Description
Classical/Swedish massage involves mechanical manipulation of muscles and soft tissues. Practitioners claim that massage may have several positive effects in the treatment of people suffering from cancer, including psychological improvements (e.g. reduction of anxiety and depression) or alleviation of physical symptoms associated with cancer (e.g. reduction of nausea and strengthening of the immune system). Massage has also been promoted to improve overall quality of life.
Efficacy
Evidence from 13 systematic reviews (eight of which included a meta-analysis) is available on various outcomes in the supportive and palliative treatment of cancer. This includes a Cochrane review of the effects of breast cancer, five reviews focused on the effects on pain, one on cancer-related fatigue, two on a range of breast cancer-related symptoms, and the remainder on a range of physical and psychological problems encountered by cancer patients.
Cancer pain: very low quality evidence supports the use of massage for relief of short-term pain. Evidence on longer term pain is too heterogeneous for firm conclusions due to variations in types of massage studied and comparators against which these are assessed.
Fatigue: the evidence for massage is mixed, with some reviews reporting positive results and others reporting no significant differences.
Nausea and vomiting: few trials have been carried out, and the overall results do not confirm any benefit of massage on nausea and vomiting
Anxiety: While trials have reported positive results, these are in small numbers and either low quality or at high risk of bias. Overall, the net benefit is anticipated to be small.
Depression and low mood: Improved depression has been reported with various massage interventions, but this is not consistent across all studies and appears to be dependent on participant motivation or to be short-term.
Quality of life: positive effects have been found with massage combined with essential oils but not with massage alone. Very few trials have, however, assessed these effects.
Other outcomes: the effects of massage on long-term symptoms in breast cancer and a range of other outcomes have been evaluated but the evidence is not sufficient for any firm conclusions.
Overall, there is some evidence that classical/Swedish massage administered as a symptomatic treatment has benefits for cancer patients and is generally safe. It is not possible to draw firm conclusions due to mixed methodological quality of the available research.
Safety
Contraindications include strong forceful massage in patients suffering from hemorrhagic disorders, low platelet counts, and blood thinning medication.
Citation
Pilkington K, CAM Cancer Collaboration. Massage (Classical/Swedish) [online document], Feb15, 2021.
Document history
Latest update: February 2021
Next update due: February 2024
Description and definition
Massage involves kneading, stroking or rubbing, and sometimes vibration, of the body’s muscle and soft tissues. Massage therapists commonly use their hands, and sometimes also their forearms, feet and elbows to treat their clients. Special rollers, water pressure or vibrating tools may also be used as part of a massage session.
Lubricants such as oils and diluted essential oils are sometimes used to facilitate smoother massage and in order to avoiding skin irritation. Massage may be deep or more light/shallow. A variety of massage techniques exist. For the purposes of this CAM summary, only classical/Swedish massage will be reviewed. The majority of research has been carried out on this type of massage.
Components
In Swedish massage soft tissues are manipulated by the use of:
- Effleurage: light gliding strokes of the skin;
- Petrissage: lifting, pressing and kneading skin and muscles;
- Friction: rubbing of skin and muscles;
- Tapotement: rapid tapping, rhythmical movements of the skin and muscles;
- Vibration: vibration of the skin (Natural Medicines Database; Ernst 2008).
Background and prevalence
The use of massage therapy in fever, chills and paralysis dates back to 2700 BC and also appears in early Japanese, Roman, Greek, Arabic, Egyptian and Indian history. It became popular in the renaissance and spread throughout Europe, but it was only in the 19th and 20th century that massage, and in particular Swedish massage, became familiar to the general public. Swedish massage, developed Swedish physician Per Henrik Ling in the early 1800s, is currently one of the most commonly used forms of massage. (Natural Medicines Database 2016)
Massage is a popular treatment modality across the world. A European Survey of cancer patients reported that 3.9 % of respondents used massage after their cancer diagnosis (Demmer 2004). Use varies across the different cancers with 15-18% of breast and gynaecological cancer patients using massage (Molassiotis 2006a and 2006b) after diagnosis compared with less than 10% use by people with colorectal, haematological or lung cancer (Molassiotis 2005a; 2005b and 2006c).
Alleged indications
Massage is thought to bring about psychological and physiological changes which include: psychological relaxation, improvement in mood and sleep, reduction in muscle tension and stress, reduction in blood pressure, increase in pain threshold, improvement of nausea, constipation, and blood and lymph circulation (Frey 2008; Coelho 2008; Durkin 2006; Ouchi 2006; Aourell 2005; Mori 2004). Massage practitioners claim that their intervention is safe and that it does not result in the spreading of cancer.
