Anxiety

Autogenic therapy

CAM Cancer admin — Mon, 30 Oct 2023 09:22:35 +0000

Autogenic therapy CAM Cancer admin Mon, 10/30/2023 - 10:22

Abstract and key points

Autogenic therapy refers to a particular technique of mental exercises involving relaxation and autosuggestion, which aims to teach individuals to switch off the fight/flight/fight stress response at will.

Supportive care

Four randomized controlled trials and two uncontrolled trials of autogenic therapy have been carried out in cancer patients.

Sleep: one large RCT (n=229) reports AT and progressive muscle relaxation (PMR) as equally effective in improving various sleep parameters and reducing need for sleep medication, and better than standard treatment controls.
Anxiety and depression: An RCT (n=60) reports decreased anxiety perioperatively for breast cancer patients compared to control.
A pilot RCT (n=31) reports significant improvements in anxiety and depression (HADS) with AT added to standard care; all studies have significant methodological limitations.
Pain: An RCT (n=60) did not find differences in pain or analgesic use perioperatively for breast cancer patients, compared to control.
Immune function: results from two small pilot RCTs are inconclusive; one (n=14) reported higher salivary immunoglobulin A levels compared with controls receiving standard care while the other (n=31) not report any effects on immune function.

Autogenic therapy has a good safety record.

Citation

Lorenc A, CAM Cancer Collaboration. Autogenic therapy [online document], Oct 30, 2023.

Document history

Latest update: October 2023 by Ava Lorenc. Assessed as up to date in August 2020, January 2019, February 2017 and August 2013 by Barbara Wider. Updated in May 2015 and June 2012 by Helen Cooke. Summary first published in August 2011, authored by Helen Cooke. Next update due: October 2026.

What is it?

Description

Autogenic therapy refers to a particular technique of mental exercises involving relaxation and autosuggestion, which aims to teach individuals to switch off the "fight-flight stress response" at will. The term “autogenic” means generated from within. Having been taught the method, the patient is encouraged to carry out the exercises regularly as a form of self-help (Ernst 2000; Payne 2010).

Background and prevalence

Autogenic therapy dates back to the 1930s and is a form of self-hypnosis. Johannes Schultz, a German psychiatrist and neurologist, developed autogenic therapy after having observed that some patients were able to learn to put themselves in a hypnotic state by concentrating on images of heaviness and warmth and reciting a series of phrases. He believed that their state of mental health benefited from going into such a self-generated trance-like ‘autogenic’ state (BAS 2023).

Schultz’s work was further developed by Wolfgang Luthe who introduced additional elements, including organ-specific techniques and ‘intentional exercises’, which are supposed to affect the person’s emotional level. These latter elements are not generally included in standard autogenic training (Hidderley 2004).

Although prevalence data for autogenic therapy are not available, a population-based study found that 8.3% to 15.4% of cancer survivors used mind-body medicine in a 12-month period (Campo 2016)

Alleged indications

It has been claimed that autogenic therapy can be beneficial for a wide range of disorders such as high blood pressure, asthma, colitis, migraines, acute anxiety and sleep disturbances associated with stress (Hidderley 2004).

Mechanism of action

Possible mechanisms of action include cognitive, by means of its attention-focusing phrases and physiological, by means of a reduction in physiological arousal (Hidderley 2004). It has been proposed that autogenic therapy may be beneficial for people who have been diagnosed with cancer by helping them to reduce their level of stress and pain, and by assisting them to confront any fears arising from after cancer diagnosis (Kanji 2000). Although not autogenic therapy, it has been suggested similar stress management interventions in cancer may reduce chronic stress and adversity, and alter immune cell activity, which may mitigate the impact of stress early in treatment, and potentially influence disease progression and clinical outcomes (Antoni 2019).

Application and providers

Autogenic therapy in its standard form involves a series of six mental exercises. The mental exercises involve the patient focusing on (a) heaviness of the limbs, (b) warmth of the limbs, (c) regularity of the heartbeat, (d) ease of breathing, (e) warmth of the abdomen, and (f) cooling of the forehead (Hudcek 2007).

Autogenic therapy is taught over a series of eight to ten weekly sessions which last approximately sixty minutes for individual sessions and up to two hours for small group sessions. People are encouraged to practice the exercises for about 10 minutes three times a day, until they have mastered the technique and can practice when needed (BAS 2023). The technique is taught in a quiet, comfortable setting. Participants are invited to sit or recline in a relaxed position. Once taught, it has been suggested that the exercises can be used anywhere in everyday situations which might induce stress (BAS 2023).

Training for AT teachers are provided by e.g. The German Society for Medical Relaxation Methods, Hypnosis, Autogenic Training and Therapy which offers training courses and certification for practitioners and teachers. The British Autogenic Society is the professional, regulatory organisation in the UK. It offers a post graduate certificate which allows people to teach autogenic training to others.

Legal issues

There is no information available regarding the legal issues of autogenic therapy from a European perspective.

Does it work?

Supportive care

Four randomized clinical trials of autogenic therapy have been carried out in cancer patients. (Hidderley 2004; Minowa 2013, Minowa 2014; Simeit 2004) These RCTs were summarized in one systematic review (SR; Sivero 2023) together with two uncontrolled trials (Wright 2002, Marafante 2016). As the authors did not perform a quality/risk of bias assessment and a meta-analysis, the SR does not add any additional information to the RCTs summarized below. A further uncontrolled trial of autogenic training for stress is also available (Sahdev Singh 2022).

Two of the RCTs were small pilot studies (Hidderley 2004; Minowa 2014) and two were larger RCTs (Minowa 2013; Simeit 2004). Simeit 2004 assessed the effects on sleep in cancer patients and Minowa 2013 the effects on perioperative pain and anxiety in breast cancer. All studies have considerable methodological limitations. Due to the difficulty in creating appropriate and credible placebo conditions that are not obvious to research participants, blinded studies cannot be carried out for this intervention.

The American Society of Clinical Oncology does not make any recommendations for AT for mental health, citing inconclusive evidence (Carlson 2023)

Description of included studies

Sleep

A randomised trial examining the effects of a multi-modal psychological sleep management programme for people with a variety of different cancers (n=229), found that Progressive Muscular Relaxation (n=80) and autogenic therapy (n=71) were equally effective in enhancing various sleep parameters and reducing the need for sleep medication (Simeit 2004). The control group (n=78), which received only the standard rehabilitation programme, reported no changes in the use of sleep medication. Patients in all groups improved on all scales of the quality-of-life EORTC-QLQ-30 questionnaire, with the exception of pain, which started at a low level and did not alter significantly. Limitations of this study include lack of a non-treatment control group.

Anxiety and depression

An RCT (n=60) assessed the effects of autogenic therapy on anxiety perioperatively for women with breast cancer (Minowa 2013). Results showed significant reductions in anxiety for compared to control (day 1 p=0.005; day 2 p=0.001; day 3 p=0.001). However, there was high dropout in the autogenic therapy group.

A pilot randomised study (n=31) assessed the effects of autogenic therapy on the psychological status and immune system responses over a two-month period in women with early-stage breast cancer who had undergone a lumpectomy (Hidderley 2004). Women receiving autogenic therapy in addition to home visit showed a statistically significant improvement in the Hospital Anxiety and Depression Scale (HADS) score (inter-group difference: anxiety p=0.0027, depression p=0.0001) compared to those receiving only a home visit. Limitations of this study include the small sample size and subjective evaluation of the participants’ meditative state.

