Peri-operative Therapy for Cardiac Surgery Pain
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Quicker, More Efficient Surgery Recovery
Over the last few years, we’ve noticed a dramatic increase in clinical evidence showing that incorporating massage therapy as part of surgery recovery can be of great benefit. Post-operative patients often struggle to manage both physical pain and emotional distress, and recent research indicates that peri-operative massage treatments have both physiological and psychological benefits.
Some of the most powerful evidence we’ve seen for this proposition comes from a study published late last year in Massage and Bodywork, the professional journal of Associated Bodywork & Massage Professionals – our industry’s professional association.
Massage Therapy for Cardiac Surgery Pain
The article argues that cardiac patients who accessed post-operative massage therapy tended to have a quicker, less painful surgery recovery than those who did not. The article further lays out some specific ideas for how patients can effectively incorporate massage therapy into their recovery process.
At Soulstice, we’ve been putting this theory into practice for decades, helping people to heal faster and more efficiently after all kinds of surgical procedures. Soulstice Peri-operative Therapy specialty services are effective because of our 2-pronged approach:
- The physiology – Manipulating soft tissue increases blood circulation.
Our integrated manual techniques increase blood flow to traumatized tissue down to the cellular level. Blood is the deliverer of oxygen and nutrients to help traumatized tissue heal. We also facilitate lymph flow. The lymph system is the body's filtration system, and helps reduce post-surgical swelling. - The human connection and relationship building – We got our start by treating patients who'd undergone plastic elective and reconstructive surgery procedures. When they found themselves suffering from surgical pain, and healing more slowly than expected, they turned to us – not only for the physical relief we were able to give, but for the human touch and strong relationships that are critical to our success to help our patients heal their spirits and emotions, as well as their bodies.
Today, we’ve recognized that the body responds similarly to any surgical trauma. This realization has empowered us to to approach all surgeries in a similar manner including cardiac surgery, as described in the article.
Massage Therapy for Cardiac Surgery Pain
By Jerrilyn Cambron
[Somatic Research]
According to the US Centers for Disease Control and Prevention, 51.4 million Americans have inpatient surgery each year, with the majority focusing on heart procedures such as cardiac catheterizations, angioplasty, or bypass surgery.1 Postsurgical pain management is essential for comfort and recovery. Narcotic sedatives may relieve the pain, but they can also lead to respiratory suppression, nausea, and constipation. Massage therapy is an adjunct therapy that might relieve some of the postsurgical pain while patients are in acute and critical care units.
In a recent Canadian study, 40 subjects were randomized to hand massage versus hand-holding for pain after cardiac inpatient surgery.2 The use of hand massage was chosen due to the ease of access for the massage, as well as the likely patient comfort regardless of patient body position.
Potential subjects were approached the day before the surgery to determine their interest and eligibility. Inclusion criteria for the study were: 18 years of age and older, able to speak French or English, elective cardiac surgery requiring sternal incision (such as bypass surgery or valve replacement), ejection fraction of 35 percent or more, and ability to answer questions and self-report pain.
Patients at higher risk of postoperative complications were excluded, as well as those with abnormalities to one or both hands. Specific exclusion criteria included: documented diagnosis of cognitive or psychiatric disorder, pulmonary artery pressure >50mm Hg, right ventricular failure, and body mass index >30.
Subjects were randomized to receive either hand massage intervention (n=21) or the control intervention of holding hands (n=19). The same research nurse performed both interventions. This nurse was trained to do hand massage during a 10-hour workshop. All subjects received their intervention 30 minutes after a dose of morphine, and each intervention was repeated two to three times within 24 hours after admission to the ICU.
The massage intervention started with closing the curtains, placing a “do not disturb” sign on the door, and reducing other intrusions that might affect relaxation. Next, the nurse applied lavender cream to the right hand and wrist followed by 5 minutes of massage on the palm and back of the right hand. The same procedure was repeated on the left hand. The research nurse remained silent during the massage intervention. The total time spent with the subject was 15 minutes followed by 30 minutes of rest.
The control group included the same process of initiating a relaxing environment and applying lavender cream to the hand. But, instead of performing hand massage, the research nurse held the subject’s right hand and then left hand in her hands for 5 minutes each without performing massage. The total time spent with the subject was 15 minutes followed by 30 minutes of rest.
The main outcome measured in this study was pain. Pain was measured using three validated scales: a 0–10 numeric rating scale called the Faces Pain Thermometer (FPT), the Critical Care Pain Observation Tool (CPOT) for pain behaviors, and the Brief Pain Inventory for global experience of pain after ICU discharge. Secondary outcomes included muscle tension (assessed by the research nurse) and the subject’s vital signs such as changes in blood pressure, heart rate, respiratory (breathing) rate, and pulse oximetry (amount of oxygen in the blood).
The self-rated numeric pain rating scale did not demonstrate a significant difference between the two groups after the first massage; however, there was a trend toward statistically significant differences between the groups after the second massage. The third massage demonstrated a statistically significant difference in pain favoring the massage group.
