Journal of Pediatric Oncology Nursing OnlineFirst, published on December 11, 2008 as doi:10.

1177/1043454208323295

DOCTYPE = ARTICLE

Massage Therapy for Children With Cancer

Janice Post-White, PhD, RN, FAAN
Maura Fitzgerald, MS, MA, RN, CNS
Kay Savik, MS
Mary C. Hooke, MS, RN, CPON
Anne B. Hannahan, MA, RN, LP
Susan F. Sencer, MD
This pilot study aimed to determine the feasibility
of providing massage to children with cancer to
reduce symptoms in children and anxiety in parents.
Twenty-three children/parent dyads were enrolled; 17
completed all data points. Children with cancer, ages
1 to 18 years, received at least 2 identical cycles of
chemotherapy, and one parent, participated in the 2period crossover design in which 4 weekly massage
sessions alternated with 4 weekly quiet-time control
sessions. Changes in relaxation (heart and respiratory rates, blood pressure, and salivary cortisol level)
and symptoms (pain, nausea, anxiety, and fatigue)
were assessed in children; anxiety and fatigue were
measured in parents. Massage was more effective
than quiet time at reducing heart rate in children,
anxiety in children less than age 14 years, and parent
anxiety. There were no significant changes in blood
pressure, cortisol, pain, nausea, or fatigue. Children
reported that massage helped them feel better, lessened their anxiety and worries, and had longer lasting effects than quiet time. Massage in children with
cancer is feasible and appears to decrease anxiety in
parents and younger children.
Key words: massage, cancer, children, cortisol,
symptoms, parent massage

emarkable progress has been made over the past 30

years in cancer treatment for children and adolescents (Curesearch, 2008). The intensified treatments,
2008 by Association of Pediatric Hematology/Oncology Nurses
DOI: 10.1177/1043454208323295

16

however, result in greater physical symptoms and emotional distress (Docherty, 2003; Hockenberry, 2004;
National Institutes of Health, 2002), including pain,
nausea, fatigue, fear, anxiety, uncertainty, and irritability (Collins et al, 2000; Hedstrom, Haglund, Skolin, &
Von Essen, 2003; Woodgate, Degner, & Yanofsky,
2003). Parent distress can influence the childs ability to
cope with the treatment and can affect parent and child
quality of life post treatment (Kazak & Barakat, 1997;
Santacroce, 2002). Parents of children recently diagnosed with cancer have anxiety levels comparable to
hospitalized persons with anxiety disorders
(Santacroce, 2002). Additionally, anxiety has been
found to be significantly correlated with measures of
posttraumatic stress (Santacroce, 2002).
From 31% to 84% of children with cancer use
some type of complementary and alternative medicine (CAM) (Kelly, Kennedy, & Weiner, 2000;
Myers, Stuber, Bonamer-Rheingans, & Zeltzer,
2005), often in an effort to reduce symptoms. In surveys
Janice Post-White, PhD, RN, FAAN, is an adjunct associate professor at
the University of Minnesota and a research consultant in complementary
and alternative therapies. Maura Fitzgerald, MS, MA, RN, CNS, is a clinical nurse specialist in integrative medicine at Childrens Hospital and
Clinics of Minnesota. Kay Savik, MS, is senior biostatistician at the
University of Minnesota School of Nursing. Mary C. Hooke, MS, RN,
CPON, is a clinical nurse specialist in hematology/oncology at Childrens
Hospital and Clinics of Minnesota. Anne B. Hannahan , MA, RN, LP, has
a private practice coaching patients and families who are adapting to cancer. Susan F. Sencer, MD, is medical director of hematology/oncology at
Childrens Hospitals and Clinics of Minnesota. Address for correspondence: Janice Post-White, PhD, RN, FAAN, University of Minnesota
School of Nursing, 707 Kenwood Parkway, Minneapolis, MN 55403;
e-mail: postw001@umn.edu.

Journal of Pediatric Oncology Nursing, Vol 26, No 1 (January-February), 2009: pp 16-28

