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The Effects of Massage
Therapy in Symptom Management for a Patient Undergoing
Chemotherapy for Cancer
by Eric Mathis, DipMT,
LMT
Abstract
The author designed and implemented a treatment plan to
investigate the effects of massage therapy (MT) on pain reduction
in patients undergoing chemotherapy for cancer. It was expected
that a 50% reduction in pain scores would result. The subject was a
68 year-old female with a history of non-progressive,
non-metastatic breast cancer who was undergoing chemotherapy
following a complete mastectomy of her right breast, including
removal of all axillary lymph nodes. Intense, intermittent pain was
reported, along with moderate levels of anxiety and fatigue and low
levels of depression. Five MT treatments were applied over a
six-week period. All symptoms were assessed before, during, and
after the study using a visual analog scale (VAS) and the Memorial
Pain Assessment Card (MPAC).
Data from the subject’s daily journal showed a 45.1% improvement
in pain scores during the first five weeks of therapy. From
beginning to end of the treatment series, scores for pain at its
worst improved by 51%, despite the aggravation of all symptoms due
to a stressful travel period during Week 4. Marked reductions in
anxiety, depression were documented, as well as strong trends
towards a decline in fatigue and sleeplessness. These data strongly
suggest that MT is an appropriate tool for the management of pain
and associated symptoms in patients undergoing chemotherapy for the
treatment of cancer.
KEY WORDS: Massage; Cancer; Pain; Insomnia;
Chemotherapy
Introduction
The five common symptoms associated with cancer and cancer
treatments are pain, anxiety, nausea, fatigue, and depression. Pain
is considered to be one of the greatest fears for people with
cancer,1 and it is estimated that between 6% and 26%
incorporate MT into their treatment.2,3 Although history
has seen some controversy over the use of MT to treat patients with
cancer, its safety is generally considered to be no longer in
question.2,4 The Canadian Cancer Society, the BC Cancer
Agency, the American Cancer Society, and the U.S. National Cancer
Institute all recommend MT for the treatment of pain.
5–8
Recent studies have been directed at establishing the efficacy
of MT for the treatment of symptoms of cancer. A randomized trial
conducted at the Memorial Sloan-Kettering Cancer Center in New York
City resulted in a 47.8% improvement in pain symptoms among cancer
patients through the use of MT.9 The same research also
documented improvements in anxiety (59.9%), nausea (51.4%),
depression (48.9%), and fatigue (42.9%). Data also suggested that
the effects of MT probably increase for each additional treatment.
Another study resulted in a 41% reduction in the use of
nonsteroidal anti-inflammatory drugs over the course of a four-week
treatment plan.10 The current study used general
relaxation MT to treat a subject undergoing chemotherapy for the
treatment of breast cancer. It was expected that a 50% reduction in
pain symptoms would result.
Method
Symptoms were assessed qualitatively and quantitatively before
and after each session using the MPAC, a tool validated by
Fishman11 and recommended as an outcome measure in
clinical trials.12 The MPAC is an 8.5 by 11 inch card
which measures pre-treatment pain intensity eight pain intensity
indicators along with a VAS. Two more VASs measure post-treatment
pain relief and mood. A VAS was also used before and after the
treatment series to measure changes in current and average pain,
pain at its best, and pain at its worst. Secondary outcome measures
were anxiety, nausea, physical fatigue, depression, quality of
life, and quality of sleep. In addition, the subject maintained a
daily journal13 to track symptoms with VASs, as well as
hours of sleep and the consumption of analgesic and sleep
medication.
The VAS is one of the most frequently used outcome measures for
pain. It has been accepted by Magee and others as a reliable
quantitative measurement of a patient’s characteristic that occurs
across a continuum.14,15 It consists of a 100mm
horizontal line accompanied by narrative descriptions at each end.
All scores reported are based on a scale of 0 to 100. It is a
highly subjective measure and is most useful when attempting to
assess change in patients.
Subject Profile
A 68 year-old female was referred for this study by the medical
staff at Dr. Edward Chalmers Hospital (DECH). The subject was
undergoing treatment for early stage intraductal and lobular cancer
in her right breast. The diagnosis was based on the results of a
biopsy and a complete mastectomy had been successfully performed,
including removal of all 14 axillary lymph nodes. Ongoing medical
assessments found no metastases. The MT treatment series began on
October 17th, four months after the mastectomy, and 12
days after the subject’s fourth cycle of chemotherapy. The final
two cycles, consisting of epirubicin, fluorouracil, and
cyclophosphamide, were administered during the course of the
massage treatment series.
The subject was taking a number of different medications,
including pravastatin for cholesterol reduction. For four days
after each cycle of chemotherapy, the subject consumed antiemetics
(Zofran®, Decadron®, and Maxeran®) which eliminated all symptoms of
nausea. The anti-anxiety medication lorazepam was prescribed as a
sleep-aid. The only analgesic medication being consumed was
Tylenol®, taken as needed.
