Abstract
Background
Despite the existence of controlled trials (CTs) and a handful of meta-analyses investigating the effects of massage on postoperative pain and anxiety, recent comprehensive reviews in this area are scarce.
Aim
This study seeks to fill this gap by quantifying the impact of massage therapy on pain and anxiety levels in patients who have undergone cardiac surgery, thereby enriching the existing body of literature.
Design
A systematic review and meta-analysis.
Review methods
The random effect model was applied to estimate the effects since the heterogeneity between results was high.
Data Sources
Five databases (Scopus, Clinical Key, Web of Science, Pubmed, Science-Direct) were searched for CTs from July to October 2023.
Results
The analysis included 19 control trials and showed that massage therapy is effective in reducing postoperative pain (95 % CI, g = 0.899, p < .000) and anxiety (95 % CI, g = 0.705, p < .000). In our study significant variations in effect sizes based on the person applying the massage, and the type of massage used ( p < .05 for all), suggesting these factors significantly moderate the effect of massage therapy on pain and anxiety reduction.
Conclusion
The results advocate for the integration of massage therapy into the postoperative recovery plans of patients undergoing cardiac surgery, highlighting its potential to alleviate pain and anxiety effectively. As such, massage therapy represents a valuable complementary approach to traditional care methods.
1
Introduction
With an aging and increasing population, a total of 280 million procedures are performed globally each year, including cardiac surgery (procedures on cardiac valves, repair of congenital defects, coronary artery bypass grafts (CABG), and heart transplants), joint replacement, cardiovascular and cerebrovascular surgeries, and cancer surgeries. These procedures significantly impact patients across physical, psychological, social, and economic dimensions. , In 2019, an estimated 17.9 million people died from cardiovascular diseases (CVDs), comprising 32 % of all global deaths, with 85 % of these fatalities attributed to heart attack and stroke. Over three-quarters of CVD deaths occur in low- and middle-income countries. A study conducted in Turkey revealed that between 2009 and 2019, deaths caused by circulatory system diseases were at their highest level in the country. In cardiac diseases that cannot be managed with medical treatment, cardiac surgery is considered a safe and effective treatment option.
Following cardiac surgery, various complications may arise, with pain being the primary complication depending on the intervention applied to the patient. Prolonged hospital stay and psychological symptoms such as anxiety and depression related to interventions are commonly observed. During this period, patients’ oral intake is reduced. Some drugs (especially opioid derivatives) used in postoperative pain management suppress the release of neurotransmitters in the enteric nervous system. They disturb the diversity and balance of the intestinal microbiota and slow down intestinal contractions by binding to μ-opioid receptors in the myenteric plexus in the intestinal wall and additional medical issues can contribute to an increase in the patient’s anxiety levels. , Prolonged anxiety causes a continuous release of stress hormones (e.g. cortisol and adrenaline). These hormones increase blood pressure and vascular tone by constantly activating the ‘fight or flight’ response. Continually high levels of adrenaline can cause spasms in the artery walls. Anxiety-induced chronic inflammation increases oxidative stress and can lead to microvascular damage in brain tissue. This may contribute to spasms and hypoxia in brain arteries, leading to intensification of pain. Consequently, anxiety can lead to spasms in brain arteries, resulting in regional changes in the brain and heightened pain perception. Importantly, ineffective postoperative pain and anxiety control are associated with poor prognosis, including longer hospital stays, sleep disturbances, longer time to resume activity, and increased use of opioids.
Traditional analgesic measures with drugs (e.g., opioids) only for pain relief not only fail to achieve the desired effect, but also can lead to multiple somatic and psychological consequences including depressive disorders, anxiety disorders, sleep disorders, sexual dysfunction, and delirium. Therefore, complementary treatment methods, applied alongside pharmacological approaches, are important in postoperative pain and anxiety management.
Nurses play a vital role in effective pain management as they provide round-the-clock care for the patient and are responsible for assessing managing pain and anxiety after cardiac surgery. In this context, non-pharmacologic therapies are techniques that, when administered by trained professionals, carry a low risk of side effects and are easily performed. Massage therapy (MT) is one of these treatments and is a widely used complementary treatment method in nursing. This method involves stimulating tissues and systems through mechanical and neural methods to manipulate the body’s soft tissues for therapeutic purpose.
Clinical evidence supports MT’s effectiveness in alleviating symptoms like pain and anxiety when complemented with conventional medical treatment. Research across various populations indicates massage can reduce pain, anxiety, blood pressure, and heart rate, offering a safe, non-invasive method that benefits circulation, muscle relaxation, and general restfulness. Clinical Trials (CTs) have shown MT’s positive effects on pain and anxiety, enhancing the quality of life and emotional well-being for cardiac surgery patients.
