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Effectiveness of massage therapy on postoperative outcomes among patients

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journal-of-nursing-sciences/2352-0132

Review

Effectiveness of massage therapy on post-operative

outcomes among patients undergoing cardiac
surgery: A systematic review

C. Ramesh a, Vasudev Baburaya Pai b, Nitin Patil b, Baby S. Nayak a,*,

Anice George a, Linu Sara George a, Elsa Sanatombi Devi a
a
Manipal College of Nursing, Manipal University, Manipal, India
b
Kasturba Medical College, Manipal University, Manipal, India

article info abstract

Article history: The incidence and prevalence of cardiovascular disease (CVD) are increasing rapidly in
Received 27 May 2015 developing countries. Most patients with CVD do not respond to medical treatment and
Received in revised form have to undergo cardiac surgery. This highly stressful experience results in increased levels
8 July 2015 of anxiety for patients. The objective of this review was to evaluate the efficacy of massage
Accepted 30 July 2015 therapy on postoperative outcomes among patients undergoing cardiac surgery. A
Available online 7 August 2015 comprehensive literature search was made on PubMed-Medline, CINAHL, Science Direct,
Scopus, Web of Science and the Cochrane library databases for original research articles
Keywords: published between 2000 and 2015. Original articles that reported the efficacy of massage
Anxiety therapy in patients undergoing cardiac surgery were included. The Cochrane data
Heart surgery extraction form was used to extract data. A total of 297 studies were identified in the
Massage literature search. However, only seven studies were eligible for analysis. Of the seven
Pain studies, six studies demonstrated the effects of massage therapy on improving post-
Post-operative period operative outcomes of patients, while one study found no evidence of improvement.
Although the methods varied considerably, most of the studies included in this review
reported positive results. Therefore, there is some evidence that massage therapy can lead
to positive postoperative outcomes. Evidence of the effectiveness of massage therapy in
patients undergoing cardiac surgery remains inconclusive. Additional research is needed
to provide a strong evidence base for the use of massage therapy to improve post-operative
outcomes and recovery among cardiac surgery patients
Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier
(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

*
Corresponding author.
E-mail address: baby.s@manipal.edu (B.S. Nayak).
Peer review under responsibility of Chinese Nursing Association.
http://dx.doi.org/10.1016/j.ijnss.2015.07.006
2352-0132/Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2 305

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
2.1. Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
2.2. Literature search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
2.3. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
2.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
3.1. Sample characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
3.2. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
3.3. Risk of bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
3.4. Intervention details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
3.5. Outcome measurements and effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
3.6. Primary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
3.7. Secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
3.8. Validity and reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
4.1. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
4.2. Implications for clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
5. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
7. Financial support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
8. Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

found to have marked effect in decreasing pain and anxiety

1. Introduction
Every year the number of cardiac surgeries is increasing
steadily in India and other developing countries due to a high
prevalence of CVD [1,2]. Postoperative outcomes such as se-
vere pain, anxiety, psychological distress and sleep distur-
bance are commonly associated with recovery from cardiac
surgery. These factors may compromise the effective of their
treatment and quality of life of patients undergoing major
heart surgery [3]. Pain can prolong a patient's post-operative
stay in the hospital and affects their satisfaction level [4].
There is a need for clinicians and nurses to identify safe and
effective therapeutic interventions to use following a major
cardiac surgery [5].
In recent years, there has been a focus on complimentary
therapies to manage or alleviate pain and anxiety. These
therapies have many noninvasive techniques that are cost
effective and simple with fewer side effects when compared
to drugs [6]. Complimentary therapies are used as adjuvant
therapy alongside conventional medical treatments to
enhance overall health and promote a faster recovery. Mas-
sage therapy is one type of complimentary therapy and is
recognized as an essential part of health and wellness [7e9].
Body massages have been tested in different populations and
[10].
Nurses caring for patients during the post-operative period
find it challenging to manage their pain and anxiety. Although
analgesic drugs are helpful in reducing pain, the adverse ef-
fects lead to further discomfort. Therefore, there is a need for
nurses to have scientifically tested, simple and effective in-
terventions to manage the pain and anxiety. A steady,
emerging body of evidence suggests that massage therapy is
vital to the healing process of patients undergoing general
surgery. However, very little is known about their effective-
ness in cardiac surgery patients. The objective of this review
was to evaluate the efficacy of massage therapy on post-
operative outcomes among patients undergoing cardiac
surgery.
2. Methods
2.1. Design
This review was conducted according to the guidelines
described in the Preferred Reporting Items for Systematic
Reviews and Meta-analyses (PRISMA). The PRISMA includes a
306 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2

