients with metastases admitted to oncology units were stratified by low and high pain scores into foot reflexology or standard care with an offering of foot reflexology at the end of the study. Immediate pain scores following the session were significantly lower for the reflexology group⁶⁰.

The sixth unblinded randomized trial evaluated effects upon pain and relaxation for 87 patients. Pain and relaxation scores significantly decreased after the first and second massage sessions, but not after the control sessions^47b.

Three remaining unblinded RCTs evaluated other effects among adult patients in a bone marrow transplant unit⁴⁹, children with leukemia⁶¹ and spouses of patients with cancer⁶². Adult patients in the bone marrow transplant unit (n=88) were randomized to receive massage, Therapeutic Touch or a friendly (control) visit every third day until discharge. Significant reductions in neurological complications, increased comfort and perceived benefits were reported for the massage group compared with the friendly visit group. (Therapeutic Touch was also associated with increased comfort compared with friendly visit.)⁴⁹. The trial for children with leukemia evaluated anxiety, depression and immune system responses after 15-minute parent administered massages for 30 days compared with a group on a wait-list for massage. After the first massage parents and children had significantly lower mean anxiety and depressed mood levels compared with controls. At the end of 30 days, depression significantly decreased for parents in the massage group and white blood cell and neutrophil counts significantly increased for the children. Unfortunately, these findings are in question because of conflicting statements in the article concerning the sample size (20 in each group versus 20 total)⁶¹. Forty-two spouses of patients receiving either radiation or chemotherapy were randomized to receive either a 20-minute therapeutic back massage or to read a non-anxiety provoking book for the same amount of time. Both groups had an intravenous catheter that remained during and following their session. Positive changes in mood and perceived stress were found in those receiving the back massage; however, neither group had any significant changes in natural killer cell activity (NKCA). The authors of this study propose that the lack of observed effects may have been due to the stress of an IV in both groups, the limited duration and intensity of the massage and/or the short-term measurement of NKCA⁶².

The remaining studies were non-randomized prospective controlled trials. The largest study to date of massage for cancer patients was conducted at Memorial Sloan-Kettering Cancer Center. Over a three-year period, 1290 inpatients and outpatients who received either Swedish massage or light touch or foot massage according to their choice were assessed pre and post each session. Patients receiving Swedish or light touch massage had superior outcomes in symptom scores compared to those receiving foot massage. A general linear model also suggested that the effects of massage significantly increased for each additional session. The effects of massage therapy lasted longer for outpatients, with inpatients severity scores returning to baseline within a day or so⁵⁰.

One of two smaller nonrandomized controlled studies evaluated the effect of, two 30-minute foot reflexology sessions given in a cross-over design pattern so that half of the patients received the foot reflexology in the first session followed by a session of their regular routine of rest and activity and the other half followed a reverse pattern. Average anxiety scores were significantly lower after foot reflexology for all 23 patients who had foot reflexology either before or after a control session of regular activity (Sample mean 21.83 lower, P=0.000). The 11 patients with breast cancer who initially reported pain had a significant mean decrease following the reflexology (SF-MPQ mean score decrease 0.41, P=<0.05)⁶³. The other study assigned 41 patients at a Veterans Administration hospital to massage or nurse communication as a control depending on their date of entry to the hospital. Differences in pain, sleep and symptom distress were found, but they were not significant at the generally accepted level of 5% or less of probability of occurring by chance alone⁶⁴.

Two uncontrolled clinical series were identified within RCTs that were designed to evaluate different types of massage, but not massage compared with non-massage; accordingly, these RCTs are considered as uncontrolled series for evaluating massage itself. One of these studies compared three session of 40-minutes of foot reflexology with simple foot massage for 12 patients in a palliative care setting. Patients indicated their impressions on a Visual Analogue Scale. More quality of life components improved significantly for the reflexology group than for the foot massage alone group with the greatest improvements in appetite, breathing, constipation, diarrhea, fear of the future, pain, nausea, sleep, communication and tiredness⁶⁵. Another RCT compared three or four (reports not consistent) sessions of full body massage with and without aromatherapy. Both groups were evaluated with pre- and post-test scores of quality of life using the Rotterdam Symptom checklist that takes into account both the number and severity of 30 symptoms of pain, nausea, fatigue and other quality of life indicators. According to matched pair comparisons of mean scores, the aromatherapy group had significantly improved physical symptoms, psychological symptoms and quality of life⁶⁶.

Additional uncontrolled prospective clinical series^4,53,67-70 and two uncontrolled retrospective clinical series^71,22,72 are individually described in the Annotated Bibliography.

Conclusions concerning effects of massage upon pain, relaxation and other quality of life measures are that positive immediate effects are likely, but not long term. It has been shown that professional massage can be more effective than self- or parent-administered massage. However, unknown benefits may be added in that receiving professional massage was associated with increased frequency of parental massage in one study.

Potential Adverse Effects of Massage

Potential adverse effects of massage were reported in one prospective controlled trial⁷³ and six case reports^16,74-76.

A randomized controlled trial compared three groups of patients who were scheduled for axillary sentinal node mapping during the mastectomy procedure. All patients were injected with a radiocolloid one to six hours before the surgery and a blue dye five minutes before surgery. One group did not receive any massage of the breast, a second group received a five minute massage of the breast only after injection of the blue dye and a third group received a five minute breast massage after both the blue dye and the radiocolloid injections. Greater proportions of sentinal lymph nodes were identified in the groups with either time of massage compared with controls; however, only the combination of massage after both injections was significant (P<0.001). The difference between Group A and Group B was not significant. Although identification of a sentinal lymph node was considered a positive effect in this study, it also raises the question of the spread of malignancy. The authors have addressed this concern by initiating a larger study (in process). A pathologist, responding to this study in a letter¹⁷, noted his own previously published concerns about the possible traumatic origin of occult micrometastases⁷⁷ and urged not only caution, but a cessation of the practice of postinjection massage until it could be proved safe¹⁷.

Two sets of case reports included one report that described a young man with an osteochondroma (soft tissue and bone tumor) that was repeatedly massaged. This resulted in a ruptured aneurysm (weakened blood vessel wall) that bled into the tissues behind the knee⁷⁴. Another article described seven of 15 patients with head and neck cancer in which syncope (fainting) was induced by massage of the carotid sinus¹⁶.

Two articles describe four patients in whom light and careful massage brought about or reactivated lymphedema and/or inflammation following radiation^75,76.

Conclusions concerning potential adverse effects of massage are that the risk is especially elevated during and after some of the treatments for cancer. Although massage has generally been contraindicated in the past, a trained practitioner who consults with the oncologist may be able to provide some beneficial touch. However, those who are not trained in the special needs of patients with cancer, should not attempt even light touch massage. Rather they should help the client to find another therapist who is so trained^18,76.

Brief details of each study are summarized in three Summary Tables for Human Studies.

Additional details for each study are provided in the Annotated Bibliography.

Annotated Bibliography

Human Studies

Disease Response and Survival

No studies (not applicable)

Relief of lymphedema (swelling)

Seventeen studies identified

Randomized Controlled Trials (4) 

³⁶McNeely ML, Magee DJ, Lees AW, Bagnall KM, Haykowsky M, Hanson J. The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast Cancer Res Treat 2004 Jul; 86(2):95-106.

Purpose: Reduction of arm edema after mastectomy
Type of Study: Randomized controlled trial, single blinded
Methods: (Breast Cancer) Fifty of 63 eligible female patients with breast cancer and diagnosed lymphedema were included in the study. The number of potential patients was not defined in the article. These subjects had been referred to the Rehabilitation Department at a Canadian Cancer Center and screened for eligibility in the study. None of the subjects had received active treatment for lymphedema within the past six months, and if a compression sleeve had been used, a four-month wait period was observed. Exclusions are discussed in the article. The subjects were randomized, 25 per group, to receive either Manual Lymphatic Drainage (MLD) and compression bandaging (CB) or CB alone, for four weeks of treatment. The MLD/CB group received daily MLD according to specific protocol using the Vodder method. Volume and circumference were used to assess outcome, with the unaffected arm serving as the control.
Results: No significant difference in lymphedema reduction was found between the two groups using water displacement or circumference for assessment. A significantly larger reduction was found in the MLD/CB group for subjects with mild lymphedema compared with all other edema/treatment subgroups (p<0.05).

³⁷Forchuk C, Baruth P, Prendergast M, Holliday R, Bareham R, Brimner S, et al. Postoperative arm massage: a support for women with lymph node dissection. Cancer Nurs 2004 Jan-2004 Feb; 27(1):25-33.

Purpose: Reduction of edema after mastectomy
Type of Study: Randomized controlled trial
Methods: (Breast Cancer) Sixty women diagnosed with breast cancer and scheduled for surgeries with lymph node dissection were recruited for the study out of an unknown number of potential subjects. Only women with spouses or significant others were eligible for the study. The subjects were randomized to receive either massage and medication for pain control, or medication alone. Each group had 30 subjects, with the medication group losing one subject to death before the end of the study. The significant others in the massage group received training in massage techniques by a registered nurse (massage training of nurse not mentioned). Following a massage demonstration, significant others were given an instructional sheet and demonstrated their massage technique to the RN. Massages were provided by the significant others for ten minutes when requested by the patients. Postoperative pain was recorded daily and collected after two weeks. Other measurements, such as swelling, were taken prior to surgery, and then at three follow-up visits 24 hours, two weeks and four months post surgery.
Results: Participants in the massage group provided overall positive feedback, though felt that the 10-minute massage was not long enough. Requests for massages varied from one to 10 massages per day. On the first day postoperation, subjects in the massage group reported significantly greater pain control, but no significant differences were found after the third day. At the second follow-up, women in the massage group had improved shoulder function, reporting significantly less difficulty performing common tasks, but by the third follow-up, no significant difference was noted. No significant difference was found between the massage and control group when measuring for range of motion. After the removal of one outlier, no significant difference was found in swelling. No significant difference was found in the cost/utilization of health care services between groups, but these results may be limited by missing data. Differences in family stress and strengths also were evaluated and discussed in the article.

⁴¹Williams AF, Vadgama A, Franks PJ, Mortimer PS. A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. - European Journal of Cancer Care. 2002 Dec;11(4):254-61.