Mechanism of action
A range of potential effects of massage have been investigated to explain its mechanism of action. Small studies of massage using EEG have demonstrated changes in alpha, beta and delta waves indicative of increased relaxation (Field 1996, Diego 2004). Field and colleagues also reported decreased cortisol and increased serotonin and dopamine in people treated with massage (Field 2005). Subsequently, a large number of small studies have reported effects on salivary or plasma cortisol levels (Rapaport 2018). These have in most cases only shown short-term effects.
Neuroimaging studies of the effect of massage on the brain are limited but small studies have shown increased activity in regions including the forebrain-amygdala system possibly linked to increased parasympathetic tone (Rapaport 2018). It has been suggested that, although the data from EEG and neuroimaging studies showing changes in the brain are limited, if these are combined with data on somatic sensory pleasure circuitry, beneficial effects on wellbeing may be explained through stimulation of specific pleasure-related brain circuits.
Effects on the immune system have also been reported including an increase in natural killer cells and in natural killer cell activity (Rapaport 2018).
Overall, various effects have been reported including those on brain circuitry leading to effects on the parasympathetic tone which may lead to a decrease in stress response and thus inflammatory response. More research is required to confirm this.
Application/providers
Massage therapy is sometimes provided by nurses or physiotherapists as an adjunct to standard medical care, but usually undertaken by licensed massage practitioners. At the first massage session, patients are often asked about their diet, medical history, lifestyle and current symptoms. Most commonly, massage is given while the patient is lying on a soft table, couch or bed, covered by a clean sheet. Patients are covered by towels or sheets to help keep warm during a treatment session. The client may lie face down for half the massage and then turn over. A typical massage lasts from 30 to 60 minutes, and the number of subsequent sessions depends on the condition.
Legal issues
Massage is used globally for people with cancer, although legislation varies from country to country. No mandatory regulation of massage therapists although massage may also be provided by registered health professionals including nurses and physiotherapists. In the UK, massage therapists may voluntarily register with the Complementary and Natural Healthcare Council (CNHC).
Supportive care
There is evidence available from 13 systematic reviews (eight of which included a meta-analysis) assessing the effect of massage on various outcomes in the supportive and palliative treatment of cancer (table 1).
A Cochrane systematic review and meta-analysis by Shin et al. (2016) aimed to examine the impact of massage with or without aromatherapy for symptom relief in people with cancer (Shin 2016). Eight electronic databases were searched for studies published through August 2015 with no language restriction. Nineteen studies (n=1274) were included in the review. Meta-analysis was conducted on 5 studies.
Of the other 12 systematic reviews, 5 have focused on effects on pain, 1 on cancer-related fatigue, 2 on a range of breast-cancer related symptoms and the remainder on a range of physical and psychological problems encountered by cancer patients. Methods used in these reviews were diverse: some restricted studies according to language; different criteria were used to assess quality or risk of bias and the definition of massage varied, with some reviews including interventions such as reflexology.
In all trials of massage, there is a risk of bias affecting reported results, particularly if outcomes are subjective and self-reported, because it is not possible to use adequate blinding. All included reviews and clinical trials had methodological shortcomings that limit their findings.
Description of studies
Cancer pain
Ten systematic reviews including a Cochrane review have assessed the effects of massage on cancer pain (table 2).
The Cochrane review by Shin et al (2016) found that short-term pain relief (Present Pain Intensity-Visual Analogue Scale) was greater for the massage group than the no-massage group (one RCT, n = 72, mean difference (MD) -1.60, 95% confidence interval (CI) -2.67 to -0.53). A difference was also seen between effects of massage and no treatment on medium and long-term pain (based on two RCTs) but the difference was not considered to be clinically significant. Differences between massage with and without aromatherapy could not be determined due to insufficient evidence. Evidence was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and found to be very low quality.
A second systematic review and meta-analysis examined the impact of massage therapy on function in cancer pain (Boyd 2016). Sixteen studies (n= 2034) published until February 2014 were included in the review. Based on the SIGN 50 Checklist, 12 of the studies were considered high quality and four low quality. Results of 11 of the 14 studies indicated massage therapy to be effective for treating cancer pain, the remaining 3 studies reported non-significant results.
