Journal Pre-proof

MASSAGE THERAPY FOR SYMPTOM REDUCTION AND IMPROVED

QUALITY OF LIFE IN CHILDREN WITH CANCER IN PALLIATIVE
CARE: A PILOT study

Lara M. Genik (Formal analysis) (Investigation) (Writing - original

draft) (Writing - review and editing), C. Meghan McMurtry
(Conceptualization) (Methodology) (Supervision) (Resources)
(Writing - review and editing) (Funding acquisition), Shannon
Marshall (Conceptualization) (Methodology) (Investigation)
(Resources) (Writing - review and editing) (Funding acquisition),
Adam Rapoport (Conceptualization) (Methodology) (Writing - review
and editing) (Funding acquisition), Jennifer Stinson
(Conceptualization) (Methodology) (Resources) (Writing - review
and editing) (Funding acquisition)

PII: S0965-2299(19)30819-2
DOI: https://doi.org/10.1016/j.ctim.2019.102263
Reference: YCTIM 102263

To appear in: Complementary Therapies in Medicine

Received Date: 6 June 2019

Revised Date: 22 November 2019
Accepted Date: 25 November 2019

Please cite this article as: Genik LM, Meghan McMurtry C, Marshall S, Rapoport A, Stinson J,
MASSAGE THERAPY FOR SYMPTOM REDUCTION AND IMPROVED QUALITY OF LIFE
IN CHILDREN WITH CANCER IN PALLIATIVE CARE: A PILOT study, Complementary
Therapies in Medicine (2019), doi: https://doi.org/10.1016/j.ctim.2019.102263
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© 2019 Published by Elsevier.

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MASSAGE THERAPY FOR SYMPTOM REDUCTION AND IMPROVED QUALITY

OF LIFE IN CHILDREN WITH CANCER IN PALLIATIVE CARE: A PILOT STUDY

Lara M. Genik* lgenik@uoguelph.ca, C. Meghan McMurtry cmcmurtr@uoguelph.ca, Shannon

Marshall shannon.marshall@sickkids.ca, Adam Rapoport adam.rapoport@sickkids.ca and
Jennifer Stinson jennifer.stinson@sickkids.ca

*
Lara M. Genik, M.A., Department of Psychology, University of Guelph

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C. Meghan McMurtry, Ph.D., C. Psych, Department of Psychology, University of Guelph,

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Clinical and Health Psychologist, Pediatric Chronic Pain Program, McMaster Children’s

Hospital, Associate Scientist, Children’s Health Research Institute, Adjunct Researcher,

Department of Pediatrics, Western University

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Shannon Marshall, RMT, The Hospital for Sick Children

Adam Rapoport, MD, The Hospital for Sick Children, Emily’s House Children’s Hospice
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Jennifer Stinson, RN, Ph.D., CPNP, The Hospital for Sick Children, University of Toronto.
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Highlights
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Massage therapy appears to be an acceptable intervention for children with cancer in

palliative care and their families.
Massage therapy may be an effective intervention for decreasing immediate pain and
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worry.

Given challenges in conducting research with palliative care populations, careful

consideration of methodology and research design is warranted.

ABSTRACT
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Background: For children with cancer in palliative care, pain and worry are common and
frequently under-managed, which negatively impacts quality of life (QOL). Massage therapy
(MT) can lead to reduced pain in children with chronic illnesses. Children with cancer have
experienced lower anxiety after MT. No studies have examined the effects of MT in pediatric
oncology patients receiving palliative care.

Objective: Conduct a MT intervention to determine intervention acceptability and initial effects

on ratings of pain, worry reduction, and quality of life.

Design: Pre-post single group pilot study.

Setting/Subjects: Eight children with cancer (age 10-17) and one of their parents were recruited

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from a palliative care service.

Procedure/Measurements: Baseline (one week prior to intervention): demographics, MT

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expectations, QOL, and pain measures. Intervention (one month): MT was provided once per
week, with children’s pain and worry ratings occurring immediately before and after each MT
session. Follow Up (4-6 weeks after baseline): QOL, pain, and MT/study acceptability

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questionnaires.

Results: Participants reported significant decreases in pain following two MT sessions, and
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worry following one session. No significant changes in pain symptoms and QOL were found
between baseline and follow up. Participants positively endorsed the study and the MT
intervention, and there were no adverse effects reported.
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Conclusions: MT may lead to immediate decreases in pain and worry in children with cancer
who are receiving palliative care, however the effects may not be sustained long term.
Difficulties regarding protocol feasibility including recruitment and study compliance remain
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important considerations for future work.

