Background. Hypnosis and self-hypnosis include the use of various relaxation techniques and imagery, in order to enter a “trance state” of focused attention, with reduced peripheral awareness. In this trance state, the individual is more receptive to suggestion, and the health care provider gives suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought, or behavior [20]. For example, the health care provider may describe imagery that transforms the individual’s pain to cold or numbness. It is usually administered with a trained therapist in the context of psychotherapy.

Clinical Studies. A clinical review of medical research on hypnotherapy and relaxation therapies with cancer patients was published in 1999 and included three reviews: two randomized clinical trials and one National Institutes of Health (NIH) Technology Assessment, all published before 1999 [21]. The authors concluded that, “There is strong evidence from randomised trials of the effectiveness of hypnosis and relaxation for cancer related anxiety, pain, nausea, and vomiting (side effects of chemotherapy), particularly in children (p. 1348).”

The Complementary and Alternative Medicine Cancer (CAM-Cancer) consortium has completed a peer-reviewed summary of the research on hypnotherapy for cancer patients [22]. Their summary included 16 randomized clinical trials and two controlled clinical trials that included studies on hypnotherapy in anticipatory nausea and vomiting during medical procedures, hypnotherapy for cancer therapy related pain, and studies of hypnotherapy in other cancer-related symptoms. Their summary states that, “Results show that hypnosis or self-hypnosis can significantly reduce cancer-related pain, antiemetic use, nausea and emesis during medical procedures, as well as anxiety related to all of the mentioned symptoms occurring in cancer patients” [22]. In their review of six studies examining hypnotherapy interventions for anticipatory nausea and vomiting during medical procedures, a significant reduction of nausea was achieved in six studies, a reduction of emesis in five, and a reduction of antiemetic use in one of the included trials. Of the nine studies reviewed for impact of hypnosis on cancer-related pain, eight showed a significant reduction of pain; and another seven also showed a reduction of anxiety or pain-related anxiety when comparing the hypnotherapy group with the control groups. With regards to three other studies examining other cancer-related symptoms, one study showed an increase of self-competence in the hypnotherapy group [22].

A recent review by Jensen and Patterson [23] discussed the clinical implications of research findings for hypnosis in chronic pain management. They note that “the clinical outcome studies on acute and chronic pain as well as neurophysiological studies in the laboratory have demonstrated that hypnosis is effective over and above placebo treatments and that it has measurable effects on activity in brain areas known to be involved in processing pain (p. 168).”

Zeltzer et al. [24] conducted a randomized clinical trial with 54 children undergoing chemotherapy treatment for cancer. The children were randomized into one of three groups: (1) hypnosis intervention, (2) non-hypnotic distraction/relaxation intervention, and (3) attention placebo groups. Findings indicated that children in the hypnosis group reported the greatest decrease in anticipatory emesis.

In an earlier study, Zeltzer and LeBaron [25] conducted a controlled clinical trial with 33 pediatric oncology patients undergoing lumbar punctures and bone marrow aspirations. Patients were randomly assigned to either a hypnosis or a non-hypnotic intervention group. Pain during lumbar punctures was reduced only by hypnosis, and anxiety was reduced by hypnosis and non-hypnotic interventions, but to a greater extent by hypnotic interventions. Pain during bone marrow aspirations was reduced by both hypnotic and non-hypnotic techniques, however, anxiety was reduced only by hypnosis.

More recently, Lang and associates [26] conducted a randomized clinical trial with 201 adult patients receiving a percutaneous tumor treatment. The patients were randomized to receive hypnotherapy, empathic attention, or standard care alone. Results indicated that the hypnosis group experienced less pain and anxiety than the patients in the other groups. Further, the hypnosis patients utilized less pain medication at several time intervals compared to the other groups.

Liossi and Hatira [27] randomly assigned 80 pediatric oncology patients with either leukemia or non-Hodgkin lymphoma who were undergoing lumbar punctures to four different groups. Group 1 received direct hypnosis combined with standard medical treatment; Group 2 received indirect hypnosis with standard medical treatment; Group 3 received attention control with standard medical treatment; and Group 4 received standard medical treatment alone. Results indicated that the patients receiving hypnosis (Groups 1 and 2) reported less pain and anxiety and demonstrated less behavioral distress than those who did not (Groups 3 and 4).

Later, Liossi and associates [28] conducted a randomized clinical trial examining the effectiveness of hypnosis on procedural distress with a sample of 45 pediatric patients diagnosed with leukemia or non-Hodgkin lymphoma. Patients were randomized into one of three groups. All patients had EMLA cream (a mixture of lidocaine and prilocaine) applied to the skin 60 min prior to the procedure. Group 1 received EMLA only, Group 2 received EMLA plus hypnosis, and group 3 received EMLA plus attention. The hypnosis group reported less anticipatory anxiety and less procedure-related pain and anxiety compared to either of the other groups, and they were also rated as demonstrating less behavioral distress during the procedure. Level of hypnotizability was also significantly associated with the magnitude of benefit seen in the hypnosis group.

The above authors conducted another similar randomized clinical trial examining effects of hypnosis on procedural distress with 45 pediatric cancer patients of various diagnoses [29]. The patients were randomized into the same three groups as above. Patients receiving hypnosis reported less anticipatory anxiety, procedure-related pain, and anxiety. Patients were also rated as demonstrating less behavioral distress during the procedure compared to the other two groups. Parents of children who received hypnosis also reported less anxiety themselves during their child’s procedure than parents whose children were randomized into one of the other two groups.

In contrast, some studies have not found significant benefit for hypnosis compared to other interventions (e.g., play, cognitive distraction, or supportive counseling). For example, Wall and Womack [30] did not find significant benefits for hypnosis versus cognitive distraction in reducing pain or anxiety in 20 pediatric oncology outpatients undergoing bone marrow aspiration or lumbar puncture. Patients were randomly assigned to two different groups for self-instruction with hypnosis or with cognitive distraction. Neither intervention was associated with anxiety reduction; however, both hypnosis and cognitive distraction were associated with pain reduction. A “hypnotizability scale” was not associated with pain reduction. Similarly, Katz et al. [31] randomized 36 pediatric patients to either hypnosis or play intervention group. The patients were all being treated for acute lymphoblastic leukemia, had undergone at least three bone marrow aspirations (BMAs), and were scheduled for repeated BMAs. The authors found that both hypnosis and play were associated with reduced self-report of pain and distress. There was no between groups difference. Oddby-Muhrbeck et al. [32] conducted a randomized clinical trial with 70 adult female oncology patients who were scheduled for elective breast surgery. Patients were randomized to either self-hypnosis (listening to a message with reassuring information focused on minimizing postoperative nausea and vomiting) or listening to a blank tape with low background music during surgery. There were no significant differences in the number of patients who experienced nausea and vomiting in the 24 h post-operative period. However, the patients exposed to positive suggestion less often recalled nausea and vomiting compared to the control group. While these findings suggest the power of hypnotic suggestions, researchers were not able to rule out some implicit processing during balanced anesthesia.

Hockenberry-Eaton and Cotanch [33] conducted a randomized clinical trial with 22 pediatric oncology patients examining impact on self-competence scores (utilizing the Harter Perceived Self-Competence Profile [34]. Patients were randomized into two different groups: (1) self-hypnosis and (2) standard care. Over four courses of chemotherapy, the self-hypnosis group showed increased self-competence scores, while the control group evidenced a decrease in this score. Limitations of this study include small sample size and lack of p-values reported.

Mechanism of Action. Two recent reviews of the use of hypnosis in management of chronic pain provide detailed discussion of the flourishing research over recent years adding significantly to our understanding of the mechanisms of action involved in clinical effects of hypnosis [7, 23]. In their review of hypnotic approaches for chronic pain management, Jensen and Patterson [23] emphasize that findings from controlled clinical trials show effectiveness in reducing chronic pain, but note that response to hypnosis treatment is variable by individual. They describe that recent advances in the literature show how hypnosis has a measurable impact on neurophysiological activity and functioning of pain. Specifically, “the cortical areas most activated during pain are the thalamus, anterior cingulate cortex (ACC), primary and secondary sensory cortices and prefrontal cortex” (p. 171), and they explain how there is a growing body of evidence that each of these areas respond to hypnosis in some fashion. Overall, hypnosis appears to be involved in the processing of pain in several regions of the brain, rather than a single, unilateral mechanism. Furthermore, they review studies that demonstrate how hypnosis can be targeted to specific brain regions [35, 36], by decreasing beta activity while increasing alpha activity [37, 38]. Liossi et al. [7] expand the discussion to include supraspinal sites that have been implicated in responding to the analgesic effects of hypnosis. They also emphasize that these studies have been conducted primarily on adults, and making direct inferences to the pediatric population, due to differences between structural and functional neurodevelopment throughout childhood, may be a stretch. Rubia [39], reviewing functional magnetic resonance imaging (fMRI) studies on brain development, explains that as the brain matures, there is increased functional activation in several brain regions that mediate higher level control functions, including the lateral and medial frontal, striatal, and parieto-temporal areas. This developmental trajectory may help explain the tendency for increasing pain toleration and coping abilities in adolescence compared to children.

