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The Effect of Massage on Pain and Anxiety in Hospitalized Patients: An Observational Study.
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The use of massage in hospitalized participants can aid in reducing anxiety, muscle tension, and pain. Findings of this study suggest massage can be a safe, pleasant treatment for hospitalized patients. Incorporating massage into patient care may yield positive results.
Massage is the intentional and systematic manipulation of the soft tissues of the body to enhance health and healing (National Certification Board for Therapeutic Massage and Bodywork, n.d.). It can be used alone or with essential oils. Until the 1990s, many nurses believed massage was part of their nursing care; in early nursing education, massage was part of bath and evening care rituals (Westman & Blaisdell, 2016). More recently, massage has not been included routinely in nursing care.
Significance of Research
The use of massage for hospitalized participants can aid in reducing anxiety, muscle tension, and pain (Dreyer et al., 2015). Increased research in recent years has evaluated the effect of massage on the management of pain and anxiety, but evidence is mixed regarding the degree of impact and related often to individual differences (Dreyer et al., 2015; Toth et al., 2013). Decreased anxiety has been shown in a recent study of hospitalized participants in acute care settings (Dreyer et al., 2015). Randomized controlled trials (RCTs) on the use of massage are increasing, and findings suggest promising results for pain and anxiety (Buyukyilmaz & Asti, 2013; Dreyer et al., 2015; Halm, 2015).
Reporting on the results from a larger study that identified hospitalized participants' responses to experiences of massage and prayer, this article focuses on participant responses to the massage experience. The research questions were:
1. How does massage affect patients' pain and anxiety?
2. How does massage affect distress and daily function?
Key words massage, pain, pain and anxiety, therapeutic massage, Swedish massage, hospitalized patient, and postoperative patient were searched for 2009-2015 in CINAHL. Researchers selected eight studies to include in this discussion. Other studies were excluded due to type of massage used and the patient populations.
In an RCT of patients who had undergone cardiac surgery in Quebec, Canada, 40 subjects were randomized to a hand massage group or a hand-holding group (Boitor, Martorella, Arbour, Michaud, & Gelinas, 2015). Subjects in the hand massage group were offered a 15minute hand massage two to three times in the 24 hours following surgery while controls' hands were held. This was followed by a 30minute rest period. The experimental massage group showed a reduction in pain intensity from moderate to mild only at 30 minutes after the massage (p=0.008). Initial pain assessment did not show statistically significant differences between the groups.
Another RCT involved 127 subjects who had undergone colorectal surgery (Dreyer et al., 2015). Participants received a 20-minute massage or a relaxation session on postoperative days 2 and 3. The relaxation session was introduced by the massage therapist, who talked with patients and instructed them to relax in the bed or chair while listening to music. The study found subjects in the massage group had reduced perception of pain (p<0.001) and anxiety (p<0 .001), with no change to these measures in the relaxation group.
Massage also has been used in oncology settings. In an RCT by Toth and colleagues (2013), 39 oncology patients were randomized into one intervention (massage) and two control groups. The intervention group (n=20) received three massages in their home within the first week of enrollment. One control group received no-touch treatments with the massage therapist, who held her hands about 12 inches over the participant's body for the treatment time (n=10). The other control group received usual care (n=9). After adjusting for baseline differences, researchers found no statistical differences in pain or anxiety. There was, however, an increase in quality of life at 1 week after intervention in the massage group.
Additional studies in varying populations included a descriptive study of a convenience sample on two cardiac wards in a medical center in Taiwan that assessed anxiety and other physiologic measures (Chen et al., 2013). In 64 participants, authors found a significant decrease in blood pressure and anxiety levels (p<0.01), with a greater positive effect on male participants than females (p=0.01). In another descriptive study, Armstrong, Dixon, May, and Patricolo (2014) found a decrease in anxiety and blood pressure in a convenience sample of 55 inpatients and outpatients who received massage before undergoing cardiac catheterization.
In a retrospective study of 6,589 cardiovascular inpatients, Johnson and colleagues (2014) found participants who received integrative medicine (IM) therapies (massage, mind-body, energy therapies, traditional Chinese medicine) at a large, teaching hospital had 46.5% decrease in pain and 54.8% decrease in anxiety (p<0.001). Practitioners collected self-reported pain and anxiety data before and after each IM session. Pain intensity reduction was similar among therapy types, with a decrease of 45%-54% in mean scores among all therapies. Combination therapies, however, were more effective in reducing anxiety; mind-body energy therapies showed a mean decrease of 57% and traditional Chinese medicine a decrease of 71.5% in anxiety scores.