Keywords: pain, pediatric oncology, palliative care, massage therapy, quality of life, anxiety
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INTRODUCTION
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Pediatric palliative care focuses on optimizing quality of life (QOL) and reducing

suffering experienced by children with serious illness1. Unfortunately, symptoms experienced by

dying children are frequently undermanaged through traditional interventions, resulting in

increased suffering and decreased QOL. For example, although pain is reported as one of the

most prevalent symptoms near end of life2,3, it is successfully managed less than 30% of the
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time3. While effective to some degree, using pharmacological strategies on their own may be

insufficient to fully treat symptoms, such as pain, experienced by these children3. Instead, a

combination of pharmacological, psychological and physical management approaches may

provide optimal symptom relief.

Massage therapy (MT) is a low-risk, manipulative body-based physical intervention

falling under the umbrella of complementary health approaches4. Based on previous research in

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adult and pediatric populations with chronic illnesses, MT may help reduce symptoms such as

pain and fear/anxiety and improve functioning1,5,6,7. MT may also be a promising intervention for

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reducing pain, fatigue and anxiety in oncology populations8. To date, a small body of literature

has documented the use of MT within pediatric oncology. A systematic review of integrative

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clinical trials with a pediatric oncology population identified only nine studies investigating the
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efficacy of MT but found encouraging evidence that it may be beneficial for several symptoms

including pain and anxiety9. An overview of mind-body therapies in pediatric oncology10 also
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highlighted several small pilot studies outlining positive psychological and physiological impacts

of MT (e.g., decreased stress and anxiety). More recent use of MT in pediatric palliative care
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contexts has also demonstrated promising results, such as decreased symptom burden11.

The aim of this initial quantitative pre-post single group pilot study was to set the
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groundwork for future research on use of MT in children with cancer in palliative care. The

specific study objectives were to: (1) determine the acceptability of the massage intervention to
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parents and children, and (2) obtain preliminary pre-post effectiveness data. Specifically, it was

hypothesized that post MT intervention, children would report reduced pain and worry as well as

improved QOL.

METHODS
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Recruitment and Participants

Eight to 18-year-old children with cancer who had been referred to palliative care for

either supportive or end-of-life care and one of their primary caregivers were eligible to

participate. Parents and children also had to be proficient in the English language. The exclusion

criteria were: (a) presence of a cognitive impairment, (b) receipt of MT within the past month,

and (c) residing more than 90 km away from the pediatric health center. The exclusion criteria

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for distance from the pediatric health center was placed as participants could receive massages at

home or in hospital.

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Recruitment was completed at a single tertiary care pediatric institution in Canada

between October 2013 and February 2017, where parents and children were initially made aware

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of the study by nurses on the institution’s Paediatric Advanced Care Team. Data regarding the
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number of parents and children approached are not available. The study’s massage therapist then

made secondary contact with interested parents and children to provide further information and
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connect them with a research assistant. The final sample included eight children and a primary

caregiver. See Table 1 for general demographic information about participating children and
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caregivers, and Table 2 for children’s cancer-specific information. Several factors including low

referral rate for massage therapy upon entry into the institution’s palliative care service, and lack
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of participants meeting study inclusion/eligibility criteria (e.g., were too unwell to complete

surveys, not proficient in English, too young, living further than 90km radius from hospital)
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contributed to the study’s long recruitment timeframe.

Intervention

The MT intervention consisted of four weekly massages by a registered massage therapist

who had experience in palliative care settings since 2007. Massages took place either in hospital
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or at home as per the contract between the registered massage therapist and the hospital’s

palliative care service. Each massage was approximately 60 minutes in length. A balance was

sought between standardization of the intervention and individualization. For example, special

considerations or alterations were applied to the MT session when they were related to the

child’s physical care and well-being such as type of cancer, location of metastases, adverse

reactions to treatments, skin fragility, edema, and open wounds or inflammation. Table 3

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describes factors which remained standardized versus individualized.

