Our results demonstrated the feasibility of providing and studying a combined Swedish massage and acupressure intervention in a pediatric HCT unit. While the sample size was small, the data suggested some efficacy of the massage/acupressure intervention, particularly related to a reduction in days with mucositis, improvements in fatigue, and reduced pain and loss of appetite. Use of daily nurse's clinical data combined with biweekly self-report data from both children and parents provided multiple perspectives on the clinical efficacy of the intervention for our key outcomes. While the effect sizes we observed are encouraging, the results must be interpreted cautiously given the small sample size and lack of statistically significant differences between groups. A larger study would be needed to determine whether the effect sizes suggested in this pilot study can be confirmed with statistically significant results. Based on our results for a key study outcome—the summary score of the three key symptoms of pain, nausea, and fatigue (ES = 0.62), the study would have required at least 64 participants in each group to show a statistically significant difference.
The feasibility of the study was further supported by enthusiastic qualitative data obtained from parent interviews and nurses' reports. These findings are reported separately in a detailed qualitative report (manuscript submitted) [68
There are a number of unique aspects of the present pilot study compared to other studies in the field of massage and pediatric oncology. The present pilot tested an integration of Eastern and Western massage styles, as is increasingly practiced in the United States. The potential benefits include the relaxing aspects of Swedish massage [1
] combined with the potential efficacy of acupoint therapy for pain, nausea, and other symptom relief [22
]. To our knowledge, there are no comparable studies that have tested an integration of Eastern and Western massage. Involvement of parents in providing additional nonprofessional massages is another innovative feature of our intervention with the added benefits of increasing the massage dose, supporting timely symptom management and enabling parents to help their children directly.
A previous single-site pilot study performed by Phipps and colleagues [16
] demonstrated promising results in improved symptom management, but these results were not confirmed in a larger multisite study [17
]. The intervention used in this larger study, a combination of a laugh cart, a guided relaxation and Western massage was substantially different from the present study, with most overlap in the shared aim of reducing child discomfort by nonpharmacological means. The present study may have benefited from the additional use of acupressure, which may account for the moderate-to-high effect sizes for some symptoms compared to this prior study.
Another small feasibility study in 17 children with cancer who were undergoing chemotherapy used a crossover design in which 4 weekly massage sessions alternated with 4 weekly quiet-time control session. This study found that massage was more effective than quiet time at reducing heart rate and anxiety in children less than 14 years but did not show improvements in pain, nausea, or fatigue [70
]. The authors concluded that massage in children with cancer is feasible and appears to decrease anxiety. The present study also showed feasibility, but otherwise found different results with moderate ES for a decrease in pain and fatigue and less improved anxiety in the intervention group compared to controls. The addition of acupressure in the present study may have improved symptom management over the previous study, but sample sizes are small in both studies.
Finally, a randomized feasibility study of acupressure in preventing chemotherapy-associated nausea by Jones and colleagues was conducted among 21 pediatric oncology patients, ages 5 to 19 years, using wrist bands compared to placebo bands [71
]. Acupressure applied using wrist bands was feasible and well tolerated but there were not statistically significant results compared to placebo, potentially due to small sample size.
While Jones's study used a bead to apply pressure on one acupoint, it differed from the present study, in which acupressure was provided by experienced practitioners who used multiple points.
The finding that the intervention may have reduced days with mucositis and reduced tiredness, although at first surprising, may in fact reflect a potential mechanism of action that has been suggested by results from prior acupoint studies, namely, a reduction in proinflammatory cytokines such as TNF-α
, IL-1, and IL-6 [72
]. These proinflammatory cytokines are increased during chemotherapy, probably due to high levels of apoptosis (programmed cell death). Some of these proinflammatory cytokines, in turn, are hypothesized to be important factors in chemotherapy-related fatigue [73
] and mucositis [74
]. This hypothetical mechanism may deserve further investigation in a larger trial with the addition of biological samples.
The present study focused on longer-term changes in symptoms (assessed every other week from self-report or daily by the nurses) rather than short-term changes (minutes or hours) after the intervention. This design allowed us to assess only the more enduring effects of massage, but not the immediate effects. Future studies might benefit from both short- and longer-term assessments. Short-term benefits from massage have been reported in other studies [75
] and appear to be more consistent than longer-term effects.
Limitations of this feasibility study include the small sample size and the limited number of time points for self-report assessments. In addition, the dose of the massage intervention averaged 1.8 massages per week, while the target dose was 3 per week. This difference occurred in part because of scheduling difficulties related to periods of time with severe symptoms, unscheduled naps, and high health care demands. Participants often preferred massage sessions in the evening when medical procedures were over, but massage providers had limited evening availability. Finite resources made it difficult to ensure wider availability of the massage provider. Based on our results, we believe that an increased dose of massage would be facilitated by having a provider regularly available during the late afternoon and evening for several hours per day (rather than individually scheduled visits).
Major strengths of the study include the feasibility and acceptability of a massage/acupressure study on a busy pediatric stem cell transplant unit, indications of efficacy of the intervention, the lack of side effects, and the enthusiastic support for the intervention by the involved pediatricians, nurses, and parents [68
This study provided new data on the efficacy of combined Swedish massage and acupressure for improved symptom management in children undergoing hematopoietic cell transplants. Findings from this and larger future studies have the potential to influence clinical practice related to stem cell transplant-associated symptoms in children by introducing massage and acupressure, an ancient healing modality, into a “high-tech” pediatric hospital setting. Massage and acupressure for symptom management are attractive, given their potential to treat multiple symptoms with few or no side effects. Future studies should enroll sufficient numbers to better test the efficacy of combined Swedish massage and acupressure in symptom management of pediatric hematopoietic stem cell transplant.