Level of Scientific Efficacy. Strong evidence for benefits. Challenges of applying blinding contributes to difficulty in examining the effectiveness of hypnotherapy. However, there is a growing literature of large, well-designed studies that provides firm evidence documenting positive effects of hypnosis in reducing both acute and chronic pain [7] and strong evidence of effectiveness specifically for use of hypnosis with cancer patients on reducing anticipatory nausea and vomiting, cancer-related pain, and anxiety [22].

Finding a Provider. Many hypnosis providers are licensed in another area of health care, such as psychology or nursing; or they may be a dentist or physician, or work under the supervision of a physician. Some hypnosis providers choose to become certified to demonstrate their training and expertise. A good starting place to find a qualified hypnosis provider is to contact an organization such as the American Society of Clinical Hypnosis (http://​www.​asch.​net/​).

Background. Biofeedback is a process in which the individual receives “feedback” regarding physiological processes during relaxation training. Often this is accomplished through the use of a computer and various sensors, although there are additional ways to obtain data regarding the individual’s reaction to training, such as measurement of skin temperature. Biofeedback has several uses, but it is commonly used to help reduce pain, anxiety, or other discomfort by helping the individual become more aware of their bodily reactions and then learning strategies to control physiological changes associated with the stress response. These monitored changes [40] may include muscle tension, peripheral skin temperature, sweat gland response, heart rate variability, brain wave activity, or breathing rate, with the goal of increasing the body’s “relaxation response.” Using biofeedback helps individuals learn about their body’s responses to stress and become aware of their own abilities to alter those responses.

Clinical Studies. A small randomized control study with advanced cancer patients examined the effect of relaxation training supplemented with electromyographic (EMG) biofeedback on cancer-related pain [41]. The experimental group (n = 12) received six EMG biofeedback-assisted relaxation sessions over a 4-week period. The control group (n = 12) received conventional care. After intervention, the treatment group reported significantly lower pain levels compared to the control group. Study limitations include small sample size and a study design in which EMG biofeedback was combined with relaxation training. Thus, it was not possible to determine whether relaxation alone would have produced the same benefits.

However, an earlier randomized clinical trial examined the effects of EMG biofeedback, skin-temperature (ST) biofeedback and relaxation training (RT) in reducing the adverse reactions associated with chemotherapy [42]. Eighty-one cancer patients were matched on multiple individual-difference variables and randomized to one of six groups formed by a 3 (EMG Biofeedback, ST Biofeedback) x2 (RT, No RT) factorial design. Outcomes included physiological data, and both patient- and nurse-reported measures assessed over five consecutive chemotherapy treatments. RT patients showed decreases in nausea and anxiety during chemotherapy and physiological arousal after chemotherapy. EMG and ST biofeedback reduced some indication of physiological arousal but had no other effects on chemotherapy side effects. Results suggest that relaxation training is better at reducing the aversive effects of chemotherapy when compared to biofeedback training. The authors concluded that the positive effects found for biofeedback in earlier research resulted from the RT that was provided during biofeedback, rather than to the biofeedback alone [42].

In another study, investigators assessed change in the immune system and psychological symptoms of 13 women with breast cancer over the course of 18 months who had recently undergone radical mastectomy [43]. Patients were randomized into either the immediate treatment group or the delayed treatment control group. In the immediate treatment group, patients were trained in relaxation, guided imagery, and biofeedback over a 24-week period. The delayed treatment (control) group was placed on a waiting list. Results indicated that relaxation, guided imagery, and biofeedback interventions were associated with immune system changes, including natural killer cell activity, mixed lymphocyte responsiveness, concanavalin A responsiveness, and the number of peripheral blood lymphocytes. No significant psychological changes were reported, though some reductions were seen in psychological inventory scales measuring anxiety. Small sample size and multi-modal intervention limit the conclusions that can be drawn [43].

Biofeedback has been extensively evaluated in its effectiveness for treating headaches, and there are several studies examining its efficacy in the pediatric population [44–50]. Additionally, biofeedback has been found to be effective in the treatment of abdominal pain in the pediatric population [51, 52].

Fentress et al. [44] randomized 18 children ranging in ages from 8 to 12 years, who had recurrent intermittent headaches to assess efficacy of EMG biofeedback, relaxation-response training, and pain behavior management. Six patients received all three treatment interventions, six received relaxation-response training and pain behavior management (without biofeedback), and the remaining six were assigned to a wait-list control group. Treatment groups completed nine 1-hour sessions in 11 weeks. Headache diaries were evaluated throughout the study and at a 1-year follow-up assessment. Outcome measures included frequency, intensity, and duration of headaches. Compared to the control group, both treatment groups had improvement documented in their headache diary compared to baseline and at the end of the 15-week study period. The headache reduction in the treatment groups was maintained 1 year after end of treatment. Results suggested that a combination of relaxation-response training together with pain behavior management (with or without biofeedback), was effective in treating pediatric migraine. This study was limited by small sample size, absence of data, and other design problems [44].

Bussone et al. [45] randomized 30 children ranging in age from 11 to 15 years with episodic tension-type headaches to either a biofeedback-relaxation (BFB-REL) intervention or a relaxation placebo (REL-PLAC) control condition for ten sessions occurring twice weekly. Both groups had a 55 % improvement in headache severity at the 1 month assessment, but only the BFB-REL group had improvement at the sixth and 12 month follow-ups, with an 85 % improvement in headache severity by the last assessment [45].

Kroner-Herwig et al. [46] randomized 40 children, ages 8–14 years, with tension-type or combined headaches to an EMG-frontalis biofeedback or progressive relaxation (PR) condition with and without parental involvement (PI) or to a wait list control group. There were 12 bi-weekly sessions and the parent condition included three 1-hour parent sessions. All four intervention groups had significant main effects in all outcome domains post-intervention. Yet, at the 6 month assessment, the biofeedback group without PI showed the greatest changes, followed by biofeedback with PI, PR alone, PR with PI, and then the control group. The biofeedback group without PI had the highest mean effect size for headache outcomes, suggesting that parental involvement in this adolescent population was not a necessary component in achievement positive results [46].

Grazzi et al. [47] provided EMG biofeedback to ten children, ages 12–15 years, with tension headaches twice weekly for 6 weeks. The “Pain Total Index” was collected with a headache diary, and muscular tension scores decreased in all patients from baseline to treatment completion. In a later longitudinal study, Grazzi et al. [48] provided an EMG biofeedback-assisted relaxation program in 54 children, mean age of 12 years, with episodic tension-type headaches with two treatment sessions per week for 5 weeks. The Pain Total Index via daily diaries were significant at treatment termination but not at the 1 year follow-up. At the 3 year follow-up assessment, 84 % of the participants were symptom-free. Given the lack of a control condition, the percent of children who would have been headache free even without intervention at 3 years is unknown. Other study design weaknesses limit the generalizability of the findings [48].

Arndorfer and Allen [49] conducted a within subject, multiple baseline, time-lagged study to evaluate thermal biofeedback therapy in five children, aged 8–14 years, with tension-type headaches. Baseline data over 4–7 weeks were followed by six thermal biofeedback treatments. All participants showed clinical improvement via daily headache diaries and four of the five were headache-free at 6 months. While these findings are promising, the size of the treatment group limits the generalizability [49].

Scharff et al. [50] randomized children ages 7–17 years with migraines to one of three groups in order to examine benefits of thermal biofeedback (TB) on pain, anxiety, and depression. The groups included: (1) a treatment condition including stress management with thermal biofeedback (TB), (2) a control condition consisting of hand-cooling biofeedback (HCB) only, and (3) a wait-list control condition. At the 6 week post-treatment assessment, no one in the waitlist control condition had headache improvement with one child (10 %) in the HCB reporting decreased headache severity, while seven (54 %) in TB group had significant reduction in headache severity. In a combined analysis, both treatment groups had reduced headache severity and frequency, although no changes were appreciated in anxiety or depression measures. Upon 6 month follow-up, there were no measurable changes. While this study is often cited as evidence of thermal biofeedback for migraines in children and despite its promising title, caution is warranted because the confounding variables limit generalizability of the findings [50].

