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Pain Level Outcomes after Massage Therapy in Cancer Patients

Andie Ziegler, Jordan Mapp, Siara Martinez, and Beau Askins

College of Nursing Integrative Health, University of Arizona

NURS 379: Scholarly Inquiry in Evidence-Based Practice

Dr. Stephanie Kelly

18 April 2021
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Introduction

Cancer is the second leading cause of death in the United States and over 1,000,000 new

cases of cancer were reported in the year 2017 (United States cancer statistics, 2020). Cancer

comes with an array of complications, side effects, and adverse effects. Pain is a major side

effect that comes from both the cancer and its treatment. Cancer pain, if not managed, is a

detrimental factor to a person’s wellbeing and recovery. There are many types of pain associated

with cancer including chronic, acute, and breakthrough pain (Cancer pain management, 2021).

Utilizing a variety of therapies to manage pain promotes better pain relief outcomes. Members of

this evidence based practice (EBP) group have relatives who have dealt with cancer and the

troublesome pain that came along with it. We came to the consensus of implementing massage

therapy (MT) for cancer pain management, as it can be both a nursing intervention and a simple

home remedy. This holistic therapy can reduce pain, decrease use of addictive medications, and

prevent further adverse effects. Evidence displays “opioids have a potential to promote cancer

progression and metastases in multiple different types of cancers including breast, prostate, lung,

esophageal and hepatocellular cancer by various mechanisms” (Barlass et al., 2021). With the

invasive and painful treatments cancer patients go through, it is merited to explore other

approaches of treatment, such as massage therapy, to determine if cancer patients benefit from an

integrative method of symptom management and healing.

Background and Purpose

Cancer is generally treated using invasive pharmaceutical interventions, opposed to

holistic therapies, which often result in extreme adverse effects such as pain. The invasive

interventions for treating cancer often leave a patient physically and emotionally depleted,

rendering the patient in constant discomfort. Integrative medicine focuses on combining

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pharmaceuticals with therapeutic treatments to involve the patient’s mind, body, and spirit in the

healing process. Pain has been managed with various modes of touch and massage, which creates

a spiritual and emotional means of treatment. Touch therapy can be traced back to ancient times,

but the official adaptation and standardization of it was not applied to clinical practice until the

1970s (Therapeutic touch, 2016). The idea of touch as a healing power has become more widely

accepted for treating pain in modern medicine; there are many different forms of massage

therapy to be used as a treatment. Applying massage therapy in a patient care setting allows

nurses to incorporate an integrative intervention within their daily practice. The purpose of this

paper is to analyze the existing data from various studies to determine the effectiveness of

massage therapy as a holistic treatment of pain management for cancer patients.

PICOT Question

Taking into consideration the variety of painful procedures cancer patients endure, we are

focusing on the effects of a noninvasive approach. Our research puts into question what the

effects of massage therapy are on pain levels in cancer patients compared to those who do not

participate in massage therapy. In being a part of the healthcare system, it is important to

determine holistic nursing interventions such as massage therapy to provide comfortable and

beneficial care to patients.

Research Database Search

The University of Arizona Health Sciences Library was the search engine tool the group

utilized to access various databases. A wide variety of databases were initially searched,

including Nursing and Allied Health Connection, MEDLINEplus, CINAHL, PsycARTICLES,

PubMed, Embase, Wiley Online Library, Gale, Science Direct, Allied and Complementary
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Medicine (AMED), and Google Scholar. The final research articles were sourced from Science

Direct, Google Scholar, PubMed, and Gale Academic Onefile. The criteria for the publication

date was being less than five years old, allowing studies from April 2016 to April 2021 to be

included in the search. Using identical keywords, the initial search in PubMed without a date

restriction resulted in 6701 results, whereas the date restriction within the previous five years

resulted in 2612 results. There were two standard search phrases applied to the advanced search

within a database: cancer pain and massage therapy. Depending on the search results, variations

of these key phrases were also incorporated, including cancer patients, pain, and manual

manipulation. In order to retrieve articles within the nursing field, key phrases such as nurse

intervention, nursing care, and evidence based nursing were used.

Critical Appraisal of the Articles

Article One

Genik, McMurtry, Marshall, Rapoport and Stinson (2019) conducted a quantitative, pre-

post single group pilot study to determine how acceptable massage therapy would be for children

with cancer and their parents, while also evaluating its effectiveness in reducing pain. A

convenience sample of eight children, with cancer in end of life or supportive palliative care, and

one child’s parent answered a questionnaire about massage therapy expectations, a quality of life

cancer module, and a pain diary via PainSquad app before and after the experiment. The

participants rated their pain using a face pain scale before and after each MT session. Wilcoxon

signed-rank tests were used to analyze the data gathered during this mixed-method study.