The subject’s initial symptoms included intense intermittent
pain in the right axilla and lateral thorax around the surgical
scar when overdoing physical activity. The most significant
secondary symptoms prior to the study were moderate degrees of
anxiety (39.0) and a reduced quality of sleep (50.5). The subject
saw a physiotherapist every three weeks for treatment of Stage 3
adhesive capsulitis in the right shoulder, and did the prescribed
stretching and strengthening exercises. She considered herself to
be in excellent health and maintained an active lifestyle, swimming
one hour almost every day throughout the chemotherapy series. The
subject’s stated goal for MT was “improved spiritual and emotional
feelings.”
Treatment Plan
The treatment plan was designed to reduce the subject’s
perception of pain and to meet her personal treatment goal, as
stated above. The mutual subject-therapist conclusion was that a
light touch relaxation massage was most appropriate given the
subject’s goals and case history. Specific techniques were chosen
according to their documented analgesic effects and their ability
to reduce sympathetic nervous system (SNS) activation and
pain.15,16 The therapist did not address the adhesive
capsulitis, as it was being treated by the physiotherapist. Five
treatments were to be administered over five consecutive weeks,
applied over the clothes and without lotion at the request of the
subject.
Each session was divided into four segments. Segment 1 began
with twenty stationary circles at the terminus (just deep to the
clavicular insertions of the sternocleidomastoid muscle) to
stimulate the lymphatic system.15 The main focus was
reduction of SNS activation through the use of static contact,
stroking, effleurage, light kneadings, and muscle squeezing. Areas
treated included the occiput, neck, upper shoulders, and upper
pectorals. Specific focus was on hypertonic scalenes,
suboccipitals, and trapezius.
Segment 2 focused on the right arm and hand, with the goal of
maintaining lymph flow and reducing the risk of lymphedema.
15,16 Although no signs of lymphedema were present, the
risk contraindicated use of deep or aggressive
techniques.17–19 Reduced sensation in the right triceps
area due to iatrogenic nerve damage was an additional reason for
reduced pressure in that region. Treatment consisted of static
contact, stroking, light compressions, and light effleurage, with
gentle techniques applied specifically to the forearm flexors and
thenar muscles.
Segment 3 focused on relaxation of the left shoulder and arm.
Due to the risk of lymphedema in the right arm, the right-handed
subject was attempting to train her left hand to accomplish more
activities of daily living. No particular hypertonicities were
present.
Segment 4 returned to treatment of the posterior neck and scalp.
Focus was on the suboccipitals and temporalis, mainly using static
contact and light kneads. This region was treated last in order to
minimize the length of time the subject’s head was not wrapped with
a towel due to an expressed sensitivity to cold. Each session
concluded with static contact at the occiput.
Treatment modifications were applied according to Walton,
MacDonald, and Curties.17–19 Ongoing chemotherapy
contraindicated direct treatment to the right breast region,
including the scar. “Hands-on” treatment time per session was
reduced to 45 minutes from the typical 60 minutes in order to avoid
fatiguing the subject. Treatment 1 was expected to be shorter to
allow for a thorough health history interview. The only medication
consideration was cyclophosphamide, known to exit the patient’s
body with sweat for up to 48 hours after being
administered.18 This was not a concern in this study, as
treatments were not carried out during the critical time
period.
Results
Treatment results were divided into five periods for the sake of
data analysis (Figure 1). Periods 1 – 3 were separated by the first
three treatments. Period 4 encompassed the subject’s five-day trip
to Halifax, beginning with a stressful five-hour drive through a
snow storm. It was a distressing week for the subject due to
personal reasons and resulted in a sharp increase in all reported
symptoms, as well as an unexpected interruption in the consecutive
weeks of treatment. The treatment plan was extended one week to
accommodate a fifth session. Period 5 began one day after the
subject’s return from Halifax and continued until Treatment 4. The
daily journal was not maintained beyond Treatment 4 (Week 5), due
to the change in the treatment schedule.
A four-hour road trip during Week 1 resulted in a brief increase
in symptoms (Figure 1). One day prior to Treatment 2, the subject
began periodic attempts at reducing consumption of sleep medication
from 2 mg of lorazepam to 1 mg.13 The journal entries
for hours of sleep with either 1 mg or 2 mg were averaged within
the five periods ± 1 SD error bars (Figure 2). Treatment 2 scored 0
for pre-treatment pain, but aggravated pain associated with the
adhesive capsulitis, resulting in post-treatment pain scores of
33.0 for pain and 80.4 for mood. The subject enjoyed the treatment
otherwise and felt very relaxed.
