Massage therapy in palliative care populations: a narrative review of literature from 2012 to 2022

Introduction

Palliative care provides holistic expert symptom management for patients and families facing serious illness such as cancer, heart disease, multiple sclerosis, or kidney disease across care settings. According to the National Institutes of Health, palliative care refers to the management of physical and emotional distress caused by severe illness and is administered simultaneously with the ongoing treatment for the illness (1). Palliative care assists not only in enhancing the quality of life of the patient but also supports the patient’s family members. As such, many such patients experience lower quality of life (QOL) due to moderate-severe pain or other symptoms and require strong pharmacotherapies—often controlled substances such as opioids or benzodiazepines—to alleviate associated distress. A major tenet of quality supportive care is the combination of many types of therapy, both pharmacologic and nonpharmacologic. Some professional society guidelines now advocate for inclusion of massage therapy, as a leading integrative therapy, into symptom management in serious illness (2-4). However, broad implementation of massage therapy remains challenging, limited in large part by comparative cost, availability of practitioners, and weak evidence to support use of massage therapy (5,6).

Therapeutic massage—herein is defined as “the application of massage and non-hands-on components, including health promotion and education messages, for self-care and health maintenance; therapy, as well as outcomes, can be influenced by: therapeutic relationships and communication; the therapist’s education, skill level, and experience; and the therapeutic setting (7)”—is an increasingly common integrative modality used to improve quality of life across the United States (8). Clinical evidence supporting massage to improve the experience of living with serious illness has been evolving for several decades. For example, a now seminal retrospective study published in 2004 measured the impact of massage therapy to mitigate pain and other common symptoms in outpatient and inpatient cancer populations at a large, urban comprehensive cancer center (9). The study showed improvement in symptoms of pain and anxiety of 50% or more in both inpatient and outpatient settings and demonstrated, given the initial sample size of more than 1,000 patients, that the delivery of the service was more than feasible. In addition, no adverse effects were reported. A 2008 randomized controlled trial of massage versus light touch delivered to patients with breast cancer receiving home and inpatient hospice services showed again that the delivery of massage therapy was feasible and safe (10). In both studies, massage therapists provided a patient-centered, real-world intervention adapted in real-time to the needs of the patient. In the time since these major studies, neither massage therapy integration nor massage therapy research have progressed impactfully.

The durability of treatment effects for massage therapy interventions are often temporary, with effect duration varying between lasting a few hours after the intervention (9-14) to holding as long as 4 weeks after treatment delivery (15,16). For the seriously ill however, even temporary relief is a welcomed experience and can improve tolerance and outlook (17). Research over the last decade has demonstrated that massage therapy can be feasibly delivered across care settings to patients experiencing a wide variety of states of serious illness (18-20). Current data suggest there is therapeutic value in the incorporation of massage therapy in the care of these patients (9-21). Considering the slowly growing acceptance of massage interventions applied in palliative-eligible populations, along with the need to collate a stronger evidence base, a synthesis of current and related massage therapy research is needed. Existing reviews include massage therapy among other integrative therapies, including other “touch therapies” such as reflexology and Reiki, and thereby lack the focus intended with this review. Currently, no review exists that looks specifically at research measuring massage therapy as a discreet intervention when it is not offered with other integrative interventions like aromatherapy or when it is not compared with other integrative interventions. Our interest is in isolating massage therapy research designed to measure the impact of massage therapy alone and/or compared with standard care.

The intent of this narrative review is to summarize how massage therapy delivery is described and incorporated in clinical research with serious or advanced illness populations, regardless of underlying diagnosis, and highlight existing evidence gaps specific to patient experience, effective management of coexisting symptoms beyond pain and to specific positive outcomes conferred by improved quality of life. This work seeks to improve awareness of opportunities to deeply engage massage therapy and massage therapists into interdisciplinary care for palliative-eligible patients. This work was conducted in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-23-126/rc).