Purpose: Reduction of edema after mastectomy
Type of Study: Randomized controlled trial with cross-over
Methods: (Breast) Patients at a lymphoedema clinic with breast cancer related lymphoedema who were greater than one year post cancer treatment were eligible for the study, and 31 subjects (out of an unknown eligible number) were recruited to participate. Two subjects withdrew before the end of the study, leaving a total of 29 subjects completing both treatment periods. Subjects in Group A received three weeks of manual lymphatic drainage (MLD) by a therapist, followed by a six-week non-treatment period, then three weeks of self, simple lymphatic drainage (SLD). Subjects in Group B followed the same treatment schedule, except that they received SLD in the first three weeks and MLD in the last three weeks. MLD consisted of a 45-minute session, Monday through Friday, by therapists trained in the Vodder method. SLD was taught to the patients by the researcher and therapists and performed by the subjects for 20 minutes each day during the SLD period. Subjects kept a diary recording the areas covered and time taken each day for SLD. All subjects received skin and nail care advice and were fitted with elastic sleeves at the beginning of both the MLD and SLD periods. Measurements of limb volume, caliper creep, dermal thickness, quality of life and altered sensations were recorded before and after MLD and SLD treatment periods, at weeks 0, 3, 9 and 12.
Results: There were no statistically significant differences at baseline between groups. Following MLD treatment, statistically significant differences were observed for reduction in limb volume (P=.013), reduced dermal thickness at the deltoid site (P=.03), improved emotional function (P=.006) and reduced sleep disturbance (P=.03). MLD was also significantly more likely than SLD to improve pain (P=.01), discomfort (P=.002), heaviness (P=.003), fullness (P<.001), bursting (P=.008) and hardness (P<.001). No significant differences were found for SLD.
Note: For another trial comparing professional massage to that of others or self, see 52 in the subsequent section for nausea, pain and quality of life.

¹¹Andersen L, Hojris I, Erlandsen M, Andersen J. Treatment of breast-cancer-related lymphedema with or without manual lymphatic drainage -- a randomized study. Acta Oncologica 2000;39(3):399-405.

Purpose: Relief of edema after mastectomy
Type of Study: Randomized controlled trial
Methods: (Breast Cancer) Forty-two patients with post-mastectomy edema were randomized to receive either standard treatment consisting of compression by bandages, exercises enhancing lymphatic flow and skin care; or this same treatment plus the addition of a specific form of massage known as “manual lymphatic drainage” (MLD).  Treatments were received eight times in two weeks and patients were followed for a year. 
Results: Both groups obtained a significant reduction in edema with no significant differences in the amount of reduction.

Prospective Non-Randomized Controlled Trials (2) 

³⁸Zanolla R, Monzeglio R, Balzarini A, Martino G. Evaluation of the results of three different methods of postmastectomy lymphedema treatment. Journal of Surgical Oncology - Supplement 1984 Jul;26(3):210-3.

Purpose: Reduction of arm edema after mastectomy
Type of Study: Prospective controlled trial
Methods: (Breast Cancer) This trial evaluated three groups of 20 each: pneumatic massage with uniform pressure, pneumatic massage with differentiated pressure and manual lymphatic massage.
Results: Edema was reduced in all groups with significant reduction occurring in the uniform pressure (21%, t=3.23) and manual lymph drainage group (25%, t=2.77).

³⁹Johansson K, Albertsson M, Ingvar C, Ekdahl C. Effects of compression bandaging with or without manual lymph drainage treatment in patients with postoperative arm lymphedema. Lymphology 1999 Sep;32(3):103-10.

Purpose: Reduction of edema after mastectomy
Type of Study: Prospective controlled trial
Methods: (Breast Cancer) Patients with post-mastectomy edema (n=38) were treated with compression bandaging alone for two weeks (Part I). They were then “allocated” to receive another week of compression bandaging alone or compression bandaging plus massage (Part II). Arm volume was measured and subjective assessments of pain, heaviness and tension were recorded.
Results: During Part I, edema was reduced 188 ml (p<0.001), a mean reduction of 26%. During Part II, the group with the addition of MLD had a greater, but non-significant reduction in volume (47 ml versus 20 ml with bandaging alone, P<0.07). However, this reduction was significant when expressed in terms of percentage reduction (11% and 4%, P = 0.04) and this group also was the only group with decreased pain (p<0.03).

Prospective, No Controls (4)

²³Goffman T, Laronga C, Wilson L, Elkins D. Lymphedema of the arm and breast in irradiated breast cancer patients: risks in an era of dramatically changing axillary surgery. The Breast Journal 2004;10(5):405-11.

Purpose: Identification of edema and evaluation of its treatment
Type of Study: Prospective cohort with no controls
Methods: (Breast Cancer) Hospital records of 240 women who received surgery and radiation for breast cancer were reviewed a “minimum of 1.5 years” after completion of radiation. Cases of edema were defined based upon physicians or nurses noting swelling in the arm or breast. Forty-four women were identified with edema of the arm (n=18, 7.6%), breast (n=23, 9.6%) or both arm and breast (n=3, 1.3%). Patients with edema were referred to a physical therapist with training in manual lymphatic drainage (MLD) who treated them with MLD plus compression bandaging. 
Results: Tumor size and the number of nodes taken were the most significant risk factors for edema. MLD produced “dramatic responses to breast edema” (21 of 23 patients showed only minor persistent swelling) and “significant responses in all arm lymphedema cases”. Longterm evaluation was hard to quantify because of variability in compliance with use of compression sleeves.

²⁵Avrahami R, Gabbay E, Bsharah B, Haddad M, Koren A, Dahn J, et al. Severe lymphedema of the arm as a potential cause of shoulder trauma. Lymphology 2004;37:202-5.

Purpose: Relief of edema
Type of Study: Prospective cohort, clinical series
Methods: (Breast) All patients referred for physiotherapy for arm lymphedema after surgery (n=52) were reviewed for severe shoulder pain causing functional disability, and 10 patients were identified. The average interval between surgery and the appearance of lymphedema was 9.8 years. Five patients had a tear in the supraspinatus muscle on ultrasound scan, and five had chronic bursitis. (Such injuries were likely due to the increased weight of the arm with edema.) Average pain score was 7.6 (range 6-9). Differences in volume of the affected and non-affected arms ranged from 82 to 1367 ml (mean 568 ml). Treatment consisted of two manual lymphatic drainage sessions per week and bi-weekly sessions with a compression device for an average of 4.9 months.
Results: Differences in arm volume decreased by a range of from 88 to 342 ml (mean 170 ml), pain scores dropped from 0 to 5 ml (average 2.7) and functional improvement occurred for all patients.

²⁴Howell D, Watson M. Evaluation of a pilot nurse-led, community-based treatment programme for lymphoedema. Int J of Palliative Nursing 2005;11(2):62-9.

Purpose: Evaluate treatment with manual lymph drainage and compression bandaging
Type of Study: Prospective with no controls (pilot)
Methods: (Breast) Five women with lymphedema of the arm were referred to this study by community physicians. Treatment was provided in their homes by a nurse who was certified in Manual Lymph Drainage. One woman was found to be ineligible after recruitment. The total number of women invited to participate was not provided.
Results: Fluid volumes in the affected arm were reduced at four weeks for all women; however, it subsequently reoccurred or worsened for three women. This may have been due to variable use of compression sleeves, but further research would be needed to explore this or other factors. Compression bandaging was described by the women as a visual and depressing reminder of their breast cancer.

³⁴Mondry TE, Riffenburgh RH, Johnstone PA. Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 2004 Jan-2004 Feb;10(1):42-8.

Purpose: Reduction of arm edema after mastectomy
Type of Study: Prospective trial, no controls
Methods: (Breast Cancer) Twenty female patients with breast cancer were enrolled in the study immediately following diagnosis of lymphedema by a physical therapist. Subjects received complete decongestive therapy (CDT), which consisted of Manual Lymph Drainage, skin and nail care, compression bandaging (worn 24 hrs/day) and therapeutic exercise, for two to four weeks until girth and volume measurements plateaued. Daily compliance was also recorded during treatment, using a scale of zero to 100%, with each component worth 25%. Following treatment, subjects entered a one-year maintenance phase consisting of skin and nail care, therapeutic exercise and wearing a compression sleeve during the day and compression bandaging at night. No massage was given during maintenance. Girth, volume, pain and quality of life were measured after each week during treatment, and at three, six, nine and 12 months during maintenance.
Results: Seven of the 20 patients were lost to follow-up at one year. Statistically significant decreases were found in girth and volume by the grade of lymphedema, but no other variables were significant predictors.
Comment: A wide range of compliance by patients during the treatment phase was noted. Additionally, the specific contribution of MLD massage cannot be assessed.

Retrospective, No Controls (3)

²⁶Jeffs E. Treating breast cancer-related lymphoedema at the London Haven: Clinical audit results. European Journal of Oncology Nursing 2006;10(1):71-9.

Purpose: Relief of edema
Type of Study: Retrospective review
Methods: (Breast) Patients (260 women and three men) with swelling of the arm or breast (n=39) were referred to this specialized lymphoedema center during a four-month period and 168 were treated with Manual Lymph Drainage (MLD), compression, and other self-care measurs.  Severity of arm swelling was determined by measuring both arms with a Perometer®. Of the  52 patients with mild and uncomplicated edema, 39 received standard self-care instructions for hosiery, exercise and skin care while 13 patients also were provided with Manual Lymphatic Drainage for six sessions in two weeks. MLD plus self-instruction was offered to the 39 patients with breast or trunk swelling as their main or only problem. Intensive MLD treatment was offered to all 77 patients with moderate to severe or complicated lymphedema, but only 19 agreed to undergo one or more courses of this treatment.
Results:

• • Mild and uncomplicated lymphedema – Of 20 patients with complete data available at 12 months, a mean reduction of 20% was achieved by the seven patients with MLD plus self-care, but that was less than the mean improvement for the 13 patients who had self-care only. 
  • Trunk edema – Complete resolution for 14 (70%) of  20 individuals with complete data at 12 months. 
  • Moderate to severe or complicated edema – For the 34 patients with complete data at 12 months, edema was reduced an average of 40% in the 16 patients with intensive MLD plus self-care, 25% in the 15 with basic MLD plus self-care and 20% in the three patients with self care only.

Note: The small number with complete data at 12 months limit interpretation of these results.

⁴⁰Woods M. The experience of manual lymph drainage as an aspect of treatment for lymphoedema. Int J Palliat Nurs 2003 Aug; 9(8):336-42.

