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ONLINE EXCLUSIVE
Therapeutic Effects of Massage Therapy
and Healing Touch on Caregivers
of Patients Undergoing Autologous
Hematopoietic Stem Cell Transplant
Stephanie J. Rexilius, RN, MSN, Carla A. Mundt, RN, MA, MSN, APRN, CHTP
,
Mar y Erickson Megel, RN, PhD, CHTP and Sangeeta Agrawal, MS
,
Key Points . . .
Purpose/Objectives: To examine the effect of massage
therapy and Healing Touch on anxiety, depression, subjec-
t i v e caregiver burden, and fatigue experienced by
Caregivers play an integral role in the care of patients with
caregivers of patients undergoing autologous hematopoi-
cancer.
etic stem cell transplant.
Design: Quasi-experimental repeated measures.
Caregivers of patients with cancer experience stress.
Setting: Oncology/hematology outpatient clinic in a
Massage therapy might be useful in alleviating caregiver
large midwestern city.
stress.
Sample: 36 caregivers: 13 in the control group, 13 in the
massage therapy group, and 10 in the Healing Touch
Further research is needed regarding the use of Healing
group. Average age was 51.5 years; most participants
Touch with this population.
were Caucasian.
Methods: All caregivers completed the Beck Anxiety In-
ventory, the Center for Epidemiologic Studies Depression
diagnosis of cancer can be a devastating event for pa-
Scale, the Subjective Burden Scale, and the Multidimen-
A
sional Fatigue Inventory-20 before and after treatment
tients and their families. Not only do they have to face
consisting of two 30-minute massages or Healing Touch
the reality of the diagnosis but patients often must
treatments per week for three weeks. Caregivers in the
make decisions regarding therapy (e.g., surgery, chemo-
control group received usual nursing care and a 10-minute
therapy, radiation). In some instances, patients must relocate
supportive visit from one of the researchers.
for treatment (Patenaude, 1990). Reductions in length of hos-
Main Research Variables: Anxiety, depression, subjective
pital stay combined with the shift of treatment to outpatient
burden, fatigue, Healing Touch, massage therapy.
settings have increased patients' self-care requirements and
Findings: Results showed significant declines in anxiety
scores, depression, general fatigue, reduced motivation
fatigue, and emotional fatigue for individuals in the mas-
Stephanie J. Rexilius, RN, MSN, is a product specialist at Ortho
sage therapy group only. In the Healing Touch group, anxi-
Biotech Oncology in Omaha, NE; Carla A. Mundt, RN, MA, MSN,
ety and depression scores decreased, and fatigue and
subjective burden increased, but these changes did not
APRN, CHTP, is a clinical nurse specialist and psychiatric nurse
achieve statistical significance.
practitioner at the East-Central District Department of Public Health
Conclusions: Caregivers can benefit from massage
in Columbus, NE; Mary Erickson Megel, RN, PhD, CHTP, is an as-
therapy in the clinic setting.
sociate professor in the College of Nursing at the University of Ne-
Implications for Nursing: Oncology nurses care for both
braska Medical Center in Omaha; Sangeeta Agrawal, MS, is an ana-
patients and their caregivers. Although some transplant
lyst and courtesy instructor for the College of Nursing at the
programs provide services to support lay caregivers, stud-
University of Nebraska Medical Center. This study was supported by
ies indicate that these individuals continue to feel stressed
an Oncology Nursing Foundation/Rhône-Poulenc Rorer Oncology
by their situation. Massage might be one intervention that
New Investigators Research Grant. (Submitted September 2000. Ac-
can be used by nurses to decrease feelings of stress in
cepted for publication February 28, 2001.)
patients' caregivers.
Digital Object Identifier: 10.1188/02.ONF.E35­E44
REXILIUS ­ VOL 29, NO 3, 2002
E35
Effects of Educational Programs
placed greater responsibilities for providing care on family
members (Eilers, 1996). Caregivers must learn to participate
Emotional stress among individuals caring for patients un-
in complicated medical regimens of care (e.g., central line
dergoing BMT has been documented. The need for education,
dressing changes, medication administration) that may be re-
self-care, and emotional support for caregivers has been recog-
quired at any hour of the day or night (Franco et al., 1996).
nized (Archbold, Stewart, Greenlick, & Harrath, 1990; Foxall
Patients may require assistance with daily activities such as
& Gaston-Johansson, 1996; Stetz, McDonald, & Compton,
bathing, dressing, and traveling to and from treatment facili-
1996; Wardian, 1997). Although education and support have
ties. The energy and skill required to accomplish these activi-
been provided to friends and family members who care for in-
ties, coupled with concern about finances, household manage-
dividuals undergoing BMT (Franco et al., 1996; Lesko, 1994;
ment, and the possible death of a patient, contribute to the
Patenaude, Levinger, & Baker, 1986; Tinsley, Sherman, &
stress experienced by friends or family members providing
Foody, 1999), very few studies have tested their effectiveness
care (Foxall & Gaston-Johansson, 1996; Kurtz, Kurtz, Given,
in reducing stress experienced by lay adult caregivers. Two
& Given, 1995; Lesko, 1994; Oberst & James, 1985; Oberst,
psychoeducational programs, the Prepared Family Caregiver
Thomas, Gass, & Ward, 1989; Stetz, 1987; Wardian, 1997).
