Cancer & Massage. Information om massage til cancerramte. Af Rikke Pedersen

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1 Cancer & Massage Information om massage til cancerramte Af Rikke Pedersen

2 Indholdsfortegnelse Forord...1 Massage til cancerramte...2 Helbredserklæring...3 Lægeerklæring...7 Trykniveau...9 Vurdering af massagen...11 Tilpasninger...13 Foreningen CaMas - Cancer & Massage...14 Ansøgning...15 Referencer...16 Kvinde, 37, massage under kemokur...16 Kvinde, 48, massage under palliativ behandling...16 Massøren...17 Forskning...18 Dansk artikel...19 Amerikansk undersøgelse med 1290 cancerramte...26 Undersøgelse massage til syge børn...32 Rikke Pedersen, BodyRespons 2012

3 1 Forord Lindring til cancerramte! I bl.a USA bruger man onkologisk massage i hospitalsmiljøer til at lindre de cancerramte s bivirkninger ved at være syg samt bivirkningerne fra den medicinske behandling. Gode forskningsresultater viser, at massage er en sikker terapiform til cancerramte, når behandleren ved hvilke forholdsregler og kontraindikationer, der gør sig gældende. Massageklienter, der er nydiagnostiseret eller i gang med kemobehandling siger ofte efter massage: Jeg har fået min krop tilbage. Jeg kan føle velvære i min krop, der ellers har været svær og fremmed at være i. Der er blå himmel og solskin indeni. Dem i palliativ behandling finder ro og lindring - tit falder de i søvn. På de næste sider står beskrevet, hvordan jeg tilpasser den onkologiske massage til den canceramte alt efter hvilke cancerform, bivirkninger m.m. de har. Hos Tracy Walton, USA, som forsker i massage til cancerramte, har jeg specialiseret mig i denne lindrende, non-invasive og omsorgsfulde massage. Jeg håber, at I vil overveje den onkologiske massage til jeres patienter! Tak!

4 Massage til cancerramte 2 Massagen, som vi tilbyder, er en massage som er designet til de specielle behov en massageklient med cancer har - det gælder både, hvis klienten er i aktiv behandling, i bedring eller i palliativ behandling. Har klienten haft cancer og er helbredt - er der stadig behov for at tilpasse massage efter, hvilken medicinsk behandling for canceren klienten har modtaget. Massagen er sammensat udfra forskningsresultater og 15 års erfaring med massage af cancerramte af Tracy Walton, Boston, som er forsker, biolog og massør. Massagen er en blid, non-invasiv massage, der fokuserer på at fremme afslapning, lindre angst og frygt, samt sænke stressniveauet og dulme smerter. Massagen er unik for den enkelte klient og for hver session. Massage tilpasningerne kan være positionering, trykniveau, tempo eller sted i forhold til medicinsk udstyr, bivirkninger af den medicinske behandling, operation, stråleterapi, kompromitterede lymfeknuder eller lave blodtal. Visse tilpasninger vil gøre sig gældende mange år efter behandlingen er afsluttet. Når der gives massage til nogen med en cancerhistorie, vil massøren bl.a. tage hensyn til knogleinvolvering, involverede vitale organer og kompromitterede lymfeknuder. Er der nogen tvivl hos massøren vil der altid masseres mest muligt konservativt dvs. et trykniveau på 1 jvf trykskala. (Se side 10) Massage til børn Til børnene vil massøren bruge rim og remser, så massagen bliver til en leg og ikke endnu en behandling. Berøring er et fundamentalt behov hos mennesket, derfor kan massage hurtigt give barnet komfort og trøst, reducere angst samt give barnet følelsesmæssigt tryghed. Desuden kan massagen hjælpe med at reducere smerter. En massør vil altid spørge barnet om lov til at massere og barnet får selv lov til at vælge hvor på kroppen - så længe det ikke konflikter med sygdommen. Massage er positiv omsorgsfuld berøring i en hverdag med diverse undersøgelser, tests og blodprøver.

5 Helbredsinformation/Lægeerklæring 3 Helbredsinformationen må den enkelte massageklient gerne udfylde inden massageaftalen, da informationerne indgår i planlægningen af massagen. Ellers vil der gå tid til det under første massagesession. Der er mange informationer om helbredet, som indgår i de tilpasninger af massagetrykket, tempo, positionering m.m. som massøren vil tage hensyn til under hver massagesession. Derfor er det vigtigt for massøren at have disse informationer og gerne sammen med informationerne på lægeerklæringen. (Se side 7). Er massøren i tvivl, vil der blive masseret konservativt om med et trykniveau på 1 jvf trykskala. En onkologisk massagesessionplan tager højde for: Moderation af massagetrykket Justering af positionering Restriktioner af hvor på kroppen, der masseres Risiko for lymfeødem Bivirkninger af medicinsk behandling Lave blodtal Kompromitterede lymfeknuder

6 1 CaMas Cancer & Massage 4 Side Helbredsinformation Navn: Dato: Adresse By: Telefon: Cpr.nr: Læge: Hvilken cancer og placering? Dato for diagnose? Nuværende status af din cancer? Metastaser? JA NEJ Hvis ja, hvor? Operation/indgreb: Type: Dato: Type: Dato: Type: Dato: Har du i øjeblikket: Sæt kryds ved det, som er gældende. sår operationssår infektioner dræn forbinding Medicinsk udstyr (Se nedenunder) Medicinsk udstyr: Sæt kryds ved det, som er gældende. Central vene kateter Port-a-cath Urinrørskateter PEG sonde Andet Fjernet lymfeknuder: Sæt kryds ved det, som er gældende. Armhule Hals Lysken Mave Antal der er fjernet Er du i behandling nu: Sæt kryds ved det, som er gældende samt udfyld dato. JA NEJ Startet: Skal begynde den: Afsluttet den: Kemoterapi: Skriv nuværende eller tidligere kemo-medicin, kemocyklus og bivirkninger. Navn på kemo: Cyklus på kemobehandling: Nuværende bivirkninger: Kan du forudsige gode og dårlige tidpunkter i hver cyklus? Strålebehandling: Skriv det, som er gældende. Områder der behandles: Cyklus på strålebehandling: Stråler i armhule, hals el. lysken Nuværende bivirkninger: Hvordan er tilstanden af din hud?

7 Tager du medicin? Skriv alt nuværende medicin inkl. håndkøbsmedicin Bivirkninger: Helsekost: 5 Seneste blodprøve: Sæt kryds ved det, som er UNDER normalværdierne. Røde blodlegemer Hvide blodlegemer Blodplader Andet Nuværende symptomer/sygdom: Sæt kryds ved det der er gældende. Kardiovasculær (blod/hjerte) Blodpropper Ødemer/hævelser Irregular hjerterytme Lymfeødem Nemt blåmærker Højt blodtryk Ekstrem varm/kold Varikøse blodåre Respiratorisk (lunger) Astma Besværet åndedræt Slim/spyt Hoste Nervesystemet (hjerne/rygrad/nerver) Depression Hukommelsesbesvær Angst Søvnbesvær Hovedpiner Koncentrationsbesvær Nerveskader (hånd/fod) Mave/tarm (fordøjelse) Kvalme/opkast Diarre Forstoppelse Mundsår/tør mund Tørstig Mistet appetit Vægt tab/øgning Lever problemer Urinveje (blære/nyrer) Inkontinence Infektion Nyresvigt Besværet vandladning Smertefuld vandladning Bevægeapparat/hud Brud/knogle metastaser Osteoporose Ødemer/hævelser Ledproblemer/gigt Smerter/ømhed Træthed/svækkelse Skrøbelig/følsom hud Eksem/sår/infektion Har canceren eller behandlingerne påvirket følgende: Hår eller hud? Muskelspændinger? Din sidde- og liggekomfort? Dit søvnmønster? Har canceren eller behandlingerne påvirket funktionen af følgende organer? olunger olever ohjerte ohjerne onyrer Har canceren eller behandlingerne øget risikoen for blodpropper, DVT eller knoglebrud? oblodpropper odvt-dyb vene trombose oknoglebrud

8 Har din læge udvist bekymring for blodpropper, venetromboser og knoglebrud? JA NEJ Hvad? 6 Beskriv dit aktivitets- og bevægelsesniveau? Er der medicinske restriktioner vedr. dine aktiviteter? JA NEJ Hvad? Smerter? Hvor? Skala (0-10): Sæt cirkel det tal, der beskriver din smerte. Ingen smerter ekstreme smerter Er der gode og dårlige tidspunkter på dagen? Generelt: Sæt kryds ved det, som er gældende. Sukkersyge Slagtilfælde Hjerteanfald Hjertesvigt KOL Er der andet du gerne vil fortælle mig? Med nedenstående underskrift erklærer jeg hermed på tro og love at samtlige spørgsmål er besvaret sandfærdigt og efter bedste evne og intet er fortiet. Dato: Underskrift: Tavshedspligt CaMas er underlagt tavshedspligt. Dette indebærer, at vi ikke videregiver oplysninger til 3. part uden dit samtykke. Med venlig hilsen CaMas Allehelgensgade 23a, st. th, 4000 Roskilde Cvr: [email protected]

9 CaMas Cancer & Massage 7 Kære Læge! Din patient har vist interesse i at modtage massage under sit cancerforløb. Onkologisk massage er en langsom, blid, non-invasiv massage med fokus på at fremme afslapning, lindre angst, frygt, stress, svimmelhed, kvalme samt smerter. Massagetrykket (maks. 3 - se trykskala), tempo og længden af massagen tilpasses den nuværende situation og kan blive ændret fra gang til gang. Patient navn: Cpr.nr: For at tilpasse massagesessionen vil massøren tage højde for følgende: (Venligst kryds af de gældende medicinske forholdsregler i spalten Medicinske forholdsregler og noter eventuelle bemærkninger) Medicinske-forholdsregler: (Forbeholdt massør) Massage-forholdsregler: Anordninger Område/tryk/forholdsregel Port-a-kath Note: Undgår området/forsigtighed ved bugleje. PEG-sonde Note: Undgår området/forsigtighed ved bugleje. IV el. CVK Note: Distalt for område/1-3. Stomi Note: Undgår området/forsigtighed ved bugleje Hæmatolog Thrombocytopeni - under / hele kroppen. Thrombocytopeni - under / hele kroppen. Thrombocytopeni - under 20 1/hele kroppen. Note: Leukopeni 1/hele kroppen/infektion-forholdsregler Note: Anticoagulant terapi 1-3/hele kroppen. Note: DVT 1/DVT-forholdsregel. Note: Onkologi Tumor Hvor? Knogle metastaser Hvor? Aktivitets rekstriktioner: Aktiv cancer Hvor? Undgår lokalt/1. Lokalt/1-2. Lokalt/1.

10 Lymfeødem forholdsregler Forstørret lymfeknude Antal? Hvor? Fjernet lymfeknude Antal? Hvor? Bestrålet lymfeknude Antal? Hvor? Lokalt/1-2. Lokalt/distalt/1. Lokalt/1 8 Hud Eksem, kløe, sår Undgår området. Note: Skrøbelig/følsom hudområde Undgår området. Note: Strålebehandlet hudreaktion Lokalt/1-2 afhængig af huden. Note: Forestående strålebehandling Undgå creme m. metal, alkohol. Note: Operationssår Undgå område eft. operation/ Note: derefter 1. Ødem Lokalt/1-2/elavere området. Note: Lymfeødem Henvis til specialist behandling. Note: Andet Forstoppelse Note: 1-3/med uret. Risiko for massør Undgå massage i dage efter: Cyclophosphamid eller thiotepa Radioaktiv jod Radioaktiv implantat Andre restriktioner, instruktioner eller kommentar: Dato: Underskrift/stempel: Med venlig hilsen Rikke Pedersen BodyRespons, Allehelgensgade 23a, st. th, Cvr: [email protected] Foreningen CaMas - cancer & massage STØT os på

11 Trykniveau 9 På næste side kan man se trykniveauskalaen. Trykniveauet bliver altid modereret, når massagen er til cancerramte eller andre kritisk/kronisk syge. Massøren vil bruge et tryk på 1-3 jvf trykskalaen. Specielt ved... Immunosuppression Ekstrem svimmelhed Kvalme Lymfeødem/risiko for lymfeødem Knogleskørhed/metastaser i knoglerne Medicinsk udstyr Skrøbelig/følsom hud Lave blodtal Perifer neuropati Smerter Smertestillende medicin...vil massøren bruge et meget let tryk - svarende til at påføre creme. Er der nogen tvivl hos massøren, vil denne altid vælge at massere med et trykniveau på 1, indtil der er konfereret med klientens læge.

