An Evaluation of the Use of Massage and Aromatherapy in Palliative Care
A review of the efficacy of massage used in palliative care
Massage is utilised by palliative care patients for a number of different reasons. The main problems encountered by therapists are anxiety, pain relief, digestive problems and emotional problems (Wilkinson et al 1999). Although there have been a number of clinical trials carried out in this area of work, it can be difficult to monitor how far these go into examining the full effects of massage.
The ability to decide whether a piece of evidence demonstrating efficacy of a treatment is reliable or not is essential when looking at any kind of healthcare, but even more so for those with little research to support them. As a practitioner, it is your own personal duty to ensure that you are enhancing the healthand wellbeing of a client. If a practitioner decides that a piece of evidence will continue to improve the level of care they provide, they have to be sure that it will work for the clients they treat, and will not harm them in any way.
Often in palliative care patients will first consult their general practitioner or consultant before deciding whether to have massage treatment. As it is one of the more comprehensively researched areas, and in a way is similar to the physical manipulation of physiotherapy, the orthodox medical professions often accept it as a viable option for their patients to use alongside their treatment (Novey 2000). Price and Price (1999) also state that it is more acceptable to the allopathic professions to use aromatherapy combined with the massage, as many patients do, as the oils can be examined as complex chemical compounds, and possible interactions can be detected before treatment is applied.
It has been acknowledged by Caldwell (2001) that professional regulation and legal indemnity are important factors for every therapist to consider. Yet the general public are not always aware that there are governing bodies that have registers of therapists working in their area. They will often approach those claiming to be therapists, who will then also advise that they are able to treat a variety of illnesses through use of their massage (Holey and Cook 2003). It is important to note that a true therapist with full registration to practice will not make any claims of being able to cure illness or disease through the provision of the therapy, as it opposes all of the ethical codes produced by the governing bodies (Fritz 2000). Although there are three main governing bodies for massage therapy in Britain, with many affiliates, it should be noted that many countries now have one governing body, controlled by governmental laws. Although very rare, there can be discrepancies between the different bodies and affiliates, causing confusion over how care should be carried out.
It is often found in palliative care that if a patient receives a massage, they will often take up aromatherapy also as an additional treatment (Corner et al 1995). This is demonstrated by the fact that in most of the trials in palliative care and massage, the massage is carried out as a joint treatment. This helps to enhance the mood of the client and creates a soothing atmosphere (Dunwoody et al 2002). Many clients will request this themselves as part of their care plan.
Gray (2000) has proposed that massage is popular amongst those with terminal disease for a small number of reasons. The first reason is the way the therapeutic touch has a way of reaching the client on an emotional and spiritual level as well as a physical level. Sayre-Adams and Wright (2001) discuss the importance of touch. Touch is a primary form of non-verbal communication, and can demonstrate feelings towards a person. Bloom (2000) states that touch is something we all take for granted, and we do not notice how much it means until we are deprived of it. In the case of massage provision, Wilcock et al (2004) suggests that it may provide some kind of outlet for emotion, anxiety or fears that the client has been unable to express to friends and family for fear of hurting them. Though this may be positive, it can also result in negative feelings, and affect the receptiveness of the client to treatment. If this is not addressed then by counselling or discussion with a consultant, this can lead to permanent emotional stresses, which can leave the client feeling much worse (Garnett 2003).
Soden et al (2004) discusses the need for emotional support in palliative care. It is suggested that as a result of the changes that can occur during treatment, such as hair loss or severe fatigue, many patients feel that they have somehow lost their integrity, and this can often result in self loathing, and can even result in displacement of these feelings onto the people around them, whether it be the nursing staff, the therapist or their family and friends. Dunn et al (1995) suggest that in depth counselling be recommended should this occur, as although communication is part of the work of a therapist, this would be out of their scope of training unless they had an official counselling qualification.
Garnett (2003) also presents the case for the emotional support offered by therapeutic massage, although within the context of complementary therapies as a whole rather than by itself. This report suggests that those patients receiving palliative care can gain emotional support and nurturing from a complementary treatment. This can be through feelings of acceptance from a person, despite their situation, or through the ability to release emotions that they have felt the need to keep hidden. It proposes that complementary treatment can often provide the emotional and spiritual guidance to a person within a palliative care setting that they may not get from the doctors or nurses, or are unable to seek from their families.
A major theme that seems to run through many of the clinical trials relating to massage and palliative care is regarding anxiety and stress, coupled with emotional wellbeing. The anxiety and stress were measured on all different scales, from physical parameters to subjective opinions about how they feel at the time. These provide a variety of views on the therapy both subjective and objective from the patient and practitioner. Wilkinson et al (1999) carried out a study into the effects of massage on the State-Trait Anxiety Index Scale and the Rotterdam Symptom Checklist scores for patients with cancer. Although only 103 participants were used for the study, this is one of the larger scale studies within massage and palliative care. The participants were given three full body massages over a period of three weeks, and then asked to complete the two forms relating to the tests. The results obtained here demonstrated that there was a statistically significant difference between the scores prior to massage and following massage, on both of the scales used for testing. This suggested that the massage had helped to reduce the anxiety felt by the patient by a considerable amount, and it had also reduced the number of times they were demonstrating symptoms of the disease, and also the intensity of the symptoms. Overall, this study showed that massage had a positive effect for the clients, making them more comfortable and enhancing the wellbeing of the client.