Procedures

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Following hospital and university ethics clearance, patients and parents meeting study

criteria were approached. Parents completed informed consent with a research assistant. Children

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provided child-specific consent or verbal assent depending on their individual capabilities. See
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Figure 1 for study procedures and study timeline. Participating parents and children received

reminder phone calls throughout the study related to measure completion/return of study
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materials and received a $20 honorarium and certificate for participation. A research assistant

completed a medical chart review which allowed the research team to gather additional medical
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information about the child such as number of surgeries, type of cancer, and medications

prescribed.
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Materials

Demographics Questionnaire. This 14-item researcher-generated, paper-based

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questionnaire asked parents to indicate information about themselves (e.g., age, relationship to

child, ethnicity, education) and their child with cancer (e.g., age, date of cancer diagnosis,

ethnicity).
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Massage Related Expectations. Two analogous (parent, child) researcher-generated,

paper-based questionnaires were used to determine children’s massage-related experiences (e.g.,

Has your child ever had massage therapy before?) and expectations of the potential helpfulness

of the intervention (e.g., Please rate how helpful you expect the massages to be in this study…).

The parent version had 2 to 7 questions (depending on whether massage had been received in the

past) whereas the child version had 2 to 5 questions.

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Pediatric Quality of Life Inventory 3.0 - Cancer Module (PedsQL - Cancer): Self-

Report and Parent Report Versions. The PedsQL-Cancer Module12 is a 27-item paper-based

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measure of QOL which was completed by both the participating child and parent. It is composed

of eight dimensions which contribute to QOL (e.g., pain and hurt, worry, procedural anxiety)12.

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As per PedsQL administration protocols, a child (ages 8-12) or adolescent (ages 13-18) version
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of this questionnaire was used depending on participants’ age. Questions on these measures are

identical and as such were grouped for analyses. For each question, participants respond on a 5-
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point Likert rating scale ranging from 0 (Never) to 4 (Almost Always)12. Individual dimension

scores as well as an overall score can be calculated. Raw scores were converted to standard
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scores which ranged from 0 to 100, and higher scores indicate better QOL12. In 8-18 year old

children with cancer, the PedsQL 3.0 – Cancer Module has demonstrated acceptable internal
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consistency reliability (average α = 0.72 child, 0.87 parent report for Cancer Module Scales)12.

Construct validity of the Cancer Module Scales using the known-groups method demonstrated
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differences on select self-report (nausea, treatment anxiety, worry) and parent proxy (pain,

nausea, procedural anxiety, treatment anxiety, worry) subscales for children with cancer who

were on treatment compared to those who had been off treatment for more than twelve months
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12
. Medium to large effects of intercorrelations between children’s self-report and parents’ proxy

reports were also noted12.

PainSquad App. The Pain Squad app is a multidimensional electronic pain diary (also

offered in paper-based format) designed for children between ages eight and 1813. It was used to

measure children’s pain (e.g., minimum, maximum, average levels, location) and pain’s

perceived impact on daily life (e.g., sleep, eating, medications)13 twice a day for four days prior

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to and following completion of the MT intervention. Items included in this diary assess the

child’s maximum, minimum, and average pain levels, locations, and durations across 12-hour

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periods of time13. This tool also assesses the perceived impact of the child’s pain on daily life

such as sleep and eating, medications, pain management strategies, and their effectiveness13. This

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app has been successfully used with youth (aged 8 to 18 years) diagnosed with cancer,
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demonstrating evidence of internal consistency (α = 0.96) and support for construct validity,

reliability, and feasibility13.

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Faces Pain Scale - Revised (FPS-R). The FPS-R14 was a single item paper-based

measure used to collect the child’s pain ratings. The FPS-R consists of six faces representing
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increasing levels of pain14. To complete this measure, participants circle the face most

representative of their current pain levels with scores ranging from 0 (no pain) to 10 (extreme
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pain)14. The FPS-R has been primarily studied with children and adolescents over the age of five

in acute, procedural and recurrent pain contexts, demonstrating strong psychometric properties
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including convergent validity, construct validity, and reliability15.

Children’s Fear Scale (CFS). The CFS16 is a single-item paper-based measure which

was used to collect children’s ratings of state worry/fear. The CFS consists of five faces showing

increasing levels of fear16. To complete this measure, participants circle the face most
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representative of their current level of “worry” or “fear” with scores ranging from 0 (not worried

at all) to 4 (the most worried or scared possible)16. The CFS has demonstrated support for

construct validity, test-retest reliability, and interrater reliability16 in the context of acute pain. It

has been successfully used in settings including procedural pain17,18,19, palliative care20,

perioperative21, pediatric oncology22 and community-based intervention settings23 with children

and adolescents.