12 Massagetryk Vævs påvirkning Massøren Standard brug Noter Ingen vævs Brug af arme 1 påvirkning eller hudbevægelse. og hænder, der Meget let tryk. Som at påføre creme. bruges ingen vægtoverførsel eller styrke. 2 Let tryk. Som at smøre cremen ud. 3 Medium tryk. 4 Hårdt tryk. 5 Dybt tryk. Lille vævs påvirkning af superficielt fedt- og muskelvæv. En vis bevægelse af medium lag af muskler, fedtvæv og blodkar. Der kan forekomme lette ledbevægelser med dette tryk. Fx kan nakken bevæge sig et par grader, når trykket er anvendt i strøg langs skulderen. Bevægelse af de dybe lag af muskler, fascier, sener, fedt og blodkar. Der forekommer tydelige ledbevægelser med dette tryk. Fx vil hofte og lår bevæge sig under massage af hofteregionen. Flytning af de dybeste lag af muskler, fascia, fedtvæv og blodkar. Brug af arme og hænder med et lille tryk, der bruges ingen vægtoverførsel eller styrke. Der bruges vægtoverførsel for at få et medium tryk samt styrke i hænderne ved æltning (petrissage). Stor styrke i overkrop eller god vægtoverførsel er nødvendig for at lave dette tryk samt gode fingerkrafter. Meget stor styrke i overkrop eller rigtig god vægtoverførsel af massørens egen vægt behøves ved dette tryk. Ofte lægges den ene hånd oven på den anden for at få det dybe tryk. Påføre massageolie og smøre det blidt ud. Maksimale tryk for klienter med skrøbelig helbred eller med meget ustabilt væv. Smøre olien ensartet ud. Maksimale tryk for de fleste klienter med dårligt helbred. Trykket der bruges til at varme vævet op hos raske klienter. Maksimalt tryk hos klienter med sygdom, hvis de har et højt aktivitets/funktions niveau. Anvendes ofte ved massage af sunde/raske klienter for at fokusere på muskelspændinger. Anvendes til robuste, raske klienter, der gerne vil have en dybt tryk. Langsomme bevægelser for at kontrollere trykket. Husk fuld håndkontakt! Som at smøre creme ind i huden. 10 Fuld håndkontakt! Ofte brugt tryk ved massage - specielt i strygninger (effleuage) og æltning (petrissage). Ved dette tryk og højere sættes gang i cirkulationen. Massør der laver dybde massage. Skifter fra fuld håndkontakt til knoer, tommelfinger, albue m.m. Sætter gang i cirkulationen. Massør der laver dybdegående massage. Skifter fra fuld håndkontakt til knoer, tommelfinger, albue m.m. Sætter gang i cirkulationen.

13 Vurdering af massagen 11 Massagen vurderes før og efter en massagesession af klienten. Ofte tages der også kontakt til klienten i de eftefølgende dage, for at høre hvilken virkning massagen har haft efterfølgende. Så vil der til næste session tages højde for virkningen, så massagen kan justeres afhængig af virkningen. Justeringen kan være: Længden af sessionen Massagetrykket Langsommere bevægelser Ligeledes vil der tages højde for ændringer i helbredsinformationerne i den næste session.

14 Vurdering af massagen 12 Navn: Massør: Tidspunkt for massage: Dato: Før massagen Sæt venligst cirkel om det tal som angiver dit niveau af smerter, fysiske og følelsemæssige komfort samt træthed/udmattelse før massagen. SMERTER Ingen smerter Ekstreme smerter FYSISK KOMFORT Ekstrem komfortabel Ekstrem ukomfortabel FØLELSESMÆSSIG KOMFORT Ekstrem komfortabel Ekstrem ukomfortabel TRÆTHED Ikke træt Ekstrem træt Efter massagen List de ord, der beskriver de fornemmelser, du bemærkede under massagen. Sæt venligst cirkel om det tal som angiver dit niveau af smerter, fysiske og følelsemæssige komfort samt træthed/udmattelse efter massagen. SMERTER Ingen smerter Ekstreme smerter FYSISK KOMFORT Ekstrem komfortabel Ekstrem ukomfortabel FØLELSES MÆSSIG KOMFORT Ekstrem komfortabel Ekstrem ukomfortabel TRÆTHED Ikke træt Ekstrem træt Massør feedback: Patient respons: Teknikker brugt: Massage længde: Tidspunkt for vurdering:

15 Tilpasninger 13 Eksempel på eventuelle tilpasninger til en leukæmiramt massageklient: Leukæmi Heldbreds information Massage retningslinier Hævet lymfeknuder Anæmi Påvirket immunforsvar Blå mærker & blødninger Lavt blodtryk Aktiv cancer Forstørret milt/lever Ødemer Meget let tryk (1), ikke sætte gang i cirkulation Let tryk (1,2) overalt pga svækkelse/ træthed Passe på med infektioner Meget let til medium tryk (1-3). Rådfør med læge før bestemmelse af tryk. Afhængig af antallet blodplader. Afslut massage blidt og langsomt op fra massagebriks Let tryk (1-2), ingen cirkulation Ingen cirkulation pga allerede belastede organer Ingen cirkulation - tegn på belastet lymfesystem. Medicin Kemo Stråler Andet medicin Bivirkninger Mange kraftige bivirkninger Justerer alt efter hvilke bivirkninger den enkelte massageklient har.

16 Foreningen CaMas - Cancer & Massage 14 Foreningen CaMas - Cancer & Massage Allehelgensgade 23 a, st. th 4000 Roskilde [email protected] CaMas er en forening, hvis formål er at tilbyde specialiseret massage til cancerramte samt undervise pårørende i, hvordan de selv kan massere den syge. I USA og England bruges massage som en del af behandlingsplanen til cancerramte. The Touch Research Institute i Miami har studeret hvilken betydning massage kan have i forbedringen af symptomer ved cancer. Det viser sig, at massagen spiller en signifikant rolle i helingsprocesen. 1,2,3 Deriblandt har massagen en positiv effekt på angst, som mindskes, den reducerer kvalme og smerter, letter depression og svimmelhed. Massage er ikke en del af behandlingsplanen på danske hospitaler - endnu. Foreningen vil arbejde med at udbrede kendskabet til massagen og dens gavnlige virkninger til cancerramte. Vi hjælper cancerramte syge og deres pårørende med at håndtere deres smerter, frygt og isolation med massage og omsorgfuld berøring. Foreningen CaMas Cancer og Massage er oprettet i 2011 for at sponsorere denne specialiserede massage til cancerramte. Via medlemskab af foreningen, kan man få sponsoreret massagen i massørens klinik, i hjemmet samt på hospitalet. Foreningens bestyrelse virker på frivillig og ulønnet basis. CaMas er afhængig af medlemskontigenter samt økonomisk bistand fra fonde, foreninger, offentlige puljer, m.v. til at kunne tilbyde massage og kurser gratis. Der bliver derfor gjort et stort arbejde for at indsamle midler. 1: Massage Therapy Research, Tiffany Field, Paperback, 272 sider, maj-2006 ISBN 10: CHURCHILL LIVINGSTONE 2: Alternativ behandling og kræft : Et review af evidens for effekt af massage, aromaterapi og zoneterapi af Anita Lunde, Cand. Cur og Helle Johannesen, Mag. Scient., PH.D. D. 29. Januar 2010 blad nr. 2. 3: A Preliminary Study of the Effects of a Single Session of Swedish Massage on Hypothalamic Pituitary Adrenal and Immun Function in Normal Individuals. The Journal of Alternative and Complementary Medicine, 2010;

17 Udfyld venligst skema og send til CaMas CaMas Allehelgensgade 23 A, st. th 4000 Roskilde Ansøger Navn Forbeholdt CaMas Modtaget d. Godkendt Ja Nej Ansøgning til CaMas om massage Fødselsdag 15 Adresse Telefon Medlemsnummer CaMas Søges for familiemedlem, skrives medlemmets navn her Fødselsdag Ansøgt CaMas om massage tidligere Ja Nej Hvornår Blev ansøgning godkendt Ja Nej Helbredsoplysninger Hvilken cancer type har du Hvornår er canceren opdaget og behandlingen startet Hvor og hvornår er du behandlet (Skriv sygehus/speciallæge) Hvilke bivirkninger har du Ved din læge, at du ønsker massage under dit cancerforløb Ja Nej Hvor skal massagen foregå På hospitalet I hjemmet På massørens klinik Andre bemærkninger Andet

18 Referencer 16 Kvinde, 37 år, massage under kemokur: Effekten af massagen - både fysisk og mentalt - var overraskende stor. Særligt i forhold til, hvor blid massagen var. Med de mere voldsomme metoder, man som cancer/kemo-patient er vant med, virker det nærmest mærkværdigt, at noget så uskyldigt og ufarligt kan gøre så godt. Inden massagen fik jeg en mundtlig introduktion, hvor jeg kunne spørge ind, og vi gennemgik min diagnose, mit behandlingsforløb og mine aktuelle behov. Selve massagen var præget af ro og fokusering. Jeg døsede hen og sov efterfølgende en halv times tid. Jeg vågnede klar og frisk i hovedet. Kvalmen var lettet. Jeg var rolig og samlet med et positivt blik ud i verden. Det var rart og fyldt med velvære at være i min krop, hvilket er særlig skønt i et forløb, hvor man - af gode grunde selvfølgelig - hele tiden skal holde øje med alle de negative signaler. Det var som at få sin krop tilbage. Jeg kom godt og sovende igennem natten, langt bedre end efter den tidligere omgang kemo, fordi roen var let at hente frem igen efter massagen. Som en ekstra bonus blev maven - modsat tidligere kemoomgange - ved med at fungere. Kvinde, 48 år, massage under palliativ behandling: Jeg lå på højre side da Rikke begyndte massagen, jeg lå og tænkte på at smerterne i højre hofte skulle blive mindre (havde taget piller), men det skete ikke. Jeg kunne slappe rimeligt af og kunne nyde massagen. Jeg sov ikke, men døsede og slappede meget af. Det var bedst, når der var helt stille i stuen. Da jeg havde fået massage på venstre side lå jeg lidt, inden jeg vendte mig om på den anden side. Det var helt fantastisk at ligge på den side og få massage, jeg nød det meget. Døsede meget og sov lidt. På et tidspunkt holdte Rikke sine hænder på min ryg, på lungerne og på siden...det var så dejligt, helt fantastisk. Jeg faldt vist i søvn. Da jeg vågnede (efter en god halv time) havde jeg det så godt, helt afslappet slet ikke ondt nogen steder. Kunne mærke jeg havde sovet rigtig godt, følte mig meget frisk. Jeg kom op og sidde, sagde farvel til Rikke. Jeg havde det bare så dejligt i hele kroppen. Afslappet, rolig og meget frisk i hovedet.

19 Massøren 17 Fysiurgisk og onkologisk massør Rikke Pedersen 2011: Kursus: Onkologisk massør - Caring for people with cancer hos Tracy Walton, Boston, USA. 2010: Kursus: Babymassage instruktør - international certificeret. 2009: Kursus: Neuro muskulær manipulation (NMM) - sportszoneterapi. 2009: Åbner egen klinik i Roskilde. 2008: Uddannet lægeeksamineret fysiurgisk massør med 660 timer. 1999: Optometrist. Andet Frivillig massør i Ronald McDonald Huset, Rigshospitalet fra Stifter af Foreningen CaMas - Cancer & Massage. Medlem af: BFM - Brancheforeningen for Fysiurgisk Massage Aimi - Association Infant Massage Instructor Kontaktinformation: Rikke Pedersen BodyRespons Allehelgensgade 23 A, st.th 4000 Roskilde [email protected]

20 Forskning 18 Forskning viser, at massage til cancerramte sigifikant kan lindre nogle af bivirkningerne, der er ved at være cancerramt. Angst & stress Smerter Kvalme Træthed Depression På Memorial Sloan-Kettering Cancer Center i New York har de lavet en undersøgelse med 1290 personer over en 3 års periode, hvor de fandt ud af, at der var en umiddelbar, hurtig og stor reducering af alle 5 symptomer - hvoraf nogle i gennemsnit blev forbedret med op til over 50 % (Angst). (Se side 25) Anita Lunde, Cand. Cur. og Helle Johannesen, Mag. Scient., PH.D, fra Syddansk Universitet har sammenholdt resultaterne fra 10 forskellige publicerede undersøgelser, der omhandler forsøg med komplementær/alternativ behandling til cancerpatienter: De fandt: Det mest konsistente resultat er, at massage signifikant reducerer angst hos kræftpatienter (evidens A). Ydermere findes nogenlunde sikker dokumentation for effekt af massage mod depression, smerter og kvalme. Ingen reviews finder skadelige virkninger af massage, og forestillingen om, at massage kan sprede kræft, afkræftes af nyere forskning. Artiklen er fra SYGEPLEJERSKEN NR. 2 d. 29. Januar (Se side 18) På University of Arizona, College of Medicine, USA lavede de en undersøgelse om effekten af massage til cancerramte børn og børn med blodsygdomme. Baggrunden for undersøgelsen var, at tidligere forskning har påvist positiv effekt af massage til for tidligt fødte spædbørn og til børn med astma, gigt og andre sygdomme. Dette førte til behovet for en undersøgelse, der fokuserer på børn med cancer og blodsygdomme. Tredive børn med cancer eller blodsygdomme, i alderen fra 6 måneder til 17 år deltog i undersøgelsen. Deres fysiske sundhed og mentale trivsel blev målt, før undersøgelsen begyndte. Behandlingsgruppen fik 20 minutters massage én gang dagligt i ca. 4 dage. Resultaterne viste en betydelig psykologisk forbedring af barnets angst og følelsesmæssige tilstand. Det fremgik også, at barnet fik betydelige fysiske forbedringer på muskelømhed, respirationsfrekvens og generelle fremskridt. Konklusionen på undersøgelsen var, at massage kan reducere psykiske og fysiske bivirkninger ved at være syg og kan have en positiv effekt på livskvaliteten hos børn med cancer og blodsygdomme. (Se side 31)

