The effect of massage therapy in relieving anxiety in cancer

Title patients receiving chemotherapy

Author(s) Huen, Suk-ting; 禤淑婷

Huen, S. [禤淑婷]. (2013). The effect of massage therapy in

relieving anxiety in cancer patients receiving chemotherapy.
Citation (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR.
Retrieved from http://dx.doi.org/10.5353/th_b5088336

Issued Date 2013

URL http://hdl.handle.net/10722/193054

The author retains all proprietary rights, (such as patent rights)

Rights and the right to use in future works.
 Abstract of dissertation entitled

The effect of massage therapy in relieving anxiety

in cancer patients receiving chemotherapy

Submitted by

Huen Suk Ting

for the degree of Master of Nursing

at The University of Hong Kong

in July 2013

Chemotherapy is one of the major treatments for cancer patients to cure or

palliate their disease. Cancer patients experience physiological and psychological

distress during chemotherapy treatment. Anxiety is the most common symptom

observed in cancer patients undergoing chemotherapy. Anxiety has also proven to be

highly associated with anticipatory nausea and vomiting (ANV). In the local

chemotherapy day ward, almost half of the cancer patients verbalize that they feel

i
anxious and are afraid of turning up for chemotherapy due to the fear of its side

effects. However, clinical measure for treating patients’ anxiety during chemotherapy

is limited. One of the complementary and alternative medicines (CAM), massage

therapy, becomes a useful means for cancer patients to relieve their physical and

psychological distress. Yet, massage is not a routine CAM being integrated into the

cancer treatment in Hong Kong, including the target center. Thus, a translational

study is proposed in order to develop a massage program for cancer patients receiving

chemotherapy to relieve their anxiety.

A systematic search of five electronic journal databases identified 9

randomized controlled trials (RCTs) on the use of massage therapy for cancer patients

in relieving their anxiety. The appraisal tool developed by the Critical Appraisal Skills

Programme was used to evaluate the quality of the selected studies. The findings of

the selected studies concluded that massage therapy is effective in relieving anxiety

for cancer patients.

A massage program is proposed to be implemented in a chemotherapy day ward.

This translational research proposal will illustrate how such a massage program is

planned. The implementation potential has been assessed and the potential benefits of

massage do outweigh its risks and the costs of running this program. An

ii
evidence-based guideline has been developed to ensure patient safety and increase

effectiveness of the massage program.

The communication process with stakeholders has been planned in order to

gain their support for this massage program. Staff training will be organized and a

pilot study has been designed to test the feasibility of this program.

An evaluation plan has also been developed to assess the effectiveness of this

program. Anxiety level, measured by using State Trait Anxiety Inventory-State

(STAI-S), is set as the primary patient outcome of this study. In addition, Numerical

Rating Scale (NRS), rating from 0 to 10, will be used as the secondary patient

outcome to measure the severity of nausea and vomiting. Lastly, the satisfaction level

of patients, volunteers and nurses will be measured using a 4-point Likert scale.

Therefore, the proposed massage program can be improved and refined according to

the evaluation findings. It is believed that the proposed massage program can reduce

anxiety for cancer patients receiving chemotherapy and thus improving their quality

of life.

iii
The effect of massage therapy in relieving anxiety

in cancer patients receiving chemotherapy

by

Huen Suk Ting

Bachelor of Nursing, Registered Nurse

A dissertation submitted in partial fulfillment of the requirements for

the degree of Master of Nursing

at The University of Hong Kong

July 2013

iv
 Declaration

I declare that this dissertation represents my own work, except where due

acknowledgement is made, and that it has not been previously included in a theses,

dissertation or report submitted to this University or to any other institution for a

degree, diploma or other qualification.

Signed _________________________________

Huen Suk Ting

v
 Acknowledgements

I would like to express my heartfelt gratitude to my supervisor Miss Idy Fu, who

provided guidance and inspirations on this dissertation. Her encouragement and

support throughout these two years has enabled me to complete this dissertation.

I am also grateful to my Ward Manager, Mr. Rayman Wan and Advanced

Practice Nurse, Miss Yuen Mei-Lin, for their sincere encouragement in my

postgraduate studies.

Finally, I deeply thank my family and friends for their constant love and support

to complete this master programme.

Huen Suk Ting

vi
 Table of contents

Declaration .................................................................................................................. v

Acknowledgements ................................................................................................... vi

Table of contents ...................................................................................................... vii

Chapter 1: Introduction ............................................................................................ 1

1.1Background ..................................................................................................... 1

1.2 Affirming the need ......................................................................................... 3

1.3 Objectives and significance ............................................................................ 5

Chapter 2: Critical Appraisal ................................................................................... 8

2.1 Search strategies ............................................................................................. 8

2.1.1 Selection criteria ...................................................................................... 8

2.2 Search results .................................................................................................. 9

2.2.1 Study characteristics ................................................................................ 9

2.2.2 Methodological assessment ................................................................... 10

2.3. Summary and synthesis of data ................................................................... 14

2.3.1 Characteristics of participants ............................................................... 14

2.3.2 Selection of participants ........................................................................ 15

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 2.3.3 Dropout rate .......................................................................................... 16

2.3.4 Intervention ........................................................................................... 17

2.3.5 Type and area of massage used ............................................................. 18

2.3.6 Duration and frequency of massage ...................................................... 19

2.4 Recommendation and conclusion ................................................................. 19

Chapter 3: Translation and Application ................................................................ 23

3.1 Implementation potential .............................................................................. 23

3.1.1 Transferability of the findings ............................................................... 23

3.1.1.1 Target setting .................................................................................. 23

3.1.1.2 Target audience .............................................................................. 24

3.1.1.3 Philosophy of care .......................................................................... 25

3.1.1.4 Proposed massage intervention ...................................................... 26

3.1.2 Feasibility of the innovation .................................................................. 27

3.1.2.1 Organizational and administrative support .................................... 27

3.1.2.2 Frontline staff support .................................................................... 28

3.1.2.3 Volunteers’ support ........................................................................ 30

3.1.3 Cost/Benefit ratio of the program .......................................................... 31

viii
 3.1.3.1 Potential risks ................................................................................. 31

3.1.3.2 Potential benefits ............................................................................ 33

3.1.3.3 Cost ................................................................................................. 34

Chapter 4: Evidence-Based Practice Guideline .................................................... 37

4.1 Aim ............................................................................................................... 37

4.2 Objectives ..................................................................................................... 37

4.3 Target population ......................................................................................... 38

4.4 Recommendations ........................................................................................ 39

Recommendation 1.0 .................................................................................. 39

Recommendation 2.0 .................................................................................. 39

Recommendation 3.0 .................................................................................. 40

Recommendation 4.0 .................................................................................. 40

Chapter 5: Implementation Plan ............................................................................ 42

5.1 Communication plan .................................................................................... 42

5.1.1 Identifying stakeholders ........................................................................ 42

5.1.2 Formation of a working group .............................................................. 43

5.1.3 Communication process ........................................................................ 44

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 5.2 Staff training program .................................................................................. 46

5.3 Delivery of intervention ............................................................................... 46

5.4 Pilot study ..................................................................................................... 47

5.5 Ongoing monitoring of the massage program .............................................. 48

5.6 Evaluation plan ............................................................................................. 48

5.6.1 Identifying outcomes ............................................................................. 48

5.6.2 Nature and number of clients to be involved ........................................ 50

5.6.3 Data collection and data analysis .......................................................... 51

5.6.4 Basis for as effective change of practice ............................................... 52

Chapter 6: Conclusion ............................................................................................. 53

References ................................................................................................................. 55

Appendix A: Search history .................................................................................... 64

Appendix B: Summary of search results ............................................................... 69

Appendix C: List of selected studies ...................................................................... 70

Appendix D: Appraisal tool (RCTs checklist) ....................................................... 72

Appendix E: Level of evidence ................................................................................ 76

Appendix F: Quality assessment ............................................................................. 77

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Appendix G: Table of evidence ............................................................................... 86

Appendix H: Table of summary for the Studies’ Results .................................... 95

Appendix I: Estimated expenses that can be saved by reducing use of potent

anti-emetics ......................................................................................... 97

Appendix J: Budget plan for implementing the massage program .................... 98

Appendix K: Grade of recommendation ............................................................... 99

Appendix L: Evidence-based practice guideline of massage for cancer patients

receiving chemotherapy ................................................................... 100

Appendix M: Timetable for implementation of the massage program ............ 110

Appendix N: Assessment form for the massage program .................................. 111

xi
 Chapter 1: Introduction

Cancer patients experience physiological and psychological distress during

chemotherapy treatment (Icomonou, et al., 2004). Anxiety is the most common

symptom observed in cancer patients undergoing chemotherapy. A

non-pharmacological method, massage therapy, is suggested for those patients to

reduce their level of anxiety, decreasing the side effects of chemotherapy and

improving their quality of life. This chapter will illustrate the needs and significance

of implementing massage interventions for cancer patients in Hong Kong in order to

reduce their anxiety.

1.1 Background

Cancer is a stressful event for patients as it is a life-threatening and chronic

illness requiring life-long monitoring for disease recurrence. According to the

Department of Health, cancer is the most leading cause of death in Hong Kong,

accounting for 31.2% of all deaths in 2009. Moreover, The Hong Kong Cancer

Registry (2007) reported that the cancer burden in our population is increasing. It is

shown by the continually rising number of new cancer cases, a rate of around 2%

every year, and the steadily increasing life expectancy for both sexes in Hong Kong in

the past 25 years. As well, the survival time for cancer patients has been lengthened

by advanced medical technology and aggressive cancer treatments (Schreier, et al.,

1
2004). However, the increasing number of cancer survivors also implies a longer life

with a longer treatment period, including surgery, chemotherapy, radiotherapy and

target therapy, causing cancer patients to suffer for longer periods of and more severe

side effects from cancer treatments (Listing, et al., 2009). These lengthy treatments

can cause emotional distress for cancer patients such as anxiety, sense of guilt and

low self-esteem, due to the uncertainty of treatment and disease progression (Lin, et

al., 2011). Thus, such impact becomes an important issue for cancer patients’ quality

of life (Listing, et al., 2009).

The use of chemotherapy in cancer patients is strongly correlated with cancer

survival (Bender, et al., 2002). Chemotherapy can be classified into Curative Intent, to

eradicate tumor cells, and Palliative Intent, to decrease tumor load and symptoms so

as to prolong life. Cancer patients usually suffer from physical and psychological

problems related to fatigue, anxiety and depression during chemotherapy (Icomonou,

et al., 2004). Undesirable side effects such as nausea, vomiting, sleep disturbance and

fatigue further increase patients’ psychological distress (Lin, et al., 2011). A study

showed that 15-40% of cancer patients suffered from psychological disorders related

to anxiety and depression during chemotherapy, and that anxiety highly contributed to

the incidence of pre-therapy and post-therapy nausea and vomiting (Molassiotis, et al.,

2002).

2
 There has been an increase in cancer patients seeking complementary and

alternative medicine (CAM) in addition to conventional treatments to improve

common treatment side effects and disease symptoms over the past decade (DiGianni,

et al., 2002). The National Center for Complementary and Alternative Medicine

(NCCAM) (2010) defines CAM as “a group of diverse medical and health care

systems, practices, and products that are not presently considered to be part of

conventional medicine’. A survey conducted in Taiwan showed that 98.1% of cancer

patients receiving chemotherapy simultaneously used CAM such as diets, massage

and herbal medicine (Yang, et al., 2008). The Hong Kong Breast Cancer Registry

(2011) also reported that 33.5% of breast cancer patients received CAM.

Massage is one of the common CAM practices employed to relieve anxiety, pain

and nausea for cancer patients and has been widely used as a treatment for over 3000

years (Quattrin, et al., 2006). Massage is defined as ‘a rhythmic form of touch done by

a specially trained person to communicate empathy to the recipient, thus, producing

positive psychological and physiological states of being’ (Tappan, 1980).

1.2 Affirming the need

In the local chemotherapy day ward, almost half of the cancer patients admitted

for receiving chemotherapy verbalize that they feel anxious and are afraid of turning

up for chemotherapy due to the fear of its side effects. Those patients manifest anxiety

3
by developing hand tremors, restlessness, nausea and vomiting before administration

of chemotherapy. This type of nausea and vomiting is referred to as ‘anticipatory

nausea and vomiting (ANV)’.

ANV is defined as developing nausea and vomiting during the 24 hour period

prior to chemotherapy administration (Andrykowski, et al., 1985). It is reported that

approximately 30% of cancer patients develop ANV before their chemotherapy

treatment (Morrow, et al., 1998). Anxiety has proven to be a significant predisposing

factor which is highly associated with ANV and is difficult to be controlled by

pharmacological treatment (Roscoe, et al., 2011). As a result, patients still experience

discomfort and suffer from chemotherapy side effects despite the use of anxiolytic

agents (Billhult, et al., 2007). Eventually, these anticipatory problems and undesirable

side effects further exaggerate the level of anxiety that is already present with the

cancer diagnosis, and therefore worsening the patient’s quality of life (Lin, et al., 2011).

Some cancer patients even refuse or defer chemotherapy due to the fear of its

associated side effects. This delay in receiving treatment then lowers their chance of

recovery (Dibble, et al., 2003).

Currently, patients’ anxiety and ANV can only be improved by reassurance from

nurses, pharmacological use and referring symptomatic cases to a clinical

psychologist. However, time available for nurse counseling is limited due to a

4
shortage of manpower. Moreover, the choice of anxiolytic and anti-emetic drugs are

limited and not recommended since their side effects may induce drowsiness, further

worsening the patients’ fatigue and concentration (Traeger, et al., 2012). On the other

hand, the clinical psychologist will only be referred in the target clinic if the cancer

patient experiences excessive anxiety causing a psychological disorder. The waiting

period for such a consultation is often more than two weeks once a referral is

recommended.

A local survey (Williams, et al., 2010) reported that massage becomes a useful

means for cancer patients in dealing with such physically and psychologically

stressful treatments for enhancing their quality of life. However, massage is not a

routine CAM being integrated into cancer treatment in Hong Kong, including the

target center. Discussions about massage therapy between cancer patients and health

care professions are also uncommon in the target center. To date, no study has been

conducted in Hong Kong on the effectiveness of massage therapy in reducing anxiety

on cancer patients undergoing chemotherapy. Therefore, a literature review must be

performed to examine the effectiveness of massage therapy for cancer patients

receiving chemotherapy in relieving anxiety and thus reducing the severity of ANV.

1.3 Objectives and significance

The burden of psychological distress, anxiety and depression in cancer

5
patients undergoing chemotherapy cannot be neglected. Ineffective coping of anxiety

may cause anxiety disorders and depression, which has been estimated to be 4 times

more common in cancer patients compared to the general population (Corbin, 2005).

Anxiety may also exacerbate cancer patients’ physical symptoms such as nausea,

vomiting, insomnia, fatigue and decreased appetite, which will further impair their

quality of life (Corbin, 2005). Massage therapy is believed to help cancer patients to

interrupt the cycle of distress and induce a relaxation response, thus, improving their

quality of life (Ahles, et al., 1999). It is also believed to have a boosting effect on the

immune system and an increase in serotonin level which reduces muscle tension and

anxiety (Billhult, et al., 2007).

Current oncology treatment has evolved from merely cancer killing to enhancing

patients’ comfort throughout their treatment and recovery phases (Currin & Meister,

et al., 2008). There is a growing need in CAM to augment cancer care. However,

discussion on the use of massage between nurses and cancer patients remains

uncommon in most clinical settings (Ahn, et al., 2006). Health care professionals are

an important and trustful source of information on medical treatment for cancer

patients (Li, et al., 2010). With the increasing use of massage therapy within the

community, nurses have an obligation to provide information and service for cancer

6
patients to reduce their anxiety and mood disturbance, assisting them in going through

the treatment period.

Therefore, the research question is posed; ‘Is massage therapy effective in

reducing anxiety in adult cancer patients undergoing chemotherapy?’

