Meditation entails a systematic mental focus on particular aspects of inner or outer experience. Meditation encompasses practices to increase mental awareness and clarity of mind (concentrative meditation), quiet the ordinary stream of internal mental dialogue (transcendental meditation), or focus attention on the flow of sensations experienced from moment to moment (mindfulness meditation) (Cassileth et al. 2007; Astin et al. 2003). The most commonly studied meditation practice appears to be the Mindfulness-Based Stress Reduction (MBSR) program developed by Jon Kabat-Zinn, usually operationalized as 8–10 weeks of weekly 2½  h sessions. A review of experimental and nonexperimental studies of meditation, such as mindfulness meditation and transcendental meditation for chronic pain, concluded that the limited available data seems to indicate that meditation programs may ease the burden of chronic pain with both short- and long-term effects (Teixeira 2008).

Given limitations of existing data (few randomized clinical trials with small sample sizes and variable control groups), it appears that meditation is a safe, well-accepted intervention for chronic pain and in the palliative care setting, and may have benefits on pain intensity, functional status, quality of life, function, sleep quality, well-being, and mood (anxiety and depression) (Table 35.1). Pending additional research evidence, meditation is likely a viable option for patients with chronic pain or palliative care needs. The American College of Chest Physicians (ACCP) recommends mind–body modalities as part of a multidisciplinary approach to reduce anxiety, mood disturbance, or chronic pain among patients with lung cancer (Cassileth et al. 2007).

Yoga combines physical movement, breath control, and meditation with the goal of uniting the mind, body, and spirit for health and self-awareness. Studies of yoga for chronic low back pain and knee osteoarthritis suggest that it may be effective for decreasing pain and fatigue and improving function (Table 35.2). A clinical practice guideline on the diagnosis and treatment of low back pain issued by the American College of Physicians (ACP) and the American Pain society weakly recommends, based on moderate-quality evidence, yoga for patients with chronic or subacute low back pain (Chou et al. 2007). A systematic review of literature examining the impact of yoga on psychological adjustment of cancer patients identified ten studies, six of which were RCTs. Overall study quality was high; limiting factors included lack of long-term data and small sample size. Studies demonstrated improvements in sleep, stress levels, and mood. While a number of positive results were found, the authors concluded that the variability across studies and methodologic drawbacks limit the extent to which yoga can be considered effective for managing psychological symptoms associated with cancer (Smith & Pukall 2009). Yoga thus appears to be a promising intervention for improving psychological symptoms among cancer patients and for improving function among persons with chronic pain.

Acupuncture, a CAM modality that originated from traditional Chinese medicine, is based on the theory that one can regulate the flow of “Qi” (vital energy) by stimulation of certain points on the body with needles, heat, or pressure. Stimulation of specific points along the 12 primary and 8 secondary meridians is believed to restore the proper flow of Qi. It appears that the effects of acupuncture are mediated by the nervous system. Evidence includes observations that administration of local anesthesia at acupuncture needle insertion sites completely blocks the immediate analgesic effects of acupuncture and documented neurotransmitter release and changes in brain functional MRI signals during acupuncture (Han 2003; Wu et al. 1999; Berman et al. 2010).

Systematic reviews of the use of acupuncture for chronic low back pain have concluded that while real acupuncture was no more effective than sham acupucture, both real and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional treatment for low back pain (Yuan et al. 2008; Rubinstein et al. 2010; Chou & Huffman 2007). A clinical practice guideline on the diagnosis and treatment of low back pain issued by the ACP and the American Pain Society weakly recommends, based on moderate-quality evidence, acupuncture for patients with chronic or subacute low back pain (Chou et al. 2007). The North American Spine Society concluded that acupuncture provides better short-term pain relief and functional improvement than no treatment and that the addition of acupuncture to other treatments provides a greater benefit than other treatments alone (Ammendolia et al. 2008). The U.K. National Institute for Health and Clinical Excellence has recommended acupuncture as a treatment option for patients with low back pain (Royal College of General Practitioners 2009).