Participants were open to using MT before and after the study was conducted and had reported

reduced pain on the face scale after each session. However, when comparing the PainSquad
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diaries from pre- and post- intervention, the pain scores were the same and showed no significant

change, showing MT is a short term solution. The study’s strength is it focused on implementing

the MT intervention for children, who are a highly underrepresented population in research.

Limitations in this study were a lack of a control group, difficulty finding participants to

complete the whole study, and non-compliance with study protocol. This study relates directly to

our evidence-based practice topic because it is implementing massage therapy for pain, similar to

the other studies, but in children with terminal cancer.

Article Two

Mardaneh, Jenabian, and Moghaddam (2020) directed a randomized two-group pre-

posttest clinical trial to explore the effectiveness of Thai massage on pain in cancer patients

undergoing chemotherapy. A group of 60 females underwent the clinical trial either at the

individual’s home or the Bu-Ali hospital in Iran. The dependent variables were measured by two

questionnaires: Kolcaba’s General Comfort Questionnaire (GCQ) and the Edmonton Symptom

Assessment Scale (ESAS), using a number value score system, with zero as no symptoms

present to 10 being the worst experience of the symptoms. The data was then analyzed via a

Kolmogorov-Smirnov test, Chi-square, Fisher’s exact, and independent-sample t-test, which

yielded a normal distribution. The results showed there was no statistical difference between the

control and intervention groups in the pre test, but during the post test there was a statistical

significant decrease in all nine cancer symptoms. A strength of the study is the participants were

actively undergoing chemotherapy while the Thai massage was being implemented, offering a

more comprehensive look at how MT can influence pain in various areas of the treatment

process. The study was limited by the participants only being female and there was no control of

outside variables which likely influenced the severity of the symptoms being tested. This study
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relates to our EBP topic because it explores a unique form of MT and various different cancer

symptoms, including pain as a priority symptom.

Article Three

Miladinia, Baraz, Shariati, and Malehi (2017) conducted a randomized two-group

controlled quantitative study to determine the effectiveness of slow-stroke back massage

(SSBM) therapy in adult patients with acute leukemia undergoing chemotherapy. A convenience

sample of 60 cancer patients, who were between their first and third chemotherapy cycles, were

recruited from outpatient chemotherapy and hematology units and then randomly placed into two

groups (intervention and control). This study’s theoretical framework of symptom management

theory measured the symptom cluster intensity of pain using the numeric rating scale (NRS) at

the end of each week during face-to-face interviews. The documented pain intensity trend had a

reliability level of α = .90 on the Cronbach’s alpha test score scale. Miladinia et. al (2017) used

independent t tests to compare the estimated symptom cluster intensity of pain over the four-

week intervention period using the mean pre- and post- test from the two groups. The pain

intensity of the control group remained consistently high with slight increase, while there was a

significant decrease in progressive pain intensity of the intervention group over time. However,

one week after the study, the SSBM group had a rapid increase in pain intensity compared to the

control group who again only showed a small increase in pain. Results imply the massage

intervention is effective in reducing cancer patients’ pain but may only be a short-term solution.

A strength of this study is the exploration of multiple adverse effects associated with cancer as

the dependent variables, offering a deeper understanding of the various symptoms that SSBM

can alleviate. Some limitations of this study were: a) patients were from only one medical center,

b) dependent variables were subjective to outside influences, and c) music was used during
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massage sessions which could have impacted results. This study directly relates to our EBP topic

because it assesses the usefulness of massage therapy and how it can reduce pain in cancer

patients.

Article Four

Gentile, Boselli, O’Neill, Yaguada, Bailey-Dorton, and Eaton (2018) led a pre- and post-

test, observational, retrospective study to establish the value of one-time implementation of

Healing Touch (HT) and Oncology Massage (OM). HT and OM interventions are explored as a

method to reduce cancer pain at a clinically significant level, defined as a decrease of two or

more points on the pain scale adapted from the Edmonton Symptom Assessment System

(ESAS). A convenience sample of 572 cancer patients, at an outpatient cancer institute, self-

reported their pain before and after either HT or OM interventions on a scale from zero to 10,

indicating no pain (0) to the worst possible pain (10). The data was then analyzed using paired t-

tests, chi-square tests, and logistic regression analysis. It found cancer patients had significantly

reduced numerical pain scores after 45 minutes of either an OM or HT interventions. OM has

increased odds of significant pain improvement when assessing only the pre- and post- test pain

scores. A strength of the Gentile et al., 2018 study is the large sample size, allowing the study to

evaluate the integrative intervention on an array of cancer types such as: breast, lung, colon,

pancreas, brain, etc. Limitations of this study include: a) the unknown total duration of pain relief

provided, b) reduced validity from participants self-selecting their desired therapeutic

intervention, and c) no control of confounding variables influencing pain, such as analgesic use

or the patient’s stage of cancer. This study relates to our EBP topic because it evaluates the

effectiveness and direct relationship of two types of massage therapy on cancer pain.
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Summary

In the process of appraising four separate research articles, it is apparent the existing

research on MT for the reduction of cancer pain is not substantial. It is evident there are no

specific cancer types that show greater promise in benefiting from massage therapy, as each

study explored a different type of cancer. It was challenging to find similar studies to synthesize

together because no two studies had remarkable areas of direct overlap and often several

dependent variables were measured within one study. The four research articles regarding our

PICOT question established pain levels of cancer patients are decreased after undergoing MT.

