Applied Nursing Research 26 (2013) 210–217

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Applied Nursing Research

journalhomepage:www.elsevier.com/locate/apnr

Effects of back massage on chemotherapy-related fatigue and anxiety: Supportive care and
therapeutic touch in cancer nursing
a, b
Serife Karagozoglu, BSc, MSc, PhD, RN , Emine Kahve, BSc, MSc, RN
a Cumhuriyet University Faculty of Health Science, Division of Nursing, Department of Fundamentals of Nursing, 58140, Sivas, Turkey
b Cumhuriyet University Research and Application Hospital, Sivas, Turkey

article info abstract

Article history: This quasi-experimental and cross-sectional study was carried out to determine the efficacy of back massage, a nursing
Received 9 August 2012 intervention, on the process of acute fatigue developing due to chemotherapy and on the anxiety level emerging in cancer
Revised 12 July 2013 patients receiving chemotherapy during this process. The study was conducted on 40 patients. To collect the data, the Personal
Accepted 23 July 2013
Information Form, the State Anxiety part of Spielberger State-Trait Anxiety Inventory and the Brief Fatigue Inventory were
used.
Keywords:
In our study, it was determined that mean anxiety scores decreased in the intervention group patients after chemotherapy. The
Chemotherapy
level of fatigue in the intervention group decreased statistically significantly on the next day after chemotherapy (p = .020;
Side effects of chemotherapy
Anxiety effect size = 0.84). At the same time, the mean anxiety scores of the patients in the intervention group decreased right after the
Fatigue massage provided during chemotherapy (p =
Massage .109; effect size = 0.37) and after chemotherapy. In line with our study findings, it can be said that back massage given during
Cancer (oncology) nursing chemotherapy affects anxiety and fatigue suffered during the chemotherapy process and that it significantly reduces state
anxiety and acute fatigue. Therefore, the effective use of back massage in the process of chemotherapy by oncology nurses
who have a key role in cancer treatment and care can make it more modulated.

© 2013 Elsevier Inc. All rights reserved.

