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cancer is the second most frequent cause of death after cardiovascular diseases , leading to unbearable and hardly controllable symptoms in 70 to 80% of the cases , especially when the healing phase is over and the therapy has to be continued with palliative intent . depending on the type of cancer and the stage of the disease , different physical and mental symptoms can be noted , with pain , anxiety , and depression playing a central role in the care and treatment of critically and terminally ill patients as the disease progresses . in order to alleviate severe pain ,
opioid analgesics are administered because of their high efficacy and the absence of specific organ toxicity . despite their good effectiveness , several side effects such as nausea and vomiting , drowsiness , confusion , respiratory depression , antitussive effect , urinary retention , itchiness , constipation , hyperalgesia , tolerance , and dependency
can be noted [ 2 , 3 ] . due to the progression of cancer and the simultaneous presence of severe pain , there is an increased risk of mental complications such as anxiety and depression [ 2 , 4 ] .
anxiety disorders can be found with a prevalence of 13 to 79% in this group of patients .
anxiety is a multifactorial disorder which can be connected with other symptoms such as depression , and its pharmacological treatment mainly consists of benzodiazepines , antidepressants , neuroleptics , and opioids [ 1 , 6 , 7 ] .
the side effects of these medications include ataxia , respiratory problems , amnesia , cardiac muscle fatigue , psychomotor and cognitive impairments , sleep disorders , and paradoxical reactions [ 1 , 5 ] .
as pharmacological treatment causes a number of side effects , oncological patients frequently turn to complementary medicine therapies as an adjunctive treatment to ease the symptoms .
their effectiveness with regard to the reduction of symptoms of pain , anxiety , and depression in oncological patients has been examined in several studies [ 812 ] .   as far as nursing practice is concerned
, it is currently difficult to consult scientific works clearly illustrating the influence and effectiveness of this method in oncological patients [ 8 , 13 , 14 ] .
the aim of this literature review is to examine the effectiveness of massage therapy for reducing pain , anxiety , and depression in patients receiving palliative oncological care .  
in order to respond to the above questions in narrative literature review was conducted from march to july 2010 in the following databases : the cochrane library , cinahl ( cumulative index to nursing and allied health literature ) , psychinfo ( ebsco ) , medline ( national library of medicine ) , embase , amed ( ebsco ) , and tripdatabase .
in addition , the bibliographical references of the authors and the selected journals were examined for further references .
the literature was selected according to the inclusion and exclusion criteria stated in table 1 .
by applying the described strategy , a total of 69 articles were found , 38 of which were relevant hits .
after carefully sorting through the relevant hits , the duplicates were removed . applying the in- and exclusion criteria ,
20 articles were found appropriate .   the search strategy and the selection and quality rating of the relevant studies were carried out and analysed separately by two persons in a first step and jointly synthesised and discussed in a second step .
the studies that had been found were selected according to the inclusion criteria and the quality criteria of the jadad score ( 2000 ) for rcts and the checklist of downs and black ( 1998 ) for randomised and nonrandomised studies . using these criteria ,
six articles were eventually included in the final analysis ( see figure 1 ) .  
the classification of the studies according to evidence level was carried out according to kunz et al . , with four studies corresponding to evidence level i [ 12 , 13 , 16 , 17 ] and two to evidence level iii [ 18 , 19 ] .
the analysis of the publications and the data extraction was done using a tabular format ( see table 3 ) .
the six selected studies comprised a total of n = 1,558 adult oncological patients receiving palliative care .
the six analysed studies included both female and male patients , with female patients accounting for a higher percentage share in four of the examined studies [ 12 , 13 , 17 , 18 ] .
the average age was between 65 and 66 years in five studies [ 12 , 13 , 16 , 17 , 19 ] .
the patients suffered from lung , breast , pancreas , prostate , and colorectal cancer [ 12 , 13 , 1619 ] .
the probable life expectancy of the patients which took part in the studies was estimated at less than six months . in five studies ,
the patients received palliative care in a hospice or in an oncological centre [ 13 , 1619 ] .
cassileth and vickers   had also included additional patients living and receiving palliative care at home .
kutner et al .   found that 49% of the patients were in a relationship .