course and Coping With Cancer, were developed to provide
information and teach problem-solving strategies to caregivers
Literature Review
of patients with cancer. Evaluations of the Prepared Family
Caregiver course indicated a high level of satisfaction with the
Effects of Caregiving
program (Houts, Nezu, Nezu, & Bucher, 1996). Although spou-
sal caregivers who took the course reported satisfactory per-
Several studies support the hypothesis that caregivers expe-
sonal coping, no differences were found in reported anxiety,
riencing high levels of stress are at risk for mood disturbances
depression, and caregiver burden between those who did and
(e.g., anxiety, depression), sleep disturbances, and fatigue
did not take the course (Toselind et al., 1995).
(Andrykowski, 1994; Dermatis & Lesko, 1990; Kurtz et al.,
Although they are important, educational and support pro-
1995; Patenaude, 1990; Schumacher, Dodd, & Paul, 1993). A
grams for caregivers do not seem sufficient to diminish stress
family caregiver is affected by a loved one's illness. Blanchard,
among caregivers of patients with cancer. Very few studies
Albrecht, and Ruckdeschel (1997) noted that 20%­30% of
have examined stress-reducing effects of massage therapy and
partners suffered psychological and mood disorders because of
Healing Touch among caregivers, but evidence exists for ben-
their spouses' diagnoses of cancer. In another study, compared
eficial effects.
with a community sample, spouses of patients with cancer
demonstrated higher levels of anxiety and depression, even
Effects of Massage Therapy
when providing little care to their loved ones (Blanchard,
Toselind, & McCallion, 1996; Toselind, Blanchard, &
Massage therapy is an ancient form of healing that involves
McCallion, 1995). A third study revealed greater levels of an-
the therapeutic manipulation of soft tissues of the body by
ger, anxiety, confusion, and fatigue among caregivers of pa-
various hand movements (e.g., rubbing, kneading, pressing,
tients undergoing inpatient bone marrow transplants (BMTs),
rolling, slapping, tapping) (Beck, 1994; Tappan, 1988). Mas-
compared with their counterparts in an outpatient care facility
sage therapy can elicit the relaxation response as measured by
(Grimm, Zawacki, Mock, Krumm, & Frink, 2000).
decreases in heart rate, blood pressure, and respiratory rate
Fatigue, both physical and emotional, has been identified in
(Fakouri & Jones, 1987; Longworth, 1982). Ironson et al.
other studies as a problem faced by family caregivers. Jensen
(1996) found that anxiety diminished significantly after a
and Given (1991) reported that in a sample of 248 individu-
month of massage therapy in a group of HIV-positive adult
als caring for patients with cancer, 98% reported some degree
males. Massage therapy also decreased perceptions of anxiety
of fatigue and 28% reported severe fatigue. Fatigue, anxiety,
and improved mood among institutionalized elderly people
and depressed mood were found among caregivers who were
(Corley, Ferriter, Zeh, & Gifford, 1995; Fraser & Kerr, 1993).
primary caregivers for adult patients undergoing BMT (Foxall
Hospitalized patients also have benefited from massage
& Gaston-Johansson, 1996). The researchers also found that
therapy. Significant reductions in pain and anxiety and in-
levels of perceived caregiver burden were high and remained
creased feelings of relaxation were found among male patients
relatively constant throughout the study.
with cancer who received 30 minutes of therapeutic massage
These studies indicate that caregiving might negatively affect
(Ferrell-Torry & Glick, 1993). In another study of 34 patients
the emotional and physical well-being of spouses, family mem-
undergoing autologous BMT, those who received massage
bers, and friends providing care to patients with cancer. Specific
therapy demonstrated significant reductions in distress, anxi-
effects include anxiety, depression, fatigue, and perceived
ety, and nausea compared with controls (Ahles et al., 1999).
caregiver burden. The general population increasingly is using
A third study, involving a small sample of five terminally ill
alternative and complementary therapies to promote health,
Japanese patients, revealed a decrease in fatigue after only
prevent disease, and manage stress (Eisenberg et al., 1993,
three 15-minute massages (Arinaga, 1998).
1998). Because many complementary practices are noninvasive
In a study of 100 healthy hospital employees, massage
and promote a sense of well-being, such modalities could be
therapy was found effective in reducing anxiety, depression,
useful in helping caregivers of patients undergoing BMT cope
and fatigue related to job stress (Field, Quintino, Henteleff,
with the experience. Therefore, the current study specifically
Wells-Keife, & Delvecchio-Feinberg, 1997). In addition, one
examined the effectiveness of two complementary modalities,
slow-stroke back massage treatment given to 32 healthy
massage therapy and Healing Touch, in reducing symptoms of
women who were members of the staff and student body at a
stress among adult caregivers of patients undergoing autolo-
midwestern school of nursing resulted in significant decreases
gous hematopoietic stem cell transplant (HSCT).
in anxiety scores (Longworth, 1982).