1. Introduction
Chemotherapy is a long-term treatment and leads to many side effects in
individuals receiving it (Can, Erol, Aydiner, & Topuz, 2011; Cleeland et al.,
2000; Kearney et al., 2008; Turgay, Khorshid, & Eser, 2008). One of the most
common side effects of chemotherapy is fatigue (Ahlberg, Ekman, Gaston-
Johansson, & Mock, 2003; Barsevick et al., 2010; Breitbart & Alici, 2010;
Gerber et al., 2011; Mitchell, 2010; Rotonda, Guillemin, Bonnetain, &
Conroy, 2011; Schulmeister & Gobel, 2008; Wu & McSweeney, 2004; Wu &
McSweeney, 2007). The term fatigue used as the synonym of weakness,
exhaustion, tiredness, weariness can also be defined as a state of mental and
physical exhaustion which covers all these concepts (Ahlberg et al., 2003;
Cheville, 2009; Iop, Manfredi, & Bonura, 2004; Mitchell, 2010; Wu &
McSweeney, 2007; Yurtsever, 2007). Fatigue is a multi-dimensional problem
arising from the combination of physical, psychological and situational
factors. Fatigue adversely affects not only a patient's sense of wellbeing but
also his/her daily performance, activities, profes-sional life, relationships with
his/her family and friends, sexual life and tolerance to the treatment (Curt et
al., 2000; Jean-Pierre et al., 2007; Kearney et al., 2008; Lee, Tsai, Lai, & Tsai,
2008; Oh & Seo, 2011).
Corresponding author. Tel.: +90 1 532 7427059; fax: +90 1 346 2191261. E-mail
addresses: serifekaragozoglu@gmail.com (S. Karagozoglu),
emine_kahvecioglu@hotmail.com (E. Kahve).
0897-1897/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnr.2013.07.002
Acute and chronic fatigue should be distinguished from each other. Although
acute fatigue is experienced by everyone, chronic fatigue is a serious
condition which accompanies a disease or treatment, is not relieved by rest
and affects a person's quality of life and ability to do activities (Ahlberg et al.,
2003; Trendall, 2000; Yurtsever, 2000).
Fatigue is a universal, chronic problem suffered by cancer patients, and the
severity of its symptoms often varies from time to time during the course of
the disease (Finnegan-John, Molassiotis, Richardson, & Ream, 2013;
Mitchell, 2010; Oh & Seo, 2011; Werner, 2009). Of the patients receiving
chemotherapy, 80–96% suffer fatigue which in-creases over time (Cheville,
2009; Iop et al., 2004; Kearney et al., 2008; Kwekkeboom, Cherwin, Lee, &
Wanta, 2010; Rotonda et al., 2011; Sood, Barton, Bauer, & Loprinzi, 2007;
Stasi, Abriani, Beccaglia, Terzoli,
& Amadori, 2003). Fatigue can be caused by either the disease itself,
or by anemia, a decrease in hematocrit values, the accumulation of waste
products resulting from the destruction of cells, interruptions in sleep, pain,
anxiety, depression, immobility, anorexia, nausea and vomiting and
malnutrition due to chemotherapy (Barsevick et al., 2010; Can, Durna, &
Aydiner, 2004; Franklin & Packel, 2006; Harper & Littlewood,
2005; Lane, 2005; Mitchell, 2010; Mock et al., 2001; Oh & Seo, 2011;
Rabbetts, 2010; Yavuzşen & Kömürcü, 2008).
Cancer treatment, which takes a long time and has a great
many side effects, shatters an individual's family, work and
social life and thus leads to the loss of role and status,
hopelessness, helplessness, anxiety about the future, social
isolation and exhaustion. Therefore,
 S. Karagozoglu, E. Kahve / Applied Nursing Research 26 (2013) 210–217
the disease, treatment and uncertainties about the future can lead to anxiety
and depression (Arslan & Bölükbaş, 2003; Beşer & Öz, 2003; Nagel, 2004;
Şenler, 2001). In cancer patients, there is a strong association between
depression and fatigue (Dimeo et al., 2004; Kwekkeboom et al., 2010; Winell
& Roth, 2004) and between anxiety and fatigue (Brown & Kroenke, 2009; Li
& Yuan, 2011; Mansky & Wallerstedt, 2006; Oh & Seo, 2011; Reddick,
Nanda, Campbell, Ryman,
& Gaston-Johansson, 2005; Redeker, Lev, & Ruggiero, 2000). Although it is
common in patients with cancer, fatigue, which is often neglected, imposes
psychological stress on the patient and is assumed to be the most important
cause of non-compliance to treatment (Glaus, Crow, & Hammond, 1996).
Nursing interventions aiming to reduce distress and anxiety in cancer patients
are of great importance in ensuring the patient's compliance to treatment and
enhancing the quality of life (Schreier & Williams, 2004; Smith, Gomm, &
Dickens, 2003).
Nurses who directly observe the inconveniences due to unwanted effects
of chemotherapy in patients receiving chemotherapy are the professionals
who have a key role in dealing with problems experienced in patient care
(Aghabati, Mohammadi, & Pour Esmaiel, 2010; Aslan, Vural, & Kömürcü,
2006; Berger, 2001). Nursing interventions performed to control symptoms in
cancer patients receiving chemotherapy help them relieve and regain their
confi-dence. Today, given the fact that providing cancer treatment and care in
outpatient care centers is becoming widespread, it is obvious that nurses'
increasingly expanding roles will come to the fore even more.
Complementary therapies, palliative and supportive care have an
important place in the control of fatigue and anxiety suffered by patients
receiving chemotherapy (Ernst, 2001; Fontaine, 2004; Henricson, Berglungd,
Matta, & Segesten, 2006; Kwekkeboom et al., 2010; Mitchell, Beck, Hood,
Moore, & Tanner, 2007; Parkman, 2001; Walters, 2010). Complementary
therapies are not curative applications, but they aim to alleviate the symptoms
of the disease or to reduce the adverse effects of traditional therapy, and
improve the individual's general well-being and quality of life (Ernst, Filshie,
& Hardy, 2003; Finnegan-John et al., 2013; Fox et al., 2013; Harrington,
Baker, & Hoffman, 2012; Henricson et al., 2006). Back massage, a nursing
intervention, is one of the complementary treatment approaches.
Massage is a way of communication performed not by using words but by
touching the individual (Currin & Meister, 2008; Fontaine, 2004; Gleeson &
Timmins, 2005; Henricson et al., 2006; Jane, Wilkie, Gallucci, & Beaton,
2008; Toth et al., 2013). Massage is a cheap and easy-to-perform application
with no side effects and, unlike stress response, leads to relaxation in the
muscles by reducing tension (Field, 1998; Jane et al., 2008; Menefee &
Monti, 2005; Mok
& Woo, 2004; Myers, Walton, & Small, 2008; Smith, Yamashita, Bryant,
Hemphill, & Kutner, 2009). Massage can be defined as the systemic
stimulation of the body's soft tissues manually or mechanically for therapeutic
purposes in order to maintain blood and lymph circulation, relax muscles,
relieve pain, reduce fatigue and ensure sleep (Ernst, 2009; Fontaine, 2004;
Menefee & Monti, 2005; Monti & Yang, 2005; Thompson, Sherman, Dixon,
& Cherkin, 2006; Wolsko, Eisenberg, Davis, & Phillips, 2004). The
application area of classical massage is the skin and the muscles under the
skin. The effects of massage applied can be seen either locally or in the other
parts of the body as a result of stimuli transmitted through the nervous
system. Manual massage techniques provide both physical and mental
relaxation (Beck, 2006; Collinge, Macdonald, & Walton, 2012; Ernst, 2009;
Fernández-Lao et al., 2012; Jane et al., 2008; O'Mathúna, 2009; Quattrin et
al., 2006; Thompson et al., 2006; Timby, 2009; Werner, 2009).
Massage is used as a supportive treatment method in cancer patients
(Cassileth & Vickers, 2004; Collinge et al., 2012; Finnegan- John et al., 2013;
Fontaine, 2004; Gross, Cromwell, Fonteyn, Matulonis, & Hayman, 2013;
Sagar, Dryden, & Wong, 2007; Walters, 2010; Wilkinson, Barnes, & Storey,
2008). In the literature, there are
211
many studies demonstrating the benefits of massage applications in cancer
patients. However, there are no studies demonstrating the effects of back
massage provided during chemotherapy on acute chemotherapy-induced
fatigue and the level of anxiety developing during this process. In our country
too, the number of experimental studies specific to complementary treatment
approaches aiming to control the side effects occurring in patients receiving
chemotherapy is quite inadequate.
1.1. Purpose and hypothesis
This quasi-experimental and cross-sectional study was carried out to
determine the efficacy of back massage, a nursing intervention, on the process
of acute fatigue developing due to chemotherapy and on the anxiety level
emerging during this process in cancer patients receiving the third and fourth
day chemotherapy cycles of one-day chemotherapy.
The hypotheses to be tested in the study are as follows:
H1: Back massage provided during chemotherapy decreases
chemotherapy-related fatigue.
H2: Back massage provided during chemotherapy reduces chemo-therapy-
related anxiety.
1.2. Ethical considerations
During the planning stage of the study, written permission was received
from the chief physician and the Presidency of the Radiation Oncology
Department of the hospital where the study was carried out. Then, Ethics
Committee Decision (decision no. 2007/10-03) was obtained from the
Presidency of the Ethics Committee of Cumhuriyet University Faculty of
Medicine. The study was conducted in accordance with the principles of the
Helsinki Declaration.
All patients were informed about the study and provided time to ask
questions, prior to providing their oral-written consent to participate. All the
participants of this study gave their verbal and written informed consents. The
patients were assured that the data to be obtained in the study would be used
only in the scope of the study and would not be shared with any other person,
institution or organization.
2. Methods
2.1. Setting and sample
The study was carried out at the Chemotherapy Unit of the Radiation
Oncology Center of a university hospital. In this unit which started to offer
service in March 2007, patients having lung, breast, stomach, rectum, and
colon, ovarian or cervical cancer receive outpatient chemotherapy service.
The unit has two separate sections furnished with recliners in which patients
comfortably sit during chemotherapy. In each section, three patients can
receive chemo-therapy at the same time. In the unit, approximately 1–10
patients per day receive chemotherapy between 8 a.m. and 5 p.m.
The chemotherapy nurse admits patients presenting to the unit to have
chemotherapy, and then prepares and implements the treat-ment according to
the chemotherapy cure protocol determined previously. The chemotherapy
nurse provides education for patients on chemotherapy and side effects of
chemotherapy. In addition, patients having undergone chemotherapy are given
an appointment by the chemotherapy nurse for the subsequent cycle of
chemother-apy. Within the first 30 minutes after the patient's admittance to the
chemotherapy unit, chemotherapeutic medicines are prepared for
administration in a special pharmaceutical preparation cabin. For the
preparation of antineoplastic drugs, class II biological safety cabin, which is
placed in the unit where entering is limited, only drug
212 S. Karagozoglu, E. Kahve / Applied Nursing Research 26 (2013) 210–217
preparation process is conducted and there is no in-room air turbulence, is
used. In the cabin, there is downward airflow and HEPA (high-efficiency
particulate air) filter is available in the cabin. While the applications in the
cabin are performed, gloves are worn. While preparing antineoplastic drugs,
the nurses wear chemotherapy gloves, gown, mask, and goggles as personal
protective equipment.
Of the patients who underwent one-day chemotherapy, those who received
the third and fourth chemotherapy treatments in this unit comprised the
population of the study. The data were collected by the researchers between
August 1, 2007 and May 30, 2008, until the number of the patients reached
40. In this study, it was decided to include 20 people in each group when α =
0.05, β = 0.20 and 1−
β = 0.80, and the power of the test was determined as p = .80482. Of the
patients included in the study, 20 were in the intervention group and the other
20 were in the control group. The first three patients were assigned to the
intervention group and the second three patients to the control group and so on
until the number of the patients reached 40.
2.2. Eligibility criteria
The following patients were included in the study: (1) those who had no
speech and hearing problem so that the data collection forms could be clearly
filled in through face to face talks with the patient or on the telephone, (2)
those who received the third and fourth chemotherapy cycles because during
these cycles, the side effects of chemotherapy are heavily observed, (3) those
who had one-day chemotherapy so that all the patients could get back massage
on the same day for the same length of time, (4) those who had chemotherapy
for less than 8 hours in order that all the patients could have back massage for
the same length of time, (5) those who did not have open wounds, fractures
and/or luxation in the back, neck, shoulders and arms likely to cause them to
suffer problems in addition to the problems caused by the disease itself and
chemotherapy. During the chemotherapy process, none of the patients who
participated in the study had an active working life which might cause fatigue
and insomnia.
2.3. Instruments
To collect the data, the Personal Information Form, the State Anxiety part
of Spielberger State-Trait Anxiety Inventory/STAI and the Brief Fatigue
Inventory/BFI were used.
2.3.1. Personal information form
The Personal Information Form based on the literature included nine
questions: patient's age, gender, diagnosis, starting date of chemother-apy,
chemotherapeutic and other medicines taken, feelings and thoughts about the
disease and treatment, support resources, chemo-therapy, thoughts and
feelings about the environment where chemo-therapy is provided, how
satisfied with nursing services and the factors likely to affect the level of
chemotherapy-related fatigue and anxiety. The list of chemotherapeutic or
other drugs administered to the patients was obtained from the medical
records. In the Personal Information Form, patients were asked an open-ended
question whether they were satisfied with nursing care, and the answers
received were evaluated in two groups: (a) satisfied and (b) not satisfied.
2.3.2. Spielberger State-Trait Anxiety Inventory/STAI
In the study, State-Trait Anxiety Inventory/STAI was used to measure the
level of anxiety before and after chemotherapy. STAI, which was developed
by Spielberger et al. in 1964 in order to determine the state and trait anxiety
levels separately, is a self-report questionnaire consisting of short statements.
It was adapted into Turkish by Öner and Le Compte (1998) and its validity–
reliability studies were conducted by them as well. In several studies,
Cronbach's
alpha coefficient was found to be between 0.83 and 0.92 and was stated that
the scale had high validity. In our study, Cronbach's alpha coefficient of the
scale was found to be 0.78 for pre-chemotherapy and 0.80 for post-
chemotherapy.
State-Trait Anxiety Inventory includes two 20-item scales. It is a
psychological assessment tool used to determine the levels of state anxiety
and trait anxiety. The former perceived by individuals as a result of stresses
they face in their daily lives reflects transitory, situational circumstances. The
latter is independent of conditions, and reflects personality characteristics. It
was especially developed for use in research (Öner & Le Compte, 1998). State
Anxiety Inventory was configured to measure what is felt at the time of
measurement. On this scale, the answer options are as follows: (1) not at all,
(2) somewhat, (3) moderately so and (4) very much so. Theoretically, scores
obtained from the inventory range between 20 and 80. The higher the score is,
the greater the anxiety is (Öner & Le Compte, 1998.
2.3.3. Brief Fatigue Inventory/BFI
In the study, in order to assess fatigue levels of patients who received
chemotherapy, the Brief Fatigue Inventory, consisting of 10 questions, was
used. Çınar, Sezerli, Sarsmaz and Menteş (2000) performed the validity and
reliability study of the Turkish version of Brief Fatigue Inventory/BFI, which
was developed by Mendoza et al. (1999) at MD Anderson Cancer Center, and
the internal consistency of the scale was determined to be 0.98. In our study,
the Cronbach alpha reliability coefficient of the scale was determined to be
0.93 for pre-chemotherapy and 0.96 for post-chemotherapy. BFI includes
items assessing general fatigue levels of individuals (fatigue felt at the time of
the interview, fatigue in general and the worst fatigue suffered in the past 24
hours) and the interference of fatigue with daily activities (general activity,
mood, walking ability, work life, relationships with other people, the joy of
life) in the past 24 hours. Scoring ranges between “0” and “10”, “0” indicating
no impact at all and “10” indicating the highest level of impact. In the
assessment of fatigue levels, “0” referred to no fatigue at all, “1–2” to the very
low level of fatigue, “3–4” to the low level of fatigue, “5–6” to the moderate
level of fatigue, “7–8” to the high of level fatigue and “9–10” to the very high
level of fatigue. Each item in the BFI can be evaluated singly, or the overall
fatigue level and the level of interference on activities can be determined by
calculating the total score. The point value of each item is no more than 10,
the overall fatigue level (containing 10 items) is maximum 100, and the level
of impact on activities (including 6 items) is maximum 60 points.
2.4. Procedures
During the implementation process of the research, one researcher stayed
in the unit full time and applied the back massage exactly as planned. In order
to maintain the integrity of the data collection process and massage treatment,
no more than one patient a day was included in the sample. In order to create a
study mechanism, six patients (three from the intervention group and three
from the control group) having chemotherapy in the unit underwent a pre-
implementation process after verbal or written permissions were received.
After the pre-intervention process, the study process was initiated. Before
chemotherapy was started, Personal Information Form, STAI and BFI were
filled in through face-to-face interviews with all the patients participating in
the study. During the chemotherapy process, the patients in the intervention
group had repetitive back massage for 15 minutes before the infusion,
between 25th and 40th minutes of each 1-hour period during the treatment and
for 15 minutes at the end of the treatment in accordance with the duration of
chemotherapy. Chemotherapy cycles administered to the patients included in
the study were minimum 2-hour and maximum 3-hour cycles. Thus, patients
had a 60-minute back massage during the 2-hour cycle (Table 1) and a 75-
minute back massage during the
 S. Karagozoglu, E. Kahve / Applied Nursing Research 26 (2013) 210–217 213