Biofeedback was successfully applied to middle school students who demonstrated significant anxiety [51]. In this study, 300 seventh and eighth grade students were given a self-report anxiety measure, the IPAT Anxiety Scale [52], and 150 students were identified as “highly anxious” on the basis of this measure. They were then randomly assigned to the biofeedback experimental treatment group or to the no-intervention group. The treatment group subjects (N = 72) received 12 sessions of biofeedback training (six session of thermal training and six session of EMG training). Results indicated that compared to the control group, the subjects in the treatment group experienced significantly lower state and trait anxiety scores. The authors concluded that these findings were very promising, but that future research was needed to determine the long-term stability of the reduced anxiety levels [51].

Heart rate variability (HRV) has also been shown to be promising in the treatment of cardiac vagal tone restoration, of which has been thought to be an indicator of overall parasympathetic nervous system status. Sowder et al. [53] provided six sessions of HRV biofeedback to restore vagal tone in 20 children, ages 5–17 years, with functional abdominal pain (FAP) and compared outcomes to ten children without FAP. The significant decrease in low frequency/high frequency (LF/HF) ratio after intervention suggested an improvement in cardiac vagal tone, along with a decrease in pain frequency and a significant correlation between the decrease in LF/HF ratios and pain frequency. This novel study of heart rate variability biofeedback in FAP was limited by the study design (no randomized trial with a control condition), but demonstrates some indication that HRV may be beneficial in the treatment of FAP [53].

In another study examining FAP, Schurman et al. [54] randomized 20 children, ages 8–17 years, with FAP to an intervention group consisting of standardized medical care (SMC) plus ten sessions of biofeedback-assisted relaxation training (BART), or to a control group consisting of SMC only. Children in the intervention group demonstrated significantly improved pain intensity and duration of pain episodes, as reported via pain diary. The intervention group also showed greater clinical improvement in comparison to the control group on a physician-rated Global Response Assessment rating. Methodological limitations include the lack of a true attention control group. Specifically, although children in both groups returned to clinic to meet with physician staff on the same schedule, children receiving medication plus BART had six additional visits and greater contact time than children receiving medication only. As a result, the authors could not rule out the possibility that some of the effect of the combined treatment could be due to this attention factor [54].

A small, non-randomized feasibility study was completed with 12 children examining benefits of HRV biofeedback, a technique introduced above that measures the rhythms of the naturally occurring “beat-to-beat” changes, on reducing procedural distress [55]. Participants completed a 4-session intervention combining relaxation and biofeedback. Participants showed lower state and trait anxiety scores from session 1 to session 4. Participants also demonstrated an improvement in HRV coherence scores in sessions 3 and 4. Eleven of the 12 participants also completed a 5-item Likert-type scale satisfaction questionnaire. The majority of those 11 participants reported belly breathing alone helped them feel less scared (63 %), and that the combination of belly breathing and biofeedback techniques helped them to feel more “in charge” of their bodies before their procedures (81 %). Less than half reported that biofeedback alone helped them to feel less scared (45 %). Procedural fear scores did not change. This study is limited by small sample size and lack of control group, although it provides promising efficacy of HRV training [55].

Mechanism of Action. Shifts in heart rate variability in some studies of biofeedback suggest that changes are autonomically mediated [56]. But additional research is needed to examine the physiological and biochemical changes associated with biofeedback.

Level of Scientific Efficacy. As reviewed above, research support is suggestive of efficacy, but not strong. There is presently a lack of good quality, single-intervention trials. Some studies indicate an improvement in pain relief and chemotherapy-related nausea and anxiety. However, these studies have not been replicated and have considerable methodological limitations [57]. Also, biofeedback is often used together with relaxation procedures, so it is difficult to discern separate effects. In addition, due to the difficulty in creating appropriate and credible placebo conditions, double-blind studies are difficult to complete for this intervention.

That being said, some children report significant benefit from biofeedback and greater engagement when using it as an adjunct in learning relaxation strategies. Providing targeted biofeedback to children who need self-management tools to cope with pain, anxiety, or stress, long after treatment has been completed has appeared to be beneficial. For example, when muscle tension is a primary cause of pain, it may be useful to utilize EMG biofeedback to help learn to reduce muscle tension in those body areas where it is a primary cause or contributor to the pain. Alternately, skin temperature warming might be appropriate for children with migraines. HRV biofeedback may be useful in teaching a general relaxation response to help reduce anxiety and stress.

Finding a Provider. Many biofeedback therapists are licensed in another area of health care, such as psychology, nursing, or physical therapy, and there are technicians who are able to work under a licensed provider. Some biofeedback therapists choose to become certified to demonstrate their training and expertise. A good starting place to find a qualified biofeedback provider is to contact an organization such as the Association for Applied Psychophysiology & Biofeedback (http://​www.​aapb.​org) or the Biofeedback Certification International Alliance (http://​www.​bcia.​org).

Background. Aromatherapy is another common type of CHA and refers to the therapeutic use of essential or aromatic oils [58]. The oils used in aromatherapy are extracted from the roots, flowers, leaves, and stalks of plants and certain trees using steam distillation or mechanical expression. These essential oils are also known as “volatile oils” [59]. Typically, the essential oils of aromatherapy are inhaled after being diffused in the air or administered topically in diluted form (e.g., via massage). They are not commonly administered orally. There are over 300 different essential oils available in today’s market [60, 61]. Some essential oils are known to have antibiotic and antiviral properties. Aromatherapy is widely used in different cultures to calm, balance, and rejuvenate mind, body, and spirit [58, 62].

Clinical Studies. A survey study indicated that aromatherapy has been used by 31 % of newly diagnosed adult cancer patients in the U.K. [63]. In the U.S., aromatherapy is increasingly utilized as a complementary therapy among childhood cancer survivors who have completed treatment. In one study of 197 pediatric/young adult cancer survivors, approximately 14 % reported utilizing aromatherapy within the past 12 months [14].

Studies have indicated a positive effect of aromatherapy in promoting psychological well-being by reducing anxiety and depression [62, 64]. Specifically, with respect to clinical effects of aromatherapy among cancer patients and survivors, studies have suggested some positive effects of this intervention, such as alleviating pain, constipation, stress, depression, and anxiety [65–69].

In one study, 39 cancer patients were randomly assigned to receive either aromatherapy massage (n = 20) or cognitive behavioral therapy (n = 19) in addition to cancer treatment as usual for up to eight weekly sessions [68]. Cognitive Behavioral Therapy (CBT) is considered to be an efficacious psychotherapeutic intervention for many psychiatric conditions [70]. The authors found that the patients who received aromatherapy massage sought more sessions (mean = 7.2 sessions) than the patients who received cognitive behavioral therapy (mean = 5.4 sessions), suggesting patients’ preference for the aromatherapy massage intervention. Additionally, results indicated that aromatherapy massage and CBT were both effective in reducing anxiety and depression over the course of treatment. Another study examined the effectiveness of aromatherapy in stress reduction (i.e., cortisol levels) among cancer patients. In this study, a total of 39 patients, ages 16 and older, who were actively in treatment (i.e., chemotherapy and/or bone marrow transplant) were randomly assigned to receive a 20-minute massage therapy with aromatherapy oil (treatment group 1), massage with regular oil (treatment group 2), or to rest only with no massage (control group). The results indicated that those who received massage with or without aromatherapy oil revealed a significant reduction in cortisol, as measured through serum cortisol and prolactin levels compared with the group that engaged in resting only [69]. The lack of difference between treatment conditions (massage with and without aromatherapy) suggests that positive changes observed could be due to the massage intervention, rather than aromatherapy.

Other studies failed to show clinical benefits of aromatherapy. For instance, Graham and associates [71] investigated the effectiveness of aromatherapy in the form of inhalation among adult cancer patients in reducing anxiety. In this study, 313 adult cancer patients, ages 33–90 years, who underwent radiotherapy were randomly assigned to receive inhalation of either essential oil (a combination of bergamot, cedar wood, and lavender oil), carrier oil (sweet almond cold-pressed pure vegetable oil), or carrier oil with fractionated oils (low grade and low dosage essential oil) during radiation treatment. The authors found that there were no significant differences in the participants’ anxiety level between the treatment (patients who received essential oil) and control (carrier oil and carrier oil with fractionated oils) groups and concluded that aromatherapy was not effective in reducing anxiety among this particular population. The authors indicated that patients may have negatively associated the aromas with radiotherapy, which was already anxiety-provoking for them [71].