ONF ­ VOL 29, NO 3, 2002
E36
One study examined the effects of massage therapy on a
peutic Touch in decreasing anxiety in a variety of populations,
group of 13 older adults who were providing home care for
including psychiatric inpatients (Gagne & Toye, 1994), eld-
dying spouses (MacDonald, 1997). Results revealed decreases
erly individuals living in long-term care facilities (Simington
in self-identified levels of emotional stress, physical stress,
& Laing, 1993), recently widowed women (Quinn &
physical pain, and sleep difficulties after a series of weekly or
S t r e l k a u s k a s , 1993), and healthy female volunteers
biweekly massages. Further study of massage's effects on
(LaFreniere et al., 1999). Therapeutic Touch also has been
caregivers clearly is indicated because the study did not in-
found to calm children after a stressful procedure (Kramer,
clude a control group or description of instrument reliability
1990), decrease agitation in patients with Alzheimer's disease
and validity and only frequencies and percentages were used
(Woods, Craven, & Whitney, 1996), and result in sensations
to analyze data.
of warmth, relaxation, calmness, and sleepiness among adult
patients in an intensive care unit (Cox & Hayes, 1999).
Effects of Touch Therapies
Although massage therapy and Therapeutic Touch have
Therapeutic Touch and Healing Touch are classified as en-
been effective in reducing symptoms of stress in a variety of
ergy tools for healing. Therapeutic Touch is a single technique
populations, no studies have addressed the effectiveness of
developed by Dolores Krieger, PhD, RN, in the early 1970s.
these therapies on caregivers of patients undergoing transplants.
It is a five-step process of intentionally directed, hand-medi-
Therefore, the research question asked in this study was "What
ated energy exchange between practitioner and patient
is the effect of massage therapy and Healing Touch on anxiety,
(Wright, 1994). Healing Touch is a program of study that in-
depression, fatigue, and subjective caregiver burden among
volves training in Krieger's Therapeutic Touch technique, in
caregivers of patients undergoing HSCT?"
addition to other energy-based healing techniques (e.g.,
chakra connection, chelation, Hopi back technique, lymphatic
Methods
drain, magnetic unruffling, mind clearing). Developed in 1990
by Janet Mentgen, BSN, RN, the Healing Touch program can
This quasi-experimental study used a repeated measures
lead to practitioner and instructor certification (Wright). A
pretest/post-test design in which groups rather than individual
certification process has been developed for Therapeutic
caregivers were randomized. This allowed caregivers to be
Touch practitioners (Nurse Healers-Professional Associates
enrolled in one group at a time without risk of cross-contami-
International, Inc., 2000).
nation that might have occurred if all caregivers were enrolled
Both Therapeutic Touch and Healing Touch assume that all
simultaneously in all three groups. Group order was deter-
living things possess an energy field that surrounds and per-
mined by a coin toss. The study was approved by the institu-
meates the physical body. This field is perceived as a com-
tional review board for the protection of human subjects. After
plex, dynamic, fluctuating, and vibrating open system
participants gave informed consent, data were collected from
(Gerber, 2000; Schwartz & Russek, 1997). Disturbance in any
the control group, followed by the massage therapy and Heal-
part of the field can cause an imbalance in any other aspect of
ing Touch groups, respectively.
a person's physical, emotional, mental, or spiritual well-being.
Setting and Sample
Balancing an individual's energy system through gentle touch
promotes physical, emotional, and spiritual healing and relax-
The study was conducted in an oncology outpatient setting
ation (Hover-Kramer, 1996).
in a large, urban midwestern university hospital. Subjects
The development of Healing Touch as an established pro-
were asked to participate in the study if they were essentially
gram of study for nurses and others is quite recent. Therefore,
healthy adults designated as primary caregivers by patients
although research on the effects of Healing Touch is in
undergoing HSCT. Caregivers assumed primary responsibil-
progress, no published studies on its effects were found at the
ity for care of patients throughout the transplantation process.
time this study was conducted. In contrast, a great deal of re-
Potential subjects were excluded from participation if they
search documents the benefits of Therapeutic Touch (Easter,
were not primary caregivers, were currently being treated for
1997; Quinn, 1988, 1989a). Because Therapeutic Touch and
an acute health problem, or had preparation as a massage
Healing Touch possess similar philosophical assumptions,
therapy or Healing Touch practitioner.