Purpose: Develop an understanding of the experience of MLD for cancer related lymphedema
Type of Study: Retrospective review with interviews, no controls
Methods: (various cancers) Six patients, out of an undefined number, with cancer related lymphedema were identified as having received Manual Lymph Drainage and interviewed by the author. They had completed a three week course of one hour daily Manual Lymph Drainage, provided by a trained therapist. The intent of the interviewer was to select patients with a variety of causes of lymphedema, but the final group chosen was dependent on the caseload of the therapist.
Results: Six common themes were revealed through the patient interviews in relation to their MLD treatment:

1. 1. Hopes and expectations that MLD treatment would reduce the size and soften the tissues of the limb
   2. Expectations that the swelling reduced during MLD treatment would return
   3. A sense of calm and relaxation in all patients during MLD treatment
   4. The role of the MLD therapist as an educator, providing explanations about the lymphatic system and the effect of MLD and practical advice
   5. Frustration at the high cost of MLD treatment
   6. Varying coping mechanisms with edema as a chronic illness

³³Mondry TE, Johnstone PA. Manual lymphatic drainage for lymphedema limited to the breast. J Surg Oncol 2002 Oct; 81(2):101-4.

Purpose: Reduction of breast edema after treatment
Type of Study: Retrospective chart review, no controls
Methods: (Breast Cancer) Four patients with edema limited to the breast after undergoing wide local excision or lumpectomy and axillary lymph node sampling and radiotherapy were identified out of 349 patients with breast cancer who had undergone breast conservation therapy during the study period. Treatment consisted of therapist delivered Manual Lymphatic Drainage (MLD), self MLD and a compression bra, lasting two to eight weeks according to need. For maintenance, subjects continued to wear the compression bra during the day and were instructed in skin and nail care. Edema was evaluated by the physical therapist on the last day of treatment and 23 to 56 months (median = 40) after treatment.
Results: All four subjects had reduced breast edema following treatment. Forty months after treatment, three of the four subjects were evaluated and presented with no visible breast edema. The fourth patient was lost to follow-up.

Single Subject Designs and Case Reports (3)

⁴²Aldridge RL Jr, Clifft J. Effect of manual lymphatic drainage on edema and function in a patient with postmastectomy lymphedema. - Journal of the Section on Women's Health. 2002 Mar;26(1):25-9, 33.

Purpose: Reduction of edema after mastectomy
Type of Study: Prospective single subject design
Methods: (Breast) The study was originally designed to include three women with post-mastectomy edema; however, lack of available subjects led to only one subject in the study. The subject had upper extremity edema of 27 years duration. The subject received two treatments in a cross-over design. Treatment A consisted of MLD, compression wraps, remedial exercise and skin and nail care. Treatment B included all of Treatment A with the exception of MLD. The subject was seen three times a week for eight consecutive weeks, and received Treatment A for the first four weeks and Treatment B for the last four weeks. Water displacement measurements were taken of the affected limb during the initial evaluation and prior to each treatment session. The subject’s functional abilities were also assessed at these intervals. The same therapist treated the subject and performed the measurements during the entire regimen.
Results: A larger reduction in edema and a slight increase in the subject’s functional abilities occurred during Treatment A, leading to significantly different effects observed between Treatments A and B (P=.046 and P=.002). Overall, improvement was noted when MLD was included as a treatment component, but the improvement was not consistently maintained when MLD was removed from the treatment. It was noted, though, that the subject reported changes in her activity level and salt consumption during the final three weeks of the study when she was receiving Treatment B without MLD.

³²Katz EE, Lyon MB, Davis D, Gottlieb LJ, Brendler CB. Manual lymphatic drainage for the treatment of acute genital lymphedema. J Urol 2004 Jul; 172(1):157-8.

Purpose: Reduction of edema after prostatectomy
Type of Study: Case report
Methods: (Prostate Cancer) The author describes one patient who, after undergoing a prostatectomy and pelvic lymphadenectomy, experienced severe edema in the genital area. Three weeks after surgery, Manual Lymphatic Drainage was performed for two weeks, three to four hours daily, and compressive wrappings were applied after each session.
Results: After several days of therapy, edema and pain improved and were resolved after two weeks. Three months postoperation, subject still had no residual edema.

⁷⁶MacDonald G. Cancer, radiation and massage. 2001:17, 20-32.

Purpose: Reduction of edema after mastectomy
Type of Study: Case report
Methods: (Breast) Three separate reports are described of women with slight to no lymphedema present who received light touch massage on the affected limb. Two of them subsequently developed increased swelling and one had a recurrence of lymphadema.

Nausea, Pain and Quality of Life

Thirty-one studies identified

Randomized Controlled Clinical Trials, Blinded (3)

⁵⁵Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med 2004 Mar; 18(2):87-92.

Purpose: Evaluation of effects upon pain, anxiety, depression and sleep quality
Type of Study: Randomized controlled trial, single blinded
Methods: (36% breast, 19% lung, other) Adult patients were recruited from three palliative care units and were eligible if they had a cancer diagnosis and could complete assessment scales. Subjects (n=42) were randomized into three groups:

1. 1. Massage with lavender essential oil (aromatherapy)
   2. Massage with inert oil only
   3. No massage (control)

The two massage groups received a 30-minute back massage weekly for four weeks. Measurements for pain, sleep quality, depression, anxiety and quality of life were taken at baseline and post intervention, along with before and after massage sessions. The control group completed the assessments weekly without any intervention. Researchers recording and analyzing the data were blinded to the interventions. Patients entered the study with varying levels of physical and psychological symptoms. No significant differences were found between groups in baseline characteristics of patients other than more women in the control group.

Results: Although a large number of analyses of subgroups were performed, the author noted that there was no adjustment to the P value for significance. Immediate effects (pre-post session) were found in the massage group for sleep quality (P=.02) and depression scores (P<.05 and P <.01). The aromatherapy group experienced immediate effects in pain (P<.05). The massage groups combined had immediate effects for pain (P<.05) and sleep quality (P=.03). No longterm effects (baseline to final assessment) on symptoms were found for any group.

⁵⁷Ross C, Hamilton J, Macrae G, Docherty C, Gould A, Cornbleet M. A pilot study to evaluate the effect of reflexology on mood and symptom rating of advanced cancer patients. 16. 2002;16(6):544-5.

Purpose: Evaluation of reflexology upon mood and symptom rating
Type of Study: Randomized controlled trial, single blinded (pilot)
Methods: Twenty-six patients in a palliative care setting (out of an unknown eligible number) entered the study. Due to death and other circumstances, nine patients did not complete the study, leaving 17 evaluable patients. Subjects were randomly assigned to one of two treatment groups: reflexology and basic foot massage. Both treatment groups received a therapy session by trained reflexologists once a week for six weeks. A standardized technique was used for both the reflexology and basic foot massage. Participants and interviewers remained blind to the intervention, which was known only to the therapists. Measurements on mood and symptom ratings were taken at baseline and within 24 hours of each session. Participants were also contacted by interviewers over the phone to “transcribe” the results of the questionnaires and to conduct a short, structured interview.
Results: When analyzing the transcribed data assessing symptom relief, there were approximately equal numbers of negative responses between treatment groups. Responses were also fairly balanced between groups regarding general expressions of pleasure for the therapy. In summary, the authors noted that patients in both groups generally enjoyed their therapy and there were few possible adverse effects, such as foot discomfort, nausea, shaking or sleep disturbance.

⁵⁶Wilkie DJ, Kampbell J, Cutshall S, Halabisky H, Harmon H, Johnson LP, et al. Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: a pilot study of a randomized clinical trial conducted within hospice care delivery. Hospice Journal - Physical, Psychosocial, & Pastoral Care of the Dying. 2000;15(3):31-53.

Purpose: Evaluate effects on pain and QOL
Type of Study: Blinded randomized controlled trial (pilot)
Methods: (Lung, breast, prostate, colorectal and other cancers) Hospice patients were randomly assigned to usual hospice care as controls or to hospice care plus massage twice weekly for two weeks. Each massage session was 30-45 minutes of “hands-on” time and followed a standardized protocol. Of 599 eligible patients, 173 were screened for eligibility for the study* and 84 were found to be eligible. Of these 84 patients, 56 (67%) consented to participate. Ages ranged from 30 to 87 with an average of 64 years. None had received previous massage. Sixteen control patients and 11 massage patients withdrew due to death (n=15) or rapid physical or mental deterioration (n=6). Six patients withdrew for other reasons and five of these were assigned to the control group. The resulting 15 massage and 14 control patients were not statistically different in age or baseline mean scores for any of the outcome variables. Primary nurses collected pain intensity and analgesis use as part of their routine hospice care. Quality of life data was collected by a professional with a master’s degree who was unaware of the patient’s group assignment. Massages were provided by five licensed massage therapists who were trained in the written study protocol. Before and after the massage, the therapist asked the subject to complete a written self report tool of present pain intensity and emotional distress measured on a 0 to 10 scale of Wilkie, Olsson & Metcalf, 1993. Also, the therapist recorded the heart and respiration rates, length of the massage, description of subject’s position and responses and types of strokes applied to specific areas of the patient’s body. Data was abstracted from medical records by a nurse who was not involved with patient care and a random sample of these abstracts were verified by the author. Several assessment tools are detailed in the article.
Results, Short-term Outcomes: Statistically significant (P<0.05) reductions occurred in pulse rates after each of the four massages and in respiratory rates after all except the third massage. Pain intensity was significantly reduced after the first and third massages. Emotional distress scores were reduced after all massages, but not significantly.
Results, Long-Term Outcomes: Sensory Pain at baseline was present constantly in 50% and intermittently in 30% in each group. The constant pain resolved over the course of the study to intermittent or episodic pain in 14% of the patients in both groups. One significant negative effect apparently occurred in that intermittent pain escalated to constant pain in 7% of patients in the massage therapy group, but none of those in the usual hospice care group. Average pain intensity was reduced by 42% for the massage group and 26% for the controls, but this difference was not statistically significant. Analgesic doses of intra muscular morphine equivalent doses remained stable for both groups over the course of the study. Numbers of hospital admissions were too small to compare statistically. Most Quality of Life scores did not have statistically significant differences, but the Global Well Being scores showed a trend (p<0.09) for the massage group. Median longevity was 41 days for the massage group and 91 days for the control group. Longevity was negatively correlated with Global Well Being scores at the beginning and end of the study. According to multiple regression analysis, the following were significant predictors of Long-term Global Well Being: initial Global Well Being scores (p=0.001), pain intensity scores (p<0.03), initial prescribed analgesic doses (p<0.07), and initial number of pain sites which together explained 55% of the variance in these scores (P<0.07).
Results, Gender and Age Effects: No apparent age effects were noted, but women in both groups reported higher mean pain intensity scores and higher quality of life scores than the men.
Authors’ Conclusions: For the next study:

1. 1. Screen all potentially eligible patients.
   2. Stratify the random group assignments by gender, baseline pain intensity levels and quality of life scores.
   3. Perhaps include longevity as a co-variate.
   4. Require 80 subjects per group to allow for missing data and still have a power of .80 at P<0.05.