In another RCT, Buyukyilmaz and Asti (2013) evaluated the effect of relaxation techniques and massage on postoperative pain in participants who had undergone total hip or knee arthroplasty. Sixty participants were assigned randomly to a control group or an experimental group receiving massage. Those receiving massage showed less pain intensity and lower anxiety than the control group f=9.13; p=0.000). Measures were taken using the McGill Pain Questionnaire Short Form and the State Anxiety Inventory. Finally, Halm (2015) conducted a systematic literature review of 10 studies assessing effects of massage in patients who had undergone cardiac surgery. Findings in eight of the studies indicated a decrease in pain. Five studies also showed decreased anxiety following massage.
The literature suggests massage therapy is beneficial in reducing pain and anxiety for patients with oncology or cardiac diagnoses. It also has positive impact on patients undergoing colorectal surgery. However, due to small sample sizes, multiple therapies provided, and lack of randomization, more research is needed in this area.
This study was approved by the Loma Linda University Health Institutional Review Board and conducted with the use of verbal consent.
Design and Method
This descriptive explorational study was conducted on a surgical unit selected because potential participants were expected to be more homogeneous in diagnosis than those on other units. The 26-bed unit had semi-private rooms. All participants received standard care in all aspects.
Participants in the convenience sample of all patients on the unit were alert and awake, allowing informed verbal consent, and had projected hospital length of stay of 2-8 days. Included participants were at least age 18; could read, write, and speak English; were medically stable; and were able to participate for at least 48 hours. Participants were excluded if they were medically unstable (fever >102[degrees] F, blood pressure 20 mm Hg below admission baseline) or had altered level of consciousness. The proposed intervention was offered Monday-Friday only, so a participant's first massage could occur 24-72 hours after admission.
A list of eligible participants was compiled each morning. Once a patient was cleared by nursing staff, the massage therapist asked the patient if he or she wanted to participate. After verbal consent was obtained, the pre-massage Emotional Thermometer (ET) was completed by the participant and a massage then was provided. The ET is a simple, rapid modular screening tool for detecting and monitoring distress in clinical practice (Mitchell, 2007). This self-report, pencil-and-paper assessment includes a line with 0-10 scale (0=no distress, 10=extreme distress). Participants are asked to indicate their current level of pain, anxiety, distress, and daily function. The tool has 80.9% sensitivity and 60.2% specificity (positive predictive value [PPV] 32.8%, negative predictive value [NPV] 92.9%) for depression, sensitivity 77.3% and specificity 56.6% (PPV 55.2%, NPV 80.25%) for anxiety, and sensitivity 77.1% and specificity 66.1 % (PPV 55.6%, NPV 84.0%) for broadly defined distress (Mitchell, 2007).
Swedish massage was performed in the participant's room by a certified massage therapist. Massages were performed while the participant was sitting in a chair or lying in bed, and were 25-35 minutes in length. Hands, arms, shoulders, neck, and feet were included in the massage as desired by the participant and determined medically suitable by the massage therapist. A primary effleurage stroke with a speed of 10-12 inches per 5 seconds was used. The pressure varied from light (less than the pressure of the hand) to medium (heavy enough to affect the underlying tissues but not to press through to the bone), depending on participants' preference and condition. All strokes were conducted in the direction of venous flow. Circular strokes were used on hands and feet. BonVital organic massage cream (Performance Health; Akron, OH) was used as a lubricant on the skin. Easy-listening instrumental music was played during the massage. Initial massage was performed on day 1, followed by subsequent massage on day 2 of the study.
In 1-4 hours after the massage, another member of the research team (not the massage therapist who had treated the patient) asked the participant to complete another ET and a participant questionnaire. If the participant could complete the paperwork independently, the research team member returned in 10-20 minutes to collect the forms; these had been placed and sealed in an envelope by the participant. If the participant was unable to write or stated it was too difficult to complete the forms, the team member asked the participant the questions and recorded the answers on the forms. If the participant was sleeping, the paperwork was left with the charge nurse who subsequently asked the participant to complete it.
At the conclusion of the massage, the massage therapist completed the Demographic Data & Massage Therapist Questionnaire. This team-developed questionnaire collected participant age, gender identity, and reason for admission; length of massage; and information about conversations during the massage. Information also was collected about any interruptions during the massage. All paperwork was returned to the massage therapy office and kept in a locked cabinet.
This study was conducted April 21-August 29, 2014. The sample was comprised of 124 recruited participants; however, 32 participants were withdrawn due to hospital stays of less than 24 hours or cancellation of surgery. The remaining 92 subjects participated in the study, but only 88 had complete data packets. The majority of the sample was female (n=53, 60%); age range was 18-91 (M=55). Average length of hospitalization was 3 days. See Table 1 for additional demographic information.