Methods

A literature search of PubMed was conducted for publications circulated between 01/01/2012 and 12/31/2022 (Figure 1). Search term combinations focused on the intervention of interest (e.g., “massage”, “massage therapy”) and the patient population of interest (e.g., “palliative care,” “advanced illness”, “serious illness”). Search terms “therapeutic touch”, “touch massage”, “reflexology”, “aromatherapy”, and “reiki” were intentionally excluded as the focus of this review is not integrative therapies broadly, but specifically massage therapy.

Figure 1 Search procedure for narrative review.

Titles and abstracts were reviewed to determine relevance for inclusion (Table 1). An article was included for consideration if it reported a clinical study of a patient population with serious or advanced illness that primarily employed massage therapy, without aromatherapy, as the intervention of interest. Articles focusing on non-massage interventions (e.g., discrete aromatherapy, reflexology, Reiki, healing touch), on non-adult populations with serious illness, and/or were not published in English were also excluded. Additional articles were included following a manual review of references. Upon manuscript completion, the Narrative Review Reporting Checklist was saved and finalized.

Results

A total of 7,259 results were discovered in PubMed with the use of “massage” as the keyword inclusive of the review period 2012 to 2022. This number decreased to 1,882 when limited to clinical studies/trials, meta-analyses, and systematic reviews. Further restriction to “massage” and “palliative care” yielded 28 results. These results were reviewed by the authors and restricted to only those in which massage was a primary study focus (e.g., studies focusing on acupuncture or aromatherapy were excluded). Articles discovered in references meeting the inclusion criteria and that were not identified in PubMed, were included in the review. Table 2 summarizes the literature included in this review (N=13).

Variability across included articles was the key finding in this narrative review and is presented within four categorizations: study outcomes, massage providers, intervention specifics, and population. Each variability categorization highlights an aspect of research that is essential to understanding the impact of massage therapy in this population. These variabilities result in unique and specific challenges to how the research informs and is applicable to massage therapy as part of the care for patients experiencing advanced and serious illness.

Study outcomes

Primary outcome measures used in the reviewed studies vary widely and challenge general synthesis. Outcome measures include biomarkers (e.g., salivary cortisol and alpha-amylase), physiological indicators, including arterial pressure, vital signs, dyspnea, leg cramping, and spasticity (12-14,16,21). Quality of life and psychosocial metrics were captured with the State Trait Anxiety Inventory (STAI) (12,13), and a variety of modifications of validated scales including the Health Status Questionnaire (modified from the McGill Quality of Life Scale) (16), an adaptation of Giasson’s Well-Being Scale (14), and the Kidney Disease Quality of Life Short Form (KDQOL-SF) (18). Finch et al. measured self-efficacy in multiple sclerosis patients using the Multiple Sclerosis Self-Efficacy (MSSE) survey (15). Pain is included as a discrete primary outcome measure in three of the included trials with each using a different measurement tool to assess the degree to which pain interfered with function or quality of life (14,16,26).

Reviewed literature demonstrates a common, reductive view not only of massage therapy, but also the experience of patients living with serious illness. Symptoms like pain and anxiety are measured separately and without the benefit of qualitative data to explore patients’ experience of the relationship of their symptoms to each other in many of the included articles (11-15,25,26). Eight of the ten trials included were conducted with a population living with a specific diagnosis (11,12,15,16,18,21,24,26). Each lacked exploration of other conditions with which these individuals may be living or the potential impact of those other conditions on overall symptom burden. In addition, as is highlighted by Armstrong et al., the quality-of-life measurement tools used in many of the studies include questions about factors, such as spending more time with family and financial or work concerns, that could not reasonably be ameliorated by even the most skillfully administered massage therapy intervention (5). Certainly, these factors are important to quality of life, but including them in the measurement of impact of a massage therapy intervention may hinder sensitivity of the tool to detect change specific to the intervention.

Several studies demonstrated that the state of peacefulness or relaxation achieved through massage therapy allowed patients to better tolerate pain or other physical symptoms or emotional distress (14,17,20). Mitchinson’s study examining the effect of massage therapy on pain, anxiety, dyspnea, relaxation, and inner peace in veterans included “pain unpleasantness” allowing for exploration of patients’ subjective experience of symptoms (14).