Two tablets of Tylenol® were consumed daily until a complete
cessation from the day of Treatment 3 to the end of the subject’s
log. A fifth cycle of chemotherapy was administered on October 26,
resulting in another spike in symptoms during Period 2. Treatments
4 and 5 were the only two in which the subject reported
pre-treatment pain (47.4, 22.7). Massage resulted in post-treatment
relief scores of 91.8 and 100, respectively. The subject typically
slept through the sessions, including the one that aggravated the
adhesive capsulitis pain. Post-treatment mood scores were high
throughout the series (93.8, 80.4, 94.8, 100, 100).
Average pain scores improved 45.1% over the first five weeks of
the study (Figure 1). Post-series scores for pain at its worst and
average anxiety showed improvements of 51.0% and 76.9%,
respectively, from the pre-series assessment (Table 1). The subject
reported improved spiritual and emotional feelings consistent with
her initial goals and expressed an appreciation for time spent with
the therapist relative to the time available with her conventional
healthcare specialists. The therapist had more time to listen to
the subject’s questions and concerns, and was able to address them
either immediately or upon further research. The score for quality
of life at the end of the series was 100 (Table 1).
Discussion
The 45.1% improvement in pain scores was consistent with
published findings as well as the study’s hypothesis. Evidence of
pain relief was further supported by cessation of Tylenol®
consumption. The interruption in the treatment plan provided an
unexpected benefit to the study of an upset. Over the course of the
first three weeks of consecutive treatments, average pain scores
showed an 86.2% improvement with a corresponding decrease in scores
for anxiety and depression (Figure 1). Period 5 indicated
resumption of the downward symptom trends. The increase in overall
scores for average fatigue (Table 1) reflects single data point
observations at the beginning and end of the series, measurements
which are much less statistically relevant than the daily logs
which indicate a strong trend towards a decline in fatigue over the
course of consecutive massage treatments (Figure 1). The increase
in depression scores (Table 1) is statistically indistinguishable,
given the standard deviation.
A significant secondary outcome of the study was the improvement
in sleep patterns. Published research shows mixed results in the
ability of MT to treat insomnia. Effects were determined to be
inconclusive in one study,20 while others have presented
improved sleep as one of MT’s possible benefits.21,22 At
the end of Period 5 in the current study, the subject was sleeping
8 hours per night with only 1 mg of lorazepam (Figure 2). This
reflected a dramatic increase from 3 hours slept on October 23 with
1 mg, and an improvement over the series average of 7.4 hours per
night when consuming 2 mg. Within the daily data, there was also a
progressive decline in hours slept per night in the days following
a treatment until the following session provided a renewed
increase.13 These data were considered to be much more
statistically relevant then the negative results indicated by the
pre- and post-series assessments of quality of sleep (Table 1).
It has been reported that patients use complementary and
alternative medicine (CAM) in part because they value the closer
relationships possible with CAM practitioners.23 This
was also clearly expressed by the subject of the current study, and
it is speculated that this contributed to the reduction in anxiety
scores. Also of note was the mention of a headache during intake
for Treatment 5. This new symptom was mostly dismissed by the
subject, but the therapist advised that her doctor be informed as
soon as possible. The doctor felt that the symptoms might indicate
temporal arteritis and immediately conducted further tests. While
the headaches proved to be harmless, the incident showed how a
massage therapist can contribute in an integrative approach to
healthcare.
A problem which may have affected results was that the
descriptors on the MPAC and VASs did not always accurately describe
the subject’s perception of symptoms. This resulted in a spoiled
pre-series score for average pain (Table 1). In addition, the
incomplete data from the journal showed clear positive trends, but
lacked the conclusiveness that a full set of data could have
provided.
Conclusion
In conclusion, this case study showed clearly that MT led to
large, immediate reductions in the pain, anxiety, and depression of
a patient undergoing chemotherapy for the treatment of breast
cancer. Marked improvements in sleep patterns were also documented,
along with a reduction in fatigue. Not only is massage an effective
therapy, it is non-invasive and greatly appreciated by its
recipients. Further random controlled trials should be conducted to
clearly establish the potential benefits to those patients whose
sleep is affected by cancer and its treatment.
Acknowledgments
This study was conducted in partial fulfillment of the
graduation requirements of the Atlantic College of Therapeutic
Massage in Fredericton, New Brunswick.
In addition to thanking the subject of this study, the author
wishes to acknowledge Dr. Nancy Mathis for her generous help in
data analysis, formatting, and editing. Lisa Ivany, RMT, Candace
Gerrior, RMT, and Sharon Jones-Gilmore, RMT served as clinical
supervisors. The cooperation of Kim Chapman, Clinical Nurse
Specialist (Oncology) at DECH was also invaluable.
Biography
Eric Mathis is a graduate of the Atlantic College of Therapeutic
Massage in Fredericton, New Brunswick and recently began practicing
as a licensed massage therapist in the State of Hawaii. In
addition, he has been Associate Principal Trombone of the Honolulu
Symphony since 1996. He can be reached for comment at eric@lonepalmmassage.com.
References
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