In my years as a massage therapist, educator, and researcher, I’ve had many opportunities to see firsthand the power of massage for people with cancer. I marvel at, and am inspired by, the work leaders like Tracy Walton, Lauren Cates, and others bring to the massage field and seek them out whenever possible to update myself on the expanding evidence base in this area of our field. While not an expert in the subject of massage for cancer, I am happy to have this opportunity to share the results of the recently completed collaborative research efforts between Emory University’s School of Medicine and the Atlanta School of Massage.
There are over 15 million people in the United States today who have had cancer and received treatment for it.1 Cancer survival rates are on the rise due to improved treatments, early diagnoses, and preventive care, and twice as many individuals living with a cancer history are expected within a generation.2 In addition to strong funding for research focused on cancer-treatment efficacy and effectiveness, research examining posttreatment quality of life for cancer survivors is increasing. Cancer-related fatigue (CRF) is one of several conditions experienced by cancer survivors and is “a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment … not proportional to recent activity and [which] interferes with usual functioning.”3 Experienced by approximately one-third of cancer survivors, CRF is associated with higher levels of disability and is particularly challenging to address.4 Pharmaceutical options for CRF (e.g., Paxil, Provigil, Armodafinil, Ritalin) are available but are not first-option treatments because they have been determined to be less effective than exercise and psychological interventions,5 both of which (importantly) introduce no additional pharmacological burden to cancer survivors. Massage therapy has also been identified as an effective, nonpharmacological approach to manage cancer treatment-related side-effects such as CRF, and this column’s highlighted research study points to positive massage outcomes specifically for postcancer treatment CRF.6
Massage Therapy for Cancer-Related Fatigue
Becky Kinkead, PhD, and Mark Rapaport, MD, lead the research group at Emory University’s School of Medicine, and their efforts are the first randomized controlled clinical trial focused on massage therapy for CRF in breast cancer survivors. The results of the NIH-funded early-phase trial were recently published in the scientific journal Cancer and provide exciting results to inform evidence-based massage practice.7 Specifically, the study found that a course of weekly, 45-minute Swedish massage therapy sessions over six weeks significantly decreased CRF in breast cancer survivors compared to both no treatment and active treatment control groups.
The single-masked controlled trial randomized 66 women, 18–72 years old, who were three months to four years posttreatment for stage 0–III breast cancer into three groups: a once-weekly Swedish massage therapy (SMT) group, a once-weekly light touch (LT) group, or a waitlist/no-treatment control group. To be eligible to participate, breast cancer survivors could not have used or be actively using massage therapy, and had to experience close to moderate or higher CRF, as assessed by a nine-item rapid fatigue severity assessment. Only the study’s principal investigator, physicians, and statistician were blinded to intervention randomization.
For the study, licensed massage therapists were vetted and/or provided by the Atlanta School of Massage Therapy and were trained to perform all SMT and LT study interventions. Both the SMT and LT interventions were manualized, meaning each session was the same with regard to length (45 minutes), timing per area of the body addressed, and progression. Massage therapists followed scripts for all participant interactions and additional conversation was kept to a minimum. Research intervention rooms emulated typical massage treatment rooms in that they were private, contained standard massage equipment (table and linens), were dimly lit, and utilized a sound machine to mask environmental noise. Each 45-minute SMT and LT session began with participants supine as the therapist began at participants’ shoulders and worked down to their feet. Participants turned onto their stomachs for the second half of the intervention and therapists worked from participants’ feet through to their back, arms, shoulders, and head. SMT sessions included effleurage, petrissage, and tapotement techniques/strokes, and the LT sessions provided a light, laying-on-of-hands for the same amount of time and in the same sequence as the SMT sessions.
Results
Three standardized measures were used to assess CRF and quality of life and were collected for all participants at baseline and six weeks. The study’s main outcome was the multidimensional fatigue inventory (MFI), which is a 20-item self-report Likert-based questionnaire used in research to quantify the subjective experience of fatigue.8 The MFI is used quite a bit in studies examining CRF and was scored for this study with a range of 20–100 points (with each question worth 1–5 points each; higher scores indicate more fatigue). The MFI has five four-question domains that assess general fatigue, physical fatigue, fatigue-related activity reduction, fatigue-related motivation reduction, and mental fatigue. A minimal clinically important difference has been established for the scale as 10 points, or two points per component.9 Question samples from each domain include: “I feel tired,” “Physically I feel I am in an excellent condition,” “I think I do very little in a day,” “I can concentrate well,” and “I feel like doing all sorts of nice things.” The PROMIS Fatigue Short Form 7a was also used in the study, as well as the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q; available at www.outcometracker.org/library/Q-LES-Q-SF.pdf).10 The Q-LES-Q is a 16-item Likert survey asking respondents to consider the last week and indicate how satisfied they’ve been with things like their physical health, mood, work, and other activities and relationships.