Table 1
Massage treatment schedule in 2-hour chemotherapy protocols.
Prior to chemotherapy
The first hour of chemotherapy
Onset of chemotherapy
25–40 minutes of chemotherapy
40–60 minutes of chemotherapy The
second hour of chemotherapy 60–85
minutes of chemotherapy
85–100 minutes of chemotherapy
100–120 minutes of chemotherapy
After chemotherapy
15 minute massage treatment
No massage treatment in the first 25
minutes
15 minutes of massage treatments No
massage treatment for 20 minutes
No massage treatment for 25 minutes 15
minutes of massage treatments No
massage treatment for 20 minutes 15
fibers. Several variations of petrissage are one handed, two hand, alternate
minutes of massage treatments
may be linear or circular. Over the scapulae, the hands were separated
from each other and stroking was continued and
repeated several times in larger circular movements. Effleurage was
implemented during the first 5 and last 4 minutes of the 15-minute
back massage.
(6) After completing the effleurage phase of the massage, starting around
the waist, the researcher maintained the back massage with petrissage by
grasping the subcutaneous tissues and muscles with the thumb and other
fingers. Petrissage is the application of cycles of rhythmic lifting,
squeezing, and releasing of tissue, often working parallel to the muscle
hand, and skin rolling. Kneading movements were started from the waist
and continued to shoulders and arms,