Massage Therapy for Children With Cancer

of the use of CAM in children with cancer, massage

therapy is consistently among the top 5 therapies
most commonly used (Bold & Leis, 2001; Fernandez,
Stutzer, MacWilliam, & Fryer, 1998; McCurdy,
Spangler, Wofford, Chauvenet, & McLean, 2003;
Molassiotis & Cubbin, 2004; Post-White, Sencer, &
Fitzgerald, 2000). Massage has reduced anxiety,
depression, and cortisol levels in children and adolescents with eating disorders, depression, posttraumatic
stress disorder, juvenile arthritis, and asthma (Field,
2002; Field et al., 1998; Field, Hernandez-Reif,
Diego, Schanberg, & Kuhn, 2005). Adults with cancer have responded to massage by experiencing less
anxiety (Ahles et al., 1999; Cassileth & Vickers,
2004; Hernandez-Reif et al., 2005; Post-White et al.,
2003), less fatigue (Ahles et al., 1999; Cassileth &
Vickers, 2004; Hernandez-Reif et al., 2005), less acute pain
(Cassileth & Vickers, 2004; Hernandez-Reif et al.,
2005; Post-White et al., 2003; Grealish, Lomasney, &
Whiteman, 2000), less nausea (Ahles et al., 1999;
Cassileth & Vickers, 2004; Grealish et al., 2000), and
improved mood (Hernandez-Reif et al., 2005; PostWhite et al., 2003). The stress-relieving effects of
massage on pain and mood are proposed to occur
through the release of endogenous oxytocin (Lund et
al., 2002), serotonin, and dopamine and by decreased
salivary and urinary cortisol (Field et al., 2005;
Hernandez-Reif et al., 2005; Deigo, Field, Sanders, &
Hernandez-Reif, 2004).
Although massage is used clinically for children
with cancer, few studies have tested its effectiveness
(Beider & Moyer, 2006). In 2 studies conducted by
Phipps and colleagues (Phipps, Dunavant, Rai, Deng,
& Lensing, 2004; Phipps, Dunavant, Gray & Rai,
2005), children undergoing bone marrow transplant
(BMT) and hematopoietic stem cell transplantation
(HSCT) were randomized to professional massage or
parent massage 3 times per week or no massage.
Although massage did not reduce symptoms in 50
children undergoing BMT, children undergoing
HSCT had less anxiety after the first massage. Both
studies support the feasibility of providing massage
to hospitalized children by professional therapists
and training parents to deliver massage to their children. Field et al. (2001) found a 15-minute parent
massage effective in reducing anxiety and depression
in children with leukemia.
In a preliminary feasibility study, we provided 1
massage each to 23 hospitalized children with cancer

Journal of Pediatric Oncology Nursing 26(1); 2009

and a parent. Although children had no changes in

anxiety, pain, or nausea after 1 massage, their parents
anxiety was significantly lower, with mean scores on
the Anxiety subscale of the Profile of Mood States
decreasing from 11.7 before to 3.8 after the massage
(z = 4.2, P < .0001). No negative responses were
reported (Post-White & Hawks, 2005).
With no apparent effect observed in children after
just 1 massage, we hypothesized that repeated massage might be more beneficial, allowing the child to
become familiar with the techniques, touch, and therapist. The aims of this study were to determine
whether 4 weekly sessions of massage, compared
with 4 quiet-time control conditions, would reduce
anxiety, cortisol levels, fatigue, nausea, and pain in
children with cancer undergoing chemotherapy and
would reduce anxiety, fatigue, and mood disturbance
in a parent.

Methods
Participants
Children with cancer, 1 to 18 years of age, and 1
parent or guardian were recruited from 2 hematology/
oncology clinics and 2 inpatient units at Childrens
Hospital and Clinics of Minnesota. Children had to
be receiving at least 2 identical cycles of chemotherapy in 4- to 8-week cycles. Other inclusion criteria
3
were a platelet count greater than 20 000 mm at least
48 hours postoperatively, ability to give consent (parent/guardian) and assent (children 7 and older), and
ability to read and speak English. Following approval
by the hospital and university institutional review
boards, the research team explained the study and
obtained consent/assent.
Design and Procedure
In the 2-period crossover design, children and their
parent were randomized to the massage therapy (MT)
or quiet-time (QT) group and then crossed over to the
other condition at the same point in their next identical chemotherapy cycle. Each condition consisted of
4 weekly sessions. Follow-up assessments were done
at the end of each condition. The last follow-up
included an audiotape-recorded structured interview
with the parent and child together.

17

Post-White et al

Table 1. Timing of Outcome Measures for Children and Parents

Session
Children
Before and
after
MT/QT

Before
MT/QT
Parents
Before and after
MT/QT
Before
MT/QT

Follow-up 1,
Between
MT/QT

Follow-up
2, End
of Study

T1 MT/QT

T2 MT/QT

T3 MT/QT

T4 MT/QT

HR, RR, BP,

pain,
nausea,
anxiety,
salivary cortisol

HR, RR, BP,

pain,
nausea,
anxiety

HR, RR, BP,

pain,
nausea,
anxiety

HR, RR, BP,

pain,
nausea,
anxiety,
salivary cortisol

Anxiety

Anxiety

Fatigue

Fatigue

Fatigue

Interview
fatigue

Anxiety

Anxiety

Anxiety

Anxiety

Fatigue,
mood state

Fatigue,
mood state

Fatigue,
mood state

Interview
fatigue,
mood state

NOTE: T1-T4 = first through fourth sessions, respectively; MT = massage; QT = quiet time; HR = heart rate; RR = respiratory rate;
BP = blood pressure.