*Comments: Two sources of bias exist in this study, the unknown reasons for failure to screen all eligible patients and the assignment of patients asking to withdraw to the control group.

Randomized Controlled Trials, Not Blinded (9)

⁵¹Hernandez-Reif M, Ironson G, Field T, Hurley J, Katz G, Diego M, et al. Breast cancer patients have improved immune and neuroendocrine functions following massage therapy. Journal of Psychosomatic Research 2004;57:45-52.

Purpose: Evaluation of effects upon immune functions and quality of life
Type of Study: Randomized unblinded controlled clinical trial
Methods: (Breast) Women (number not reported) responding to an announcement at a university cancer center or its support groups were screened for eligibility. Screening criteria included stage 1 or 2 breast cancer diagnosis within the past three years and being at least three months after completion of surgery, chemotherapy and/or radiotherapy. Additional criteria are described in the article. Forty women who met the eligibility criteria were randomly assigned to a massage or control group. Six women dropped out for a variety of reasons described in the article, leaving 34 in the final sample, of whom 27 provided immune measures (15 in the massage group and 12 in the control group). Women in the massage group received three 30-minute massages a week for five weeks given by a trained massage therapist. Women in the control group received standard medical care alone, but were offered massage at the end of the five-week study period. The 30-minute massage included Swedish, trager and acupressure techniques according to a standardized protocol. During the study, women were screened for use of medications and herbs/vitamins/minerals. Standardized assessment scales, urinalysis, blood assays and statistical evaluations are described in the article.
Results: Significant reductions occurred in the Profile of Moods States (POMS) for anxiety, depression and anger (P<0.05). Significant reductions also occurred in the Self-Reports of depression (P<0.01) and hostility (P<0.05). The natural killer (NK) cell number significantly increased for the massage group (P<0.05) and decreased for the control group, but NK cell cytotoxicity did not differ significantly between the two groups. Cortisol stress hormone, norepinephrine and epinephrine levels did not decrease following massage.
Note: Data for the subjects in this study was later added to a subsequent study comparing three groups: Massage, standard treatment and relaxation as described below under non-randomized prospective controlled studies⁵².

⁴⁹Smith MC, Reeder F, Daniel L, Baramee J, Hagman J. Outcomes of touch therapies during bone marrow transplant. Altern Ther Health Med 2003 Jan-2003 Feb;9(1):40-9.

Purpose: Evaluate effect upon engraftment time, complications and perceived benefits
Type of Study: Randomized controlled trial
Methods: (Bone Marrow) Adult patients (n=88 out of an unknown eligible number) at a bone marrow transplant unit at a tertiary care hospital were randomized into three groups:

A. Massage therapy (MT)
B. Therapeutic touch (TT)
C. Friendly visit/control (FV)

Massage consisted of a Swedish massage performed by a registered nurse certified in massage therapy. Therapeutic Touch followed the Krieger-Kunz method and was administered by a nurse who was a trained practitioner. Friendly visits consisted of social conversation with a volunteer who was not a family member or health care provider. All sessions lasted 30 minutes, and were administered every third day from the time chemotherapy began until discharged from the program. Engraftment time, complications and perceived patient benefits were measured.
Results: No significant differences were found among the three groups with respect to the time required for subjects to engraft following BMT or gastrointestinal complications. Of the complications measured, only CNS/Neurological complications showed significant differences between MT and FV (P=0.031). Significant differences in “comfort” were found for TT (P=0.007) and MT (P=0.000) compared with FV. A statistically significant difference for the total Patients’ Perceived Benefits score was found for MT (P=0.003).

⁶⁰Stephenson N, Dalton JA, Carlson J. The effect of foot reflexology on pain in patients with metastatic cancer. Appl Nurs Res 2003 Nov; 16(4):284-6.

Purpose: Evaluation of foot reflexology upon pain
Type of Study: Randomized controlled trial
Methods: (36% lung, 22% lymphoma, 11% colorectal, other) Thirty-six out of 45 eligible patients with metastasis on an oncology unit participated in the study. They were stratified by low (2-4) and high pain scores (5+) into the foot reflexology or control group. Foot reflexology was delivered two times, 24 hours apart, by a certified foot reflexologist using the original Ingham method. Control patients were offered a reflexology session at the conclusion of data collection. Pain scores were assessed at baseline, immediately following intervention, and three and 24 hours post intervention. Analgesic use was measured for three days (timing unclear). Most patients had no knowledge of foot reflexology prior to the intervention.
Results: Using baseline adjusted measurements, post treatment pain scores immediately following intervention were significantly lower (P<.01) for the foot reflexology group. No significant effects were found at three or 24 hours.

⁵⁹Taylor AG, Galper DI, Taylor P, Rice LW, Andersen W, Irvin W, et al. Effects of adjunctive Swedish massage and vibration therapy on short-term postoperative outcomes: a randomized, controlled trial. J Altern Complement Med 2003 Feb; 9(1):77-89.

Purpose: Evaluation of massage and vibration therapy upon surgical pain, distress and anxiety
Type of Study: Randomized controlled trial
Methods: One hundred forty seven adult female patients scheduled to undergo an abdominal laparotomy for the removal of suspected cancerous lesions volunteered for the study out of an unknown eligible number. The sample size required for 80% power was 130; however only 105 of the 147 subjects completed the study. Subjects were divided into three groups:

1. 1. Usual postoperative care (UC)
   2. UC plus therapeutic massage
   3. UC plus vibration therapy

All participants received analgesia on induction of surgical anesthesia, and additional analgesia was available when needed as part of UC. The massage group received a 45-minute Swedish massage following surgery, and at the same time on the next two postoperative days. The massage session could be terminated early at the request of the patient. The massage was administered by licensed massage therapists with over five years experience, following a protocol designed by a panel of experts on medical massage for use in postoperative patients. The vibration therapy group received vibrations administered in inaudible, low frequency sound waves, resonating through the mattress and into the body tissues. They received a 20-minute session following surgery and at the same time on the next two postoperative days. Patients were allowed to activate the vibration therapy at additional times during the day if they desired. Measurements were taken at baseline, and pre and post intervention on the day of surgery and postoperative day 1 and 2. Primary outcomes measured were sensory and affective pain, anxiety and distress. Secondary outcomes measured were state anxiety, positive and negative affective states, patient-controlled analgesia, systolic blood pressure, 24-hour urine free cortisol, duration of hospital stay, postoperative complications. Stage of cancer cancer was determined by the physician following surgery and subsequently analyzed for correlations with any of the other outcomes. A variety of validated measurement scales were used in the measurement of these outcomes and are described in the article.
Results: No significant differences were found between the different groups at baseline, or between those who completed the study and those who dropped out. Massage was significantly better than UC (P=.0244) and vibration therapy (P=.0015) for affective pain, and significantly better than UC for sensory pain (P=.0428) on the day of surgery. On postoperative day 2, massage was significantly better than UC for distress (P=.0085) and vibration therapy for sensory pain (P=.0085), and vibration therapy was significantly better than UC for sensory pain (P=.009) and distress (P=.009). After, controlling for multiple comparisons and outcomes (P=.05/4), no significant differences were found between groups for any of these primary outcomes. The authors provided several reasons for the effect of massage being less effective than predicted, notably its small effect size, the reduced sample size, and low baseline pain, anxiety and distress scores. The authors concluded that the low pain and distress scores of the participants suggest that standard postoperative care alone provided good pain relief. No significant differences were found for the secondary outcomes measured.

⁶²Goodfellow LM. The effects of therapeutic back massage on psychophysiologic variables and immune function in spouses of patients with cancer. Nurs Res 2003 Sep-2003 Oct; 52(5):318-28.

Purpose: Evaluation of massage upon stress in spouses of patients with cancer
Type of Study: Randomized controlled trial
Methods: (Various) Eligible subjects for the study were spouses of patients with cancer who were receiving either radiation or chemotherapy. For a power of 80%, 42 participants, 21 per group, were needed. Out of 87 spouses who were interested in the study (out of an unknown number), 65 met eligibility requirements and a total of 42 were able to participate and complete the study, thus fulfilling the power requirements. Spouses were randomized into two groups, with one group receiving therapeutic back massage (TBM) and the other group reading a non-anxiety provoking book (control). Both the TBM and reading time lasted 20 minutes. To obtain measurements of NKCA, subjects in both groups had an IV inserted into their antecubital vein (in front of the elbow) that remained there during and 20 minutes after the massage and control sessions. IVs were inserted by trained registered nurses who also collected all data. Massages were administered by a registered nurse who teaches TBM in clinical practice (massage credentials unknown). Measurements were taken pre-intervention (Time 1), immediately following intervention (Time 2) and 20 minutes following intervention (Time 3) for natural killer cell activity (NKCA), heart rate, systolic blood pressure, diastolic blood pressure, mood and perceived stress. After the last measurement was taken for control subjects, they were also given a TBM. All patients were monetarily reimbursed for participation in the study.
Results: At baseline, no significant differences between groups were found except that women overall had higher mean scores of depression and stress. Various measures of baseline characteristics are described in the article. The TBM group had a significant positive change in mood (P=.0005) and a significant decrease in perceived stress (P=.001) from Time 1 to Time 3. As predicted by the author, significant inverse relationships were found between mood and NKCA (P=.009) and between perceived stress and NKCA (females only, P=.03). However, no significant change in NKCA occurred between the two post intervention time points for either group. The author discussed possible reasons for not observing significant effects upon NKCA. These included the presence of an IV line during and after massage, limited duration and intensity of the massage and not waiting long enough after the massage to assess the NKCA.

⁵⁸Weinrich SP, Weinrich MC. The effect of massage on pain in cancer patients. Applied Nursing Research 1990 Nov;3(4):140-5.