The three uncontrolled trials all report positive findings for psychological health outcomes such as stress (Sahdev Singh 2022; n=60), anxiety (Marafante 2016; Wright 2002), sense of coping and sleep (Wright 2002), stress and depression (but not fatigue) (Marafante2016). But these results are inconclusive due to lack of a control group, and two were small pilot studies (n=25; Marafante 2016) (n=35; Wright 2002), with one only reported in a conference abstract (Marafante 2016).

Pain

An RCT (n=60) assessed the effects of autogenic therapy on pain perioperatively for women with breast cancer (Minowa 2013). Results showed significant reductions in pain for the AT group pre-post, but not compared to control, and no difference in analgesic use.

Immune function

A small randomised study (n=14) investigated the effects of autogenic therapy on salivary immunoglobulin A (sIgA) in surgical patients with breast cancer (Minowa 2014). The participants were instructed to conduct autogenic therapy by themselves three times a day for seven days following surgery. SIgA levels were significantly higher in the intervention group than the control (usual care) group which suggests autogenic therapy may improve immune function in breast surgery patients. Limitations include a small sample size. The authors note that surgery affects physiological function including sIgA, which may affect the reliability of the results.

The above-mentioned pilot RCT (Hidderley 2004) reported no effects on immune function.

References

Antoni M and Dhabhar F, The impact of psychosocial stress and stress management on immune responses in patients with cancer. Cancer, 2019; 125: 1417-1431.

British Autogenic Society website, accessed 4^th October 2023.

Campo R, Leniek K, Gaylord-Scott N. et al. Weathering the seasons of cancer survivorship: mind-body therapy use and reported reasons and outcomes by stages of cancer survivorship. Support Care Cancer 2016; 24: 3783–3791

Carlson L, Ismaila N, Addington E, Asher G, Atreya C et al. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology–ASCO Guideline. Journal of Clinical Oncology, 2023; 41:28:4562-4591

DGAEHT, Deutsche Gesellschaft für ärztliche Entspannungsmethoden, Hypnose, autogenes Training und Therapie (German Society for Medical Relaxation Methods, Hypnosis, Autogenic Training and Therapy), accessed 4^th October 2023.

Ernst E, Kanji N. Autogenic training for stress and anxiety: A systematic review. Complement Ther Med 2000; 8(2): 106-110.

Ernst E, Pittler M, Wider B and Boddy K. Oxford. Handbook of Complementary Medicine. Oxford: Oxford University Press, 2008.

Gansler T, Kaw C, Crammer C, Smith T. A population-based study of prevalence of complementary methods use by cancer survivors: a report from the American Cancer Society's studies of cancer survivors. Cancer 2008; 113(5): 1048-57.

Hidderley M, Holt M. A pilot randomized trial assessing the effects of autogenic training in early stage cancer patients in relation to psychological status and immune system responses. Eur J Oncol Nurs 2004; 8(1): 61-5.

Hudacek KD. A review of the effects of hypnosis on the immune system in breast cancer patients: a brief communication. Int J Clin Exp Hypn 2007; 55(4):411-25.

Kanji N. Management of pain through autogenic training. Complement Ther Nurs Midwifery 2000; 6(3): 143-8.

Marafante G, Bidin L, Seghini P, Cavanna L N08 - Mood and distress in cancer patients after Autogenic Training (AT): a pilot study in an Italian Oncologic Unit Annals of Oncology. 2016; 27 S4: iv93

Minowa C, Koitabashi K. Effects of Autogenic Training on Perioperative Anxiety and Pain in Breast Cancer Patients: A Randomized Controlled Trial. Kitakanto Med Jour 2013; 63: 1-11

Minowa C, Koitabashi K. The effect of autogenic training on salivary immunoglobulin A in surgical patients with breast cancer: a randomized pilot trial. Complement Ther Clin Pract 2014; 20(4): 193-6.

Payne, R and Donaghy, M. Fourth Edition. Payne’s Handbook of Relaxation Techniques: a practical guide for the health care professional. London: Churchill Livingstone, Elsevier, 2010.

Sahdev Singh VV, Premavathy R. Assess the effectiveness of autogenic training exercise on stress among cancer patients. Int J Community Med Public Health 2022;9:2970-3.

Simeit R, Deck R and Conta-Marx B. Sleep management training for cancer patients with insomnia. Supp Care Cancer 2004; (3): 176-83.

Sivero S, Maldonato N, Chini A, Maione R, Vitale R, Volpe S, Siciliano S, Bottone M,Sivero L. Evaluation of the effect of autogenic training as psychological support to patients operated for cancer: a systematic review. Chirurgia 2023;36(1): 34-7

Wright S, Courtney, U, Crowther, D. A quantitative and qualitative pilot study for the perceived benefits of autogenic training for a group of people with cancer. Eur J Cancer Care 2002; 11(2): 122-130.

Tilpasset byline

By the CAM Cancer Collaboration

Is it safe?

Adverse events

There are no known adverse effects (Ernst 2008). No adverse events were reported in the studies analysed for this summary.

Contraindications

It is suggested that autogenic therapy is not suitable for children under the age of five (Payne 2010). People who are actively psychotic or with schizophrenia should refrain from putting themselves into trans-like states (Ernst 2008).

Interactions

No known interactions.

Warnings

See contraindications.

Biofeedback

CAM Cancer admin — Sun, 15 Nov 2020 09:29:25 +0000

Biofeedback CAM Cancer admin Sun, 11/15/2020 - 10:29

Abstract and key points

Biofeedback involves the use of instrumentation to monitor, amplify, and feed back information on physiological responses so that a patient can learn to regulate these responses.

There is some evidence from two good-sized RCTs and a cohort study that biofeedback may improve intestinal/anorectal function for rectal cancer patients.
There is currently inclusive evidence from a very small number of studies, all with small sample sizes or other limitations for the effects of biofeedback on anxiety (n=1), pain (1 SR, 1 RCT), nausea (n=1), immune function (n=1), fatigue (n=1), speech quality (for laryngectomized patients, n=1), or peripheral neuropathy (n=1).
Evidence for biofeedback for continence in prostate cancer (n=2) is conflicting and limited due to small sample sizes.
Positive effects of biofeedback may be no different to relaxation therapy (n=1)

Biofeedback is considered to have few adverse effects.

Citation

Lorenc A, Cooke H, CAM Cancer Collaboration. Biofeedback [online document], Nov 15, 2020.

Document history

Latest update: November 2020
Next update due: November 2023

What is it?

Description and definition

Biofeedback is a process that is used to enable an individual to learn how to change physiological activity for the purposes of improving health and performance (Association for Applied Psychophysiology and Biofeedback USA 2020). A variety of different biofeedback techniques are available. The two most commonly used techniques by people with cancer are electromyography (EMG), which measures the electric activity in muscles, and skin temperature (ST) biofeedback. These instruments rapidly and accurately 'feed back' information to the user. The presentation of this information — often in conjunction with changes in thinking, emotions, and behaviour — supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.