Study measures of children included presession

and postsession vital signs (heart rate, respiratory
rate, blood pressure) and self-report (parent proxy
report for age 1-2 years) of pain, nausea, and anxiety
(Table 1). Fatigue was measured before sessions 1
and 4 and at each follow-up. Parent measures
included anxiety, fatigue, and mood states.
Massage Intervention
Massage was provided in the Integrative Medicine
Clinic, at the Hematology/Oncology Clinic, or in
patient rooms. Parents received massage first and
remained in the room during the childs massage. Four
certified massage therapists with experience with
adults and children provided all massages; no child had
more than 2 therapists. A massage in progress sign
was posted on the door, and the massage was scheduled before or after treatments to avoid interruptions.
The massage protocol was developed by the
therapists. Each therapist was trained for consistent
approach and technique. The sequence of strokes
and length of massage were recorded, in addition to
any observations and comments from the parent or
child. For the parents seated chair massage, the
therapist began with the shoulders, worked down the
back, massaged the arms and hands, and finished
with the neck and head. The childrens massage

18

included the back, legs, arms, stomach/chest, and

face. The therapist gave the child the choice of
where to start on the body and whether to keep
clothes on or take them off. The strokes were the
same whether children were clothed or unclothed.
Strokes used were primarily effleurage (gently
rhythmic gliding strokes), raking (gently stroking
with the tips of the fingers), thumb stroking (shorter
strokes using the broad side of the thumbs), and
petrissage (gentle kneading). The pressure was firm
but gentle and was guided by the childs feedback
and tolerance. Surgical sites and central line locations were avoided. Biotone Advanced Therapy
unscented massage lotion (Biotone, San Diego,
California) was used. Very little conversation occurred
during the massage and no music was played.
Control Condition: Quiet Time
The child and parent participated together in the
quiet-time control condition, which was held in a
private room in the Hematology/Oncology Clinic,
the Integrative Medicine Clinic, or the childs hospital room. A do not disturb sign was placed on
the door for the same period of time as the massage.
Age-appropriate toys were provided and children
and parents read, rested, talked quietly, or watched
a video.

Journal of Pediatric Oncology Nursing 26(1); 2009

Massage Therapy for Children With Cancer

Table 2. Instruments Used to Assess Outcomes by Age Group

Relaxation
Age of child, y
1-2

BP, HR, RR

3-6

BP, HR, RR

7-13

BP, HR, RR

14-18

BP, HR, RR

Salivary
cortisol
Salivary
cortisol
Salivary
cortisol
Salivary
cortisol

Parent

Anxiety/Mood

Pain

Nausea

STAIC,
parent proxy
STAIC, child

PAT,
parent proxy
FACES

Parent
report
FACES

STAIC, child

FACES

FACES

STAI,
adolescent
POMS: subscale,
mood state

VAS

VAS

Fatigue
Lanskys Play Performance,
parent proxy
Lanskys Play Performance,
parent proxy
Child Fatigue
Scale
Child Fatigue Scale
POMS:
subscale

NOTE: BP = blood pressure; HR = heart rate; RR = respiratory rate; STAIC = StateTrait Anxiety Inventory for Children; PAT = Pain
Assessment Tool; FACES = Wong-Baker FACES Pain Rating Scale; STAI = StateTrait Anxiety Inventory; VAS = visual analog scale
(0-10); POMS = Profile of Mood States.

Outcome Measures
Measures were assessed just before and 15 to 20
minutes after the massage (MT) and control conditions (QT). Instruments were developmentally appropriate for the childs age (Table 2). Five demographic
questions assessed the childs gender, ethnicity, and
race and parent income and education.
Heart and respiratory rates were obtained by auscultation, and an electronic Dinamap (GE Healthcare,
Waukesha, Wisconsin) monitor measured blood pressure with the appropriate cuff size.
Salivary cortisol was collected according to
Dr Megan Gunnars protocol at the University of
Minnesota (Larson, White, Cochran, Donzella, &
Gunnar, 1998). Saliva was stimulated with Kool-Aid
brand crystals or sugarless gum (age 6-18 years), and
either children expressed their saliva directly into Nunc
cryotube vials (Thermo Fisher Scientific, Rochester,
New York) through a straw or a dental roll was placed
in their mouth and the saliva was extracted. Samples
were stored in a 70C freezer and analyzed together
using a standard radioimmunoassay kit, with duplicates, standards, and controls. A mean score of 2 duplicate measures was calculated for each time point.
Children were asked to avoid caffeine for 2 hours and
dairy products for 15 minutes before their appointment.
Other factors potentially influencing cortisol levels
were assessed, including amount and quality of sleep
the night before, length of time since eating, and medications taken that day. Attempts were made to schedule all sessions for each child at the same time of day.