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MT and Study Acceptability. This 10-item researcher-generated and paper-based

questionnaire asked parents and/or participating children about the acceptability of the MT

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intervention as well as the study and related procedures. This questionnaire consisted of a series

of ratings from 0 (Strongly Disagree) to 5 (Strongly Agree) such as ‘massage therapy helped

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with relaxation’. It also included open-ended questions (e.g., What aspect(s) of the study did you
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find easiest to complete?).

RESULTS
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Analytic Approach and Missing Data

Inspection of the data revealed that children’s pain and worry ratings following massage
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interventions as well as child and parent ratings of quality of life were not normally distributed.

Therefore, although we had planned parametric analyses (paired sample t-tests), we instead
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conducted their nonparametric equivalent, Wilcoxon signed rank tests, to account for non-

normality*. Descriptive statistics (means, medians, standard deviations, ranges), 95% confidence
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intervals, and effect sizes (r) were used to report outcomes.

*
The overall pattern of results when comparing Wilcoxon signed rank tests to paired sample t-tests was the same
[i.e., lower pain and worry following each massage; no change in QOL from baseline to follow up] but the number
of analyses reaching significance differed.
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Completion of study materials and MT intervention proved difficult to coordinate with a

majority of the participants. Nevertheless, participants completed data relevant to the time points

in which they were able to participate. Seven of eight participants completed baseline data. Four

participants completed all MT sessions as intended by the study; two missed one massage time

point, and one did not complete any massages. Five participants completed follow up data.

Participants missing data on a variable needed for a specific analysis were excluded only from

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that particular analysis. The number of participants represented in each analysis is provided for

each result. Of note, there were many challenges associated with gathering the PainSquadTM app

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data (e.g., missed data collection points, inability to complete the PainSquadTM app during

predetermined time points) resulting in a large amount of missing data (of those who did

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complete the PainSquadTM there was less than 55% compliance). Therefore, these data were not
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analyzed.

Expectations Regarding MT
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As per parent (85.7%; n = 6/7) and child report (71.4%; n = 5/7), the majority of children

had not previously received MT. Participants anticipated the MT intervention would be helpful
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(0-10; 10 = Extremely Helpful): parents (Mean = 7.00/10; Median = 7.00/10; range = 5-10; SD =

1.83; n = 7) and children (Mean = 7.29/10; Median = 7.00/10; range = 5-10; SD = 1.89; n = 7).
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Preliminary Pre-Post Effectiveness of MT on Pain, Worry, and QOL

Wilcoxon signed rank tests revealed statistically significant decreases in self-reported

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pain immediately following two MT sessions, and worry immediately after one MT session (see

Table 4). Data from all other time points were trending towards significant decreases in pain and

worry with medium to large effects. Compared to baseline, there were no significant differences

in parent or child reported overall QOL one week following completion of the MT intervention
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(Table 5). Similarly, there were no significant differences in parent or child reported levels of

pain or worry reported on a QOL measure at one week follow up (Table 5).

Acceptability of a MT Research Protocol

Participants indicated that the study was clearly explained (Mean = 4.20/5; Median =

4.00/5; range: 3-5; SD = 0.84), and that they would encourage other families in similar situations

to take part in this research (Mean = 4.60/5; Median = 5.00/5; range: 4-5; SD = 0.55).

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Participants were neutral (i.e., did not have strong opinions) regarding the amount of materials to

complete in this study (Mean = 3.00/5; Median = 3.00/5; range: 2-4; SD = 1.00). All participants

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rated the MT intervention as acceptable and agreed that it helped with muscle aches/pains (Mean

= 4.80; Median = 5.00/5; range: 4-5; SD = 0.45), lowered worry/stress (Mean = 4.40; Median =

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4.00/5; range: 4-5; SD = 0.55), helped with relaxation (Mean = 5.00; Median = 5.00/5; range: 5;
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SD = 0.00), and improved their overall QOL (Mean = 4.60; Median = 5.00/5; range: 4-5; SD =

0.55).
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DISCUSSION

Symptoms such as pain and worry/fear are common in children with cancer receiving
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palliative care, and adequate management of these symptoms is difficult2,3. Complementary

therapies such as MT may show promise in further alleviating these symptoms while also
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improving QOL5,6. MT is low-risk, currently being used in some pediatric oncology services, and

has demonstrated positive effects in both adults and children with chronic illnesses4,5,6. To date,
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research has not directly evaluated the use of this approach for children with cancer receiving

palliative care. Despite the challenges accompanying research in palliative populations, this work

is important to determine factors such as the impact of MT, frequency, and dosage. The purpose
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of this study was to obtain preliminary acceptability and pre-post effectiveness data associated

with MT’s impact on pain, worry, and overall QOL.