The objectives of this dissertation are as follows:

1. To review studies on the effectiveness of massage in reducing anxiety of adult

cancer patients undergoing chemotherapy.

2. To critically appraise, summarize and synthesize the research findings from

selected studies.

3. To formulate evidence-based guideline on implementing massage therapy for

cancer patients undergoing chemotherapy.

4. To assess the implementation potential of the proposed massage program.

5. To develop an implementation and evaluation plan for the proposed program.

7
 Chapter 2: Critical Appraisal

In this chapter, a literature review is performed with the detailed search strategies

described. Then, a critical appraisal is done on the selected studies, and

recommendations are made after summarizing and synthesizing the data extracted

from those studies.

2.1 Search strategies

Both electronic and manual searches were performed from 29th July 2012 to 30th

August 2012 to identify eligible studies for a comprehensive literature review. Five

electronic databases: Medline (OvidSP) (1946 to July Week 3 2012), CINAHL Plus

(EBSCOHost) (1967 to 2012), British Nursing Index (ProQuest), The Cochrane

library and The PsycINFO (1800s to 2012), were used.

Several keywords were used to limit the number of literature results related to

the chosen topic. The keywords used were grouped according to population (Cancer,

neoplasm, oncology, carcinoma, malignancy), treatment (chemotherapy), intervention

(massage therapy, complementary treatment, alternative therapies and alternative

medicine), and outcome (anxiety, anxiety disorder, mood disturbance, psychological

discomfort, relaxation, anticipatory nausea and anticipatory vomiting).

2.1.1 Selection criteria

Inclusion and exclusion criteria were developed to select eligible studies. For

8
the inclusion criteria, studies must be randomized controlled trials (RCTs). RCTs

have the highest level of evidence to examine the effectiveness of the studied

intervention (Petrisor & Bhandari, 2007). Studies should be written in English since

the author is unable to translate the studies appropriately and precisely into English.

The participants of the studies should be cancer patients aged 18 or above, as the

target population is adult cancer patients. Moreover, massage therapy should be the

only intervention assigned to the intervention group. Any combinations of massage

with other innovations such as aromatherapy or reflexology as the only intervention

were not included to avoid any confounding effect. Also, the included studies had to

have at least one outcome measure relating to anxiety. Any unrelated massage such as

prostatic massage and carotid massage were also excluded.

2.2 Search results

Details of the search history and a summary of the search results are shown in

appendix A and B respectively. After manual screening using the inclusion and

exclusion criteria and discarding duplicated ones, nine studies were identified. A

manual search from the reference list was also performed and no further studies were

found. A list of the selected papers is shown in appendix C.

2.2.1 Study characteristics

All of the nine selected papers were published from 1999 to 2011. The

9
majority of these were conducted in western countries: three in the USA (Ahles, et al.,

1999; Hernandez, et al., 2004; Post-White, et al., 2003), two in the UK (Soden, et al.,

2004; Sharp, et al., 2010), one in Germany (Listing, et al., 2010), two in Sweden

(Billhult, et al., 2007; Billhult, et al., 2008) and one in Taiwan (Jane, et al., 2011).

Massage therapy was the only different treatment used between the

intervention and control groups in all studies. Participants of both the intervention and

control groups within each study (N=9) were given the service in the same

environment such as a quiet and private room to minimize any confounding factors

altering the study’s outcomes.

2.2.2 Methodological assessment

The quality of the studies was evaluated by the Critical Appraisal Skills

Programme (Guyatt, Sackett, & Cook, 1993, 1994). Its RCTs checklist, which

consists of 10 questions, was used as the appraisal tool to guide the review. Detail of

the RCTs checklist is shown in appendix D. Then, the level of evidence for all

selected studies was classified using the Scottish Intercollegiate Guidelines Network

(SIGN) (SIGN, 2008). Details are provided in appendix E.

All studies stated clearly-focused research questions including the population

(cancer patients), intervention (massage therapy) and the outcomes related to anxiety.

All studies are RCTs which was considered to have the most powerful and convincing

10
evidence on the causal effect between interventions and study outcomes (Petrisor &

Bhandari, 2007).

All participants in the nine studies were appropriately allocated to either

intervention groups or control groups by randomization. Seven studies clearly stated

their method used for randomization. Four studies were using sealed opaque

envelopes (Soden, et al., 2004; Bullhult, et al., 2007; Billhult, et al., 2008; Sharp, et

al., 2010); one study used a computer program (Jane, et al., 2011); one study used a

simple randomization list (Listing, et al., 2010) and one study used the flip of a coin

(Hernandez-Reif, et al., 2004). All studies compared baseline demographic variables

between intervention and control groups at the entry of the trials. Only one study

showed significantly more women in the control group than the intervention group

after randomization (Soden, et al., 2004). Nevertheless, their baseline assessment

scores of the measured outcomes were compared and showed no significant

difference between groups.

It was not feasible to ‘blind’ participants for the group assignments. They

would know whether they were in the control group receiving usual care, or the

intervention group receiving massage therapy. However, an informed consent was

obtained from the participants prior to the treatment allocation. Concealment was

achieved. Three studies had enough participants to have a statistical power of 80%

11
(Hernandez-Reif, et al., 2004; Post-White, et al., 2003; Billhult, et al., 2008), and two

studies had enough participants to reach the power of 95% (Sharp, et al., 2010; Jane,

et al., 2011). However, one study’s sample size was less than expected (Soden, et al.,

2004), and three studies did not set minimum sample size to achieve certain statistical

power (Ahles, et al., 1999; Listing, et al., 2010; Bullhult, et al., 2007). Those with

insufficient sample size might cause difficulties in establishing a conclusion as to

whether the outcome was a real effect from massage therapy or due to some

characteristic of the participants, causing a risk for inducing type II errors (Soden, et

al., 2004).

All nine studies used self-assessment tools for primary outcome data

collection. Some studies (N=5) used one-dimensional tools such as State Trait

Anxiety Inventory (STAI), visual analogue scale (VAS) on relaxation, mood and

nausea (Ahles, et al., 1999; Hernandez-Reif, et al., 2004; Billhult, et al., 2007;

Billhult, et al., 2008; Jane, et al., 2011). The reliability and validity of these tools are

well established (Spieberger, 1983; Lee & Kieckhefer, 1989). A two-dimensional

tool, the Hospital Anxiety and Depression Scale (HADS) was also used to measure

the change in anxiety and depression level for the participants (Soden, et al., 2004;

Sharp, et al., 2010; Billhult, et al., 2007; Billhult, et al., 2008). Its validity was also

verified (Zigmond & Snaith, 1983). Furthermore, some multi-dimensional tools, the

12
Profile of Mood States (POMS), the Mood Rating Scales (MRS) and the Berlin Mood

Questionnaire (BMQ) had been used to measure participants’ mood states and quality

of life in 3 studies (Post-White, et al., 2003; Listing, et al., 2010; Sharp, et al., 2010).

These tools consist of several subscales measuring participants’ anxiety level and

their reliability was also well established (Redd, et al., 1991; Anderson, et al., 2000;

Hoerhold & Klapp, 1993). All of the assessment tools used were self reported

questionnaires to measure subjective feelings of anxiety. Therefore, the data can be

collected without using an interviewer or data collector to decrease the risk of

detection bias (Gurusamy, et al., 2009).

All nine studies present their results precisely using mean change, percentage

change and effect size of the scores by different well established measuring tools. All

studies set 5% as the level of significance. Six studies showed the baseline scores and

change in post intervention scores in the form of tables, while the other three studies

(Post-White, et al., 2003; Listing, et al., 2010; Jane, et al., 2011) presented the results

in the form of both tables and graphs of mean score over time. All tables and graphs

were clearly presented with the p-value provided so that the effect of massage therapy

at different time periods was clearly indicated.

According to the above critical appraisal, three studies (Sharp, et al., 2010;

Hernandez-Rief, et al., 2004; Jane, et al., 2011) were graded as the highest quality

13
RCTs with a very low risk of bias (1++) while four studies (Ahles, et al., 1999;

Post-White, et al., 2003; Listing, et al., 2010; Billhult, et al., 2007) were rated 1+ with

a low risk of bias. The remaining two studies (Soden, et al., 2004; Billhult, et al.,

2008) were labeled as high risk of bias (1- ). A detailed quality assessment of each

selected study is shown in appendix F.

2.3 Summary and synthesis of data

The contents of the selected studies were reviewed and data were extracted

using tables of evidence. The tables of evidence for each study are itemized in

appendix G and the summary is briefly described. Appendix H clearly shows a table

of summary for the studies’ results.

2.3.1 Characteristics of participants

All participants in the nine studies were cancer patients and five of them were

breast cancer female patients (Sharp, et al., 2010; Hernandez-Reif, et al., 2004;

Listing, et al., 2010; Billhult, et al., 2007; Billhult, et al., 2008). Also, participants in

five studies were receiving chemotherapy during the study period (Ahles, et al., 1999;

Sharp, et al., 2010; Post-White, et al., 2003; Billhult, et al., 2007; Jane, et al., 2011).

This population is the same as that in the local setting, a chemotherapy day ward,

where breast cancer patients are the majority in the population. These patients require

a relatively longer treatment period, about one and a half years to receive target and

14
conventional chemotherapy. In addition, women with breast cancer are a vulnerable

group among cancer patients since they are at higher risk for depression, elevated

stress and anxiety levels, and anger (Longman, et al., 1999).

The mean age of participants ranged from 41 to 62.5 in eight studies except

one study with a median age of 73 (Soden, et al., 2004). This is similar to the peak age

group among the prevalence of cancer in Hong Kong, aged 45-64 (Hong Kong Cancer

Registry, 2009). Therefore, the results of the studies should be applicable to the local

clinical setting.

2.3.2 Selection of participants

Although no adverse effect was reported in all the selected studies, some

literature showed that massage might increase the risk of fractures and dislocation,

hemorrhage, hematoma and dislodging of deep vein thrombosis in certain populations

(Corbin, 2005). Participants in all the studies required doctor approval before entering

the studies. In addition, assessment had been done in some studies to exclude cases

with underlying medical conditions such as lymphoedema, inflamed skin in the area

of therapy, anticoagulants problems, thrombocytopenia, spinal cord compression

syndrome and deep vein thrombosis (Hernandez-Reif, et al., 2004; Listing, et al.,

2010; Jane, et al., 2011). Moreover, Post-White, et al. (2010) stated that the massage

technique and the area of massage should be modified and adjusted to avoid tumor or

15
surgical sites. The study also suggested that the depth of touch should be limited

according to individual tolerance (Post-White, et al., 2010). Therefore, assessment

should be performed prior to the proposed massage therapy. Furthermore, an

informed consent should be obtained from participants prior to massage therapy to

ensure that participants understand the purpose of the program and the risk of the

intervention, even though the adverse effect of massage therapy reported to be very

low in all the studies.

2.3.3 Dropout rate

The dropout rate among the selected studies ranged from 0-29%. Eight studies

had a dropout rate less than 20%. Some studies tried to minimize the possibility of

dropout by offering the control group to receive complimentary massages

(Hernandez-Rief, et al., 2004; Jane, et al., 2011) and progressive muscle relaxation

(Listing, et al., 2010) after completion of the studies. Eventually their dropout rates

were lowered to 0% (Hernandez-Rief, et al., 2004), 6.9% (Jane, et al., 2011) and

14.7% (Listing, et al., 2010). One study (Post-White, et al., 2003) had a dropout rate

of 29% and it explained that the participants left the study due to their advancing

disease causing a subsequent change in their treatment plan or the participants died

before completion of the study. Nevertheless, no differences had been detected from

the baseline data between adherers and dropouts in the study.

16
 In addition, all dropout participants in all the studies were included to which

they were originally allocated for intention-to-treat analysis so that all participants

were accounted for at the conclusion to ensure the validity of the results (Montori &

Guyatt, 2001).

2.3.4 Intervention

The overall effectiveness of massage therapy in reducing anxiety for cancer

patients has been demonstrated among the selected studies. After implementing

massage therapy for cancer patients, two of them found that the mean STAI-S scores

have been significantly decreased by >10 (P<0.05) (Ahles, et al., 1999;

Hernandez-Reif, et al., 2004). One study had significant decrease in median HAD

scores by 2 after massage therapy (P≦0.05) (Soden, et al., 2004). Sharp, et al. (2010)

also found that the mean difference of MRS relaxation subscale had significantly

reduced by ≧18 (P≦0.02). Post-White,et al. (2003) showed that the mean difference

of POMS mood disturbance and anxiety subscales had improved by ≧3 significantly

(P≦0.02). In addition, Listing, et al.’s study (2010) calculated the effect size of

BMQ-anxious depression as 0.9 (P<0.05) in the study while Jane, et al.’s study (2011)

got a significant improvement in VAS- relaxation in their study with effect size ≧

0.45 (P≦0.03). Only 2 studies failed to prove the effect of massage in reducing

anxiety (Billhult, et al., 2007; Billhult, et al., 2008). However, the mean change of

17
VAS nausea in Billhult, et al. study (2007) had significantly improved (P=0.025).

Although the STAI-S score in Billhult, et al.’s study (2008) was not significantly

improved, this score from their intervention group had still been greatly reduced.

Small sample size was the major cause for these diverse results, recruiting only 19

(Billhult, et al., 2007) and 11 (Billhult, et al., 2008) participants into each treatment

group in their studies. Small sample size might alter the results caused by

confounding factors such as age and disease prognosis of the participants other than

the effect of the interventions (Gurusamy, et al., 2009). Nevertheless, none of the

studies showed any negative effect of massage therapy on cancer patients.

2.3.5 Type and area of massage used

Majority of the studies (N= 7) used the Swedish technique to implement

massage therapy and five of them showed significant effect in anxiety reduction

(Ahles, et al., 1999; Hernandez-Reif, et al., 2004; Post-White, et al., 2003; Listing, et

al., 2010; Jane, et al., 2011). Swedish massage is the technique of using smooth, long,

rhythmical strokes and gentle kneading of the body. This type of massage is soft and

comfortable enough for cancer patients (Billhult, et al., 2007).

Five studies applied massage over the participants’ whole body and upper part

of body which showed an effective improvement in anxiety level (Hernandez-Reif, et

al., 2004; Ahles, et al., 1999; Post-White, et al., 2003; Listing, et al., 2010; Jane, et al.,

18
2011). However, only one study was conducted in a Chinese country, Taiwan (Jane,

et al., 2011).

2.3.6 Duration and frequency of massage

Majority of the studies (N=6) set the duration of the massage therapy as 20-30

minutes (Soden, et al., 2004; Ahles, et al., 1999; Hernandez-Reif, et al., 2004; Listing,

et al., 2010; Billhult, et al., 2007; Billhult, et al., 2008). Three of the studies (Ahles, et

al., 1999; Hernandez-Reif, et al., 2004; Listing, et al., 2010) showed significant

improvement in anxiety and one of them showed a reduction in the sense of nausea

(Billhult, et al., 2007).

The frequency of massage sessions among the studies was discrete. Some

studies performed massages weekly over 4 to 8 weeks (Soden, et al., 2004; Sharp, et

al., 2010; Post-White, et al., 2003) while some studies performed massages two to

three times weekly over 3 to 5 weeks (Ahles, et al., 1999; Hernandez-Reif, et al.,

2004; Listing, et al., 2010; Billhult, et al., 2008). One study implemented massage

therapy concurrently with chemotherapy for 5 cycles (Billhult, et al., 2007); and one

study performed massage on 3 consecutive days (Jane, et al., 2011).

2.4 Recommendation and conclusion

After summarizing and synthesizing the data from the selected studies, it can

be concluded that massage therapy is proven to be effective in relieving anxiety in

19
cancer patients. As such, it is proposed to implement a massage program in the target

chemotherapy day ward to reduce anxiety in cancer patients receiving chemotherapy.

Swedish massage will be used in the proposed massage program.