Background and prevalence

Scientists began to make the link between electrical responses in nerve and muscle activity in the early 1900s. Edmund Jacobson who worked as a physiologist/physician in the 1930s and John Basmajian, a Canadian academic and scientist were early pioneers in the field of biofeedback (Payne and Donaghy 2010).

The exact prevalence of the use of biofeedback for cancer patients is unknown.

Alleged indications

Biofeedback is aimed at allowing people to monitor and influence specific physiological responses the individual would likely to be otherwise unaware of by providing information about moment-to-moment physiological responses such as muscle tension and skin temperature (Burish and Jenkins 1992).

EMG feedback is most commonly used by people with cancer as a technique to initiate a deep state of muscle relaxation, with the aim of inducing a generalised relaxation response and relief in cancer-related symptoms. Adverse effects, including gastro-intestinal upsets such as nausea and vomiting that are caused by high levels of anxiety also appear to be reduced through this muscle relaxation mechanism.

Mechanism of action

It is thought that muscular relaxation may directly inhibit the characteristic sequence of muscular activity that generally precedes nausea and vomiting. It has been suggested that the 'relaxation response' may help break the pain-anxiety-muscle-tension cycle (Tsai et al. 2007). ST biofeedback aims to help people control peripheral blood flow to their peripheries and has been shown to improve circulatory and vascular disorders such as Raynaud’s disease (Burish and Jenkins 1992). Skin temperature drops just before vomiting, it has therefore been proposed that by teaching patients to adapt their skin temperature biofeedback may also benefit chemotherapy-related nausea and vomiting (Burish and Jenkins 1992).

It has been proposed that learning biofeedback and relaxation skills can contribute to improved feelings of self-efficacy, by helping people with cancer feel more in control of any side-effects including chronic pain (Tsai et al. 2007).

Application and dosage

Biofeedback is most commonly taught by health care professionals including clinical psychologists and nurses, as well as hypnotherapists and complementary practitioners. Training is either conducted in groups or one-on-one sessions, lasting twenty to thirty minutes. Patients are informed about the purpose of the training; i.e. to help them become relaxed and comfortable. The therapist then attaches electrodes or skin temperature thermistors and demonstrates how to use the equipment (Sellick and Zaza 1998).

Participants are subsequently given suggestions about how to influence physiological responses and any symptoms they are experiencing. For example EMG-biofeedback users are told they may find it helpful to imagine relaxing and letting go of any muscle tension and see how this alters the biofeedback reading and tone. ST-biofeedback users are told they may find it helpful to imagine that their fingers and hands are warm and comfortable. A small band indicates changes in finger temperature.

Patients are recommended to use the equipment once or twice a day, in order for them to master the skill (Burish and Jenkins 1992).

Legal issues

The Biofeedback Certification International Alliance (The Biofeedback Certification International Alliance 2020) certifies individuals who meet education and training standards in biofeedback. It is the certification body for the clinical practice of biofeedback by the Biofeedback Foundation of Europe (Biofeedback Foundation of Europe 2020), the Association for Applied Psychophysiology and Biofeedback USA (Association for Applied Psychophysiology and Biofeedback USA 2020) and the International Society for Neuroregulation and Research (International Society for Neuroregulation and Research 2020).

Does it work?

Supportive care

In cancer care, different types of biofeedback have been used in a wide variety of health care and rehabilitation settings. One systematic review (Hetkamp et al. 2019) of neurofeedback (NF) or electroencephalogram (EEG)-biofeedback in cancer patients included six studies: three RCTs (n=71, 71 and 82, respectively), one observational study (n=22) and two case reports. In addition, eight RCTs (de Lira et al. 2019; Kye et al. 2016; Şahin et al. 2016; Schwenk et al. 2016; Burish and Jenkins 1992; Tsai et al. 2007; Gruber et al. 1993; Liu et al. 2019), and two controlled cohort studies (Liang et al. 2016; Yoshida et al. 2018) have assessed the benefits of biofeedback for cancer patients. There are few trials per treatment outcome and most trials have small sample sizes and other methodological limitations. The trials are presented in table 1.

The results of the SR and trials suggest:

There is some evidence (n=3) that biofeedback may improve intestinal/anorectal function for rectal cancer patients.
There is currently not enough evidence for conclusions to be made about the effects of biofeedback on anxiety (n=1), pain (1 SR, 1 RCT), nausea (n=1), immune function (n=1), fatigue (n=1), speech quality (for laryngectomized patients, n=1), or peripheral neuropathy (n=1) in cancer patients.
Evidence for biofeedback for continence in prostate cancer (n=2) is conflicting and limited due to small sample sizes.
Positive effects of biofeedback may be no different to relaxation therapy (n=1)

Description of studies

Anorectal function

An well-conducted RCT (n=126) of EMG biofeedback for patients with middle and low rectal cancer found significant improvements in intestinal function compared to both pelvic floor muscle training (although compliance with this intervention was not assessed) and standard care (Liu et al. 2019). The study was large (although unclear how sample size was calculated) but there were no objective outcome measures.

An interim analysis of a well conducted RCT (n=56) (Kye et al. 2016) of biofeedback for rectal cancer patients with sphincter-saving surgery found a significant difference in the change of mean resting pressures between biofeedback and control group (p=0.002) (indicating less deterioration of anal hypersensitivity), but no difference in any other measures of anorectal function. Both study groups also received recommendation to do self-rehabilitation e.g. Kegel exercises. The sample size was powered and the study is well written, although there is little information on the biofeedback intervention.

A nonrandomised retrospective cohort study (n=61) (Liang et al. 2016) also studied biofeedback for rectal cancer patients and found significant differences for maximum resting pressure, maximum squeeze pressure and rectal capacity compared to healthy volunteers. Although well conducted, as a cohort study it cannot control for time, attention, therapist interaction, or other treatments.

Pain

An SR from 2019 evaluated the effects of a specific type of biofeedback – neurofeedback or EEG biofeedback, on people with cancer (Hetkamp et al. 2019). Six studies were included: three RCTs (n=71, 71 and 82, respectively), one observational study (n=223 and two case reports. Although the SR seems well conducted in line with PRISMA principles, meta-analysis was not possible due to study heterogeneity, and even the narrative synthesis is limited. The authors do not provide a summary of the effects, but conclude that neurofeedback could be helpful in alleviating pain.

A small RCT (n=37) by Tsai et al (2007) of biofeedback-assisted relaxation training for patients with advanced cancer found significant reduction in pain intensity compared to standard care. However this study is limited by a small non-powered sample size and high dropout rate, and unclear method of randomisation.

Chemotherapy-induced nausea and vomiting

A randomised clinical trial (RCT) (n=81) assessed the effectiveness of electromyography (EMG) biofeedback, skin-temperature (ST) biofeedback and relaxation training in reducing the aversiveness of cancer chemotherapy for cancer patients with a history of or likely to have anxiety/nausea (Burish and Jenkins 1992). This study was good quality, but it is difficult to ascertain the impact of biofeedback alone due to the use of six intervention groups. Results showed that all three groups which used relaxation training experienced a reduction in nausea during their chemotherapy, when compared to groups receiving no relaxation therapy. EMG and ST biofeedback alone both reduced some indices of physiological arousal but did not reduce other measures of aversiveness of chemotherapy. Results suggest that relaxation training, but not biofeedback is effective in reducing adverse effects of chemotherapy. Due to 6 groups being used the size of each group is small, and it is unclear if the study was powered.