21 AROMATERAPI ALTERNATIVBEHANDLINGOGKRÆFT ETREVIEWAFEVIDENSFOREFEKTAFMASAGE,- OGZONETERAPI Dansk artikel 19 AF ANITA LUNDE, CAND.CUR., OG HELLE JOHANNESSEN, MAG.SCIENT., PH.D. D. 29. JANUAR 2010 BLAD NR. 2 VIDENSKAB & SYGEPLEJE Denne artikel er godkendt gennem dobbeltblindt peer review. Artiklens hovedbudskab er, at massage signifikant reducerer angst hos kræftpatienter, ligesom der findes nogenlunde sikker dokumentation for effekt af massage mod depression, smerter og kvalme. Massage er tillige en sikker terapiform og kan derved indgå i evidens-baserede sygeplejefaglige tiltag mod psykiske og fysiske følgevirkninger af kræft. RESUMÉ Baggrund: Interessen for komplementær og alternativ behandling (KAB) er stadigt stigende, og også blandt kræftpatienter kan der dokumenteres et større forbrug af KAB. Kræftpatienter anvender primært KAB som supplement til deres konventionelle behandling, og flere undersøgelser tyder på, at sygeplejersker er den faggruppe, som er mest åbne over for patienters brug af KAB. Patienter såvel som sundhedsprofessionelle mangler dog overblik over eksisterende viden om effekt af KAB til kræft. Denne artikel undersøger evidensen for effekt af manipulativ og kropsbaseret KAB til kræftpatienter. Metode: Der er foretaget systematisk søgning i databaserne Pubmed, Cochrane-biblioteket, AMED, CHINAL og Web of Science efter reviews, systematiske reviews og metaanalyser over effekt af KAB til kræft eller kræftrelaterede symptomer publiceret i Med udgangspunkt i guidelines udviklet af the Scottish Intercollegiate Guidelines Network, SIGN, er de inkluderede reviews kvalitetsvurderet og de fundne effekter bedømt efter fire evidensniveauer. Resultater: 10 reviews omhandler manipulativ og kropsbaseret praksis, og heraf er fem af høj kvalitet. Det mest konsistente resultat er, at massage signifikant reducerer angst hos kræftpatienter (evidens A). Ydermere findes nogenlunde sikker dokumentation for effekt af massage mod depression, smerter og kvalme. Ingen reviews finder skadelige virkninger af massage, og forestillingen om, at massage kan sprede kræft, afkræftes af nyere forskning. Konklusion: Massage er en sikker terapi i kombination med konventionel kræftbehandling og kan indgå i evidensbaserede sygeplejefaglige tiltag mod psykiske og fysiske følgevirkninger af kræft. Der er behov for undersøgelser, der dokumenterer effekten af andre manipulative og kropsbaserede terapiformer som eksempelvis zoneterapi. På nuværende tidspunkt er det ikke muligt at differentiere effekten i forhold til typen af massage, kræftform eller sygdomsstadie. Nøgleord: Komplementær og alternativ behandling, kræft, evidensbaseret sygepleje, massage, angst. Baggrund Komplementære og alternative behandlingsformer (KAB) defineres ofte som behandlinger, der baserer sig på metoder, som hovedsagelig anvendes uden for det etablerede sundhedsvæsen (1). Feltet er komplekst, og KAB dækker en lang række alternative behandlingsformer samt naturmedicin og kosttilskud. Grænserne mellem KAB og etableret behandling er dog både kulturelt og historisk betinget: F.eks. er kiropraktik i dag en autoriseret behandling i Danmark, mens det stadig betragtes som ukonventionelt og alternativt i Italien og USA (2). Interessen for og forbruget af KAB har været stadigt stigende gennem de sidste årtier. Statens Institut for Folkesundheds sundhedsog sygelighedsundersøgelse fra 2005 viste, at godt 40 pct. af den danske befolkning har anvendt alternativ behandling, heraf 20 pct. inden for det sidste år. Til sammenligning havde kun 23 pct. i 1987 brugt alternativ behandling på et eller andet tidspunkt i deres liv (3). Det stigende forbrug af KAB i Danmark afspejler en generel tendens i den vestlige verden (4). Som den primære årsag til brug af KAB angives milde lidelser, forebyggelse og generelt velvære (5,6), men også blandt kræftpatienter synes der at være et stort forbrug af KAB. Et europæisk studie viser, at gennemsnitligt 36 pct. af patienter med kræft anvender KAB (7), og en undersøgelse fra Kræftens Bekæmpelse finder, at 55 til 75 pct. af de patienter, der kontakter kræftlinjen, har anvendt alternativ behandling (8). En ph.d.-afhandling om kræftpatienters brug af alternativ behandling viser tilsvarende, at 45 pct. har anvendt naturlægemidler eller kosttilskud og pct. alternativ terapi (9). De fleste kræftpatienter anvender KAB for at lindre bivirkninger af etableret kræftbehandling, for at styrke immunforsvaret og almentilstanden eller som en vej til at finde håb og genvinde kontrol (10). Kræftpatienter søger primært KAB som et supplement til etableret behandling (5,11). Mange patienter ønsker i den forbindelse at drøfte deres brug af KAB med en sundhedsprofessionel, og ca. 43 pct. af alle adspurgte hospitaliserede kræftpatienter i et norsk studie udtrykker, at de gerne så KAB integreret med den konventionelle behandling (12). Samtidig med det øgede forbrug kan der også konstateres stor forskningsaktivitet vedrørende KAB. I Pubmed er indekseret godt

22 Dansk artikel artikler om KAB, hvoraf ca er kliniske effektstudier, og godt af disse er publiceret fra år 2000 og frem. I Cochrane-biblioteket er der indekseret 200 systematiske reviews om evidens for KAB. På trods af de forholdsvis mange publikationer kan det stadig være svært både som sundhedsprofessionel og som kræftpatient at skaffe sig et overblik over spørgsmålet om effekt af KAB til kræft. Som en reaktion på det stigende KAB-forbrug har Sundhedsstyrelsen henstillet til landets sygehuse om så vidt muligt at acceptere patienters brug af KAB, og at dette også kan ske under indlæggelse (13). Sundhedsstyrelsen anbefaler endvidere, at sygehusafdelinger udarbejder retningslinjer, der kan guide sundhedsprofessionelles vejledning om, hvorvidt en given KABbehandling indebærer mulige risici (13). Spørgsmål om effekt af KAB samt mulige bivirkninger eller interaktioner med konventionel behandling trænger sig altså på i sundhedsvæsenet. Sygeplejersker er fremhævet som en faggruppe, der let kan identificere sig med den holistiske tilgang, som findes i mange KAB-former. Samtidig oplever patienter, at sygeplejersker er mere åbne over for KAB end læger, og sygeplejersker kan derfor have en formidlende rolle mellem patient og læge (14,15). Sygeplejersker kan på denne baggrund være en central faggruppe i initieringen af retningslinjer for KAB. National Institute of Health, NIH, i USA har udviklet et klassifikationssystem, som definerer fem kategorier af KAB (se boks 1 herover) (16). I herværende artikel undersøges kategorien manipulativ og kropsbaseret praksis. Manipulative og kropsbaserede praksisformers primære fokus er kropslige strukturer og systemer som knogler, led, muskel- og bindevæv (17). Kategorien dækker således bl.a. massage og zoneterapi, som er de to hyppigst anvendte alternative behandlingsformer blandt danske forbrugere (18). Ydermere ses behandlinger som kiropraktik, osteopatisk manipulation, tui na, rolfing og Alexander-teknik. Nogle behandlinger har deres oprindelse i gamle medicinske traditioner fra lande som Kina og Indien, mens andre er udviklet i Vesten inden for de sidste 150 år (17). Artiklens formål er at evaluere effekt af manipulativ og kropsbaseret praksis til kræft og/eller kræftrelaterede symptomer og psykosociale forhold og give evidensbaserede anbefalinger for praksis. Artiklen tager udgangspunkt i guidelines udviklet af the Scottish Intercollegiate Guidelines Network, SIGN, som arbejder med et system, der kobler synteser af den eksisterende evidens med fire niveauer af anbefaling for praksis (19). Målene er: at fastlægge, hvilke behandlinger inden for kategorien der er undersøgt og i hvilket omfang at identificere, hvorvidt der er evidens for effekt at evaluere kvalitet og styrke af evidensen, samt hvilket anbefalingsniveau der gælder for den pågældende behandling, og at klarlægge evidens for sikkerhed eller alvorlige bivirkninger. Metode Systematiske søgninger er foretaget i databaserne Pubmed, CHINAL, Cochrane biblioteket, AMED og Web of Science. Til søgningerne er anvendt kontrollerede emneord for KAB og kræft: "Complementary therapies", "Alternative Therapies" og "Neoplasms", kombineret med "AND". AMED og Web of Science er ikke indekseret, hvorfor søgningen her inkluderer synonymer for de to emneord (se boks 2 side 59) med brug af trunkering og fritekstsøgning. I søgningerne er alle typer reviews søgt identificeret, herunder ekspertreviews, systematiske reviews og metaanalyser. Limit-funktionerne "review", "systematic review" og "metaanalysis" er anvendt, og i Pubmed er funktionen?clinical Queries" også benyttet. Øvrige inklusionskriterier fremgår af boks 3 side 59. Artikler, der ikke er baseret på forsøg med kræftpatienter, er ekskluderet. Ydermere er artikler, der specifikt omhandler interventioner med fysioterapeutisk og kiropraktisk behandling, ekskluderet, da disse behandlingsformer ikke betragtes som komplementære og alternative behandlinger (se boks 3). De inkluderede reviews er derefter sorteret efter NCCAM klassifikationssystem (se boks 1). I den foreliggende artikel inkluderes kun de studier, der er kategoriseret som manipulativ og kropsbaseret praksis. Hver inkluderet artikel er vurderet med baggrund i en bedømmelse af artiklernes kvalitet med en ++, + eller score. Denne score tager udgangspunkt i tjeklister udarbejdet af The Scottish Intercollegiate Guidelines Network (se boks 4 side 61), som graduerer den interne validitet i de inkluderede reviews (19). Herefter er resultater fra hvert review identificeret, og endelig er resultater og konklusioner sammenholdt med kvalitetsscoren med henblik på en samlet vurdering af dokumentationsniveauet for den anbefalede værdi af effekter af manipulativ og kropsbaseret praksis (19) (boks 4). Kvalitetsbedømmelsen og vurderingen af den anbefalede værdi er udført af to reviewere, og ved uoverensstemmelser blev konsensus opnået gennem fornyet fælles gennemgang og fortolkning af evidens vedrørende de pågældende effekter. Resultater 10 reviews omhandler manipulativ og kropsbaseret praksis (20-29) (se tabel 1 side 65). Fem reviews er vurderet til bedste kvalitetsscore (++), tre til næstbedste (+), mens de sidste to reviews har laveste kvalitetsscore (-). Seks af de 10 reviews er publiceret i 2008, og ud af de seks reviews er fire fra sygeplejefaglige tidsskrifter (23,25,28,29). De 10 reviews dækker i alt 41 kliniske studier, hvoraf de 29 er beskrevet som randomiserede kliniske studier (RCT) eller kontrollerede kliniske studier (CCT), mens de resterende 12 er observationsstudier. Derudover indeholder enkelte reviews også casebeskrivelser. De inkluderede reviews behandler således flere af de samme enkeltstudier, og et review (23) inkluderer næsten samtlige studier på nær tre RCT og et CCT. Studierne, inkluderet i de 10 reviews, er publiceret i perioden og omhandler primært massage. Et mindre antal studier har zoneterapi, aromaterapi, terapeutisk berøring og akupressur som intervention (seks studier i alt). Et review (28) behandler særskilt zoneterapi, mens de øvrige reviews alle konkluderer på effekten af massage. Massage bliver således en samlebetegnelse for flere manipulative og kropsbaserede interventioner, ligesom massage også i sig selv dækker over flere massagetyper. Den hyppigst

