Abstract
Background: Spouses of patients with cancer are at risk for stress-related disorders and may experience a reduction in immune function. Therapeutic back massage (TBM) has been shown to enhance relaxation and thus, may reduce stress associated with caring for an ill partner.
Objectives: To determine if TBM's influences on psychosocial, physiologic, and immune function variables in spouses of patients with cancer, and explore the relationships between psychosocial variables and immune function in spouses of patients with cancer.
Methods: This group experimental design measured the effects of a 20-minute TBM at three time points (preintervention, immediately postintervention, 20 minutes postintervention) on spouses of patients with cancer (N = 42) randomly assigned to either the experimental or control group. The major dependent variables including natural killer cell activity (NKCA), heart rate, systolic and diastolic blood pressure, mood, and perceived stress were measured at the three time points to examine the effects of TBM. Data collected on measures of mood and perceived stress were correlated with NKCA to examine their relationships. Prior to hypotheses testing, data collected on measures of depressive mood, loneliness, marital disruption, and health practices were also correlated with NKCA to ascertain any possible confounding variables.
Results: Two-way repeated measures analysis of variance tests determined the effects of TBM over the two postintervention time points and resulted in significant group x time interactions on mood (F [2, 40]= 14.61, p = .0005) and perceived stress (F [2, 40]= 28.66, p = .001). Significant inverse relationships were found between mood and NKCA (r = -.41, p = .009, N = 42) and perceived stress and NKCA (r = -.37, p = .017, N = 42).
Discussion: Findings suggest that TBM may enhance mood and reduce perceived stress in this population. Insight was gained into the psycho-immunologic relationships studied.
Most spouses of patients with cancer experience profound psychological and physiological disturbances when their husband or wife is diagnosed with a potential life-threatening disease such as cancer (Jensen & Given, 1991). Prior to the 1970s, little was known about spouses of patients with cancer or the impact of this illness on their lives. Spouses were viewed as passive observers instead of active participants in the cancer experience. Studies have shown that spouses report as much anxiety and distress as their partners with cancer (Davis-Ali, Chesler, & Chesney, 1993;Northouse & Peters-Golden, 1993). Interestingly, the patient's specific type of cancer seems to make little difference to the spouse in regard to stress (Jensen & Given). This may be due to the public's perception that cancer in general entails grave consequences in spite of recent success in treatment of various cancers.
Spouses have identified specific periods of time as more stressful than others over the course of the partner's illness. These include:
* prior to initial discharge from the hospital
* 2 months following hospitalization when the impact of cancer on both spouse and patient becomes more apparent
* during outpatient treatment when more assistance in self-care and symptom management is required
* with each progressive stage of the illness (Longman, Atwood, Sherman, Benedict, & Shang, 1992;Zahlis & Shands, 1993)
Research suggests that elevated levels of stress may have prolonged effects on the health and well being of the spouse with an ill partner. A high incidence of respiratory infections, hypertension, and reduction in immune function (Baron, Cutrona, Hicklin, Russell, & Lubaroff, 1990;Spurrell & Creed, 1993), as well as eating disorders, sleep disturbances, and poor health habits (Carter & Chang, 2000;Schumacher, Dodd, & Paul, 1993) have been found in spouses of patients with cancer. In addition, psychosocial disturbances (e.g., depressive mood, loneliness, marital disruption) have been reported as contributing to the stressful experience of caring for an ill partner with cancer (Carter & Chang, 2000;Zahlis & Shands, 1993).
Research conducted in populations other than spouses of patients with cancer have linked poor health habits, depressive mood, loneliness, and marital disruption to reductions in immune function (Esterling, Kiecolt-Glaser, & Glaser, 1996;Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991). Thus, poor health habits and psychosocial disturbances associated with stress and caring for an ill partner may have contributed to the reductions in immune function also found in spouses of patients with cancer (Baron et al., 1990;Spurrell & Creed, 1993). Stress-induced immune function change may be the link between stress and illness. While the relevance of stress-induced negative immune function change to clinical health outcome remains questionable, it is clear that stress affects the immune system by reducing some component of immune function (Zakowski, Hall, & Baum, 1992). It is vital that the spouse remains in optimum health during the course of his or her partner's illness.