3-hour cycle (Table 2). STAI and BFI were re-applied after chemo-therapy. To
determine the effects of back massage on acute fatigue, patients were phoned
to determine the level of fatigue experienced at home after the first 24 hours
following chemotherapy, and the BFI was filled in again by the researcher
during this interview. Each form was filled in question by question or after the
participant provided all of the responses. After the forms were read to the
patients, the researcher filled in the forms based on the patients' responses.
The patients in the control group underwent all the processes in the same way
except that they did not receive back massage during chemotherapy. The
control group had no other intervention. Both the intervention group and the
control group were treated similarly during the research, and the
communication and interaction with the groups were carried out at the same
level.
Back massage was implemented in nine stages in the intervention group
by the researchers who previously had training on this topic (Clay & Pounds,
2008; Fritz, 2004; Fritz & Grosenbach, 2004; MacDonald, 2007; Salvo, 2007;
Timby, 2009):
(1) The environment where the massage was implemented was
appropriately arranged by checking whether the door and windows
were closed in order that the ambient temperature in the chemotherapy
unit should be maintained.
(2) The patient was informed about the purpose and duration of the
massage before the massage was started.
(3) The patient's privacy was protected by separating him/her from others
with a folding screen, and the patient's back was exposed while he/she
was sitting in the recliner.
(4) After warming his/her hands by rubbing, the researcher put on some
Vaseline to make them slippery.
(5) The massage was started from the waist with long-slow effleurage and
continued to the neck with circular movements. Effleurage is a
soothing, stroking movement used at the beginning and the end of the
body massage. Effleurage is the application of unbroken gliding
movements that are repeated and follow the contour of the client's
body. These movements
Table 2
Massage treatment schedule in 3-hour chemotherapy protocols.
and then back to the waist again and then the petrissage phase
was over. Petrissage was implemented for 3 minutes between
the sixth and ninth minutes of the 15-minute back massage.
(7) After petrissage, back massage was continued through friction
movements, another phase of the massage. The thumb tips
were placed one on the other and the massage was started from
the sacroiliac junction, and circular friction movements applied
with fingertips continued along the vertebra to the occipital
region. Friction movements from the sacroiliac junction to the
occipital region were repeated several times. Friction was
applied for 3 minutes between the 9th and 12th minutes of the
15-minute back massage.
(8) Before the massage was over, effleurage was applied again for
4 minutes.
(9) Finally, after the back massage was over, the researcher
removed the Vaseline on the back of the patient with a towel
and helped the patient to wear his/her clothes. The application
was finalized after placing the patient in a comfortable position.
2.5. Data analysis
The data obtained were analyzed using SPSS 14.0 package program. The
data are normally distributed. For the data analysis, frequency distribution,
chi-square, means, Friedman test, Wilcoxon test and Man-Whitney U test
were used.
According to demographic characteristics, the difference between
intervention and control groups was evaluated with chi-square test. Mann–
Whitney U test was used to for evaluate BFI and STAI scores difference
between of the intervention and control group patients. Friedman test was
performed to compare the fatigue level of the patients before, right after and
on the next day after chemotherapy. Wilcoxon test was used to compare
anxiety level of the patients before and after chemotherapy. Values were
considered statistically significant when p b .05. In order to investigate
whether the difference between the mean scores of fatigue and anxiety
assessed before, immediately after and 1 day after chemotherapy in the study
and control groups was significant not only statistically but also in practice,
the effect size was calculated with the Cohen's d method. For Cohen's d, the
effect size of 0.2–0.4 was considered as small, of 0.5–0.7