Therapeutic Touch studies that are relevant to this research
Initially, 44 adults (15 each in the control and Healing
will be reviewed. Several studies have demonstrated the use-
Touch groups, 14 in the massage therapy group) consented to
fulness of Therapeutic Touch in reducing stress and anxiety.
participate in the study. Eight subjects failed to complete the
An early study by Heidt (1981) showed that hospitalized
study: three were too busy with caregiving activities to com-
patients with cardiovascular problems who received five min-
plete the study protocol, two dropped out when patients did
utes of Therapeutic Touch experienced a significant reduction
not undergo transplant, one ceased to be a primary caregiver,
in state anxiety compared with patients who received casual
one caregiver's spouse died, and one caregiver failed to com-
or no touch. Quinn (1984) attempted to build on that work by
plete the post-tests. The final sample consisted of 36 individu-
testing the effectiveness of Therapeutic Touch on 60 hospital-
als: 13 in the control group, 13 in the massage therapy group,
ized cardiovascular patients. Subjects who received Therapeu-
and 10 in the Healing Touch group.
tic Touch reported less state anxiety than those who received
Instruments
a placebo treatment. Quinn's (1989b) second study failed to
find significant differences in anxiety measures between sub-
Six instruments were used for data collection: Demo-
jects who received Therapeutic Touch and controls. Quinn ad-
graphic Data Form (DDF), Beck Anxiety Inventory (BAI)
ministered both the true Therapeutic Touch and the placebo
(Beck, Brown, Epstein, & Steer, 1988), Center for Epidemio-
treatments, which might have influenced the study's results.
logic Studies Depression (CES-D) Scale (Radloff, 1977),
Other studies have demonstrated the usefulness of Thera-
Multidimensional Fatigue Inventory-20 (MFI-20) (Smets,
REXILIUS ­ VOL 29, NO 3, 2002
E37
Garrsen, Bonke, & De Haes, 1995), Subjective Burden Scale
caregivers, "How are you doing?" This was done to provide
(SBS) (Potasnik & Nelson, 1984), and a poststudy question-
subjects in the control group with extra attention from the re-
naire (PSQ). Authors for the current study designed the DDF
searchers and control for the effect of the researchers' presence
and PSQ, and all other instruments were used with permis-
in the two treatment groups. At the end of the three weeks, the
sion. The DDF was used to identify caregiver age, gender,
same questionnaires were readministered, along with the PSQ.
race, education, employment status, relationship to patient,
Subjects in the massage therapy and Healing Touch groups
and type of complementary therapies used in the past. The
were provided with six 30-minute massage therapy or Heal-
PSQ provided caregivers with an opportunity to describe the
ing Touch treatments over a three-week period (see Figure 1).
experience of caregiving and offer suggestions to improve the
The first author, who is a certified massage therapist, admin-
experience for future caregivers. Subjects in the massage
istered the massages. The second author, a certified Healing
therapy and Healing Touch groups also were asked to de-
Touch practitioner, administered the Healing Touch treat-
scribe their experiences during the treatment sessions and
ments. Sessions for these treatments were scheduled at the
offer suggestions for improvement.
convenience of the subjects and took place in a conference
Anxiety: The BAI is a 21-item, Likert-type, self-report
room in the cancer treatment facility. Post-test questionnaires
questionnaire that can be used to screen the general popula-
were administered at the end of three weeks.
tion for anxiety. Scores may range from 0­63. Minimal anxi-
ety is indicated by scores ranging from 0­7, mild to moderate
anxiety scores range from 8­25, and scores 26 or greater in-
Massage Therapy Procedure
dicate severe anxiety (Beck & Steer, 1990). The instrument
1. Certified massage therapist (CMT) explained session and re-
has demonstrated high internal consistency (0.92) and reliabil-
sponded to questions.
ity in test/retest situations (r = 0.75), as well as acceptable con-
2. Subject was asked to disrobe from the waist up when the
vergent and discriminant validity (Beck et al., 1988). Further-
CMT left the room.
more, the inventory can discriminate between anxious and
3. Subject was positioned face down on massage table,
depressed patients (Fydrich, Dowdall, & Chambless, 1992). In
draped with sheet and bath towel.
this study, pre- and post-test Cronbach's alpha reliabilities
4. CMT undraped back.
were 0.91 and 0.89.
5. CMT applied massage cream to her hands.
Depression: The CES-D Scale is a 20-item, Likert-type, self-
6. CMT placed hands on subject's back to begin massage.
7. Massage consisted of
report questionnaire that measures depressive symptoms in the
a. Effleurage: Rhythmic, gliding strokes
general population. Possible scores range from 0­60, with
b. Petrissage: Gentle kneading
higher scores indicating higher levels of depression. This instru-
c. Acupressure: Manual pressure held for 10 seconds
ment has good internal consistency and correlates highly with
d. Friction: Rhythmic pressing
other measures of clinical depression, such as the Symptom
e. Wringing: Back-and-forth movement
Check List-90 (r = 0.83) (Radloff, 1977). In this study, pre- and
f. Tapotement: Quick, striking movements.
post-test Cronbach's alpha reliabilities were 0.89 and 0.87.