four of the selected studies were conducted in the usa [ 12 , 13 , 16 , 17 ] .
the patients participating in the different studies mainly received a full - body massage or partial massage [ 13 , 1618 ] .
the symptom of pain was examined in five out of the six included studies [ 12 , 13 , 1618 ] .
the analgesic effect of massage therapy in oncological patients receiving palliative care could be shown in four out of these five studies [ 12 , 13 , 16 , 18 ] . in four studies ,
the amount of pain reduction reached a statistically significant value ( see table 3 ) [ 12 , 13 , 16 , 18 ] .
the results also showed that massage therapy yielded a considerably better effect in patients with strong pain perception ( vas > 4 ) [ 12 , 13 , 18 ] .
however , downey et al .   could not prove the effectiveness of massage therapy in terminal oncological patients through their study results ( see table 3 ) .
three out of six studies examined the long - term effects of massage therapy [ 13 , 16 , 18 ] .
provided the longest followup of all analysed studies with a period of 16 to 18 hours .
found that massage therapy yielded no statistically significant effect on pain perception after this period ( see table 3 ) .
also analysed the lasting effect of massage therapy , and these authors found the immediate effects to be higher and the longer - term effects to be lower .  
in addition to the lasting effect of massage therapy , wilkie et al .   also examined the change in pain .
found a transformation from constant pain perception to intermittent or episodic pain perception in 14% of the participating patients . summing up
, it can be stated that massage therapy can achieve a reduction of pain lasting up to 18 hours [ 13 , 16 , 18 ] .
massage therapy shows a favourable effect in both the immediate and the continuous analysis of the results . in order to further support this effect , kutner et al .   and wilkie et al
.   studied the patients ' consumption of analgesics after they had received massage therapy and compared it with the previous dosage . while the decrease in the consumption of analgesics was not statistically significant , the dosage of analgesics was subject to less fluctuation .
the presence of pain can cause anxiety and depressions to develop or to become more pronounced .
for this reason , the effect of massage therapy in view of these both disease symptoms was assessed in four out of six studies [ 12 , 13 , 18 , 19 ] .
the symptom of anxiety was examined in three out of six studies ; however , the authors did not give a definition of anxiety [ 12 , 18 , 19 ] .  
the authors found physiological relaxation to be closely connected with the immediate reduction of anxiety , and they also found it to be of importance for a lasting effect [ 12 , 18 , 19 ] . monitoring the heart and respiratory rate after the respective massage therapy may indicate a relaxation . while jane et al .  
were able to note a reduction of the rates , the results were not statistically significant .
however , the patients ' perception of anxiety immediately after the intervention had decreased statistically significantly ( see table 3 ) .
the study of osaka et al .   was limited to the administration of a hand massage . despite the short duration of only five minutes , a statistically significant reduction of the perception of anxiety
cassileth and vickers   provided evidence for a considerably higher reduction both with regard to the perception of pain and with feelings of anxiety in those patients who had stated a higher initial value of anxiety ( vas > 4 ) before the intervention .
there is physical contact between the massage therapist ( the caregiver ) and the patient .
a prerequisite for the effectiveness of the intervention is that the patient can accept this close physical contact [ 16 , 17 ] .
the effectiveness of massage therapy for reducing depression and depressive states of mind was analysed in two of the selected studies as a secondary outcome [ 12 , 13 ] .
these two studies provided evidence for an improvement of the depressive mood through massage therapy . however , the authors of these two studies noted that the type of massage and the setting are to be taken into consideration as important influencing factors .
the analysis of the results of cassileth and vickers   showed that a gentle touch massage or full - body massage provides for clearly better results in easing symptoms ( p = 0.03 ) than a foot massage .
there was no significant deviation ( p = 0.12 ) between the results of full - body massage and gentle touch massage .  
massage therapy thus has a favourable influence with regard to reducing anxiety and depression [ 13 , 18 ] .
there were not any incidents either in patients who already had bone metastases [ 13 , 18 ] .
some patients were unable to find a pleasant position causing the duration of the massage to be shortened .
other patients were in a poor general state of health making it impossible to administer a full - body massage .