Prior to chemotherapy
The first hour of chemotherapy
Onset of chemotherapy
25–40 minutes of chemotherapy
40–60 minutes of chemotherapy The
second hour of chemotherapy 60–85
minutes of chemotherapy
85–100 minutes of chemotherapy
100–120 minutes of chemotherapy The
third hour of chemotherapy 120–145
minutes of chemotherapy 145–160
minutes of chemotherapy 160–180
minutes of chemotherapy After
chemotherapy
15-Minute massage treatment
No massage treatment in the first 25
minutes
15 minutes of massage treatments No
massage treatment for 20 minutes
No massage treatment for 25 minutes 15
minutes of massage treatments No
massage treatment for 20 minutes
No massage treatment for 25 minutes 15
minutes of massage treatments No
massage treatment for 20 minutes 15
minutes of massage treatments
as medium and of N 0.8 as large (Cohen, 1988; Cohen, 1992).
3. Results
Of the patients, 55.0% (11) in the intervention group and 50.0%
(10) in the control group were female. The mean age of the patients in the
study was 49.97 ± 11.31. Of them, 75.0% (15) in the intervention group and
60.0% (12) in the control group were in the 41–60 age group. In our research,
40.0% (8) of the patients in the intervention group and 50.0% (10) in the
control group had breast cancer. Of the patients, 55.0% (11) in the
intervention group and 50.0% (10) in the control group underwent the third
session of the chemotherapy (Table 3). No statistically significant difference
was determined
214 S. Karagozoglu, E. Kahve / Applied Nursing Research 26 (2013) 210–217