23 Dansk artikel 21 rapporterede massagetype er svensk (klassisk) massage (23), som oprindelig er udviklet af Pehr Henrik Ling ( ) fra universitetet i Lund. Den enkelte behandling er overvejende på minutter, mens studieperioden er meget varierende fra en behandling hver dag i tre dage til fire behandlinger pr. uge over 10 uger. Det samlede antal patienter, inkluderet i de studier, der undersøges i de 10 reviews, består af patienter i de kliniske forsøg (RCT og CCT), og patienter i observationsstudierne, hvoraf de er fra ét stort observationsstudie (30). De fleste studier er ikke afgrænset til en specifik kræfttype, men inkluderer bredt patienter med en kræftdia-gnose, og blandt de studier, der skelner mellem forskellige former for kræft, er brystkræft den hyppigst forekommende. Studierne dækker over patienter i den behandlende, rehabiliterende eller palliative fase, og effektparametrene er primært centreret om kræftrelaterede følgesymptomer. Ingen af de fem reviews med høj kvalitetsscore (23,24,26,28,29) finder det muligt at udarbejde en metaanalyse, da data fra de enkelte studier er for heterogene både mht. til, hvordan outcome er opgjort, hvilken massageintervention der bruges, og hvilke kræftdiagnoser der indgår i studierne. I de inkluderede reviews består resultaterne derfor af en sammenskrivning af data, og i reviews med høj kvalitetsscore bygger sammenskrivningen på en systematisk gennemgang af effektparametre og resultater i de inkluderede studier. De fleste reviews har som mål at bestemme evidens for effekt af massage både i forhold til psykisk og fysisk velbefindende hos kræftpatienter. Et review undersøger særligt smertelindring (25), og et andet review undersøger selvrapporterede symptomer (26). Tre reviews har fokus på særlige patientgrupper (20,23,24) (børn med kræft, kræftpatienter i den palliative fase), men inkluderer dog studier med kræftpatienter generelt og forholder sig først til den særlige patientgruppe i konklusionen. Kun et af de inkluderede reviews medtager kvalitative data vedrørende patienters oplevelse af massage (27), de øvrige reviews arbejder med kvantitative mål for effekt. Tabel 2 side 60 illustrerer på baggrund af de 10 reviews, hvilke symptomer massage har en lindrende effekt på, og i det følgende gennemgås synteser af resultaterne med henblik på at give evidensgraduerede anbefalinger for praksis. Reviewet af forsøg med zoneterapi til kræftpatienter (28) drager ingen konklusioner på effekt, idet materialet er sparsomt. Ligeledes kan det ikke konkluderes, hvorvidt aromaterapi kan forstærke de virkninger, der ses af massage (29). Derfor forholder resten af denne artikels resultatafsnit sig til massage. Der refereres til udvalgte enkeltstudier fra de 10 reviews for at uddybe resultaterne. Massages effekt: God til moderat evidens Det gennemgående og mest konsistente fund er, at massage kan reducere angst hos patienter med kræft. Dette fund kan, på baggrund af fire systematiske reviews (23,24,26,29), klassificeres som god evidens (niveau A) i henhold til SIGN's gradueringssystem. Angst er det hyppigst undersøgte effektparameter, og der ses i de fleste inkluderede enkeltstudier en statistisk signifikant reduktion i angst hos kræftpatienter, der modtager massage. Det størst inkluderede RCT er et multicenterstudie af Wilkinson et al. (31) med 288 patienter, publiceret i Her findes signifikant reduktion i såvel klinisk som selvrapporteret angst. Studiet påviser endvidere, at effekten af massage består op til to uger efter behandling, hvorimod en langtidseffekt ikke findes. I et observationsstudie, som inkluderer kræftpatienter (30), rapporteres angst også som det symptom, hvor der ses den største effekt af massage. Effekt på depression samt reduktion i smerter og kvalme er alle områder, hvor det anbefalede niveau kan klassificeres til B efter SIGN's guidelines. Effekt over for disse forhold er hyppigt rapporterede, men den fundne reduktion er ikke statistisk signifikant i alle enkeltstudier. Wilkinson et al. (31) finder en statistisk signifikant reduktion i kliniske tegn på depression efter to uger, men ikke efter seks uger og heller ikke i den selvrapporterede depression. Signifikant reduktion i smerter er fundet i to RCT fra 2007 med tilsammen 228 inkluderede kræftpatienter (32,33). Tilsvarende finder et mindre RCT fra 2007 med 39 kvinder med brystkræft også en statistisk signifikant reduktion i kvalme (34). De hyppigst anvendte skalaer i enkeltstudiernes bestemmelse af psykologiske effekter som angst og depression består af validerede spørgeskemaer (HADS, STAI og POMS) eller visuel analog skala (VAS) (se boks 5 side 62). Massages effekt: Svag evidens Reviewene oplister en lang række positive reaktioner på massage, som ikke er statistisk signifikante, og påpeger behov for, at fremtidige studier afklarer evidensen for effekt på disse områder. Det gælder eksempelvis symptomer som søvnforstyrrelser, livskvalitet, træthed, stress og obstipation samt mere objektive forhold som puls, BT, respirationsfrekvens, immunparametre samt niveauet af kortisol, serotonin og dopamin. Mulige sammenhænge mellem symptomatisk effekt af massage og gavnlig fysiologisk respons på eksempelvis puls, BT og immunforsvar kræver yderligere forskning. Et RCT forholder sig endvidere til økonomiske implikationer, men finder ikke nogen forskel i forbrug af økonomiske ressourcer mellem interventions- og kontrolgruppen (32). Sikkerhed og risiko for bivirkninger Sikkerheden ved at anvende massage til kræftpatienter er behandlet i flere reviews (21-23,25,29). Et review (29) har uønskede bivirkninger som et eksplicit undersøgelsesspørgsmål og finder, at data på mulige bivirkninger er sparsomme. Fordøjelsesproblemer og hudreaktioner er eneste rapporterede bivirkninger, som eventuelt kan tilskrives massage. Corbin (22) opstiller tre typer af potentielle alvorlige bivirkninger af massage til kræftpatienter: Blødning i tilfælde af mulige koagulationsforstyrrelser, frakturer i tilfælde af knoglemetastaser, og tiltagende smerte eller risiko for infektion i forbindelse med åbne sår eller stråleskader. Corbins liste af alvorlige bivirkninger er baseret på teoretiske betragtninger, og der findes ikke klinisk evidens herfor.

24 Dansk artikel 22 Reviewet af Calenda (21) behandler forestillingen om, at massage ved at give en forøget systemisk blodcirkulation kan være medvirkende til, at en kræftsygdom kan sprede sig. Dette findes der ingen evidens for, tværtimod har nyere forskning vist, at massage kun giver en lille umiddelbar og helt lokal forøget cirkulation og ingen systemisk påvirkning (35). To reviews (23,25) forholder sig til spørgsmålet om sikkerhed ved at referere et systematisk review, som generelt evaluerer sikkerhed ved massage (36). Her konkluderes, at antallet af rapporterede alvorlige bivirkninger efter massage er minimale, og ingen af de rapporterede var fra kræftpatienter. Der er således ingen reviews, som finder skadelige virkninger af massage til kræftpatienter, og massage kan betragtes som en sikker terapiform i kombination med konventionel behandling, når massagen udføres af en kvalificeret terapeut, som også har indsigt i patientens kræftsygdom. Diskussion Heterogenitet i studier af massage I søgeproceduren er reviews om massage inkluderet, når massage er klassificeret som en generisk kategori under KAB-feltet. Massage kan dog også indgå i en fysioterapeutisk behandling, hvorfor massage i Danmark både praktiseres som alternativ behandling og som en del af en traditionel behandling. Samtidig kompliceres feltet yderligere af, at massage som kategori rummer flere typer; eksempelvis fodmassage, massage af nakke og skuldre, helkropsmassage og aromaterapimassage med brug af æteriske olier. Reviewene konkluderer på massage generelt, og det er ikke muligt på nuværende tidspunkt at differentiere mellem effekten af de forskellige typer massage. Massage og zoneterapi er ifølge NCCAM to forskellige terapiformer (17). Zoneterapi er tryk under foden med en formodet reflekteret virkning et andet sted i kroppen, hvorimod massage har en direkte virkning på det sted, der behandles. Fodmassage er således i teorien ikke det samme som zoneterapi. I reviewene er denne skelnen ikke entydig, på trods af dette viser studierne stadig en klar effekt af massage til kræftpatienter. Derimod mangler der sikker viden om effekten af zoneterapi til kræftpatienter. Ydermere inkluderer reviewene kræftpatienter bredt og gør det ikke muligt at vurdere effekten af massage i forhold til kræfttype eller i relation til bestemte stadier i et sygdomsforløb. Til eksempel er målgruppen i reviewet af Lafferty et al. (24) kræftpatienter i terminalfasen, og hos denne gruppe patienter opstår der flere etiske og praktiske problemstillinger i gennemførelsen af kliniske forsøg. Derfor inkluderer forfatterne også studier med ikke-terminale kræftpatienter og overfører denne evidens til terminale kræftpatienter. Spørgsmålet om evidens Den anvendte SIGN-tjekliste graduerer artiklerne i tre kvalitetsniveauer, og på trods af stor overensstemmelse i konklusionerne ses det alligevel, at reviews, hvis kvalitet er kategoriseret som 1++, drager mere forsigtige konklusioner end konklusioner fra reviews rangeret som 1+/2++. Dette skyldes, at kvalitetskravene til reviews på niveau 1++ (24,28,29) fordrer, at studierne følger en stram metodik, hvor kun randomiserede kliniske forsøg (24) inkluderes. Konklusionerne i disse reviews har således det forbehold, at der er relativt få randomiserede kliniske forsøg af god kvalitet, som omhandler massage. Her fremhæves flere metodiske problemstillinger som bl.a. mangel på blinding, og at interventionerne ikke er standardiserede. Til undersøgelse af evidens for effekt betragtes RCT som den gyldne standardmetode. Efterhånden er det imidlertid almindeligt anerkendt, at resultater fra stringent udførte RCT med en høj intern validitet sjældent modsvarer de patientproblematikker, der optræder i den kliniske hverdag. I studier, der eksempelvis undersøger effekt af massage, er det vanskeligt at sikre, at alle inkluderede patienter modtager en helt ensartet behandling. Der er behov for design, der accepterer mindre standardisering og kontrol til at evaluere individualiserede interventioner (2). Netop i studier af massage må en vis grad af variation i behandlingen accepteres (eksempelvis at varigheden og typen af massagen kan individualiseres). Studierne opnår hermed en større ekstern validitet på bekostning af en vis statistisk usikkerhed angående den specifikke effekt af massage. Også forfatterne bag SIGNkomitéens anbefalinger (19) advarer mod et rigidt krav om RCT for at evidensbasere kliniske tiltag, som ikke kan blindes eller standardiseres, og påpeger, at kliniske problemstillinger kan evidensbaseres ved synteser af resultater fra flere studier med anvendelse af forskellige studie-design. Reviewet af Hughes et al. (23) er et eksempel på, hvordan der inkluderes både kliniske forsøg og observationsstudier. Konklusionerne i dette review kan derfor drages på et større patientmæssigt grundlag, og SIGNkriterierne tillader, at sådanne synteser kan danne evidensbaserede anbefalinger på A- og B-niveau. Spørgsmålet om evidens er også baggrunden for valg af metode i dette studie. Rationalet er, at reviews af effektstudier oftest genererer det højeste niveau af evidens, idet resultater fra flere studier samles, og da dette studie inkluderer seks reviews publiceret i 2008, der dækker enkeltstudier til og med 2007, må materialet anses for at være tidssvarende. Kvalitetsgradueringen af de inkluderede reviews bruges som metode til at validere påstande og identificere mulige fejltolkninger for at sikre validiteten af denne artikels konklusioner. Målet om at kunne bidrage til evidensbaserede anbefalinger for praksis indebærer også et fravalg af litteratur. "Den grå litteratur", som kan findes i blade og bøger, kan muligvis bidrage med relevant viden om, hvordan massage praktiseres, anvendes og virker, men dette falder uden for formålet for denne artikel. Derimod rummer inklusionskriterierne i dette studie af reviews både kvalitative og kvantitative metoder til at bedømme effekt af massage. Kun ét review (27) medtager dog i resultatafsnittet kvalitative beskrivelser af, hvordan virkninger af massage opleves, hvilket kan hænge sammen med, at kvalitative studier rangerer

25 Dansk artikel 23 lavt i evidenshierarkiet. Som perspektivering for resultatet af dette review kan nævnes, at to kvalitative studier (37,38) baseret på interviews af kvinder med brystkræft viser, at essensen af massage kan beskrives "som en meningsfuld lettelse fra lidelsen". Dette uddybes bl.a. med, at patienterne oplever at blive mødt som hele personer, at de oplever forbedring i relationer til de sundhedsprofessionelle og en forbedret kropslig følelse. Kvalitative fund kan således føje andre dimensioner til udbyttet af massage end reviews baseret på studier med standardiserede effektmål som f.eks. reduktion af angst. Massage og sygepleje I spørgsmålet om en mulig integration af KAB med konventionel behandling samt sundhedsstyrelsens henstilling om vejledninger til sundhedspersonale kan der peges på flere perspektiver for sygeplejen. Nærværende litteraturgennemgang giver et overblik over, hvilke KAB-former inden for gruppen af manipulativ og kropsbaseret praksis der er undersøgt til kræftpatienter, og hvilke effekter der ses. Denne viden er i sig selv relevant for sygeplejersker og kan umiddelbart formidles videre i dialogen med kræftpatienter, der ønsker at drøfte brug af KAB. Denne formidling kan være med til at sikre og maksimere den enkelte patients udbytte af massage, hvilket er væsentligt, idet kræftpatienter ofte er sårbare grundet den alvorlige sygdom. Den evidensbaserede effekt af massage på angst, depression, smerter og kvalme kan med fordel udnyttes og integreres i forskellige plejesituationer til kræftsyge patienter. I reviewene ses, at massage allerede er integreret i flere store hospitalscentre for behandling af kræft i både England og USA (23,29). Sygeplejersker beskrives både som udøvere af massage, og som facilitatorer for en sikker integration af KAB-terapier i onkologisk behandling og pleje. Sygeplejersker er centrale fagpersoner til at identificere, hvilke omstændigheder, symptomer og bivirkninger der kan lindres ved massage (23). Hvorvidt danske sygeplejersker skal tilbydes efteruddannelse som massageterapeuter for at udnytte virkningerne af massage i forskellige plejesituationer, er derfor værd at diskutere. Spørgsmålet om bivirkninger anses som særlig væsentligt, både når allerede eksisterende KAB-former udforskes (39), og når den enkelte patients ønske om at anvende KAB diskuteres (40). Derfor er det også helt centralt, at denne litteraturgennemgang finder evidens for, at massage er en sikker KAB. Denne viden kan sygeplejersker anvende i udarbejdelse af evidensbaserede retningslinjer, som netop bør indeholde en afvejning af acceptabelt evidensniveau over for klinisk relevans, omkostninger og risiko for bivirkninger (19). Konklusion Massage, aromaterapimassage og zoneterapi er de KAB-typer i gruppen manipulativ og kropsbaseret praksis, hvor der foreligger reviews af studier af effekt over for kræftpatienter. 10 reviews af massage, aromaterapi og zoneterapi til kræftpatienter konkluderer sammenfaldende, at massage har en signifikant positiv effekt på angst. Ligeledes har massage også i nogen udstrækning en positiv effekt på depression samt på smerter og kvalme forårsaget af enten sygdommen eller af den konventionelle behandling for kræft. Selvom reviewene er baseret på et begrænset antal RCT af god kvalitet, styrkes resultaterne af overensstemmende fund på tværs af de inkluderede studier og det faktum, at der ikke findes modstridende resultater. Ingen reviews har fundet bivirkninger af massage, og massage kan derfor betragtes som en terapiform, der er sikker at integrere med konventionel kræftbehandling. Der er ingen evidens for, at aromaterapi forstærker virkningen af massage, og dette studie viser endvidere, at der mangler undersøgelser, som med tilstrækkelig vægt belyser effekten af andre former for manipulativ og kropsbaseret praksis, eksempelvis zoneterapi. Det er på nuværende tidspunkt ikke muligt at differentiere effekten i forhold til, hvilken type massage der anvendes, ligesom sundhedsøkonomiske konsekvenser også er underbelyst. I en sygeplejefaglig kontekst kan der argumenteres for, at brugen af massage kan indarbejdes i klinisk praksis og i evidensbaserede tiltag, som kan lindre psykiske og fysiske følgevirkninger af en kræftsygdom. Anita Lunde er ansat som videnskabelig assistent ved enheden Helbred, Menneske og Samfund, Institut for Sundhedstjenesteforskning, Syddansk Universitet; [email protected] Helle Johannessen er professor ved enheden Helbred, Menneske og Samfund, Institut for Sundhedstjenesteforskning, Syddansk Universitet. Bidragydere: Projektet er støttet af Kræftens Bekæmpelse, Videns- og Forskningscenter for Alternativ Behandling, og Syddansk Universitet. SE BOKSE OG TABELLER Litteratur 1. Vifab. Hvad er alternativ behandling? vifab dk/alternativ+behandling/artikler/hvad+er+alternativ+behandling 2008.