for this reason , the massage therapist had to be flexible in carrying out the massage and concentrate on a partial massage if necessary [ 16 , 17 ] .
the massage sessions only had to be interrupted , if at all , due to telephone calls or visitors the patient wanted to receive .
massage therapy has proven to reduce the subjectively perceived symptom of pain in oncological patients receiving palliative care .
remission of the symptoms of anxiety and depression , examined secondarily , was also achieved . despite the different characteristics of the population , similar results with respect to reducing pain were achieved in four out of six studies [ 13 , 1618 ] .
the qualitative data gained from the analysed studies has shown that interventions such as massage therapy only seem to be effective if the patient is treated with empathy and if a relationship between the massage therapist and the patient had been formed beforehand [ 13 , 16 ] .
this observation may support the hypothesis that desired or undesired effects of a massage are not only dependent on the interventions themselves but also on the time of the day , the setting , the position of the patient , and the type of massage ; in addition , the attitude of the therapist plays an important role .
the perception of pain in the analysed studies was found to have different initial values , with the highest initial value being the one in the study of jane et al . .
while all patients were diagnosed with bone metastases , the cultural aspect may influence the subjective assessment of pain .  
that massage therapy can achieve substantial pain reduction and consequently lower the use of analgesics was not confirmed .
patients require sufficient pharmacological pain treatment ; otherwise a state of relaxation before the beginning of the massage treatment can not be achieved .
note that possible digestive problems might be a negative effect of massage therapy and that patients should therefore be examined for this condition .  
the assumption that massage therapies are to be considered contraindicated with malign tumours because tumour growth and metastasizing may be accelerated was refuted by several authors [ 8 , 16 , 18 ] . in the analysed studies , both the authors and the patients mainly aimed at a full - body massage [ 12 , 13 , 1618 ] . it had to be noted that some patients were unable to find a comfortable position or that the position needed to be changed permanently , thereby disturbing the massage and reducing its effect .
this suggests the conclusion that the duration of a massage plays a crucial role for achieving the desired effect and enabling the patient to experience relaxation during the massage therapy .  
state that seriously ill patients might associate physical contact and touch with painful invasive techniques such as taking a blood sample .
for this reason , the patient should be in a relaxed state before the beginning of the message therapy and thoroughly informed about the massage therapy and the kind of physical contact . as a matter of principle , thoroughly informing the patients and their relatives is of utmost importance in treating various symptoms of people who are to be provided with palliative care .
apart from information , direct communication gives the patient trust and a feeling of security , thus additionally increasing the amount of self - determination of the patient with respect to the treatment of potential symptoms .
a lack of information provided to the patient by the caregivers concerning the effect of massage entails the risk of the patient refusing massage therapy .
in addition , the patients might gain the impression that they are robbed of the time they have left in a senseless way .
massage therapy also enables the caregivers and the patients to deepen their relationship through mutual physical contact and to strengthen mutual trust .
the importance of thoroughly counselling and informing the patient can not be estimated high enough . offering massage therapy
those patients who experience little physical contact , affection and security may be more responsive to massage therapy .
therefore , it should especially be made available for socially isolated patients [ 9 , 26 ] .
summing up , it can be stated that massage therapy is to be considered a cost - efficient , noninvasive intervention positively influencing and contributing to the reduction of pain , anxiety , and depression in seriously ill cancer patients [ 12 , 17 ] .
further studies are necessary in order to confirm the effectiveness of massage therapy with respect to reducing the symptoms in patients receiving palliative care . future studies should deal with different kinds of massage therapy in order to be able to provide solid data for nursing practice within the vulnerable group of terminal oncological patients . furthermore , uniform interventions , assessment instruments , and designs should be used for collecting the results to enable comparability .
a considerable number of cancer patients use complementary medicine therapies in order to alleviate different symptoms such as pain , anxiety , and depression , occurring in connection with cancer . 
 
 this paper explores the question to what extent massage therapies are able to reduce the amount of pain , anxiety , and depression . for this purpose , 
 a systematic literature analysis was carried out in the electronic databases and specialist journals . 
 there is already evidence that massage therapies can influence the symptoms of pain , anxiety , and depression in a positive way .