Table 3
Distribution of the intervention and control groups according to their personal characteristics (N = 40).

Personal characteristics Intervention group (n = 20) Control group (n = 20) Significance

test
Number % Number %
Gender
Male 9 45.0 10 50.0 2
χ = 0.100
Female 11 55.0 10 50.0 p = .752
Age (X = 49.97 ± 11.31)
Between 20 and 40 3 15.0 4 20.0 a

Between 41 and 60 15 75.0 12 60.0

60 and over 2 10.0 4 20.0
Diagnosis
Breast cancer 8 40.0 10 50.0 2
χ = 1.292
Lung cancer 7 35.0 5 25.0 p = .524
b 5 25.5 5 25.0
Others
Treatment
Cyclophosphamide + doxorubicin + Fluorouracil 7 35.0 11 55.0 2
χ = 3.917
Paclitaxel + platinol 8 40.0 4 20.0 p = .141
c 5 25.0 5 25.0
Others
The number of chemotherapy treatments received
Three treatments 11 55.0 10 50.0 2
χ = 0.100
Four treatments 9 45.0 10 50.0 p = .752

a The chi-square test was not applied because in multi-cell orders, the number of the cells in which the expected frequency was less than 5 was more than 20% of the total number of the cells.

b Others (ovarian cancer, rectal cancer, stomach cancer).

c Other (platinol + etoposide; platinol + docetaxel).