A systematic review of seven systematic reviews of acupuncture as a treatment for cancer palliation and supportive care found that acupuncture as a treatment of chemotherapy-induced nausea and vomiting is backed by good evidence. Evidence is lacking as to whether acupuncture is superior to other interventions available for treatment of chemotherapy-induced nausea and vomiting (Ernst & Lee 2010). The ACCP recommends acupuncture as a complementary therapy for patients with lung cancer when pain is poorly controlled or when side effects such as neuropathy or xerostomia from other modalities are clinically significant as well as for poorly controlled nausea and vomiting associated with chemotherapy. A trial of acupuncture is recommended by the ACCP for patients with lung cancer who have symptoms such as fatigue, dyspnea, chemotherapy-induced neuropathy, or postthoracotomy pain. The ACCP notes that acupuncture should be performed by qualified practitioners and used cautiously in patients with bleeding tendencies (Cassileth et al. 2007). A Cochrane Review concluded that there is insufficient evidence to recommend the routine use of acupuncture/acupressure for relief of dyspnea in advanced stages of malignant and nonmalignant diseases, recommending further study before they are routinely used in clinical practice (Bausewein et al. 2008). A systematic review of acupressure for symptom management in end-stage renal disease (ESRD) found few well-designed trials. The authors conclude that the small number and suboptimal methodological quality of available studies preclude determination of the therapeutic effects of acupressure for ESRD patients (Kim et al. 2010). Table 35.3 details relevant available evidence.

Massage therapy (MT) is one of the oldest of the identified complementary-alternative therapies with references to its use appearing in Chinese texts at least 4,000 years ago. There are more than 80 different methods classified as massage including Swedish, sports, deep tissue, neuromuscular, trigger point, shiatsu, and manual lymph drainage. Massage can be full body or provided locally to specific areas of the body including the neck, shoulders, hands, and feet. In the mid-1800s, Swedish massage was imported to the USA, named as such by two physicians who learned the techniques in Sweden. This common form of massage includes smooth, gliding strokes over the body (effleurage), firm kneading of soft tissues (petrissage), and tapping or vibrating areas of the body (tapotement).

There are multiple hypotheses related to the mechanisms of action of MT for relief of chronic pain and other symptoms. The palliative effects of massage are proposed to be related to: an increase in blood flow and lymph drainage reducing the accumulation of metabolites in the tissues; muscle relaxation through the manual release of muscle tension; the generalized relaxation response; release of increased serotonin that decreases noxious pain impulses to the brain; increased release of somatostatin promoting restorative sleep and decreased release of substance P secreted in deep sleep deprivation (Field 1998); endorphin release from the pleasant sensation of touch; overriding pain signals (gate control theory); and energy transfer and energy field repatterning. However, the actual mechanisms of action have not been established.

Massage with common maneuvers such as effleurage and petrissage and delivered by trained professionals is a safe therapy. There are a few reports of adverse reactions to MT; however, for the most part these are related to more exotic types of manual therapies delivered by the lay public (Ernst 2003a; Grant 2003). Massage is contraindicated in persons with clotting disorders, taking anticoagulant medications, with potential or known thrombus, and at risk for fracture and over any lesions.

Research on the effects of massage related to pain and palliative care has proliferated over the past 25 years. (Field 1998; Ernst 1999, 2002, 2003a, 2004, 2009a; Cherkin et al. 2003; Fellowes et al. 2004; Furlan et al. 2002, 2008, 2009; Hughes et al. 2008; Jane et al. 2008; Lafferty et al. 2006; National Guidelines Clearinghouse 2010; Natural Standard 2010a; Pan et al. 2000; Russell et al. 2008; Tan et al. 2007; Wilkinson et al. 2008a). Two meta-analyses of massage research have been published (Fellowes et al. 2004; Moyer et al. 2004). Fellowes et al. reported on eight RCTs of MT in patients with cancer published before 2002. A 19–32% reduction in anxiety was reported in four studies. Pain was an outcome in three studies and a decrease in pain occurred in one. Two studies showed a reduction in nausea and another revealed an effect on sleep (Fellowes et al. 2004). Moyer et al. (2004) included 37 trials with statistically significant overall effect sizes in categories of state anxiety, immediate assessment of pain, and delayed assessment of pain among others; the findings support the conclusion that MT is effective.