Research studies examining the clinical effects of aromatherapy specifically among pediatric cancer patients or survivors are further limited. Ndao and colleagues [72] conducted the first double-blind, placebo-controlled randomized trial among 37 patients in a pediatric population. The patients were all between 5 and 21 years old and were undergoing stem cell infusion. The effects of the aromatherapy were evaluated with respect to anxiety, nausea, and pain reduction. Aromatherapy was administered in the treatment group (n = 17) via inhaling bergamot essential oil (a type of citrus oil believed to improve relaxation and/or anxiety and prevent nausea) during infusion. The control group (n = 20) was assigned to receive inhalation of placebo (a non-essential oil with shampoo scent). Results indicated that the bergamot essential oils were not found to reduce anxiety, nausea, and pain among children and adolescents who were going through stem cell infusion. Moreover, anxiety levels and nausea in the treatment group persisted following the infusion of stem cells, indicating that essential oils may have contributed to extended anxiety among this group. The authors also noted that this study was limited due to small sample size, and suggest further investigation with a larger sample size and additional administration of aromatherapy via massage in order to better understand aromatherapy’s potential effectiveness among childhood cancer patients and survivors [72].

Mechanism of Action. Topical application of some aromatic oils may exert antibacterial, anti-inflammatory, and analgesic effects [73]. There are different theories about other mechanisms of action for aromatherapy and essential oils. Studies in animals show sedative and stimulant effects of specific essential oils [74] as well as positive effects on behavior and the immune system in response to painful or stressful stimuli [75, 76]. Supporters of aromatherapy often reference the connection between olfaction and the limbic system in the brain as the basis for the effects of aromatherapy on mood and emotions. The National Cancer Institute’s Physician Data Query (NCI PDQ) cancer information summary about aromatherapy and essential oils notes that functional imaging studies in humans do support the influence of odors on the limbic system and its emotional pathways; and that most of the aromatherapy literature does not reference that literature or provide in-depth neurophysiological studies on the nature of that connection [73]. Researchers in animal studies have also found significant plasma levels of the fragrance compounds after inhalation, suggesting that the effects of aromatherapy may result from a direct pharmacological interaction rather than an indirect central nervous system relay [74].

Level of Scientific Efficacy. Suggestive, but not strong. Despite some promising beneficial effects of aromatherapy, the overall results do not provide firm indications for the clinical benefits of aromatherapy, especially when used alone or through inhalation [77]. There is presently a lack of good quality, single-intervention trials. Also, research is limited by lack of standardization in specific treatments used for different illnesses/symptoms across different providers. Despite some conflicting results of trials, there is some weak evidence of short lasting positive effects from aromatherapy on psychological well-being, depression, anxiety, sleep, overall well-being, symptom relief, and pain control compared to standard care alone in cancer patients. In conclusion, weak evidence suggests that aromatherapy could reduce anxiety, depression, sleep problems and improve a patient’s general well-being for periods of up to 2 weeks [78].

Potential Risks/Adverse Effects. Minimal adverse effects have been reported for use of essential oils, especially with administration topically and/or by inhalation in appropriate concentrations. However, allergic reactions can occur, especially after topical administration. There have been some reports of contact dermatitis, typically with aromatherapists who have had extended skin exposure to essential oils through massage [79]. There have also been reports of phototoxicity when essential oils are applied to the skin before exposure to the sun, especially citrus oils. In addition, a single case report indicated contact dermatitis was reported from inhaled aromatherapy [80]. Some essential oils (e.g., camphor oil) can cause local irritation; therefore, care should be taken when applying them. Care should be given to the possibility that an individual may have an adverse response as a result of a negative psychological association to particular odor(s). Lavender and tea tree oils may have weak estrogenic and antiandrogenic effects; and they were associated with reversible prepubertal gynecomastia in one study of repeated topical exposure boys [81]. Thus, NCI’s PDQ cancer information summary of aromatherapy and essential oils recommends avoiding these two essential oils in patients with estrogen-dependent tumors [73].

Finding a Provider. Several schools throughout the United States offer aromatherapy training and certification, though no license is required to practice. As a result, there is limited consistency in specific treatments utilized across providers. The National Association for Holistic Aromatherapy (NAHA) (www.​naha.​org/​) and the Alliance of International Aromatherapists (www.​alliance-aromatherapists.​org) are two governing bodies for national educational standards for aromatherapists. NAHA is taking steps toward standardizing aromatherapy certification in the United States. Many schools offer certificate programs approved by NAHA. A list of these schools can be found on the NAHA Web site (www.​naha.​org/​schools_​level_​one_​two.​htm). A starting place to find a qualified aromatherapy provider may be to contact one of these organizations or certificate programs for referrals.

Background. Massage therapy is a method of manipulating the soft tissue of one’s body with techniques such as applying pressure, stroking and rubbing [82], and is known as one of the oldest therapeutic interventions. Swedish massage is the most common type of Western traditional massage therapy and involves stroking and kneading on the superficial layers of muscles. Reflexology is one of the most common methods utilized among Eastern tradition massage therapy, and therapists use their fingers and thumb pressure to stimulate specific points on the feet, hands, or ears, which are believed to be associated with specific body zones, organs, or areas [83, 84]. And as mentioned earlier, massage therapists often use essential oil for medicinal value or as a lubricant [85], and historically, it has been utilized to improve circulation and lymph flow, which in turn induces relaxation and alleviates muscle stress and cramping [86]. Additionally, massage therapy has been used to improve mood while reducing anxiety and stress [87].

Massage therapy is one of the most popular CHA practices. Massage therapy has also been increasingly used as an intervention to relieve symptoms commonly experienced in cancer patients (e.g., stress, anxiety, depression, nausea, pain, fatigue, and/or sleep difficulties). For example, in a survey of 453 adult patients at M.D. Anderson Cancer Center, 26 % reported using massage therapy [88]. In another survey of over 4,139 adult cancer survivors, 10–24 months after diagnosis, 11.2 % percent of the cancer survivors reported utilizing massage therapy [89].

Clinical Studies. Overall, massage therapy is typically found to have few adverse effects when conducted by properly trained professionals and when appropriate precautions are utilized. Serious adverse effects are extremely rare. Minor side effects may include temporary pain or discomfort and sensitivity or allergic reaction to oils using during massage [90, 91]. Potential contraindications include burns, skin infections, open wounds, bone fractures, advanced osteoporosis and deep venous thrombosis. Pregnant women should also consult with their health care provider prior to receiving massage therapy. Corbin [90] conducted an academic topic review of safety and efficacy findings for massage therapy specifically with cancer patients. Her findings indicate that while massage is typically safe for cancer patients, this patient population may be at higher risk for rare adverse effects. Thus, oncology patients are advised to consult with their oncologist before massage therapy and to receive services from a massage professional experienced in working with an oncology population. Corbin [90] notes that intense pressure should be avoided by individuals with bleeding disorders, low blood platelet counts, or weakened bones. Direct pressure over a tumor should also generally be avoided.

Several researchers have assessed effectiveness of massage therapy, including reflexology, among cancer patients and survivors [82, 83, 92–97]. However, existing studies of massage therapy have small sample sizes and are not robustly designed, limiting conclusions that can be drawn about efficacy. For example, Listing and colleagues [94] investigated the effectiveness of massage therapy among breast cancer patients in decreasing various symptoms and improving mood. Eighty-six women were randomly assigned to two groups, either receiving massage therapy (n = 50) for 5 weeks, or receiving treatment as usual (n = 36). The results revealed that the intervention group reported significant reduction of their physical discomfort, fatigue, and mood disturbances compared with the control group. Differential sample sizes between the massage and control groups and lack of follow-up measures beyond 6 weeks post treatment limit psychometric value [94].

Another study investigated the effectiveness of reflexology among cancer patients who were going through chemotherapy [97]. Thirty patients were randomly assigned to a 30-minute therapeutic foot massage (n = 15) or no foot massage (n = 15). The authors found that the treatment group reported significant reductions in anxiety (measured by the Spielberger State-Trait Anxiety Inventory [98]) compared with the control group. Factors that may limit generalizability for this study include small sample size, randomization not accounting for patient diagnosis or illness severity, and the lack of long-term follow up measures [97].

Kutner et al. [99] conducted a study with 380 adults with advanced cancer, who were experiencing moderate to severe pain. Ninety-percent of these patients were enrolled in hospice care at the time of the study. The participants were randomized to receive either six 30-minute massage sessions (n = 188) or six simple touch sessions (n = 192) over a 2-week time period. Both groups showed immediate improvement in pain and mood. However, the massage group showed greater improvements in these symptoms. Nonetheless, there were no significant differences between the two groups over time, and both groups showed improvements in quality of life and symptom distress. Study limitations include subject attrition due to death and the lack of a “treatment as usual” control group [99].

In another study, Post-White et al. [100] randomized 230 cancer patients in a crossover design study to three different groups: standardized massage (n = 63), healing touch (n = 56), or presence of a staff member (n = 45) in the room. Each intervention was provided once a week for 45 min over a 4-week time period. All subjects also received 4 weekly sessions of a standard care/control; and the order of conditions (intervention or control) was randomized. All three groups showed physiologic effects (e.g., decreased heart rate and respirations). In the massage therapy group, use of pain and nonsteroidal anti-inflammatory medications decreased. Anxiety levels decreased in both the massage therapy and healing touch groups. Study attrition was higher in the staff member presence group, as a greater number of subjects dropped out due to not wanting to be in that control group arm of the study. Although this study provides support for the short-term effects of massage therapy and healing touch, limitations include lack of blinding. Also, as the authors note, further study is needed to test the long-term effects and the longevity of specific effects on symptoms [100].