Participants reported positive massage-related expectations and found the study and

intervention to be acceptable. Further, participants reported significant decreases in pain and

worry following select time points. Results were trending towards significant decreases at all

time points with medium to large effect sizes. These findings are similar to those reported in

other massage therapy related research with other populations5,6. Importantly, it is possible that

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external factors may have affected the impact of the MT intervention at each time point. For

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example, as children approached end of life, it is possible that their illness-related pain symptoms

may have become difficult to relieve. Similarly, symptoms of worry may fluctuate and be harder

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to alleviate at times of greater stress. Nevertheless, these results suggest potential for a MT
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protocol as employed in this study to have positive immediate effects on children’s symptoms

near end of life. MT did not translate into longer lasting improvements as measured by the
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PedQL from baseline to one week following completion of the MT intervention; yet, perhaps it is

noteworthy that there was no change in children’s QOL over the 6 week course of the study
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when one might expect it to decrease given the child’s proximity to end of life.

Despite an attempt to create a feasible study protocol given the target sample, several
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challenges occurred during the study, many of which are consistent with previous research in

palliative care settings (e.g., recruitment and retention, compliance difficulties)24. As described
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earlier in the manuscript, recruitment was slow and challenging. Similarly, aspects of the study

design proved difficult and related in many ways to the unpredictable and declining nature of

participants’ health (e.g., another more critical appointment interfering with scheduled

intervention, feeling too unwell to complete questionnaires). These findings bring to light
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important questions about how to develop feasible research projects directed towards vulnerable

groups of people. Use of participatory action research (e.g., involving stakeholders such as

parents)25 in developing similar study protocols would likely be helpful.

Strengths, Limitations, and Future Directions

To our knowledge, this was the first study to directly evaluate a MT intervention for

children with cancer in palliative care. Where possible, well-developed, psychometrically sound

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research questionnaires and tools (e.g., PedsQL, FPS-R) were used to maximize validity and

reliability and inform future research. However, this was also balanced with the need for

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standardization and individual tailoring of the MT intervention itself, allowing youth to

communicate the focus of the treatments and treatment locations. This pilot allowed researchers

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to explore the use of MT within the context of a research study in a population that poses a
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number of challenges to research.

There are also study limitations to consider. First, the pilot study did not include a control
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group. Second, recruitment was slow and challenging; consideration of research that involves

multiple sites may help improve recruitment. Third, despite a number of strategies to reduce
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participant burden and assist with protocol compliance (e.g., reminder phone calls, options to

complete MT intervention in hospital or at home, mailing study materials, and provision of an

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honorarium for study participation), this remained problematic and further limits the validity of

the results. Although the difficulty with protocol compliance is unsurprising given the challenges
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associated with research in palliative care24,26, those planning future studies will want to further

consider the demand that a study protocol may have on participants and ways to provide support

in this regard. For example, in a palliative care context, one may need to spend extra time sitting

with participants to help them complete questionnaires, embed them into other paperwork they
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are already completing for other purposes, or limit the number of questionnaires even further

than was done in this pilot study.

Future work should continue to evaluate the feasibility of studying MT in this population,

the impact of MT on pain and worry in pediatric oncology patients near end of life, as well as the

qualitative impact of MT on children. Better understanding patient needs and the impact that MT

can have on their cancer-related symptoms and overall well-being could be helpful for children

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with cancer in both inpatient and outpatient settings alike. This may also include learning more

about the impact of MT interventions implemented throughout the course of one’s journey with

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cancer versus only at the palliative care/end of life stage.

CONCLUSIONS

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Preliminary results from this study are encouraging for the use of MT as an intervention
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to decrease immediate pain and worry. There are a number of challenges associated with

research in this population, and careful consideration to the methodology and design of related
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research is critical. Future work in this area could be beneficial in providing further evidence of

the benefits MT may provide in improving a child’s quality of life.