Given that patients receiving palliative care live with an average of four comorbidities (27), future studies would do well to reflect this reality and to acknowledge the multifactorial and symbiotic relationship of symptom clusters (26). It is understood that anxiety impacts a patient’s experience of pain and that symptoms like shortness of breath can exacerbate depression and anxiety (12) and that the combination of these symptoms can adversely impact sleep quality and other aspects of experience inherent in positive quality of life (22). Discrete measurement of symptoms that occur in relationship to one another limits our ability understand and measure the impact of massage therapy on the undoubtedly complicated and multifactorial realities of patient experience. Miladinia et al. (24) is the only study in our review that addressed symptom clusters and there is a decided lack of qualitative data to capture the patients’ experience of the intervention itself, even in this study.

Sample size

Three of the 10 papers (not including qualitative and reviews) in this review have a sample size greater than 100 patients (11,22,24). These studies are outliers in the current body of literature where sample sizes tend to range between as few as 15 to just under 100 (11,15,16,23). Inadequately powered studies can point toward new directions for research, but the authors of this review did not recognize a trend of replication or expansion among published studies, regardless of sample size. None of the studies included in this review highlighted inadequate power as a possible limitation.

Variability in providers of massage intervention

A wide range of providers delivered the massage interventions included in this review. Of the ten total trials included, one does not specify the discipline or training of the clinician who provided the intervention (24), two use massage therapists trained in basic techniques (15,16), five studies employed other providers (nurses, nursing assistants, physiotherapists, massage students) (11-13,25,26), and two had specially trained massage therapists (with population-, setting-, or diagnosis-specific focus) provide the interventions (14,21).

The role and training of the intervention provider as a member of the team is rarely explored or described in the literature. Four of the ten trials in this review found massage therapists providing the study intervention (14-16,21). Mastnardo (21) and Mitchinson (14) share specific details about the broader role and specific training of the massage therapists in the care studied. The Berger and Kelemen mixed-methods (26) and qualitative (17) studies speak to specific training of the intervention providers in aspects of care like therapeutic relationship, specifics of serious illness, hospital-based practice and/or participation, with additional mention by Mitchinson (14) about the participation of the massage therapist in interdisciplinary rounds.

Given the collaborative and interdisciplinary nature of palliative care, future studies of massage therapy could include measures of the benefit that an integrated, palliative-trained massage therapist brings to the scope and continuity of care beyond the intervention itself. This could be assessed through interviews of fellow practitioners on interdisciplinary teams as well as gathering impressions from patients and family members.

Study intervention variability

Reviewed trials demonstrate wide intervention variability with a range of approaches to the hands-on mechanics of the intervention. Strict hands-on protocols in terms of timing and/or specific stroke and direction were employed in four of the ten reviewed studies (11,13,16,26). Two reviewed studies used real-world intervention applications that allowed for patient preference, patient/practitioner interaction, and attention to comfort in the environment when allowable (14,15). Among the two qualitative studies (17,25) and one mixed method study (26), little specificity is conveyed regarding intervention mechanics. One does not include any details about the mechanics of the intervention (25), one was intentionally unscripted, but the study’s authors indicated that this unscripted design was crafted to facilitate individualized co-creation of the massage intervention by the patient and practitioner (17), and the third described not scripting the hands-on aspects while also highlighting therapeutic relationship and skillful touch as integral program attributes (26). Of the two that described reasoning for their intervention approach, Kelemen et al. rationalized not using a detailed protocol because “effective massage delivery requires massage treatment ‘outside the norm’—that is to say, flexibility in timing and delivery given interruptions, noise, physical constraints, etc. …” (17). Patients in the Kelemen study also identified massage therapists’ ability and flexibility to adjust pressure as an important treatment component. Berger et al. noted that providing psychological assistance and spiritual guidance are the duty of the members of the palliative care team; furthermore, patients tend to ask questions and share their thoughts and feelings (26). While intervention variability exists among the included studies, a few speak directly to the value of the massage practitioner’s presence beyond the discreet intervention, when the provider is a massage therapist.