Journal of Pediatric Oncology Nursing 26(1); 2009

State anxiety was measured with the StateTrait

Anxiety Inventory for Children (STAIC) (Spielberger,
Gorsch, Lushene, Vagg, & Jacobs, 1973) and the
StateTrait Anxiety Inventory (STAI), which is the adolescent/adult version of the inventory (Spielberger,
Gorsch, Lushene, Vagg, & Jacobs, 1983). Parents completed the STAIC for children age 1 to 6 years; children
age 7 to 8 had the instrument read to them by a parent
or investigator. The STAI has extensive reliability and
validity in children older than 8 (Cronbachs = .82.87). Although this tool is not validated in younger children, there were no other short tools that measured state
anxiety, and so a parent proxy report was used. Because
the instrument is scored on a 3-point rating scale for
children and a 4-point scale for adolescents, anxiety
scores were analyzed separately. Children also completed the trait anxiety measure at baseline.
Pain and nausea were measured with a visual analog
scale (VAS) (range, 0-10) or the Wong-Baker FACES
Pain Rating Scale (Beyer & Wells, 1989; Bieri, Reeve,
Champion, Addicoat, & Ziegler, 1990). Because the
VAS for nausea is not successful in children younger
than 9 years of age (Zeltzer et al., 1988), nausea was
evaluated the same way as pain, using 6 line drawings
of the FACES scale with descriptors assessing for
tummy upset for age 3 to 8 years, and the VAS scale
of 0 to 10 was used for children 9 to 18 years of age.
Parents completed the Pain Assessment Tool and
reported nausea for children age 1 to 2 years (Franck,
Greenberg, & Stevens, 2000; Gaffney, McGrath, &
Dick, 2003). Parent/child agreement rates of symptoms have been substantiated (Zeltzer et al., 1988). All

19

Post-White et al

scores were converted to an even-numbered 0 to 10

scale for analysis.
Parents reported fatigue in younger children using
the Lansky Play Performance Scale (PPS) (Lansky,
List, Lansky, Ritter-Sterr, & Miller, 1987), which
reports the level of the childs activity, ranging from
0 (unresponsive) to 100 (fully active, normal).
Reliability of the PPS compared motherfather
reports (r = 0.71) and parental ratings to nurses ratings (r = 0.75). Children 7 to 18 years of age completed the Child Fatigue Scale (CFS) (Hockenberry
et al., 2003), with some modification in wording for
the 14- to 18-year-old adolescents (eg, I have been
able to play changed to I have been able to do fun
activities). The CFS is a 14-item, 2-part questionnaire that asks for a yes or no (frequency) response
and a 5-point rating of the intensity of any yes
responses, ranging from not at all to a lot. The total
fatigue score ranged from 0 to 70. In 149 children,
the internal consistency estimates were .84 for intensity (Cronbachs ) and .73 for frequency (KuderRichardson formula) (Hockenberry et al., 2003).
Parent responses were measured using the 9-item
TensionAnxiety subscale of the Profile of Mood
States (POMS) for anxiety, the 15-item Fatigue subscale, and the 65-item mood disturbance overall score
(McNair, Lorr, & Droppleman, 1992). The total mood
disturbance score is reflected by 6 subscales assessing
anxiety, depression, anger, confusion, fatigue, and
vigor. Reliability of 0.90 and testretest of 0.65 to 0.74
have been established in cancer and in well adults
(McNair et al; Levy, Herberman, Lippman, DAngelo,
& Lee, 1991).
Subjective responses and observations were
recorded by the massage therapist and the research
nurse during and after the MT and QT sessions.
Two to 4 weeks following all sessions, an 8question structured interview was conducted by 2
researchers who did not collect other data. The parent and child were interviewed together to determine acceptability of the massage and quiet time
and to assess responses not captured by the instruments. Sample questions included How was the
experience of getting massage therapy during treatment helpful or not helpful to you? and How did
you feel during or just after the massage/quiet
time? Participants were also asked what the greatest benefits of each condition were, how long the
effects lasted, and in what way massage or quiet

20

time did or did not meet their expectations. Parents

and children took turns responding to each question. Interviews were audiotape-recorded and
ranged from 10 to 30 minutes.
Analysis
Descriptive statistics were used to describe
the sample and assess the distribution of data.
Nonparametric tests were used for measures that
were not normally distributed. Analysis for the
crossover design (Pocock, 1983) included testing
sequence effects for each outcome (Grizzle, 1965).
There were no sequence (order of condition) or
period (carryover) effects of the intervention, which
allowed for use of all data from both conditions and
maximal power (although small sample sizes could
miss true sequence or period effects). Area under the
curve (AUC) for all 4 sessions was computed for
pre-intervention and postintervention data for each
vital sign and for pain and nausea. The postintervention AUC was subtracted from the pre-intervention AUC and compared with the control condition
using Wilcoxons matched-pairs signed rank test.
Changes in anxiety and salivary cortisol levels were
measured pre and post MT and QT interventions at
session 1 and session 4. Difference scores were calculated by subtracting the post score from the pre
score, with Wilcoxons matched-pairs signed rank
test comparing the change between conditions at
each session. Changes in fatigue and mood were
calculated over 4 weeks and compared between and
within each condition using Wilcoxons matchedpairs signed rank tests. An intent-to-treat model was
used, with all available data from the 25 dyads
included in any analyses. Analysis was performed
using SPSS v13 or SAS v7. Results were considered
significant at P < .05.
Interviews were transcribed verbatim and evaluated independently by 3 members of the research
team. Comparative content analysis was used to
identify responses to each item, using words supplied by parents and children; categorize/group
responses; and label the themes. Key phrases were
identified and were quantified and evaluated by the
team for 100% agreement, with common themes
identified for children and parents (Morse & Field,
1995). Parent and child responses were analyzed
separately.