checklist to ensure transparent reporting of systematic re- Types of outcome

views and a four-phase diagram [11]. Primary and secondary outcomes of effectiveness were
assessed.
Primary outcomes
2.2. Literature search strategy * Anxiety
* Pain
A comprehensive literature search for relevant original Secondary outcomes
research studies published between 2000 and 2015 was per- * Muscular tension,
formed using PubMedeMedline, CINHAL, Science Direct, * Relaxation,
Scopus and the Cochrane Library. The following keywords * Depression,
were used in the search: ‘massage’, ‘massage therapy’, ‘Chi- * Sleep,
nese massage’, ‘Swedish massage’, ‘manual therapy’, ‘body- * Satisfaction,
work’, ‘cardiac surgery’, ‘coronary artery bypass graft’, ‘heart * Heart rate,
surgery’, ‘open heart surgery’, ‘coronary artery bypass’, ‘anx- * Blood pressure,
iety’, ‘pain’, ‘discomfort’, ‘fear’, ‘psychological disturbances’, * Respiration rate,
and ‘postoperative outcomes'. Searches were limited to the * Length of hospital stay, and
English language and adult populations. Detailed methods of * Use of sedative drugs.
study retrieval from each database are shown in Table 1.
References from retrieved studies were scanned for additional
relevant studies, but none were identified. 2.4. Data extraction

The Cochrane data extraction form for systematic review was

2.3. Inclusion criteria utilized [13]. Two authors individually extracted data from
each included study and any dissimilarities were resolved
Studies were included in this review if they fulfilled the below- following a discussion.
mentioned selection criteria:
2.5. Data synthesis
Type of study:
* Original research studies were published in English be- Data was assessed for quality of methods, intervention char-
tween 2000 and 2015. acteristics and outcomes.
* Randomized controlled trials, nonrandomized controlled
trials, beforeeafter intervention trial and quasi-experi-
mental studies that included any form of massage ther- 3. Results
apy for cardiac surgery patients.
* The studies compared with any form of massage thera- Two hundred and ninety-seven (297) studies were identified
pies to usual care. through the literature. Seven duplicate articles were removed.
After assessment of titles and abstract, 267 studies were
Type of interventions excluded because they did not meet the inclusion criteria. An
The studies evaluated the effect of any farm of massage additional six studies were excluded after assessing the full
therapy on one or more postoperative outcomes. text because they did not meet the review criteria. The
exclusion criteria were qualitative designs, studies not
Type of participants involving patients undergoing cardiac surgery, and study in-
The studies involved adult patients (above 18 years) un- terventions not involving massage therapy. Finally, seven
dergoing any cardiac surgery that includes coronary artery studies were included in the data extraction (Fig. 1). In these
bypass graft, valve replacement or repair and open Ivan studies, patient demographics, types of massage therapies
surgery. used, duration of massage, research designs, and outcome
measures varied considerably. Therefore, we decided not to
conduct a meta-analysis, but synthesize the studies
Table 1 e Database search. descriptively.