Using a 5-point Likert scale (1=not satisfied, 5=very satisfied), participants indicated satisfaction with their massage experience (M=4.83; SD=0.437). Using repeated measures, a reduction in participants' pain intensity was statistically significant (p=0.000) as values before and after initial massage. Mean scores for distress and anxiety were reduced after initial massage; however, the reduction was not statistically significant. Additionally, a significant increase (p=0.004) in daily function was identified after initial massage. Examination of degree of pain, distress, and anxiety before initial massage and the second massage found statistically significant reductions (pain p=0.000; distress p=0.001; anxiety p=0.002). The increase in daily function from baseline after the second massage also was significant (p=0.011; see Table 2).
Examining the differences between surgical and medical participants (see Table 3), surgical participants showed a reduction in pain and distress between baseline and the first massage (pain p=0.013; distress p=0.006) and a significant reduction in pain, anxiety, and distress from baseline to after the second massage (pain p=0.001; anxiety p=0.021; distress p=0.003). A significant increase in daily function was found between baseline and after the first massage (p=0.023); however, no further increase was seen after the second massage (p=0.902).
In participants hospitalized with a medical condition, no significant change was found in anxiety from baseline to after the first massage. Pain and distress showed a statistically significant reduction (pain p=0.001; distress p=0.000). A statistically significant improvement in daily function (p=0.005) also was found. Following the second massage, results revealed statistical significance in reduction of pain (p=0.002), distress (p=0.000), and anxiety (p=0.013) compared to baseline levels. Participants' daily function scores were worse after the second massage.
This study evaluated potential effects of Swedish massage therapy on pain intensity, anxiety, distress, and daily function in hospitalized medical and surgical participants. This study supported findings of prior studies in which use of massage therapy resulted in a reduction in pain experienced by participants (Boitor et al., 2015; Chen et al., 2013) as well as reduction in participant anxiety (Dreyer et al., 2015).
Results provided additional insight into the participant experience by exploring participant distress and daily function. Massage therapy showed immediate, sustained results in participants with acute medical conditions over the 2-day hospital admission. In surgical participants, while distress and anxiety were shown to respond to massage therapy, pain and daily function were reduced on postoperative day 1 but improved on postoperative day 2. This improvement may have resulted in greater ability of participants to engage in their care and earlier mobility after surgery. This finding may be explained by general stress of the immediate postoperative period. These findings suggest massage can offer relief as soon as 2 days after surgery.
The unit identified for this study was expected to provide a homogeneous group of participants. However, because the unit was used as overflow for medical and surgical patients, a wide variety of diagnoses was seen. A second limitation was the ability of participants to provide written feedback on their experience. The study was begun anticipating all participants would be able to complete their own questionnaires, but about half the participants felt too weak or tired to do so. As a result, a department member who was not an active part of the massage team made rounds and asked patients the questions and recorded their answers verbatim. This introduced the possibility of bias and recorder influence on responses. These participants also did not have complete confidentiality in their responses, and they might have felt uncomfortable saying the massage was not helpful. A third limitation was the small sample at a single site. A larger multisite sample might yield different results. Participants' perceptions also could be based on their overall improving physical condition. In addition, the significant reduction in participation at the time of second massage may affect the findings. Ethnicity and the effect of pain medications were not explored in this study.
Recommendations for Future Research
This appears to be one of relatively few studies examining not only pain and anxiety, but also the effects of massage on distress and daily function. Participant surveys suggested they experienced relaxation, calming, and decreased pain from the treatment. Overall, massage treatments were considered convenient with no associated risks or adverse events. Future studies on populations with longer hospital stays could examine effects of massage on distress and daily function, and the relationship to length of stay and patient satisfaction.
Nursing Implications
With insurance carriers unlikely to begin paying for massage for patients (Massage Therapy Schools Information, 2017), reintroducing massage into nursing care may be beneficial to patients. Another option would be to provide fee-for-service massage for patients who desire this benefit or for hospitals to absorb the cost of massage therapy in the interest of helping to manage pain and increase patient satisfaction. Incorporation of nonpharmacologic methods to reduce distress in the hospitalized patient is worth consideration by nurse leaders. Likewise, nursing education in the academic and clinical settings should include information regarding nonpharmacological measures to provide comfort to patients.
Massage is not appropriate in all areas (e.g., near open wounds, lines or drains, or thrombosis). It only should include the hands, feet, or scalp in patients with sepsis, fever over 100[degrees] F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis (Westman & Blaisdell, 2016). However, findings of this study suggest massage can be a safe, pleasant treatment for hospitalized patients. Incorporating massage into patient care may yield positive results. It also can be included in the provision of nursing care without a physician order when population inclusion criteria have been developed.