Journal of Pediatric Oncology Nursing 26(1); 2009

Massage Therapy for Children With Cancer

Results
Sample
Over a 1-year period, 25 child/parent dyads were
recruited into the study, with a consent rate of 50% of
eligible families. Reasons for not participating were
long distance to travel, too many extra appointments,
and a desire not to stop massage for the control condition. Eight male children failed to complete the
study because of progressive disease, because of protocol changes, or because their families changed their
minds before the first session or later. Seventeen families completed all data points.
Twelve children were randomized to MT first and
13 to QT first. Twenty sessions (16%) were provided
as inpatient. The majority of children were male
(60%) and white (86%). Most parents were mothers
(96%) with college degrees (70%) and family
income greater than $60 000 (65%). The children
had acute lymphoblastic leukemia (28%), brain
tumors (24%), lymphoma (24%), rhabdomyosarcoma (16%), Wilms tumor (4%), or Ewing sarcoma
(4%). The median time since diagnosis was 4 months
(range, 1-19 months). All children were receiving
chemotherapy.
The time between crossover periods was a median
of 35 days, with the alternate condition starting on the
same day of an identical chemotherapy cycle. Children
with leukemia had the longest times between conditions, because the identical treatment period usually
coincided with the delayed intensification phases of
treatment, separated by a 60-day interim maintenance
cycle. The time of the interview was a median of 21
days following the last study session point.
Descriptive Findings
The mean length of the childrens full-body massage was 29.2 minutes (SD 11.4) and the parents
seated chair massage was 17.0 minutes (SD 3.4). The
mean length of time for quiet time was 27.8 minutes
(SD 7.1). All parents reported liking their massage and
many noted less muscle tension (6), pain (1), and
fatigue (2) and greater feeling of relaxation (10) after
the first massage. Children often fell asleep or became
very relaxed and drowsy after their massage, with
increasing relaxation noted by the massage therapist

Journal of Pediatric Oncology Nursing 26(1); 2009

throughout the course of 4 massages. Most children

(89% to 100%) reported liking the massage at each
session. Two children, age 15 months and 5 years, did
not like massage the first session but stayed in the
study and reported liking it better over time. Two children dropped out after the second massage session: a
16-year-old who reported liking massage and a 4year-old who requested that the massage be stopped
during the second session.
Intervention Effects in Children and Adolescents
Heart rate (z = 2.4, P = .02) was significantly
lower and respiratory rate was close to being significantly lower (z = 1.96, P = .05) in response to massage than quiet time, indicating a relaxed state in
children (Figure 1). There were no significant differences between MT and QT in systolic (z = 1.7, P =
.26) or diastolic blood pressure (z = .42, P = .67),
pain (z = 1.6, P = .11), or nausea (z = 1.8, P = .07).
Mean pain and nausea scores were low (<2.0) before
and after each massage and control condition.
Changes in salivary cortisol were not significantly
different between the MT and QT conditions (Table
2). One subjects cortisol level increased from pre to
post massage (from 0.12 g/DL to 0.29 g/DL) when
he was told just after the massage that he would need
additional chemotherapy treatment that day (MT session 4). There were no differences between the MT
and QT conditions on potential contributing factors,
including reported stress level, hours of sleep the
night before, time since eating, and time between the
session ending and the cortisol collection. Despite
efforts to avoid sessions while on prescribed corticosteroids, 1 child was taking steroids during her massage
sessions; these samples were eliminated from the
cortisol analysis.
There were no differences between the 2 groups on
baseline trait anxiety, and mean values were similar to
normative values for healthy children of the same age
(Spielberger et al., 1973; Spielberger et al., 1983).
Children age 1 to 13 years had less state anxiety after
MT than QT at session 4 (P = .04) but not after session
1 (P = .15). Adolescents age 14 to 18 years had a trend
toward significantly less anxiety in response to massage at session 4 (P = .058) and no difference between
massage and control conditions at session 1. There
were no significant changes in fatigue in children over
the 4-week MT or QT conditions either independently

21

Post-White et al

15 to 131, n = 17) to 2.0 (range, 20 to 37, n = 17)

(z = 2.3, P = .02). Parent fatigue was reduced during
QT (median 11; range, 0-27; to 4.7; range, 0-19; n =
14) (z = 2.2, P = .03) but not during massage (median
8.5; range 2-22; to 6.0; range, 2-26; n = 14) (z = .25
P = .81) and was close to significance when we compared change in fatigue between the MT and QT conditions (z = 1.8, P = .07).
Interview Responses
Figure 1. Comparison of Area Under the Curve Differences in
Heart Rate Between Massage and Quiet-Time Control.

