The Effectiveness of Aromatherapy in Clients with Cancer in Reducing Fatigue and Improving Sleep Quality

1. The Effectiveness of Aromatherapy in Clients with Cancer in Reducing Fatigue and Improving Sleep Quality Presented by Jeremy Pierce, MOTS

2. Objectives • Background • Objective • Search Methods • Summary of Study Procedures • Methodological Quality • Results • My Conclusions

3. BACKGROUND

4. What is Cancer? • Life threatening tumor invades body tissues • Many different forms of disease • Many causes for cancer • Alcohol & tobacco use • Dietary factors • Genetic factors

5. Demographic Data on Cancer • Growing problem in U.S. • Prevalence—12 million • 2011 projections • 1.5 million new cases of cancer • 500,000 cancer-related deaths

6. Traditional Treatment • Radiation therapy • Chemotherapy • Surgery • Side-effects • Anxiety • Depression • Fatigue • Insomnia • Pain

7. Cancer-Related Fatigue • Symptom of cancer or side-effect of tx • 96% of clients with cancer • Usually doesn’t resolve after tx • Usually not screened for • Associated with poor sleep quality

8. Treatments for Fatigue • Energy conservation and activity management • Psychosocial support (CBT) • CAM • Aromatherapy • Hatha yoga • Meditation

9. Aromatherapy • Uses aromatic essential oils • Can be used to relieve hundreds of symptoms • Many types of oils used • Different methods • Massage • Inhalation • Soaking

10. Physiological Mechanism • Exact mechanism is unknown • Oils are similar in structure to cell membranes, which helps them get into the bloodstream • Aroma activates olfactory nerve

11. Justification for Evidence Review • Cancer is a growing problem • Cancer-related fatigue is a common symptom in clients with cancer • Aromatherapy is being used to tx cancer-related fatigue

12. OBJECTIVE The objective of this review is to examine the extent to which the research literature supports the use of aromatherapy as a more effective approach to decreasing fatigue and improving sleep quality in clients with cancer.

13. SEARCH METHODS Databases Searched Search Terms Aromatherapy Cancer Cancer-related fatigue Fatigue Inertia Oncology Physical Exhaustion Sleep • CINAHL (EBSCOhost: 1994 to 10/8/11) • Google scholar (1992 to 10/2/11) • PubMed (1991 to 10/9/11)

14. SUMMARY OF STUDY PROCEDURES

15. Types of Study Designs • Individual randomized controlled trial – 4 • Mixed method design – 1 • Controlled clinical trial – 1 • One group pre-post studies – 4

16. Populations Sampled • Clients with cancer • Breast cancer only – 1 study • Hematological malignancies – 1 study • Clients sampled from… • Palliative- or cancer-care centers • 1 study sampled from a hematology transplant unit

17. Inclusion Criteria • Age • Minimum of 16-20 years – 4 studies • Maximum age of 70 in one study • Most studies did not have age criteria • Gender, race, & ethnicity—no criteria

18. Exclusion Criteria • Individuals who used aromatherapy in pass 6 months – 2 studies • Individuals using aromatherapy on their own – 1 study • 2 studies excluded individuals with mental or cognitive disorders

19. Sample Sizes • 12 to 58 participants – 8 studies • 103 participants – 1 study • 313 participants – 1 study

20. Relevant Demographics • Age • Age range – 17 to 93 years • Average age – 51 to 73 years • Gender • Majority female – 6 studies • Majority male – 3 studies • Gender information not given – 1 study

21. Experimental Interventions • Method • Aromatherapy massage – 7 articles • Inhalation aromatherapy – 2 articles • Footsoak and reflexology – 1 article • Oils used • Varied, but half used lavender • 4 let client’s choose

22. Number and Duration of Intervention Sessions • Number • 3-5 sessions – 5 studies • 1 session – 2 studies • Other studies varied or did not indicate # • Duration – 15 to 60 minutes

23. Types of Outcome Measures • 3 studies used the Profile of Mood States • 2 studies used unnamed assessments • Other studies used other assessments

24. METHODOLOGICAL QUALITY

25. Threats to Validity • No control group • Pre-post studies • Three acknowledged this • Mortality and attrition • Inadequate information

26. Low Sample Size • Imanishi et al. (2009) & Kohara et al. (2004) had sizes of 12 & 20 • Three studies had total sample sizes over 40, but intentions groups had sizes of 23 or less • Wilkinson et al. (1999) stated they needed a larger sample