The studies had similar results, showing MT can be an immediate form of pain relief, but is not a

permanent solution. When pain levels of cancer patients are elevated more than usual, this would

be a recommended time for the nurse to implement MT for immediate pain relief. Based on the

fact there were reduced pain levels in our studies, we know MT is a mechanism of temporary

relief for cancer pain. However, it is still unknown whether MT provides benefits on other

adverse effects related to invasive cancer treatments.

Implications for Nursing Education, Research, and Practice

Nursing Education

It is uncertain whether nurses must be required to establish an interdisciplinary team or

become licensed themselves for the administration of this intervention. Mardaneh et al., (2021)

suggests nurses are the cornerstone of contemporary and alternative medicines and can receive

training to perform MT. More research should be conducted on MT, as a nursing intervention, to

create a curriculum to educate nurses on the proper ways to perform MT on their cancer patients.
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Nursing Research

Within the research conducted, the majority of the sources were short-term case studies

focusing on adult cancer patients. Future research on massage therapy should involve children,

be conducted over a longer period of time, and focus on the indirect effects of MT on patient

outcomes not related to pain.

Nursing Practice

To utilize MT in clinical care, there needs to be more research pertaining directly to

nurses and their application of the intervention in the field. It is promising that MT can be

administered by nurses in the same way as any pharmacologic intervention. By incorporating

MT into general nursing practice, it would allow the ability to establish whether the MT modality

is relevant to all units of care or solely oncology.

Conclusion

By exploring integrative methods of healing, such as massage therapy, the goal is to

reduce pain caused by invasive treatments cancer patients undergo. When analyzing the research

on the implementation of MT to reduce cancer-associated pain, we found MT has transient

benefits. The research regarding our PICOT question shows not only is MT an appropriate form

of pain management, but this form of pain relief is statistically significant in the clinical setting.

With the prevalence of cancer being worldwide, it is important to find non-pharmacological

interventions that can be incorporated in a cancer patient’s treatment plan. MT implementation

allows the mind, body, and spirit to be relieved from pain, promoting the body’s natural

restorative properties to take action.

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References

Barlass, U., Deshmukh, A., Beck, T., and Bishehsari, F. (January 2021). Opioid use as a

potential risk factor for pancreatic cancer in the United States: An analysis of state and

national level. PlosOne Journals, 16(1), https://doi.org/10.1371/journal.pone.0244285.

Cancer pain management. (March 2021). Drugs.com, https://www.drugs.com/cg/cancer-

pain-management.html.

Genik, L. M., McMurtry, M. C., Marshall, S., Rapoport, A., and Stinson, J. (2020).

Massage therapy for symptom reduction and improved quality of life in children with

cancer in palliative care: A pilot study. Complementary Therapies in Medicine, 48,

https://doi.org/10.1016/j.ctim.2019.102263.

Gentile, D., Boselli, D., O’Neill, G., Yaguda, S., Bailey-Dorton, C., and Eaton, T. A. (2018).

Cancer pain relief after healing touch and massage. Journal of Alternative and

Complementary Medicine, 24(9-10), 968-973, https://doi-

org.ezproxy1.library.arizona.edu/10.1089/acm.2018.0192.

Mardaneh, N., Jenabian, A., and Moghaddam, L. F. (2021). The effects of thai massage on

comfort and symptoms among female cancer patients receiving chemotherapy. Journal

of Nursing and Midwifery Studies, 10(1), 20-26, 10.4103/nms.nms_110_19.

Mojtaba, M., Baraz, S., Shariati, A., and Malehi, S. A. (2017). Effects of slow-stroke back

massage on symptom cluster in adult patients with acute leukemia. Cancer Nursing

Journal, 40(1), 31-38, 10.1097/NCC.0000000000000353.

Therapeutic touch. (2016). University of Minnesota,

https://www.takingcharge.csh.umn.edu/therapeutic-touch.
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United States cancer statistics: Data visualizations. (2020). Centers for Disease Control and

Prevention, https://gis.cdc.gov/Cancer/USCS/DataViz.html.
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PICOT Question: In cancer patients, what is the effect of massage therapy on pain levels compared to those that do not
participate in massage therapy?