Traditionally, Chinese people are less physically expressive than people in

western countries. They might feel as though they are being violated by others due to

excessive physical contact. The studies of Billhult, et al. (2007) and Billhult, et al.

(2008) also stated that participants preferred to receive massage on their foot and

lower leg rather than hand and lower arm if choice was provided. Moreover, patients

in the target center will receive chemotherapy via peripheral vein over their hands and

lower arms. Therefore, foot and lower leg massage is preferred to avoid cancer

patients requiring frequent change in position or feeling uncomfortable with intimate

touch during massage.

20-30 minutes is seen as suitable for the target population since the

administration duration of chemotherapy is 30 minutes. Setting the duration of

massage therapy as 20-30 minutes can minimize a prolonged stay in the day ward for

the target participants. In addition, frequent hospital visits may cause fatigue for

participants and thus affect the outcomes and dropout rate of a massage program.

Therefore, the frequency of massage proposed for the target chemotherapy day ward

will be concurrent with participants’ chemotherapy regimen, which is one session

20
every 3 weeks.

Although all of the studies used self reported questionnaires to measure the

subjective feeling of anxiety for cancer patients, the measuring tools used amongst the

studies varied. Anxiety possesses a multi-dimensional effect that correlates and

affects a person’s mood and quality of life, however, a one-dimensional measuring

tool is preferred to provide a simple, reliable and direct measure for the proposed

innovation (Seligman, et al., 2001). The STAI consists of two 20-items instrument

with a four point Likert Scale to measure current anxiety level (state anxiety), and the

tendency to experience anxiety (trait anxiety) (Spielberger, 1983). The higher score in

STAI indicates the high level of anxiety. The STAI-state portion (STAI-S) is

recommended to measure the current change in anxiety level before and after the

proposed massage therapy. Its reliability and validity have been well proven and the

internal consistency alpha coefficients of the state portion ranged from 0.82 to 0.92

(Spieberger, 1983). In addition, the Chinese version of the STAI-S, as shown in

appendix N, is readily available and its reliability and validity has been well

established (Shek, 1993). Thus, it will be used for the proposed massage program as

the target participants are all Chinese. A detailed evaluation plan will be elaborated in

chapter 4.

In conclusion, it is proposed to implement a massage program, providing a

21
30-minute Swedish massage on foot and lower legs for cancer patients undergoing

each cycle of chemotherapy in a local chemotherapy day ward to relieve their anxiety

and ANV so as to improve their quality of life.

22
 Chapter 3: Translation and Application

The literature review in previous chapters showed that massage therapy is

effective in reducing anxiety for cancer patients receiving chemotherapy. The

implementation potential of this innovation should be examined before it can be

translated and applied to the target local setting (Polit & Beck, 2008).

In this chapter, the transferability and the feasibility of the massage innovation

are examined. The potential risks, benefits and the cost of the proposed program are

analyzed to determine the worthiness of implementation in the target setting.

3.1 Implementation potential

3.1.1 Transferability of the findings

3.1.1.1 Target setting

Massage therapy is proposed to be implemented in a chemotherapy day ward

which is an out-patient setting managed under the Clinical Oncology Department of a

public hospital. Cancer patients must be seen and reviewed by oncologists during

each follow-up to ensure their suitability for each cycle of chemotherapy. Cancer

patients will then be admitted to the day ward on the same day or the day after the

follow-up, if they are suitable for chemotherapy.

The target setting consists of twenty-eight chemotherapy chairs. The proposed

innovation will be implemented on those chairs since massage can be applied to the

23
cancer patient in a seated position, as was the case in three reviewed studies (Billhult,

et al., 2007; Billhult, et al., 2008; Sharp, et al., 2010).

There are six nurses responsible for chemotherapy administration in the

chemotherapy day ward. Due to their heavy workload, it might not be feasible for

them to perform the massage in the proposed program. The cancer patient resource

centre of the target hospital will allocate a total of 25 volunteers. Five volunteers will

stay in the day ward each day to provide counseling for the cancer patients. These

volunteers are also cancer patients who have completely recovered. They are well

trained and qualified with more than 3 years experience on communicating and taking

care of cancer patients. Some of the reviewed studies (Ahles, et al., 1999; Billhult, et

al., 2007; Hernandez-Reif, et al., 2004) recruited self-trained nurse’s aides to perform

massages, resulting in promising outcomes. Therefore, the proposed program will

train volunteers to perform the massage to cancer patients who are waiting for their

chemotherapy in the day ward, under nurses’ supervision.

3.1.1.2 Target audience

Patients from both the reviewed studies and the target setting are cancer patients

including hematology malignancy and solid tumor with or without metastasis.

According to the annual statistics in the target setting, there were 11,692 cancer

24
patients admitted to the target setting with the mean age of 58 last year. This is similar

to those from the reviewed studies that the mean age ranged from 41 to 62.5 years old.

One reviewed study (Jane, et al., 2011) was conducted in Taiwan in which all

participants were Chinese with 76% believed in Buddhism or Taoism. This is also

comparable to the target patients as the majority of them are Chinese and also believe

in Buddhism or Taoism. A descriptive study (Williams, et al., 2010) reported that

massage is one of the complimentary methods for adult cancer patients in Hong Kong

to relieve discomfort caused by chemotherapy. In addition, four reviewed studies

involved participants that were currently receiving chemotherapy (Ahles, et al., 1999;

Billhult, et al., 2007; Jane, et al., 2011; Post-White, et al., 2003). Therefore, the target

patients in the proposed setting have similar characteristics as the patients in the

reviewed studies.

3.1.1.3 Philosophy of care

As the core value of the Hospital Authority is to provide ‘client-centered care’,

healthcare professionals should not only give patients life-saving treatment but also

empower them to regain their health, optimizing their quality of life. Cancer patients

are not merely facing physical distress but they also experience psychological distress

such as anxiety during their chemotherapy treatment (Ahles, et al., 1999; Bullhult, et

al., 2008).

25
 The massage innovation falls within this prevailing philosophy of care. As

cancer patients are seeking alternative ways to improve their quality of life, oncology

nurses have an obligation to ensure cancer patient’s quality of life in their cancer

trajectory. Therefore, both reviewed studies and the target hospital share the same

philosophy of care.

3.1.1.4 Proposed massage intervention

Six reviewed studies used 20 minute to 45 minute Swedish massage showing

significant improvement in reducing cancer patient’s anxiety (Ahles, et al., 1999;

Billhult, et al., 2007; Hernandez-Reif, et al., 2004; Jane, et al., 2011; Listing, et al.,

2010; Post-White, et al., 2003). They believed that Swedish massage with its light

strokes and kneading technique is soft and gentle enough for cancer patients.

Therefore, Swedish massage will be used as the massage technique in the proposed

program.

The waiting time for cancer patients to start chemotherapy infusion after

admission is about 30 minutes to 1 hour in the day ward. Therefore, the duration of

the proposed massage is to be 30 minutes before chemotherapy infusion, to avoid

prolonging the patient’s length of stay.

In the target setting, the total sessions for a majority of chemotherapy treatments

are 4 to 6 sessions. As massage therapy will be given to cancer patients during their

26
second chemotherapy session, a maximum of 5 sessions will be given to each eligible

cancer patient or until their chemotherapy treatment is completed.

The preparation, implementation and evaluation of the proposed innovation will

last for one year. A pilot study will be conducted to assess the feasibility and examine

any difficulties encountered during implementing the program. Details of the pilot

study will be discussed in chapter 4.

3.1.2 Feasibility of the innovation

3.1.2.1 Organizational and administrative support

The administrators of the Clinical Oncology Department include the Chief of

Service (Clinical Oncology), Consultant, Clinical Oncologists, Department Operation

Manager of Clinical Oncology, Nurse Consultant, Ward Manager and the Project

Manager of the cancer patient resource center who supervises the volunteers. The

atmosphere of promoting evidence-based practice in the department is positive. The

Nurse Consultant and the Ward Manager always offer opportunities for staff to attend

conferences to update their professional knowledge. They share the latest research

findings with colleagues and develop evidence-based guidelines for clinical use. As

the target hospital is a teaching hospital of a university in Hong Kong, the

stakeholders are well aware of the importance of evidence-based practices to improve

27
cancer treatment and service for patients. It is foreseeable that such a supporting and

experienced team will give positive support for implementing the proposed program.

3.1.2.2 Frontline staff support

There are a total of 15 nurses, including an advanced practice nurse, registered

nurses and enrolled nurses, being rotated in the outpatient clinics within the

department. These frontline staff have already noted that anxiety is one of the most

common reactions among patients undergoing chemotherapy. They report spending

most of their time reassuring and persuading anxious patients to receive

chemotherapy after their admission. The proposed massage program can reduce

anxiety and thus comfort anxious patients. This will then shorten nurses’ time spent

with the symptomatic patients.

In addition, nurses in the target setting are experienced in implementing

evidence-based practices. They understand and even welcome using new

evidence-based practices and its benefits for patients. The APN of the target setting

also pays due attention to implementing evidence-based practices. She continually

arranges lessons for nurses to update their clinical knowledge and practices related to

oncology care based on literature evidences. For example, she has illustrated the best

practice of central venous catheter care in order to reduce risk of infection last year.

28
All frontline nurses demonstrate supportive attitudes to change of current practices

whenever there is a need.

However, there are two possible factors that may undermine efforts to implement

the proposed massage program. Firstly, nurses need to spend time to attend training

sessions for the massage program during their working hours. It may increase the

workload of the other nurses who remain in the clinic during the training session.

Secondly, the change in current practice may cause stress to nurses because of the

unfamiliar guidelines and workflow of the massage program.

In order to avoid disturbing the daily operation of the out-patient clinics and

chemotherapy day ward during the training sessions, two identical two-hour training

sessions will be held in the conference room of the department. All nurses and the

volunteers recruited will be invited to attend one of the training sessions. Also, the

training sessions will be held on Friday from 3:30 pm to 5:30pm when it is less busy

in all clinics and chemotherapy day ward. The Advanced Practice Nurse, experienced

in performing massage to cancer patients, and the programme coordinator will be

responsible for the trainings. Patient benefits, program logistics, nursing assessment,

evaluation method of the innovation and the massage guideline will all be introduced

in the training programme. In order to minimize nurses’ workload, it will be explained

that they are only required to perform the assessment, using a self-designed

29
assessment form, and supervise the volunteers who perform the massage. Details of

the training sessions will be explained in Chapter 4.

Furthermore, a working group including 1 advanced practice nurse and 6 senior

registered nurses (RNs) will be established to organize, implement and evaluate the

massage program. The working group will supervise nurses and the trained volunteers,

and monitor the progress of the massage program. All nurses will be welcome to

consult the working group if they have any query during the implementation period to

minimize their stress due to this unfamiliar massage program.

3.1.2.3 Volunteers’ support

Massagists for the proposed program will be chosen from the volunteer staff at

the Patient Resource Center. The goal of the center is to ensure the best-possible

service towards optimizing cancer patients’ quality of life. The center’s manager and

the volunteers are supportive of utilizing evidence-based practices in their services. It

is their common practices to organize evidence-based workshops such as peer support

groups and role playing for cancer patients. This is intended to provide psychological

support and to strengthen their self care ability. They are also familiar with

introducing some complimentary methods, with evidence support, to cancer patients

in order to relieve physical discomfort.

30
 One element of concern stems from the fact that these volunteers are all cancer

patients who have completely recovered. Acting as the massagists in this program

may become physically demanding to the volunteers. Therefore, discussions will be

held with the project manager to invite eligible volunteers to join the massage

program. Ten volunteers will be recruited and trained. During the implementation

period, volunteers will only need to perform not more than 2 massages each day to

prevent overwhelming them. A detailed implementation plan will be described in

Chapter 4.

A further source of potential stress for volunteers may result from being

unfamiliar with the massage technique. Therefore, it will be guaranteed that training

will be given before implementing the program and that nurses will supervise them

during the massage intervention. Furthermore, regular meetings with nurses and

volunteers will be conducted for sharing opinions and raising concerns so that any

difficulties can be tackled in advance.

3.1.3 Cost/Benefit ratio of the program

3.1.3.1 Potential risks

All nine reviewed studies claimed that massage therapy is a safe treatment with

no adverse effects reported. Moreover, there is no evidence that massage therapy can

spread cancer from its local region to distal body area (Corbin, 2005). Swedish

31
massage is relatively safe when compared to other vigorous massages such as deep

body massage which might cause fracture, haematoma and pulmonary embolism

(Ernst, 2003). Even though complications related to Swedish massage is rare, the

possibility of developing bruising, hematoma and pain cannot be ignored (Corbin,

2005). Therefore, training for identifying and managing possible complications

should be given to nurses. Nursing assessment is also essential to exclude cancer

patients with contraindication such as coagulation disorder and deep vein thrombosis

from participating in the program (Billhult, et al., 2007; Post-White, et al., 2003). The

evidence-based guideline for massages will act as a reference for implementing the

program. Trained volunteers are also required to report to the core members promptly

when patients have any discomfort during massage.

Medical involvement in excluding high risk patients from the program is

essential to minimize risks for cancer patients receiving massage. The Oncologist’s

approval for patients to receive massage therapy should be obtained during the

patient’s follow-up for the second cycle of chemotherapy. Medical support from

oncologists is also required for managing any massage-related complications during

the implementation period. Therefore, a meeting will be arranged with all oncologists

in the department to introduce this program to them. Seeking their support is

32
necessary for identifying eligible patients for this program and managing patients with

massage-related complications, should these occur.

3.1.3.2 Potential benefits

As previously stated, massage therapy can greatly improve both physical and

psychological distress (Corbin, 2005). A nonrandomized study (Grealish, et al., 2000)

reported that even a 10 minute leg massage immediately improved pain, nausea and

anxiety in cancer patients. Physiologically, Field (1998) found that massage can

trigger the release of some hormones and neurotransmitters, leading to improvement

in mood, severity of nausea and sleeping quality. With improvement in these physical

symptoms, and hence quality of life, cancer patients are likely to complete

chemotherapy treatment as planned without delaying or terminating unnecessarily

(Corbin, 2005).

There is an increase in cancer patients seeking information about massage

therapy to relieve treatment-related discomfort. Implementing this program would

enrich nurse’s professional knowledge about massage and by doing so nurses can

provide a means for cancer patients to consider the information. With the target

setting being able to provide a qualified massage service for cancer patients, this will

enhance both holistic patient care and nurses’ job satisfaction.

33
 As massage therapy can be performed by nurses, volunteers and family members

(Reaves & McManis, 2010). If this program can be proved as effective in reducing

anxiety, nurses can teach patient’s families to perform massage for cancer patients

themselves. Consequently, cancer patients can receive massages at home more

frequently and therefore, better control the patient’s discomfort. Rapport between

nurses, patients and their family members can also be enhanced from this interaction.

Although implementing the program may induce extra workload for nurses, their

effort in managing patients with anticipatory nausea and vomiting will then be

inversely lower if patient’s anxiety level is reduced by the massage program.

From observation, there are approximately half of the cancer patients admitted to

the day ward behave anxiously. Considering 20% of these patients are eligible and

willing to participate in this program, it is estimated that there will be 1,169 cancer

patients benefiting from this program every year.

3.1.3.3 Cost

Without effective intervention, cancer patients experiencing severe nausea and

vomiting due to chemotherapy may suffer from dehydration or electrolyte imbalance.

It may lead to not only delaying their chemotherapy treatment but also being admitted

to the day ward or even to the in-patient unit for rehydration or electrolyte supplement.

This causes extra admission and medical treatments for the patients during their

34
treatment period, increasing medical expenses for cancer patients. As cancer patients

are required to pay an additional $150 for every extra admission, this may increase the

patients’ financial burden, on top of their current medical costs.