Purpose: To evaluate the effect of massage on cancer pain
Type of Study: Randomized controlled trial
Methods: (Various cancers) Patients (n=28) were randomly selected from the 30 bed oncology floor of a hospital and paired according to frequency of medication for pain, tranquilizer, or antiemetic effect. Each member of a pair was then randomly assigned to receive a 10-minute Swedish style back massage with lotion or to sit and visit with a nurse for ten minutes. Massages were given by seven nurses who had received one hour of training in massage, interview techniques, and use of a Visual Analog Scale (VAS) to measure self-reports of pain intensity before and one and two hours after each session. Medications taken were also included in the study. Before the procedure, subjects in the massage group had higher mean levels of initial pain (3.1) than the control group (2.2). Males in the treatment group had the highest mean level of pain (4.19). (All standard deviations reported were overlapping with each other.) Analysis of covariance and repeated measures were performed to detect group differences in perceived pain over time.
Results: A significant decrease in pain levels occurred immediately after massages (F(5,13) = 8.24, p = 0.01) for males, but not females ((F(4,6) = 2.52, p = 0.17). No significant differences occurred comparing one versus two hours after the massages. No significant differences occurred after the control sessions. Age had no significant effects upon pain on any of the VAS measures. Medication given one to four hours before the procedure was not significantly associated with a decrease in pain immediately after the intervention (F(4,24) =1.44, p = 0.24) or one hour after the intervention (F(5,23) =3.09, p = 0.09); however it was associated with a decrease in pain two hours after the intervention for the females (F(3,7) =29.37, 29.37, P = 0.002), but not the males (F3,5) = .03, P = .87. In summary, significant decreases in pain occurred for those with significantly higher levels of pain at baseline (males) who received massage.
Authors’ Conclusions: It had been assumed before the study that persons with higher frequencies of medication would have higher levels of pain, but in this study, patients with higher levels of pain did not take more medication. Future studies should match for gender when assigning patients into control and treatment groups. Based upon this study, massage could be effective for immediate pain relief and medication could be used for longterm pain relief.

⁶¹Field T, Cullen C, Diego M, Hernandez-Reif M, Sprinz P, Kissell B, et al. Leukemia immune changes following massage therapy. Massage Therapy Journal. 2003 Winter;41(4):58-9, 60-7.

Purpose: Assess effects upon anxiety, depression and immune system
Type of Study: Randomized controlled trial
Methods: (Acute Leukemia) Conflicting statements in the article indicate that either 20 children received massage and were compared to an unknown number on a wait-list control group or 20 children were randomly assigned to one of these two groups. All children continued to receive standard medical care during the 30-day study period. Parents of children in the massage group were guided through a 15-minute structured massage for their child on the first day. They were instructed to give these massages each evening before bedtime on the remaining days. On the first day, anxiety (State/trait Anxiety Inventory) and depression (Profile of Moods States) were assessed pre- and post-session for both the parent and the child. Complete blood counts (CBC) were recorded from the child’s medical record on the first and last days of the study.
Results: (Day 1) Parents and children had significantly lower mean anxiety and depressed mood levels after the massage session compared with the control group (all p values <0.05 according to repeated measures analysis and t-test). (First and last days) Depression significantly decreased for parents in the massage group (P=.05). White blood cell counts and neutrophils significantly increased for children in the massage group (P=.05).

²¹Phipps S, Dunavant M, Rai SN, Deng X, Lensing S. The effects of massage in children undergoing bone marrow transplant. Massage Therapy Journal. 2004;43((3)):62-71.

Purpose: Evaluation of massage upon distress, pain and engraftment time in children
Type of Study: Randomized controlled trial (pilot)
Methods: (Leukemia, other) A total of 50 patients undergoing bone marrow transplant (BMT) (out of an unknown number), ranging in age from one year to 19 years, were enrolled in the study. Patients were randomized into one of three groups:

1. 1. Professional massage
   2. Parent-administered massage
   3. Standard care controls

The professional massage group received therapeutic massages from licensed massage therapists three times per week for the four week period from admission for BMT through three weeks post-transplant. In the parent-administered massage group, parents were trained by a licensed massage therapist in basic massage techniques through demonstration, guided practice and written handouts. Parents were asked to give their child massage at least three times per week. The standard care group received the standard psychosocial services provided to all BMT patients. Immediate pre- and post-massage assessments were obtained from parents (rating their child) and patients age six and up to measure anxiety and discomfort. Quality of life data was collected on a weekly basis from parents and children age six and up. Data regarding narcotic analgesics and anti-emetic medications were obtained from the day of transplant through day 28. The number of days until engraftment and the number of days in the hospital from transplant were also measured. Parents in the professional massage and standard care groups received no suggestions that they provide massages, but it was also made clear that this was not prohibited.
Results: Results: In the professional massage group, the number of massages sessions actually received ranged from one to 14, with a median of nine. Reasons for refusal from patients included nausea, itchy skin, and the desire to not be touched. Considerable variability occurred in the parent-administered massage group, but patients received approximately three massages per week, as recommended. Immediate effects in reducing anxiety (child report P=.004, parent report P<.0001) and discomfort (parent report P=.004) were found in the professional massage group. Significant differences were observed for days to engraftment for the parent-administered massage group (P=.01) and both massage groups combined (P=.02). Quality of life measurements, patient use of narcotics (p-values not provided) and days in the hospital (P=.07) saw positive trends, though significance was not reached. The authors noted that the small sample size and unavailable self report data on patients under six may have contributed to these results. Based on the results of an after-study questionnaire, it was found that patients in the professional massage and standard care groups were also receiving massages from their parents. There was an apparent effect of receiving professional massage that increased the frequency of parental massage.
Note: For another trial comparing professional massage to that by others or self, see ³⁴ in the above section for relief of edema. This trial has also been reported in another journal⁶⁷.

⁴⁶Ahles TA, Tope DM, Pinkson B, Walch S, Hann D, Whedon M, et al. Massage therapy for patients undergoing autologous bone marrow transplantation. Journal of Pain and Symptom Management 1999;18(3):157-63.

Purpose: Evaluation of massage upon anxiety, depression, mood, fatigue, nausea and pain
Type of Study: Randomized controlled trial
Methods: (Various) Thirty-eight patients scheduled for autologous bone marrow transplant (BMT) were approached (out of an unknown number during an unknown time period), 33 of whom agreed to participate and completed the study. Subjects were randomized into a massage or standard medical care group. Patients in the massage group received up to nine 20-minute Swedish/Esalen massages during their hospital stay with a goal of approximately three per week. A trained, healing-arts specialist with over 10 years of experience performed all massages. Subjects in the standard care group had 20 minutes when staff were instructed not to enter their rooms or interrupt them. (Uninterrupted times were a normal part of the usual care offered to all patients in the autologous BMT program.) The overall effects of massage on anxiety, depression, and mood were assessed pretreatment, midtreatment and predischarge for both groups. Immediate effects on distress, fatigue, nausea, pain, systolic and diastolic blood pressure, heart rate, respiration rate and medication use were assessed before and after the first, fifth and final massage by a nurse after the therapist left the room. Control subjects were instructed to have a “quiet times” for 20 minutes on schedules that approximated the massage schedules. Data were collected before and after these quiet times.
Results: The number of massages received by the massage group ranged from four to nine, with the majority receiving eight or nine. There were no significant group effects overall by the end of the study, although the massage group had significantly lower anxiety levels at midtreatment (P=.02). Immediate effects of massage were observed for diastolic blood pressure (P=.01), distress (P=.02), nausea (P=.01) and anxiety (P=.0001) and these immediate effects were strongest during the first week of treatment. No significant differences at any points in time were detected in medication use or fatigue.

Randomized Controlled Trials with Cross-Over (2)

⁴⁸Post-White J, Kinney ME, Savik K, Gau JB, Wilcox C, Lerner I. Therapeutic massage and healing touch improve symptoms in cancer. Integr Cancer Ther 2003 Dec; 2(4):332-44.

Purpose: Evaluation of effects upon pain, nausea, mood states, anxiety and fatigue
Type of Study: Randomized controlled trial with cross over
Methods: (52% breast cancer, 19% gynecological or genitourinary cancer, 11% gastrointestinal, other) Adult patients were eligible if diagnosed with cancer and receiving chemotherapy that included an identical repeating cycle for two or more remaining cycles, and rated pain, nausea or fatigue as 3 or greater on a scale of 0 to 10 (10 being the worst). Two hundred thirty out of 549 patients eligible were randomized into three interventions:

A. Therapeutic massage (MT)
B. Healing touch (HT)
C. Caring presence and calming music (CP)

Therapeutic massage and healing touch were administered by credentialed practitioners, who were also registered nurses, following a specific script and protocol. The same practitioner usually provided all four sessions. Patients received four weekly 45-minute sessions of the assigned intervention and four weekly sessions of standard care (chemotherapy only), with the order of conditions randomized, starting on the day before the first day of their next chemotherapy cycle and crossing over to the alternate assigned intervention after the four weekly sessions. Vital signs and self reports of pain, nausea, anxiety, fatigue and mood disturbances were assessed pre- and post-session. Diaries recording use of analgesics and antiemetics were collected at each weekly session. Overall satisfaction with care was assessed at baseline and at the end of each four-week period. Open-ended questionnaires evaluating each intervention were given at the last session of each intervention. Of the 230 patients who consented to participate, 164 (71%) completed all eight sessions. Half of the subjects who dropped out did so because they wanted a different treatment or schedule change. Demographic characteristics were similar, but higher proportions of those who dropped out had more advanced stages of disease, pain, mood disturbance and fatigue scores at baseline than those who remained in the study. Wash-out times averaged 16.7 days, but the intervals between interventions varied from three to 56 days. Pain and nausea were only measured for the first four sessions and not sessions 5 – 8 because it was found that the medications had a carry over effect between sessions.
Results: No lasting effects were found on pain, but mean pain scores were all < 3 for each session in spite of this being a criteria for entry into the study, possibly due to a carry over effect. No effects were found on nausea, but mean nausea scores were consistently < 1 at the start of each session prior to chemotherapy. The following table summarizes significant differences:

⁴⁷Grealish L, Lomasney A, Whiteman B. Foot massage. A nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalized with cancer. Cancer Nursing 2000 Jun;23(3):237-43.