27. Psychometric Properties of Assessments • 2 used non-standardized tests • Kite et al. (2008) • Stringer and Donald (2008) • Wilkinson et al. (1999) used a subtest only • Not psychometrically evaluated

28. RESULTS

29. Pre-Post Studies • Pre-post studies showed decreased fatigue • Kohara et al. (2004): p < 0.001 • Stringer et al. (2008) & Wilkinson et al. (1999): p < 0.05 • Imanishi et al. (2009), Kite et al. (1998), & Stringer & Donald (2011): no p-values

30. Aromatherapy vs. Massage Only vs. Control • Aromatherapy massage vs. control group & massage only vs. control group • 3 studies showed significant improvements (p < 0.05) • 1 study showed no improvement (Wilcock, 2004) • Aromatherapy massage vs. massage only • Stringer et al. (2008) & Wilkinson et al. (1999) using p < 0.005 and < 0.0001 showed no improvement.

31. Long-Term Effects of Aromatherapy • Aromatherapy vs. CBT (Serfaty et al., 2011) • Short-term: aromatherapy massage > CBT • Long-term (3 months & 6 months): aromatherapy < CBT • No p-value reported, but significance stated • Imanishi et al. (2009) • Showed favorable results 3 months out • Did not report significance

32. Aromatherapy Not Beneficial • Wilcock et al., 2004 • Graham et al., 2003 • Put essential oils on bibs for clients to use during radiation treatment • Found that fatigue got worse for control group and intervention group

33. MY CONCLUSIONS

34. Discussion • Generally speaking, aromatherapy is beneficial – 8 of 10 articles indicated this • However • Many threats to validity and in these studies • Several studied did not report p-values • For aromatherapy massage, the benefits appear to be due to the massage, not the essential oils

35. Discussion cont’d • Long-term vs. Short-term • Long-term benefits not likely • Graham et al. • Found that an association developed between side-effects of treatment and the scent of the essential oils

36. Implications For OT Practice • Aromatherapy can be used by OT’s to: • Reduce clients’ fatigue to improve energy for participation in occupations • Improve clients’ sleep participation • Practitioners must be aware of negative associational effects of essential oils • Do not provide aromatherapy during radiation treatment

37. Implications for OT Practice, cont’d • OT’s must understand that effects of aromatherapy are short-term • Teach clients and caregivers how to perform aromatherapy in the absence of the OT • Provide clients with aromasticks to help with rest and sleep • Use aromatherapy massage • Adjunct to massage • Client-centered

38. Implications for Future Research • Aromatherapy needs more research • Effects of aromatherapy on fatigue and sleep quality are even more limited • Need research on OT interventions that improve sleep participation • Which essential oils are beneficial?

39. References • American Cancer Society. (2011a). Cancer facts and figures 2011. Retrieved from http://www.cancer.org/acs/groups/content/ @epidemiologysurveilance/documents/document/acspc-029771.pdf • American Cancer Society. (2011b). The history of cancer. Retrieved from http://www.cancer.org/Cancer/CancerBasics/TheHistoryofCancer • American Cancer Society. (2011c). Treatment types. Retrieved from http://www.cancer.org/Treatment/TreatmentsandSideEffects/ TreatmentTypes/index • American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. • Anand, P., Kunnumakara, A.B., Sundaram, C., Harikumar, K.B., Tharakan, T.T., Lai, O.S., … Aggarwal, B.B. (2008). Cancer is a preventable disease that requires major lifestyle changes. Pharmaceutical Research, 25(9), 2097-2116. • Ancoli-Israel, S., Moore, P.J., & Jones, V. (2001). The relationship between fatigue and sleep in cancer patients: A review. European Journal of Cancer Care, 10(4), 245-255. • Barsevick, A.M., Dudley, W., Beck, S., Sweeney, C., Whitmer, K., & Nail, L. (2004). A randomized clinical trial of energy conservation for patients with cancer-related fatigue. Cancer, 100, 1302-1310.