Date of Database Years No of studies Total

3.1. Sample characteristics
search searched retrieved
05-04-2015 PubMed 2000e2015 74 297
The seven reviewed studies involved 764 patients (range:
06-04-2015 CINHAL 2000e2015 24
40e252) and the age group was 18e85 years of age (mean age:
07-04-2015 Scopus 2000e2015 56
08-04-2015 Science 2000e2015 101 52e67 years). Mean ages and both genders were not
Direct mentioned in one study [18]. In six of the studies, both the
09-04-2015 Web of 2000e2015 22 genders were included [14e17,19,20]. The majority of patients
Science were male. All studies patients underwent elective cardiac
10-04-2015 Cochrane 2000e2015 20 surgery including coronary artery bypass graft, valve
Library
replacement and valve repair. Three studies [14e16] included
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2 307

Fig. 1 e Flow diagram of study selection process.

Table 2 e Patient characteristics in reviewed studies.

Study Quality score Sample no. Age group Mean age Surgery type Massage type
Brent A et al. [14] 7 113 Not 65 CABG/valve repair/replacement Integrative
2010 Male: 78 mentioned or both
USA Female: 35
Lesley A et al. [15] 7 152 >18 years 67 CABG Swedish
2012 Male: 113 Valve surgery/open heart surgery
Australia Female: 39
Nancy M et al. [16] 7 252 18e85 65 CABG General
2009 Male: 184 Heart valve surgery/open
USA Female: 68 heart surgery
Sied Saeed et al. [17] 6 70 18e70 60 CABG Thai
2014 Male: 38
Iran Female: 32
Sima B et al. [18] 5 72 18e75 Not CABG Swedish
2012 mentioned
Iran
Flavia B N et al. [19] 4 40 40e80 62 CABG Swedish
2011 Male: 27
Brazil Female: 13
Marziyeh et al. [20] 4 65 Not 52 Cardiac surgery Hand and foot
2011 Male: 40 mentioned
Iran Female: 25

Table 3 e Delphi list criteria for assessing methodological qualities.

Item no. Quality Assessment criteria
1 Randomization Was a method of randomization done?
2 Allocation concealment Was the study performed concealment of treatment allocation?
3 Groups comparable at baseline Were the groups comparable at baseline regarding the most important
prognostic indicators?
4 Inclusion and exclusion criteria Did the study mention both inclusion and exclusion criteria?
5 Outcome assessor blinded Was the outcome assessor blinded?
6 Care provided blinded Was the care provider blinded?
7 Patient blinded Was the patient blinded?
8 Point estimates Were point estimates and measures of variability for the primary
outcomes measured?
9 Intention to treat analysis Did the analysis include an intention to treat analysis?
308 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2

combinations of coronary artery bypass graft surgery and

score
Total
valve replacement or repair. In all reviewed studies, massage

7
7
7
6
5
4
4
therapy was administered to the experimental group and the
control group received the standard of care. Table 2 summa-

treat analysis
Intention to
rizes the sample characteristics of the reviewed studies.

Unclear
Unclear
Unclear
Unclear
Unclear
Unclear
Unclear
3.2. Quality assessment

Delphi list criteria (Table 3) were utilized by two independent

estimates
authors to assess the methodological qualities (Table 4) of the

Unclear
Point
included studies [12]. In the case of a disagreement a final

Yes
Yes
Yes
Yes
Yes

No
decision was made by consensus with a third reviewer. The
studies with a score
5 (range 0e9) were considered high

blinded
Patient

Unclear
quality. Among the seven studies none received the
maximum quality score of nine points. Three reviewed

Yes
Yes
Yes
Yes

Yes
No
studies [14e16] had a methodological quality score of seven,
one [17] had a score of six, one [18] had five and the remaining

Care provided
two studies [19,20] had a quality score of four.

blinded

Unclear
All reviewed studies were randomized, specified patient

Yes
Yes
Yes
No
No
No
characteristics, reported inclusion and exclusion criteria and
had a <20% drop out rate. Four studies had concealment of
treatment allocation [14e16,20] and five studies [14e18] did

Outcome assessor
not report a sample size estimation. No study included an
intent to treat analysis. Three studies [14e16] had blinded care

blinded

Unclear
providers and study participants; while two studies [17,18]
had blinded outcomes assessors and sample size estimation

Yes
Yes
No
No
No

No
was mentioned in five studies [14e18].