A range of types of massage was included: massage therapy, therapeutic massage, light Thai massage, and lymphatic drainage, as were a range of comparators. Three studies (n=167 cancer patients) were pooled for the meta-analysis Standardised Mean Difference (SMD) was −0.20: 95% CI, −0.99 to 0.59 compared with no treatment and −0.55 (95% CI, −1.23 to 0.14; I2 = 89.26%) compared with active comparators for a reduction of pain intensity/severity; the results were not conclusive and showed a high degree of heterogeneity. Chen and colleagues (2016) also found a non-significant effect (SMD = 0.01; 95% CI [-0.23,0.24]) based on meta-analysis of 3 RCTs (n= 278) comparing massage with essential oil against usual care.
Conversely, another systematic review that investigated the effects of massage therapy for all types of cancer patients experiencing pain (Lee 2015) concluded that massage therapy significantly reduced cancer pain (especially surgery-related pain) compared with no massage treatment or conventional care (SMD), −1.25; 95% CI, −1.63 to −0.87). In this case, 12 RCTs (total sample size n=559) were included in the meta-analysis. The larger overall effect sizes for massage on cancer pain may be due to including other types of massage (reflexology/shiatsu), use of different appraisal methods and the small number of long-term studies included in the analysis. A review by Pan (2014) also found significantly greater reductions in pain (n=4) SMD, -0.33; 95% CI, −0.69, -0.03; p=0.07).
Systematic reviews published since 2016 do not add significantly to the evidence base as they have: based conclusions on studies other than RCTs in addition to RCTs (Behzadmehr 2020); not carried out any form of meta-analysis (Behzadmehr 2020, Lee 2016, Radossi 2018) or found fewer trials or insufficient evidence to assess (Greenlee 2017, Lee 2016, Radossi 2018).
Two reviews focusing on pain in children with cancer found no significant effect of massage (Jong 2020) and studies reporting mixed results (Rodríguez-Mansilla 2017) respectively.
Fatigue
Five systematic reviews assessed effects of massage on fatigue (table 3). Of these, one found insufficient evidence (Greenlee 2017) and one found two trials with contrasting results (Lee 2016). One reported significantly greater reductions in fatigue based on 5 trials (SMD, -0.61; 95% CI, −1.09, -0.13; p=0.01) but compared massage against a range of interventions (Pan 2014). A similarly inclusive review included 3 of the 6 identified studies in a meta-analysis (Boyd 2016). A significant difference was not found but high levels of heterogeneity were recorded (SMD, −1.06 (95% CI, −2.18 to 0.05; I2 = 92.81%).
The most recent review, which did focus on fatigue, did find a significant difference between massage and usual care but all trials were assessed as at high risk of bias (SMD (−0.78; −1.55 to −0.01) (Hilfiker 2018).
Nausea and vomiting
Effects of massage treatment on nausea and vomiting have been evaluated in 3 systematic reviews. Few trials were located in any of the reviews and one review concluded that there was insufficient evidence for any assessment (Greenlee 2017). Radossi (2018) reported that two fair quality trials found beneficial effects while Rodríguez-Mansilla (2017) found that only one of 3 trials reported positive effects (table 4).
Anxiety
Seven systematic reviews have assessed effects on anxiety (table 5). The Cochrane review published in 2016 found no significant difference in anxiety (State-Trait Anxiety Inventory-state) between massage and control groups (three RCTs, n = 98, combined MD -5.36, 95% CI -16.06 to 5.34) (Shin 2016). The subgroup analysis for anxiety demonstrated that the anxiety relief for children was greater for the massage group compared with the no-massage group (one RCT, n = 30, MD -14.70, 95% CI -19.33 to -10.07). The size of this effect was not considered clinically significant.
Other systematic reviews have not added significantly to these conclusions. Another review in 2016 (Lee 2016) carried out a meta-analysis on 5 trials and found a significant difference but also significant heterogeneity (SMD = −0.38, 95% CI = −0.75 to −0.01, I2= 66%). The heterogeneity was probably due to inclusion of trials of reflexology, foot massage and scalp massage. Additionally, massage trials with and without essential oils were combined. While trials reporting positive results have been identified, these are in small numbers and either judged to be low quality or high risk of bias (Calcagni 2019, Radossi 2018, Rodríguez-Mansilla 2017). Thus, overall, the evidence was graded as Grade C based on one systematic review (Greenlee 2017). The authors explain that Grade C indicates that ‘the evidence is equivocal or that there is at least moderate certainty that the net benefit is small’. The final review reported significantly reduced anxiety but only searched for trials up to 2013 (Pan 2014).