Immune system changes

A small RCT (n=13) explored changes in the immune system and psychological profile of women with breast cancer who had recently undergone radical mastectomy (Gruber et al. 1993). Patients were randomised to either an intervention group who were trained in relaxation, guided imagery and biofeedback over a 24-week period or a waiting list control. Results indicate that a relaxation, guided imagery and biofeedback intervention can be correlated with immune system measures. Due to the small participant numbers, no details of randomisation, no simultaneous control group and the use of a multi-modal intervention it is impossible to draw conclusions about the benefits of biofeedback.

Mental health/fatigue

The RCT by Burish and Jenkins (1992) showed that patients who undertook relaxation training, but not biofeedback, experienced a reduction in anxiety during their chemotherapy, when compared to the no-intervention group.

Gruber et al (1993) (n=13) showed that a relaxation, guided imagery and biofeedback intervention can be correlated with reduced anxiety, but there were no significant effects, and evidence is inconclusive due to study limitations.

Hetkamp et al’s SR concludes that neurofeedback could be helpful in alleviating cognitive impairments and fatigue, but is very limited (see above) (Hetkamp et al. 2019)

Continence

A well conducted RCT (n=31) by De Lira et al (2019) of pelvic floor muscle training including EMG biofeedback for men undergoing radical prostatectomy for prostate cancer found no significant differences for incontinence compared to usual care. Although there was no loss to follow up the sample size was just under the number needed and objective outcome measures were not used.

A prospective cohort study (n=116) by Yoshida et al (2018) found biofeedback using ultrasound with pelvic floor training significantly reduced the mean time to continence recovery for men undergoing radical prostatectomy compared to pelvic floor training only, although the sample size was not powered and group allocation included an element of preference.

Other physiological outcomes

A small RCT (n=26) by Sahin et al (2016) compared intraluminal impedance biofeedback and classical oesophageal speech therapy to classical oesophageal speech therapy only, for total laryngectomized laryngeal cancer patients. Both groups had significant improvements in oesophageal speech quality but no difference between groups. This study may have been underpowered and gave no details of randomisation.

Schwenk et al (2016) conducted a study which they described as an RCT, but was small (n=22), and reads more like a feasibility study. They compared sensor-based balance training (using wearable sensors to provide real-time visual/auditory feedback of limb movement) with usual care for older cancer patients with chemotherapy-induced peripheral neuropathy. They found sway of hip and ankle in feet open and sway of hip and centre of mass were significantly reduced in the intervention group compared to control (p=0.010; 0.022; 0.008; -0.035), but no significant difference for tests with eyes closed, or for gait speed or fear of falling. This study is likely underpowered but well randomised.

The RCT by Burish and Jenkins (1992) showed that the EMG- and skin temperature-biofeedback reduced levels of physiological arousal in participants compared to no intervention.

Evidence tables

Table 1: Clinical trials of biofeedback.

References

Association for Applied Psychophysiology and Biofeedback USA. 2020. 'Association for Applied Psychophysiology and Biofeedback USA', Accessed 01/10/20..

Biofeedback Foundation of Europe. 2020. 'Biofeedback Foundation of Europe', Accessed 01/10/20.

Burish, T. G., and R. A. Jenkins. 1992. 'Effectiveness of biofeedback and relaxation training in reducing the side effects of cancer chemotherapy', Health Psychol, 11: 17-23.

de Lira, G. H. S., A. Fornari, L. F. Cardoso, M. Aranchipe, C. Kretiska, and E. L. Rhoden. 2019. 'Effects of perioperative pelvic floor muscle training on early recovery of urinary continence and erectile function in men undergoing radical prostatectomy: a randomized clinical trial', International braz j urol, 45: 1196‐203.

Ernst, E., M. Pittler, B. Wider, and K. Boddy. 2008. Oxford Handbook of Complementary Medicine. (Oxford University Press: Oxford).

Gruber, B. L., S. P. Hersh, N. R. Hall, L. R. Waletzky, J. F. Kunz, J. K. Carpenter, K. S. Kverno, and S. M. Weiss. 1993. 'Immunological responses of breast cancer patients to behavioral interventions', Biofeedback Self Regul, 18: 1-22.

Hetkamp, M., J. Bender, N. Rheindorf, A. Kowalski, M. Lindner, S. Knispel, M. Beckmann, S. Tagay, and M. Teufel. 2019. 'A Systematic Review of the Effect of Neurofeedback in Cancer Patients', Integr Cancer Ther, 18: 1534735419832361.

International Society for Neuroregulation and Research. 2020. 'International Society for Neuroregulation and Research', Accessed 01/10/20..

Kye, B. H., H. J. Kim, G. Kim, R. N. Yoo, and H. M. Cho. 2016. 'The Effect of Biofeedback Therapy on Anorectal Function After the Reversal of Temporary Stoma When Administered During the Temporary Stoma Period in Rectal Cancer Patients With Sphincter-Saving Surgery: the Interim Report of a Prospective Randomized Controlled Trial', Medicine, 95: e3611.

Liang, Z., W. Ding, W. Chen, Z. Wang, P. Du, and L. Cui. 2016. 'Therapeutic Evaluation of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Sphincter-Saving Surgery for Rectal Cancer', Clin Colorectal Cancer, 15: e101-7.

Liu, Li, Xiaodan Wu, Qianwen Liu, Caixing Tang, Baojia Luo, Yujing Fang, Zhizhong Pan, Desen Wan, and Meichun Zheng. 2019. 'The effect of biofeedback training on intestinal function among patients with middle and low rectal cancer: a randomized controlled study', Annals of translational medicine, 7: 605.

Payne, R., and M. Donaghy. 2010. Payne’s Handbook of Relaxation Techniques: a practical guide for the health care professional (Churchill Livingstone, Elsevier: London).

Şahin, M., M. F. Ogut, R. Vardar, T. Kirazli, E. Z. Engin, and S. Bor. 2016. 'Novel esophageal speech therapy method in total laryngectomized patients: biofeedback by intraesophageal impedance', Diseases of the esophagus : official journal of the international society for diseases of the esophagus, 29: 41‐47.

Schwenk, M., G. S. Grewal, D. Holloway, A. Muchna, L. Garland, and B. Najafi. 2016. 'Interactive Sensor-Based Balance Training in Older Cancer Patients with Chemotherapy-Induced Peripheral Neuropathy: a Randomized Controlled Trial', Gerontology, 62: 553‐63.

Sellick, S. M., and C. Zaza. 1998. 'Critical review of 5 nonpharmacologic strategies for managing cancer pain', Cancer Prev Control, 2: 7-14.

The Biofeedback Certification International Alliance. 2020. 'The Biofeedback Certification International Alliance', Accessed 01/10/20.

Tsai, P. S., P. L. Chen, Y. L. Lai, M. B. Lee, and C. C. Lin. 2007. 'Effects of electromyography biofeedback-assisted relaxation on pain in patients with advanced cancer in a palliative care unit', Cancer Nurs, 30: 347-53.

