Patient experience is commonly referred to as the fifth vital sign. Persistent suffering is at the crux of the term patient experience.1 Hospitals dependent on patient satisfaction surveys for funding and ratings are trying a variety of interventions to improve the patient’s experience and relieve postoperative pain and distress. According to recent studies, massage therapy safely and effectively improves patients’ postoperative experience.
Massage is becoming a cost-effective, noninvasive approach to “meaningful relief.” In addition, findings demonstrate massage improves patient-caregiver relations, enhancing the therapeutic relationship and the sense of connection with loved ones, both critical for optimal recovery.2
Commonly, inpatient and outpatient surgical patients experience postoperative symptoms that typical pharmacological interventions alone may not fully address. Pain, distress, anxiety, poor sleep quality, nausea, and fatigue are among these symptoms. Routinely, patients report mild to moderate pain even with the use of pain medications.3 More importantly, the unpleasantness of the pain persists, even though the level of pain is lessened.
Reducing recovery time and postoperative complications are critical for cost savings and to ensure long-term success of surgery. Ka-Kit Hui, MD, FACP, the director and founder of the UCLA Center for East-West Medicine, a hospital that routinely uses massage therapy for most patients, from providing postoperative care to treating migraines, believes in using physical methods to help stimulate the body to correct its own chemical flow. “Muscle spasm is not normal,” Hui says. “When you take care of that, other conditions can be helped.”4 If massage therapy can improve patient outcomes early in the healing process, the patient’s long-term healing is positively affected.
Demographics
More than 48 million inpatient surgical procedures are performed annually in the United States.5 This number doesn’t account for the less invasive procedures that allow patients to recover at home. Additionally, major surgical interventions are on the rise. Knee replacement surgeries, for example, are expected to increase by nearly 700 percent between 2005 and 2030.6 This increase is anticipated in part due to the fact that people are living 25 percent longer and are more physically active, yet 20 percent heavier than decades ago.7
More than a decade of studies have investigated the use of postoperative massage therapy for a range of surgical interventions. While the surgical procedures and the patient populations vary, the postoperative symptoms are similar and consistently unrelieved through conventional means. Pain and its unpleasantness persist, anxiety is prevalent, and nausea and poor quality sleep are commonplace. The evidence consistently points to the positive effects of massage therapy.
The Job Market
Massage therapists currently working in hospital settings are primarily hired and paid through research funding or provide services on a volunteer basis. Publishing positive patient outcomes may encourage full-time positions for massage therapists, particularly if patients demand it.8 Integrative medicine is on the rise, both in the United States and Canada, paving the way for new workplace opportunities for practitioners.9 More cost-effectiveness studies are necessary to dramatically influence the job market for massage in hospital and medical clinic settings; however, change is happening regardless, as health-care reform demands a team approach to wellness, and preventive health care and community education takes center stage over curative medicine.
There is much to learn to adapt to the foreign and unpredictable hospital environment. We have little control over the bright lights, beeping and whirring machines, and constant interruptions. There is no autonomy in team medicine. We must learn to communicate up the hierarchical structure using conventional means. Professional boundaries, dress codes, and hygiene requirements are rigid, and rightly so. We must learn a new language, adopt a new uniform, and stretch how we deliver hands-on healing.
We are accustomed to maximizing healing by creating beautiful, peaceful spaces. Traditional massage studios are sanctuaries with soft lights, soothing music, water fountains, and colorful art. Additional effort is required to create a safe, healing haven in a hospital room using only our presence and our touch. But we are not alone in this effort to transform hospital settings. The Samueli Institute, a research facility known for its studies on alternative approaches to treating veterans, has implemented a program to help hospitals create “optimal healing environments” that support and stimulate patient healing. One of the Samueli Institute’s main goals is to understand what components of a hospital environment contribute to optimal patient recovery and well-being. Another is to evaluate the business impact of optimal healing environments.10 Hospitals are contracting the institute’s services to evaluate their current environment and help implement change in hopes of promoting comprehensive approaches to health care. Promoting massage therapy services could be a strategy hospitals adopt to assist them in achieving optimal healing environments.
Effective Massage Strategies
In order to best determine the techniques and modalities to employ when providing postoperative massage, it is important to identify the goals for treatment based on the symptoms and concerns specific to the individual patient’s experience. We can look to research protocols and results to help inform our approach to postoperative care.