Corner et al (1995) utilised a quasi-experimental trial to test the effects of massage and aromatherapy on the well being of cancer patients. This was an eight-week trial, with 52 participants. After providing massage, the therapists monitored the patients using the Hospital Anxiety and Depression Scale, involving a questionnaire and behaviour monitoring. Massage was reported from this study to be highly effective in reducing both the anxiety and the symptoms experienced by clients, and induced a feeling of relaxation. The only problem highlighted was the sample size of the study, which was deemed too small to have conclusive results. Yet this is good base to start from when considering the effects of the treatment on clients, as it shows there is a positive effect.
In Dunwoody et al (2002), a focus group interview was used to explore the personal meanings of the massage treatment to the patients. There were eight people participating in the focus group, and they discussed a number of things. Eight key themes emerged during the discussion. The main theme was the de-stressing effect of the therapy. The patients said that they had experienced this and as a result had better sleep patterns, increased energy and felt relaxed. They also discussed the role of the therapist as a counsellor, someone with whom they were able to discuss their fears and anxieties about the future, without fear of reprisals or the person reacting in a negative way. One of the patients in the discussion group also said that they found it easier talking to the therapist rather than to a counsellor, as the therapist was not demanding that they open up and release their feelings, it was more of a voluntary action. Many of the patients also saw the treatment as a treat, and it made them feel special as a result. This meant that they could feel good about something, rather than concentrate on their illness.
It was noted that the patients said they felt empowered after the massage treatment, as they were given time to make informed decisions about the treatment they wanted and were made to feel at ease when asking about anything that worried them. This often contrasted strongly with the way they felt when asking their doctor or consultant something about the chemotherapy.
As discussed before, the patients mentioned the touch being therapeutic and accepting, and made them feel much more secure, especially if they had recently had surgery and were not very confident about the way they looked. Yet most of the participants also felt that they were more comfortable receiving the treatment within the cancer unit or at home, as if they had to attend a therapy centre, they felt uncomfortable and as if people were staring at them because they were ill. This showed that majority of the group felt more secure when they were attending treatments as in-patients, rather than at an outside facility. The report also showed that many of the patients, especially the male participant, were very unsure about trying the massage and aromatherapy beforehand, as they were told by others, especially GP’s, that it wouldn’t work, or that it was only for women. This made them fear any reprisals, and many of them only informed close friends and family of the treatment they were receiving. The main negative point to emerge from the discussion, was the lack of availability on the NHS to those who wish to use massage. They also said that this should be brought in on the NHS as it would benefit a lot of people. Overall, the reaction in this study was very positive, although again the study was very small and not conclusive in its results.
Wilkinson et al (1995) carried out a study into the effects of aromatherapy massage on the Rotterdam Symptom Checklist and the State-Trait Anxiety Inventory. These are quantitative methods and are deemed by medical practitioners to be more accurate when evaluating the success of a treatment. The results from the participants were very positive, with statistically significant improvements in the scores across all aspects of the tests. This was only a little better in the group receiving aromatherapy massage than those in the group receiving massage alone. This suggests that the main effect is due to the massage, and that the aromatherapy should be combined with massage to have any kind of significant effect on the body.
Evans (1995) audited the effects of aromatherapy massage on cancer patients through a small-scale study. This used a questionnaire following treatment to evaluate its success. There was a reported eighty percent success rate post treatment, in that the patients felt that their situation had improved in some way, either the physical or psychological aspects. As there were only sixteen participants, the author of the research advised that more in depth research be carried out, with more participants and a defined structure to the research plan. They also suggest the use of qualitative and quantitative methods, rather than just qualitative. This would give the research a broader spectrum of results, and make it more accurate.
In Buckley (2002), the article reviews the role of complementary and alternative medicine within palliative care, specifically dealing with massage. The author states that massage should play a large role in palliative care, as they are very similar disciplines. It suggests that they are growing at an equivalent rate, and that palliative care is the key part of the NHS healthcare to incorporate complementary therapies in with mainstream treatment. This is an important role for palliative care to play, as there are many people who would like to see certain treatments integrated into allopathic regimens. The article also states that research needs to be carried out with larger sample sizes, as the current research only uses small numbers of participants in the studies. Trials need to be carried out on a larger scale if they are to give credibility to a profession, especially within healthcare provision.
Hadfield (2001) utilised the Hospital Anxiety and Depression Scale to assess the effect of massage on the patients, along with semi-structured interviews. In this study, the Hospital Anxiety and Depression Scale questionnaire was answered both before and after treatment had taken place. It was found here that the massage had little or no effect on these scores, however only one treatment was carried out on each participant, therefore only immediate short-term effects could be measured. In the semi-structured interviews, however, the clients reported feeling much better, as they were relaxed and less tense than before. They also said that they enjoyed the accepting physical contact they were receiving from the therapist at the time, as it made them feel wanted and cared for.
There are also certain dangers of using massage, especially within a palliative care setting where the patients have terminal, metastasising disease within the body. Maxwell-Hudson (1996) explains that the action of massage can improve blood and lymphatic flow, accelerating the waste removal processes in the body. Although this may seem like a good thing, this will also increase the rate at which malignant cells are transported within these systems. As they travel around the body faster, it could be possible for them to invade another part of the body, and for the cells to develop here. This could then cause further problems for the patient, as they would have cancer in sites where they did not previously have it. It can also worsen the pain being experienced by the client, for example if pressure is applied to a tumour site (Holey and Cook 2003).
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