Figure 2. Comparison of Area Under the Curve Differences in

Respiratory Rate Between Massage and Quiet Time-Control.

(change over time) or when we compared fatigue by

condition.
Intervention Effects in Parents
Parent anxiety (measured before and after each session) was significantly lower after massage compared
with after the quiet time at session 1 (P = .008) and session 4 (P = .001) (Table 3). Total mood disturbance and
fatigue, measured at week 1 (baseline pre) and week 4
(post condition), tended to decrease more over the 4week quiet time than the 4-week massage, although the
differences between the massage and quiet time control group were not significant (z = 1.6, P = .10). Total
mood disturbance scores during 4 weeks of massage
decreased from a median of 19.0 (range, 21 to 68, n =
16) to 10.5 (range, 17 to 63, n = 16) (z = .60, P = .55)
compared with quiet time changes from 16.0 (range,

22

The themes derived from the interviews were that

massage reduced anxiety and stress in children and
parents by relaxing them and taking their mind off
of the stressful circumstances and reduced physical
symptoms of pain, fatigue/tiredness, and nausea in
children and muscle tension and pain in parents.
Children/adolescents. All (100%) of the children
and adolescents reported feeling relaxed and refreshed
and feeling good after the massage. The primary benefits of massage were categorized as physical (n = 9),
mental (n = 5), and emotional (n = 3). Physical benefits included feeling relaxed, feeling better overall, and
having less pain (n = 5) and nausea (n = 1). Mental
effects were reported as having a sense of calmness,
taking a weight off your shoulders, being able to
release my thoughts, feeling relaxed, and taking
stress away from thinking about the treatment.
Emotional effects included feeling special, being in
a better mood, and enjoying the moment.
The majority of children reported that the benefits lasted several hours or for the rest of the day.
There were similar responses by gender, with a mix
of physical and emotional effects for both boys and
girls. Both the younger children and the adolescents
found the most benefit from less stress and anxiety.
Parents of younger children (age 1-3 years) reported
that their children took longer to accept massage
and were more sensitive to a change in massage
therapist. Although they liked the massage better,
several children said they liked the opportunity in
QT to relax and spend time with their parent. Half of
the responses to QT were neutral or negative and the
benefits lasted only during the designated quiet
time. Children of all ages indicated they had a hard
time conceptualizing the difference between fatigue
and the feeling of being tired that they associated
with being relaxed.

Journal of Pediatric Oncology Nursing 26(1); 2009

23

13

10

15

0.14
(0.03-6.9)
28.5
(25-43)
35.0
(24-48)
7.0
(2-22)

0.13
(0.02-5.4)
27.0
(20-37)
25.5
(22-36)
1.0
(0-4)

Post,
Median
(Range)
0.14
(0.04-3.4)
28.5
(20-31)
40.5
(27-53)
7.0
(1-18)

Pre,
Median
(Range)
0.15
(0.04-10.9)
24.5
(20-32)
35.0
(23-51)
4.0
(1-11)

Post,
Median
(Range)

QT T1

2.7, .008

0.95, .34

1.4, .15

0.11, .91

Wilcoxons
MatchedPairs
Signed
Rank
Test, z, Pa
Post,
Median
(Range)

0.143
0.12
(0.04-0.38) (0.05-0.47)
10
29.5
26.5
(23-40)
(23-37)
6
30.0
25.0
(22-44)
(22-33)
15
7.0
1.0
(1-16)
(0-6)

14b

Pre,
Median
(Range)

MT T4

0.15
(0.08-0.69)
29.5
(20-33)
22.0
(5-31)
4.0
(0-13)

Pre,
Median
(Range)

0.15
(0.06-0.28)
28.5
(20-34)
24.5
(21-42)
1.0
(0-10)

Post,
Median
(Range)

QT T4

3.3, .001

1.9, .058

2.1, .04

.63, .53

Wilcoxons
MatchedPairs
Signed
Rank
Test, z, Pa

NOTE: T1 = first session; MT = massage therapy; QT = quiet-time control condition; T4 = fourth session; STAIC = StateTrait Anxiety Inventory for Children: range, 20-60;
STAI = StateTrait Anxiety Inventory: range, 20-80; POMS = Profile of Mood States, Anxiety subscale: range, 0-32.
a. For Wilcoxons tests, the values reported for each session are reported as median and ranges; the test of significance compared pre and post differences between MT and QT
at each time point (sessions 1 and 4).
b. One subject on exogenous prednisone was eliminated from cortisol analysis; only subjects with data at all time points are reported.