26 Dansk artikel Institute of Medicine. Complementary and alternative medicine in the United States. Washington, D.C.: National Academies Press; Lønroth HL, Ekholm O. Alternativ behandling i Danmark - brug, brugere og årsager til brug. Ugeskr Laeger 2006 Feb 13;168(7): Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van RM, et al. Trends in alternative medicine use in the United States, : results of a follow-up national survey. JAMA 1998 Nov 11;280(18): Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, Adv Data 2004 May 27;(343): Lønroth HL, Ekholm O. Alternativ behandling i Danmark - brug, brugere og årsager til brug. Ugeskr Laeger 2006 Feb 13;168(7): Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol 2005 Apr;16(4): Anker N. Kræftpatienters brug af alternativ behandling. En undersøgelse blandt brugerne af Kræftens Bekæmpelses telefonrådgivning: Kræftlinien. Patientstøtteafdelingen Kræftens Bekæmpelse; Damkier. Kræftpatienters brug af alternativ behandling. Odense: Syddansk Universitet, Det Sundhedsvidenskabelige Fakultet; Verhoef MJ, Balneaves LG, Boon HS, Vroegindewey A. Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review. Integr Cancer Ther 2005 Dec;4(4): Lønroth HL, Ekholm O. Alternativ behandling i Danmark - brug, brugere og årsager til brug. Ugeskr Laeger 2006 Feb 13;168(7): Risberg T, Kaasa S, Wist E, Melsom H. Why are cancer patients using non-proven complementary therapies" A cross-sectional multicentre study in Norway. Eur J Cancer 1997 Apr;33(4): Sundhedsstyrelsen. Brev til landets sygehuse om patienters ønske om at benytte alternativ behandling under indlæggelse. www sst dk/publ/publ2000/indlaeg sygehus alt beh pdf Damkier A, Elverdam B, Glasdam S, Jensen AB, Rose C. Nurses' attitudes to the use of alternative medicine in cancer patients. Scand J Caring Sci 1998;12(2): Tovey P, Broom A. Oncologists' and specialist cancer nurses' approaches to complementary and alternative medicine and their impact on patient action. Soc Sci Med 2007 Jun;64(12): NCCAM. What is CAM" nih gov/health/whatiscam/pdf/d347 pdf NCCAM. Manipulative and Body-Based Practices: An Overview. nih gov/health/backgrounds/d238 pdf Ekholm. Sundhed og sygelighed i Danmark 2005-& udviklingen siden Kbh: Statens Institut for Folkesundhed; Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001 Aug 11;323(7308): Buckley J. Massage and aromatherapy massage: nursing art and science. Int J Palliat Nurs 2002 Jun;8(6): Calenda E. Massage therapy for cancer pain. Curr Pain Headache Rep 2006 Aug;10(4): Corbin L. Safety and efficacy of massage therapy for patients with cancer. Cancer Control 2005 Jul;12(3): Hughes D, Ladas E, Rooney D, Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncol Nurs Forum 2008 May;35(3): Lafferty WE, Downey L, McCarty RL, Standish LJ, Patrick DL. Evaluating CAM treatment at the end of life: A review of clinical trials

27 Dansk artikel 25 for massage and meditation. Complementary Therapies in Medicine 2006;14(2): Liu Y, Fawcett TN. The role of massage therapy in the relief of cancer pain. Nurs Stand 2008 Jan 30;22(21): Myers CD, Walton T, Bratsman L, Wilson J, Small B. Massage modalities and symptoms reported by cancer patients: narrative review. J Soc Integr Oncol 2008;6(1): Russell NC, Sumler SS, Beinhorn CM, Frenkel MA. Role of massage therapy in cancer care. J Altern Complement Med 2008 Mar; 14(2): Wilkinson S, Lockhart K, Gambles M, Storey L. Reflexology for symptom relief in patients with cancer. Cancer Nurs 2008 Sep;31 (5): Wilkinson S, Barnes K, Storey L. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs 2008 Sep;63 (5): Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage 2004 Sep;28(3): Wilkinson SM, Love SB, Westcombe AM, Gambles MA, Burgess CC, Cargill A, et al. Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: a multicenter randomized controlled trial. J Clin Oncol 2007 Feb 10;25(5): Mehling WE, Jacobs B, Acree M, Wilson L, Bostrom A, West J, et al. Symptom management with massage and acupuncture in postoperative cancer patients: a randomized controlled trial. J Pain Symptom Manage 2007 Mar;33(3): Stephenson NL, Swanson M, Dalton J, Keefe FJ, Engelke M. Partner-delivered reflexology: effects on cancer pain and anxiety. Oncol Nurs Forum 2007 Jan;34(1): Billhult A, Bergbom I, Stener-Victorin E. Massage relieves nausea in women with breast cancer who are undergoing chemotherapy. J Altern Complement Med 2007 Jan;13(1): Mars M, Maharaj SS, Tufts M. The effect of compressed air massage on skin blood flow and temperature. Cardiovasc J S Afr 2005 Jul;16(4): Ernst E. The safety of massage therapy. Rheumatology (Oxford) 2003 Sep;42(9): Billhult A, Dahlberg K. A meaningful relief from suffering experiences of massage in cancer care. Cancer Nurs 2001 Jun;24(3): Billhult A, Stener-Victorin E, Bergbom I. The experience of massage during chemotherapy treatment in breast cancer patients. Clin Nurs Res 2007 May;16(2): Fonnebo V, Grimsgaard S, Walach H, Ritenbaugh C, Norheim AJ, MacPherson H, et al. Researching complementary and alternative treatments - the gatekeepers are not at home. BMC Med Res Methodol 2007;7: Adams KE, Cohen MH, Eisenberg D, Jonsen AR. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med 2002 Oct 15;137(8):660-4.

28 Amerikansk undersøgelse med 1290 cancerramte 244 Journal of Pain and Symptom Management Vol. 28 No. 3 September Original Article Massage Therapy for Symptom Control: Outcome Study at a Major Cancer Center Barrie R. Cassileth, PhD and Andrew J. Vickers, PhD Integrative Medicine Service (B.R.C., A.J.V.) and Biostatistics Service (A.J.V.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA Abstract Massage is increasingly applied to relieve symptoms in patients with cancer. This practice is supported by evidence from small randomized trials. No study has examined massage therapy outcome in a large group of patients. At Memorial Sloan-Kettering Cancer Center, patients report symptom severity pre- and post-massage therapy using 0 10 rating scales of pain, fatigue, stress/anxiety, nausea, depression and other. Changes in symptom scores and the modifying effects of patient status (in- or outpatient) and type of massage were analyzed. Over a three-year period, 1,290 patients were treated. Symptom scores were reduced by approximately 50%, even for patients reporting high baseline scores. Outpatients improved about 10% more than inpatients. Benefits persisted, with outpatients experiencing no return toward baseline scores throughout the duration of 48- hour follow-up. These data indicate that massage therapy is associated with substantive improvement in cancer patients symptom scores. J Pain Symptom Manage 2004;28: U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Massage, cancer, pain, anxiety, depression, nausea, fatigue, clinical trials Introduction In the 1940s, Rene A. Spitz learned that foundling home infants, well fed and warm but not held or touched, tended to wither away and die. Of 91 such babies he observed, 27 died in their first year of life, followed by seven more in their second year; in other homes, up to 90 percent died in early infancy. Babies who survived in the institutions were classified as hopeless. 1,2 Harlow s studies of monkeys that had been removed from their mothers showed Address reprint requests to: Barrie R. Cassileth, PhD, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, H13, New York, NY 10021, USA. Accepted for publication: December 23, U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. similar results, plus major dysfunctions as they developed and when they themselves became mothers. 3 His major work, Touching: The Human Significance of the Skin, 4 clarified a major message: tactile stimulation is essential to normal development and even to survival. The use of human touch as an intervention against pain and other problems has great appeal. If effective, it could provide a non-invasive, inexpensive adjunct to the management of pain and other symptoms experienced by patients with major chronic illnesses. Data from related, difficult to control clinical circumstances are promising. Massage therapy, defined as manipulation of soft tissue areas of the body, is offered in clinical settings to assist relaxation, facilitate sleep, and relieve muscular /04/$ see front matter doi: /j.jpainsymman

29 Amerikansk undersøgelse med 1290 cancerramte Vol. 28 No. 3 September 2004 Massage for Cancer-Related Symptoms aches and pains. 5 It is increasingly used for symptom relief in patients with cancer. Approximately 20% of U.S. cancer patients seek massage therapy, 6,7 and approximately 70% of U.K. hospices offer it. 8 Massage is included in treatment guidelines such as those of the National Comprehensive Cancer Network, which recommends consideration of massage for refractory cancer pain. 9 Research supports such recommendations. Several trials suggest that massage can reduce pain in cancer patients at varying stages of disease. 10,11 In the largest study to date, 87 hospitalized cancer patients were randomized to massage therapy or to control on a crossover basis. Pain and anxiety scores fell by approximately 40% during massage compared with little or no change during control sessions. 12 Massage therapy was superior to control against anxiety, nausea, fatigue and general well-being in a randomized study of patients awaiting bone marrow transplantation. 13 Massage has been available systematically at Memorial Sloan-Kettering Cancer Center (MSKCC) since establishment of the Integrative Medicine Service in Twelve licensed massage therapists treat inpatients and also provide massage therapy at our outpatient facility. Patients who receive integrative medicine therapies record symptom scores before and after treatment as a routine part of clinical management. To avoid bias, staff not associated with the evaluation, rather than therapists, provide cards on which patients complete symptom rating scales. These cards are placed privately by patients in a closed box. Only research staff work with the completed cards. Data from these scores, reported here, shed important light on the management of common and often refractory symptoms experienced by patients with cancer. Methods Patients at MSKCC may self-refer to massage therapy or may be referred by a health professional responsible for their care. About 50% of inpatient referrals come from MSKCC nurses; self- and family referrals account for a further 20% and 10%, respectively. Physicians and other health professionals account for the remaining approximately 20%. Outpatient massage therapy is self-referred. Three variations of massage therapy are available to patients at MSKCC: standard ( Swedish ) massage, 5 light touch massage, and foot massage. A specific type of massage is requested for almost all referrals. Patients receive the requested type of massage approximately three times out of four. The majority of the remaining cases are requests for regular massage in which either light touch or foot massage was given, typically because the practitioner felt that a weak or late-stage patient could not tolerate a regular massage or because the patient was too ill to move into a comfortable position to receive standard massage therapy. Massage sessions average 20 minutes in length for inpatients and 60 minutes for outpatients. Before and 5 15 minutes after massage therapy, patients are given a 5 8 inch card with numerical rating scales for common symptoms: pain, fatigue, stress/anxiety, nausea, depression, and other. Patients rate each on a 0 ( Not at all bothersome ) to 10 ( Extremely bothersome ) scale. Data from symptom cards for massage therapy from April, 2000, when use of the rating scales was initiated, to March, 2003 were analyzed. Combinations of interventions, such as massage and a simultaneous relaxation therapy, were excluded. Comparisons between different types of massage or symptoms were conducted by ANCOVA of the presenting symptom, with baseline score as a covariate. The presenting symptom was defined as that with the highest baseline score. If more than one symptom was scored equally high, the presenting symptom was chosen in the following priority order: pain, depression, anxiety, nausea, fatigue, other. The main analyses concern the initial episode of care. This ensures that each patient is included in the analysis only once. Analyses were conducted by AV using Stata 7 statistical software (Stata Corp., College Station, Texas). Ethical approval for this retrospective review of clinical data was given by the MSKCC IRB. Results Cards were returned for 3,609 episodes of care; post-therapy data were available for 3,359 (93%). Of these, 2,465 (73%) involved care of an MSKCC patient, with smaller numbers for cancer patients from other hospitals (94, 3%),