between the participants' gender, diagnosis and treatment, and the
chemotherapy cycles received by the participants in the study and control
groups: (gender: p = .752; diagnosis: p = .524; treatment: p = .141; the number
of chemotherapy treatments received: p =
.752).Thus, the subjects in both groups had similar characteristics. Of the
patients, 80.0% (16) in the intervention group and 95.0%
(19) in the control group expressed their satisfaction with the environment
where they received chemotherapy. When the patients were asked about their
perception of comfort and discomfort during chemotherapy, 75.0% (15) in the
intervention group and 80.0% (16) in the control group said that they were
comfortable.
When the BFI mean scores of the study and control group patients were
compared, there was a statistically significant difference between the two
groups in terms of the level of fatigue observed before chemotherapy (Z =
2.516; p = .012; effect size = 0.81) and on the next day after chemotherapy (Z
= 2.315; p = .020; effect size = 0.84). It was higher in the control group on the
next day after
chemotherapy (48.05 ± 22.90). However, intra-group comparisons revealed
2
that, though statistically was not significant (χ = 3.308; p = .191), the control
group patients' fatigue level after chemother-apy (39.55 ± 17.67) and on the
next day after chemotherapy (48.05 ± 22.90) was higher than that before
chemotherapy (39.40 ± 18.03) whereas the intervention group patients' fatigue
level after chemotherapy (44.5 ± 23:10) and on the next day after
2
chemotherapy (30.15 ± 19.59) was statistically significantly lower (χ =
25.600; p = .000) than that before chemotherapy (55.20 ± 20.85) (Table 4).
When the pre- and post-chemotherapy STAI mean scores of both the study
and control group patients within the scope of the study
were compared, the level of anxiety was higher after chemotherapy in the
control group, but the difference between the groups was not statistically
significant (Z = 1.602; p = .109; effect size = 0.37). However, intra-group
comparisons revealed that, though statistically was not significant (Z = 0.427;
p = .670), the mean anxiety scores of the patients in the control group raised
up to 29.50 ± 7.68 after chemotherapy which was 28.80 ± 6.75 before
chemotherapy, where-as the mean anxiety scores of the patients in the
intervention group decreased statistically significantly (Z = 3.703; p = .000)
down to 26.70 ± 7.35 after chemotherapy which was 33.35 ± 11.89 before
chemotherapy (Table 5).
When the chemotherapy sessions of the patients who participated in study
were compared, anxiety and fatigue levels in the third and fourth
chemotherapy treatments were close to each other, but the difference was not
statistically significant (p N .05).
4. Discussion
Complementary and alternative approaches are the practices which help
individuals to lead a healthy life and to improve their quality of life, and these
approaches are a unique opportunity for nurses so that they can provide
holistic care. In the literature, it is reported that massage, one of the
complementary and alternative approaches, is effective in relieving overall
symptoms and side effects cancer patients suffer due to the disease and
treatment. Although there are several studies evaluating the efficacy of
massage applied to cancer patients on the quality of life (Sturgeon, Wetta-
Hall, Hart, Good, & Dakhil, 2009; Toth et al., 2013; Wyatt, Sikorskii, Siddiqi,
&

Table 4
Mean BFI scores of the patients before, right after and the next day after chemotherapy.