Cassileth and Vickers [101] conducted a large retrospective study of pre- and post-massage symptom scores with 1,290 patients at Memorial Sloan-Kettering Cancer Center. Patients rated symptoms including pain, fatigue, anxiety, nausea and depression on a 0–10 scale. An average 50 % reduction in symptoms was reported after massage, and follow up surveys 48 h later showed continued benefit. For the symptom rated highest pre-massage, improvement was 54 %. The authors note that the effects of massage were smaller and less persistent for inpatients; and that long-term follow up data would be important to determine persistence of benefits [101].

A survey of 191 parents of healthy children, conducted in a primary care medical setting indicated that massage therapy is one of the most popular types of CHA modalities, and was utilized to help promote children’s relaxation, stress reduction, sleep, and headaches [102]. In the same survey, parents also reported that they utilized reflexology for their children to treat medical conditions, such as asthma and diarrhea [102]. In a study with preschool children, massage therapy was found to be effective in improving mood and cooperative behaviors in school and home settings [103].

Among children with cancer, massage therapy has shown increased use based on a recent survey, with utilization ranging from 7 to 66 % over the previous decade [104]. According to parents’ report in this survey, massage therapy has been employed to reduce various symptoms, such as fatigue, pain, and nausea, as well as improving children’s overall quality of life. Field et al. [105] examined the effects of massage on child and parent mood, as well as immune functioning in 20 children diagnosed with acute lymphoblastic leukemia. Children were randomly assigned to either daily 15-minute massage from their parent for 30 days or to a waitlist control group. Child and parent anxiety and mood were assessed before and after the first massage and on the last day of the trial. Massage was associated with reduced negative mood in children and parents, as well as increased white blood cell and neutrophil counts in children from first to last day of the study. This study is limited by the small sample size, which may limit its generalizability [105].

Post-White and colleagues [106] conducted a study with children with cancer, ages 1–18 years undergoing chemotherapy. Twenty-three children/parent dyads were enrolled in the 2-period crossover design study, in which 4 weekly massage sessions alternated with 4 weekly quiet-time control sessions. Massage was more effective than quiet time at reducing the following: heart rate in children, parent anxiety, and anxiety in children less than 14 years old. However, there were no significant reductions in blood pressure, cortisol levels, pain, nausea, or fatigue. Furthermore, a systematic literature review examined the feasibility of incorporating massage therapy for children with cancer, and found that massage is noninvasive and can be applied to cope with various treatment-induced side effects and emotional difficulties linked to cancer treatment [86].

Mechanism of Action. Many studies examining clinical effects of massage have demonstrated increased vagal activity, which has been shown to decrease cortisol and improve immune functioning [56].

Level of Scientific Efficacy. Positive, but weak findings for benefits of massage. In summary, there is a growing literature that massage therapy may provide a wide range of benefits, particularly in a cancer population, such as reduction in pain, nausea, anxiety, depression, stress, and/or fatigue and improving quality of life. However, methodological limitations of existing studies (e.g., small sample sizes, lack of blinded assessment) remain a barrier to definitive conclusions that massage therapy is indeed effective. Therefore, further investigation with rigorous research methodology is needed. Also, with rising use of pediatric massage therapy, including reflexology among children with cancer, specific massage guidelines will be important, relating to type, location, duration, and pressure level, in order to provide appropriate treatment to this particular population [86].

Finding a Provider. Most states require licensure for massage therapists. Local massage therapy schools can be a source of referrals, as can the American Massage Therapy Association (http://​www.​amtamassage.​org/​).

Background. Reiki, a Japanese term that signifies universal life energy, is a form of natural healing techniques and classified as part of “biofield energy therapy” [107]. Reiki is originally rooted in ancient Tibetan healing arts and was re-discovered and refined by a Japanese master in the early 1900s [108]. Reiki practitioners typically administer Reiki through a gentle laying of their hands on the recipient’s body, and it is believed that people have natural ability to heal their body. Therefore, Reiki facilitates the process of “re-balancing” the body’s life energy, which in turn enhances physical, emotional, and spiritual well-being [109]. In recent years, Reiki has been utilized to reduce stress while promoting relaxation [110] and generally does not require any particular facilities or equipment; thus, it can be applied in many settings, including the hospital environment. Of the studies conducted examining the efficacy of Reiki, some have demonstrated improved mood, alleviation of pain, and facilitating recovery following surgery [109, 111–113]. However, these studies have limited design methodology, and findings have overall been variable.

Clinical Studies. The effectiveness of Reiki has not been firmly established in use with cancer survivors due to serious methodological limitations, such as small sample size, inadequate study design, and a low quality of reporting [107, 114, 115]. Nevertheless, in a recent survey study among patients who utilized Reiki therapy at a cancer infusion center, over 90 % of the participants reported Reiki as a positive experience, and more than 70 % of them also reported improved mood and relaxation, as well as reduced anxiety [116]. Additionally, Birocco and associates [108] conducted a 3-year study to investigate the role of Reiki in managing anxiety, pain, and overall well-being among 118 cancer survivors. All 118 participants received at least one Reiki treatment, 61 participants received two Reiki treatments, 37 participants received three treatments, and 22 received four Reiki treatments. Results indicated that individuals who completed a total of four Reiki treatments reported significant reduction in their anxiety and pain post-treatment, as well as enhanced quality of life compared to their baseline scores. However, study design limitations prevent generalizability of findings [108].

In contrast, a pilot randomized control trial examined the effectiveness of two types of CHAs among 54 prostate cancer patients undergoing radiation treatment [117]. In this study, the patients were randomly assigned to receive either weekly relaxation response therapy (RRT) plus cognitive restructuring training (CR) (n = 18), twice weekly Reiki (n = 18), or control wait-list (n = 18). Participants completed anxiety, depression and quality of life questionnaires at multiple time points. While the results revealed no statistical significance between RRT plus CR, Reiki therapy, and control group on anxiety, depression, or overall quality of life, the RRT plus CR subjects showed improved scores on the emotional well-being subscale of the quality of life measure [117].

Finding a Provider. The best way to find a qualified provider is to contact the Reiki Membership Association, a non-profit organization that offers training and resources. In addition to specific courses that need to be taken with a Certified Reiki Teacher, members also abide by a code of ethics and professional standards of practice. The directory can be accessed through their website at www.​reikimembership.​com.

Background. Chiropractic is derived from the Greek words praxis and cheir, which means to treat by hand, and involves various techniques, such as joint adjustment and manipulation with a particular focus on joint subluxation [118]. Chiropractic is typically used to treat and prevent abnormalities of the neuromusculoskeletal system, reduce pain, and promote overall health [119].

Chiropractic is the most commonly sought treatment among CHAs, and estimates of 6-12 % of the U.S. population utilize chiropractic techniques, primarily for back and neck pain [120]. Among children, chiropractic is also the most common CHA modality [121, 122]. In addition to treating the traditional musculoskeletal conditions, parents seek chiropractic care for their children to treat feeding problems, sleep difficulty, ear infections, asthma, headaches, constipation, and a various symptoms of autism [123, 124].

Chiropractic is also popular among adult cancer patients [125], as well as childhood cancer survivors [126]. Montgomery and associates [126] surveyed over 9,000 childhood cancer survivors and found that this population was more likely to utilize chiropractic service (12.4 %) compared with physical therapy (9.2 %). The authors also found that greater severity of late effects (e.g., musculoskeletal, neurological, or cardiovascular conditions) were associated with higher chiropractic utilization.

Potential Indications. In addition to treating the traditional musculoskeletal conditions such as back and neck pain, parents seek chiropractic care for their children to treat a wide variety of concerns, including but not limited to: ear, nose and throat difficulties, digestive problems, headaches, attention problems, asthma, and allergies [127]. In their 2002 Position Statement regarding chiropractic care for children, the Canadian Pediatric Society notes that different philosophies have developed within the profession of chiropractic with regard to whether chiropractic should be considered a nonsurgical musculoskeletal discipline or a broadly based alternative to traditional medicine. They also reference a framework developed by Biggs et al. [128] to help clarify the different approaches to the practice of chiropractic. The conservative chiropractic philosophy emphasizes the scientific validation of chiropractic concepts and methods. In general, chiropractors who adhere to this philosophy have a narrow scope of practice restricted to treating musculoskeletal conditions. The liberal philosophy posits that chiropractic treatment encompasses a broad range of practices beyond the treatment of only musculoskeletal conditions. Results of a 1997 Canadian survey by Biggs et al. [128] found that 19 % of respondents held the conservative viewpoint, 22 % of respondents endorsed the liberal philosophy, and 59 % held “moderate” beliefs somewhere in between these two positions. However 74 % of the chiropractors in the study believed that they should not be limited to treatment of only musculoskeletal conditions. Similarly, a survey of chiropractors in the US showed that most respondents considered chiropractic to be a complete system of healing rather than therapeutic techniques [129].