During patients’ follow-up, if they feel nervous about chemotherapy or their

nausea and vomiting was poorly controlled in the previous admission, doctors may

add a potent anti-emetic, i.e. the 5-HT3-receptor antagonist on top of the usual

anti-emetics. Yet, these strong anti-emetics such as Navoban are relatively expensive

($63.5/tablet) when compared with the commonly used anti-emetics such as Maxolon,

($0.08/tablet). These potent anti-emetics also carry more side effects. If implementing

the massage program reduces patient’s anxiety and decreases their severity of nausea

and vomiting, then the use of such costly anti-emetics will be lowered. If the use of

those potent anti-emetics can even be reduced by 20% among the patients in the

massage program, the medication expense can be greatly reduced. The estimated

expense that can be saved is calculated in appendix I. It is estimated that $57,000 will

be saved on the use of potent anti-emetics after cancer patients join the massage

program.

On the other hand, implementing the massage program will bear some material

costs. However, these costs will be limited to stationery and massage oil since

audio-visual aids and the conference venue are already available at the target setting.

35
Assuming that there will be 1,100 cancer patients joining the massage program a year,

the estimated annual budget for running the program will be $12,000. A detailed

budget plan is listed in Appendix J.

The necessary training and preparation for this massage program will require

extra expenditures from the department. However, considering the patient benefits

and the long term cost saved from using costly anti-emetics, it is worth to implement

the massage program in the target setting.

36
 Chapter 4: Evidence-Based Practice Guideline

The evidence-based practice (EBP) guideline is developed based on the literature

review conducted in the previous chapter. It provides structural and clear information

for nurses on the use of massage on adult cancer patients receiving chemotherapy to

reduce anxiety in the target hospital. The level of evidence and recommendations

extracted from the nine RCTs are graded according to the Scottish Intercollegiate

Guideline Network (SIGN, 2008), as shown in appendix E and K respectively. A

working group will be formed to include Clinical Oncologists, the Nurse Consultant

and the Ward Manager to develop and review the guideline regularly to ensure its

quality and applicability. The aim, objectives, target population and recommendations

are extracted and shown below. A detailed EBP guideline is available in appendix L.

4.1 Aim

The aim of this guideline is to implement feasible and effective massage

interventions to reduce anxiety for cancer patients receiving chemotherapy in an

outpatient clinic setting.

4.2 Objectives

To provide a consistent framework for implementation of safe and effective massage

therapy to cancer patients to reduce their anxiety from receiving chemotherapy.

37
4.3 Target population

The massage therapy is applicable to both male and female adult cancer patients

who are receiving chemotherapy in the chemotherapy day ward.

Inclusive criteria

- Aged 18 or above

- Cantonese- and Mandarin-speaking patients who are able to read Chinese.

- Cognitively competent

Exclusive criteria

- Coagulation disorder

- Spinal cord injury

- Venous thrombosis

- Bone metastasis

- Peripheral neuropathy

- Radiation dermatitis

- Open wound over lower limbs

38
4.4 Recommendations

Recommendation 1.0

Nursing assessment should be performed to exclude high risk patients from

joining the massage program. (Grade of recommendation: A)

Patients with medical conditions including coagulation disorder, spinal cord

injury, thrombosis, bone metastasis, peripheral neuropathy, radiation dermatitis and

open wound over lower limbs are excluded from receiving massage in four of the

reviewed RCTs(Hernandez-Reif, et al., 2004; Jane, et al., 2011; Sharp, et al., 2010;

Listing, et al., 2010). This is necessary as these conditions may heighten the risk of

massage complications such as neuropathy damage, hematoma, bleeding and

dislodging of deep venous thrombosis causing embolism (Hernandez-Reif, et al,

2004; Jane, et al., 2011; Sharp, et al., 2010; Listing, et al., 2010) (1++; 1++; 1++;

1+).

Recommendation 2.0

Swedish massage is recommended to perform on patient’s lower limbs.

(Grade of recommendation: A)

No complication such as fractures, dislocations, nerve damage and pulmonary

embolism were reported from participants in seven reviewed RCTs which used

Swedish massage as their intervention. (Ahles, et al., 1999; Billhult, et al., 2007;

39
Billhult, et al., 2008; Hernandez-Reif, et al., 2004; Jane, et al., 2011; Listing, et al.,

2010; Post-White, et al., 2003). (1+; 1+; 1-; 1++; 1++; 1+; 1+)

Recommendation 3.0

The duration of massage therapy is recommended as 30 minutes. (Grade of

recommendation: A)

Six reviewed studies used 20-30 minute massage and five of them reported to

have positive effects in reducing level of anxiety and sense of nausea for cancer

patients (Ahles, et al., Billhult, et al., 2007; Billhult, et al., 2008; Hernandez-Reif,

et al., 2004; Listing, et al., 2010; Soden, et al., 2004). The immediate short-term (30

min) benefits of massage therapy is well proved to reduce anxiety for cancer

patients (Hernandez-Reif, et al., 2004; Listing, et al., 2010; Soden et al., 2004).

(1++; 1+; 1- )

Recommendation 4.0

The State-Trait Anxiety Inventory (STAI-S) measuring tool should be used to

measure the patient’s level of anxiety before and after the massage so as to

evaluate the effectiveness of this massage program. (Grade of

recommendation: A)

Five reviewed RCTs used one-dimensional self assessment tools to measure the

subjective feeling of anxiety for cancer patients (Ahles, et al., 1999; Billhult, et al.,

40
2007; Bullhult, et al., 2008; Hernandez-Reif, et al., 2004; Jane, et al., 2011). Three

of them used STAI-S assessment tool to measure anxiety level for cancer patients

and resulted in decrease in their anxiety level (Ahles, et al., 1999; Billhult, et al.,

2008; Hernandez-Reif, et al., 2004). STAI-S is a valid and reliable

one-dimensional assessment tool that is short and easy for cancer patients to

complete. (1+; 1-; 1++)

41
 Chapter 5: Implementation Plan

An implementation plan is essential to facilitate communication and the

realization of the massage innovation into the target setting. This chapter will

illustrate a detailed communication, execution and evaluation plan for the massage

program for cancer patients receiving chemotherapy in the target setting.

5.1 Communication plan

Communication enhances dissemination of information about the

innovation among the stakeholders who are the key persons affecting the success of

the program (Burns and Grove, 2005). A good communication plan is needed in order

to give stakeholders a better understanding of and support for the innovation. The

stakeholders of this program would include the hospital administrators, frontline

nurses, cancer patients, and volunteers and the manager from the patient resource

centre.

5.1.1 Identifying stakeholders

The Chief of Service (Clinical Oncology), the Department Operation Manager

(DOM), the Nurse Consultant and the Ward Manager are the key administrators. They

have the authority to endorse guidelines and interventions used in the target setting.

Their approval must be obtained before implementing this massage program.

Therefore, the aims, benefits and costs of this program will be explained to them

42
through meetings and emails to gain their support. In addition, they will be consulted

for opinions to revise the guidelines as necessary, given their rich experiences in

implementing new programs in the target setting.

Clinical oncologists are responsible for assessing eligibility of cancer patients to

ensure the appropriate patients are selected to receive massage therapy. They will also

provide medical support if patients develop any adverse effects due to massage

therapy such as muscular pain and shortness of breath. Therefore, a meeting with all

10 oncologists will be held to explain the aims and benefits of this massage program.

The frontline nurses will conduct and supervise this massage program while the

volunteers, supervised by their manager from the patient resource centre will perform

the massage interventions. Briefing sessions will be held to explain the purpose of this

innovation to the nurses, manager and the volunteers of the resource centre in order to

gain their support. Training will be provided for the nurses and volunteers with

regards to the knowledge and skills about massage. Details of the briefing and the

training sessions will be described in a later section.

5.1.2 Formation of a working group

A working group will be established to facilitate propagation of information

about this massage program to different stakeholders effectively. The group will be

comprised of an advanced practice nurse (APN), who is familiar with massage and

43
responsible for the training sessions, and six senior registered nurses, including the

program coordinator. This group will be responsible for organizing, executing and

evaluating the massage program. They will develop and help revising the EBP

massage guidelines. They will monitor and provide knowledge and skills support for

frontline nurses and volunteers when needed during the implementation period.

5.1.3 Communication process

The communication process will begin with the Ward Manager and the Nurse

Consultant, who are responsible to review new nursing guidelines and innovations

within the department. A meeting will be held with them so that their concern can be

considered and tackled in advance. The working group will convey that anxiety is the

common clinical problem identified among cancer patients receiving chemotherapy.

After that, the evidence-based massage programme will be introduced as a solution to

minimize anxiety in those cancer patients. Training of the nurses and volunteers will

also be discussed. The ward manager and nurse consultant will then be invited to give

their advice about the innovation, and the working group will revise the logistics of

the program accordingly. After gaining the initial support from these key personnel,

the idea of this innovation can then be further disseminated to other stakeholders.

The objectives of this innovation will then be explained in a formal presentation

to others administrators including the Chief of Service, DOM and oncologists. The

44
presentation will clearly elaborate the current situation of patients’ anxiety during

chemotherapy. The benefits of massage will be explained with literature evidence

provided. Their concerns and comments will be used to refine the innovation further.

Communication with the frontline nurses is essential as they are the key persons

who will conduct and monitor the massage program. A briefing session will be held to

disseminate the details of the innovation by the program coordinator in the conference

room of the department. The aim and benefits of the proposed program will be

explained. Its workflow will be elaborated and their concerns will be considered in

order to refine the programme.

The manager of the patient resource centre will also be invited to join the nurses

meeting. This will promote communication between them and assist in selecting

eligible volunteers to join the program. As the volunteers are all cancer survivors, the

selection of eligible volunteers will be based on their medical conditions. This is done

to avoid overwhelming them physically due to performing massage intervention. The

selected volunteers will then join other nurses in the training sessions to learn the

details of the massage program. Ten volunteers will then be recruited into this

programme and arranged for the training.

In order to implement the program seamlessly and effectively, a timetable

(appendix M) is stipulated.

45
5.2 Staff training program

Before implementing the innovation, two identical two-hour training sessions

will be held in the conference room of the department every Friday from 3:30 pm to

5:30pm. All nurses working in the chemotherapy day ward and the volunteers

recruited will need to attend one of the training sessions. The APN, having rich

clinical experience and knowledge in performing massage to cancer patients, will hold

the training sessions. Theory, technique and benefits of massage will be explained.

The logistics of the program, nursing assessment, evaluation plan and the massage

guidelines will also be elaborated upon. At the end of the training session, both nurses

and volunteers will be asked to demonstrate the massage technique to the APN. A

checklist designed by the working group will be used for assessing their skills in order

to ensure the quality of the massage technique.

5.3 Delivery of intervention

Posters about the program will be placed on the notice board in the

chemotherapy day ward. A leaflet with details of the massage program will be given

to every patient during their admission. If the patients wish to join this program, nurse

will check their eligibility according to the inclusion criteria documented in the

evidence-based guideline. If the patients are eligible, nurse will fill in part 1 of the

assessment form (Appendix N) and file it in the patient’s kardex. Further assessment

46
for eligibility will be performed by oncologists during their second follow up. This is

to ensure no hidden or recently developed illnesses such as venous thrombosis that are

contraindicated to the massage program. Patients will join the massage program only

after getting approval from the oncologists. Then, a 30-minute massage session will

be performed every 3 weeks on the same day when patients return for chemotherapy.

A maximum of 5 massage sessions will be given.

After getting approval from the oncologists, nurses will complete part 3 of the

assessment form when the patients are admitted to the chemotherapy day ward. They

will explain the procedure of massage to the patients and obtain their informed

consent. Patients will be asked to complete the pre-massage form on measuring their

level of anxiety, nausea and vomiting. Nurses will then supervise the trained

volunteers to perform massage and monitor the patient’s condition during the

intervention. Immediately following the massage therapy, the same measurement will

be collected from patients again. Nurses will document on patients’ kardex if they

develop discomfort during the massage therapy.

5.4 Pilot study

A pilot study should be conducted to test the feasibility and the logistics of this

massage program so as to identify any difficulties related to implementing the

program. It is proposed to conduct a pilot test in the chemotherapy day ward with 10

47
cancer patients or setting the pilot period for one month, whichever is achieved first.

The trained nurses and volunteers who will work in the day ward during the pilot

period will be responsible for conducting the pilot test. Meetings with the nurses and

volunteers will be conducted to share their opinions and difficulties encountered at the

end of the pilot study period. Revision and refinement of the program will then be

made before the full-scale implementation of this program.

5.5 Ongoing monitoring of the massage program

The working group will monitor the entire innovation process continuously to

ensure the massage program is properly implemented in the target setting. Meetings

with nurses and volunteers will be arranged every 3 months to share their insights on

the massage program. Revisions will be made accordingly.

5.6 Evaluation plan

To determine if the innovation achieves its objectives or not, an outcome

evaluation must be performed.

5.6.1 Identifying outcomes

Anxiety level among cancer patients receiving chemotherapy is set as the

primary patient outcome of this massage program. Patients’ pre and post-massage

anxiety level will be measured by using the Chinese version of State Trait Anxiety

Inventory-State (STAI-S) which is a reliable and validated tool measuring current

48
change in anxiety level (Spieberger, 1983). STAI-S was also used by the reviewed

studies to verify the effect of massage in reducing anxiety among cancer patients

(Ahles, et al., 1999; Hernandez, et al., 2004; Bullhult, et al., 2007).

The secondary patient outcome will be the change in severity of nausea and

vomiting for patients during the course of massage therapy. A Numerical rating scale

(NRS), rating from 0 to 10, will be used to measure both the severity of nausea and

vomiting. 0 represents an absence of nausea and vomiting while 10 is an extreme

level of the symptoms. This is a common self-reporting measure to quantify

subjective feelings with established reliability and validity (Ahles,et al., 1999;

Post-White, et al., 2003). Since anxiety is proven to be highly associated with

anticipatory nausea and vomiting, measuring the severity of nausea and vomiting can

also determine whether the massage program achieves its intended effect (Morrow, et

al., 1998).

A successful massage program requires target patients, volunteers and frontline

nurses to accept and participate in this so that it can be developed and implemented

effectively. Therefore, their satisfaction will be measured after the last session of

massage using a 4-point Likert Scale survey. For the patients who have discontinued

treatment prior to the fifth massage session, the survey will be mailed to them in order

to obtain their score of satisfaction.

49
 5.6.2 Nature and number of clients to be involved

Target patients of this program are adult cancer patients including hematology

malignancy and solid tumor with or without metastasis. The eligibility criteria will be

cancer patients; aged 18 or above; Cantonese- or Mandarin-speaking patients who are

able to read Chinese; and cognitively competent and being admitted to the

chemotherapy day ward receiving chemotherapy. Patients with medical conditions

such as coagulation disorder and bone metastasis will be excluded from the massage

program (Hernandez, et al., 2004; Jane, et al., 2011; Sharp, et al., 2010).

In order to determine whether the anxiety level of cancer patients will be reduced

or not after receiving the massage interventions, an adequate sample size is required.

The number of patients is calculated using the one-sample t test analysis (Russ Lenth,

2009). Taking references from the reviewed studies, a mean difference of 5 between

pre- and post-test on the STAI-S score and a standard deviation of 13 will be used to

calculate the sample size required (Ahles, et al., 1999; Hernandez, et al., 2004). A

paired t test with alpha as 0.05 and power 80% are used. It is assumed that there will

be a 5% drop out rate due to change in patients’ severity of illness causing

discontinuation of chemotherapy and early withdrawal from the massage program.

Therefore, the number of patients required for joining the program is 60. It is

50
estimated to take six months to recruit 60 cancer patients and have them completed a

maximum of 5 massage sessions.

5.6.3 Data collection and data analysis

The massage sessions will be conducted every 3 weeks during their

chemotherapy treatment. A total of five measurements in pre- and post-massage

STAI-S will be obtained. STAI-S form is a 20-item inventory with each item

measured on a 1-4 numeric rating scale scored from 20-80. The higher the STAI-S

score means the higher the anxiety level of the patients. Since the reviewed studies

reported that massage has an immediate effect on reducing anxiety for cancer patients,

STAI-S scores will be measured immediately before and after each session of

massage (Ahles, et al., 1999; Hernandez, et al., 2004; Listing, et al., 2010; Post-White,

et al., 2003; Sharp, et al., 2010; Soden, et al., 2004).