Data from 57 evaluable participants were included in the analysis. Study results for the MFI and Q-LES-Q found that each group had significant changes from baseline to six weeks, but only those in the Swedish massage and light touch groups had significant improvements from baseline. Participants randomized to the no-treatment control group actually had significant negative changes in their CRF and quality of life from baseline to six weeks. When treatment outcomes were compared between the three groups, results for those who received the course of Swedish massage treatments had significantly better outcomes than those who received light touch or (obviously) no treatment. More importantly, those randomized to the Swedish massage treatments reported clinically meaningful improvement in their CRF by having their MFI scores improve 16.5 points on average. (Refer to the January/February 2018 Somatic Research column “4 Points Arising from Low-Back Pain Study: For MTs and Their Practices,” page 46,” for an in-depth discussion on the differences between statistical and clinically meaningful differences.)
Addressing Questions
Let’s take a look at some questions that arise from the study, starting with some about the effectiveness of massage versus simple light touch.
Why does this research include a light touch comparison arm? Do the positive results experienced from massage therapists just touching people diminish the beneficial results found in the massage group? Does this research minimize the massage therapist’s significance or that of massage specifically for CRF?
The short answer to that final question is absolutely not! The importance of having the light-touch comparison group in addition to the no-treatment control group in this study should not be unacknowledged or understated. Statistical comparison between an intervention group and nonintervention group is standard for research and is enough when a definite effect mechanism can be isolated (for example, in pharmaceutical or medical device research). However, when the intervention in question can be influenced/affected by various internal (e.g., human related) and external (e.g., environmental) factors, and has all manner of understood and nonunderstood direct and indirect variables, a “simple” treatment versus no treatment group research design is not enough. It is no surprise that those who received the light touch intervention had benefit with regard to their CRF and quality of life. Touch, presence, and attention are powerful, important, and beneficial elements of general care and support for emotional well-being, and are key to facilitating the healing process. They are also elements inherent to massage therapy application. Without a way to account for these nonspecific, yet very real, treatment effects, the effects related to the actual massage component of a practitioner-provided therapeutic massage intervention cannot be isolated, specified, or hypothesized. Without the light-touch comparison group, the great results found in this study for CRF and quality of life for breast cancer survivors could simply have been attributed to the 45 minutes of weekly attention provided to them by people who happened to be trained in massage therapy. Because the benefits experienced by those in the Swedish massage group were significantly better than those in the light touch group, this study points to the significant benefit massage therapy specifically has for those with postcancer treatment CRF.
Providing the exact same treatment to every client isn’t how massage is practiced or how therapists work with clients. How can research findings about a manualized massage “routine” apply to practice?
Studies seeking to determine if an intervention can work (efficacy) are different from those seeking whether an intervention does work when applied in practice settings (effectiveness). Establishing the efficacy of an intervention is rather important when considering how much research costs, and this study’s researchers point to the purpose of this work as a proof-of-concept that massage is beneficial for CRF. To determine if an intervention can work, studies have to examine said intervention in as controlled a way as possible to have confidence that outcomes truly were caused by the intervention under study. Just like the importance of having a comparison group to account for nonspecific effects (discussed earlier), researchers for efficacy research have to design the intervention application protocol so that study participants get the same treatment as other participants every time they get a treatment. This sort of thing is much easier in pharmaceutical or substance research when precise measures of active ingredient dosage and consumption can be made. For research in applied disciplines like massage therapy, the items manualized in this study are the places where additional parameters need to be set to ensure consistent intervention application throughout the study: massage timing, technique usage and sequencing, areas addressed and sequencing, duration, therapist/participant interaction, and others. These parameters are meant to reduce the variability of treatments within and between study participants, which ultimately allows researchers to point with confidence and validity to the intervention as the cause of study outcomes. It is important to note as well that while manualized, the briefly described massage protocol delivered in this study is reasonably one that any one of us would do for a similar client, considering it addressed the full body, used Swedish massage techniques typical in practice, and followed a logical progression and flow.