Purpose: Evaluation of effect upon nausea and pain
Type of Study: Randomized controlled trial with cross over
Methods: (Various cancers) Patients (n=87) were randomized to one of three different combinations of intervention sessions:

A. Control, massage, massage
B. Massage, control, massage
C. Massage, massage, control

Massage sessions consisted of a 10-minute foot massage by a nurse who was trained in massage techniques and control sessions were quiet periods of watching television or reading. At entrance to the study, the patients’ quality of life was assessed with the Eastern Cooperative Oncology Group (ECOG) scale. Almost half were in group numbers 2 (ambulatory, self caring, unable to carry out work, up and about more than 50% waking hours) and 3 (limited self-care, confined to bed or chair more than 50% waking hours). Pain, nausea and relaxation were measured with visual analogue scales before and after the massage and control interventions. Heart rate was also measured pre and post intervention.
Results:

Nausea: Mean nausea scores significantly decreased after the first massage sessions (17.5 + 24.4 mm to 11.1 + 19.1 mm; t=3.117; p = 0.0012) and after the second massage sessions (17.7 + 23.6 mm to 12.8 +18.6 mm ; t=3.178; p = 0.0011). Control sessions had no significant changes (18.4 + 22.5 mm to 17.4 + 20.5 mm; t = 0.942; p = 0.1745). (Effect of massage upon pain was also evaluated in this study as described under 39A.)
Pain: For the massage sessions, the pre-test mean pain score for the first massage was 25.1 21.7mm which significantly decreased to 15.3 19.0 mm immediately after massage (5=5.979; p = 0.0001). Similarly, the mean pain score immediately after the second massage session decreased 9.4 mm from 27.9 25.5 mm to 18.5 19.1 mm (t-5.751; p=0.0001).
No significant differences in pain scores occurred after the control sessions: pre-test mean pain score was 21.3 20.2 mm, compared with a post-test mean pain score of 20.4 19.8 mm, which was a non-significant difference (t=0.867; p=0.1943).
Relaxation: Mean relaxation scores significantly improved after first (22.2 mm; t= 11.308; p=0.0001) and second massage (16.5 mm; t=7.547;p=0.0001). The difference after control session was not significant (2.7 mm; t=1.504; p=0.0681).

Prospective, Non-Randomized Controlled Trials (4)

⁵²Hernandez-Reif M, Field T, Ironson G, Beutler J, Vera Y, Hurley J, et al. Natural killer cells and lymphocytes increase in women with breast cancer following massage therapy. International Journal of Neuroscience 2005;115(4):495-510.

Purpose: Evaluation of pain, mood and immune effects
Type of Study: Non-randomized prospective controlled trial (Note that this study added subjects to a previous randomized trial51.)
Methods: (Breast) Fifty-eight women (out of an unknown eligible number) diagnosed with breast cancer within the past three years were recruited and screened for this trial (out of an unknown number initially applying). Screening for eligibility included being at least three months post surgery and/or had completed their last radiation and/or chemotherapy session. They were assigned to massage (n=22), relaxation (n=20) or standard treatment (n=16). The 22 women in the massage group were added on to 15 women in the massage group of the previous randomized study51. Women in the massage group received three 30-minute sessions per week for five weeks conducted by different massage therapists trained on a specific protocol. Participants assigned to the relaxation group practiced Progressive Muscle Relaxation (adapted from Bernstein & Borkovec, 1973) for three sessions per week for five weeks. The standard treatment control group came in only on the first and last days of the five-week study for assessments and measurements, but they were offered complementary massages at the end of the study. Assessments occurred at the beginning and end of the study and before and after each session. These included the Profile of Mood States (POMS), the Symptom Checklist 90 Revised (SCL-90R), the State Anxiety Inventory (STAI) and the Short-Form McGill Pain questionnaire (SF-MPQ;Melzack, 1987). Neuroendocrine and neurotransmitter levels were assayed from urine. Immune measures were assayed from blood.
Significant Results (P<0.05):

• • Depression – Massage reduced compared with standard treatment
  • Anxiety – Massage or relaxation reduced comparted with standard treatment control
  • Vigor – Massage improved compared with relaxation and compared with standard treatment
  • Pain – Reduced with massage or relaxation compared with standard treatment

Neuroendocrine and neurotransmitter (dopamine and serotonin) levels increased with massage. Natural killer cells and lymphocytes increased with massage. Natural killer cell cytotoxicity increased with relaxation.

⁶⁴Smith MC, Kemp J, Hemphill L, Vojir CP. Outcomes of therapeutic massage for hospitalized cancer patients. J Nurs Scholarsh 2002; 34(3):257-62.

Purpose: Evaluation of effects upon pain, sleep quality, symptom distress and anxiety
Type of Study: Non-randomized prospective controlled trial
Methods: (Various) Forty-one patients (out of an unknown eligible number) undergoing chemotherapy or radiation at a Veterans Administration Medical Center with an expected length of stay seven days or greater were recruited for the study. Because staff believed that patients would perceive care inequities if some received massage and others did not, patients were assigned to the therapeutic massage (TM) group during the first eight months of the study only, and during the last eight months of the study, patients were assigned to the control group only, with standard care and nurse interaction (NI). Patients in the TM group received three 15 – 30 minute Swedish massages, at least 24 hours apart (depending on nurse’s work schedule) during their hospital stay in addition to standard care. All massages were provided without cost by one nurse certified in hospital-based massage therapy. The NI group received 20 minutes of focused communication with the same nurse who provided massage therapy to the TM group. Participants had input into the timing of the nurse interactions. No significant differences were found in demographic characteristics of the TM and NI groups at baseline. Pain, sleep quality, symptom distress and anxiety were measured at baseline and on the seventh day after admission.
Results: The authors accepted the hypotheses that therapeutic massage would improve pain, sleep and symptom distress when compared to standard care with nurse interaction; however, they based their acceptance on findings of significant differences at the P<1.0 level. (That is, these differences could have occurred at a less than 10% probability by chance alone rather than that customary 5% probability.) Significant changes in pain (P<1.0) and symptom distress (P<1.0) were found for the Therapeutic Massage group and in sleep (P<1.0) for the Nurse Interaction group.

⁵⁰Cassileth BRVAJ . Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage 2004 Sep;28(3):244-9.

Purpose: Evaluation of the effects upon pain, fatigue, anxiety, nausea and depression
Type of Study: Non-randomized prospective controlled trial
Methods: (Various cancers) Subjects consisted of inpatients and outpatients (n=1290) at a comprehensive cancer center who either self-referred or were referred by a health professional for massage therapy. Three variations of massage were available upon request (standard Swedish massage, light touch massage, and foot massage) and sessions lasted on average 20 minutes in length for inpatients and 60 minutes for outpatients. Before and after massage sessions, patients were assessed for pain, fatigue, anxiety, nausea, depression, and “other” on a scale of 0 (not at all bothersome) to 10 (extremely bothersome) from April 2000 to March 2003. Comparisons between different types of massage were conducted.
Results: Standard Swedish massage and foot massage were the most commonly administered. After adjusting for baseline scores, outpatients reported symptom scores 0.56 points lower (95% C.I. 0.27, 0.85; P=.0002) than inpatients, for a 10% greater improvement. Adjusting for in- or outpatient status, patients receiving Swedish and light touch massages had superior outcomes in symptom scores compared to those receiving foot massage (0.32 points, 95% C.I. 0.03, 0.60; P=0.03). There were no significant differences between Swedish and light touch massage. Mean reductions between baseline and post-treatment for all massage therapies combined follow:

Pain: 2.9 (Standard Deviation 2.2)
Fatigue: 2.8 (SD 2.4)
Anxiety: 4 (SD 2.4)
Nausea: 3.1 (SD 2.4)
Depression: 3 (SD 2.3)

Comment: This is the largest study of massage for cancer patients to date.

⁶³Stephenson NL, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum 2000 Jan-2000 Feb;27(1):67-72.

Purpose: Effect upon anxiety and pain
Type of Study: Prospective controlled (pre-post and cross-over) trial
Methods: (Lung and Breast Cancers) Patients with chronic pain were screened for eligibility in the study only if they had lung or breast cancers in order to limit the types of chronic pain. Those patients who had indications of anxiety on a Visual Analogue Scale (VAS) were then asked to participate in the study. In order to exclude patients with acute and/or surgical pain, they were excluded if they had recent surgery, open skin wounds on the feet, tumors or metastases in the feet or radiation to the feet. Patients with any symptoms of deep vein thrombosis were first required to have a medical consultation. Twenty-four patients agreed to participate, but one died before the start yielding 23 eligible patients (13 with breast cancer and 10 with lung cancer). Foot reflexology was given by the researcher who was trained and certified in the Original Ingham Method. Two 30-minute foot reflexology sessions were given in a cross-over design pattern so that half of the patients received the foot reflexology in the first session followed by a session of their regular routine of rest and activity and the other half followed a reverse pattern. At least 48 hours elapsed between these interventions and the control sessions. Areas of the foot were massaged that corresponded, according to reflexology theory, to areas in the body with chronic pain and/or cancer (breast or lung) and/or supportive areas such as the pituitary, thyroid and adrenal glands. Before and after each session, the VAS scale was used to measure anxiety and the Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure pain.
Results: Medications given on control and intervention days were not significantly different. Average anxiety scores were significantly lower after foot reflexology in both groups of patients (Sample mean 21.83 lower, P=0.000). The 11 patients with breast cancer who initially reported pain, had a significant mean decrease following foot reflexology (SF-MPQ mean score decrease 0.41, P=<0.05). Other differences in pain intensity on the SF-MPQ and VAS scales were not significant. Only two patients with lung cancer initially reported pain so appropriate differences in results could not be calculated.

Uncontrolled Prospective, Clinical Series (9)

⁶⁷Iwasaki M. Interventional study on fatigue relief in mothers caring for hospitalized children - effect of massage incorporating techniques from oriental medicine. Kurume Medical Journal 2005;52:19-27.

Purpose: Relief of stress and fatigue
Type of Study: Prospective noncontrolled trial (“controls” noted in the abstract were between demographic rather than treatment groups)
Methods: (Various Conditions Including Cancer) Two groups were enrolled in this study and both groups were informed of the purpose of the research and that refusal to participate would not prejudice their care and written consent was obtained, but initial numbers of eligible and approached were not described. One group (n=68) consisted of mothers (mean age 34.8, SD 5.6) of children (mean age 4.5, SD 4.0) hospitalized for various conditions including cancer. The other group (n=20) was mothers (mean age 31.1, SD 3.7) of healthy children (mean age 3.7, SD 1.2) attending nursery school in the same city. Before and after massage, a Japanese version of the Profile of Moods States (POMS) was administered followed by measuring the vital signs of forehead and palm temperatures, blood pressures and heart rates. Massage was carried out for 20 minutes with an essential oil (rose) on the fingers, hand, forearm, neck, scapular area and back. Massage procedures were prescribed in accordance with the theory of ki (vital energy) flows and performed by the author.
Results:

Moods: Significant (P<0.01) improvements occurred in both groups in all mood states (vigor, fatigue, confusion) in both groups. Before and after massage POMS scores for Tension-Anxiety, Depression-Dejection, Anger-Hostility and Fatigue were significantly higher in the mothers of hospitalized children, while the scores for Vigor and Confusion were significantly lower. Before intervention, Tension-Anxiety scores for the mothers of hospitalized children with cancer (n=30) were similar to those of mothers of children without cancer (n=38). After intervention these scores improved in both groups (significance not stated), but those of the mothers of children without cancer were significantly lower (P<0.05) than those of mothers of children with cancer. 
Vital Signs: No significant differences were detected in frontal deep temperature and palmar deep temperature before or after massage between the mothers of hospitalized or healthy children. Systolic blood pressure was significantly lower (P<0.05) before massage in mothers of hospitalized children and remained significantly lower (P<0.01) after massage compared with that of mothers of healthy children.