3.3. Risk of bias exclusion criteria

Inclusion and

The Cochrane Collaboration tool [13] assessed the risk of bias

in each study (Table 5). The overall quality of reviewed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
studies was moderate and we found no bias in random
sequence generation. Three [14,16,20] studies had no risk of
bias in concealment of allocation and the remaining four
studies [15,17e19] did not provide any information. Five
Groups similar

studies [16e20] provided very little information to judge the

at baseline

risk of bias in blinding participants and personnel. Bias of

Yes
Yes
Yes
Yes
Yes
Yes
Yes

incomplete outcome addressed and free of selective report-

ing were not able to assess all the studies as it was not
mentioned clearly.
concealment

3.4. Intervention details

Allocation

Unclear
Unclear
Unclear
Table 4 e Methodological quality assessment.

Yes
Yes
Yes

Yes

Various types of massage therapies were given post-

operatively as a pain and anxiety intervention. These
include Swedish massages, foot massages, integrative mas-
Randomization

sages, hand massages, Thai massages and massage therapy

on the neck, shoulders, back, abdomen, arms, and legs (Table
Key: Yes ¼ 1, No ¼ 0, Unclear ¼ 0.
Yes
Yes
Yes
Yes
Yes
Yes
Yes

7). The massage combined acupressure, neuromuscular

techniques, trigger point therapy, deep tissue, reflexology,
manual lymphatic drainage, and Swedish massage pro-
cedures [14]. Three studies used Swedish massage as inter-
Sied Saeed et al. [17]

vention [15,18,19]. In one study [16], general massage therapy

Flavia B N et al. [19]
Marziyeh et al. [20]
Nancy M et al. [16]
Brent A et al. [14]

was given on the shoulders, neck, back, hands, legs as an

Sima B et al. [18]
Lesley A al [15].

intervention. Another study [17] administered Thai massage

on the neck, shoulders, arms, forearms, legs, and feet for the
study participants. The duration of massage intervention
Study

lasted for 20 minutes [14,15,18e20] or 30 minutes [16,17]. In

three studies [14e16], the frequency of therapy lasted for two
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2 309

Table 5 e Risk of bias assessment.

Study Random sequence Allocation Blinded participants Blinded Incomplete Free of
generation concealment and personnel outcome outcome data selective
data addressed reporting
Brent A et al. [14] þ þ þ ? ? ?
Lesley A al [15]. þ ? þ ? ? ?
Nancy M et al. [16] þ þ þ ? ? ?
Sied Saeed et al. [17] þ ? ? þ ? ?
Sima B et al. [18] þ ? ? þ ? ?
Flavia B N et al. [19] þ ? ? ? ? ?
Marziyeh et al. [20] þ þ ? ? ? ?

Key: þ Yes; e No; ? Unclear e insufficient information provided in the article to make a judgement.

Table 6 e Outcomes measures of massage therapy.

Outcomes Brent A Lesley A Nancy M Sied Saeed Sima B Flavia B N Marziyeh
et al. et al. et al. [16] et al. [17] et al. et al. [19] et al. [20]
[14] [15] [18]
Anxiety Y Y ¼ Y
Pain Y Y ¼ Y Y Y
Satisfaction [ [ [
Relaxation [
Fatigue Y Y
Sleep [
Blood pressure ¼ ¼ ¼
Heart rate ¼ ¼ ¼
Respiratory rate Y ¼ ¼
Tension Y Y ¼
Confusion ¼ Y
Hospital stay ¼ ¼
Depression ¼ Y
Use of sedative ¼ ¼ Y

¼: No difference between experimental and control group.