Systematic review and meta-analysis of CTs provide more reliable treatment effectiveness estimates than single studies, given their larger statistical power and the ability to clarify effects on clinically significant outcomes. ,
The aim of this study is to systematically evaluate and synthesize existing CTs to determine the effectiveness of MT in reducing pain and anxiety among patients undergoing cardiac surgery. By focusing on quantifiable outcomes related to patient-reported pain and anxiety levels, this meta-analysis seeks to provide a comprehensive assessment of MT as a non-invasive adjunct to traditional postoperative care.
2
Materials and methods
2.1
Aim
The current review aims to: systematically evaluate and synthesize the existing evidence assessing the effectiveness of massage therapy on pain and anxiety levels in patients who have undergone cardiac surgery.
2.2
Design
This systematic review and meta-analysis were designed following the PRISMA reporting guideline to ensure rigor and comprehensiveness. The International Prospective Register of Systematic Reviews (PROSPERO) registration number was 347,072. Meta-analysis synthesizes findings from various quantitative studies on a common topic, offering systematic insights and effect size estimations. Studies were selected based on defined inclusion criteria, with data synthesized through statistical methods to ascertain effect sizes and interpretations. To minimize bias, literature searches, article selection, and data extraction were conducted independently by two researchers, followed by a quality assessment of the included studies.
2.3
Data collection
Five databases (Scopus, Clinical Key, Web of Science, Pubmed, Science-Direct) were searched for CTs from July to October 2023. We conducted searches using specific keywords (“pain”, “massage”, surgery” and “anxiety”) in line with Medical Subject Headings (MeSH) across multiple databases, focusing on controlled studies to establish a robust evidence level 19 articles, the full text of which was available, were examined according to the inclusion and exclusion criteria and taken into analysis. Explanations about the selection process of the articles are given in Fig. 1 . and the inclusion and exclusion criteria were detailed in Table 1 , following the PICOS framework: Population, Intervention, Comparison, Outcomes, and Study Design.
| Inclusion Criteria | Exclusion Criteria |
|---|---|
| 1. Being a research article, | 1. The exclusion of abstracts, papers, editorial comments, interviews, advertisements, news, bulletins, reports, studies in the nature of master’s or doctoral thesis by researchers, |
| 2. Dependent and independent variables in the studies are suitable for meta-analysis, | 2. Studies that did not meet the dependent and independent variable criteria were excluded, |
| 3. Having patients undergoing cardiovascular thorasic heart surgery, | 3. The patient population that has not undergone cardiovascular-thorasic surgery was excluded, |
| 4. Having a randomized controlled trial design, | 4. Studies without randomized controlled design studies were excluded, |
| 5. Studies should include quantitative data such as mean, standard deviation, number of members in the sample, and p-value required to analyze effect size in the meta-analysis, | 5. Studies without sufficient quantitative data were excluded. |
| 6. The study is middle or high quality in terms of methodology. | 6. Studies with low quality in terms of methodology were excluded |
2.3.1
PICOS
P (Population): Patients who have had a cardiac surgical operation
I (Intervention): Massage
C (Comparison): Trial and control group
O (Outcomes): The effect of massage on pain and anxiety
S (Study Design): Controlled studies
2.4
Inclusion and reliability of the study
The titles and abstracts of all articles identified by the search strategy were assessed by two reviewers (E.Ö and N.G.B) independently through a checklist containing the criteria for inclusion and exclusion in the study. The abstract of all articles was read in full by the two re-viewers. Those who did not meet the checklist criteria or did not pro-vide sufficient information were excluded. Articles that fulfilled these criteria were selected for full-text evaluation.
The reliability of the findings in a meta-analysis is about inter-coder reliability at the stage of coding the studies included in the meta-analysis. In this line, we created a coding protocol and form including the quality, content and data of the studies included in the current study. We noted down the data in the studies included in the coding protocol by the two coders separately. We used Cohen’s Kappa statistics to ensue inter-coder reliability. We found out that the inter-coder reliability was 0.6 and 1.0 for pain and anxiety respectively. We concluded that inter-coder agreement was significant for the variable of pain, and it was perfect for the variable of anxiety.
2.5
Validity of the study
In meta-analysis studies, identifying all relevant studies as a result of database searches and selecting them in accordance with the inclusion criteria is an important step in ensuring the validity of the study. In the current study, all relevant studies were included in the meta-analysis after a comprehensive review. Each of the 19 studies examined was analyzed in detail and the validity of the data collection tools used in these studies was confirmed. Therefore, it can be stated that the current meta-analysis is a methodologically valid study.
2.6
Methodological evaluation of the studies
The quality assessment was done by two independent reviewers. Conducted the methodological evaluation of the studies included in the current study according to Joanna Briggs Institute (JBI) critical evaluation lists for CTs Nahçıvan and Seçginli conducted the Turkish validity and reliability studies of JBI quality measurement tools and control lists. This Quality evaluation form consists of 13 questions. The questions in these tools are answered with the options “Yes, No, Uncertain, Not Applicable”. The evaluation results for each study in this study are given as “Quality score” in Table 1 . We included 19 studies that were evaluated to be good and medium quality in the current meta-analysis.