In a study published earlier this year, massage and acupressure were found to relieve symptoms and promote relaxation and sleep among pediatric patients undergoing hematopoietic cell transplant. If the interventions are administered with attention to patients’ needs and hospital routines, massage and acupressure may also relieve stress among parents, improve caregiver competence, and enhance the sense of connection between parent and child.11 The massage intervention was a semi-standardized integration of Swedish massage (gentle to moderately firm strokes; light pressure; holding touch to the back, shoulder girdle, hands, and legs) and acupressure based on traditional Chinese medicine using points on the feet, lower legs, wrist, and chest that are commonly used to address nausea, pain, and distress. Professional practitioners provided up to three massage/acupressure treatments per week during the patients’ hospital stay and demonstrated the techniques to the parents whenever the parent was present and amenable to it. Parents provided additional massage/acupressure, following a handout that outlined the standardized routine demonstrated by the therapists.
Last year, a study was conducted on thoracic surgery patients at a Mayo clinic, demonstrating that massage can be successfully integrated into a high-volume thoracic surgical practice.12 The study highlighted the specific process and reality of providing massage therapy in a hospital environment. The massage therapy provided was a picture of the reality of how massage is provided in hospital settings and emphasized how massage needs to be focused on patient symptoms and individualized according to symptoms, medical status, and positioning tolerance.
Each massage session consisted of a 1–5 minute assessment, including comfortable positioning of the patient, and 20 minutes of hands-on massage that focused on the areas of primary concern as indicated by the patient. Typically requested areas were the back, neck, and shoulders. There were no contraindications for patients to receive massage, but the therapist did not massage within 2 inches of any surgical wound. Depth and pressure of massage was light to moderate. Two therapists used the following techniques: Swedish, craniosacral, myofascial release, reflexology, and diaphragmatic breathing. The therapists focused on using and adjusting massage techniques to help patients release tension and pain, increase relaxation, and promote deeper breathing. Massage techniques were selected by the therapist and tailored on the basis of the patient’s symptoms, symptom location, medical status, and positioning tolerance. The therapist modified massage techniques to avoid bruising, to avoid a negative impact on low or high blood pressure and heart rate, and to not pull on the incision site. Therefore, the angle of the massage stroke, pace, and amount of pressure were administered carefully. Massage was provided to head, neck, shoulders, back, hands, or feet, depending on patient preference. Supportive positioning was used at the end of each session to maintain the patient’s level of relaxation.
A 2010 study conducted in Brazil focused on the effects of massage for improving sleep in patients following cardiopulmonary artery bypass graft surgery.13 Poor sleep and fatigue are common following thoracic surgery and can compromise treatment and recovery. Poor sleep quality in the postoperative period may be due to several factors, including pain from surgical incision, presence of a thoracic drain, pain caused by prolonged time in bed, and high anxiety levels. In addition, muscle pain, particularly in the neck, shoulders, and back, may make it difficult for patients to breath, cough, move, and sleep.
Following discharge from the ICU to the ward during the postoperative period, the participants were randomized into control and massage therapy groups. Massage therapy was performed by the same physiotherapist during the protocol and consisted of back, neck, and shoulder massages. The massages were initiated with light compression by the inner regions of the fingers and progressed to hard compression. Manual kneading, friction (i.e., digital compression with the thumb) on trigger points, cervical traction, and mobilization in all planes (e.g., the front, back, and sides) followed. The massage was finished with light manual compression. This intervention was performed around 7:00 p.m., 2–3 hours before sleep. The control participants sat in comfortable chairs for three consecutive nights and were not subjected to massage therapy.
The results indicate that massage therapy improved the comfort level of the massage therapy group participants in comparison with those patients in the control group. Recovery from fatigue was significantly faster in the massage therapy group, reaching statistically significant differences by Day 1 and Day 2. Sleep effectiveness was also significantly higher in the massage group participants during all the study period. In addition, the results indicate that the beneficial effects of massage were not mediated by reducing pain because the number of complaints about pain was similar in both the control and massage therapy groups.