Little attention has been given to help spouses of patients with cancer reduce the effects of stress associated with their partner's illness. Therapeutic back massage (TBM) is an intervention that promotes relaxation. Therapeutic back massage can be defined as a systematic form of touch that manipulates soft tissues of the body to promote comfort and healing (Beck, 1999). Different types of strokes are used to administer massage and elicit different effects. For example, a long, slow, rhythmic stroke such as effleurage is thought to produce a sedative effect, while a rapid, firm stroke such as tapotement is thought to produce a stimulating effect (Beck).
Because the type of massage examined has not always been well described, it is somewhat difficult to compare the effects of massage across studies. Results of studies measuring physiologic variables have been mixed. Although significant reductions in both heart rate (HR) and blood pressure (BP) have been shown after massage (Fakouri & Jones, 1987;Meek, 1993), no significant changes have been reported (Fraser & Kerr, 1993). Inconsistent results may be due to the length and type of massage given as well as the study design. Most massage studies have used a within-participant design with participants serving as their own controls. It is critical to use both an experimental group and a control group to determine the efficacy of TBM.
Despite inconsistent physiologic findings, participants across studies have perceived TBM as relaxing (Fraser & Kerr, 1993;Meek, 1993;Smith, Stallings, Mariner, & Burral, 1999) and a positive change in mood has been reported (Smith et al.). Evidence suggests that relaxation may have positive effects on some component of the immune system (Jasnoski & Kugler, 1987;Kiecolt-Glaser & Glaser, 1992). Significant increases in salivary Immunoglobin A (sIgA) have been shown in healthy participants after 20 minutes of massage (p < .01) (Green & Green, 1987) and after 10 minutes of massage (p < .004) (Groer et al., 1994). Long, slow, rhythmic strokes were used in both of these studies to elicit relaxation and a positive change in sIgA.
A significant increase in natural killer cell activity (NKCA) has also been reported in participants after 1 month of daily massages (Ironside et al., 1996). Rapid, deep tissue manipulation lasting 45 minutes achieved the positive change in NKCA. Interestingly, but contrary to the principles of massage (Beck, 1999), the significant increase in reported relaxation was achieved through rapid, deep tissue manipulation (Ironside et al., 1996), which is generally considered more stimulating than relaxing (Beck).
Few well-controlled studies have systematically examined the effects of massage on stress and physiologic variables. Massage has recently been examined for its effects on components of the immune system. In particular, the effects of TBM on NKCA need further examination because natural killer (NK) cells and their activity have important implications on health outcome. The NK cells are well known for their ability to destroy tumor cells and virus-infected cells (Whiteside, Bryant, Day, & Herberman, 1990). The NKCA also plays an important role in immune surveillance and indicates overall health status (Rabin, 1999; Whiteside et al.).
The purpose of this research was to test the efficacy of TBM to reduce stress in spouses of patients with cancer. The specific aims were to:
(a) test TBM for positive influences on NKCA, HR, SBP, DBP, mood, and perceived stress in spouses of patients with cancer
(b) examine the relationships between mood and NKCA and perceived stress and NKCA in spouses of patients with cancer
The following hypotheses were tested:
1. TBM will reduce the effects of stress experienced by spouses of patients with cancer as measured by an increase in NKCA at two postintervention time points compared to a control group of spouses of patients with cancer.
2. The TBM will reduce the effects of stress experienced by spouses of patients with cancer as measured by a positive change in mood and a decrease in perceived stress, HR, and BP at two postintervention time points compared to a control group of spouses of patients with cancer.
3. Negative mood will be inversely correlated with NKCA in spouses of patients with cancer.
4. Perceived stress will be inversely correlated with NKCA in spouses of patients with cancer.