8. CMT massaged upper, middle, and lower back; shoulders;
Fatigue: The MFI-20 is a 20-item, Likert-type question-
neck; and scalp for 20 minutes with subject prone.
naire that measures five dimensions of fatigue: general fa-
9. Subject was redraped and repositioned supine.
tigue, physical fatigue, reduced activity fatigue, reduced mo-
10. CMT massaged shoulders, neck, and scalp.
11. CMT closed session with a facial massage.
tivation fatigue, and mental fatigue. Scores can range from
12. CMT left room when the subject dressed.
4­20 on each of the five scales, with higher scores indicating
13. CMT offered a glass of water and asked if there were com-
greater fatigue. The instrument has demonstrated internal con-
ments or questions.
sistency (subscale reliabilities average = 0.84) and convergent
validity (Smets et al., 1995). In this study, pretest Cronbach's
Healing Touch Procedure
alpha reliabilities for the five subscales ranged from 0.75­0.85
1. Certified Healing Touch practitioner (CHTP) explained the
procedure and responded to questions.
and post-test reliabilities ranged from 0.75­0.88.
2. Subject was asked to remove shoes, eye glasses, and any
Subjective burden: The SBS is a 20-item, Likert-type,
other articles of clothing that could be uncomfortable dur-
self-report questionnaire that measures caregivers' feelings of
ing the session.
burden. Scores may range from 20­100. Higher scores on this
3. Caregiver was asked to lie in a supine position on the mas-
scale indicate a greater perception of burden. The instrument
sage table.
has been correlated with the Objective Burden Scale (r =
4. CHTP performed an energetic assessment by passing hands
0.71), indicating an acceptable level of construct validity
slowly over the subject's body.
(Potasnik & Nelson, 1984). In this study, pre- and post-test
5. Healing Touch techniques included
Cronbach's alpha reliability coefficients were 0.89 and 0.90,
a. Magnetic unruffling: Used to clear the human energy field
respectively.
b. Chelation: Full-body technique used to clear, energize,
and balance the field
Procedures
c. Energizing and sealing the seventh level of the human en-
ergy field to protect the individual's aura.
Potential subjects were recruited in the outpatient oncology
6. CHTP performed the above techniques for 30 minutes.
clinic and treatment center when patients were admitted for
7. CHTP disconnected her energy field from that of the subject.
high-dose chemotherapy and HSCT. All completed the BAI,
8. On completion of the session, the subject was assisted in
DDF, CES-D, MFI-20, and SBS during the patients' first week
sitting up.
in the transplant program. One of the researchers visited the
9. CHTP answered any questions asked by the subject.
control group caregivers for about 10 minutes twice a week for
Figure 1. Study Interventions
three weeks. During these visits, the researchers asked
ONF ­ VOL 29, NO 3, 2002
E38
Data Analysis
Table 2. Use of Complementary Therapies
Sample size for the study was determined by power analy-
Massage
Healing
sis that indicated that with a minimum of 12 individuals in
Control
Therapy
Touch
Total
each group and a large effect size (f = 0.55), power would be
Group
Number
Modality
Group
Group
estimated at 0.82. Descriptive statistics were used to analyze
demographic data. Differences between pretest means were
Prayer
7
4
6
17
tested using one-way analysis of variance (ANOVA). Analy-
Nutritional
2
2
5
9
sis of covariance (ANCOVA) applying pretest scores as the
supplements
covariates was used to test differences between post-test
Massage
1
4
3
8
scores. If the assumption of equality of slopes was not met at
the 0.05 level of significance, repeated measures ANOVA
Herbal
2
2
3
7
was performed on means using the Bonferroni adjustment to
supplements
protect a family-wise error rate (Tabachnick & Fidell, 1996).
Chiropractic
­
1
5
6
Information from the PSQ was analyzed descriptively by
grouping comments into general themes.
Yoga
1
2
2
5
Imagery
3
­
1
4
Results
Reiki, Therapeutic
1
1
2
4
Description of the Sample
Touch
Subjects' average age was 51.5 years. Their levels of educa-
Acupuncture
­
1
1
2
tion averaged 13.8 years, or almost two years of college. Most
Tai ch'i
­
­
2
2
of the subjects were Euro-American, on leave from their jobs,
and the spouses of patients undergoing HSCT. The only char-
Craniosacral
­
­
1
1
therapy
acteristic that differed significantly between groups was gender
(χ2 [2, n = 36] = 6.974, p = 0.031). More women comprised the
None
5
6
2
13
intervention groups than the control group (see Table 1).
Twenty-three caregivers had used at least one complementary
therapy prior to participating in the study, as shown in Table 2.