Yoshida, M., A. Matsunaga, Y. Igawa, T. Fujimura, Y. Shinoda, N. Aizawa, Y. Sato, H. Kume, Y. Homma, N. Haga, and H. Sanada. 2018. 'May perioperative ultrasound-guided pelvic floor muscle training promote early recovery of urinary continence after robot-assisted radical prostatectomy?', Neurourol Urodyn, 38: 158-64.

Tilpasset byline

By the CAM Cancer Collaboration

Is it safe?

Biofeedback appears to have a good safety record (Ernst et al. 2008).

Adverse events

No adverse events were reported in the studies analysed for this summary.

Contraindications

Some concern has been raised on the use of this intervention in individuals who have a history of psychiatric illness (Ernst et al. 2008).

Interactions

None known.

Warnings

None known. Some participants found the technique a little cumbersome and inconvenient when they were attempting to use biofeedback equipment at the same time as undergoing chemotherapy (Burish and Jenkins 1992).

Aromatherapy

CAM Cancer admin — Fri, 14 Feb 2020 08:19:31 +0000

Aromatherapy CAM Cancer admin Fri, 02/14/2020 - 09:19

Abstract and key points

Aromatherapy, also called essential or volatile oil therapy, entails the controlled use of essential oils that have been extracted from a variety of plant sources. Therapy is usually given via massage, inhalation or a foot- or full-body bath.

Claims of benefits for cancer patients include reduced anxiety levels and relief of emotional stress, pain, muscular tension and fatigue. Claims for the effect of certain oils range from ‘restoring harmony to the energy’ of the body, altering mood and improving overall health, to more specific claims such as having anticonvulsive and spasmolytic properties.

The overall evidence for aromatherapy based on three systematic reviews (including one Cochrane review) and three subsequently published randomised clinical trials provides limited evidence that aromatherapy might have positive short-term effects on quality of life, physical and psychological problems for people with cancer. There were large variations in the type of aromatherapy used, controls and outcomes in the assessed studies. Most studies had methodological limitations.

The latest Cochrane review (Shin 2016) evaluated massage with or without aromatherapy for symptom relief in people with cancer. This systematic review (SR) presented evidence from six randomized controlled trials (RCTs) comparing aromatherapy massage with no massage and two RCTs comparing aromatherapy massage and massage without aromatherapy. The review concludes that there is limited evidence that aromatherapy may be useful for people with cancer in terms of relief from pain and anxiety, this was due to methodological limitations of studies. Two further systematic reviews (n=43, n=3) plus several RCTs have been published subsequently. The overall findings are:

Anxiety

There is evidence of possibly beneficial but small effects of aromatherapy massage but currently insufficient evidence of consistent effects of inhalation aromatherapy on reducing anxiety (2 SRs and 3 RCTs).

Depression, mood and psychological symptoms

There is currently no evidence of significant effects of aromatherapy on mood or depression in cancer patients (2 SRs and 2 RCTs).

Fatigue

There is not convincing evidence of an effect on fatigue (2 SRs).

Nausea and vomiting

Only single small trials have reported positive results and further confirmation of these is required (1 SR).

Pain

Some evidence of benefit exists of aromatherapy-massage over no treatment on medium and long-term pain but effects were small. There is insufficient evidence on adding aromatherapy to massage over massage alone (3 SRs).

Quality of life

Some evidence exists of a benefit of aromatherapy-massage compared with no massage but this depends on how quality of life is measured. There is insufficient evidence on adding aromatherapy to massage versus massage alone (2 SRs).

Sleep

There is some preliminary evidence of effects on sleep but this is not yet conclusive (1 SR).

Wellbeing

There is some preliminary evidence of improved wellbeing but further confirmation is needed (1SR).

Other outcomes

Gastro-intestinal related: preliminary evidence is reported for a range of outcomes including constipation (n=1), mucositis (n=2), salivary gland damage (n=1) and nutritional status (n=2). Further confirmation is needed.
Phlebitis: a single small trial reported effects but further confirmation is needed.
General symptom relief: Beneficial effects are reported for aromatherapy massage on a range of self-reported physical and psychological symptoms (n=3) along with improvements in quality of life and wellbeing but the effects were not always clinically significant and risk of bias is high.
Physiological measures: mixed results are reported for effects on physiological measures including immune measurement (n=2), cortisol and prolactin (n=1) and vital signs (n=2).

Although essential oils have generally shown minimal adverse effects, when used in appropriate dilutions, allergic reactions can occur with all oils. Repeated topical administration of lavender and tea tree oil has been associated with reversible prepubertal gynecomastia, consequently there may be issues for cancer patients with oestrogen-dependant tumours.

Citation

Pilkington K, Seers H, CAM Cancer Collaboration. Aromatherapy [online document]. Feb 14, 2020.

Document history

Summary fully revised and updated in December 2019 by Karen Pilkington.
Summary fully revised and updated in May 2017 by Helen Seers.
Summary fully revised and updated in December 2015 by Helen Seers.
Last updated in September 2013 by Katja Boehm.
Summary fully revised and updated in June 2012 by Katja Boehm.
Summary first published in March 2011, authored by Katja Boehm and Thomas Ostermann.

What is it?

Description and definition

Aromatherapy encompasses the controlled use of aromatic essential oils derived from many different types of plants (more often the uncrushed whole plant) claimed to possess therapeutic properties within a variety of application methods. Aromatherapy is also referred to as essential or volatile oil therapy or, more rarely, aromatic medicine.

Approximately 40 different essential oils extracted from various plants are used in aromatherapy, processed either through distillation or cold pressing (expression). Lavender, rosemary, eucalyptus, chamomile, marjoram, jasmine, peppermint, lemon, ylang ylang and geranium are some of the most popular plants used (Tisserand 1995; CRUK 2021).

Background and prevalence

Aromatic, perfumed oils were used in ancient Egypt to embalm mummies, as well as in ancient China and India. The Persian philosopher and scientist Avicenna (c. AD 980–1037) was the first to distil oil from the rose plant (Tisserand 1988). The term ‘aromatherapy’ was coined by French chemist and perfumiér René Maurice Gattefossé in his 1937 book “Aromathérapie: Les Huiles essentielles hormones végétales” as a subcategory of ‘herbal medicine’.

Gattefossé suggested aromatherapy could be used to treat diseases in virtually every organ system, citing mostly anecdotal and case-based evidence (Gattefossé 1993). Other notable aromatherapists who helped lay the foundation for modern practice are Dr Jean Valnet, who used aromatherapy to treat soldiers during WWII; Madame Marguerite Maury, an Austrian biochemist who brought aromatherapy into the world of cosmetics and developed their use in massage; and Robert B. Tisserand, an English Aromatherapist recognized for bringing aromatherapy to English speaking populations (Gattefossé 1993). In the 1980s aromatherapy increased in popularity in the USA.

Today aromatherapy is fairly well-established in countries such as Australia, Canada, France, Germany, New Zealand, Switzerland and the UK (Boehm 2012). Professional aromatherapists, nurses, physical therapists, pharmacists and massage therapists can all provide topical or inhalation aromatherapy treatment. (Wilkinson 2008) Aromatherapy use by cancer patients varies from country to country. A systematic review in 2011 showed, for example: 1% in Australia (three surveys); between <1 and 4% in Canada (two surveys); <1–2% in Italy, Spain and Turkey; 40.6% in the UK (six surveys); 11% in the USA, and 6% in New Zealand (Horneber 2012).