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Author Contribution Statement

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Lara Genik: Formal analysis, Investigation, Writing - Original Draft, Writing - Review and Editing; C.
Meghan McMurtry: Conceptualization, Methodology, Supervision, Resources, Writing - Review and
Editing, Funding Acquisition; Shannon Marshall: Conceptualization, Methodology, Investigation,
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Resources, Writing - Review and Editing, Funding Acquisition; Adam Rapoport: Conceptualization,
Methodology, Writing - Review and Editing, Funding acquisition; Jennifer Stinson: Conceptualization,
Methodology, Resources, Writing - Review and Editing, Funding acquisition.
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Baseline
Measures:
Baseline:
Demographics Questionnaire
(parent; ~5 minutes)
Pain (e-data: iPhone Pain
Squad for 4 days; child;
~10-15 minutes each time
completed)
QOL including anxiety
(PedsQLTM Cancer
Module; 1 week prior to
1st massage; parent and
child; ~5 minutes)
na
Treatment expectations
survey (1 week prior to 1st
massage; parent and
child; ~2-5 minutes)
ur
Figure 1. Summary of study procedures.
Jo
Pre-post Each Massage
Session (#1-4):
-p
Pain (Faces Pain Scale
Revised; child; ~1
minute)
re
Worry/fear (Children’s Fear
Scale; child; ~1 minute)
lP
9
of Follow Up
ro
Follow Up:
Pain (e-data: iPhone Pain
Squad for 4 days; child;
~10-15 minutes each time
completed)
QOL including anxiety
(PedsQLTM Cancer
Module; 1 week post 4th
massage; parent and
child; ~5 minutes)
Acceptability and satisfaction
survey (1 week post 4th
massage; parent and/or
child; ~5 minutes)
 10

Table 1

Child and caregiver demographic information.

n=6-8
Child age, mean (range, SD) 14.57 (10-17; 2.51)
Child sex, n (%)
Female 2 (28.57)
Male 5 (71.43)
Child Ethnicity, n (%)
European-Canadian 3 (42.85)
Asian-Canadian 3 (42.85)

of
Other 1 (14.30)
Caregiver age, mean (range, SD) 43.67 (33-51, 6.41)
Caregiver relationship to child, n (%)

ro
Mother 6 (85.71)
Father 1 (14.29)
Caregiver ethnicity, n (%)

-p
Asian-Canadian 3 (42.85)
European-Canadian 3 (42.85)
Other 1 (14.30)
Caregiver education, n (%)
re
Some High School/High School Graduate 2 (28.57)
Trade School/Community College 2 (28.57)
University/Graduate School/Professional Training 3 (42.86)
lP

Caregiver marital status, n (%)

Married 5 (71.43)
Divorced/Separated/Never Married 2 (28.57)
Note. Valid percent was used throughout this table; a range of n’s is listed at the top of this table.
na

SD = standard deviation
ur
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 11

Table 2

Child cancer-specific information.

n=6-8
1
Time since date of initial cancer diagnosis, range in years 0.17 - 6.42
Children with cancer relapse, n (%) 2 (25.00)
Cancer type, n (%)
Carcinoma 1 (12.50)
Leukemia 4 (50.00)
Lymphoma 2 (25.00)
Sarcoma 1 (12.50)

of
Children receiving chemotherapy within 10 days of any MT intervention,
n (%)
Yes 4 (57.14)

ro
No 3 (42.86)
Children receiving surgery up to 6 months prior to MT intervention, n (%)
Yes 4 (66.67)

-p
No 2 (33.33)
Children receiving radiation up to 6 months prior to MT intervention, n
(%)
Yes 2 (28.57)
re
No 5 (71.43)
Children prescribed pain and/or anxiety medication, n (%)
Pain medication only 1 (14.29)
lP

Anxiety medication only 2 (28.57)

Both pain and anxiety medication 2 (28.57)
No pain or anxiety medication recorded 2 (28.57)
Note. Valid percent was used throughout this table; a range of n’s is listed at the top of this table.
na

1
Time since date of initial cancer diagnosis is based on the date of the child’s first MT
intervention when this date was available. In cases where the first MT intervention date is not
available, these data were not reported.
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 12

Table 3

Massage therapy intervention information.