Three of the trials had interventions provided by a single person (12-14). Backus et al. noted their attempt to ensure all interventions were provided by a single practitioner, but they indicated that they were not always successful (16). Finch, Schaub, and Mastnardo all employed multiple practitioners, but none provided information about specific intent to support or avoid a provider/recipient dynamic resulting from the same provider engaging with the same patients throughout the study period (11,15,21). The remaining three trials did not specify how many providers were involved in delivering the intervention or allude to concerns to control for “therapist effect” (15,22,24).

Exploration about the possible benefits or drawbacks of a dynamic in which subjects receive massage from a variety of providers throughout a study versus from a single provider is largely missing from the reviewed studies, but contradictory concerns were noted. Both Schaub and Finch noted it as a possible limitation in their studies that the same patient received interventions from different nurses or massage therapists (11,15). On the other hand, Mitchinson noted the delivery of all interventions by a single massage therapist as a limitation (14). While generalizability challenges exist for effectiveness research using a single practitioner to deliver all interventions (28), continuity of care and therapeutic relationship is perhaps more easily cultivated when treatments are provided by the same clinician (29,30). None of the reviewed studies directly evaluated or discussed the possible therapeutic value of provider continuity. This information would be important to consider in terms of staffing for massage therapy integration.

Studies that employ a strict protocol understandably desire standardization for replicability. Still, it is possible that essential aspects of the interpersonal, patient-centered value of an intervention like massage therapy are not captured in this structure. As Armstrong et al. note, not all interventions, especially those that are complex, are suited for strict standardization (5). Future research about the use of massage therapy in palliative populations should consider this guidance carefully.

Heterogeneity across studies was found regarding setting, intervention dosing, and timing of data collection. Two studies taking place in the intensive care unit (ICU) involved interventions on consecutive days (12,23). Two studies involved weekly interventions: one for 6 weeks (16), and one for 8 weeks (15)—in an inpatient rehabilitation facility and a student massage therapy clinic, respectively. One study involved a single dose (30 min) of massage therapy in an ICU (13). Another involved multiple massage sessions in both inpatient and outpatient settings, but the data presented in the study looked only at the first encounter (12). Two trials took place in outpatient dialysis centers (21,22). In one study, the intervention was delivered multiple times per week (frequency not specified) and each intervention involved massage of unspecified duration focused on the lower back and lower legs (22). The interventions took place at the beginning of dialysis and again every hour for each of the four hours of the dialysis process, ultimately resulting in four mini-interventions in close succession within each documented, 4-hour encounter. As a result, patients may have been receiving up to twelve small interventions each week, but this is not clear. In the other dialysis study, patients received a specific 20-min lower leg massage protocol three times per week for 2 weeks (21). Finally, Miladinia et al. conducted a study in an outpatient oncology setting specifically geared to explore dosing strategies (24). The study compared six intervention arms with patients randomized to receive massage therapy either twice per week or three times per week and either 15, 30, or 60 min of massage therapy for four weeks with a usual care control arm.

Data collection timing varied among the reviewed studies and included simple, immediate pre- and post-intervention measures as well as more complicated schemes of pre-, post-, time point, and intra-intervention data collection. Among the ten reviewed trials, seven different data collection and follow-up strategies were employed. Three studies used a simple immediate pre- and post-intervention data collection strategy (12,14,25). In their ICU study, Alves da Silva et al. employed immediate pre- and post-intervention data collection as well as a follow-up at 30 min post-intervention (13). Three studies collected baseline data at the beginning of the study and the only other data collection point was at the end of the study with study lengths of 2 weeks (21), 6 weeks (16), and 8 weeks (22). In Miladinia’s dosing study, data were collected at baseline, weekly during the intervention period, and weekly throughout a 4-week, non-intervention follow-up period (24). Hsu et al. took baseline measures and then daily measures were collected at an unspecified time during the three-day study period (23). Patients in Hsu’s study also wore actigraphs throughout the study to measure sleep quality and duration. The data collected through actigraphy was compared with data collected by nurses trained to observe and track patients’ sleep, however it was also noted that nurses’ observations of sleep were not often accurate. In Finch’s 8-week study, data were collected at baseline, mid-study, end of study, mid-post-study (4 weeks post-intervention) and end-post-study (eight weeks post-intervention) (15). Schaub et al.’s trial represented the most complex process, measuring agitation in addition to salivary cortisol and alpha-amylase levels (11). Cortisol and alpha-amylase were collected at pre-intervention and both 20 and 40 min post-intervention, while agitation was measured immediately before the intervention, during the intervention, and 3 hours after the first, fourth, and seventh intervention; essentially once each week during the 3-week study period. The authors of the four reviews noted that the follow-up strategies of the studies they reviewed were also varied (5,31-33). Some of these variations can be accounted for by the requirements of the measurement tools in use, but it is unclear why researchers made the choices they made regarding the frequency or timing of data collection in most of the studies included in this review. Future research would benefit from a more complete explanation of the rationale for various collection strategies, particularly given that many massage therapy studies indicate that the effects are temporary.