Alleged indications

Essential oils are used to improve physical, spiritual and emotional wellbeing. A wide range of claims have been made for the effect of certain oils, ranging from affecting the ‘subtle body’ of a patient to having anticonvulsive and spasmolytic properties. It has been suggested that the topical application of aromatic oils may exert antibacterial, anti-inflammatory and analgesic effects (NMD 2021).

It has been claimed that the application of aromatherapy can help patients with stress, chronic pain, nausea and depression; in addition they may contribute towards the relief of bacterial infections, stimulation of the immune system; it has also been asserted that they can assist in combating colds and sore throats, increasing urine production and circulation, relieving cystitis, herpes simplex, acne, headaches, indigestion, premenstrual syndrome and muscle tension. Specific indications vary according to the oils used (Hudson 1996).

For cancer patients, claims of benefits include reduced anxiety levels and relief from emotional stress, pain, muscular tension and fatigue (NMD 2021).

Mechanisms of action

The chemical properties and composition of a specific type of essential oil determines the therapeutic qualities it might have. A number of theories, which fall within the two broad categories of psychological aspects or neuro-chemical effects, try to explain the mechanisms of action. It has been suggested that effects on the limbic and olfactory system also affect mood(Boehm 2012), but only very limited research confirms such mechanisms. Proponents of essential oils/aromatherapy also believe that the overall effects these oils have on the body are greater than the sum of the individual components of the scents (Perry 2006),

Application and provider

Aromatherapy/essential oils can either be self-administered or administered by a practitioner. An aromatherapy massage typically lasts between 60 and 90 minutes. Many aromatherapists are primarily trained as massage therapists and use essential oils as part of their practice. Most commonly diluted oils are applied topically, often together with a carrier oil, as part of massage therapy to manipulate soft body tissue, or else by inhalation of the aroma using an incense burner or via ‘aromasticks’. In addition, some essential oils are ingested as teas, added to bathwater or pillows, or added to ointments, creams and compresses. It has been suggested that a safe and effective maximum dilution for most aromatherapy/essential oils in massage therapy is 2.5% for adults (2 drops of essential oil per 100 drops of carrier oil) and 5–10 drops for full-body baths.

Legal issues

There is no single regulatory organisation specifically for aromatherapy, but membership of a number of professional organisations is open to aromatherapists such as the International Federation of Aromatherapists. Also, legal restrictions apply in some countries because of the way in which essential oils can be administered, namely both orally and rectally; in such instances the application must be carried out by a medically qualified person.

Does it work?

The overall evidence for aromatherapy based on systematic reviews and randomised clinical trials provides limited evidence suggesting that aromatherapy might have positive short-term effects on quality of life, physical and psychological problems for people with cancer. There were large variations in the type of aromatherapy used, controls and outcomes in the assessed studies. Most studies had methodological limitations.

The latest Cochrane review (Shin 2016) evaluated massage with or without aromatherapy for symptom relief in people with cancer. This systematic review (SR) presented evidence from six randomized controlled trials (RCTs) comparing aromatherapy massage with no massage and two studies comparing aromatherapy massage and massage without aromatherapy. The review concludes that there is limited evidence that aromatherapy may be useful for people with cancer in terms of relief from pain and anxiety, this was due to methodological limitations of studies. Two further systematic reviews plus several RCTs (see table 1) have been published subsequently. Farahani 2019 included 43 studies (31 RCTs, 11 quasi-experimental studies and one case series) and Chen 2016 included three RCTs of cancer pain. The overall findings are:

Anxiety: There is evidence of possibly beneficial but small effects of aromatherapy massage but currently insufficient evidence of consistent effects of inhalation aromatherapy on reducing anxiety (2 SRs and 3 RCTs).

Depression, mood and psychological symptoms: There is currently no evidence of significant effects of aromatherapy on mood or depression in cancer patients (2 SRs and 2 RCTs).

Fatigue: There is not convincing evidence of an effect on fatigue (2 SRs).

Nausea and vomiting: Only single small trials have reported positive results and further confirmation of these is required (1 SR).

Pain: Some evidence of benefit exists of aromatherapy-massage over no treatment on medium and long-term pain but effects were small. There is insufficient evidence on adding aromatherapy to massage over massage alone (3 SRs).

Quality of life: Some evidence exists of a benefit of aromatherapy-massage compared with no massage but this depends on how quality of life is measured. There is insufficient evidence on adding aromatherapy to massage versus massage alone (2 SRs).

Sleep: There is some preliminary evidence of effects on sleep but this is not yet conclusive (1 SR).

Wellbeing: There is some preliminary evidence of improved wellbeing but further confirmation is needed (1SR).

Other outcomes:

Gastro-intestinal related: preliminary evidence is reported for a range of outcomes including constipation (n=1), mucositis (n=2), salivary gland damage (n=1) and nutritional status (n=2). Further confirmation is needed.
Phlebitis: a single small trial reported effects but further confirmation is needed.
General symptom relief: Beneficial effects are reported for aromatherapy massage on a range of self-reported physical and psychological symptoms (n=3) along with improvements in quality of life and wellbeing but the effects were not always clinically significant and risk of bias is high.
Physiological measures: mixed results are reported for effects on physiological measures including immune measurement (n=2), cortisol and prolactin (n=1) and vital signs (n=2).

Description of included systematic reviews and clinical trials

Anxiety

A Cochrane review in 2016 on symptom relief for cancer patients offered by massage with or without aromatherapy included five RCTs that assessed effects on anxiety (Shin 2016). Four compared massage with aromatherapy versus no-massage, one trial also compared massage plus aromatherapy with massage alone and one only compared aromatherapy massage with massage alone. The quality of the evidence was judged very low due to high risk of bias. While there was some evidence of benefit of aromatherapy-massage over no treatment on anxiety (two RCTs, n=253, combined MD -4.50, 95% CI -7.70 to -1.30), the effects were small and not considered clinically significant. Insufficient evidence was found on the potential benefit of adding aromatherapy to massage over massage alone.

A subsequent systematic review published in 2019 included 16 studies that assessed effects of aromatherapy on anxiety, the majority involving aromatherapy in combination with massage and the use of lavender oil. (Farahani 2019) The authors concluded that aromatherapy relieved ‘a various range of cancer related symptoms including: Anxiety…’.Six of these studies were not randomised studies and four of the RCTs were included in the Cochrane review above. Of the six RCTs not included in the Cochrane review, four were on the use of aromatherapy for anxiety related to various procedures. Aromatherapy massage with lavender oil prior to colorectal surgery was more effective than no treatment in one trial. Mixed result were reported for inhalation of various essential oils during chemotherapy, radiotherapy and infusion of stem cells. Two RCTs in breast cancer patients, one using aromatherapy inhalation and one using aromatherapy massage reported beneficial effects. All RCTs were rated at least 3 out of 5 on the Jadad scale but blinding is not possible and the outcome is subjective and self-assessed and thus prone to bias.