Note: Statistical comparisons reported in this study were between mothers of hospitalized versus non-hospitalized children rather than improvement or lack in either group.

²²Mackereth P, Sylt P, Weinberg A, Campbell G. Chair massage fro carers in an acute cancer hospital. Euro J of Oncol Nurs 2005;9:167-79.

Purpose: Improvement in well-being
Type of Study: (Stage 2 of article) Prospective uncontrolled clinical series
Methods: Pre- and post-tests were administered to 34 carers who received chair massages during one “typical” week.
Results: After massage, 91% of participants experienced a significant improvement in their general well-being scale and 8% felt no change, but no one felt worse. Again, female carers appeared to have significantly improved in comprison to male carers. Parents received the highest level of benefit, but both females and parents had the lowest levels of well-being before massage. Both physical and psychological well-being scales were significantly reduced. A “next-day” questionnaire was returned by 68% of participants and these showed that benefits appeared to have been retained. These included reduced levels of worry and better sleep.
Notes: Details of scale changes and significance testing are reported in the article; however, some of the scores are not clearly linked with the statistics reported. The “stage 1” retrospective review of this article is summarized in the section below for retrospective reviews.

⁶⁵Hodgson H. Does reflexology impact on cancer patients' quality of life? Nursing Standard 2000 Apr;14(31):33-8.

Purpose: Effect upon quality of life
Type of Study: Uncontrolled clinical series within a randomized clinical trial
Methods: (Various types of cancer) A convenience sample of 12 patients in the palliative stages of cancer was recruited and randomized to receive three 40-minute sessions of either reflexology or placebo reflexology (gentle foot massage). These sessions were carried out on days one, three and five. Patients with previous experience with reflexology were not eligible for the study. The visual analogue scale (VAS) of Holmes and Dickerson (1987) was modified with permission to incorporate an open-ended question: “Are there any more comments you would like to make?” Five of the 28 components of the original tool were inadvertently omitted regarding future ability to earn, recreational activity, ability to eat, texture of food and general restrictions. The study was continued without these components. The 12 participants completed two separate scales: one prior to randomization and one within 24 hours following the intervention. Probability of significance was calculated for the differences between both groups for each of the 18 components of the VAS. The data was analyzed using the Mann-Whitney U test.
Results: All participants in both groups found the experience to be relaxing. All six participants in the reflexology group reported an increase in their quality of life compared with two of the six in the placebo group. Differences in the 18 individual components of the before and after VAS scales indicated that four quality of life components in the placebo group improved compared with 16 components in the reflexology group. The areas which demonstrated the greatest improvement were appetite, breathing, constipation, diarrhea, fears of the future, pain, nausea, sleep, communication and tiredness.

⁶⁶Wilkinson S, Aldridge J, Salmon I, Cain E, Wilson B. An evaluation of aromatherapy massage in palliative care. Palliative Medicine 1999 Sep;13(5):409-17.

Purpose: To compare massage with and without aromatherapy
Type of Study: Uncontrolled clinical series within a randomized clinical trial
Methods: A total of 103 patients with a variety of cancer types who had been referred for anxiety/tension, pain or depression were randomly assigned to a course of three separate full-body massages over three weeks with or without aromatherapy consisting of chamomile. (Chamomile was chosen because of a previous study that had demonstrated its efficacy in reducing childbirth-associated pain.) Four nurses holding recognized diplomas from massage schools gave the massages. Guidelines for the massage technique were developed, presented in a training session and spot checked monthly for consistency. Both groups were evaluated with pre- and post-test scores of quality of life using the Rotterdam Symptom checklist, which takes into account both the number and severity of 30 symptoms of pain, nausea, fatigue and other quality of life indicators. Post-test questions were given within 20 minutes of the end of the massage sessions. Another semi-structured questionnaire was mailed to the patient two weeks after the last massage to determine the patients’ perceptions of massage.
Results: Sixteen patients did not complete the study because of death (13) or illness (three). Of the remaining patients, 43 were in the aromatherapy group and 44 in the massage group. According to matched pair comparisons, mean scores were significantly improved for physical symptoms, psychological symptoms and quality of life for the group with massage plus aromatherapy. The number of persons with severe physical or psychological symptoms or decrease in activities was also decreased in the massage plus aromatherapy group. Levels of anxiety according to the State-Trait Anxiety Inventory Scale were reduced between pre- and post-test scores after all three sessions of massage either with or without the chamomile aromatherapy. See 69 for an additional survey of these patients.

⁶⁹Wilkinson S. Palliative care. Get the massage. Nursing Times 1996 Aug;92(34):61-4.

Purpose: Quality of life
Type of Study: Mailed survey component of larger study⁶⁶
Methods: Of the patient population described previously⁶⁶, 71 patients were mailed a survey. The remaining 32 who were not sent a survey had died (19), were too ill (seven) or inadvertently left out (six). The survey asked them to describe what benefits, if any, they felt they had received from their massages and what they liked and what they disliked.
Results: Forty-eight (68%) questionnaires were returned. All of the respondents liked some aspect of their massage, and 45 said they had benefited from it. All 48 said that relaxation was a positive result, and 14 said that this relaxation continued after the massage. Pain reduction was cited as a benefit by 16 patients, and 10 patients cited other physical benefits. Approximately half of the patients indicated that the positive aspects had been mainly emotional or spiritual. Positive appraisal of massage therapists was a predominant theme. Only eight patients reported some negative reactions consisting of: the smell of the oil (one person), oil on face or hair (three people), initial embarrassment (two patients).

⁴Ferrell-Torrey AT, Glick OJ. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nursing 1993;16(2):93-101.

Purpose: Evaluate effects upon pain, anxiety and other measures
Type of Study: Uncontrolled clinical series
Methods: (Various sites) Thirty minutes of therapeutic massage were given on two consecutive evenings to a “convenience sample” of nine hospitalized men experiencing cancer pain. One of the men required emergency surgery on the second day and another was two nauseated to receive the second massage yielding seven men who actually completed the study. For this study, therapeutic massage was defined as “A rhythmic, sensitive form of touch performed by a specially trained individual with a desire to communicate empathy to the recipient, thus producing positive psychological and physiological states of being.” Self-reports of pain and relaxation were measured with a Visual Analogue Scale (VAS) and anxiety with the State-Trait Anxiety Inventory (STAI-Y-1). Relaxation was also estimated through the physiological measures of heart rate, respiratory rate, systolic pressure, diastolic pressure and mean arterial pressure. Massage was performed by the investigator and included trigger point therapy. Measures were taken before and immediately after the massage, and 10 minutes later.
Results: Significant decreases (i.e. improvements) occurred in average levels of pain perception, anxiety, heart rate, respiratory rate and blood pressure. The average pain score significantly decreased 29.5 mm (p<0.01) on day one and 22.6 mm (t=3.0; p = 0.025) on day two. The average anxiety score significantly decreased 13.3 mm (t=3.1; p=0.02) on day one and 12.9 mm (t=4.6; p=0.004) on day two. (Pre-massage scores for both pain and anxiety on day two were slightly lower than pre-massage scores on day one.) Average relaxation scores decreased 32 mm (t=6.9; p=0.0001) on day one and 35.5 mm (t=7.2; p=0.0004) on day two. Heart rate decreased after both massages, but only the decrease was not significant until 10 minutes after the massage on day one and none of the heart rate decreases on day two were significant. Respiratory rates on both days were significant reduced after massage (p<0.05). Blood pressure (mmHg) significantly decreased after massage on day one (p<0.05). On day two, the decrease was not significant until 10 minutes after the massage (P=0.05). (Individual components of blood pressure change are detailed in the article.)

⁶⁸Billhult A. A meaningful relief from suffering: experiences of massage in cancer care. Cancer Nursing 2001 Jun;24(3):180-4.

Purpose: Evaluate perceptions of massage experience
Type of Study: Uncontrolled clinical series
Methods: (Breast and rectal cancer) Eight women with cancer were given light massage for 10 consecutive days and then interviewed. Ages ranged from 54-80 years. The massage sessions lasted for 20 minutes and included the hand/forearm or loot/lower part of the leg. Cold-pressed sunflower and rapeseed oil was used. Five patients were massaged by students of a one-day course in massage, and the other three were massaged by the instructor and first author. Accordingly, the latter three were interviewed by the second author. The interviews were given on the last day of massage, lasted from one to 1½ hours and were defined by the authors as “phenomenological”. That is, the subsequent analysis of taped or hand-written notes first attempted to understand the interviews as a whole, then focused upon breaking it down into parts, and then returned to the whole with the intent of “deepening and synthesizing its meaning”.
Results: Quotations are provided in the report of the recipients’ descriptions of the essence of getting massage as part of the daily care. These descriptions included “meaningful relief from suffering”, an experience of “being special”, the development of a positive relationship with personnel, a sense of being strong, a balance between autonomy and dependence and “feeling good”. Negative reactions were not reported.

⁵³Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. Journal of Advanced Nursing 1999 May;29(5):1113-20.

Purpose: To evaluate massage as an aid to adjusting to a changed body image
Type of Study: Uncontrolled clinical series
Methods: “Practitioners” invited women to enter the study who showed signs of having significant problems in adapting to the loss of their breast, and revealed that they were particularly distressed about their changed appearance. The women had to be cancer-free following mastectomy, aged between 25 and 65 years and referred not later than one year after their original diagnosis. The initial number who were screened in not stated in this report, but three women were invited to participate. Each woman participated in two one-hour semi-structured interviews and six sessions of therapeutic massage conducted by the author. The follow-up interview was conducted by an independent researcher. For each massage session, participants were offered a choice of where to be massaged: foot, arm, face or back. The massage was limited to light, gentle effleurage strokes (rhythmic long strokes following the longitudinal axis of the body).
Results: Positive effects reported from the massage experience included help in relaxation and sleeping plus and ability to look at or touch themselves again. One person experienced a couple of weeks of feeling “low” that may have followed the opening up of feelings during the massage sessions. Although she was offered the chance to discontinue the massage sessions, she elected to continue and talked about her grief with having cancer.