Study participant populations

Demographic data in the reviewed trials lack useful detail. Four are limited to factors like age, sex, diagnosis and other disease-specific data (11,15,16,24) with one including body mass index as well (19). Information about marital status, education level, and socioeconomic status were included in four trials (12,14,22,23). Race and ethnicity were captured in two (14,21) of the trials, but Mitchinson et al. captured only “white” as a race indicator with 89% of participants identified as white. There is no specific breakout of the distribution of non-white participants in this study and more than 97% of participants were male. The authors note that this is a possible limitation of the study, as female veterans make up 30% of the population of veterans who receive care through the Veterans Health Administration (34). Broader, more inclusive demographic data in future studies will support our understanding of the impact of massage therapy interventions on patients of varied socioeconomic status, race, and ethnicity. These factors are increasingly understood as determinants of likelihood to access and receipt of effective healthcare (35-38). As such, it will be important for future research to describe the patient population more specifically regarding these factors so identified disparities can be addressed.

The exclusion criteria of many trials may also benefit from closer examination and expansion when it comes to palliative care-eligible populations. Presence of comorbidities (23), limb amputation (13), dementia (12,23), low platelets (23), recent surgery or history of surgery (13,23), hearing or sight problems (12,23), and wounds (13) were all factors that excluded patients from participation in the included studies. The researchers’ decision to exclude these patients makes sense as these conditions could be confounding variables. Nevertheless, low platelets, surgery, and wounds, for instance, are commonplace among these (23) and, with appropriate adaptation of massage therapy, should not exclude patients from receiving massage. Future studies could benefit not only from listing these exclusions as possible limitations when they occur, but also by considering the inclusion of patients who are experiencing these issues. In the case of challenges like hearing or sight impairment, additional exploration of the impact of massage therapy among these patients is certainly warranted, perhaps as a discrete study population within palliative care.

It is important to note the prevalence of some level of bias in a majority of the studies in this review. The intervention provider collected the data in three of the ten included trials (12-14). It was not made clear who collected the data in two (22,23) of the trials and three studies relied heavily on patient self-report instruments, including a researcher-generated paper journal (15,21,24). Backus et al. employed a study coordinator (16) and Schaub et al. indicated that “research team members” handled data collection (11). It is notable that all four of the included systematic reviews reported potential for bias as a limitation that was omnipresent in the body of research (5,31-33). Future study designers would be wise to include funding to support objective data collection. There is also likely value in establishing validity and patient comprehension and competency checks when using patient self-report tools.

Discussion

This narrative review explores the use of massage therapy with patients affected by serious illness and reveals an array of data gaps that would benefit from further exploration and focus. Patients affected by serious illness experience multiple symptoms simultaneously and those symptoms impact each other and a patient’s experience of their illness in a way that is unique when compared with more robust populations. The studies reviewed here primarily measured symptoms discreetly and were limited by the need to use adapted, shortened or novel, but unvalidated measurement tools to assess the intervention’s effect on symptom burden and quality of life. Most studies were subject to bias and did not employ real-world interventions that support models of effective implementation. The volume of data about massage therapy in the serious illness population has undoubtedly grown in the last decade, but the ability of that data to translate into practice has not.