Table of Evidence

Author(s) Questions, Variables Design, Sample, Results/Findings Level of

and Date Objectives, Hypothesis(es) Setting Evidence
Genik et al. Question: Can massage therapy Design: Quantitative, Massage therapy has short term positive Level VI
effectively reduce the symptoms, such pre-post single group effects on pain relief and worry.
November as pain, in children with cancer in pilot study
2019 palliative care? Sample: Eight Pain and worry intensities measured via face
Variables: children (10-17 years pain scale after each MT session. Findings
United Independent variable(s): massage old) with cancer and showed a less distressed face post MT.
States/Canada therapy 1x a week one parent of a child
Dependent variable(s): with cancer P < 0.05 = statistically significant
Pain and worry Setting: Tertiary care Ratings on the face pain scale after MT
Objective: To determine how pediatric hospital sessions showed significant improvement in
acceptable massage therapy would be pain (p = 0.03).
to children with cancer and their
parents, but also determine its
effectiveness in reducing symptoms
like pain.
Hypothesis: In pediatric oncology
patients receiving palliative care, they
will report lower ratings of pain and
worry.
Mardaneh et Question: Does Thai massage have a Design: randomized Massage therapy significantly reduced six Level II
al. positive effect on the chemotherapy clinical trial, 2-group out of the nine cancer-related symptoms,
symptoms of female cancer patients? pretest-posttest namely pain, fatigue, nausea, depression,
January 2021 Variables: Sample: 60 females anxiety, and drowsiness.
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Independent variable(s): Thai Massage undergoing

Iran Dependent variable(s): Comfort, chemotherapy ESAS used for symptom cluster assessment
Cancer symptoms (including: pain, Setting: Either the
fatigue, nausea, depression, anxiety, individual’s home or Mean scores of pain, fatigue, nausea,
drowsiness, appetite, well-being, the Bu-Ali hospital in depression, anxiety, and drowsiness in
dyspnea) Iran. Baseline intervention group were significantly less
Objective: The aim of the present assessment carried than control at p < 0.05
study was to evaluate the effects of out in the hospital.
Thai massage on comfort and Intervention group:
symptoms among female cancer Pain before: p = 0.704
patients receiving chemotherapy. Pain after: p = 0.001
Hypothesis: Female cancer patients
who undergo Thai massage along with
routine care will have a reduction of
cancer-related symptoms compared to
female cancer patients who solely
undergo routine care.
Mojtaba et al. Question: Does slow-stroke back Design: Randomized SSBM reduced the progressive fatigue, pain, Level II
massage reduce the adverse effects control 2-group and sleep disorders, yet a short-term effect
2017 related to leukemia and its treatment (intervention, control) of the massage intervention in alleviating
(including pain, fatigue, and sleep trial the symptom cluster is noted.
Iran disorders)? Sample: 60 patients
Variables: with acute leukemia Pain, fatigue, and sleep disorder intensities
Independent variable(s): Slow-stroke between 18 and 50 measured using a
back massage (SSBM) years of age; at least numerical rating scale.
Dependent variable(s): pain, fatigue, & 3 months after the
sleep disorder system cluster intensities diagnosis of cancer p < 0.05 = statistically significant
Objective: To examine the effects of and between the first Baseline: Mean scores of pain (P = 0.473)
slow-stroke back massage (SSBM) on and third did not differ significantly between the 2
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the symptom cluster in acute leukemia chemotherapy cycles groups

adult patients undergoing Setting: Outpatient Results: Mean scores (P = 0.001) showed a
chemotherapy chemotherapy and statistically significant difference between
Hypothesis: Manual massage hematology units at the 2 groups from baseline to end of fifth
techniques will diminish fatigue, pain, Shafa Hospital, Iran week
and sleep disorders and provide both
physical and psychological relaxation
in patients of the intervention group
receiving SSBM.
Theoretical Framework: Symptom
Management theory
Gentile et al. Question: Is there a clinically Design: Pretest/post- p < 0.05 = statistically significant. Level IV
significant pain improvement after a test, observational, Both HT and OM patients reported
single-administration of HT or OM retrospective study reductions in numerical pain score (p <
therapy? Sample: 572 cancer 0.001 for both).
September Variables: outpatients
2018 Independent variable(s): Healing Setting: Outpatient OM associated with increased odds of
Touch (HT) and Oncology Massage oncology setting at an significant pain improvement independent
United States (OM) therapy academic hybrid, of pretherapy pain score (p = 0.041).
Dependent variable(s): Pain community-based
Objective: To establish and compare cancer institute Results measured using ESAS adapted
the effectiveness of HT and OM numerical pain scale 0-10
therapies on cancer patients’ pain
Hypothesis: Patients undergoing either
HT or OM therapy modalities will
report a clinically significant reduced
pain score after 45 minutes of therapy.
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Burns, P. B., Rohrich, R. J., and Chung, K. C. (2011).