In terms of pain behaviors measured by the CPOT, such as facial expression and body movements, there were statistically significant differences between the groups 30 minutes after the first intervention with massage leading to better scores. The massage group again trended toward improvement compared to the hand-holding group after the second massage. After the third massage, there was no difference in pain behaviors between groups.
Muscle tension was significantly less in the massage group compared to the hand-holding group after the third massage, with the massage group demonstrating more relaxed muscles 30 minutes after the massage. This difference did not occur after the first or second massage. No other outcome measures demonstrated significant differences between the two groups.
Overall, this study demonstrated that pain and pain behaviors were significantly improved in the hand-massage group compared to the hand-holding group. Interestingly, the differences in pain behaviors were seen during the first and second interventions, whereas the differences in measured pain were seen during the third intervention, indicating that change in behavior might occur before a noticeable decrease of measured pain occurs.
One limitation in this pilot study was the small sample size. This small number further decreased by the third intervention due to the subjects transferring out of the ICU. A second limitation was the higher baseline pain level in the massage group (an average of 3.6 out of 10) compared to the hand-holding group (2.4 out of 10). These differences might have affected the amount of pain reduction measured because lower levels of pain are less likely to decrease at the same rate as higher levels of pain. A third limitation is that the duration and frequency of treatment might not be adequate for optimal benefits.
In a similar Iranian clinical trial, 74 patients who received coronary artery bypass graft (CABG) surgery were randomized to a group that received massage by a trained relative versus standard care.3 Subjects were screened the day before surgery. They were included if they were a candidate for CABG; willing to participate in the research; 18–70 years old; hospitalized for at least three days after the operation; oriented to person, place, and time; did not use narcotics or alcoholic drinks during the last two months; had no history of nervous, neurovascular, psychiatric, or respiratory disturbances; and did not have coagulation disorders. Exclusion criteria included severe pain after cardiac surgery, reduction of level of consciousness, instability in hemodynamic status, unwilling to continue cooperation, presence of coagulation problems, and suffering from chronic pain.
On the third day after the surgery, subjects were randomized to either massage or standard care control. The massage was performed by a family member who was trained for 60–90 minutes and also received an educational CD for home viewing. The research nurse taught and approved each participating family member, most of which were the patient’s children (68.6 percent).
The massage intervention was the Thailand classic method performed with sweet almond oil under the nurse’s supervision for 30 minutes. Massage was based on the patient’s tolerance and could include the back, lumbar, shoulders, arms, forearms, palm and fingers of both hands, thighs, foreleg, soles, insteps and toes, abdomen, and neck. The single intervention was performed when the patient was transferred from ICU to the cardiac surgery unit on the third day after the operation.
Pain was measured using McGill’s Visual Analogue Scale (VAS) with a line numbered 0–10 and was collected before the massage, as well as 30 minutes, 60 minutes, and 2 hours after the intervention. The control group received routine care and their pain rating was collected on the third day after surgery at the same time intervals.
The average initial pain levels were 6.6 out of 10 in the intervention group and 7.1 in the control group. Immediately after the intervention, the respective pain levels were 3.4 and 7.1. After 30 minutes, the pain levels were 3.0 and 7.1. After 60 minutes they were 2.8 and 7.1, and after 120 minutes they were 3.3 and 7.2. All results demonstrated significant differences between the groups, with the massage group having a higher level of improvement. All of the patients in the intervention group were satisfied with massage therapy.
Limitations of this study include not having a consistent massage treatment protocol completed by a trained massage therapist. Even though the family members were trained in massage, it was minimal compared to that of a licensed massage therapist. Findings might have been even more improved if a trained therapist was utilized. Second, reduction in pain may have been overestimated because of the positive attention shown by the family member to the patient. Third, there was no mention of pain medication used by the patients in either group, which may have affected the pain outcomes. Finally, it is unknown if the pain reduction lasted beyond 2 hours.
Conclusions
Overall, the following conclusions can be made:
1. Patients in the ICU and cardiac ward who underwent cardiac surgery appeared to have a reduction in pain with massage therapy.
2. The duration and type of care that demonstrated benefits included three 15-minute hand massages by a trained research nurse, and a single 30-minute full-body massage by a trained family member.
3. Massage type, duration, and frequency will most likely affect the outcomes. Currently, the best protocol for surgical cardiac patients is not known. More research is needed.
4. Even though no adverse events were disclosed in these articles, each patient is different. Be sure you discuss any massage protocol with your client’s cardiologist and health-care team prior to providing a postsurgical massage.
Notes
1. US Centers for Disease Control and Prevention, “Inpatient Surgery,” accessed July 2015, www.cdc.gov/nchs/fastats/inpatient-surgery.htm.
2. M. Boitor et al., “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, no. 3 (June 2015): 354–66.
3. S. S. Najafi et al., “The Effect of Massage Therapy by Patients' Companions on Severity of Pain in the Patients Undergoing Post Coronary Artery Bypass Graft Surgery: A Single-Blind Randomized Clinical Trial,” International Journal of Community Based Nursing and Midwifery 2, no. 3 (July 2014): 128–35.
Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the National University of Health Sciences and president of the Massage Therapy Foundation. Contact her at jcambron@nuhs.edu.