Of concern, racial and ethnic demographics explored in the reviewed studies demonstrate a lack of focus on the growing and underserved population of patients of color. The Center to Advance Palliative Care noted marked disparities in the experience and treatment of pain in Black patients (38). As a currently non-standard form of pain and symptom management, massage therapy could be uniquely positioned as an addition to the suite of services offered to Black and brown palliative care-eligible patients of color who are historically distrustful of mainstream medicine (39,40).

The literature reviewed in this narrative finds research subjects receiving care in inpatient palliative care units/facilities (14,17,26), intensive care units (12,13,23), outpatient and inpatient oncology settings (24), dialysis centers (21,22), a massage school clinic (18), post-stroke recovery facilities (25) and inpatient geriatric psychiatric centers (11). Five studies in this review used non-massage therapists to provide interventions, reflecting a basic lack of feasibility with the assumption that nurses, nursing assistants, or other traditional allopathic care providers could be expected to add massage therapy to their already burdensome workloads (11-13,23,24). The responsibilities carried by modern nurses has been an increasing area of concern over the last few decades, but certainly something to consider with an even sharper focus in a post-pandemic healthcare system (41-43). Proponents of massage therapy may reflect times past when nurses provided nightly back rubs as a part of standard patient care. Indeed, massage therapy was once part of physician and nurse training and delivery repertoire in the 1800s and early 1900s (44,45). Reference to such nostalgia speaks not to the feasibility of nurses or doctors returning to this historic practice, but to the long-held belief that massage, and touch delivered through massage, is valuable and integral to the provision of comfort and care, contributing to a positive patient experience. Massage therapy provided by healthcare workers whose responsibilities already exceeds practice time allotments is not a sustainable or feasible approach to delivering massage therapy within palliative patient populations (41-43). In addition, Schaub et al. reported study outcomes for hand massage provided by nurses in an acute geriatric psychiatric unit, noting particular challenges including the fixed time within a busy schedule that could sometimes cause nurses to have less patience and empathy for the patients they were expected to massage (11). Patients were further noted to not necessarily want massage at planned times or at all, wanting seemingly instead to spend the contact time chatting with the nurse providing the massage; essentially, desiring to socially engage with their massage provider. Schaub also indicated the likelihood that some patients in their study had less affinity with intervention-delivery nurses which could have potentially impacted patient and/or clinician willingness to engage in the massage intervention (11). Studies that measure the impact of protocol-driven massage provided by caregivers other than massage therapists do not provide practical evidence for a future in which massage therapy as a discipline, with its related physiological and spiritual benefits, is a standard aspect of patient-centered care for palliative populations (5,26,46).

Most studies of massage therapy lack the necessary scientific rigor, sample size, and/or focus on measures appropriate to the improvement of outcomes and experiences of palliative care patients (5). Few studies in this review seek to investigate effective, sustainable implementation of massage within a realistic healthcare context. Rather, the existing body of literature seems to reflect a frantic, worldwide effort to provide “more data”, while the lack of financial drivers (47-49), limited specialized education and training for massage providers (2,44), and limited systems integration persists. Many clinical research studies focused on massage are plagued with small sample sizes (9,11,13,15,16), moderate to high risk of bias (10) and inadequately nuanced tools (5) to measure possible improvement in patients’ outcomes or quality of life through reliably available, massage therapy or palliative-trained massage therapists. Despite multiple published guidelines and recommendations (3) for the incorporation of massage therapy into mainstream care, existing evidence is challenged by lack of large, randomized trials.

Without exception, the duration of the studies explored in this review is short and the frequency of interventions is variable. Some employ a single intervention (13,14). Others measure the impact of interventions over a period of weeks with some follow-up in the weeks after the intervention has been discontinued (11,15,16,21,22,24). If massage therapy is being asked to “compete” with other symptom management interventions like physical therapy and pharmacology, studies need to demonstrate parity and include massage intervention approaches with more frequent durations reflective of a symptom management approach. The standard of care for other interventions is daily at least, and typically multiple times per day. It would be unethical to offer a patient an opioid for pain management or rehabilitation twice a week. It is neither reasonable nor useful to hold massage therapy to a different standard. In addition, the publication of more studies comparing integrative therapies like Reiki, aromatherapy, and Therapeutic Touch to each other does not advance the implementation of integrative therapies. These modalities will be empowered to serve the future of care more effectively if measured against or as augmenting the benefits of established standards of care.