Three further RCTs, not included in either of the reviews above, include a feasibility study of aromatherapy massage versus cognitive behavioural therapy which found non-significant differences (Serfaty 2012); a trial of Citrus aurantium (orange oil) versus diazepam and saline in which groups were not matched at baseline (Pimenta 2016) and a trial in which non-significant differences were found between acupressure with essential oils and acupressure alone. (Tang 2014)

Thus, it appears that the conclusions of the Cochrane review still apply: possibly beneficial but small effects of aromatherapy massage. There is currently insufficient evidence of consistent effects of inhalation aromatherapy on reducing anxiety.

Depression, mood and psychological symptoms

The Cochrane review included four RCTs comparing aromatherapy massage to no treatment (Shin 2016). Three of these were small (n=32-66) and one larger (n=221) trial used different outcomes measures but no significant difference was seen in each case. One trial assessed effects on mood disturbances and one assessed psychological symptoms but both were small and, again, no significance differences were measured. No difference was seen between aromatherapy massage and massage alone on psychological symptoms. One trial of aromatherapy massage versus massage alone did report significant reductions in depression scores in the massage group but the trial was small data was not evaluable.

A more recent SR stated that six of the included studies investigated the effect of aromatherapy massage (n=5) and inhalation aromatherapy (n=1) on depression (Farahani 2019). The review states that inhalation aromatherapy does not have a significant effect and aromatherapy massage reduced depression in cancer patients in all studies. The table of studies, however, indicates that depression had been measured in 11 studies and it is unclear why only six studies are summarised. Lavender was the most commonly used aroma.

Two further RCTs have been published: one found improvements with aromatherapy massage and cognitive behavioural therapy (CBT) but no significant difference between these. (Serfaty 2012) The trial was, however, a pilot study and may have not been sufficiently large to detect a difference. The other trial of acupressure with essential oils, acupressure only and sham acupressure suffered similar problems (Tang 2014).

Thus, there is currently no evidence of significant effects of aromatherapy on mood or depression in cancer patients.

Fatigue

The Cochrane review reported on two trials that assessed effects on fatigue (Shin 2016). A large RCT (N=221) found no significant difference between aromatherapy‐massage using a range of essential oils and usual care only (no massage). While the second, smaller study did report a difference, appropriate data was not available for meta-analysis.

A subsequent SR included four studies on fatigue all reporting positive effects of aromatherapy (Farahani 2019). One of these trials was included in the Cochrane review and one was not an RCT. The two remaining RCTs, one recent (n=46) and one older study (n=87), both involved use of chamomile and both reported improved fatigue with aromatherapy massage compared with usual care or massage alone.

One further RCT found no significant difference between acupressure with essential oils and acupressure alone (Tang 2014).

Overall, there is not convincing evidence of an effect on fatigue.

Nausea and vomiting

No studies assessing the effects of aromatherapy in nausea and vomiting were included in the Cochrane review (Shin 2016).

Nine studies including seven RCTs were included in a subsequent systematic review (Farahani 2019). Two studies (n=66, 87) reported positive effects of aromatherapy massage using ginger/coconut and chamomile respectively on nausea along with various other outcomes. The remaining five RCTs employed inhalation: two trials of ginger and one of bergamot reported no effect. One trial (n=66) reported positive effects of cardamom on nausea and a trial (n=100) of peppermint oil reported significant but small effects.

The wide range of different oils that have been used mean that it is currently unclear if there is a beneficial effect from some oils and not others. Only single small trials have reported positive results and further confirmation of these is required.

Pain

The Cochrane review in 2016 on symptom relief for cancer patients offered by massage with or without aromatherapy included five RCTs that assessed effects on pain (Shin 2016). All five compared massage with aromatherapy versus no-massage and one trial also compared massage plus aromatherapy with massage alone. The quality of the evidence was judged very low due to high risk of bias. While there was some evidence of benefit of aromatherapy-massage over no treatment on medium and long-term pain (medium-term: one RCT, n = 86, MD 5.30, 95% CI 1.52 to 9.08; long-term: one RCT, n = 86, MD 3.80, 95% CI 0.19 to 7.41), the effects were small and not considered clinically significant. Insufficient evidence was found on the potential benefit of adding aromatherapy to massage over massage alone.

Chen et al. (2016) conducted a meta-analysis of RCTs to look at the clinical effectiveness of aromatherapy massage on reducing pain. The authors identified three studies meeting their criteria for inclusion in the meta-analysis, only one of these studies was also included in the above Cochrane review by Shin et al. Chen et al.’s meta-analysis pooled data from 278 participants (135 in aromatherapy and 143 participants in control group). Aromatherapy had a non-significant effect on reducing pain (standardized mean difference, SMD=0.01; 95% CI −0.23, 0.24).

A systematic review published in 2019 included a total of 13 studies on pain: 3 of those included in the Cochrane review plus 10 additional studies (Farahani 2019). Six of the additional studies were not randomised trials. The four additional RCTs included a study of essential oils used in a gargle for oral mucositis and related pain and one using an essential oil mixture applied to the skin for radiation-related skin reactions. A third involved inhalation aromatherapy prior to sickle cell infusion therapy and the fourth was a trial published in Chinese that involved an aromatherapy and music intervention. The review concluded that aromatherapy relieved pain but few details were presented in support of this other than that the majority of studies reported beneficial effects (3 found no effect).

Quality of life

In assessing the effect of adding aromatherapy to massage against that of massage alone, the Cochrane review concluded that the quality of evidence was very low with studies at a high risk of bias (Shin 2016). There was some indication of benefit of aromatherapy-massage in that the medium-term (4-8 weeks) quality of life score was lower (better) than in a no-massage group (one RCT, n = 30, MD -2.00, 95% CI -3.46 to -0.54). Two trials using difference outcome measures found no difference. There was insufficient evidence on adding aromatherapy to massage versus massage alone.

A subsequent systematic review included nine studies on quality of life, three of which were included in the Cochrane review (Farahani 2019). Three RCTs tested aromatherapy-massage, two tested inhalation aromatherapy and one tested both forms. Inhalation aromatherapy was not effective in one study and less effective than aromatherapy massage in another trial. Three of the four RCTs found aromatherapy massage to be effective.

Overall, the evidence for aromatherapy massage was more convincing than for inhalation aromatherapy. Quality of life is, however, a self-assessed subjective measure and patients could not be blinded to treatment.

Sleep

The Cochrane review did not report any results on sleep (Shin 2016).

Four studies on sleep were included in the more recent SR, involving between 45 and 80 participants: three tested inhalation of various essential oils and one compared massage with lavender oil with usual care (Farahani 2019). All 4 reported positive findings and were rated as good quality in the review (Jadad score of at least 3) but blinding was not possible and sleep quality was self-rated and, therefore, prone to bias.

One further RCT found some differences in sleep quality between acupressure with essential oils and acupressure alone but these were not consistent at both time points measured.37

Overall, there is some preliminary evidence of effects on sleep but this is not yet conclusive.

Wellbeing

Wellbeing was not assessed in the Cochrane review (Shin 2016).

The more recent systematic review included two studies on wellbeing, both of which showed beneficial effects of aromatherapy massage (Farahani 2019).