Y: Significant decrease in the experimental group.
[: Significant increase in the experimental group.

sessions and was administered on two different post-
operative days. A single session of massage therapy was
administered in two studies [17,20]. Only one study [18] had
four sessions of Swedish massage on the legs, hands, back,
shoulders for four consecutive post-operative days.
3.5. Outcome measurements and effectiveness
Each study evaluated anxiety, pain, muscular tension, patient
satisfaction, relaxation, heart rate, respiration rate, blood
pressure, sleep, length of hospital stay and the use of seda-
tives as an outcome measure (Table 6). Most outcome mea-
sures were self-reported and collected using generic or cardiac
disease-specific tools. Most studies focused on psychological
outcomes.
another study utilized the Profile of Mood States (POMS) [18].
In three studies, massage therapy significantly reduced
anxiety levels in patients undergoing cardiac surgery
[14,15,18]. Only one study [16] reported that massage therapy
did not yield any therapeutic benefit but considered massage
therapy a feasible intervention for patients undergoing car-
diac surgery.
Six studies [14e17,19,20] used VAS to measure the effec-
tiveness of massage therapy to reduce pain levels in patients
undergoing cardiac surgery. Five studies [14,15,17,19,20] re-
ported that massage therapy significantly reduced pain levels
in patients following cardiac surgery. One study [16] reported
that massage intervention did not yield any therapeutic
benefit, but considered massage therapy a feasible interven-
tion for patients undergoing cardiac surgery.