30 Amerikansk undersøgelse med 1290 cancerramte 246 Cassileth and Vickers Vol. 28 No. 3 September Table 1 Types of Massage Therapy Received Inpatients Outpatients Total Therapy n (%) n (%) n (%) Massage 316 (33) 244 (74) 560 (43) Light touch 69 (7) 21 (6) 90 (7) massage Foot massage 536 (56) 49 (15) 585 (45) More than 40 (4) 15 (5) 55 (4) one therapy Total 961 (74) 329 (26) 1290 (100) family members (78, 2%), staff (345, 10%) and members of the public (377, 11%). Data reported below reflect the initial episode of care for the 1,290 different MSKCC patients who provided post-treatment data. As indicated in Table 1, the most commonly administered touch therapies were standard (Swedish) massage or foot massage, with far fewer patients receiving light touch massage. Fifty-five patients received more than one type of touch therapy during the same session, i.e., some foot massage and some Swedish massage during a single session. Foot massage was predominantly used for inpatients; standard and light touch massage was more equally balanced between in- and outpatients. The most common presenting symptom was anxiety (397, 31%), followed by pain (366, 28%) and fatigue (312, 24%). Fewer than 10% of patients reported greatest distress from depression, nausea or another symptom. The immediate effects of massage therapy on symptoms are shown in Table 2. Although major improvements in symptom scores are apparent severity of the presenting symptom was reduced by a mean of 54% (95% C.I. 52%, 56%) Table 2 may actually underestimate massage effects. Patients did not necessarily experience high levels of all symptoms. Therefore, the data for each symptom includes a significant number of zero or near zero scores. A patient presenting with depression, for example, may have reported no pain or nausea. For such a patient, no improvement in pain and nausea would be possible, thus diluting the apparent effects of treatment on these symptoms at the group level. Accordingly, Table 3 includes only data for symptoms rated four or higher at baseline, the traditional threshold for considering a symptom of at least moderate severity. The strongest effects were seen for anxiety and the smallest changes for fatigue, although a 43% reduction in fatigue is clinically relevant. There was no evidence of an attenuation of effect at high baseline scores. For example, an approximate 45% improvement in pain scores was seen even in the 244 patients with baseline scores of seven or above, and in the case of anxiety, improvements were always close to 60%, regardless of baseline score. After adjusting for baseline score, outpatients reported symptom scores 0.56 points lower (95% C.I. 0.27, 0.85; P ) than inpatients, equivalent to an approximate 10% greater improvement. Effects by type of massage are shown in Table 4. Adjusting for in- or outpatient and baseline score, patients receiving Swedish and light touch massage had superior outcomes to those receiving foot massage (0.32 points; 95% C.I. 0.03, 0.60 P 0.03). Patients receiving Swedish or light touch massage had an average 58% improvement in severity of their presenting symptom compared to a 50% improvement in patients receiving foot massage. There was no significant difference between Swedish and light touch massage (0.41 points better response for light touch; 95% C.I. 0.11, 0.13; P 0.12). Table 2 Improvements in Symptom Scores Following Massage Therapy Symptom n Baseline Post-treatment Change Improvement Presenting a (2.5) 3.2 (2.7) 3.4 (2.6) 54.1% (34.1) Pain (2.9) 1.9 (2.2) 1.7 (2) 40.2% (40.9) Fatigue (2.9) 2.7 (2.7) 2.1 (2.2) 40.7% (39.1) Anxiety (3.1) 1.8 (2.2) 2.8 (2.5) 52.2% (39.5) Nausea (2.4) 0.7 (1.6) 0.7 (1.6) 21.2% (38.3) Depression (2.8) 1.2 (2) 1.2 (1.9) 30.6% (41.0) Other (2.5) 3.4 (2.8) 3.1 (2.8) 46.6% (36.9) Figures are given as mean (standard deviation). a Defined as the symptom with the highest score at baseline.

31 Amerikansk undersøgelse med 1290 cancerramte Vol. 28 No. 3 September 2004 Massage for Cancer-Related Symptoms Table 3 Improvements in Symptom Scores After Massage Therapy Symptom n Baseline Post-treatment Change Improvement Presenting a (1.9) 3.5 (2.7) 3.7 (2.6) 52.0% (33) Pain (1.8) 3.3 (2.3) 2.9 (2.2) 47.8% (32.2) Fatigue (1.8) 3.8 (2.6) 2.8 (2.4) 42.9% (35.4) Anxiety (1.9) 2.7 (2.3) 4 (2.4) 59.9% (30.2) Nausea (1.9) 3 (2.5) 3.1 (2.4) 51.4% (37.4) Depression (1.9) 3.2 (2.5) 3 (2.3) 48.9% (35.7) Other (2) 3.7 (2.8) 3.4 (2.8) 48.3% (35.5) Data include only baseline scores of four or higher. Figures are given as mean (standard deviation). a Defined as the symptom with the highest score at baseline. Similar effects appear for additional massage therapy interventions. Percent improvement in presenting symptoms for episodes two to five for the same individuals are, respectively: 53% (n 450; 95% C.I. 50%, 56%); 58% (n 203; 95% C.I. 54%, 63%); 56% (n 118; 95% C.I. 49%, 62%) and 61% (n 73, 95% C.I. 53%, 69%). Indeed, in a general linear model adjusted for baseline score and clustered by patient, the coefficient for each treatment was negative and statistically significant (P 0.001), suggesting that the effects of massage therapy probably increase for each additional treatment. We attempted to follow about one in four patients (83 outpatients and 247 inpatients) for up to two days to obtain data in addition to their immediate post-treatment scores. Inpatients and outpatients were assessed typically two to five hours after treatment; outpatients were additionally assessed approximately 24 and 48 hours after treatment. Data were obtained from 74 outpatients (89%) and 237 inpatients (96%). These patients versus those we did not attempt to follow beyond 48 hours received similar therapies: 43%, 53%, 9% vs. 48%, 47%, 8% received regular, foot or light massage, respectively. The two groups also had comparable immediate responses to therapy (53% vs. 54% improvement, P 0.6) and similar proportions of inpatients (78% v. 73%). Baseline scores were slightly lower in patients followed longer (6.3 vs. 6.7), suggesting that patients followed beyond 48 hours were reason- ably representative of the whole sample. As shown in Table 5, the effects of touch therapy for inpatients did not persist in the longer term. Two to five hours after treatment, scores were approximately 0.5 points higher than immediately after treatment. This suggests that inpatient severity scores returned to baseline within a day or so. The effects of massage therapy lasted longer for outpatients. Indeed, there is no evidence that symptom scores regress toward baseline values (Fig. 1). There was no difference between types of massage therapy concerning the time course of symptom improvement. Discussion This is the largest study of massage for cancer patients yet reported. Such studies typically note sample sizes of six, and We found no study of massage therapy with a sample size greater than 100. This may reflect that massage therapy services have been available only rarely until recently, at major cancer centers. Our first conclusion, therefore, is that implementation of a high volume massage therapy service is feasible at a major cancer center. Major, clinically relevant, immediate improvements in symptom scores were reported following massage therapy. Given the observational nature of this study, we cannot make conclusions about the cause of this effect. However, Table 4 Differences in Effect by Type of Massage Therapy Type of massage n Baseline Post-treatment Change Improvement Swedish (2.5) 3.1 (2.7) 3.1 (2.7) 57% (32) Light touch (2.5) 2.7 (2.7) 2.7 (2.7) 62% (35) Foot (2.5) 3.4 (2.8) 3.4 (2.8) 50% (36) Figures are given as mean (standard deviation).

32 Amerikansk undersøgelse med 1290 cancerramte 248 Cassileth and Vickers Vol. 28 No. 3 September Table 5 Symptom Scores for Longer-Term Follow-Up Outpatients Baseline n 74: 5.8 (2.2) Post-treatment n 73: 2.7 (2.1) Later same day n 53: 2.9 (2.3) Next day n 49: 2.7 (2.2) Two-day follow-up n 38: 2.6 (2.4) Inpatients Baseline n 237: 6.2 (2.4) Post-treatment n 237: 3.1 (2.7) Later same day n 237: 3.7 (2.9) Figures are given as mean (standard deviation). it is notable that the size of the effects found are highly similar to those reported in prior randomized trials of massage therapy in cancer patients. For example, Grealish et al. reported that pain and anxiety scores improved during treatment from approximately 2.5 to 1.5 (40%) and from 5.4 to 3.2 (41%), respectively, with no change in controls. 12 The comparable figures reported by Stephenson et al. are 2.9 to 1.4 (53%) and 4.7 to 2.4 (50%), again, with marginal change in controls (15). This suggests that the results reported in randomized trials can be achieved in the clinical setting. The effects of massage were smaller and less persistent for inpatients. There are two possible explanations. First, inpatients are more subject to intervening events than are outpatients. They may undergo procedures or have medication changed. Inpatients also tend to receive shorter massage treatments in less comfortable settings than do our outpatients. The relationship between the length of massage treatment and the size and duration of effects is worthy of further research. We found that Swedish and light touch massage were superior to foot massage, even after controlling for baseline severity and location of treatment. It may be that the effects of touch to the body are more profound than touch given only to the feet. However, it is also possible that the apparently lesser effects of foot massage reflect a case mix inadequately captured by baseline symptom scores. For example, weak or cachectic patients often receive massage just to the feet rather than the whole body. Set against such an explanation is that such patients also receive light touch massage. In conclusion, massage therapies apparently lead to large, immediate improvements in symptoms scores in cancer patients, even those with very high baseline scores indicating substantial levels of pain, anxiety, or other symptoms. Outpatients experienced persisting benefit across the total of 48 hours studied. We plan a prospective controlled trial for longer periods of time to determine the duration of effect. Meanwhile, it is clear that massage therapy achieves major reductions in cancer patients pain, fatigue, nausea, anxiety and depression. Massage therapy appears to be an uncommonly non-invasive and inexpensive means of symptom control for patients with serious chronic illness. It is non-invasive, inexpensive, comforting, free of side effects and greatly appreciated by recipients. This non-randomized study suggests that it is also markedly effective. Acknowledgments Anne Seidler collated and entered the data for this article. The authors also thank the MSKCC massage therapists, headed by Wendy Miner, LMT and the staff of the MSKCC Bendheim Integrative Medicine Center. Fig. 1. Time course of treatment effects for outpatients: symptom scores are given as means with standard errors. References 1. Spitz RA. Hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood. The Psychoanalytic Study of the Child, Vol. 1. New York: International Universities Press. 1945;1:53 74.

33 Amerikansk undersøgelse med 1290 cancerramte Vol. 28 No. 3 September 2004 Massage for Cancer-Related Symptoms Spitz RA, Wolf KM. Anaclitic depression: an inquiry into the genesis of psychiatric conditions in early childhood. The Psychoanalytic Study of the Child, Vol. 2. New York: International Universities Press. 1946;2: Harlow H. A variable-temperature surrogate mother for studying attachment in infant monkeys. Behav Res Meth 1973;5(3): Montagu A. Touching: The human significance of skin. New York: Harper & Row, Vickers A, Zollman C. ABC of complementary medicine. Massage therapies. BMJ 1999;319(7219): Ashikaga T, Bosompra K, O Brien P, et al. Use of complementary and alternative medicine by breast cancer patients: prevalence, patterns and communication with physicians. Support Care Cancer 2002; 10(7): Bernstein BJ, Grasso T. Prevalence of complementary and alternative medicine use in cancer patients. Oncology 2001;15(10): Vickers A. Massage and aromatherapy: a guide for health professionals. London: Chapman and Hall, Grossman SA, Benedetti C, Payne R, et al. NCCN practice guidelines for cancer pain. Oncology 1999; 13(A11): Weinrich SP, Weinrich MC. The effect of massage on pain in cancer patients. Appl Nurs Res 1990; 3(4): Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nurs 1993;16(2): Grealish L, Lomasney A, Whiteman B. Foot massage. A nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalized with cancer. Cancer Nurs 2000;23(3): Ahles TA, Tope DM, Pinkson B, et al. Massage therapy for patients undergoing autologous bone marrow transplantation. J Pain Symptom Manage 1999;18(3): Sims S. Slow stroke back massage for cancer patients. Nursing Times 1986;82(47): Stephenson NL, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncol Nurs Forum 2000;27(1):67 72.