Mean BFI scores

Time Intervention group (n = 20) Control group (n = 20) Mann–Whitney U Cohen's d

test effect size
X ± SD X ± SD
Before chemotherapy 55.20 ± 20.85 39.40 ± 18.03 Z = 2.516 p = .012 ES = 0.81
Right after chemotherapy 44.5 ± 23.10 39.55 ± 17.67 Z = 0.758 p = .449 ES = 0.24
The next day after chemotherapy 30.15 ± 19.59 48.05 ± 22.90 Z = 2.315 p = .020 ES = 0.84
Friedman Test 2 2
χ = 25.600 p = .000 χ = 3.308 p = .191
 S. Karagozoglu, E. Kahve / Applied Nursing Research 26 (2013) 210–217
Table 5
The mean STAI scores of patients before and right after chemotherapy.
Mean STAI scores
Patient group Intervention group (n = 20)
X ± SD
Before chemotherapy 33.35 ± 11.89
Right after chemotherapy 26.70 ± 7.35
Wilcoxon test Z = 3.703 p = .000
Given, 2007), pain (Aghabati et al., 2010; Chang, 2008; Ferrell-Torry &
Glick, 1993; Gross et al., 2013; Smith et al., 2009; Toth et al., 2013), sleep
(Smith, Kemp, Hemphill, & Vojir, 2002; Toth et al., 2013), muscle tension
and anxiety (Campeau et al., 2007; Hernandez-Reif et al., 2004; Post-White,
Kinney, & Savik, 2003; Post-White et al., 2009; Wilkinson et al., 2007),
nausea (Billhult, Bergbom, & Stener-Victorin, 2007; Fellowes, Barnes, &
Wilkinson, 2004), fatigue (Aghabati et al., 2010; Listing et al., 2009; Monti &
Yang, 2005; O'Mathúna, 2009; Sood et al., 2007), and many of these
difficulties (Cassileth & Vickers, 2004; Fellowes et al., 2004; Myers, Walton,
Bratsman, et al., 2008; Pruthi Degnim, Bauer, DePompolo, & Nayar, 2009;
Russell, Sumler, Beinhorn,
& Frenkel, 2008; Smith et al., 2002; Wilkinson et al., 2008), we have not seen
any national or international studies investigating the effects of back massage
implemented during chemotherapy on chemother-apy-related fatigue and
anxiety. Therefore, we consider that our study findings will provide a
significant contribution to the literature.
When the patients' BFI scores in our study obtained before, right after and
on the next day after chemotherapy were compared, it was determined that the
control group patients' fatigue levels right after and on the next day after
chemotherapy were higher than those before chemotherapy, and that their
post-chemotherapy fatigue levels increased gradually. However, the
intervention group patients' fatigue levels statistically significantly decreased
on the next day after
chemotherapy (p = .020; effect size = 0.84) (Table 4). Therefore, it can be said
that the hypothesis H1, that the back massage provided during chemotherapy
significantly reduces fatigue suffered in the process of chemotherapy was
supported. However, in the literature, there are studies with the results that the
fatigue level caused by chemotherapy increases gradually in the process of
chemotherapy treatment. In studies which evaluated the level of fatigue after
chemotherapy, it is stated that 70–100% of the patients suffer fatigue (Gerber
et al., 2011), that they suffer fatigue even after a year or more subsequent to
chemotherapy (Cella, Davis, Breitbart, & Curt, 2001), that the level of fatigue
increases in the further phases of chemotherapy, that those who receive
chemotherapy for the third time have higher levels of fatigue than do those
who receive chemotherapy for the first time (Lee et al., 2008) and that the
highest level of fatigue is observed on the day chemotherapy is received
(Schwartz, 2000). Therefore, if fatigue caused by the chemotherapy process is
to be brought under control, it can be said that back massage during
chemotherapy is an important and primary nursing practice. During the
interviews conducted with the participants of our study on the next day after
chemotherapy, those who had massages during chemotherapy treatments
stated that they were more comfortable than they were in previous
chemotherapy treatments, which is a noteworthy feedback in the assessment
of the efficacy of our study. In their study, Cassileth and Vickers (2004)
reported that the effectiveness of the massage provided for cancer patients to
reduce the symptoms was more in the first 2–5 hours and that the effects of
the massage lasted longer in outpatients. Wilkinson et al. (2007) stated that
the effectiveness of the massage provided for cancer patients might last for 2–
6 weeks after the intervention.
When the state anxiety levels of the patients participating in our
investigation were taken into consideration, it was observed that the mean
anxiety scores of the patients in the control group increased
215
Control group (n = 20) Mann–Whitney Cohen's d
U test effect size
X ± SD
28.80 ± 6.75 Z = 1.152 p = .249 ES = 0.47
29.50 ± 7.68 Z = 1.602 p = .109 ES = 0.37
Z = 0.427 p = .670
after chemotherapy but the mean anxiety scores of the patients in the
intervention group decreased after chemotherapy (Table 5). In line with our
findings, it can be said that hypothesis H 2, that the back massage during
chemotherapy is effective on anxiety suffered during chemotherapy and that
the massage significantly reduces state anxiety, was supported. During the
phone calls made to patients a day after chemotherapy, the patients stated that
they had a comfortable sleep and they felt more energetic and comfortable,
which supports the findings of our study. Therefore, it is thought that back
massage during chemotherapy, a nursing practice, is an effective method in
reducing the level of anxiety suffered by individuals. In another study, it is
stated that massage applied to control the symptoms in cancer patients affects
anxiety more than it affects all other symptoms (Myers, Walton, Bratsman, et
al., 2008).
In this context, one of the strengths of our study is that the study was
conducted with the matched control group in terms of personal characteristics
such as age, gender, diagnosis and treatment. Another strong aspect of this
study is that it reveals the importance of the complementary and supportive
nursing interventions which help cancer patients cope with the symptoms they
experience during the treatment process of the disease. On the other hand,
since the study was conducted on a small sample group, it is hard to
generalize the findings of the study.
5. Conclusions
In line with the findings of our study conducted to determine the effects of
back massage, a nursing intervention, on the chemotherapy induced acute
fatigue and the level of anxiety developing in this process, it can be suggested
that back massage administered during chemotherapy is effective on anxiety
and fatigue suffered during chemotherapy, and decreases state anxiety and
acute fatigue significantly. Therefore, it can be recommended that the
awareness, understanding and sensitivity of professionals, especially of
nurses, working in oncology centers and chemotherapy application units
regarding this application should be increased and that they should be
encouraged to implement this intervention.
Acknowledgments
The authors express their thanks to Dr. Ziynet Çiner of the Department of
Statistics of Cumhuriyet University, for help with the statistical evaluations in
this investigation.
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