The Statistical Package for Social Sciences (SPSS) version 17.0 will be used to

analyze the data. Descriptive statistics will be used to summarize patients’

demographic data. The mean STAI-S scores will be generated at each time of

measurement. Two-tailed paired t-test will be used to analyze the STAI-S scores

obtained to determine if the massage program can significantly decrease patients’

level of anxiety or not.

51
 To evaluate the change in severity of nausea and vomiting during the course of

massage, patients will be asked to grade their feeling of nausea and vomiting by using

NRS (0-10) at 0, 15 and 30 minutes after starting the massage intervention. The mean

scores of NRS-nausea and NRS-vomiting at each time point will be generated

respectively and presented by mean, mean difference and standard deviation using

two-tailed paired t-test.

The satisfaction level of patients, volunteers and nurses towards receiving or

delivering the intervention will be measured using a 4-point Likert scale survey

(4=totally satisfied; 3=satisfied; 2=dissatisfied; 1=totally dissatisfied). The mean

satisfaction score will be calculated and compared.

5.6.4 Basis for an effective change of practice

The massage program will be considered as effective if there is a statistically

significant decrease in patients’ STAI-S score, NRS-nausea and NRS-vomiting after

each massage session with a p-value less than 0.05.

Moreover, if the mean scores of the satisfaction level among patients, volunteers

and nurses are greater than 2, the massage program will be considered successful.

52
 Chapter 6: Conclusion

Cancer patients are experiencing high levels of psychological and

physiological distress during chemotherapy treatment. Of these patients, anxiety is the

most commonly reported symptom from the target population in a local chemotherapy

day ward. It has also been demonstrated that elevated anxiety increases the severity of

chemotherapy side effects, anticipatory nausea and vomiting, thus, impairing cancer

patients’ quality of life to a greater extent. Massage is one of the common CAM that

is effective in reducing anxiety for cancer patients, non-pharmacologically.

After summarizing and synthesizing the data from the 9 reviewed studies, a 30

minute Swedish massage on the lower legs is suggested to be performed on cancer

patients during each cycle of chemotherapy to reduce their anxiety.

An evidence-based guideline on implementing massage therapy for cancer

patients undergoing chemotherapy was set to ensure patient safety and increase

effectiveness in executing the massage program. A detailed implementation plan was

developed to gain support from the stakeholders in the target chemotherapy day ward.

Also, an evaluation plan was designed to assess the effectiveness of this program.

Patients’ level of anxiety, nausea and vomiting will be evaluated. Satisfaction of

patients, volunteers and nurses will also be measured to determine whether the

program can be implemented and developed effectively.

53
 It is hoped that this massage program can be realized and implemented in the

target clinical setting in the future. If so, this program should lead to a significant

improvement in relieving anxiety for cancer patients receiving chemotherapy.

Ultimately, this can result in a better quality of life for cancer patients in Hong Kong.

54
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 Appendix A: Search history

Database 1: Medline (OvidSP) (1946 to July Week 3 2012)

Date of search: 29th July 2012

Search keywords Results

1. Cancer.mp. or Neoplasms/ 893322
2. Oncology.mp. 50794
3. Carcinoma.mp . 535241
4. Malignancy.mp. 77770
5. Chemotherapy.mp. 258505
6. Massage.mp. 9816
7. Complementary therapies.mp. or Complementary Therapies 13047
8. Alternative therapies.mp . 2579
9. Alternative medicine.mp. 4871
10. Anxiety/ or Anxiety Disorders/ or anxiety.mp. 125830
11. Psychological discomfort.mp. 148
12. Relaxation.mp. 77684
13. Mood disturbance.mp. 888
14. Anticipatory nausea.mp. 170
15. Anticipatory vomiting.mp. 29
16. 1 or 2 or 3 or 4 1467032
17. 6 or 7 or 8 or 9 24872
18. 10 or 11 or 12 or 13 or 14 or 15 214267
19. 16 and 5 and 17 and 18 49

Results

Total journals yielded= 49

Limited electronically to English, Full text & RCT= 13
Manual screened under inclusion and exclusion criteria= 8

64
Database 2: CINAHL PLUS (EBSCOHost) (1967 to 2012)

Date of search: 29th July 2012

Search ID # Search Terms Results

S1 Cancer 27396
S2 Neoplasms 33609
S3 Oncology 4411
S4 Carcinoma 5225
S5 Malignancy 958
S6 Chemotherapy 4320
S7 Massage 731
S8 Complementary therapies 316
S9 Alternative therapies 3953
S10 Alternative medicine 921
S11 Anxiety 9437
S12 Anxiety disorders 2029
S13 Psychological discomfort 17
S14 Relaxation 1331
S15 Mood disturbance 101
S16 Anticipatory nausea 12
S17 Anticipatory vomiting 11
S18 S16 or S17 14
S19 S1 or S2 or S3 or S4 or S5 45559
S20 S7 or S8 or S9 or S10 4741
S21 S11 or S12 or S13 or S14 or S15 or S18 12701
S22 S19 and S6 and S20 and S21 14

Results

Total journals yielded= 14

Limited electronically to English, Full text, RCT = 10
Manual screened under inclusion and exclusion criteria= 1
Discarded duplicated studies= 0

65
Database 3: British Nursing Index (ProQuest)

Date of search: 30th August, 2012

Set Search Results

S1 Cancer 12441
S2 Neoplasms 11
S3 Oncology 3153
S4 Carcinoma 148
S5 Malignancy 104
S6 Chemotherapy 1332
S7 Massage 436
S8 Complementary therapies 1536
S9 Alternative therapies 2788
S10 Alternative medicine 1092
S11 Anxiety 1925
S12 Anxiety disorders 512
S13 Psychological discomfort 8
S14 Relaxation 282
S15 Mood disturbance 24
S16 Anticipatory nausea 9
S17 Anticipatory vomiting 5
S18 16 or 17 9
S19 1 or 2 or 3 or 4 or 5 12627
S20 S7 or S8 or S9 or S10 2437
S21 S11 or S12 or S13 or S14 or S15 or S18 2649
S22 S19 and S6 and S20 and S21 13

Results

Total journals yielded= 13

Manual screened under inclusion and exclusion criteria= 1

Discarded duplicated studies= 0

66
Database 4: The Cochrane Library (ProQuest)

Date of search: 30th August, 2012

ID Search Hits
#1 (Cancer): ti,ab,kw 5732
#2 (Neoplasms): ti,ab,kw 38865
#3 (Oncology): ti,ab,kw 813
#4 (Carcinoma): ti,ab,kw 8898
#5 (Malignancy): ti,ab,kw 26
#6 (Chemotherapy): ti,ab,kw 13891
#7 (Massage): ti,ab,kw 909
#8 (Complementary therapies): ti,ab,kw 359
#9 (Alternative therapies): ti,ab,kw 63
#10 (Alternative medicine): ti,ab,kw 78
#11 (Anxiety) : ti,ab,kw 9584
#12 (Anxiety disorders): ti,ab,kw 3588
#13 (Psychological discomfort): ti,ab,kw 0
#14 (Relaxation): ti,ab,kw 2289
#15 (Mood disturbance): ti,ab,kw 2
#16 (Anticipatory nausea): ti,ab,kw 121
#17 (Anticipatory vomiting): ti,ab,kw 138
#18 (#16 OR #17) 187
#19 (#1 OR #2 OR #3 OR #4 OR #5) 68502
#20 (#7 OR #8 OR #9 OR #10) 1112
#21 (#11 OR #12 OR #13 OR #14 OR #15 OR #18) 19434
#22 (#6 AND #19 AND #20 AND #21) 54

Results

Total journals yielded= 54

Limited electronically to English, Full text & RCT= 20

Manual screened under inclusion and exclusion criteria= 4
Discarded duplicated studies= 0

67
Database 5: The PsycINFO database (1800s to 2012)

Date of search: 3rd August, 2012

Set Search Results

S1 Cancer 46704
S2 Neoplasms 27785
S3 Oncology 10658
S4 Carcinoma 1051
S5 Malignancy 1108
S6 Chemotherapy 3418
S7 Massage 1010
S8 Complementary therapies 2681
S9 Alternative therapies 11995
S10 Alternative medicine 10578
S11 Anxiety 157408
S12 Anxiety disorders 88889
S13 Psychological discomfort 1798
S14 Relaxation 13090
S15 Mood disturbance 3741
S16 Anticipatory nausea 137
S17 Anticipatory vomiting 108
S18 16 or 17 145
S19 1 or 2 or 3 or 4 or 5 52757
S20 S7 or S8 or S9 or S10 21200
S21 S11 or S12 or S13 or S14 or S15 or S18 179486
S22 S19 and S6 and S20 and S21 33

Results

Total journals yielded= 33

Limited electronically to English and adulthood (18 Yrs & Older) = 20
Manual screened under inclusion and exclusion criteria= 3
Discarded duplicated studies= 1

68
 Appendix B: Summary of search results

Medline CINAHL British The The

PLUS Nursing Cochrane PsycINFO

Index Library database

Electronic search by 49 14 13 54 33

keywords

Limited electronically to 13 10 1 20 20

English, adulthood and RCT

Manual screened under 8 1 0 4 3

inclusion and exclusion

criteria

Discarded duplicated studies 8 0 0 0 1

RCTs identified 8 0 0 0 1

69
 Appendix C: List of selected studies

1. Ahles, T. A., Tope, D. M., Pinkson, B., Walch, S., Hann, D., Whedon, M., Dain,

B., Weiss, J. E., Mills, L.& Silberfarb, P. M. (1999). Massage Therapy for

Patients Undergoing Autologous Bone Marrow Transplantation. Journal of Pain

and Symptom Management, 18(3), 157-163.

2. Billhult, A., Bergbon, I. & Stener-Victorin, S. (2007). Massage Relieves Nausea

in Women with Breast Cancer Who Are Undergoing Chemotherapy. The Journal

of Alternative and Complementary Medicine, 13(1), 53-57.

3. Billhult, A., Lindholm, C., Gunnarsson, R. & Stener-Victorin, E. (2008). The

effect of massage in cellular immunity, endocrine and psychological factors in

women with breast cancer- A randomized controlled clinical trial. Autonomic

Neuroscience: Basic and Clinical, 140, 88-95.

4. Hernandez-Reif, M., Ironson, G., Field, T., Hurley, J., Katz, G., Diego, M., Weiss,

S., Fletcher, M. A., Schanberg, S., Kuhn, C. & Burman, I. (2004). Breast cancer

patients have improved immune and neuroendocrine functions following massage

therapy. Journal of Psychosomatic Research, 57, 45-52.

5. Jane, S. W., Chen, S. L., Wilkie, D. J., Lin, Y. C., Foreman, S. W., Beaton, R. D.,

Fan, J. Y., Lu, M. Y., Wang, Y. Y., Lin, Y. H. & Liao, M. N. (2011). Effects of

massage on pain, mood status, relaxation, and sleep in Taiwese patients with

70
 metastatic bone pain: A randomized clinical trial. The Journal of the

International Association for the Study of Pain, 152, 2432-2442.

6. Listing, M., Krohn, M., Liezmann, C., Kim, I., Reisshauer, A., Peters, E., Klapp,

B. F. & Rauchfuss, M. (2010). The efficacy of classical massage on stress

perception and cortisol following primary treatment of breast cancer. Archives of

Womens Mental Health, 13, 165-173.

7. Post-White, J., Kinney, M. E., Savik, K., Gau, J. B., Wilcox, C. & Lerner, I.

(2003). Therapeutic Massage and Healing Touch Improve Symptoms in Cancer.

Integrative Cancer Therapies, 2(4), 332-344.

8. Sharp, D. M., Walker, M. B., Chaturvedi, A., Upadhyay, S., Hamid, A., Walker,

A. A., Bateman, J., Braid, F., Ellwood, K., Hebblewhite, C., Hope, T., Lines, M.

& Walker, L. G. (2010). A randomized, controlled trial of the psychological

effects of reflexology in early breast cancer. European Journal of Cancer, 46,

312-322.

9. Soden, K., Vincent, K., Craske, S., Lucas, C. & Ashley, S. (2004). A randomized

controlled trial of aromatherapy massage in a hospice setting. Palliative Medicine,

18, 87-92.

71
 Appendix D: RCTs checklist
CRITICAL APPRAISAL SKILLS PROGRAMME (CASP)
Making sense of evidence
10 questions to help you make sense of a
randomised controlled trial

General comments

 Three broad issues need to be considered when appraising research.

A. Are the results of the study valid?

B. What are the results?

C. Will the results help locally?

The questions on the following pages are designed to help you think
about these issues systematically.

 The first two questions are screening questions and can be answered
quickly. If the answer to both is "yes", it is worth proceeding with the
remaining questions.

 There is a degree of overlap between several of the questions.

 You are asked to record a "yes", "no" or "can't tell" to most of the
questions.

 A number of italicised hints are given after each question. These are
designed to remind you why the question is important.

 These questions are adapted from: Guyatt GH, Sackett DL and Cook
DJ. Users’ guide to the medical literature II. How to use an article about
therapy or prevention. JAMA; 1993; 270(21): 2598-2601 and JAMA
1994; 271(1): 59-63

72
A. Are the results of the study valid?
Screening Questions

1. Did the study ask a clearly focused research question?

Consider: if the research question in ‘focus’ in terms of :
- The population studied
- The intervention given
- The outcomes considered
2. Was this a randomized controlled trial (RCT) and was that an appropriate
design?
Consider:
- Why was this study was carried out as an RCT
- If this was the right research approach for the question being asked

Is it worth continuing?
------------------------------------------------------------------------------------------------------

Detailed questions

3. Did the reviewers try to identify all relevant studies?

Consider:
- How participants were allocated to intervention and control groups. Was
the process truly random?
- Whether the method of allocation was described. Was a method used to
balance the randomization, e.g. stratification?
- How the randomization schedule was generated and how a participant was
allocated to a study group?
- If the groups were well balanced. Are any differences between the groups at
entry to the trial reported?
- If there were differences reported that might have explained any outcome(s)
(confounding)
4. Were the participants, staff and study personnel ‘blind’ to participants’
study group?
Consider:

- The fact that blinding is not always possible

- If every effort was made to achieve blinding

73
 - If you think it matters in this study

- The fact that we are looking for ‘observer bias’

5. Were all of the participants who entered the trial accounted for at its
conclusion?
Consider:

- If any intervention-group participants got a control-group option or vice

versa?
- If all participants were followed up in each study group (was there
loss-to-follow-up)?
- If all the participants’ outcomes were analysed by the groups to which
they were originally allocated (intention to treat analysis)
- What additional information would you like to have seen to make you
feel better about this?
6. Were the participants in all groups followed up and data collected in the
same way?
Consider:

- If, for example, they were reviewed at the same time intervals and if they
received the same amount of attention from researchers and health
workers. Any differences may introduce performance bias.

7. Did the study have enough participants to minimise the play of chance?
Consider:
- Is there a power calculation. This will estimate how many participants
are needed to be reasonably sure of finding something important (if it
really exists and for a given level of uncertainty about the final result)

B. What are the results?

74
8. How are the results presented and what is the main result?
Consider:

- If, for example, the results are presented as a proportion of people

experiencing an outcome such as ‘risk’ or as a measurement such as mean
or median differences, or as survival curves and hazards.
- The magnitude of the results and how meaningful they are.
- How you would sum up the ‘bottom-line’ result of the trial in one
sentence?

9 How precise are the results?

Consider:

- If the result is precise enough to make a decision

- If a confidence interval was reported. Would your decision about the
effectiveness of this intervention be the same at the upper confidence limit
as the lower confidence limit?
- If a p-value is reported where confidence intervals are unavailable?