Armstrong, K., Dixon, S., May, S., & Patricolo, G. (2014). Anxiety reduction in participants undergoing cardiac catheterization following massage and guided imagery. Complementary Therapies in Clinical Practice, 20(4), 334-338. doi:10.1016/ j.ctcp.2014.07.009
Boitor, M., Martorella, G., Arbour, C., Michaud, C., & Gelinas, C. (2015). Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: A pilot randomized controlled trial. Pain Management Nursing, 16(3), 354-366. doi:10.1016/j.pmn.2014.08.014
Buyukyilmaz, F., & Asti, T. (2013). The effect of relaxation techniques and back massage on pain and anxiety in Turkish total hip or knee arthroplasty participants. Pain Management Nursing, 14(3), 143-154. doi:10.1016/j.pmn.2010.11.001
Chen, W., Liu, G., Yeh, S., Chiang, M., Fu, M., & Hsieh, Y. (2013). Effect of back massage intervention on anxiety, comfort, and physiologic responses in participants with congestive heart failure. Journal of Alternative & Complementary Medicine, 19(5), 464-470. doi:10.1089/ acm.2011.0873
Dreyer, N., Cutshall, S., Huebner, M., Foss, D., Lovely, J., Bauer, B., & Cima, R. (2015). Effect of massage therapy on pain, anxiety, relaxation and tension after colorectal surgery: A randomized study. Complementary Therapies in Clinical Practice, 21(3), 154-159. doi:10.1016/ j.ctcp.2015.06.004
Halm, M. (2015). East meets West: Effects of massage on the experience of cardiac surgery participants. American Journal of Critical Care, 24(2), 176-180. doi:10. 4037/ajcc2015947
Johnson, J., Crespin, D., Griffin, K., Finch, M., Rivard, R., Baechler, C., & Dusek, J. (2014). The effectiveness of integrative medicine interventions on pain and anxiety in cardiovascular in participants: A practice-based research evaluation. BMC Complementary and Alternative Medicine, 14, 390-410. doi:10.1186/ 1472-6882-14-486
Massage Therapy Schools Information. (2017). Who likely provides reimbursable coverage and who does not. Retrieved from http ://www. massagetherapyschools information.com/insurance-medicare-medicaid/
Mitchell, A.J. (2007). Pooled results from 38 analyses of the accuracy of distress thermometer and other ultra-short methods of detecting cancer-related mood disorders. Journal of Clinical Oncology, 25(29), 4670-4681.
National Certification Board for Therapeutic Massage and Bodywork. (n.d.). Glossary: Therapy and techniques. Retrieved from http://www.ncbtmb.org/ consumers/glossary-therapy-techniques
Toth, M., Marcantonio, E.R., Davis, R.B., Walton, T. Kahn, J.R., & Phillips, R.S. (2013). Massage therapy for participants with metastatic cancer: A pilot randomized controlled trial. Journal of Alternative & Complementary Medicine, 19(7), 650656. doi:10.1089/acm.2012.0466
Westman, K.F., & Blaisdell, C. (2016). Many benefits, little risk: The use of massage in nursing practice. American Journal of Nursing, 116(1), 34-41. doi:10.1097/01. NAJ.0000476164.97929.f2
Kathleen McMillan, MS, BSN, RN, is Director of Spiritual Care and Wholeness, Loma Linda University Medical Center, Loma Linda, CA.
Debi Glaser, AA, AS, CMT, is Massage Specialist, Loma Linda University Medical Center, Loma Linda, CA.
Patti Radovich, PhD, RN, CNS, FCCM, is Director, Nursing Research, Loma Linda University Medical Center, Loma Linda, CA.
Participant Demographics
n    %
18-30                               15   17
41-50                               9    10
71-80                               4    5
>80                                 4    5
Female                              53   60
Male                                35   40
Acute trauma                        17   20
Acute abdominal                     9    10
Orthopedic                          18   21
Oncology                            4    5
Neurologic                          2    2
Complications of chronic disease    8    9
Infection                           7    8
Sepsis                              3    3
Miscellaneous                       20   23
Overall Effect of Massage
Measure          Baseline   M Post            M Post 2nd     p
Initial            Massage
Pain               5.63      4.89     0.04       3.63      0.000
Distress           3.66      2.69     0.07       2.69      0.001
Anxiety            3.31      2.37     0.82       1.58      0.002
Daily function     6.23      4.26     0.004      4.72      0.011
NOTE: Computed using alpha=0.05.
Effect of Massage on Surgical and Medical Participants
Measure                Baseline   M Post      p     M Post      p
Initial             2nd
Massage           Massage
Surgical Participants
Pain                     6.16      4.22     0.013    3.50     0.001
Distress                 3.86      2.33     0.006    1.69     0.003
Anxiety                  4.06      2.39     0.059    1.69     0.021
Daily function          6.639      3.94     0.023    5.75     0.902
Medical Participants
Anxiety                  2.64      1.86     1.00     1.08     0.374
Daily function           6.47      3.33     0.005    5.61     1.00
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McMillan, Kathleen; Glaser, Debi; Radovich, Patti
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