Anxiety
As noted previously, ANCOVA or repeated measures
Average BAI scores were low for the control and Healing
ANOVA was used to determine the effects of massage therapy
Touch groups and moderate for the massage therapy group at
and Healing Touch on depression, anxiety, fatigue, and per-
the beginning of the study. As shown in Figure 2, scores in-
ceived caregiver burden experienced by the participants. Using
creased for the control group from pre- to post-test, and scores
ANOVA, no significant differences between groups were
declined for both treatment groups. The null hypothesis of
found for any pretest scores. Results for each variable are dis-
equality of slopes was rejected (F [2, 27] = 18.45, p = 0.001);
cussed next, and mean scores are shown in Table 3.
hence, repeated measures ANOVA was used instead of
ANCOVA. This analysis revealed a significant treatment by
Table 1. Sample Characteristics
time interaction for anxiety between groups from pre- to post-
test (F [2, 32] = 3.842, p = 0.032). Posthoc analysis showed
Massage
Healing
a significant decline in anxiety scores for the massage therapy
Control
Therapy
Touch
group only (p = 0.004).
Group
Group
Group
Total
(n = 13)
(n = 13)
(n = 10)
(N = 36)
12
Characteristic
n
%
n
%
n
%
n
%
10
Gender
Female
06
046
11
85
09
90
26
72
8
Male
07
054
02
15
01
10
10
28
6
Relationship
Spouse
06
46
09
90
25
69
10
077
4
Sister
02
015
03
23
01
10
06
17
Mother
01
008
03
23
0­
0­
04
11
2
Fiancé
01
08
0­
0­
01
03
­
00­
0
Employment
Full-time
04
030
02
15
0­
0­
06
17
Pretest
Post-test
Part-time
01
008
­
0­
0­
0­
01
02
On leave
10
77
06
60
23
64
07
054
Control group
Unemployed
01
008
01
08
04
40
06
17
Massage therapy group
Healing Touch group
Race
Euro-American
13
100
12
92
10
100
35
97
Figure 2. Mean Pretest and Post-Test Beck Anxiety Index
African American 0­
01
08
0­
00­
01
03
00­
Scores
REXILIUS ­ VOL 29, NO 3, 2002
E39
Table 3. Anxiety, Depression, Fatigue, and Subjective Burden Scores
Control Group
Massage Therapy Group
Healing Touch Group
--
--
--
n
Variable
SD
n
SD
n
SD
X
X
X
Anxiety
13
00­
­
13
­
­
9
­
­
Pretest
­
06.76
06.26
­
10.61
11.00
­
08.00
6.58
05.00  c
03.98
Post-test
­
08.15
09.55
­
­
05.11
3.62
11a
Depression
12
00­
­
­
­
10
­
­
Pretest
­
11.58
07.44
­
13.90
11.50
­
11.40
7.86
06.09  c
Post-test
­
15.83
12.43
­
03.70
­
08.70
5.12
12  a
General fatigue
13
­
­
­
­
10
­
­
Pretest
­
10.77
03.42
­
10.58
05.43
­
19.30
4.69
09.00  b
Post-test
­
11.92
03.90
­
04.39
­
11.10
4.72
12  a
Emotional fatigue
13
­
­
­
­
10
­
­
Pretest
­
10.00
04.85
­
12.08
05.43
­
08.50
4.81
06.75  b
Post-test
­
10.38
04.75
­
03.36
­
09.10
4.60
12  a
Physical fatigue
13
­
­
­
­
10
­
­
Pretest
­
07.77
03.47
­
08.33
04.56
­
07.70
2.98
Post-test
­
07.77
03.29
­
07.50
03.92
­
08.70
3.49
12  a
Decreased activity
13
­
­
­
­
10
­
­
Pretest
­
07.85
02.79
­
08.75
04.85
­
08.00
4.64
Post-test
­
08.77
02.62
­
08.75
04.20
­
08.90
4.75
12  a
Reduced motivation
13
­
­
­
­
10
­
­
­
07.75
04.49
Pretest
­
07.54
02.79
­
06.60
2.41
05.92  b
Post-test
­
08.77
03.65
­
02.15
­
07.00
3.06
12  a
­
­
Subjective burden
13
­
­
10
­
­
­
42.92
11.84
­
40.46
14.49
Pretest
­
41.00
10.87
­
47.00
16.02
­
38.61
11.72
Post-test
­
39.55
9.55
a
Missing data resulted in loss of one subject from this group; b Difference from control group is p < 0.05; c Difference between pre-
test and post-test is p < 0.05.
Depression
Increases in post-test fatigue scores were found for the Healing
Touch group, but these did not achieve significance.
Average CES-D scale pretest scores revealed a relatively
low level of depression among caregivers at the beginning of
Subjective Burden
the study. Post-test scores increased in the control group and
Subjective burden scores indicated that the participants
decreased in both intervention groups (see Figure 3). The null
perceived themselves to be somewhat burdened by their
hypothesis of equality of slopes was rejected (F [2, 27] =
caregiving activities at the beginning of the study, but not
16.83, p < 0.001); therefore, repeated measures ANOVA was
used instead of ANCOVA. Results revealed a significant
treatment by time interaction for depression between groups
from pre- to post-test (F [2, 30] = 7.18, p = 0.003). Although
18
depression scores declined for both treatment groups, only the
16
massage therapy group achieved significance on posthoc
14
analysis (p = 0.002).