34 Undersøgelse massage til syge børn 32 International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice, Vol 2, No 2 (2009) Children with Cancer and Blood Diseases Experience PositivePhysical and Psychological Effectsfrom Massage Therapy Jolie N. Haun, PhD, LMT; John Graham-Pol, MD; Brendan Shortley, BA, BS University of Arizona, College of Medicine, Tucson, AZ, USA Background: Previous research has shown positive effects from massage therapy (MT) for premature infants and for children with asthma, arthritis, and other illnesses. Although these effects have been demonstrated, MT research on children with cancer and blood disease is needed. Purpose and Setting: The present study, conducted at the Cancer Center, Shands Hospital, at the University of Florida, Gainesville, measured the physical and psychological effects of MT on pediatric oncology and hematology patients. The participants were 30 children with cancer or blood disease, ages 6 months to 17 years. Research Design: This randomized, non-blinded prospective study used measures of physical health and mental wellbeing that were completed before, during, and after four MT sessions were implemented. Descriptive statistics, one-way betweensubjects analysis of variance, and an independent-samples t-test were used to analyze the data. Intervention: The treatment group received 20minute sessions of Swedish MT once daily for approximately 4 days (inpatients), or once weekly for approximately 4 weeks (outpatients); the control group received no MT. Results: Between-groups analyses indicated significant psychological improvements for the MT group on state anxiety (F 1,58 = 16.79, p < 0.000), trait anxiety (F 1,58 = 3.95, p < 0.000), and emotional state (F 1,238 = 42.39, p < 0.001)]. Betweengroups analyses indicated significant physical improvements for the MT group on muscle soreness (F 1,238 = 38.96, p < 0.001), discomfort (F 1,238 = 50.16, p < 0.001), respiratory rate (F 1,237 = 22.47, p < 0.000)], and overall progress (t 28 = 25.55, p < 0.000). No significant differences were found between groups on parent-completed ratings of their child s physical or psychological health, pulse rate, or blood pressure. Conclusions: In children with cancer and blood diseases, MT can reduce psychological and physical distress and can have a positive effect on quality of life. KEYWORDS: Massage, pediatrics, palliative therapy, oncology, hematology INTRODUCTION The American Cancer Society estimated 10,400 newly diagnosed pediatric cancer cases and 1545 deaths from cancer in children in 2007 (1). Pediatric cancer patients commonly experience adverse symptoms including nausea, physical pain, anxiety, depression, weight loss, and hair loss during treatment. As providers seek affordable palliative treatment options for pediatric patients, the use of complementary and alternative modalities (CAM) such as massage therapy (MT) is becoming popular. A study in 2003 reported that 33% of parents in a primary care setting used CAM, with MT being most commonly preferred (2). Research findings indicate that MT can improve circulation and immune function, dissolve soft adhesions, reduce swelling, and relieve the pain and stress associated with many illnesses (3 6). These outcomes make palliative treatment with MT a viable option for children with cancer and related blood diseases such as hemophilia. Although MT provides a promising option for children with cancer, little data focus on this population of oncology and hematology patients (5). However, related research suggests that MT is an effective treatment for other pediatric populations, including premature and HIV-exposed newborns, and children with asthma, cystic fibrosis, diabetes, and rheumatoid arthritis (3 11). Documented outcomes include weight gain; reduced levels of stress hormone; decreased anxiety, stress, and depression; improved sleep; enhanced immune function; and reduced pain (3 11). Data from previous studies in various pediatric populations and settings provide supportive evidence suggesting that children with cancer and related blood diseases will receive similar benefits from MT. Pain, a common adverse outcome associated with cancer treatment, has been defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, coupled with the high prevalence of painful neurological conditions (12). Several chemotherapeutic agents can cause peripheral neuropathy, a syndrome characterized by painful dysesthesia in the hands and feet, with associated sensory, motor, and autonomic deficits (12). Chronic pain can lead to disability, limited activity, and psychological problems. Increased pain perception is also correlated with higher levels of anxiety and lower self-esteem (13). The relative resistance of neuropathic pain to medication justifies the use of a modality such as MT (12,13). A review of five non-pharmacologic strategies for managing cancer pain in adults noted that MT promotes relaxation, relieves muscle spasms, reduces pain and swelling, increases blood circulation, decreases the heart rate, and inhibits transmission of noxious stimuli by stimulating large nerve fibers that reduce pain perception (14). When used during chemotherapy treatment in adult populations, MT has been found to reduce anxiety, nausea, and stress; to enhance sleep; and to boost the number and function of the immune system s natural killer cells (15,16). If such improvements are replicated in future research, MT can be justified as a viable option of palliative care for pediatric cancer and blood disease patients, promoting a greater focus on healing and quality of life for these children. The current study had three primary objectives: To determine the physiologic effects of MT in a pediatric oncology and hematology population To determine the psychological effects of MT in a pediatric oncology and hematology population To determine the feasibility of implementing MT as a palliative treatment option in a cancer clinic setting The first two objectives led to the following study hypotheses: H a1 : Children with cancer and blood diseases who receive MT will experience beneficial physiologic outcomes significantly more than will equivalent children who do not receive MT. H a2 : Children with cancer and blood diseases who receive MT will experience beneficial psychological outcomes significantly more than will equivalent children who do not receive MT.

35 Undersøgelse massage til syge børn 33 METHODS Participants Using convenience sampling, resident physicians chose 30 participants from a patient population in the pediatric hematology and oncology division at the Cancer Clinic and Shands Hospital at the University of Florida. Members of the control group (8 females, 7 males) and the treatment group (7 females, 8 males) were aged 6 months to 17 years (mean: treatment 10.7 years; control 9.3 years). There were 14 inpatients (8 control, 6 treatment) and 16 outpatients (7 control, 9 treatment). Table 1 gives descriptive statistics for the study participants. The diversity in age, disease, and inpatient or outpatient status was included to represent the diverse patient population in this clinical setting and to permit an evaluation of the feasibility of implementing massage in the clinical setting while also maximizing the external validity of the study. Participants received no compensation for their participation in the study. TABLE 1 Participant Descriptive Statistics MT = massage therapy. Design and Procedure Potential participants were identified by physicians and subsequently approached by an investigator, at which time potential participants were informed about the study process and any possible adverse effects and benefits of the study. Consenting participants were randomized into two groups by coin toss ( heads, treatment; tails, control) called by a witness in the presence of patient participants and their parents or guardian. Consent forms were give to each participant old enough to give consent and to the parents, parent, or guardian to read and sign. The consent of the legal guardian was obtained for all minors. Participants and parents unable to read or to understand any part of the consent form were given a verbal explanation. All participants were volunteers and were treated according to the ethical standards of the American Psychological Association code of conduct (17). Each participant was assigned a unique number to ensure confidentiality. Treatment and control participants were assigned to one of two schedules of four sessions each. Inpatients received daily sessions, and outpatients received weekly sessions. Sessions were conducted during regularly scheduled appointments in a treatment room or the patient s room within the clinical setting. Treatment participants received 20 minutes of Swedish MT including effleurage (gliding stroke), petrissage (kneading), percussion (tapping with fingertips, palm, fist, or side of hand), compression (constant pressure with hand or fists), and friction (deep circular or vertical motion with fingertips). The MT was provided in the spots most comfortable for the participant, most often on the hands, feet, arms, neck, back, and shoulders. To ensure participant comfort, participants were not required to disrobe for treatment. The hospital robes worn by participants made for easy access to bare hands, feet, arms, shoulders, and backs. Covers were also provided, as in standard MT practice. The therapist (JH) is a nationally certified massage therapist, licensed in the State of Florida (where study was conducted), with 5 years of experience in the field of MT. A parent or legal guardian of the participant was present during each treatment. At each session, the massage therapist facilitated MT with the participants and thus provided a detailed demonstration for the parent or guardian, enabling parents to possibly continue implementing treatments at home; however, during the study, only the therapist provided massage to participants. Attention was given at all times to appropriate ethical procedures to ensure the safety of the participants and the continued trust and approval of the parents. Before and after each session, the participant s vital signs (collected by BS or clinical nursing staff), discomfort level, and Faces muscle soreness and emotional data were recorded by the research assistant (BS). The research assistant (BS) collected the general clinical progress scale after the second, third, and fourth sessions. Participants or parents (or both) completed standardized measures [the State Trait Anxiety Inventory for Children (STAIC) and the Child Health Questionnaire Parent (CHQ-Parent)] before the first and after the final session (collected by BS). The data collection schedules were the same for the treatment and control groups. Control participants were seen in the same environment for the same period of time for conversation and play with the therapist. If control participants were not feeling well, the therapist sat with them quietly. Measures Physiologic Measures A Faces My muscles feel... soreness scale with assigned values ranging from 1 ( very sore ) to 5 ( very good ) was used to assess muscle soreness before and after each session. The pictorial Faces self-report response scales have become increasingly popular for evaluating clinical symptoms and have been found to be valid and reliable for measuring pain-related symptoms in diverse pediatric settings (18 25). Overall discomfort level was recorded before and after each session on a scale from 0 to 4 (0 being no discomfort, 4 being maximal discomfort ). This measure was collected as a verbal self-report, as is commonly done in clinical settings such as the one in which the present study was conducted. Standard methods were used to assess the participants blood pressure, respiratory rate, and pulse rate before and after each session. The Child Health Questionnaire (CHQ) Parent (26) has two primary scales: physical health and psychological health. It has been extensively validated in evaluations of pediatric health status internationally (27 30). The physical health scale was used to assess general health physical function in study participants before and after the series of sessions. Psychological Measures The CHQ Parent psychological health scale was used to assess general mental health in the study participants before and after the series of sessions. The STAIC (31) was used to record levels both of situational and of characteristic anxiety (minimum score: 20; maximum score: 60). The STAIC has been tested and extensively validated in diverse pediatric populations internationally (32 36,a). Spielberger and colleagues indicate that the State Trait Anxiety Inventory (STAI) and the STAIC have been used in 8000 studies and have been translated into 58 languages and dialects (35). A Faces I feel... affective scale was used to measure emotion, with a score ranging from 1 ( not good at all ) to 5 ( very good ). As with the Faces selfreport pain scale, this pictorial scale has been adapted and validated for measuring emotional symptoms in diverse pediatric settings (37 40). General Clinical Measure A general clinical progress measure was collected at the end of the second, third, and fourth sessions to assess progress at each treatment or control session. This verbal self-report measure was rated on a scale from 0 to 10 (0 = no progress; 10 = maximal progress). Progress was defined as feeling better overall, muscles and body feeling better, with less pain, and calmer with less tension. This measure was used as a verbal self-report, commonly collected and documented in patient records that is, clinical SOAP (subjective data, objective data, assessment, and plan) notes. If participants were unable to respond because of age or illness, parent reports were collected in lieu of the self-reports, consistent with common practice in clinical settings (41 49). There are constraints related to such parent-proxy reports, but Varni et al. suggest that although pediatric patient self-report is advocated, there remains a fundamental role for parent proxy-report in pediatric clinical trials and health services research (49). Data Analysis

36 Undersøgelse massage til syge børn 34 Statistical analyses were conducted to evaluate the mean differences between the treatment group and the control group. For measures collected before and after each session, including the Faces scales, discomfort scale, and vital signs, the differences between the groups were examined using a 2 (treatment)! 4 (time) one-way between-subjects analysis of variance (ANOVA). Additionally, 2 (treatment)! 2 (time) one-way between-subjects ANOVAs were used to compare group mean scores for the STAIC and CHQ Parent measures taken before and after the series of sessions. Post hoc analyses using a Scheffe multiple comparisons test were conducted to identify the source of significant differences. Because of the use of a mean composite score calculated for overall progress, an independent-samples t-test was used to determine any differences between the treatment and control groups in self-reported progress across the series of four sessions. Statistical significance was set at p " RESULTS Physiologic Measures Faces My Muscles Feel... Scale No significant difference was observed between treatment and control groups before treatment. However, significant mean differences on the scale of muscle soreness were found between the groups after treatment (F 1,28 = , p < 0.001), such that members of the treatment group reported significantly less posttreatment muscle soreness than did members of the control group. Scheffe comparisons indicated that the mean values of the muscle soreness scores in the treatment group increased significantly (indicating positive change) and that no significant change occurred in the control group scores. Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. TABLE 2 Study Outcome Scores for the Treatment and Control Groups