A study on massage postsurgery for breast cancer found that massage consisting of stroking, squeezing, and stretching techniques to the head, arms, legs, feet, and back reduced anxiety and depression and increased body image, function, and vigor.14 Another studied gentle touch, light massage, and guided imagery, finding it was easy to implement in a busy critical care setting and safely reduced pain and tension in heart surgery patients.15 Postoperative hand and foot massage interventions were effective, low risk, noninvasive, and easily applied strategies for pain management and for promoting psychological well-being.16 A 45-minute gentle Swedish massage each day for three days following abdominal surgery reduced pain and distress more effectively than vibration or usual care alone.17
Moving Forward
From the above studies, we can infer the need to integrate comfortable positioning into individualized treatment sessions to assist in recovery from surgery. A variety of techniques and pressure is appropriate for most any area of discomfort as directed by the patient, as long as care is taken to avoid the surgical incision sites. Treatment should be focused on relieving pain and discomfort, enhancing sleep and encouraging rest, decreasing anxiety, and improving mood and self-esteem.
We have all experienced how human touch can help alleviate suffering. Add the educated hands of a trained and experienced massage therapist and the benefits are profound. Be the calming and comforting presence and provide skilled touch to those who have just experienced the lifesaving, but invasive and often terrifying, experience of surgery.
Notes
1. S.L. Ackerman et al., “Massage for Children Undergoing Hematopoietic Cell Transplantation: A Qualitative Report,” Evidence Based Complementary and Alternative Medicine 2012 (2012): doi: 10.1155/2012/792042.
2. Ibid.
3. A.R. Mitchinson et al., “Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy: A Randomized Trial,” Archives of Surgery 142, no. 12 (2007): 1,158–67; H.L. Wang and J.F. Keck, “Foot and Hand Massage as an Intervention for Postoperative Pain,” Pain Management Nursing 5, no. 2 (2004): 59–65; M.M. Piotrowski et al., “Massage as Adjuvant Therapy in the Management of Acute Postoperative Pain: A Preliminary Study in Men,” Journal of the American College of Surgeons 197, no. 6 (2003): 1,037–46.
4. K. Mahr, “Post-Op Rx: Get a Massage,” Time, December 18, 2007.
5. Centers for Disease Control and Prevention, “Inpatient Surgery,” www.cdc.gov/nchs/fastats/insurg.htm, accessed September 2012.
6. S. Kurtz et al., “Projections of Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030,” The Journal of Bone and Joint Surgery 89, no. 4 (2007): 780–5.
7. R.D. Crowninshield, A.G. Rosenberg, and S.M. Sporer, “Changing Demographics of Patients with Total Joint Replacement,” Clinical Orthopaedics and Related Research 464, no. 2 (2006): 266–72.
8. K. Mahr, “Post-Op Rx: Get a Massage.”
9. P.M. Barnes, B. Bloom, and R. Nahin, “Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007,” CDC National Health Statistics Report #12, December 10, 2008.
10. Samueli Institute, “Optimal Healing Environments,” www.samueliinstitute.org/authoring/g4/g2/30-IIB.html?layoutType=plain, accessed September 2012.
11. S.L. Ackerman et al., “Massage for Children,” doi: 10.1155/2012/792042.
12. L. Dion et al., “Effect of Massage on Pain Management for Thoracic Surgery Patients,” International Journal of Therapeutic Massage & Bodywork 4, no. 2 (2011): 2–6.
13. F.B. Nerbass et al., “Effects of Massage Therapy on Sleep Quality After Coronary Artery Bypass Graft Surgery,” Clinics (Sao Paulo) 65, no. 11 (2010): 1,105–10.
14. M. Hernadez-Reif et al., “Breast Cancer Patients Have Improved Immune and Neuroendocrine Functions Following Massage Therapy,” Journal of Psychosomatic Research 567, no. 1 (2004): 45–52.
15. V.R. Kshettry et al., “Complementary Alternative Medical Therapies for Heart Surgery Patients: Feasibility, Safety, and Impact,” The Annals of Thoracic Surgery 81, no. 1 (2006): 201–5.
16. H.L. Wang and J.F. Keck,” Foot and Hand Massage,” 59–65. J. Hattan, L. King, and P. Griffiths, “The Impact of Foot Massage and Guided Relaxation Following Cardiac Surgery: A Randomized Controlled Trial,” Journal of Advanced Nursing 37, no. 2 (2002): 199–207.
17. A.G. Taylor et al., “Effects of Adjunctive Swedish Massage and Vibration Therapy on Short-Term Postoperative Outcomes: A Randomized Controlled Trial,” Journal of Alternative and Complementary Medicine 9, no. 1 (2003): 77–89.
A licensed massage practitioner since 1984, Diana L. Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to match how we practice. Contact her at soapsage@comcast.net.