40. References cont’d • Center for Disease Control and Prevention. (2011). Cancer survivors: United States, 2007. Morbidity and Mortality Weekly Report, 60(9), 269-296. • de Haes, J.C.J.M., Olschewski, M., Fayers, P., Visser, M.R.M., Cull, A., Hopwood, P., Sanderman, R. (1996). Measuring the quality of life of cancer patients with the Rotterdam Symptom Checklist: A manual. Retrieved from http://www.rug.nl/ gradschoolshare/research_tools/assessment_tools/ rscl_handleiding.pdf • Engstrom, C., Strohl, R.A., Rose, L., Lawandowski, L., & Stefanek, M. (1999). Sleep alterations in cancer patients. Cancer Nursing, 22(2), 143-148. • Essential Science Publishing. (1999). People’s desk reference for essential oils. Orem, UT: Essential Science Publishing. • Graham, P.H., Browne, L., Cox, H., & Graham, J. (2003). Inhalation aromatherapy during radiotherapy: Results of the placebo-controlled double-blind randomized trial. Journal of Clinical Oncology, 12(12), 2372-2376. • Howlader, N., Noone, A.M., Krapcho, M., Neyman, N., Aminou, R., Waldron, W., … Edwards, B.K. (Eds.). SEER cancer statistics review 1975-2008. Retrieved from http://seer.cancer.gov/csr/1975_2008

41. References cont’d • Imanishi, J., Kuriyama, H., Shigemori, I., Watanabe, S., Aihara, Y., Kita, M., … Fukui, K. (2009). Anxiolytic effect of aromatherapy massage in patients with breast cancer. Evidence-based Complementary and Alternative Medicine (eCAM), 6(1), 123-128. • Kite, S.M., Maher, E.J., Anderson, K., Young, T., Young, J., Wood, J., … Bradburn, J. (1998). Development of an aromatherapy service at a cancer centre. Palliative Medicine, 12, 171-180. • Kohara, H., Miyauchi, T., Suehiro, Y., Ueoka, H., Takeyama, H., & Morita, T. (2004). Combined modality treatment of aromatherapy, foot soak, and reflexology relieves fatigue in patients with cancer. Journal of Palliative Medicine, 7(6), 791-796. • National Cancer Institute. (2007). Radiation therapy side effects. Retrieved from http://www.cancer.gov/cancertopics/coping/radiation-therapy-and-you/page6 • National Cancer Institute. (2011). Aromatherapy and essential oils (PDQ). Retrieved from http://www.cancer.gov/cancertopics/pdq/cam/ aromatherapy/healthprofessional/page4

42. References cont’d • National Cancer Institute. (n.d.a). A to Z list of cancers. Retrieved from http://www.cancer.gov/cancertopics/types/alphalist • National Cancer Instiute (n.d.b). Chemotherapy side effects fact sheet. Retrieved from http://wwwcancer.gov/cancertopics/coping/chemo-side-effects • Serfaty, M., Wilkinson, S., Freeman, C., Mannix, K., & King, M. (2011). The ToT study: Helping with Touch or Talk (ToT): A pilot randomized controlled trial to examine the clinical effectiveness of aromatherapy massage versus cognitive behaviour therapy for emotional distress in patients in cancer/palliative care. Psycho-Oncology. Advance online publication. doi: 10.1002/pon.1921 • Silver, J.K., & Gilchrist, L.S. (2011). Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions. American Journal of Physical Medicine and Rehabilitation 90(5), S5-S15. • Soden, K., Vincent, K., Craske, S., Lucas, C., & Ashley, S. (2004). A randomized controlled trial of aromatherapy massage in a hospice setting. Palliative Medicine, 18(2), 87-92.

43. References cont’d • Sood, A., Barton, D.L., Bauer, B.A., & Loprinzi, C.L. (2007). A critical review of complementary therapies for CRF. Integrative Cancer Therapies, 6(1), 8-13. • Stringer, J., & Donald, G. (2011). Aromasticks in cancer care: An innovation not to be sniffed at. Complementary Therapies in Clinical Practice, 17, 116-121. • Stringer, J., Swindell, R., & Dennis, M. (2008). Massage in patients undergoing intensive chemotherapy reduces serum cortisol and prolactin. Psycho-Oncology, 17, 1024-1031. • University of Idaho College of Science. (2004). Amygdala. Retrieved from http://www.sci.uidaho.edu/med532/amygdala.htm • Wilcock, A., Manderson, M., Weller, R., Walker, G., Carr, D., Carey, A., Broadhurst, D., … Ernst, E. (2004). Does aromatherapy massage benefit patients with cancer attending a specialist palliative care day centre?. Palliative Medicine, 18, 287-290. • Wilkinson, S., Aldridge, J., Salmon, I., Cain, E., & Wilson, B. (1999). An evaluation of aromatherapy massage in palliative care. Palliative Medicine, 13, 409-417.