Efficacy Of Massage Therapy In EndofLife Care

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Efficacy Of Massage Therapy In End-of-Life Care

• Marlaine C. Smith, RN, PhD, AHN-BC, FAAN
• Jean S. Kutner, MD, MSPH
• Lisa Corbin, MD Linnea Hemphill, MSN Diane
  Fairclough, DrPH
• Christine E. Lynn College of Nursing, Florida
  Atlantic University (MCS)
• University of Colorado at Denver Health
  Sciences Center (JSK, LC, DF)
• Denver VA Medical Center (LH)

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Background Significance

• Symptom relief is central to end-of-life care
  however, many people continue to experience
  serious pain and other symptoms diminishing
  functional ability and quality of life.
• Studies examining efficacy of therapies to
  mediate symptoms deserve our highest priority.
• Research on massage provides some evidence of
  efficacy in palliation of symptoms, but there are
  only a few studies and of variable quality.

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REST Reducing End-of-life Symptoms with Touch
PoPCRN Population-Based Palliative Care
Research Network
www.uchsc.edu/popcrn
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Specific Aim

• To evaluate the efficacy of massage therapy (MT)
  compared to simple touch (ST) for decreasing
  pain, improving quality of life, and lessening
  symptom distress among persons with advanced
  cancer.

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Primary Hypothesis

• Massage therapy will decrease pain in patients
  with advanced cancer.

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Secondary Hypotheses

• Massage therapy will
• improve quality of life
• decrease physical symptom distress
• decrease emotional distress
• result in a need for less total pain medication

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Study Design Multi-site RCT
Baseline assessments
Randomize
Follow-up assessments
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Study Sites
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Study population

• Inclusion Criteria
• English-speaking
• Age gt 18 years
• Diagnosis of advanced cancer
• At least moderate pain (score gt 4) in the prior
  week
• Anticipated life expectancy gt 3 weeks
• Consent to and are able to participate in study
• Exclusion Criteria
• Professional massage in past 4 weeks
• Anticoagulants
• Platelet count gt 10,000
• Unstable spine

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Intervention and Control Exposures

• Intervention Massage Therapy (MT)
• Gentle effleurage, petrissage and myofascial
  trigger point release
• Six 30 minute sessions, at least 24 hours apart,
  over 2 week period
• Biotone massage crème
• No music, talk or aromatherapy
• Control Simple Touch (ST)_
• Same timing and conditions as MT
• 3 minutes of simple touch at 10 defined body
  locations
• Disruption of healing intention
• Control for time, attention, touch healing
  intention

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Data Collection
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Sample Participant Timeline
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Analysis

• Intention to treat analyses
• Repeated measures model that accommodates
  incomplete data
• Models adjusted for
• Age, co-morbid conditions, gender, prior massage
  therapy, worst pain in prior week at study entry,
  Karnofsky Performance Status
• Evaluated potential moderators
• Perceived efficacy of massage therapy
• Presence of neuropathic pain
• Presence of bony metastases

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Study Population Characteristics (n380)
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Study Population Characteristics (n380)
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MT vs. ST Immediate Beneficial Effect
Adjusted for age, comorbid conditions, gender,
prior MT, worst pain in prior week, Karnofsky
Performance Status
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MT vs. ST No Sustained Effect
Adjusted for age, comorbid conditions, gender,
worst pain in prior week, prior MT, Karnofsky
Performance Status
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Summary

• Both massage and simple touch were associated
  with statistically significant improvements in
  immediate and sustained pain outcomes, immediate
  improvements in mood and sustained improvements
  in physical and emotional symptom distress and
  quality of life.
• Immediate improvements in pain and mood were
  clinically significant.
• MT provided greater short-term improvement in
  pain and mood than did simple touch, findings
  that were not sustained over time.
• Pain scores were stable despite NO increase in
  parenteral morphine equivalents.
• No harmful effects of massage therapy were
  identified.

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Qualitative StudyThe experience of receiving
touch

• Qualitative descriptive study
• 17 audiotaped interviews of patients receiving
  massage or simple touch
• Semi-structured interview guide used to ask about
  patient experiences
• Inductive analysis using Atlas TI (codes,
  families of meanings, themes)

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Representative Quotations

• I really looked forward to it because it helped
  me to relax, and the more relaxed the better I
  felt
• I just felt cared forit felt so nice to have
  something relaxed related to cancerrather than
  injections, it was a nice contrast from that
• I would sleep better at night which helped a
  lotI rememberthe feeling of well-being
• It was really goodI think at least four hours
  afterward I had no pain at all

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Findings from the Study of Experiences of
Receiving Touch Therapy

• Touch is valued by patients with advanced cancer
  whether it is massage or simple touch. They
  welcomed and looked forward to the treatments.
• Touch accelerates a sense of intimacy allowing
  patients to open up and share their thoughts,
  feelings and perceptions.
• Patients described working through things as they
  received the therapy they had important insights
  or perceived things differently.
• Patients valued the relationship they developed
  with their therapist.
• Touch facilitated relaxation and sleep and
  promoted pain relief and comfort.

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Strengths Limitations

• Strengths
• Large sample size
• Multi-site
• Parallel qualitative study
• Multiple measures of primary outcome, pain
• Control for time, attention, intention and touch
• Limitations
• Reporting bias
• May not be representative of all with advanced
  cancer.
• Those receiving massage may have greater
  expectancy of benefit.
• Sensitivity of outcome measures sustained
  effects measured only weekly no measures of
  sleep may be unmeasured benefits.
• Lack of a usual care arm.

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Conclusions

• Immediate benefits of MT for pain and mood
  evidence supports offering MT on an individual
  basis and evaluating for immediate beneficial
  effects.
• Improvements in pain, non-pain symptom distress,
  and quality of life in both study arms may
  indicate that attention and touch, which are
  simple and inexpensive to provide, are beneficial
  to persons with advanced cancer.

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REST Study Team

• William Henderson, PhD (Statistician)
• Karen Mellis, MS (Research Assistant)
• Sue Felton (Research Assistant)
• Traci Yamashita (Research Assistant)
• Brenda Beaty, MSPH (Data Analyst)
• Katie Benton, MSPH (Data Analyst)
• Jeanette Ezzo, CMT, MPH, PhD (Consultant)
• Cindy Bryant, PhD (Consultant)
• Kathryn Gray (Administrative Assistant)
• Bev Gonzales (Administrative Assistant)

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Funding

• National Institutes of Health National Center
  for Complementary and Alternative Medicine (1 R01
  AT01006-01A2 )
• Mendel/Asarch Lung Cancer Family Foundation
  Grants Program
• Paul Beeson Physician Faculty Scholars in Aging
  Research Award
• Robert Wood Johnson Generalist Physician Faculty
  Scholars Program

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Reference

• Kutner, J.S., Smith, M.C., Corbin, L., Hemphill,
  L., Benton, K., Mellis, B.K., Beaty, B., Felton,
  S., Yamashita, T.E., Bryant, L.L. Fairclough,
  D.L. (In Press). Massage therapy vs. simple touch
  to improve pain and mood in patients with
  advanced cancer A randomized trial. Annals of
  Internal Medicine. Planned publication date
  9/16/08.

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Thank You!