12
Fatigue
10
8
Moderate fatigue scores were recorded for all three groups at
6
the beginning of the study. The assumption of equality of slopes
was met for each of the fatigue scores. ANCOVA showed sig-
4
nificant group effect for three fatigue subscales: general fatigue
2
(F [2, 31] = 5.31, p = 0.01), reduced motivation fatigue (F [2,
0
31] = 4.01, p = 0.028), and emotional fatigue (F [2, 31] = 7.22,
Pretest
Post-test
p = 0.003). Posthoc analysis of adjusted post-test scores with
Bonferroni adjustment for multiple comparisons revealed a sig-
Control group
nificant difference between the control and massage therapy
Massage therapy group
groups for general fatigue (p = 0.029) (see Figure 4), reduced
Healing Touch group
motivation fatigue (p = 0.024) (see Figure 5), and emotional fa-
Figure 3. Mean Pretest and Post-Test Center
tigue (p = 0.004) (see Figure 6). No significant differences in
for Epidemiologic Studies Depression Scale Scores
post-test scores were found for physical fatigue and activity.
ONF ­ VOL 29, NO 3, 2002
E40
14
14
12
12
10
10
8
8
6
6
4
4
2
2
0
0
Pretest
Post-test
Pretest
Post-test
Control group
Control group
Massage therapy group
Massage therapy group
Healing Touch group
Healing Touch group
Figure 6. Mean Pretest and Post-Test Emotional Fatigue
Figure 4. Mean Pretest and Post-Test General Fatigue
Scores
Scores
excessively, as shown in Figure 7. Although the perception of
indicated that more information might be helpful and seemed
burden increased for the control group and decreased for both
unclear about available resources and what to do in an emer-
treatment groups, these differences were not significant.
gency after discharge. One caregiver felt that her needs for
support had not been met. She wrote the following.
Poststudy Questionnaire
The caregiver, although not ill, does experience stress by
Control group: Caregivers were asked to describe the
being with the patient for extended periods of time.
most beneficial and negative aspects of the care they had re-
Simple acknowledgment of that is appreciated, and the
ceived during the patients' HSCT experiences. Control group
caregiver can offer valuable information to the patient's
participants gave 12 usable responses. The authors descrip-
overall care.
tively compiled general themes and discussed them until they
Two respondents advised future caregivers to "get your rest"
reached agreement on categorization. Themes included the
and involve other family members in patients' care as much
need for education and information about the condition of
as possible.
their loved ones. Six caregivers were concerned about a lack
Massage therapy group: All members of this group re-
of communication between staff and family members. Two
sponded to the PSQ. Eight noted that the massage sessions
caregivers noted how difficult it was to see their loved ones so
provided them with undivided attention and a "time out" from
ill. Four caregivers denied or did not respond when queried
caregiving. Seven described a feeling of relaxation as a result
about problems with nursing care.
of massage, and one felt energized. As one participant wrote,
The last question on the PSQ asked participants for sugges-
tions to improve the experience for future caregivers. Four
"Even during the worst period, the massage was the only
50
10
45
9
40
8
35
7
30
6
25
5
20
4
15
3
10
2
5
1
0
0
Pretest
Post-test
Pretest
Post-test
Control group
Control group
Massage therapy group
Massage therapy group
Healing Touch group
Healing Touch group
Figure 5. Mean Pretest and Post-Test Reduced
Figure 7. Mean Pretest and Post-Test Subjective Burden
Motivation Fatigue Scores
Scores
REXILIUS ­ VOL 29, NO 3, 2002
E41
thing that improved my positive energy and strength." Seven
of the subjects in the massage therapy group also participated in
respondents denied negative experiences associated with their
traditional inpatient care, and half were caregivers in the coop-
massage therapy sessions, but five noted that scheduling mas-
erative care center. All of the subjects in the Healing Touch
sages was difficult because they felt obligated to stay with
group participated in the cooperative care center. Because the
their patients. Suggestions for improving the experience in-
researchers were concerned about the possible influence of this
cluded longer massage sessions, time afterward to lie quietly,
change in study site, the data were analyzed using two-way
more flexible scheduling, aromatherapy or music during mas-
ANOVA with study site as one variable. This analysis revealed
sage, and availability of massage therapy to all caregivers.
no significant differences between groups because of the study
Three participants requested specific educational content to be
site. Nevertheless, future research should maintain consistency
included in the caregiver classes, and two caregivers sug-
of setting for the duration of the study.
gested additional support services.