Standardized
Consistent registered massage
therapist
Minimal communication (except for
safety communication)
Safety communication regarding:
o massage pressure
o body location
o reminders that the child can
Individualized
Massage location (hospital, home)
Time of day
Massage surface (hospital bed, bed,
massage table)
Massage length (45 - 60 minutes)
Body location for massage (e.g., back,
feet, legs)

of
Massage focus (pain, relaxation, both)
stop the massage at any time Massage techniques used (static,
Unscented oils rocking, fascia, effleurage, petrissage,

ro
No music passive range of motion, stretch)
Massage pressure (range: light -
moderate)

-p
Use of sheets/blankets
Presence of others in the room during
massage
re
lP
na
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 13

Table 4

Wilcoxon signed rank results comparing participant self-report ratings of pain and worry/fear
immediately following each MT session.

Medianpre (M; SD; Medianpost (M; SD; z p 95% CI r

Range) Range)
Massage 1
Pain 4.00 (5.20; 2.68; 4- 0.00 (2.00; 3.46; 0-8) -2.07 0.03* 1.84, 4.56 0.59
Worry/Fea 10) 1.00 (0.60; 0.55; 0-1) -1.34 0.18 -0.51, 1.71 0.39
r 1.00 (1.20; 1.10; 0-3)
Massage 2
Pain 4.00 (4.67; 3.27; 0- 0.00 (1.67; 3.20; 0-8) -2.12 0.03* 1.24, 4.76 0.71
Worry/Fea 10) 0.00 (0.17; 0.41; 0-1) -2.12 0.03* 1.66, 3.87 0.71

of
r 1.00 (1.17; 0.75; 0-2)
Massage 3
Pain 6.00 (5.20; 3.63; 0- 2.00 (2.00; 2.45; 0-6) -1.84 0.07 0.37, 6.03 0.55

ro
Worry/Fea 10) 0.00 (0.60; 0.89; 0-2) -1.34 0.18 -0.82, 2.42 0.40
r 2.00 (1.40; 1.34; 0-3)
Massage 4
Pain 5.00 (5.50; 3.42; 2- 1.00 (1.50; 1.92; 0-4) -1.86 0.06 0.33, 7.68 0.62

-p
Worry/Fea 10) 0.50 (0.50; 0.58; 0-1) -1.86 0.06 0.58, 2.42 0.62
r 2.00 (2.00; 0.82; 1-3)
Note. Pain ratings were measured using the FPS-R (Hicks et al., 2001), where ratings can range
from 0 (no pain) to 10 (extreme pain). Worry/Fear ratings were measured using the CFS
re
(McMurtry et al., 2011), where ratings can range from 0 (no fear/worry) to 4 (high fear/worry). *
= p < .05
lP
na
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 14

Table 5

Wilcoxon signed rank results of parent and child reports of overall QOL and pain/worry QOL
dimensions between baseline and follow-up.

Medianpre (M; SD; Range) Medianpost (M; SD; z p 95% CI r

Range)
Parent Report
Overall QOL 48.15 (39.07; 14.37; 41.67 (50.37; 13.47; -1.49 0.1 -32.12, 0.43
Pain 17.59-58.33) 39.81-70.37) -0.73 4 9.53 0.21
Dimension 25.00 (17.50; 14.25; 0.00- 25.00 (35.00; 41.83; 0.00- -0.56 0.4 -74.10, 0.16
Worry 50.00) 100.00) 7 39.10
Dimension 50.00 (35.00; 32.49; 0.00- 33.33 (38.33; 36.13; 0.00- 0.5 -19.02,
91.67) 83.33) 8 12.34

of
Child Report
Overall QOL 56.48 (53.40; 6.17; 46.30- 49.07 (56.17; 15.97; -0.54 0.5 -54.56, 0.17
Pain 62.04) 38.89-70.37) -0.55 9 49.01 0.16

ro
Dimension 25.00 (22.50; 18.54; 0.00- 12.50 (35.00; 40.89; 0.00- -1.13 0.5 -67.37. 0.34
Worry 75.00) 100.00) 8 42.37
Dimension 48.83 (41.67; 26.35; 0.00- 33.33 (56.25; 42.70; 8.33- 0.2 -57.04,
75.00) 100.00) 6 27.87

-p
Note. QOL was measured using the PedsQL (Varni et al., 2002).
re
lP
na
ur
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