⁷⁰Toth M, Kahn J, Walton T, Hrbek A, Eisenberg DM, Phillips RS. - Therapeutic massage intervention for hospitalized patients with cancer: a pilot study. - Alternative & Complementary Therapies. 2003 Jun;9(3):117-24.

Purpose: Assess effects upon pain, anxiety and alertness
Type of Study: Uncontrolled clinical series (pilot study)
Methods: (Metastatic solid cancers) Out of 79 total patients with metastatic cancers who were admitted to the hospital, 11 patients were invited to participate in this study, out of 26 eligible patients. Seven patients agreed to participate, but massage could only be provided for six because the family of one patient subsequently refused to allow massage. One of the six remaining patients was admitted to the hospital twice and counted as a separate patient for each admission. Short interviews were conducted upon study entry and then patients were offered massage every day during their eight- to 16-day stay. Length of each massage varied from 10 to 60 minutes depending upon patient tolerance. Massage therapists were required to have professional and state accreditation plus three years of full-time or five years of part-time experience with training in Swedish massage plus at least two other modalities at least one of which was a gently form of massage. “Scope of practice” guidelines were given to therapists that allowed them to adjust techniques according to their professional judgments. Detailed documentation of rationale for treatment design and length was required after each session. Patients were asked to complete a brief questionnaire and report on their experiences at study entry and each day thereafter. Medical charts were reviewed each day for clinical status, medications and use of other medical interventions.
Results: All patients receiving massage reported that it was helpful and no patient reported adverse effects. Four reported that massage provided relaxation, three that it eased their pain and two that they felt more comfortable. Mean pain levels decreased from 5.5 to 3.5 (significance not reported) and alertness level increased from 3.67 to 5.50. However, mean anxiety level also increased (3.67 to 5.50).

Retrospective Uncontrolled Series (3)

²²Mackereth P, Sylt P, Weinberg A, Campbell G. Chair massage fro carers in an acute cancer hospital. Euro J of Oncol Nurs 2005;9:167-79.

Purpose: Improvement in well-being
Type of Study: (Stage 1 of article) Retrospective review
Methods: (“Carers” of Patients with Cancer) Records were reviewed of 182 carers who had received a chair massage during the past 12 months. These records contained post-massage comments and scores from a “Feeling Good Thermometer" (FGT), a visual analogue scale for pre- and post-treatment well-being.
Results: Significant general improvement in well-being was experienced in 97% of carers. Female carers felt a higher level of benefit than male carers, but they had a lower pre-massage level of well-being. One person felt worse and expressed that the massage had been relaxing but that she felt emotional afterwards.
Note: Details of scale changes and significance testing are reported in the article; however, some of the scores are not clearly linked with the statistics reported.

⁷¹Wright S, Courtney U, Donnelly C, Kenny T, Lavin C. Clients' perceptions of the benefits of reflexology on their quality of life. Complement Ther Nurs Midwifery 2002 May;8(2):69-76.

Purpose: Evaluation of reflexology upon quality of life
Type of Study: Retrospective clinical series with chart review, no controls
Methods: (Breast, other) A sample of 47 client reflexology charts were randomly selected out of an unknown number of clients who had undergone reflexology treatments at a cancer support center. The charts contained patients’ qualitative, evaluative comments that were recorded by the therapist during the course of reflexology. These comments were categorized based upon the patient’s perceptions of the benefits of reflexology.
Results: Benefits were reported for relaxation, decreased tension, enhanced sense of self, sleep patterns, energy levels and pain relief; however, the exact method of patient selection and the methods and definitions used for the quality of life measurements were not clear.

⁷²Milligan M, Fanning M, Hunter S, Tadjali M, Stevens E. Reflexology audit: patient satisfaction, impact on quality of life and availability in Scottish hospices. Int J Palliat Nurs 2002 Oct; 8(10):489-96.

Purpose: Evaluation of reflexology upon quality of life
Type of Study: Retrospective clinical series with interviews, no controls
Methods: (Various) Twenty patients (out of an unknown eligible/screened number) were invited to complete a questionnaire. All had a confirmed diagnosis of cancer, had been attending a support group and had received reflexology treatments from the same trained reflexologist.
Results: All 20 questionnaires were returned by mail for a 100% response rate. The respondents varied in age and stage of cancer, though all had received between three and five reflexology treatments. Respondents described the physical, psychological, spiritual and other benefits they received from reflexology sessions in open ended questions.

Case Reports (3)

⁷⁸Martin M. The art and science of reflexology. Positive Health 2004 Jun;20.

Purpose: Support of patient
Type of Study: Case reports
Methods/Results: Benefits of reflexology are described for two patients: One patient had been critically ill with lymphoma. His hearing returned, his coughing and breathlessness decreased and his sleep improved. The other patient had had a mastectomy and recent flu. Her sinuses cleared and she gained increased movement of her arm and shoulder.

⁷⁹Buckley J. Massage and aromatherapy massage: nursing art and science. Int J Palliat Nurs 2002 Jun; 8(6):276-80.

Purpose: Evaluation of massage in palliative care setting
Type of Study: Case Reports
Methods/Results: Benefits were described for four cases where massage was used by nurses when words seemed inadequate.

⁵⁴van der Riet P. The sexual embodiment of the cancer patient. Nursing Inquiry 1998 Dec;5(4):248-57.

Purpose: To describe sexual issues arising during massage
Type of Study: Case report
Methods: The author describes two massage clients who were part of a larger series of patients (not identified) who received massages in the palliative care unit of a hospital or in their homes. Results: The dialogue of one patient who has lost her breast is compared to another patient who is a male who is concerned about control during the disease process.

Potential Adverse Effects

Four studies identified

Prospective Controlled Trials (1)

⁷³Bass SS, Cox CE, Salud CJ, Lyman GH, McCann C, Dupont E, et al. The effects of postinjection massage on the sensitivity of lymphatic mapping in breast cancer. Journal of the American College of Surgeons. 2001 Jan;192(1):9-16.

Purpose: To determine if massage could help in the identification of cancer in axillary nodes
Type of Study: Prospective controlled trial
Background: (Breast) In order to identify patients with breast cancer most likely to benefit from axillary lymph node dissection with a minimum of surgery, the concept of sentinal lymph node mapping was developed. During this procedure, a radiocolloid, a blue dye or combination of the two is injected into a lymphatic channel of the breast. The axillary nodes are then observed for blockage of the injected substance and that node is removed so that a pathologist can examine it for signs of malignancy.
Methods: All patients presenting to the cancer center with breast cancer were evaluated for possible lymphatic mapping and single lymph node biopsy and 594 eligible patients were enrolled. All patients were injected with a radiocolloid one to six hours before the surgery and a blue dye five minutes before surgery. Group A (n=230) did not receive any massage of the breast. Group B (n=134) received a five minute massage of the breast only after injection of the blue dye. Group C (n=230) received a five minute breast massage after the blue dye injection and also after the radiocolloid injection. Sentinal lymph nodes were then assessed and characterized as identification from blue dye and/or radiocolloid. The proportion of patients in each group with sentinal lymph nodes identified was then compared with each other and the probability of finding a difference as large or larger was then determined in a two sided hypothesis test with 95% confidence limits.
Results: Significantly greater proportions of SLNs were identified in Group B (massage after blue dye injection) compared with controls (P=0.001) and in Group C (massage after blue dye injection and after radiocolloid) compared with controls (P<0.001). However, the difference between Group A and Group B was not significant. The proportions of patients identified in each group by blue dye or radiocolloid were:

Group A (controls) - 215 patients (93.5%, CI 89.5-96.0)
Group B (massage after blue dye injection) - 129 patients (96.3%, CI91.6-98.4)
Group C (massage after blue dye and radiocolloid) - 225 patients (97.8%, CI 95.0-99.1)

Comments: The authors have addressed the concern that post-injection massage might spread disease by initiating a larger study. A pathologist, responding to the study in a letter to the editor¹⁷, noted his own previously published concerns about the possible traumatic origin of occult micrometastases⁷⁷ and urged not only caution, but a cessation of the practice of postinjection massage until it can be proved safe¹⁷.

Case Reports of Adverse Events (3)

⁷⁴Kalinga MJ, Lo NN, Tam SK. Popliteal artery pseudoaneurysm caused by an osteochondroma--a traditional medicine massage sequelae. Singapore Medical Journal 1996 Aug;37(4):443-5.

Purpose: Reporting of an adverse event
Type of Study: Case report
Summary of Onset and Treatment: A young man had several osteochondromas (hereditary benign tumors containing both bone and cartilage usually occurring near the end of long bones). He felt pain on the middle of his right thigh following a three-day camping trip although he had no history of trauma to that area. He received five massage sessions in which the region over a previously existing osteochondroma was rubbed “with some force” after applying herbal medicine.
Results: His pain was initially relieved, but his lower thigh began to swell and by the fifth session he was experiencing intolerable pain. A CT-scan revealed a benign exostosis with a cartilaginous cap and blood clot in the surrounding area. A femoral angiography revealed a pseudoaneurysm swelling of the popliteal artery with a leak at the level adjacent to the osteochondroma. During local surgery a hole in the wall of the fibrotic and swollen femoral artery was detected and repaired with a venous graft.
Discussion: The authors describe this case as a common situation in which a growing chondroma begins to impinge upon an artery. Because the femoral artery is relatively fixed, it was stretched over the chondroma and eroded by the repeated massages.

¹⁶Macdonald DR, Strong E, Nielsen S, Posner JB. Syncope from head and neck cancer. J of Neuro-Oncol 1983;1(3):257-67.

Purpose: Description of characteristics of syncope (fainting) in patients with head and neck cancer
Type of Study: Case reports of adverse effect of massage within a retrospective review
Summary of Onset: Of 17 patients with cancers of the head and neck who experienced fainting, seven patients were identified in whom the fainting was sometimes induced by carotid sinus massage.

⁷⁵Roy L. Massage therapy for people with cancer: a practitioner's experience. - Positive Health. 2004 Feb;(96):48-50.

Purpose: Description of unexpected adverse effects of light massage
Type of Study: Case report
Summary: An experienced massage therapist provided cautious light touch massage for a woman with recurrent cervical cancer who had recently received a short course of radiotherapy. She reported deep relaxation and positive effects afterwards, but called a few days later to report severe pain in her groin and chest.
Conclusions of the Author: Based upon a reference¹⁸ by another therapist, the author concluded that even such light touch had probably contributed to an inflammatory process in overly sensitive skin and possibly damaged regional lymphatic nodes.

For case reports describing potential adverse effects of massage upon lymphedema, see ⁷⁶ under Case Reports in the section for Relief of Lymphedema.

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