C. Will the results help locally?

10. Were all the important outcomes considered so the results can be applied?
Consider whether:
- The people included in the trial could be different from your population in
ways that might produce different results
- Your local setting differs from that of the trial
- You can provide the same treatment in your setting
Consider outcomes from the point of view of the:
- Individual
- Policy maker and professionals
- Family/carers
- Wider community
Consider whether:
- Any benefit reported outweighs any harm and/or cost. If this information
is not reported, can it be filled in from elsewhere
- Policy or practice should change as a result of the evidence contained in
this trial.
------------------------------------------------------------------------------------------------------

75
 Appendix E: Level of evidence

SIGN grading system: Level of evidence (Scottish

Intercollegiate Guidelines Network, 2008)

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a
very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk

of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies

High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2- Case control or cohort studies with a high risk of confounding or bias and a
significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Scottish Intercollegiate Guidelines Network. (2008). Key to evidence statements and

grades of recommendations. Retrieved 30th August, 2012, from

http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html

76
 Appendix F: Quality assessment
1) Bibliographic citation: Ahles, et al., 1999 RCT

1. Did the study ask a clearly-focused Yes

question?

2. Was this a randomized controlled Yes

trial (RCT)?

3. Were participants appropriately Yes. But the randomization method was not
allocation to intervention and described. There was no significant
control groups? difference between groups.

4. Were participants, staff and study No. Blinding was impossible to the study
personnel ‘blind’ to participants’ participants.
study group?

5. Were all of the participants who Yes. Dropout rate was 2.9%. All participants
entered the trial accounted for at its were included in the intent-to-treat analysis.
conclusion?

6. Were the participants in all groups Yes. Same measurement tools were used to
followed up and data collected in collect data for all groups.
the same way?

7. Did the study have enough Can’t tell. The study did not set minimum
participants to minimize the play of sample size to achieve certain statistical
chance? power. The number of patients was n=16 &
18 each group.

8. How are the results presented, and State-Trait Anxiety Inventory-state (STAI-s)
what is the main result? (Higher the score, higher level of anxiety.)
Anxiety level decrease after first and fifth
massage.

9. How precise are these results? Mean change and P value were showed.

10. Were all important outcomes Yes. The result can be applied as the studies
considered so the results can be and target population were the same.
applied?

Level of evidence 1+

77
2) Bibliographic citation: Billhult, et al., 2007
1. Did the study ask a
clearly-focused question?
2. Was this a randomized controlled
trial (RCT)?
3. Were participants appropriately
allocation to intervention and
control groups?
4. Were participants, staff and study
personnel ‘blind’ to participants’
study group?
5. Were all of the participants who
entered the trial accounted for at
its conclusion?
6. Were the participants in all
groups followed up and data
collected in the same way?
7. Did the study have enough
participants to minimize the play
of chance?
8. How are the results presented,
and what is the main result?
9. How precise are these results?
10. Were all important outcomes
considered so the results can be
applied?
Level of evidence
RCT
Yes
Yes
Yes. Randomization was adopted using sealed
opaque envelops. There was no significant
difference between groups in demographic and
clinical variables.
No. Blinding was impossible to the study
participants.
Yes. All patients were involved and provided
data throughout the study period.
Yes Same measurement tools were used to
collect data for all groups.
Can’t tell. The study did not set minimum
sample size to achieve certain statistical power.
The number of patients was n=19 & 20 each
group.
HADS; VAS-nausea (Higher the score, higher
the sense of nausea.) no statistically difference
between groups in HADS.
Massage group statistically reduced sense of
nausea than control group.
Mean change, SD, percentage change and P
value were showed.
Yes. The result can be applied as the studies and
target population were the same.
1+
78
3) Bibliographic citation: Billhult, et al., 2008
1. Did the study ask a
clearly-focused question?
2. Was this a randomized controlled
trial (RCT)?
3. Were participants appropriately
allocation to intervention and
control groups?
4. Were participants, staff and study
personnel ‘blind’ to participants’
study group?
5. Were all of the participants who
entered the trial accounted for at
its conclusion?
6. Were the participants in all
groups followed up and data
collected in the same way?
7. Did the study have enough
participants to minimize the play
of chance?
8. How are the results presented,
and what is the main result?
9. How precise are these results?
10. Were all important outcomes
considered so the results can be
applied?
Level of evidence
RCT
Yes
Yes
Yes. Randomization was adopted using sealed
opaque envelops. There was no significant
difference between groups in demographic
characteristics.
No. Blinding was impossible to the study
participants.
Yes. All participants were involved and
provided data throughout the study period.
Yes Same measurement tools were used to
collect data for all groups.
Yes. The number of participants was enough to
achieve a power of 80%. However, the number
of patients was small (n=11/group).
Number of cells in blood specimen; HADS;
STAI-s.
No significant change of number of cells,
anxiety and depression identified between
groups.
Median, 25th-75th percentile and P value were
showed.
Yes. The result can be applied as the studies and
target population were the same.
1-
79
4) Bibliographic citation: Hernandez-Reif, et al., 2004 RCT

1. Did the study ask a Yes

clearly-focused question?

2. Was this a randomized controlled Yes

trial (RCT)?

3. Were participants appropriately Yes. Randomization was adopted using a flip of

allocation to intervention and a coin. There was no difference between groups
control groups? on stage of cancer, type of surgery, treatments
received and demographic variables.

4. Were participants, staff and study No. Blinding was impossible to the study
personnel ‘blind’ to participants’ participants.
study group?

5. Were all of the participants who Yes. All participants followed up until the end
entered the trial accounted for at of study.
its conclusion?

6. Were the participants in all Yes Same measurement tools were used to
groups followed up and data collect data for all groups.
collected in the same way?

7. Did the study have enough Yes. The number of patients was enough (N=34)
participants to minimize the play to have power of 80%. But the sample size was
of chance? small (n=18 & 16 on massage and control
group).

8. How are the results presented, STAI-s (Higher the score, higher level of
and what is the main result? anxiety.)
The anxiety level of massage group statistically
lower than the control group.

9. How precise are these results? Mean, percentage change and P value were
showed.

10. Were all important outcomes Yes. The result can be applied as the studies and
considered so the results can be target population were the same.
applied?

Level of evidence 1++

80
5) Bibliographic citation: Jane, et al., 2011 RCT

1. Did the study ask a clearly-focused Yes

question?

2. Was this a randomized controlled Yes

trial (RCT)?

3. Were participants appropriately Yes. Randomization was adopted using

allocation to intervention and computerized minimization program. There was
control groups? no significant difference between groups on
demographic and medical characteristics.

4. Were participants, staff and study No. Blinding was impossible to the study
personnel ‘blind’ to participants’ participants.
study group?

5. Were all of the participants who Yes. Dropout rate was 6.9%. Reasons for the
entered the trial accounted for at its dropout rate were explained. All participants
conclusion? were included for the intent-to-treat analysis.

6. Were the participants in all groups Yes. Same measurement tools were used to
followed up and data collected in collect data for all groups.
the same way?

7. Did the study have enough Yes. The number of patients was enough
participants to minimize the play of (n=36/group) to have power of 95%.
chance?

8. How are the results presented, and
what is the main result?
Present pain intensity (PPI-VAS); Mood-VAS;
Relaxation-VAS; Sleep-VAS (Higher the score,
higher level of the outcome measures.)
The level of pain, mood and relaxation reduced
in massage group than in control group.

9. How precise are these results? Mean, SD, ES, P value and the graphic results
of means scores for the outcome measures over
time were showed.

10. Were all important outcomes Yes. The result can be applied as the studies and
considered so the results can be target population were the same.
applied?

Level of evidence 1++

81
6) Bibliographic citation: Listing, et al., 2010
1. Did the study ask a
clearly-focused question?
2. Was this a randomized controlled
trial (RCT)?
3. Were participants appropriately
allocation to intervention and
control groups?
4. Were participants, staff and study
personnel ‘blind’ to participants’
study group?
5. Were all of the participants who
entered the trial accounted for at
its conclusion?
6. Were the participants in all
groups followed up and data
collected in the same way?
7. Did the study have enough
participants to minimize the play
of chance?
8. How are the results presented,
and what is the main result?
9. How precise are these results?
10. Were all important outcomes
considered so the results can be
applied?
Level of evidence
RCT
Yes
Yes
Yes. Randomization was adopted by a simple
randomization list by a study nurse not involved in
the conduction of the study. There was no
significant difference between groups in
socio-demographic and clinical variables.
No. Blinding was impossible to the study
participants.
Yes. Dropout rate was 14.7%. All participants were
included for the intent-to-treat analysis. Difference
of dropouts and completers was compared.
Yes. Same measurement tools were used to collect
data for all groups.
Can’t tell. The study did not set minimum sample
size to achieve certain statistical power. The
number of patients was n= 17/group.
Berlin Mood Questionnaire (BMQ)- subscale
anxious depression.
The effect size (ES) of anxious depression in
massage group statistically improved at the end of
the 5 weeks intervention period.
Mean, SD, 95% CI, ES and P value were showed.
Yes. The result can be applied as the studies and
target population were the same.
1+
82
7) Bibliographic citation: Post-White, et al., 2003 RCT

1. Did the study ask a clearly-focused Yes

question?

2. Was this a randomized controlled Yes

trial (RCT)?

3. Were participants appropriately Yes. Randomization was adopted. But the

allocation to intervention and method of randomization was not mentioned.
control groups? There was no significant difference between
groups in demographic characteristics.

4. Were participants, staff and study No. Blinding was impossible to the study
personnel ‘blind’ to participants’ participants.
study group?

5. Were all of the participants who Yes. Dropout rate was 29%. All participants
entered the trial accounted for at its were included in the intent-to-treat analysis. The
conclusion? reasons for the dropout rate were discussed.

6. Were the participants in all groups Yes Same measurement tools were used to
followed up and data collected in collect data for all groups.
the same way?

7. Did the study have enough No. The number of patients was enough
participants to minimize the play (>32/group) to have power of 80%.
of chance?

8. How are the results presented, and
what is the main result?
Brief Profile of Mood States (POMS)-anxiety
subscale.
The mean change of anxiety level in massage
group statistically greater than the control
group.

9. How precise are these results? Mean, standard deviation (SD) and P value were
showed.

10. Were all important outcomes Yes. The result can be applied as the studies and
considered so the results can be target population were the same.
applied?

Level of evidence 1+

83
8) Bibliographic citation: Sharp, et al., 2010 RCT

1. Did the study ask a clearly-focused Yes

question?

2. Was this a randomized controlled trial Yes

(RCT)?

3. Were participants appropriately Yes. Randomization was adopted using sealed

allocation to intervention and control opaque envelops. All groups did not differ
groups? significantly for any demographic, clinical or
outcome variables.

4. Were participants, staff and study No. Blinding was impossible to the study
personnel ‘blind’ to participants’ study participants.
group?

5. Were all of the participants who Yes. Dropout rate was 9.3%. All participants
entered the trial accounted for at its were included in the intent-to-treat analysis.
conclusion? Reasons for the dropout rate were explained.

6. Were the participants in all groups Yes. Same measurement tools were used for
followed up and data collected in the data collection in all groups.
same way?

7. Did the study have enough participants Yes. The number of patients was enough
to minimize the play of chance? (>60/group) to provide power of 95%.

8. How are the results presented, and
what is the main result?
HADS; Mood Rating Scale (MRS)-relaxation
subscale. (Higher the score, higher level of
anxiety, depression and relaxation.)
MRS-relaxation score in both reflexology
group and massage group was statistically
higher than control group.

9. How precise are these results? Mean, 95% confidence intervals (CI) and P
value were showed.

10. Were all important outcomes Yes. The population of studies’ patients and
considered so the results can be target patients were the same.
applied?

Level of evidence 1++

84
9) Bibliographic citation: Soden, et al., 2004 RCT

1. Did the study ask a Yes

clearly-focused question?

2. Was this a randomized Yes

controlled trial (RCT)?

3. Were participants appropriately Yes. Randomization was adopted using concealed

allocation to intervention and numbered opaque envelopes. There were significant
control groups? more women in the control group than intervention
group. But their baseline assessment scores were not
significant differences between groups.

4. Were participants, staff and No. blinding was impossible to the study
study personnel ‘blind’ to participants. Researchers were blind to the
participants’ study group? interventions.

5. Were all of the participants who Yes. Dropout rate was 14.3%. All participants were
entered the trial accounted for at included in the intent-to-treat analysis. Reasons for
its conclusion? the dropout rate were explained.

6. Were the participants in all Yes. Same measurement tools were used to collect
groups followed up and data data for all groups.
collected in the same way?

7. Did the study have enough No. The number of patients was small (total N=42)
participants to minimize the (<45) and the power of 80% did not reached.
play of chance?

8. How are the results presented, The Hospital Anxiety and Depression Scale (HADS)
and what is the main result? (Higher the score, higher level of anxiety and
depression)
nd
Depression score in HADS decreased after 2 and
th
4 massage.

9. How precise are these results? Mean change, median change and P value were
showed.

10. Were all important outcomes Yes. The result can be applied as the studies and
considered so the results can be target population were the same.
applied?

Level of evidence 1-

85
 Appendix G: Table of evidence 1
Study, No. of patients & Interventions Compariso Length of Outcome measures Result/Effect size
Design, Patients n/control follow up
Evidenc characteristic
e level,
Country
1. N=34 n=16 n=18 -First massage 1. State-Trait Mean changes after first massage:
Ahles, et Mean age (SD) Dropout =0 Dropout=1 Anxiety 1. STAI-state: -13.57 (P≦0.0001)
al., 1999 =41(9.3) - 20 minutes - Fifth massage Inventory-state 2. NS
- Swedish receive (mid-treatment (STAI-s) 3. NS
RCT Diagnosed breast massage usual care ) 4. Distress scale: -1.6 (P=0.002)
1+ cancer, lymphoma Area: in the 2. Beck Depression Fatigue scale: -1.94 (P=0.02)
and leukemia shoulders, autologous -Final massage Inventory (BDI) Nausea scale: -1.94 (P=0.01)
USA admitted for bone neck, face and BMT (predischarge) Mean changes after fifth massage (mid-treatment):
marrow transplant scalp program 3. Brief Profile of 1. STAI-state: -7.94 (P=0.02)
(BMT) requiring - 3 massages Mood States 2. NS
high dose per week (POMS) 3: NS
chemotherapy - 3 weeks 4. NS
4. Numerical scales Mean changes after last massage (predischarge):
Massager: trained (0-10) of emotional 1. NS
healing-arts distress, fatigue, 2. NS
specialists nausea and pain 3. NS
4. Fatigue scale: -1.71 (P=0.03)

86
 Table of evidence 2
Study, No. of Interventions Comparison/contr Length of follow Outcome Result/Effect size
Design, patients & ol up measures
Evidence Patients
level, characteristic
Country
2. N=39 n=19 n=20 -VAS scores of 1. VAS of 1. Mean change of VAS nausea in
Billhult, Mean age Dropout=0 Dropout=0 nausea and nausea and massage group vs mean change in control
et al., (SD)=51.8 anxiety before anxiety group:
2007 (9.3) -20 minutes -Visited by a and immediate 73.2% vs 49.5% (P=0.025)
-Sweden massage hospital staff for after each 2. The
RCT Women with with soft strokes 20 minutes with intervention Hospital No statistically significant differences in
1+ breast cancer - Either foot/lower leg unstructured Anxiety and anxiety between 2 groups.
undergoing or hand/lower arm conversation -HADS assessed Depression
Sweden chemotherap -A cold-press about any subject, before the first scale (HADS) 2. No statistically differences between
y which vegetable oil used but did not and the last groups in changed in HAD anxiety and
would be -Total 5 massage receive massage intervention depression.
given every 3 given during
weeks chemotherapy cycle 3
to 7
Massager:
nurses and
nurse’s aids