Summary

This review highlights problematic and pervasive shortcomings in recent existing research about the use of massage therapy with palliative care-eligible populations. Research questions and outcome measures that do not support a greater understanding of the impact of massage on patient experience, on other members of the care team, or on hospitals’ and care teams’ abilities to implement massage therapy are problematic. Short-duration, small-sample study designs generate more data, but not necessarily more valuable data.

Several overarching modifications to research approaches for massage therapy within the palliative context can improve the value of evidence moving forward. Qualitative data and even some quantitative data demonstrate the potential for massage therapists to engage patients across the domains that adversely affect quality of life. As such, resources should be placed with well-designed, appropriately powered research that moves beyond the confines of the randomized controlled trial and which makes room for and deeply explores the nuances of the illness experience and what improves it. Additional, thoughtful, forward-thinking research will be essential to gathering the data necessary to ensure the proper integration of massage therapy and massage therapists into standard palliative care.

One key action that should be taken in the near future is the validation of new measurement instruments specific to the effects of massage therapy that have been highlighted in qualitative analysis. When researchers are required to use modified versions of tools that were designed to measure standard interventions like function after surgery and pharmacotherapy, the unique value of massage therapy is likely to be misinterpreted or overlooked entirely.

Mixed-methods study designs that combine qualitative and quantitative data will be indispensable to a strong future for massage therapy in palliative care (29,50). These studies should be supported by the funding necessary for appropriate analysis of the interplay between the real-world factors that influence the most common and burdensome symptoms experienced by palliative patients such as comorbidities, polypharmacy, social support, and patient perspective. In addition, appropriate levels of funding should be available to support unbiased data collection by researchers who are not also intervention providers.

Massage therapy dosing needs to be studied more fully, more rigorously, and in real-world care environments. The ideal palliative care trajectory is that a patient begins receiving palliative care from the moment of diagnosis with a chronic or serious illness (51,52). Millions of patients will benefit from this proactive implementation of interdisciplinary palliative care, but this future requires, among other things, a clear understanding of how and how often massage therapy should be provided for maximum benefit in outpatient, inpatient, and actively dying populations. Recommendations will vary for these populations in ways not yet understood.

There may also be value in additional studies that compare symptom clusters (i.e., anxiety, pain, fatigue) treated with medication versus treatment with massage therapy (24). Semi-structured interviews with patients whose symptoms would likely be improved by both interventions could help us better understand the specific value and appropriate dose of each as it relates to the experience of patients and perhaps support our ability to understand how pharmacotherapy and massage therapy could work together in appropriate doses.

As with any narrative review, a limitation is potentially overlooked literature despite a thorough search and manual review of citations. Another potential limitation is that there are very few studies that name the population they are studying as “palliative care” despite the likelihood that the population they are referring to would be considered under the broad umbrella of populations that would benefit from palliative care (52).

Conclusions

While several massage focused studies within serious illness populations have been published in the past decade, a cohesive and robust evidence base supporting real-world massage integration into clinical care has yet to emerge. Challenges presented in this review reflect variability across many aspects of study design, outcome practicality, and intervention delivery approach; including, few articles examining interventions delivered by massage therapists, who are the most feasible clinical care professionals poised and capable to provide massage within the busy clinical care environment.

There is clearly a valuable role for massage therapists and massage therapy in palliative care, and continued research is needed. The evolution of our understanding of massage therapy’s benefit to the interdisciplinary team, particularly in the palliative care environment, is only just beginning. The next decade of research into massage therapy will need to focus on meaningful, collaborative implementation strategies in real-world environments to measurably improve clinical and experiential outcomes for those with advanced and serious illness.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-23-126/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-126/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-126/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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