Clinical Studies. Spinal manipulation therapy (SMT) is one technique practiced by health care professionals such as chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and some medical doctors. Practitioners perform spinal manipulation by using their hands or a device to apply a controlled force to a joint of the spine. The amount of force applied depends on the form of manipulation used. A 2011 review of 26 randomized controlled trials [130] examined the effectiveness of SMT in adults with chronic low back pain. Results indicated that SMT is as effective as other common interventions (e.g., exercise therapy, standard medical care or physiotherapy) for reducing pain and improving function in adult patients with chronic low-back pain. However, our literature review found few studies of effectiveness of pediatric chiropractic overall, and none with pediatric cancer survivors specifically.

Vaughn et al. [131] conducted a systematic review to evaluate the evidence for SMT interventions in pediatric patients presenting with headaches and/or mechanical spinal pain. In their literature search, they were only able to identify two randomized control trials and two studies with lower levels of evidence that met their search criteria. Furthermore, the authors report that the four studies reviewed were not of adequate quality to either support or refute the use of SMT interventions with the pediatric pain population that was a focus of their study. They emphasize that in order to establish efficacy, well powered studies with strong research design will be necessary [131].

Gleberzon and associates [132] conducted a search of the literature between 2007 and 2011, examining use of SMT for various pediatric health conditions. They identified 16 studies, none of which examined the effectiveness of SMT for spinal pain. Six studies investigated effectiveness of SMT for infantile colic. Two studies evaluated use of SMT on children with asthma. Two studies examined effectiveness of SMT on enuresis. One study each examined effectiveness of SMT for hip extension, otitis media, suboptimal breastfeeding, autism, idiopathic scoliosis, and jet lag. The authors reported that conclusions about efficacy of SMT for these pediatric conditions were not possible, given serious methodological flaws of many of these studies (including small sample sizes, lack of significant follow up periods, and failure to account for confounding variables). Overall, the authors concluded that further research will be necessary to support the use of pediatric SMT, given the poor methodological quality of many existing studies [132].

In their 2010 literature review, Ferrence and Miller [133] report that there is a large literature base describing the response (or lack of response) of various common pediatric conditions to chiropractic care. They also explain that most existing publications are case reports or case series, and thus of lower scientific value. They further note that the more scientifically rigorous studies indicate conflicting results for conditions of colic and crying infants and provide little support for benefits with conditions of otitis media, asthma, nocturnal enuresis, or attention deficit/hyperactivity disorder. They conclude that, “The efficacy of chiropractic care in the treatment of non-musculoskeletal disorders has yet to be definitely proven or disproven, with the burden of proof still resting upon the chiropractic profession.” ([133], p. 1)

Mechanism of Action. A central belief of chiropractic care is that diseases are often caused by subluxations of the vertebrae, which lead to an interruption of nervous impulses; and that the correction of these subluxations allows the body to heal itself. In their 1996 consensus statement, The Association of Chiropractic Colleges stated that: “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health” [134]. However, research is still lacking with respect to the theory that musculoskeletal dysfunctions can be implicated and appropriately treated in children with nonmusculoskeletal conditions [135].

Level of Scientific Efficacy. SMT has shown effectiveness for reducing low-back pain in adults. However, to our knowledge, this has not been examined in a pediatric population, or specifically within a population of pediatric cancer survivors. Despite chiropractic popularity and high rate of utilization, the efficacy of chiropractic, especially with a pediatric population and for the range of problems treated with this modality, is not well studied, and existing research suffers from multiple methodological limitations [131–133]. Researchers argue that more rigorous research studies are warranted before drawing conclusions on the efficacy of chiropractic [136]. Furthermore, practitioners should have training in chiropractic with children and specifically pediatric cancer survivors before providing care to this population [137].

Potential Risks/Adverse Effects. Short-term side effects from spinal manipulation are relatively common and can include headaches, tiredness, or discomfort in the parts of the body that were treated. Serious complications such as stroke, cauda equina syndrome, and worsening of herniated discs have been rarely reported. Vohra and associates [138] conducted a comprehensive literature search to identify and summarize available data regarding adverse events that have been linked to pediatric SMT. Thirteen studies (2 randomized trials and 11 observational reports) were included in their review. Fourteen cases of direct adverse events involving neurologic or musculoskeletal events were identified. Of those 14 cases, nine involved serious adverse events such as subarachnoid hemorrhage or paraplegia. Two of the cases involved moderately adverse events that required medical attention (e.g., severe headache). Three cases involved minor adverse events (e.g., midback soreness). In addition to the 14 cases of direct adverse events, another 20 cases of indirect adverse events were indicated. These indirect adverse events involved issues such as delayed diagnosis (e.g., diabetes, neuroblastoma) and/or inappropriate use of SMT for serious medical conditions (i.e., meningitis, rhabdomyosarcoma). The authors conclude that serious adverse events may be associated with pediatric SMT and that multiple risk factors (e.g., immaturity of the spine) may cause children to be more vulnerable to adverse events from SMT [138]. Given the findings from these observational studies, they express particular concern that spontaneous reporting of adverse events (such as through the case studies typical in the current literature on pediatric SMT) is widely recognized to underestimate the risk. They caution that “neither causation nor incidence rates can be inferred from observational data (p. 1),” and emphasize that prospective population-based active surveillance studies will be necessary to appropriately examine the possibility of rare, yet serious, adverse events related to SMT with pediatric patients ([138], p. 1). Vaughn et al. [131] also emphasize that research regarding patient safety of SMT with a pediatric population is critical and cannot be inferred from existing studies. They explain that the current literature of observational data is not sufficient to determine causality and/or frequency of adverse events. Accordingly, there is wide consensus that patient safety should remain an important and ongoing focus of research in pediatric SMT [139, 140]. Of note, Marchand [141] recently developed a scaling model to help guide safety and clinical decisions for SMT with infants and children. This model is based on a literature review of tensile strength in adult compared to pediatric samples, in which the author found tensile strength differences in these groups. Based on these findings, the author has proposed a preliminary model of care that includes maximum loading forces by age group [141].

Finding a Provider. To find a provider, the American Chiropractic Association (ACA) is a resource to identify providers that meet minimum requirements for training and experience. Their website is www.​acatoday.​org.

Background. Acupuncture, having originated in China over 2,000 years ago, includes various modalities, such as Japanese acupuncture, French auricular acupuncture, and trigger-point acupuncture [142]. Five-Element acupuncture, or Traditional Chinese Medicine (TCM) acupuncture, is an ancient type of acupuncture and the most well-known form. TCM acupuncture has been practiced as a form of healing by inserting thin needles on particular acupuncture points (acupoints) into the skin to provide proper energy (Qi) distribution via a complex network channel called “meridians” [143–145]. In traditional Chinese medicine, it has been believed that various issues, such as physical, psychological, spiritual, and emotional challenges, obstruct Qi; therefore, acupuncture has been utilized to assess and treat such issues by restoring altered Qi [146].

Acupressure is a technique derived from acupuncture, where physical pressure, instead of needles, is applied to acupoints by one’s hand, elbow, or with various devices to treat disease [147]. Several advantages of acupressure over acupuncture include one’s ability to self-administer with little effort and time, low cost, and minimal training [147]. Additionally, some people prefer to use acupressure intervention due to its non-invasive nature [148].

Among the CHAs, acupuncture is the most frequently referred type of intervention and is currently practiced in over 140 hospitals in the United States [149–151]. In general adult populations, various research studies indicate that acupuncture is effective in treating many conditions, including nausea and vomiting [152], anxiety [153, 154], and pain management [155]. Similarly, self-administered acupressure is shown to have positive effects on sleep quality and quantity [148, 156, 157] in chronically ill individuals.

Clinical Studies. In reviewing acupuncture and acupressure treatment among cancer patients and survivors, researchers suggest that, although potential benefit is emerging, firm conclusions are yet to be drawn on its efficacy in treating various cancer-related symptoms [158–160]. That being said, many studies demonstrate promising efficacy of acupuncture on reducing nausea and vomiting, including those induced by chemotherapy and radiation treatment [159–162]. In addition, the effectiveness of acupuncture for treating cancer-related pain has been emerging. Some research, however, has not found discernable benefits of true acupuncture compared to sham acupuncture [163].