87
 Table of evidence 3
Study, No. of patients & Interventions Comparison Length of follow Outcome measures Result/Effect size
Design, Patients /control up
Evidence characteristic
level,
Country
3. N=22 n=11 n=11 -Blood samples 1. Peripheral blood 1. No statistically differences on
Billhult, Mean age (SD) Dropout=0 Dropout=0 taken before the sample on the number peripheral blood concentration of NK cell
et al., =62.5 (7) first and last of NK cell and T helper and T helper cell between groups
2008 -20 minutes -20 minutes massage/control cell
Women with effleurage visit by visit 2. No statistically differences on HADS
RCT breast cancer massage hospital 2. HADS between groups
1- undergoing -either staff with -HADS and STAI
radiation therapy foot/lower leg unstructured taken prior the 3. STAI 3. No statistically differences on STAI
Sweden or hand/lower conversatio first and last between groups
Massager: trained arm n about any massage/control
registered nurses -10 times topic visit
during 3 to 4
weeks

88
 Table of evidence 4
Study, No. of patients Intervention Comparison Length of Outcome Result
Design, & Patients s /control follow up measures
Evidenc characteristic (Pre/post % change in intervention vs control)
e level,
Country
4. N=34 n=18 n=16 -First day of 1. STAI 1. Significant improvement in STAI at the first and the
Hernand Mean age Dropout=0 Dropout=0 massage 2. POMS last day of massage.
ez-Reif, (SD)=53(10.4) First day : ↓ 27% vs ↓6% (P<0.01)
et al., -Swedish Receive -Last day of 3. Symptom Last day: ↓ 29% vs ↓6% (P<0.01)
2004 Women with massage standard massage Checklist-90-R
stage 1 or 2 medical (pretest of (SCL-90-R) 2. Significantly decrease at the first day of massage:
RCT breast cancer -head/neck, care outcome POMS-Depression: ↓75% vs ↓25% (P<0.01)
1++ after surgery shoulder, measures 3, 4. Urinary And POMS-Anger: ↓80% vs ↓17% (P<0.01)
back, arms 4, 5 were biochemistry
USA Massager: and performed on dopamine % change from means difference of first-last day measures
trained legs/feet before the 1st and serotonin in intervention group for the longer term effect:
massage -30 minutes day of 3. Depression ↓46% (P<0.05), Hostility ↓50% (P<0.05)
therapist -3 times per massage and 5. Serum level 4. Urine level of dopamine: ↑26% (P<0.05), serotonin ↑60%
week posttest of natural (P<0.05)
-5 weeks performed killer (NK) cell 5. Serum NK cells↑12% (P<0.05), lymphocytes ↑10%
after last day and (P<0.05)
of massage) lymphocytes

89
 Table of evidence 5
Study, No. of Interventions Comparison Length of follow up Outcome measures Effect size between massage group and
Design, patients & /control control group
Evidence Patients
level, characteristic
Country
5. N= 72 n= 36 n= 36 -Baseline 1. Present pain intensity All outcome measures showed significant
Jane, et Mean age Dropout= 2 Dropout= 3 assessment on Day (PPI-VAS) improvement at measurement time points
al., 2011 (SD) = 50 1 (T0) T1, T2 and T3.
(10.6) -45 minutes -Presence of 2. Mood-VAS
RCT Female: 58% full body a caring -Pre & posttest 1. PPI-VAS: ES > 0.69 (P= 0.01)
1++ massage therapist for taken on Day 2 3. Relaxation-VAS
Cancer -3 45 minutes (T1), Day 3 (T2) 2. Mood-VAS: ES > 0.49 (P < 0.04)
Taiwan patients who consecutive (social and Day 4 (T3)
were able to sessions attention) 3. Relaxation-VAS: ES > 0.45 (P < 0.03)
speak and -Last measures on
read Chinese Relaxation-VAS &
with bone Sleep-VAS done
metastases on Day 5 (T4)

Massager:
nurses

90
 Table of evidence 6
Study, No. of patients & Interventions Comparison Length of Outcome measures Result/Effect size
Design, Patients /control follow up
Evidence characteristic
level,
Country
6. N=34 n=17 n=17 T1: baseline 1. Perceived Stress 1. PSQ-worries decreased significantly in
Listing, et Mean age(SD)= Dropout=1 Dropout=4 Questionnaire (PSQ) intervention group from 37.5 (T1)to 31.3(T2)
al., 2010 59.7(11.8) -Biweekly T2: at the (P=0.047) and remain low 28.3(T3) (P=0.003)
-30 minutes Routine end of the 5 2. Berlin Mood 2. At T2, BMQ-Anger Effect size(ES) =0.82
RCT Women with Swedish health care week Questionnaire (BMQ) (P<0.05)
1+ primary breast massage to the intervention At T2, BMQ-anxious depression ES=0.90
cancer back, neck and 3. Serum cortisol and (P<0.05)
Germany head T3: 6 weeks serotonin measure At T3, BMQ-Tiredness mean difference
Massager: -5 weeks after T2 between massage and control group= -15.73
licensed, trained (P<0.05)
female massage
therapist 3. Serum cortisol level decreased significantly at
T2 (P=0.03). NS in serum serotonin level.

91
 Table of evidence 7
Study, No. of Interventions Compariso Length of follow Outcome Result/Effect size
Design, patients & n/control up measures
Evidence Patients
level, characteris
Country tic
7. N=230 -4 weekly Standard - Outcome 1. Heart rate, 1. MT and HT reduced respiratory rate (P<0.001),
Post-White, Mean age -45 minutes care measures 1& 2 respiratory rate heart rate (P<0.001) and systolic (P<0.001) and
et al., 2003 (SD) = A: Therapeutic were measure and blood diastolic pressure (P<0.001)
54.7(11.7) massage (MT) (crossover before and after pressure 2. MT (P<0.001) and HT (P<0.011) have
RCT n=78 from each significantly lower in pain level. There is no
(crossover) Female: -Swedish massage interventio intervention. 2. 0-10 scale of significantly different in nausea scale in MT and HT.
1+ 86.1% on whole body n groups) - Outcome current pain and 3. NS
Adult with massage gel measures 3, 4, 5 current nausea 4. NS
USA out-patient B: Healing touch measures before Mean of MT at session 1→4 vs control at session
s receiving (HT) session 1 and 3. Brief Pain 1→4:
chemother n=77 each 4-week Index (BPI) 5. POMS-Mood disturbance: 32.9→17.8 vs
apy C: Caring crossover period 31.0→29.6 (P=0.004)
Massager: presence (P) session 4, 5, 8. 4. Brief Nausea POMS-Anxiety: 11.1→7.6 vs 10.8→9.6 (P=0.02)
Registered n=75 Index (BNI) HT reduced total mood disturbance (P=0.003) and
nurses fatigue (P=0.028)
5. POMS Presence had no different than control in POMS
measures.

92
 Table of evidence 8
Study, No. of Interventions Compari Length of Outcome measures Result/Effect size
Design, patients & son/contr follow up
Evidenc Patients ol
e level, characteristi
Country c
8. N=183 Intervention Intervent - Primary 1st outcome: Means difference at primary end-point:
Sharp, et A: n=60 ion C: end-point: 18 1. The Trial Outcome 1. Intervention B has significant improvement on
al., 2010 Mean age Dropout=3 n=62 weeks after Index (TOI): TOI: 4.01 (P=0.03)
(SD)= reflexology dropout= surgery (4 composed of the sum 2. Both intervention A and B have significant
RCT 58.78 on foot plus 11 week after of scores on the improvement in MRS-relaxation:
1++ (10.31) usual care Usual last massage) physical, functional Intervention A-C: 26.92 (P≦0.0005)
Breast Intervention care and breast cancer Intervention B-C: 26.21 (P≦0.0005)
UK cancer B: n=61 Secondary concern subscales. Intervention B has significant improvement in
nd
female 6 Dropout=3 end-point: 24 2 outcome: MRS-easy goingness:
weeks post Scalp weeks after 2. Mood Rating Scale Intervention B-control: 24.8 (P≦0.0005)
breast massage plus surgery (10 (MRS) 3. NS
surgery usual care week after 3. HADS Means difference at secondary end-point:
last massage) 1. Intervention A has significant improvement on
Massager: -1 hour TOI: 5.4 (P=0.02)
not mention session 2. Intervention A has significant improvement on
- Weekly MRS-relaxation: 18.23 (P=0.02)
-8 weeks 3. NS

93
 Table of evidence 9
Study, No. of Interventions Comparison Length of Outcome measures Result/
Design, patients & / control follow up Effect size
Evidence Patients
level, characteristic
Country
9. N=42 - 30 minutes Usual care Weekly 1st outcome: 1. Statistically improvement on the mean
Soden, et Aged:44-85 - Back N=13 after every 1. Visual Analogue Scale change in pain VAS scores compared
al., 2004 years massage massage (VAS) of pain intensity with baseline in second massage: AT:
Median: 73 - Weekly Did not -1.15 (P=0.01)
RCT years - 4 week receive any 2nd outcome:
1- Female: 76% Aromatherapy massage 2. HADS 2. MT have significant improvement on
Dropout: 6 group: (AT) n= during the median HAD scores in second and fourth
UK 16 massage study period treatments:
All kind of with lavender 2nd week: -2.0 (P≦0.05)
cancer essential oil 4th week: -1.5 (P≦0.01)
diagnosis Massage
Metastatic group: (MT)
disease: 55% n= 13 massage
with inert
Massager: carrier oil
not Massager: not
mentioned mentioned.

94
 Appendix H: Table of summary for the studies’ results
Citations Level of Participants Mean age Area of massage Duration Frequency Massager Follow-up Outcome Results
evidence (Sample size) (SD) measures

1. Ahles, et al., 1+ BMT 41 Swedish on 20 min 3/week, Trained healing arts 1st, 5th & final STAI-s Improve STAI-s
st th
1999 USA N=34 (9.3) shoulders, neck, face 3 wks specialists massage after 1 and 5
and scalp massage

2. Billhult, et 1+ Breast cancer 51.8 Swedish on either 20 min Q3wks, Nurses VAS: Before and after HADS Improve in
al., 2007 Sweden female on (9.3) foot/lower leg or on cycle 3-7 each massage Anxiety and VAS-nausea
chemo hand/lower arm HADS: before the 1st Nausea-VAS
N=39 and after last massage

3. Bullhult, et 1- Breast cancer 62.5 Swedish on either 20 min 10 time Nurses Before the 1st and after HADS No significant
al., 2008 Sweden female in RT (7) foot/lower leg or during 3-4 the last massage STAI improvement
N=22 hand/lower arm wks

4. Hernandez, 1++ Breast cancer 53 Swedish on head/ 30 min 3/week, Trained massage 1st and last day of STAI-s Improve STAI-s in
et al., 2004 USA female (10.4) neck, shoulder, back, 5 wks therapists massage both follow up
N=34 arms, leg/feet

95
Citations Level of Participants Mean age Area of massage Duration Frequency Massager Follow-up Outcome Results
evidence (Sample size) (SD) measures

5. Jane, et al., 1++ Cancer patient 50 Swedish on whole 45min 3 consecutive Nurses Baseline: day 1 VAS-Mood Improve mood and
2011 Taiwan with bone met (10.6) body session Mood-VAS: Day 2, 3, 4 VAS-Relaxation relaxation on day 2,
N=72 Relaxation-VAS: Day 5 3, 4.

6. Listing, et 1+ Breast cancer 59.7 Swedish on back, 30 min Biweekly, Licensed trained Baseline, at the end BMQ-anxious Improve BMQ-
al., 2010 Germany female (11.8) neck and hand 5 wks massage therapists and 6 wk after final depression anxious depression at
N=34 massage the end of massage

7. Post-White, 1+ Chemo pt 54.7 Swedish on whole 45 min Weekly, Nurses Before 1st and after POMS-anxiety Improve POMS-
et al., 2003 USA N=230 (11.7) body 4 wks 4th massage subscale anxiety

8. Sharp, et al., 1++ Breast cancer 58.78 Scalp 1 hr Weekly, Not mentioned 4 week and 10 week HADS Improve MRS-
2010 UK female (10.31) 8 wks after last massage MRS-relaxation relaxation score after
N=183 subscale 4 weeks

9. Soden, et al., 1- All cancer Median: Back 30 min Weekly, Not mentioned Weekly HADS Improve in
2004 UK N=42 73 4 wks HADS-depression on
nd th
2 & 4 week

96
 Appendix I:

Estimated expenses that can be saved by reducing use of potent

anti-emetics

Choice of potent anti-emetics:

Anti-emetics Dosage Frequency #Cost for 1 day Duration Cost for 3 days per patient

Navoban 5mg Daily $63.5 3 days $63.5 x3 = $190.5

Kytril 1mg Twice a $71.4 x2 3 days $142.8 x3 = $428.4

day = $142.8

Zofran 8mg Twice a $20 x2 3 days $40 x3 = $120

day = $40

# the price of medication is based on the Drug formulary at the Hospital Authority.

The average costs of taking these drugs for 3 days per patient:

($190.5+$428.4+$120)/3 = $246.3

Assuming 20% of total patients (233 patients) joining the program per year do

not require the use of these potent anti-emetics after receiving massage,

The estimated costs saved: $246.3 x233 ～ $57,000

97
 Appendix J

Budget plan for implementing the massage program

Budget Plan Estimated Cost

Training

-Venue for holding the briefing session $0

-Printing notes for the training:

RNs x15 $5/ person x25 =

Volunteers x10 $125

-Computer and projector device $0

Total estimated expense for training: $125

Running cost

Printed materials:

 Posters and leaflet

 Consent

 Self-design nurse assessment checklist $5/ person

-Massage oil (lubricant) $5/ person

Estimated expenses for running the program

$10/person
per patient:

Estimated expenses for the program per year:

Total patients admitted to the day ward in the past year 11,692

Assuming half of the total patients 11,692 / 2 5,846

experience anxious:
If 20% of the anxious patients are 5,846 x 20% 1,169
eligible and willing to join the program:
Estimated expenses for running the $125 + ($10 x 1,169) ～ $12,000
program for a year:

98
 Appendix K: Grade of recommendation

SIGN grading system: Grade of Recommendation

(Scottish Intercollegiate Guidelines Network, 2008)

A At least one meta analysis, systematic review, or RCT rated as 1++,

and directly applicable to the target population; or
A systematic review of RCTs or a body of evidence consisting
principally of studies rated as 1+, directly applicable to the target
population, and demonstrating overall consistency of results.
B A body of evidence including studies rated as 2++, directly
applicable to the target population, and demonstrating overall
consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable
to the target population and demonstrating overall consistency of
results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
D (GPP) Recommended best practice based on the clinical experience of the
guideline development group
GPP: Good practice points

Scottish Intercollegiate Guidelines Network. (2008). Key to evidence statements and

grades of recommendations. Retrieved 30th August, 2012, from
http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html

99
 Appendix L

Evidence-based practice guideline of massage for cancer

patients receiving chemotherapy

Introduction

Cancer patients receiving chemotherapy experience various treatment-related

side effects including nausea, anxiety, impairing their quality of life. A study

(Molassiotis, et al., 2002) showed that there were 15-40% cancer patients suffering

from psychological disorders related to anxiety and depression during chemotherapy.

The use of massage for cancer patients receiving chemotherapy can greatly improve

their anxiety, mood status and severity of nausea and vomiting, hence, improving

their quality of life (Corbin, 2005). The following evidence-based practice (EBP)

guideline is developed for the use of massage on adult cancer patients receiving

chemotherapy to reduce anxiety in the chemotherapy day ward. This EBP guideline is

developed based on the evidence generated from nine RCTs. The recommendation

and the level of evidence are graded according to the Scottish Intercollegiate

Guideline Network (SIGN, 2008).

Aim

The aim of this guideline is to implement feasible and effective massage

interventions to reduce anxiety for cancer patient receiving chemotherapy in an

outpatient clinic setting.