A number of reviews have found that massage has demonstrated benefits for improving symptoms and functions those for those with subacute and chronic nonspecific low back pain (Cherkin et al. 2003; Ernst 1999, 2004; Furlan et al. 2002, 2008, 2009). For those with chronic low back pain the effects were long lasting (at least a year after the end of sessions). The greatest benefit seemed to come from massage delivered by professional massage therapists with many years of experience and when massage was combined with stretching exercises and education. These reviews conclude that massage is effective for persistent low back pain and has the potential to reduce costs of care after an initial course of therapy but more and stronger investigations are needed (Cherkin et al. 2003; Ernst 2009a).

There appears to be consistent common findings across MT studies, including decreases in anxiety, depression, and stress hormones and an increase in parasympathetic activity (Field 1998). Since pain is exacerbated by stress and tension, this is an important consideration. MT has been found to be “useful for pain relief in numerous chronic pain conditions” (Tan et al. 2007). There is less support for its efficacy for neck pain and fibromyalgia.

Several reviews focus specifically on massage for cancer, cancer pain and palliative care at end of life. These reviews conclude that there is support for the use of massage for relief from cancer pain in those at end of life (Lafferty et al. 2006; Pan et al. 2000). The Natural Standard Database rated the evidence that massage improved quality of life at a “B” or good rating; all other outcomes including for pain and anxiety were rated “C” or inconclusive (Natural Standard 2010a). In his review of 14 trials of massage for cancer palliation and supportive care, Ernst (2009a) reported “encouraging evidence.” He stated that the effect sizes for massage were small to moderate, but added that these effects can be beneficial for this population. Finally, he noted the methodological flaws and pitfalls of the studies and pointed to the Kutner et al. (2008) study as a model for future research. While it is difficult to compare across studies because of variation related to type of massage, dosage, control conditions, and outcomes, there is a trend that massage has more positive effects than controls for decreasing pain intensity, nausea, fatigue, distressing symptoms, anxiety, and enhancing relaxation. The most inconsistent outcomes are related to sleep, analgesic consumption, quality of life, and depression/mood disturbance (Jane et al. 2008; Wilkinson et al. 2008a). It appears that MT has an immediate or short-term (5–20 min) effect on symptoms, but there is no evidence that these effects are sustained over hours or days even with multiple treatments (Russell et al. 2008). MT can be safely integrated into the care of children with cancer, and that it can be beneficial for managing side effects and the emotional turbulence of the experience (Hughes et al. 2008).

Table 35.4 summarizes the research in MT for chronic pain and palliative care. The table includes randomized controlled trials (RCTs) and some quasi-experimental designs without controls or randomization. Only studies of chronic pain, those conditions that are persistent, recurring, and not self-limiting were included. For this reason, studies of episodic pain syndromes such as acute back pain, postoperative pain, and tension headaches were not included.

Many of the studies listed have methodological weaknesses, and a quality analysis was not conducted for this review. For example, small sample sizes are the norm, possibly because a considerable portion of the studies listed were unfunded or underfunded. Research related to MT can be expensive because of the cost of administering massage. These small sample sizes compromise the ability to detect actual differences that may exist. The intensity and duration of the intervention varies widely, so it is challenging to compare results. Some studies examine the effects of a few treatments while others use ten or more treatments over weeks or months. Many studies have no follow up. The control conditions vary from usual care, exercise, relaxation, or other therapies. Many reports lack adequate descriptions of outcome variables. All this compromises the ability to draw evidentiary conclusions.

Types and dosages of the MT varied across the studies. Pain was most frequently measured using a visual analogue or numeric rating scale, with immediate and follow-up measures variably present. Based on these data, MT provides some degree of efficacy, if only short term, for a variety of chronic pain syndromes. This conclusion is consistent with other reviews of MT for back pain.