37 Undersøgelse massage til syge børn 35 a n = 15 for each group. b Values are between-groups standardized mean effect sizes; a positive value indicates a better outcome for the MT group. SD = standard deviation; MT = massage therapy; CHQ = Child Health Questionnaire. Discomfort Level We observed no significant difference in discomfort between the two groups before treatment, but significant differences between group means were indicated after treatment (F 1,238 = 50.16, p < 0.001), such that the treatment group reported significantly less discomfort than did the control group. Scheffe comparisons showed that the mean values of the treated group s discomfort level scores declined significantly, but that no significant change occurred in the control group scores. Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. Vital Signs We observed no significant difference between the groups in pulse rate (F 1,238 = 0.049, p < 0.825) or in systolic (F 1,238 = 0.593, p < 0.442) and diastolic blood pressure (F 1,238 = 0.246, p < 0.620), before or after treatments. However, MT affected respiratory rate (F 1,237 = 22.47, p < 0.000), such that, post treatment, the rate declined significantly in the treatment group as compared with the control group. Scheffe comparisons indicated that the mean values of the treated group s respiratory rate declined significantly; no significant change was observed in the scores for the control group. Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. CHQ Parent, Physical Scale On the CHQ Parent questionnaire, we found no significant differences between the treatment and control groups for physical health, before or after treatments (F 1,58 = 1.05, p = 0.310). Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. Psychological Measures CHQ Parent, Psychological Scale On the CHQ Parent questionnaire, we found no significant differences between the treatment and control groups for psychological health, before or after treatments (F 1,58 = 1.06, p = 0.308). Table 2 provides pre-and post-session means and standard deviations both for the treatment group and for the control group. State Anxiety Inventory for Children We observed no group difference in the State Anxiety Inventory for Children before treatment. Post-treatment levels of state anxiety were lower in the treatment group than in the control group (F 1,58 = 16.79, p < 0.000). Scheffe comparisons indicated that the mean values of the state anxiety scores in the treatment group declined significantly; no significant change occurred in the scores for the control group. Table 2 provides pre-and post-session means and standard deviations both for the treatment group and for the control group. Trait Anxiety Inventory for Children We observed no significant difference between the two groups in the Trait Anxiety Inventory for Children before treatments, but a significant treatment effect was evident for the treatment group as compared with the control group after the series of sessions (F 1,58 = 13.95, p < 0.000), such that the treatment group reported significantly decreased trait anxiety. The control group reports showed no significant change. Scheffe comparisons indicated that the mean values of the trait anxiety scores declined significantly in the treatment group; no significant change was observed in the scores for the control group. Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. Faces Emotion I Feel... Scale The treatment and control groups showed no significant differences in their Faces I Feel... scores before treatment. However, post-treatment, the treatment and control group means showed significant differences (F 1,238 = 42.39, p < 0.001), such that the treatment group reported feeling significantly better, and the control group reported no significant change. Scheffe comparisons indicated that the mean values of the emotion scores in the treatment group improved significantly. We observed no significant change in the scores for the control group. Table 2 provides pre- and post-session means and standard deviations both for the treatment group and for the control group. General Clinical Progress Scale We found significant differences in the mean progress scores between the treatment and control groups (t 28 = 25.55, p < 0.001). The treatment group reported significant progress after the treatment series; the control group reported no change. Mean value [standard deviation (SD)] for the control group was 0.49 (0.87); for the treatment group, it was 8.62 (0.87). DISCUSSION Research into MT in the area of pediatric oncology and hematology is limited. The present study was conducted to examine the physiologic and psychological effects of MT on children with cancer and blood diseases. Our findings indicate a general improvement in physical and psychological wellbeing that supports both hypotheses posited in this study findings that are largely consistent with those reported in related research (4 7,14). As seen in other cancer populations, the findings in this study are consistent with the positive rehabilitative effect of MT (5,6,14). Physiologic measures suggest that MT reduced muscle soreness, discomfort, and respiratory rate. Psychological measures indicate that MT reduced state and trait anxiety and positively influenced overall emotional well-being, and they support prior findings that indicate that lasting psychological effects result from MT (3,5 8). Additionally, the general clinical progress found in the treatment group suggests that MT can provide a general improvement in quality of life. In relating measure outcomes, participants who received MT experienced a significant reduction in muscle soreness and discomfort that corresponded with slowed respiration, improvement in emotional state, and overall progress. The combination of muscle relaxation and decreased anxiety suggest that MT can induce a general sense of relaxation for recipients. Considered together, these psychophysiologic effects indicate that MT could also promote optimal immune system functioning, although the current study does not examine that effect directly. Current findings also indicate that MT can be effectively

38 Undersøgelse massage til syge børn implemented within an oncology setting and can provide significant palliative benefits to pediatric recipients across a diverse age range and disease population. The results indicate that clinicians, parents, and other caregivers should consider MT a viable palliative intervention for symptom relief in children with cancer and blood disease. It should be noted that, because parents or guardians were present for each child s treatments (which could serve as demonstrations of how MT can be provided), it is possible they may have spontaneously provided additional MT to outpatient participants in the home setting. Data concerning this possibility were not collected in the current study. We recommend that future pediatric studies collect such data from parents or guardians to account for potential confounding effects. Further, bias may have occurred in self-reports from the participants or their parents (or both) because of expectancy or social desirability effects. Finally, this pilot study did not collect data on symptoms such as nausea, headaches, and pain around access portals, although many participants reported a decrease in such symptoms. These validity threats should be addressed in subsequent studies. Our pilot study needs to be replicated in a larger sample of patients that would allow for subgroup analysis by age, diagnosis, stage and severity of disease, and inpatient or outpatient status. A larger study might also examine the effects of MT on a diverse range of symptomology. Further, a larger study would also allow for more robust complex multivariate statistical analyses and, potentially, broader generalization of the findings. 36 CONCLUSIONS The findings of this pilot study suggest that MT can be effectively implemented for pediatric oncology and hematology patients within the clinical setting to reduce adverse physical and psychological symptoms associated with cancer treatment and cancer pain. The successful recruitment and implementation in inpatient and outpatient recipients alike suggest that positive outcomes associated with MT can be achieved both for oncology and for hematology pathologies, for girls and for boys, in a wide range of age groups, in diverse clinical environments. Although cancer clinics and oncology/ hematology wards are hectic clinical settings that must provide necessarily invasive clinical care such as chemotherapy, which clearly comprises the immune system, our data suggest that the addition of MT as a palliative treatment can increase quality of life and the health of pediatric oncology and hematology patients. CONFLICT OF INTEREST NOTIFICATION Dr. Haun and co-authors conducted this research at the University of Florida, College of Psychology, and the Cancer Center at Shands Hospital. Research was conducted in cooperation with the Shands Hospital and the University of Florida. Dr. Haun is now at the University of Arizona College of Medicine. This publication was made possible in part by grant T32 AT from the National Center for Complementary and Alternative Medicine (NCCAM). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM, the National Institutes of Health, Shands Hospital, or the University of Florida. The authors declare that there are no conflicts of interest. COPYRIGHT Published under the CreativeCommons Attribution NonCommercial-NoDerivs 3.0 License. REFERENCES 1. The American Cancer Society. Cancer Facts and Figures Atlanta, GA: American Cancer Society; Loman DG. The use of complementary and alternative health care practices among children. J Pediatr Health Care. 2003; 17(2): Field T. Massage therapy for infants and children. J Dev Behav Pediatr. 1995; 16(2): Yates J. A Physician s Guide to Therapeutic Massage: Its Physiological Effects and Their Application to Treatment. Canada: Massage Therapists Association of British Columbia; Beider S, Moyer CA. Randomized controlled trials of pediatric massage: a review. Evid Based Complement Alternat Med. 2007; 4(1): Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage. 2004; 28(3): Field T, Hernandez-Reif M, Seligman S, Krasnegor J, Sunshine W, Rivas-Chacon R, et al. Juvenile rheumatoid arthritis: benefits from massage therapy. J Pediatr Psychol. 1997; 22(5): Field T, Henteleff T, Hernandez-Reif M, Martinez E, Mavunda K, Kuhn C, et al. Children with asthma have improved pulmonary functions after massage therapy. J Pediatr. 1998; 132(5): Field T, Hernandez-Reif M, LaGreca A, Shaw K, Schanberg S, Kuhn C. Lifestyle and behavior: massage therapy lowers blood glucose levels in children with diabetes mellitus. Diabetes Spectrum. 1997; 10(4): Hernandez-Reif M, Field T, Krasnegor J, Martinez E, Schwartzman M, Mavunda K. Children with cystic fibrosis benefit from massage therapy. J Pediatr Psychol. 1999; 24(2): Scafidi F, Field T, Schanberg S, Bauer C, Tucci K, Roberts J, et al. Massage stimulates growth in preterm infants: a replication. Infant Behav Dev. 1990; 13(2): Martin LA, Hagen NA. Neuropathic pain in cancer patients: mechanisms, syndromes, and clinical controversies. J Pain Symptom Manage. 1997; 14(2): Varni JW, Rapoff MA, Waldron SA, Gragg RA, Bernstein BH, Lindsley CB. Chronic pain and emotional distress in children and adolescents. J Dev Behav Pediatr. 1996; 17(3): Sellick SM, Zaza C. Critical review of 5 nonpharmacologic strategies for managing cancer pain. Cancer Prev Control. 1998; 2(1): Ironson G, Field T, Scafidi F, Hashimoto M, Kumar M, Kumar A, et al. Massage therapy is associated with enhancement of the immune system s cytotoxic capacity. Int J Neurosci. 1996; 84(1-4): Lerner M. Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer. Cambridge, MA: MIT Press; American Psychological Association. Ethical principles of psychologists and code of conduct. Am Psychol. 1992; 47(12): Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1988; 14(1): McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson MC. A new analogue scale for assessing children s pain: an initial validation study. Pain. 1996; 64(3):

39 Undersøgelse massage til syge børn 20. Chambers CT, Giesbrecht K, Craig KD, Bennett SM, Huntsman E. A comparison of Faces scales for the measurement of pediatric pain: children s and parents ratings. Pain. 1999; 83(1): Chambers CT, Hardial J, Craig KD, Court C, Montgomery C. Faces scales for the measurement of postoperative pain intensity in children following minor surgery. Clin J Pain. 2005; 21(3): Perrott DA, Goodenough B, Champion GD. Children s ratings of the intensity and unpleasantness of post-operative pain using facial expression scales. Eur J Pain. 2004; 8(2): Miró J, Huguet A. Evaluation of reliability, validity, and preference for a Pediatric Pain Intensity Scale: the Catalan version of the Faces Pain Scale Revised. Pain. 2004; 111(1 2): Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990; 41(2): Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale Revised: toward a common metric in pediatric pain measurement. Pain. 2001; 93(2): Landgraf JM, Abetz L, Ware JE. The CHQ User s Manual. Boston, MA: The Health Institute, New England Medical Center; Raat H, Botterweck A, Landgraf J, Hoogeveen W, Essink-Bot M. Reliability and validity of the short form of the Child Health Questionnaire for Parents (CHQ-PF28) in large random school based and general population samples. J Epidemiol Community Health. 2005; 59(1): McCarthy ML, Silberstein CE, Atkins EA, Harryman SE, Sponseller PD, Hadley-Miller NA. Comparing reliability and validity of pediatric instruments for measuring health and wellbeing of children with spastic cerebral palsy. Dev Med Child Neurol. 2002; 44(7): Waters E, Salmon L, Wake M. The parent-form Child Health Questionnaire in Australia: comparison of reliability, validity, structure, and norms. J Pediatr Psychol. 2000; 25(6): Edmunds S, Garratt A, Haines L, Blair M. Child Health Assessment at School Entry (CHASE) project: evaluation in 10 London primary schools. Child Care Health Dev. 2005; 31(2): Spielberger CD, Edwards CD, Lushene RE, Montuori J, Platzek D. STAIC Preliminary Manual. Palo Alto, CA: Consulting Psychologists Press; Edwards D. Effects of midterm integration on state and trait anxiety in black and white elementary school children. Am J Community Psychol. 1979; 7(1): Hishinuma ES, Miyamoto RH, Nishimura ST, Nahulu LB, Andrade NN, Makini GK Jr, et al. Psychometric properties of the State Trait Anxiety Inventory for Asian/Pacific-Islander adolescents. Assessment. 2000; 7(1): Turgeon L, Chartrand E. Psychometric properties of the French Canadian version of the State Trait Anxiety Inventory for children. Educ Psychol Measure. 2003; 63(1): Spielberger CD, Sydeman SJ, Owen AE, Marsh B. Measuring anxiety and anger with the State Trait Anxiety Inventory (STAI) and the State Trait Anger Expression Inventory (STAXI). In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates; 1999: Spielberger CD, Edwards CD, Montuori J, Lushene R. State Trait Anxiety Inventory for Children. Mind Garden website. Published n.d. Accessed October 30, McKinley S, Coote K, Stein-Parbury J. Development and testing of a Faces scale for the assessment of anxiety in critically ill patients. J Adv Nurs. 2003; 41(1): Gustad LT, Chaboyer W, Wallis M. Performance of the Faces Anxiety Scale in patients transferred from the ICU. Intensive Crit Care Nurs. 2005; 21(6): McKinley S, Stein-Parbury J, Chehelnabi A, Lovas J. Assessment of anxiety in intensive care patients by using the Faces Anxiety Scale. Am J Crit Care. 2004; 13(2): McKinley S, Madronio C. Validity of the Faces Anxiety Scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation. J Psychosom Res. 2008; 64(5): Varni JW, Katz ER, Colegrove R, Dolgin M. Adjustment of children with newly diagnosed cancer: cross-informant variance. J Psychosoc Oncol. 1995; 13(4): Varni JW, Katz ER, Seid M, Quiggins DJL, Friedman-Bender A, Castro CM. The Pediatric Cancer Quality of Life Inventory (PCQL): I. Instrument development, descriptive statistics, and cross-informant variance. J Behav Med. 1998; 21(2): Varni JW, Seid M, Rode CA. The PedsQL: measurement model for the Pediatric Quality of Life Inventory. Med Care. 1999; 37(2): Levi RB, Drotar D. Health-related quality of life in childhood cancer: discrepancy in parent child reports. Int J Cancer Suppl. 1999; 12: Felder-Puig R, digallo A, Waldenmair M, Norden P, Winter A, Gadner H, et al. Health-related quality of life of pediatric patients receiving allogeneic stem cell or bone marrow transplantation: results of a longitudinal, multi-center study. Bone Marrow Transplant. 2006; 38(2): Vance YH, Morse RC, Jenney ME, Eiser C. Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health. J Child Psychol Psychiatry. 2001; 42(5): Chang P, Yeh C. Agreement between child self-report and parent proxy-report to evaluate quality of life in children with cancer. Psychooncology. 2005; 14(2): Yeh CH, Chang CW, Chang PC. Evaluating quality of life in children with cancer using children s self-reports and parent-proxy reports. Nurs Res. 2005; 54(5): Varni JW, Limbers CA, Burwinkle TM. Parent proxy-report of their children s health-related quality of life: an analysis of 13,878 parents reliability and validity across age subgroups using the PedsQL 4.0 Generic Core Scales. Health Qual Life Outcomes. 2007; 5: Corresponding author: Jolie N. Haun, 3750 E. Via Palomita #30202, Tucson, Arizona USA. [email protected] (Return to Top) a Kirisci L, Clark DB. Reliability and validity of the State Trait Anxiety Inventory for children in an adolescent sample: confirmatory factor analysis and item response theory. Data presented at the Annual Meeting of the American Educational Research Association; New York, New York; April 8 12, (Return to Top) INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK VOLUME 2, NUMBER 2, JUNE 2009

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