For example, Kasymjanova and colleagues [164] examined the effect of acupuncture as a potential intervention choice in 33 cancer patients who received 45-minute acupuncture sessions for at least four times. The study results indicated statistically significant improvement in pain, appetite, nausea, nervousness, and overall well-being. Study limitations of small sample size and lack of a control group limit generalizability. A meta-analysis conducted by Choi and associates [158] observed that the majority of acupuncture treatment, demonstrated positive effects for treating cancer pain. However, they concluded that acupuncture treatment alone did not result in improved relief from cancer pain compared with pharmaceutical therapy, although combined acupuncture and pharmaceutical interventions demonstrated improved outcomes [158].

Among pediatric populations, acupuncture has been utilized to treat a wide range of conditions, including nausea and vomiting [165], epilepsy [166], migraine [167], constipation [168], and allergies [169]. However, there are very few empirically supported pediatric studies available to confirm the efficacy of acupuncture for children [159].

In a multicenter, crossover study conducted by Reindl and associates [165], researchers analyzed the effectiveness of acupuncture on nausea and vomiting in nine children, ages 10–16 years, undergoing chemotherapy for solid tumors. The children were randomly assigned to undergo chemotherapy with either antiemetic medication plus acupuncture or antiemetic medication only. Acupuncture was given on day one of chemotherapy and at subsequent days upon patients’ request. Results demonstrated that those individuals who received acupuncture in addition to antiemetic medications, compared to those who receive antiemetic medications alone, experienced higher levels of alertness, as well as reduced nausea and vomiting as measured through their subjective experiences, while undergoing chemotherapy. While this study provides some efficacy of positive outcomes, the small sample size is a significant limitation. Further controlled studies are needed in order to establish the usefulness and effectiveness of acupuncture with children [159].

The effectiveness of acupressure with pediatric cancer survivors has not been extensively examined, and limited evidence suggests mixed findings in using acupressure to address nausea and vomiting among children in active treatment [170, 171]. Jones and associates [170] examined the effectiveness of acupressure to prevent chemotherapy-related nausea among 18 children who were also receiving standard antiemetic therapy. The study was a randomized crossover clinical trial in which participants were randomized into one of two treatment sequence groups. The first sequence group (n = 8) consisted of wearing acupressure wrist bands during the first chemotherapy, not wearing wrist bands during the second chemotherapy, and wearing placebo acupressure wrist bands during the third chemotherapy. The second sequence group (n = 10) consisted of wearing placebo wrist bands in the first chemotherapy, followed by not wearing wrist bands in the second chemotherapy, followed by true acupressure wrist bands in the third chemotherapy. Results indicated no significant differences in nausea between their three study conditions: acupressure wrist bands, placebo bands, and no bands. The authors concluded that while there were no adverse effects of wearing the acupressure bands, efficacy was not established. In contrast, Yeh and colleagues [171] studied the effectiveness of acupressure on chemotherapy-related nausea in a pediatric cancer population and found that acupressure significantly reduced the occurrence of nausea and vomiting among children who utilized an acupressure intervention. This study was a crossover randomized study design, and all participants received three courses of chemotherapy. All ten patients received standard care during the first course of chemotherapy. Prior to the second chemotherapy course, participants were randomized into two treatment groups: (1) auricular (outer ear) acupressure intervention (treatment condition), in addition to standard care and (2) auricular acupressure using sham points (control condition) in addition to standard care. For the third course of chemotherapy, the groups were crossed over to the other treatment condition. Results of the study indicated lower occurrence of both acute and delayed nausea and shorter duration of vomiting in the intervention condition compared to either the control condition or the standard of care condition across time. Though this study shows a strong study design, small sample size is a limitation [171].

Mechanism of Action. Traditional Chinese Medicine (TCM) theory posits that Qi can be unblocked by using acupuncture at certain places on the skin, called acupoints. These acupoints are places where meridians come to the surface of the body; with humans having more than 360 acupoints that correspond to conditions being treated. However, traditional TCM theory is not supported by scientific evidence, and it is challenged by research showing lack of differences between true and sham acupuncture. For example, Moffet [163] conducted a systematic review of 38 studies from 2005 to 2006 comparing acupuncture with needle insertion at clinical sites versus acupuncture with needle insertion at wrong points or at non-points, and comparing normal needle insertion and stimulation versus superficial insertion or minimal stimulation. The author found that most studies (22 out of 38) found no statistically significant differences in outcomes. Most (13 out of 22) found that sham acupuncture was as effective as true acupuncture, especially when superficial needling was applied to non-points [163].

Other theories being researched to explain acupuncture’s mechanisms of action include neurophysiological theories such as a gate-control mechanism, and effects on neurotransmitters like endorphins [172]. Furthermore, an NIH Consensus Panel concluded that acupuncture can cause multiple local and distal biological responses, acting on the sensory neurons within the central nervous system (CNS), and the autonomic nervous system, thereby balancing the sympathetic and parasympathetic systems. Acupuncture is also thought to regulate blood flow and activate the pituitary gland and hypothalamus, which can produce a cascade of systemic reactions, including changes in hormones, peptides, and neurotransmitters [173], and electrophysiological effects on cytokines and neuropeptides [174–176]. There may be an analgesic effect through the release of opioid peptides [177, 178]. Furthermore, animal studies have demonstrated increased immune functions by enhancing natural killer (NK) cell and lymphocyte activity [179–181], and may be beneficial in reducing chemotherapy-induced emesis [182].

Despite limited evidence available for both acupuncture and acupressure treatment with pediatric cancer survivors, the current surveys yield feasibility and acceptability data for pediatric for populations. For example, Kemper and colleagues [183] interviewed 47 children who were seeing a pediatric acupuncturist and found that the majority of children (67 %) rated acupuncture treatment positively in helping manage their pain. Clearly, more controlled study of the efficacy of acupuncture and acupressure is needed to determine the usefulness with pediatric cancer survivors, both during treatment for the cancer and for the medical late effects after treatment.

Potential Risks/Adverse Effects. Mild adverse effects (e.g., pain or bleeding at the site of acupuncture, tiredness or pain) have been reported in both adults and children, but can be minimized by appropriate management [184–187]. Serious complications, such as pneumothorax, are very rare. Also, there have been very few infection reports since 1988, when disposable needle use became widespread and national certification requirements were developed for clean-needle techniques [188]. However, given the immunocompromised condition of cancer patients undergoing chemotherapy or radiation therapy, it is important to take precautions and strictly adhere to sterile-needle techniques when acupuncture treatment is given [189]. Potential relative contraindications for acupuncture include bleeding abnormalities, infections, edema, epilepsy, pregnancy, and needle phobia [190].

One of the major concerns about utilizing acupuncture, particularly among cancer patients, has been the occurrence of thrombocytopenia, a side effect of chemotherapy, which is related to a heightened risk of prolonged bleeding. Ladas and associates [186] examined this risk in a study of thirty-two children who received acupuncture treatment for various reasons (e.g., gastrointestinal symptoms, neurologic symptoms, and pain management), with almost half of them (47 %) diagnosed with mild, moderate, or severe thrombocytopenia. During treatment, there were no reported acute side effects, and the researchers concluded that acupuncture can be safely administered to pediatric cancer patients, including children with thrombocytopenia, without an increased rate of bleeding or negative effects [186].

Finding a Provider. Most, but not all, states in the United States have laws regulating the practice of acupuncture. The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) offers national certification examinations for practitioners of acupuncture and traditional Chinese medicine (www.​nccaom.​org). Most, but not all, states require this certification. The NCCAOM website noted above has a resource to help identify appropriately trained providers. Some insurance companies provide coverage for acupuncture treatment. However, federal insurance programs (e.g., Medicare) generally do not.

Background. Mindfulness is an Eastern concept derived from a Buddhist spiritual tradition [191]. In particular, Kabat-Zinn [191] further defines mindfulness as a way of developing one’s ability to pay attention and observe in the present moment without judgment. Wallace, Benson, and Wilson [192] define meditation as a state of being awake, yet relaxed, alert, and focused. According to Segen [193], mindfulness has been referred to as a “Zen-like” approach to meditation, in which one focuses on the activity or event occurring in the moment, which is different from traditional meditation, in which the purpose is to free the mind of all thought. Nonetheless, the words mindfulness and meditation are utilized interchangeably in research settings [194, 195].

Historically, within the Buddhist religion, mindfulness has been an essential component to achieve enlightenment and is attained through meditation practice [196]. In modern Western psychology and behavioral medicine settings, mindfulness meditation is taught and applied to potentially change one’s perception and behavior patterns by deliberately observing and describing experiences nonjudgmentally in the present moment [197].