Cortisol, g/
DL
Anxiety,
STAIC, 1-13 y
Anxiety, STAI,
14-18 y
Parent anxiety,
POMS

Pre,
Median
(Range)

MT T1

Table 3. Comparison of Effects of Massage (MT) and Quiet Time (QT) on State Anxiety and Salivary Cortisol Levels Before and After Sessions 1 and 4

Post-White et al

Parents. All (100%) of parents reported that massage made them very relaxed, they had less tension, they were more calm, and it took their mind
off of things. Parents reported feeling less tense and
anxious and had a greater sense of calm for the rest of
the day (n = 11) or through the next day (n = 2). More
parents (n = 8) than children (n = 5) enjoyed the quiet
time. Several mothers liked the chance to relax and
calm down, with time to catch up, organize their
thoughts, and spend time with their child.

Discussion
This study showed that providing massage to children with cancer is feasible. Although 2 children
dropped out because they did not like the massage,
most children reported that the massage reduced
stress and was relaxing. It was possible to deliver
massage in outpatient and inpatient areas in a manner
that was calming and relaxing for the child but did not
limit the ability to perform nursing care.
The most significant finding was the consistent
lowering of anxiety in parents receiving massage.
Just one 15-minute seated chair massage reduced tension and anxiety in parents. Allowing the child to
remain in the room for parent massage did not interfere with the parents relaxation and might have
helped them to not worry about their child.
As a group, parents in this study did not exhibit
high levels of anxiety. Baseline parent anxiety levels
ranged from 1 to 22, with a mean score of 7.0 before
massage or quiet time. This score is lower than mean
normative values for women as outpatients (8.8), college students (12.9) and psychiatric patients (20.7)
(McNair et al., 1992). Although the mean scores for
anxiety were not high, there was room to lower tension and anxiety with massage and quiet time. Parents
with high levels of anxiety (eg, scores of 13-22)
should be identified for intervention. A 15-minute
seated chair massage may be effective for reducing
tension, exhibited as feeling tense, shaky, on edge,
uneasy, restless, nervous, anxious, or panicky.
The effects of massage on children were less clear,
attributable in part to study limitations. The small
sample size reduced the power to detect a difference
in highly variable outcomes, such as cortisol, and
the use of different instruments and discrepant scoring of mood states and symptoms limited the ability

24

to analyze the entire sample together. Despite these

limitations, the study provided preliminary evidence
for the effectiveness of massage in reducing anxiety
in children, especially for children younger than age
14. The greatest benefit was observed at session 4,
presumably after they became more comfortable with
massage. In contrast, Phipps et al. (2005) found that
anxiety was lessened in transplant patients with the
first massage. Although it might vary with children,
offering more than 1 massage is likely to increase the
benefit over time.
Lower anxiety is a consistently documented
response to massage in adults with cancer (Corner,
Cawley, & Hildebrand, 1995; Ferrell-Torry & Glick,
1993; Kite et al., 1998; Wilkinson, Aldridge, Salmon,
Cain, & Wilson, 1999) and children with asthma
(Field et al., 1998; Field et al., 2005) and behavioral
conditions (Field, 1995). Childrens anxiety levels in
this study were similar to those reported by Field and
colleagues (2001) and the normative mean values
reported for elementary (mean 30.7-31.0) and high
school children (mean 39.5-40.5) (Spielberger et al.,
1973; Spielberger et al., 1983). Anxiety after massage
was lower than the reported norms in healthy children. The findings of reduced stress and anxiety are
supported by the qualitative responses and most
likely reflect true effects.
Massage was more effective than quiet time in
inducing a relaxed state. Some of these effects, however, could be explained by a recumbent position and
silence during the session. Although many children
were lying down during the quiet time, it was difficult
to simulate the conditions of a massage session, especially in younger children.
Lack of significant differences in cortisol may be
attributable to small sample sizes or individual variability (large standard deviations). We detected small
changes of 0.03 to 0.04 g/mL presession to post-session. Other massage studies reported decreases in
salivary cortisol of 0.2 to 0.7 mg/mL in children with
asthma (Field, Henteleff et al., 1998), although some
citations only report percentage change rather than
absolute values (Field et al., 2005). Cortisol is
reported to be a valid correlative measure of anxiety
when anxiety levels are high (Boudarene, Legros, &
Timsit-Berthier, 2002). Reporting group scores of
small samples may preclude detection of significant
changes when only a few individuals have high anxiety. Alternatively, blunted cortisol changes might