Objectives

To provide a consistent framework for implementation of safe and effective massage

therapy to cancer patients to reduce their anxiety from receiving chemotherapy.

100
Target population

The massage therapy is applicable to both male and female adult cancer patients

who are receiving chemotherapy in the chemotherapy day ward.

Inclusive criteria

- Aged 18 or above

- Cantonese- and Mandarin-speaking patients who are able to read Chinese.

- Cognitively competent

Exclusive criteria

- Coagulation disorder

- Spinal cord injury

- Venous thrombosis

- Bone metastasis

- Peripheral neuropathy

- Radiation dermatitis

- Open wound over lower limbs

(Recommendation 1.0)

Roles and responsibilities of nurses

1. Introduce and explain the massage program to potential patients and give a

pamphlet on the massage therapy to them.

2. Seek oncologist’s approval for the selected patient to receive massage therapy

during patient’s second chemotherapy follow-up by asking oncologist to sign on

the assessment form attached on patients’ medical record.

3. Reconfirm eligibility of patient during the next admission to day ward for

chemotherapy and obtain a written consent.

101
4. Ask patient to complete the State-Trait Anxiety Inventory (STAI) assessment

form on admission and after receiving the massage to measure patient’s level of

anxiety. (Recommendation 4.0)

5. Check patient’s vital signs including blood pressure, pulse, respiratory rate and

oxygen saturation and document in the assessment form before and after the

massage intervention.

6. Refer appropriate patient to the massagist for therapy.

7. Educate patient to report any discomfort or abnormalities when receiving

massage therapy.

8. Observe patient’s response to the therapy for at least 5 minutes after

commencement for the first treatment and as necessary.

9. Monitor and manage patients with massage-induced complications (see Table 1).

10. Refer patients to oncologist for subsequent treatment if necessary.

The massage protocol

1. 30 minutes Swedish massage is recommended to perform on patient’s lower

limbs every 3 weeks. (Recommendations 2.0 and 3.0)

2. Maximum 5 sessions will be given to cancer patients or until patient’s

chemotherapy treatment completed.

3. Step of massage (Table 2.):

I. Strokes from the ventral side of the foot up around the knee and back to the

foot.

II. Small circular movements and kneading on the side of the calf from the foot

to the knee.

102
III. Circular stroking around the sides of the knee and the ankle.

IV. Stroking on the ventral side of the foot.

V. Strokes on the dorsal side of the foot.

VI. Strokes from the ventral side of the foot up around the knee and back to the

foot.

VII. Repeat step I to VI on another leg.

*The step of massage is based on the study (Billhult, et al., 2008). *

103
Evidence of the recommendations

Recommendation 1.0

Nursing assessment should be performed to exclude high risk patients from

joining the massage program. (Grade of recommendation: A)

Patients with medical conditions including coagulation disorder, spinal cord

injury, thrombosis, bone metastasis, peripheral neuropathy, radiation dermatitis and

open wound over lower limbs are excluded from receiving massage in four of the

reviewed RCTs(Hernandez-Reif, et al., 2004; Jane, et al., 2011; Sharp, et al., 2010;

Listing, et al., 2010). This is necessary as these conditions may heighten the risk of

massage complications such as neuropathy damage, hematoma, bleeding and

dislodging of deep venous thrombosis causing embolism (Hernandez-Reif, et al, 2004;

Jane, et al., 2011; Sharp, et al., 2010; Listing, et al., 2010) (1++; 1++; 1++; 1+).

Recommendation 2.0

Swedish massage is recommended to perform on patient’s lower limbs. (Grade of

recommendation: A)

No complication such as fractures, dislocations, nerve damage and pulmonary

embolism were reported from participants in seven reviewed RCTs which used

Swedish massage as their interventions. (Ahles, et al., 1999; Billhult, et al., 2007;

Billhult, et al., 2008; Hernandez-Reif, et al., 2004; Jane, et al., 2011; Listing, et al.,

2010; Post-White, et al., 2003). (1+; 1+; 1-; 1++; 1++; 1+; 1+)

104
Recommendation 3.0

The duration of massage therapy is recommended as 30 minutes. (Grade of

recommendation: A)

Six reviewed studies used 20-30 minute massage and five of them reported to

have positive effects in reducing level of anxiety and sense of nausea for cancer

patients (Ahles, et al., Billhult, et al., 2007; Billhult, et al., 2008; Hernandez-Reif, et

al., 2004; Listing, et al., 2010; Soden, et al., 2004). The immediate short-term (30 min)

benefits of massage therapy is well proved to reduce anxiety for cancer patients

(Hernandez-Reif, et al., 2004; Listing, et al., 2010; Soden et al., 2004). (1++; 1+; 1- )

Recommendation 4.0

The State-Trait Anxiety Inventory (STAI-S) measuring tool should be used to

measure the patient’s level of anxiety before and after the massage so as to

evaluate the effectiveness of this massage program. (Grade of recommendation:

A)

Five reviewed RCTs used one-dimensional self assessment tools to measure the

subjective feeling of anxiety for cancer patients (Ahles, et al., 1999; Billhult, et al.,

2007; Bullhult, et al., 2008; Hernandez-Reif, et al., 2004; Jane, et al., 2011). Three of

them used STAI-S assessment tool to measure anxiety level for cancer patients and

resulted in decrease in their anxiety level (Ahles, et al., 1999; Billhult, et al., 2008;

Hernandez-Reif, et al., 2004). STAI-S is a valid and reliable one-dimensional

assessment tool that is short and easy for cancer patients to complete. (1+; 1-; 1++)

105
Table 1. Potential massage-induced complications, manifestations and

management

Potential Patient Manifestation Management

complications
 Petechia  Blue or purple  Stop the massage.
 Bruise discoloration on  Assess the possible cause of skin rash.
 Hematoma skin  Maintain a patent intravenous line.
 Dizziness  Inform doctor.
 Decrease in blood
pressure
 Tachycardia

 Muscular  Pain  Stop the massage.

pain over the  Assess the cause of pain.
site where  Immobilize the leg.
massage is  Inform doctor if necessary.
applied
 Embolism  Shortness of breath  Stop the massage.
 Tachycardia  Lie down the patient.
 Dramatically change  Close monitor patient’s vital signs
in blood pressure including blood pressure, pulse, oxygen
saturation (SpO2), and temperature.
 Maintain a patent intravenous line.
 Provide oxygen therapy if necessary.
 Provide basic life support.
 Inform doctor.

106
Table 2. Step of massage

Apply to left / right leg

I. Strokes from the ventral side of the foot up

around the knee and back to the foot.

II. Small circular movements and kneading on

the side of the calf from the foot to the

knee.

III. Circular stroking around the sides of the

knee and the ankle.

Stroking on the ventral side of the

IV. Strokes on the ventral side of the foot.
foot.

V. Strokes on the dorsal side of the foot.

VI. Strokes from the ventral side of the foot up

around the knee and back to the foot.

VII. Repeat step I to VI on another leg

107
Reference of the guideline:

1. Ahles, T. A., Tope, D. M., Pinkson, B., Walch, S., Hann, D., Whedon, M., Dain,

B., Weiss, J. E., Mills, L.& Silberfarb, P. M. (1999). Massage Therapy for

Patients Undergoing Autologous Bone Marrow Transplantation. Journal of Pain

and Symptom Management, 18(3), 157-163.

2. Billhult, A., Bergbon, I. & Stener-Victorin, S. (2007). Massage Relieves Nausea

in Women with Breast Cancer Who Are Undergoing Chemotherapy. The Journal

of Alternative and Complementary Medicine, 13(1), 53-57.

3. Billhult, A., Lindholm, C., Gunnarsson, R. & Stener-Victorin, E. (2008). The

effect of massage in cellular immunity, endocrine and psychological factors in

women with breast cancer- A randomized controlled clinical trial. Autonomic

Neuroscience: Basic and Clinical, 140, 88-95.

4. Hernandez-Reif, M., Ironson, G., Field, T., Hurley, J., Katz, G., Diego, M., Weiss,

S., Fletcher, M. A., Schanberg, S., Kuhn, C. & Burman, I. (2004). Breast cancer

patients have improved immune and neuroendocrine functions following massage

therapy. Journal of Psychosomatic Research, 57, 45-52.

5. Jane, S. W., Chen, S. L., Wilkie, D. J., Lin, Y. C., Foreman, S. W., Beaton, R. D.,

Fan, J. Y., Lu, M. Y., Wang, Y. Y., Lin, Y. H. & Liao, M. N. (2011). Effects of

massage on pain, mood status, relaxation, and sleep in Taiwese patients with

metastatic bone pain: A randomized clinical trial. The Journal of the

International Association for the Study of Pain, 152, 2432-2442.

6. Listing, M., Krohn, M., Liezmann, C., Kim, I., Reisshauer, A., Peters, E., Klapp,

B. F. & Rauchfuss, M. (2010). The efficacy of classical massage on stress

perception and cortisol following primary treatment of breast cancer. Archives of

Womens Mental Health, 13, 165-173.

108
7. Post-White, J., Kinney, M. E., Savik, K., Gau, J. B., Wilcox, C. & Lerner, I.

(2003). Therapeutic Massage and Healing Touch Improve Symptoms in Cancer.

Integrative Cancer Therapies, 2(4), 332-344.

8. Sharp, D. M., Walker, M. B., Chaturvedi, A., Upadhyay, S., Hamid, A., Walker,

A. A., Bateman, J., Braid, F., Ellwood, K., Hebblewhite, C., Hope, T., Lines, M.

& Walker, L. G. (2010). A randomized, controlled trial of the psychological

effects of reflexology in early breast cancer. European Journal of Cancer, 46,

312-322.

9. Soden, K., Vincent, K., Craske, S., Lucas, C. & Ashley, S. (2004). A randomized

controlled trial of aromatherapy massage in a hospice setting. Palliative Medicine,

18, 87-92.

109
 Appendix M: Timetable for implementation of the massage program

Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 to Jun 2014 Jul 2014 Aug 2014
1. Forming a team of core members
2. Seeking administrator’s approval
3. Refining the guideline
4. Training to nurses and volunteers
5. Pilot study
6. Amending guideline and logistics of
the program
7. Implementing the program
8. Evaluating the outcome
9. Generating report and disseminating
the finding

110
Appendix N
Gum label
Assessment form for the massage program
Part 1

Patient Diagnosis: ________________ No. of massage sessions received:

Name of chemotherapy received:
No. of cycle of chemotherapy: Date of receiving massage:

*********************************************************************
Part 2
Medical assessment
(Completed by oncologists during patient’s follow-up)

No Yes Remarks
1. Does the patient have coagulation disorder?
2. Does the patient have history of spinal cord injury?
3. Does the patient have history of thrombosis?
4. Does the patient have bone metastasis?
5. Does the patient experience chemotherapy-induced
peripheral neuropathy?

Can the patient receive massage therapy? No Yes

No massage therapy is allowed if any “yes” on the above items.

Doctor’s signature: Date:

*********************************************************************

111
Assessment form for massage program Page. 2

**********************************************************
Part 3
Nursing integrated assessment
(Complete by nurses on the same day of massage)

1. Is an informed consent being obtained? No Yes

2. Is the patient receiving concurrent chemotherapy and radiation? No Yes

Lower limbs skin Assessment:

1. Skin integrity Wounded Intact
2. Skin color Pale Erythema Cyanotic Pink
3. Skin texture Dry Scaly Oily Normal
4. Skin turgor Edema normal

Special Medication History:

Use of opioids: No Yes Please specify type, dosage, frequency:

Use of anxiolytics: No Yes Please specify type, dosage, frequency:

Use of antiemetics: No Yes Please specify type, dosage, frequency:

Blood Result:
Platelet count:
Clotting:

Can the patient receive massage therapy? No Yes

Pre-massage vital signs: BP: mmHg P: /min SpO2: %

Post-massage vital signs: BP: mmHg P: /min SpO2: %
Remarks:
Nurse’s signature: Date:
*******************************************************************
112
Assessment form for massage program Part 4 Page. 3
按摩前評估 Pre-massage measurement form(由病人填寫)
(一) 情景特質焦慮量表-情境焦慮部分 (STAI-S)

以下是一般人常用來描述自己感受的句子，請仔細閱讀每一句，然後根據你現在的感受 (即此時
此刻的感受)，圈選一個最適當的答案。

完 有 頗 極
全 些 為 為
不
符 符 符 符
合 合 合 合
1 我現在覺得心裡平靜 # 1 2 3 4
2 我現在覺得安全 # 1 2 3 4
3 我現在是緊繃的 1 2 3 4
4 我現在覺得很緊張 1 2 3 4
5 我現在覺得很放鬆 # 1 2 3 4
6 我感到困擾 1 2 3 4
7 我現在正擔心可能將有不幸的事會發生 1 2 3 4
8 我現在覺醒很滿意 # 1 2 3 4
9 我現在覺得害怕 1 2 3 4
10 我現在覺得心裡舒適 # 1 2 3 4
11 我覺得我是自信的 # 1 2 3 4
12 我覺得我很神經質 1 2 3 4
13 我常常是戰戰兢兢的 1 2 3 4
14 我覺得自己優柔寡斷 1 2 3 4
15 我現在是放鬆的 # 1 2 3 4
16 我現在覺得很滿足 # 1 2 3 4
17 我現在是憂慮的 1 2 3 4
18 我現在覺得困惑 1 2 3 4
19 我現在覺得穩定 # 1 2 3 4
20 我現在覺得很愉快 # 1 2 3 4
# 為反向計分

********************************************************************
113
Assessment form for massage program Part 5 Page. 4
按摩後評估 Post-massage measurement form(由病人填寫)
(一) 情景特質焦慮量表-情境焦慮部分 (STAI-S)
以下是一般人常用來描述自己感受的句子，請仔細閱讀每一句，然後根據你現在的感受 (即此時
此刻的感受)，圈選一個最適當的答案。

完 有 頗 極
全 些 為 為
不
符 符 符 符
合 合 合 合
1 我現在覺得心裡平靜 # 1 2 3 4
2 我現在覺得安全 # 1 2 3 4
3 我現在是緊繃的 1 2 3 4
4 我現在覺得很緊張 1 2 3 4
5 我現在覺得很放鬆 # 1 2 3 4
6 我感到困擾 1 2 3 4
7 我現在正擔心可能將有不幸的事會發生 1 2 3 4
8 我現在覺醒很滿意 # 1 2 3 4
9 我現在覺得害怕 1 2 3 4
10 我現在覺得心裡舒適 # 1 2 3 4
11 我覺得我是自信的 # 1 2 3 4
12 我覺得我很神經質 1 2 3 4
13 我常常是戰戰兢兢的 1 2 3 4
14 我覺得自己優柔寡斷 1 2 3 4
15 我現在是放鬆的 # 1 2 3 4
16 我現在覺得很滿足 # 1 2 3 4
17 我現在是憂慮的 1 2 3 4
18 我現在覺得困惑 1 2 3 4
19 我現在覺得穩定 # 1 2 3 4
20 我現在覺得很愉快 # 1 2 3 4
# 為反向計分
********************************************************************

114
Assessment form for massage program Part 5 Page. 5

按摩後評估 Post-massage measurement form(由病人填寫)

(二) 噁心評估量表 Numerical Rating Scale (NRS-Nausea)
請以 0-10 分之分數，表達出你於按摩時的不同時間之噁心嚴重度。
(0 分為不噁心，10 分為非常噁心。)

按摩前 (0 分鐘):
開始按摩後 (15 分鐘):
開始按摩後 (30 分鐘):

(三) 嘔吐評估量表 Numerical Rating Scale (NRS-Vomiting)

請以 0-10 分之分數，表達出你於按摩時的不同時間之嘔吐嚴重度。
(0 分為沒有嘔吐，10 分為嚴重嘔吐。)

按摩前 (0 分鐘):
開始按摩後 (15 分鐘):
開始按摩後 (30 分鐘):

~問卷完~
~多謝參與~

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