Other outcomes

Symptoms relating to the breast

The relief of long-term symptoms relating to the breast in people with breast cancer (one RCT, n = 86, MD -9.80, 95% CI -19.13 to -0.47) was greater for the aromatherapy-massage group than no treatment, but the results were considered not clinically significant (Shin 2016). There was insufficient evidence to assess the effect of adding aromatherapy to massage on physical symptom distress.

A wide range of other outcomes have been assessed and the studies were summarised in the most recent systematic review (Farahani 2019). The following is a list of the outcomes for which there is preliminary evidence based on one or two (generally small) trials:

Gastro-intestinal related

Constipation (n=1), positive results were reported in a small trial (n=32) for aromatherapy-massage compared with massage alone.
Oral mucositis (n=2), two RCTs each using a mouthwash/gargle containing essential oils (Matricaria recutita and Mentha piperita, n=60; manuka and kanuka oils, n=19). Positive results were reported in both trials.
Salivary gland damage (n=1), positive results were reported with use of inhaled aromatherapy in one trial (n=71).
Nutrition status (n=2), using a gargle and using inhaled aromatherapy (ginger oil; Manuka, kanuka oils), in two trials (n=19; 60), both of which were reported positive effects.

Chemotherapy-Induced phlebitis (n=1)

Using aromatherapy massage with sesame oil was reported to be more effective than massage alone in prevention of phlebitis (n=60).

Physical and psychological symptom relief (n=3)

using aromatherapy massage and inhalation: RCTs have shown beneficial effects on a range of self-reported physical and psychological symptoms along with improvements in quality of life and wellbeing.

Physiological measures

The evidence for effects on physiological measures is mixed:

Immune measurements (n=2), aromatherapy massage: mixed results are reported for effects on the immune system, one trial (n=66) reporting an effect and the other (n=12), no effect although this may be due to the trial being underpowered.
Cortisol and prolactin (n=1) aromatherapy massage: positive effects were reported (alongside improved quality of life) in one small RCT (n=39).
Vital signs (n=2): a large RCT (n=153) found no effect of inhalation aromatherapy while two small RCTs (n=20; 42) reported an improvement in the vital signs. One RCT assessed effects on blood pressure, cardiac and respiratory frequency as part of an assessment of effects on anxiety.

Evidence tables

Table 1: Randomised controlled trials of aromatherapy for cancer

References

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Anonymous. Final report on the safety assessment of Hypericum perforatum extract and Hypericum perforatum oil. International Journal of Toxicology. 2001;20 Suppl 2:31-9.

Boehm K, Büssing A, Ostermann T. Aromatherapy as an adjuvant treatment in cancer care--a descriptive systematic review. Afr J Tradit Complement Altern Med 2012;9:503-18. eCollection 2012. Review.

Cancer Research UK. Aromatherapy, [website], accessed 15^th November 2019.

Chen TH, Tung TH, Chen PS, Wang SH, Chao CM, Hsiung NH, et al. The Clinical Effects of Aromatherapy Massage on Reducing Pain for the Cancer Patients: Meta-Analysis of Randomized Controlled Trials. Evidence-based complementary and alternative medicine : eCAM. 2016;2016:9147974.

Clark SM, Wilkinson SM. Phototoxic contact dermatitis from 5-methoxypsoralen in aromatherapy oil. Contact Dermatitis 1998;38: 289–90.

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Ernst E, Pittler MH, Wider B, Boddy K. The Oxford Handbook of Complementary Medicine. Oxford: Oxford University Press, 2008.

Farahani MA, Afsargharehbagh R, Marandi F, Moradi M, Hashemi SM, Moghadam MP, Balouchi A. Effect of aromatherapy on cancer complications: A systematic review. Complement Ther Med. 2019;47:102169.

FDA, US Food and Drug Administration. CFR - Code of Federal Regulations Title 21. April 1^st 2020.

Gattefossé RM. Gattefossé's Aromatherapy. Edited by R Tisserand, Translated by L Davies. Saffron Waldon: The CW Daniel Company, 1993.

Henley DV, Lipson N, Korach KS, et al. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med 2007; 356:479-85.

Holmes C, Ballard C. Aromatherapy in dementia. Advances in Psychiatric Treatment 2004; 10: 296–300.

Hongratanaworakit T, Buchbauer G. Human behavioral and physiological reactions to inhalation of sweet orange oil. Acta Hort 2005;679:75-81.

Horneber M, Bueschel G, Dennert G, Less D, Ritter E, Zwahlen M. How many cancer patients use complementary and alternative medicine: a systematic review and metaanalysis. Integr Cancer Ther 2012;11:187-203.

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Pimenta F, Alves M, Pimenta M, Melo S, Almeida A, Leite J, et al. Anxiolytic effect of Citrus aurantium L. on patients with chronic myeloid leukemia. Phytother Res 2016;30:613-7.

Serfaty M, Wilkinson S, Freeman C, Mannix K, King M. The ToT Study: Helping with Touch or Talk (ToT): a pilot randomised controlled trial to examine the clinical effectiveness of aromatherapy massage versus cognitive behaviour therapy for emotional distress in patients in cancer/palliative care. Psychooncology 2012;21:563-9.

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Tilpasset byline

By the CAM Cancer Collaboration

Is it safe?

Aromatherapy is considered safe when administered by a qualified aromatherapist whose expertise includes working with the needs of people who have cancer.

Aromatherapy oil

Tests of essential oils for safety have shown minimal adverse effects. A number of oils have therefore been approved for use as food additives and are classified as GRAS (generally recognised as safe) by the US Food and Drug Administration. Nevertheless there is a risk involved in the consumption of essential oils (FDA 2020). Also, a review on the safety assessment of St John’s wort (Hypericum perforatum) oil has concluded that the available data are insufficient to support the use of ingredients from this plant as safe for use in cosmetic formulations (Anon 2001).

Adverse events

Some essential oils (e.g. camphor oil) can cause local irritation. The main concern with essential oils seems to be regarding cases of contact dermatitis, mostly reported in aromatherapists who have had prolonged skin contact with oils in the context of aromatherapy massage. Moreover, phototoxicity has been found to occur when essential oils (particularly citrus oils) are applied directly to the skin before exposure to the sun (Clark 1998).

Odours from essential oils may result in adverse psychological responses, especially if the memory of a particular scent evokes strong emotions (Holmes) In addition, Hongratanaworakit et al. have reported that sweet orange oil (Citrus sinensis) can have a stimulatory effect on the cardiovascular system (Hongratanaworakit 2005).

Contraindications

One study has shown that repeated topical exposure to lavender and tea tree oils by topical administration was associated with reversible prepubertal gynecomastia (Henley 2007). Therefore, these two essential oils could cause problems in patients with oestrogen-dependant tumours.

Further contraindications, especially for people with cancer, are associated with contagious diseases, broken skin, varicose veins and circulatory disorders (Ernst 2008). Caution is also indicated for those who are pregnant, or trying to get pregnant, breastfeeding, or have kidney disease, liver disease, asthma or epilepsy (AIA 2021).

Interactions

Drugs that act as depressants on the central nervous system can interact adversely with aromatherapy. These drugs include narcotics such as morphine or oxycodone (OxyContin) for pain, as well as sedative and anti-anxiety agents such as lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax) (drugs.com 2021). Some aromatherapies can cause sleepiness or drowsiness.

Warnings

Aromatherapy inhalation should not be used by people with asthma.