3.6. Primary outcomes 3.7. Secondary outcomes

Four studies evaluated the efficacy of massage therapy to
reduce anxiety levels in patients undergoing cardiac surgery
[14e16,18]. The Visual Analogue Scale (VAS) was used to
measure anxiety levels in two studies [14,15], the Beck
Anxiety Inventory (BAI) was used in one study [16] and
Tension, fatigue, sleep disturbance, patient satisfaction, and
the use of sedatives were secondary outcomes used to eval-
uate the effectiveness of massage therapy following cardiac
surgery. Three studies [14,15,17] concluded that massage
therapy significantly improved post-operative patient
 310
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2
Table 7 e Summary of interventions, outcome measures and study findings.
Study Design and Massage type Duration Frequency/ Outcome measures Study findings
group (minutes) post-operative day
Brent A et al. [14] RCT, Integrative massage 20 Two sessions/2nd Pain, anxiety, satisfaction, Less pain (P < 0.001), anxiety (P < 0.001),
2010 Study group: 62 (shoulders, neck, back, and 4th tension, and muscular tension (P < 0.001).
USA Control group: 51 hands, legs, feet)
Lesley A et al. [15] RCT, Swedish massage 20 Two sessions/3rd or Pain, anxiety, muscular tension, Reduced anxiety (P < 0.0001), pain (P ¼ 0.001),
2012 Study group: 76 (shoulders, neck, back, 4th and 5th or 6th relaxation, patient satisfaction muscular tension (P < 0.0001), and increased
Australia Control group: 76 hands, legs, feet) patient satisfaction (P ¼ 0.016) and relaxation
(P < 0.0001).
Nancy M et al. [16] RCT, General massage 30 Two sessions/2nd or Anxiety, pain, depression, No significant difference between groups for
2009 Study group: 126 (leg, arm, back) 3rd; 4th or 5th heart rate, any measure (P ¼ 0.11 to 0.93).
USA Control group: 126 duration of hospital stay,
respiration rate
Sied Saeed et al. [17] Single blinded RCT, Thai massage (neck, 30 One 1 session/3rd Pain, patient satisfaction Reduced pain (P ¼ 0.001).
2014 Study group: 37 shoulders, arms,
Iran Control group: 37 forearms, legs, feet)
Sima B et al. [18] Single blinded RCT, Swedish massage 20 Four sessions/3rd Anxiety, mood Reduced anxiety (P < 0.001) and improved
2012 Study group: 36 (legs, hands, back, to 6th mood (P < 0.001)
Iran Control group: 36 shoulders)
Flavia B N et al. [19] RCT, General massage 20 Three sessions/1st Pain, fatigue, sleep Reduced pain (P < 0.001), fatigue (P ¼ 0.028).
2011 Study group: 20 (neck, shoulder, to 3rd Improved sleep and recovery (P ¼ 0.536).
Brazil Control group: 20 back)
Marziyeh et al. [20] RCT, General massage 20 Single session/1st Pain, sedative use Difference in pain intensity type, and dose
2011 Study group: 32 (foot and hand) of sedative used (P ¼ 0.000).
Iran Control group: 33
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 3 0 4 e3 1 2
satisfaction after cardiac surgery. Two studies [14,15]
concluded that massage intervention significantly reduced
tension after cardiac surgery. One study [19] reported that
massage therapy relieved fatigue and improved sleep and
recovery time among patients following coronary artery
bypass graft (CABG) surgery. A randomized controlled trial
reported a significant difference in the dose of sedatives used
between the experimental (massage) and control (standard of
care) groups [20].
3.8. Validity and reliability
The validity and reliability of data collection tools used to
measure outcome variables in the reviewed studies was found
to be adequate [14e20].
4. Discussion
Our comprehensive, systematic review of research studies
published between 2000 and 2015 found six studies that
reporting that that massage therapy improves the post-
operative outcomes in patients after cardiac surgery
[14,15,17e20] while one study [16] reported no positive re-
sults. Complementary therapies are believed to minimize
anxiety, pain and promote a faster recovery by arousing the
relaxation response through the parasympathetic nervous
system [21].
Massage therapy is an ancient system of treatment that
is now gaining more recognition as an alternative and
complementary medicine. More evidence for the use of non-
pharmacological pain post-operatively is compulsory and
should involve staff acceptance, a reduced rest period, in-
clusion of families in the care plan, and repetition of
treatment [22]. In a meta-analysis of 37 randomized
controlled studies, massage therapy significantly decreased
anxiety, pain, depression, heart rate and blood pressure in
patients post-operatively [23]. Since most of the reviewed
studies were conducted in Iran and Western countries, data
from these studies should not be directly applied to coun-
tries such as China, India, and other Asian countries
without further considerations of socio-cultural factors that
may influence the patient's responses to massage in-
terventions. Long-term follow-ups, evaluation of cost-
effectiveness and the inclusion of more outcome variables
are needed.
4.1. Future directions
Very few published studies evaluate the effectiveness of
massage therapy on post-operative outcomes in cardiac sur-
gery patients. Therefore, rigorous research is needed to prove
the efficacy of massage therapy with relevant biomarkers and,
higher methodological qualities of randomized controlled
trials.
4.2. Implications for clinical practice
For most people the idea of surgery often creates a sense of
stress and anxiety. Since patients and family members seek
311
holistic approaches to health and wellness, there is an op-
portunity for clinicians and nurses to identify novel thera-
peutic interventions that are safe, effective and practical for
patients after major cardiac surgery. The use of massage
therapy in a surgical setting could be a favourable interven-
tion that minimizes anxiety, promotes relaxation and reduces
the length of stay in the hospital.
5. Limitations
In our review, only research articles published in English
were included, which may have produced a language
bias regarding the conclusion as some research studies were
published in other languages. Another potential bias is that
some research studies remained unpublished due to insig-
nificant results (publication bias). Other concerns included
modest quality of research studies, heterogeneity and small
sample sizes.
6. Conclusion
There is growing interest in understanding the significance of
massage therapy after cardiac surgery. Given the conflicting
results from published studies included in our review, there is
a need for higher methodological qualities of research studies
to create a strong evidence base for massage therapy. Addi-
tional research studies that validate massage therapy as
effective in improving post-operative outcomes and recovery
in cardiac surgery, particularly in China and India is
warranted.
Financial support
The authors received no financial support for the research,
authorship, and/or publication of this article.
Conflict of interest
There is no conflict of interest to declare.
Acknowledgement
We greatly acknowledge all the authors of the original
research articles that were found useful to write this review.
We also extend our thanks to the Manipal University's health
sciences library for providing facilities to retrieve relevant
studies from various online databases.
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