2.7
Data analysis
We conducted the data analysis on CMA Ver.2. [Comprehensive Meta Analysis Version 2 Free Trial] ( https://www-analysis.com/page/demo.php ). We calculated the effect size in line with Hedge’s g calculation suggested by Hedges and Olkin. We interpreted the effect of studies according to level classification suggested by Thelheimer and Cook (2003), and we interpreted the general effect size according to Hedge’s g. We evaluated the heterogeneity among studies via I 2 statistics. In this context, 25 % refers to a low-level of heterogeneity, 50 % refers to a medium-level heterogeneity and 75 % refers to a high-level heterogeneity. Subgroup analyzes were performed as a result of heterogeneity analysis. We used the statistics of publication bias to evaluate the publication bias.
2.8
Ethical permission
As a meta-analysis synthesizes existing literature, no direct ethical approval was required for this study.
2.9
Report
Fig. 1 below shows the Turkish version of the PRISMA flow chart used for systematic compilation and meta-analysis.
3
Results
3.1
Descriptive findings about the studies
The descriptive characteristics of the included studies are summarized in Table 2 . This table provides an overview of study design, participant demographics, intervention details, and outcomes measured, offering a comprehensive snapshot of the research landscape regarding MT’s impact on post-cardiac surgery recovery.
| Author | Year | Country | Number of Sample (N) | Type of Massage | Parts of the Body Where Massage was Applied | The Person Who Applies the Massage | Pain Evaluation Scale | Anxiety Evaluation Scale | Quality score |
|---|---|---|---|---|---|---|---|---|---|
| Alameri et al. | 2024 | Saudi Arabia | 31 | Foot massage | Foot | Nurse | APS-POQ | HADS | Yes: 8/13 No:3/13 Uncertain:1/13 Does not apply:1/13 |
| Chandrabubu et al. | 2020 | India | 130 | Foot massage | Foot | MT | VAS | STAI | Yes: 8/13 No:3/13 Uncertain:1/13 Does not apply:1/13 |
| Peng et al. | 2015 | China | 117 | Swedish massage | Head, neck, shoulder, back | MT | VAS | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 | |
| Boitor et al. | 2015 | Canada | 40 | Hand massage | Hand | Nurse | FPT | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 | |
| Staveski et al. | 2018 | The USA | 60 | Swedish massage | Head, neck, shoulder, back, face, hand | MT | FLACC | STAI | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 |
| Boitor et al. | 2018 | Canada | 30 | Hand massage | Hand | Nurse | NRS | NRS | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 |
| Askarkafi | 2020 | Iran | 100 | Classic massage | Head | Nurse | NEECHAM | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 | |
| Elkafafi-Hassan et al. | 2019 | Iran | 40 | Hand massage | Hand | Nurse | McGillPQ | POMS | Yes: 7/13 No:4/13 Uncertain:1/13 Does not apply:1/13 |
| Abbaszadeh et al. | 2018 | Iran | 40 | Foot massage | Foot | Nurse | STAI | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 | |
| Solimon et al. | 2017 | Egypt | 97 | Swedish massage | Leg, hand, back | Nurse | FRS | DASS | Yes: 7/13 No:3/13 Uncertain:1/13 Does not apply:2/13 |
| Braun et al. | 2012 | Australia | 146 | Swedish massage | Shoulder neck, back head, arm | MT | VAS | VAS | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 |
| Najafi et al. | 2014 | Iran | 70 | Swedish massage | Back, lumber, shoulder, arm, hand | Nurse | McGillPO | Yes: 8/13 No:3/13 Uncertain:1/13 Does not apply:1/13 | |
| Cutshall et al. | 2010 | USA | 58 | Swedish massage | back, shoulder, neck, | MT | VAS | VAS | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 |
| Albert et al. | 2009 | USA | 258 | Swedish massage | Leg, arm, back, and neck | MT | BAI | Yes: 9/13 No:2/13 Uncertain:1/13 Does not apply:1/13 | |
| Hanna et al. | 2007 | USA | 403 | Classic massage | back | Nurse | VAS | VAS | Yes: 7/13 No:4/13 Uncertain:1/13 Does not apply:1/13 |
| Kshettry et al | 2006 | USA | 104 | Classic Massage | – | Nurse | NRS | Yes: 7/13 No:4/13 Uncertain:1/13 Does not apply:1/13 | |
| Hattan et al. | 2002 | England | 16 | Foot massage | Foot | Nurse | VAS | VAS | Yes: 7/13 No:4/13 Uncertain:1/13 Does not apply:1/13 |
| Armstrong et al. | 2014 | USA | 74 | Swedish massage | back, scalp, and arms | MT | VAS | Yes: 7/13 No:4/13 Uncertain:1/13 Does not apply:1/13 | |
| Babaee et al | 2012 | Iranian | 165 | Swedish massage | Leg, shoulders, | Nurse | POMS | Yes: 6/13 No:4/13 Uncertain:2/13 Does not apply:1/13 |
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