Ultimately, this study demonstrates that massage for CRF has efficacy and can work for breast cancer survivors. Results from this study do not imply that only a manualized treatment delivered exactly like those in this study will produce beneficial results in practice. On the contrary, this study provides an evidence base to which massage therapists can point as explanation for results they see related to CRF.
A Larger Discussion
There are so many other great discussion topics this article could spark, but time and space do not allow for further exploration this issue. Perhaps in later columns I’ll be able to discuss some of the potentially lingering questions you may have, such as:
• Why is “blinding” important in research, and if blinding is so important, why were only the principal investigator, statistician, and physicians blinded in this study?*
• What made a study participant’s data evaluable, and why were only 57 of the 66 participants in this study used in the evaluation?*
• Do research participant expectations and preferences influence research, and do research designs account for these potential biases? (As an aside, researchers in this study did collect and consider these variables in the analysis plan.)
• How do collaborations between research and massage therapy-related institutions work?
• What were the roles and duties of the massage therapists engaged in research efforts?
*The answers to these questions do not diminish this study’s integrity or value.
I leave you for now to consider these questions and develop more as you access and consider this and other research articles in depth on your own. The research highlighted here is still in the early-trial phase, and I am confident the field can expect future related work from this research program. I encourage those interested in providing massage for individuals with CRF and other cancer-related challenges to consider taking continuing education courses specific to this work. As with research in the massage-for- cancer field, there is a lot of great practice work to be done in this regard.
Notes
1. American Cancer Society, “Cancer Facts & Figures 2017,” 2017, accessed January 2018, www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf.
2. “Cancer Facts & Figures.”
3. Network NNCCN NCCN. Cancer-Related Fatigue. In: Network N, ed. NCCN clinical practice guidelines in oncology (NCCN guidelines). Version 1. 2016 ed: NCCN National Comprehensive Cancer Network, 2016: 1–56.
4. J. M. Jones et al., “Cancer-Related Fatigue and Associated Disability in Post-Treatment Cancer Survivors,” Journal of Cancer Survivorship 10, no. 1 (2016): 51–61, http://dx.doi.org/10.1007/s11764-015-0450-2.
5. K. M. Mustian et al., “Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-Analysis,” JAMA Oncology 3, no. 7 (2017): 961–68, https://doi.org/10.1001/jamaoncol.2016.6914.
6. ClinicalTrials.gov, “Efficacy of Swedish Massage Therapy on Cancer-Related Fatigue in Cancer Survivors,” NCT01926678, https://clinicaltrials.gov/ct2/show/NCT01926678?cond=cancer+related+fatigue&rank=3.
7. J. B. Kinkead et al., “Massage Therapy Decreases Cancer-Related Fatigue: Results from a Randomized Early Phase Trial,” Cancer 124, no. 3 (October 2017), 546–54, https://doi.org/10.1002/cncr.31064.
8. E. M. Smets et al., “Application of the Multidimensional Fatigue Inventory (MFI-20) in Cancer Patients Receiving Radiotherapy,” British Journal of Cancer 73, no. 2 (January 1996): 241–45.
9. A. Purcell et al., “Determining the Minimal Clinically Important Difference Criteria for the Multidimensional Fatigue Inventory in a Radiotherapy Population,” Supportive Care in Cancer 18, no. 3 (March 2010): 307–15.
10. R. C. Gershon et al., “The use of PROMIS and Assessment Center to Deliver Patient-Reported Outcome Measures in Clinical Research,” Journal of Applied Measurement 11, no. 3 (2010): 304–14; J. Endicott et al., “Quality of Life Enjoyment and Satisfaction Questionnaire: A New Measure,” Psychopharmacology Bulletin 29, no. 2 (1993): 321–26.
Niki Munk, PhD, LMT, is an assistant professor of health sciences at Indiana University, a Kentucky-licensed massage therapist, a visiting fellow with the Australian Research Centre in Complementary and Integrative Medicine, and mother of two young daughter-scientists. Munk’s research explores real-world massage therapy for chronic pain, trigger point self-care, massage for amputation-related sequelae, and the reporting and impact of massage-related case reports. Contact her at nmunk@iu.edu.