Depression and mood
Seven systematic reviews assessed effects on depression and/or mood (table 6). The Cochrane review demonstrated no differences in effects of massage on depression, mood disturbance or psychological distress when compared with no massage (Shin 2016). The quality of the included trials was low, the majority of the studies were small and the results were not consistent and not reliable. Effects of massage with aromatherapy versus massage without aromatherapy on depression could not be assessed from the limited evidence available.
The systematic review by Boyd (2016) found massage therapy to be beneficial for treating stress, mood and health-related quality of life (SMD, −1.24 (95% CI, −2.44 to −0.03; I2 = 93.56%) compared to active comparators. This review however provides only limited evidence for the benefits of massage as the size of the benefits are moderate.
Other reviews have found trials reporting positive effects on depression but the trials are few in number and at high risk of bias due to the self-reported nature of depression and the lack of blinding (Lee 2016, Pan 2014, Radossi 2016, Rodríguez-Mansilla 2017). The review by Greenlee (2017) led to a grading of B based on 6 RCTs. This indicates a high certainty of moderate effect or moderate certainty of a moderate to substantial effect. The effects found were, however, not consistent across all studies and were dependent on participant motivation or were short-term. The actual massage intervention varied too.
Quality of life
Five systematic reviews assessed effects on quality of life (table 7). The Cochrane review demonstrated no differences in effects of massage on quality of life when compared with no massage (Shin 2016). The quality of the included trials was low, the majority of the studies were small and the results were not consistent and not reliable. A benefit was found from massage with aromatherapy compared with no-massage in the medium-term quality of life score based on one small RCT (1 RCT, n = 30, MD -2.00, 95% CI -3.46 to -0.54).
The systematic review by Boyd (2016) found that massage therapy was beneficial for treating stress, mood and health-related quality of life (SMD, −1.24 (95% CI, −2.44 to −0.03; I2 = 93.56%) compared to active comparators. This review however provides only limited evidence for the benefits of massage as the size of the benefits are moderate.
Greenlee’s 2017 systematic review found insufficient evidence to assess any positive effects on quality of life. The remaining reviews did not find a significant difference between massage and control (Lee 2016, Pan 2014).
Other outcomes
Seven systematic reviews have assessed outcomes other than those listed above (table 8).
Several systematic reviews assessed the effects of massage on symptoms associated with cancer. Massage with aromatherapy was shown to have a beneficial effect compared with no massage on long-term symptoms in breast cancer (1 RCT, n = 86, MD -9.80, 95% CI -19.13 to -0.47) (Shin 2016). The effect was not considered clinically significant.
A second review also found studies that reported improvement in symptoms but the trials were small and low quality (Calcagni 2019). Other reviews found insufficient evidence on other outcomes (Greenlee 2017, Radossi 2018, Rodríguez-Mansilla 2017). An earlier review had reported an effect on anger but not on lymphoedema or cortisol (Pan 2014). In the remaining review, effects on stress were combined with mood and health-related quality of life (Boyd 2016)
Adverse effects
A 2016 Cochrane review found no trials reporting adverse events of massage with aromatherapy or massage without aromatherapy (Shin 2016). Ernst (2003) summarized the existing documentation on adverse effects of massage therapy. The majority of adverse effects arose from the use of exotic (non-Swedish) massage techniques and is therefore not applicable to this review. Whilst massage is not risk-free, serious adverse effects are rare. Some minor musculoskeletal discomfort is experienced by a small proportion of patients (Natural Medicines 2021).
A concern that has been raised related to the theory that massage of a tumour site may induce the spreading of cancer cells and development of metastasis. There is no evidence to date that therapeutic massage interventions may have such effects (Corbin 2005), but direct pressure on a tumour site is usually discouraged in massage practice.
Contraindications
Guidelines for clinical practice of massage in breast cancer patients recommend that practitioners avoid massaging specific vulnerable areas of the body, including open wounds, bruises, areas of skin breakdown, a blood clot in a vein, a tumour site, areas near a medical device or sensitive skin after radiation therapy (Greenlee 2017). The guidelines also warn that there may be a risk of fracture during deep massage in certain patients with multiple bone metastases.
Interactions
If essential oils and massage lubricants are used, interactions are possible or they may cause allergic reactions (Natural Medicines, 2021).
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