Journal of Pediatric Oncology Nursing 26(1); 2009

Massage Therapy for Children With Cancer

reflect an underlying stress condition in which the

adrenals are less able to respond to reactive stressors
(Elzinga et al., 2008).
The lack of effect of massage on symptoms is consistent with findings by Phipps et al. (2004, 2005).
Massage might not be the most effective intervention
to reduce pain and nausea in children. In our preliminary feasibility study, we found that children who
were in pain or had significant nausea did not want to
receive massage. The low levels of nausea and pain in
this sample might preclude any chance of improvement. The difficulty some children had in differentiating fatigue from being relaxed underscores the
challenge of measuring fatigue in children. Some
children interpreted being tired or relaxed as having
greater fatigue because they felt like lying around and
sleeping or felt unmotivated to do their usual activities, all measures of fatigue in the instrument used in
the study.
Intervention research in children has unique issues.
The need for scientific rigor, such as standardization
of the intervention and consistent timing of sessions,
had to be balanced with consideration for the childrens need for control, their health status, and their
well-being on any given day and for the families
already overwhelming schedules. Several issues
affected our ability to obtain complete and evaluable
data, including recruitment of an adequately powered
sample from a single institution in a reasonable time
frame, retention of subjects with protocol changes
and progressive disease, and measurement issues for
children of all ages. These issues make us question
the feasibility of conducting a single-site massage
study in children with cancer.
Recruitment into the study was not hampered by a
lack of interest in massage but was limited by the
demands of additional appointments or extended
treatment appointments to accommodate the sessions.
Fifty percent recruitment into a CAM intervention
study is better than some CAM intervention studies in
adults (Richardson, Post-White, Singletary, &
Justice, 1998). The crossover design has the advantage of less variability within subjects and has been
used successfully for adults with cancer (Post-White
et al., 2003). However, the length of the study was a
barrier to recruitment and retention in this population.
Chemotherapy protocol changes resulted in 2 children not being able to complete the study because
they were ineligible for the crossover phase of the

Journal of Pediatric Oncology Nursing 26(1); 2009

design, in which the chemotherapy was required to be

identical to the first condition. Recruitment also was
slowed by the change to 1 delayed intensification
phase in most children with ALL, resulting in fewer
crossover periods the first year of treatment.
Although multisite studies introduce other confounding factors, the use of multiple sites may be necessary
to recruit and retain enough participants in a homogenous sample for powered studies of massage in children with cancer.
The inclusion of a large age range was purposeful.
We wanted to know whether it was feasible to conduct
massage studies in children of all ages. Although children of all ages accepted massage and diligently completed the study, assessing subjective symptoms in
preverbal children was challenging. Our recommendations for future study would be to design separate studies for children 6 years and younger, with a focus on
immediate premassage and postmassage responses,
rather than responses over time. Videotaping of behavioral observations would be a more reliable assessment
of response in this age group.
The small sample size and diversity of measurement
instruments caution against drawing conclusions without further study. These findings are not generalizable
beyond this sample. Small sample sizes and low statistical power are common problems in pediatric massage
research (Beider & Moyer, 2006; Phipps et al., 2004;
Phipps et al., 2005), along with lack of standardization
for dose, frequency, or style of massage (Underdown,
Barlow, Chung, & Stewart-Brown, 2006). Efficacy
studies in children with cancer should include a more
focused age range and multisite recruitment to attain
an adequately powered sample size.
Despite these limitations, this study has several
strengths. A crossover design allows greater power
with smaller sample sizes and eliminates heterogeneity between the control and intervention groups. It
also offers an incentive for families who want the
intervention or who do not want to commit to a study
if they might be in the control-only condition.
Including parents in the massage intervention may
have enhanced the younger childrens acceptance of
and comfort with massage and provided a much
needed stress-reducing therapy for overwhelmed parents. The inclusion of an interview validated the
reduction of anxiety after massage and provided
insight into the experience of accepting massage for
children with cancer and their parents.

25

Post-White et al

Conclusion
This study supported the feasibility and acceptability
of therapist-provided massage in children with cancer and
their parents and provided preliminary evidence for
reduction of anxiety and increased relaxation. Benefits to
children less than 3 years of age were more variable, and
parent-provided massage might be more accepted and
effective in young children. Larger studies are needed to
determine the effectiveness of massage to influence
symptoms. Because of small populations of children with
cancer at any given location, multisite studies are needed
to accrue sufficient numbers of participants to more confidently assess the influence of massage on clinical outcomes as well as on family functioning and distress.

Acknowledgments
We greatly appreciate the sensitive touch and care of the
expert massage therapists: Lisa Baker, Barb Cant,
Candace Linares, and Gretchen Zachel. We are indebted to
our families, who dared to venture into new experiences
and gave generously of their time and spirit. This study
was supported by funding from the American Massage
Therapy Association, the Pine Tree Apple Tennis Classic
of Childrens Hospital and Clinics of Minnesota, and an
American Cancer Society Professorship of Oncology
Nursing (JPW). All authors have no financial or personal
conflicts with the study or its results.

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