Instrument administration: Participants completed pre-
Healing Touch group: Nine of the 10 participants in this
test instruments when patients were admitted for stem cell
group completed the PSQ. Most said the treatments were very
collection and high-dose chemotherapy prior to HSCT. At that
relaxing and provided a time when they could focus on them-
time, the patients usually were feeling well, which might have
selves and not worry about their patients. Two caregivers
accounted for the caregivers' low-to-moderate pretest scores.
mentioned that the Healing Touch treatments provided some
Because of these low pretest scores, the interventions would
relief from arthritis pain. Scheduling sessions was problematic
not be expected to result in major decreases in post-test scores.
for one member of this group, and several were bothered by
Different results might be found if pretest instruments were
noises external to the treatment room (e.g., children playing,
administered at the time of transplant, when side effects of
workmen pounding on a wall, doors opening and closing).
treatments, such as chemotherapy and radiation, tend to be
One respondent suggested providing shorter but more fre-
more intense and patients are more ill. Instruments also should
quent sessions and background music. Another suggested
be administered midway through the transplant process to
offering Healing Touch to patients undergoing HSCT.
provide a clearer longitudinal picture of caregiver stress.
Sample characteristics: Unfortunately, attrition resulted in
Discussion
small sample size for the Healing Touch group, which might
have reduced the possibility of achieving statistically signifi-
This study tested the effectiveness of two complementary
cant results. Another characteristic of the sample that might
therapies in reducing anxiety, depression, fatigue, and subjec-
have influenced the findings is the gender difference among
tive burden among adult caregivers of patients undergoing
the groups, with men comprising half of the control group but
autologous HSCT. Results indicated significant decreases in
being underrepresented in both intervention groups. The re-
anxiety, depression, and fatigue (i.e., general fatigue , reduced
searchers might have expected that more women than men
motivation fatigue, and emotional fatigue). These results are
would have consented to participate in interventions involv-
consistent with those of other reports (Ahles et al., 1999;
ing complementary therapies because women tend to use
Arinaga, 1998; Ferrell-Torry & Glick, 1993; Field et al., 1997;
these modalities more than men (Eisenberg et al., 1998) and
Fraser & Kerr, 1993; Ironson et al., 1996; Longworth, 1982).
women appear to be more open about seeking and accepting
Although depression and anxiety scores moved in the desired
help than men (Northouse & Peters-Golden, 1993). The pos-
direction with Healing Touch and were consistent with the
sible supportive and diversionary effects of employment ap-
findings of Gagne and Toye (1994), Heidt (1981), and Quinn
pear to be negligible in this study because most caregivers had
and Strelkauskas (1993), statistical significance was not
taken leaves of absence while serving as caregivers. The re-
achieved. However, caregivers in both intervention groups
searchers were unable to control for the use of additional sup-
were unanimous in their expression of positive feelings about
portive resources used by the subjects (e.g., support groups,
the complementary therapy received.
religious practices, availability of breaks, respite). Further
study should be conducted to determine differences in re-
Limitations
sponses to the stresses of caregiving for men and women, ef-
Because the sample was not randomly selected, results can-
fectiveness of interventions designed and which are preferable
not be generalized beyond the individuals who participated. In
to each group, and the impact of other forms of social support
addition to the use of a convenience sample, several factors
on caregiver stress. In addition, because feedback from
might have influenced the results of the study. These include
caregivers indicated that massage therapy and Healing Touch
events occurring at the study site, time of administration of
alleviated some somatic symptoms not measured by the in-
pretest instruments, characteristics of the sample, and re-
struments used in this study, symptoms such as pain should be
searchers providing the intervention.
assessed in future studies.
Study site: During the study, the care of patients receiving
Researchers providing interventions: Researchers who
transplants changed from a traditional inpatient hospital setting
provided the intervention inadvertently might have introduced
to a new transplant center based on the cooperative care model
bias into the subjects' responses during the process of becom-
(Franco et al., 1996). Caregivers whose loved ones received
ing acquainted with the subjects. Subjects might have an-
chemotherapy and transplantation in the traditional hospital set-
swered the questionnaires in ways they thought the research-
ting received typical nursing care. In the cooperative care cen-
ers preferred. In future studies, separate individuals should
ter, caregivers stayed with patients in motel-like rooms and were
conduct data collection and interventions.
responsible for administering medications, providing physical
In conclusion, this study showed that caregivers of patients
care, making observations, calling for medical assistance, and
undergoing autologous HSCT do experience stress during the
performing personal chores. The control group participated
caregiving experience. Further research is necessary with a
within the context of traditional hospital-based care. About half
larger sample to validate these results and determine the effec-
ONF ­ VOL 29, NO 3, 2002
E42
tiveness of massage therapy and Healing Touch with caregivers
The authors gratefully acknowledge June Eilers, RN, PhD, and Audrey
Nelson, RN, PhD, for assistance with proposal development, oncology staff
of other oncology populations (e.g., general oncology, pediat-
at the Lied Transplant Center, Nebraska Health System in Omaha, and the
ric, allogeneic transplant). The study also demonstrated the fea-
caregivers who graciously agreed to participate in the study.
sibility of incorporating two complementary therapies into a
busy outpatient oncology setting. This might be helpful and
Author Contact: Stephanie J. Rexilius, RN, MSN, can be reached
provide support to oncology nurses for offering complementary
at srexiliu@ibus.jnj.com, with copy to editor at rose_mary@
interventions to oncology patients' caregivers.
earthlink.net.
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