Over the past 30 years, various patient populations have utilized the Buddhist concept of mindfulness-based treatments [198]. Initially, patients with chronic physical and psychological conditions had begun utilizing such interventions, but later these treatments appealed to wider, non-clinical populations [199]. In clinical settings, mindfulness practice has been used to treat various physical and emotional conditions, such as chronic pain, depression, and anxiety [196].

Mindfulness is typically gained through formal meditation practices, including sitting meditation, walking meditation, and/or mindful movements [191]. Researchers have found several positive effects of mindfulness meditation on both physical and psychological well-being, including decreased heart rate [200], lowered blood pressure [201], improved sleep [202], reducing pain level [203], and decreasing mood disturbances, such as anxiety and depression [204–207]. Estimates of between 8.4 and 41 % of breast cancer survivors have utilized relaxation/meditation techniques [208].

Among several methods to cultivate mindfulness, the Mindfulness-Based Stress Reduction (MBSR) program is the most commonly utilized training model in clinical setting [209]. MBSR, originally developed by Kabat-Zinn and colleagues in 1979, is a structured, group formatted, psycho-educational, and skill-based experiential program that patients attend once a week for an average of 2½ h for 8–10 weeks. The program is comprised of mindfulness meditation, also known as Vipassana, which includes the body scan, mindfulness of breath and other sensory experiences. Additionally, the program includes Hatha yoga exercises, designed to develop mindfulness during movement, along with an additional full day intensive “silent meditation retreat” [191]. MBSR has been prevalent and has been one of the most common interventions used by cancer patients and survivors [210].

Clinical Studies. MBSR may be a useful program for promoting physiological and psychological health and well-being for adult cancer patients and survivors [209, 211–214]. For example, Lengacher and associates [210] investigated the effects of MBSR program on symptom severity among 82 breast cancer survivors and found that, after the 6-week post-intervention, the women who received MBSR treatment (n = 41), compared to the wait-list control group (n = 43), showed statistically significant reduction in fatigue and disturbed sleep. Similarly, researchers examined the feasibility of an 8-week MBSR program on a group of 19 breast cancer survivors’ emotional well-being, physical health, and quality of life. Findings with the 17 women who completed the program indicated significant improvements on fear of recurrence, perceived stress, anxiety, depression, and overall quality of life upon completing MBSR participation [210]. However, study limitations include small sample size, lack of a control group, and lack of extended follow-up evaluation for participants. Likewise, Matchim and associates [215] examined the effects of an 8-week MBSR program on physiological and psychological well-being among 36 early-stage breast cancer survivors, and the intervention group (n = 19) exhibited statistically significant improvement in reduced blood pressure, heart rate, and respiratory rate as well as increased mindfulness state, compared to the control group (n = 17) who did not receive MBSR intervention. The authors also found that participants exhibited overall improvements in their psychological well-being with improved mood. Study limitations include small sample size and lack of randomization [215].

Despite the promising effectiveness of MBSR on adult cancer patients and survivors’ physical and psychological health, little is known about its effect on pediatric cancer patients and survivors, and to our knowledge, there is no available literature on MBSR treatment in pediatric cancer patients or survivors [126]. Nonetheless, some researchers have examined the effects of mindfulness on children’s overall well-being [217–219]. Huppert and Johnson [217] examined 155 adolescent male students’ mindfulness, resilience, and emotional health through mindfulness training. They were randomly assigned to receive either four 40-minute mindfulness classes (once per week) or to receive regular religious studies lessons. Participants completed questionnaires before and after the 4-week intervention period, measuring mindful awareness, resilience, and well-being. While this study did not indicate a statistically significant difference between the mindfulness training group and the control group on any of these measures, the participants in the mindfulness training group demonstrated a positive association between frequency of practice outside the classroom and improvement in emotional well-being and mindfulness. The authors also found that improvement in the students’ emotional well-being was mediated by personality variables, such as agreeableness and emotional stability. Another study evaluated the effects of a school-based program called Mindful Awareness Practices (MAPs) on executive function among children between the ages of 7 and 9 [218]. The MAPs program consisted of 30 min of mindfulness activities twice per week, for 8 weeks. Sixty-four children were randomized into either the MAPs intervention (n = 32) or a control group (n = 32) consisting of silent reading periods. Children who received the MAPs program exhibited greater improvement in executive functioning compared with the control group. In particular, those children demonstrated improvements in behavioral regulation, metacognition, and overall global executive control [218].

For children, Thompson and Gauntlett-Gilbert [195] suggest modifying mindfulness to correspond with different developmental stages and age ranges. For instance, compared to adult populations, adolescents require more explanation and rationale in order for them to fully engage, and benefit from shorter practice times compared to the typical 20–45 min typically utilized by adults. Finally, it is important to involve parents and caregivers when teaching mindfulness to children and youth. The overall impression of the MBSR studies is very promising for the powerful benefits among cancer survivors; therefore, researchers believe that the program may also be beneficial for childhood pediatric cancer survivors as well [216].

Mechanism of Action. Moenaert and Sieh [220] note that while research regarding the psycho-neuro-immunology effects of mindfulness-based interventions is still in its early stages, mindfulness meditation is believed to help regulate emotions, leading to a decreased sympathetic nervous system activity and reduced stress hormone levels. Field [56] describes how mindfulness research has shown that meditation practices are associated with changes in resting electroencephalography (EEG) patterns and suggests long-lasting changes in brain activity. Also, research utilizing MRI to examine differences in physical brain structure has shown increased cortical thickness in subjects with extensive meditation practice compared to matched controls. These differences in cortical thickness were observed in brain regions associated with attention and sensory processing (pre-frontal cortex and anterior insula) [221].

Level of Scientific Efficacy. Some evidence of efficacy. A 2007 NCCAM-funded review of the scientific literature found some evidence suggesting that meditation is associated with potentially beneficial health effects. However, the overall evidence was inconclusive. The reviewers concluded that future research needs to be more rigorous before firm conclusions can be drawn [222]. In a more recent systematic review and meta-analysis [203], mindfulness meditation programs with various adult clinical populations in improving stress-related outcomes, including anxiety, depression, stress/distress, positive mood, mental health-related quality of life, attention, substance use, eating habits, sleep, pain, and weight were evaluated. This review identified 47 randomized clinical trials with active controls. The authors found moderate evidence of improved anxiety (effect size, 0.38 at 8 weeks and 0.22 at 3–6 months), depression (0.30 at 8 weeks and 0.23 at 3–6 months), and pain (0.33). The authors found low evidence of improved stress/distress and mental health-related quality of life. Their findings did not suggest effects of meditation programs on positive mood, attention, substance use, eating habits, sleep and weight. Further, there was no evidence that the meditation programs were more effective than other interventions utilized in the various studies, including exercise, cognitive behavioral therapy, or medication [203].

Potential Risks/Adverse Effects. As noted in the CAM-Cancer Consortium review of Mindfulness interventions, mindfulness-based clinical interventions are generally considered to be safe. Adverse effects are rare, though there are some concerns that meditation could cause or worsen symptoms in people who have certain psychiatric problems, though this question has not been fully researched [222].

Finding a Provider. Training for mindfulness based interventions is not standardized. However, various training institutions have made recommendations for training hours and clinical experience with meditation. These recommendations vary widely. One easily accessible and helpful internet resource for both professionals and children and their families is www.​InnerKids.​org.

Background. The word Yoga, a mind-body practice that originated in India, is derived from the Sanskrit root Yuj, which means to harness or yoke [223]. As such, the purpose of yoga was originally established to integrate body, mind, and spirit to lead to self-realization or the authentic self [223]. There are over 40 different styles of yoga based on different approaches and techniques of training, and common elements of yoga include postures (asanas), breathing (pranayama), and meditation [224]. In particular, breath plays an important role in yoga as it is intricately related with the mind. Therefore, it is believed that adjusting the breath to a slow pace would slow and calm the mind.

Historically, the asanas are aimed to help both physically and psychologically, with benefits such as improved endocrine system, gastrointestinal functioning, attention, and mood [223]. The modern practice of yoga is widely used for the benefit of fitness, stress management, and other mental health concerns [225]. Its growth has facilitated yoga’s inclusion with alternative medicine in health care settings [224].

Utilization of yoga among cancer patients and survivors varies from 1.2 to 33.9 % [226]. For example, according to a nationally representative study in the United States, the National Health Interview Survey (NHIS) in 2007, 9.8 % of male and 9.9 % female cancer survivors reported having used yoga in the past year [227]. Moreover, an analysis of over 2,500 breast cancer survivors in the Women’s Healthy Eating and Living Study revealed that 33.9 % of the women reported having used yoga in the past [228]. More specifically, Park and associates [226] examined the use of yoga among 286 young adult cancer survivors. They found that 33 % of reported practicing yoga since their initial diagnosis, mostly to maintain physiological flexibility and promote relaxation, and they tended to practice yoga more than seven times per month and over 26 months of duration.