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Complementary Therapies in Clinical Practice 16 (2010) 7075

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice


journal homepage: www.elsevier.com/locate/ctnm

Effect of massage therapy on pain, anxiety, and tension after cardiac surgery:
A randomized study
Brent A. Bauer a, *, Susanne M. Cutshall b, Laura J. Wentworth c, Deborah Engen d, Penny K. Messner c,
Christina M. Wood e, Karen M. Brekke f, Ryan F. Kelly g, Thoralf M. Sundt, III g
a

Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
Department of Surgery, Mayo Clinic, Rochester, MN, USA
Department of Nursing, Mayo Clinic, Rochester, MN, USA
d
Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
e
Division of Biomedical Informatics and Biostatistics, Mayo Clinic, Rochester, MN, USA
f
Cardiovascular Research, Mayo Clinic, Rochester, MN, USA
g
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
b
c

a b s t r a c t
Keywords:
Alternative medicine
Analgesia
Postoperative pain
Relaxation

Integrative therapies such as massage have gained support as interventions that improve the overall
patient experience during hospitalization. Cardiac surgery patients undergo long procedures and
commonly have postoperative back and shoulder pain, anxiety, and tension. Given the promising effects
of massage therapy for alleviation of pain, tension, and anxiety, we studied the efcacy and feasibility of
massage therapy delivered in the postoperative cardiovascular surgery setting. Patients were randomized
to receive a massage or to have quiet relaxation time (control). In total, 113 patients completed the study
(massage, n 62; control, n 51). Patients receiving massage therapy had signicantly decreased pain,
anxiety, and tension. Patients were highly satised with the intervention, and no major barriers to
implementing massage therapy were identied. Massage therapy may be an important component of the
healing experience for patients after cardiovascular surgery.
2009 Elsevier Ltd. All rights reserved.

1. Introduction

Complementary and alternative medicine (CAM) therapies have


become a common part of healthcare for a number of Americans.1,2
Many CAM therapies specically target pain and anxiety, and it is
thus reasonable to question whether such therapies might help
address postoperative needs that are not fully accommodated by
conventional approaches. Massage therapy in particular appears to
be a reasonable CAM choice in the postoperative setting.
Extensive evaluation of massage therapy has shown that it can
effectively improve a number of outcomes.3 These improved
outcomes include reduced pain412; reduced anxiety4,5,1319;
reduced lymphedema20; increased plasma b-endorphins21;
decreased muscle tension, heart rate,22 blood pressure,23 and
galvanic skin response24; and increased skin temperature25 and
blood ow.26 Other reported ndings include improved sleep,27
improved patient-physician communication,28 and reduced
fatigue, nausea, and depression.5 For neonates in intensive care
units, massage therapy has improved weight gain, alertness, and
activity.15
Massage therapy efcacy has been studied in various patient
populations, including patients requiring hospitalization,5,29
patients in intensive care units,3033 and hospice patients.34 Other
research has focused on massage in the context of specic illnesses

Hundreds of thousands of patients undergo cardiovascular


surgery every year in the United States. Despite technical success
for most patients, clinically signicant morbidities such as physical pain, emotional pain, and anxiety are common. Indeed,
among the most difcult challenges in restoring patients to full
physical and emotional health is musculoskeletal pain, which is
often not fully alleviated pharmacologically. Periprocedural
anxiety is another considerable challenge that can delay wound
healing and decrease immune function. The associated costs can
be numerous; they include lost productivity, need for postoperative physical therapy, and prolongation of the recovery
period. Thus, novel approaches clearly are needed to help patients
recover from cardiovascular surgery and to help them manage in
the face of new challenges.

Abbreviations: CABG, coronary artery bypass graft; CAM, complementary and


alternative medicine.
* Corresponding author.
E-mail address: bauer.brent@mayo.edu (B.A. Bauer).
1744-3881/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctcp.2009.06.012

B.A. Bauer et al. / Complementary Therapies in Clinical Practice 16 (2010) 7075

or procedures, including patients with cancer,19,3539 hospitalization after acute myocardial infection,40 patients with dementia,41
preterm neonates,15,42 men positive for human immunodeciency
virus,43 patients undergoing abdominal surgery44 or bone marrow
transplantation,4 and patients recovering after cardiac surgery.45
The literature suggests that massage therapy can be provided
safely in the hospital setting and potentially has substantial clinical
benet. However, many studies examining the efcacy of massage
therapy have attempted to demonstrate a benet by using nonexperimental designs, anecdotal outcome measures, poor measurement tools, small sample sizes, no control groups, and
nonstandardized interventions. Dose level and frequency of
massage often are inconsistent. This lack of scientic rigor is
a common theme in critical reviews of the clinical effectiveness of
massage therapy.46,47
We designed the current study to overcome many of the challenges identied in prior investigations. The primary objective was
to evaluate the effect of two, 20-min massage therapy sessions on
patient-reported pain, anxiety, and tension after cardiac surgery.
The secondary objective was to evaluate the feasibility of integrating massage therapy into acute and postacute cardiovascular
surgical practices.
2. Methods
2.1. Inclusion and exclusion criteria
This study was approved by our institutional review board.
Eligible participants were scheduled to undergo coronary artery
bypass graft (CABG) surgery, valve repairs or replacements, or both
through a median sternotomy. Patients were approached preoperatively for participation in the study from November 3, 2006,
through February 14, 2008. We included only those who gave
consent and were medically able to participate in massage therapy
on postoperative days 2 and 4. Patients who had undergone
previous cardiac surgery, patients with chronic pain syndromes,
and patients with a history of psychosis were excluded from the
study. In addition, patients with prolonged bleeding or intubation
greater than 24 h also were excluded.

71

Massage Therapist with an occupational therapy background and


knowledge of the care of patients after cardiac surgery. Each integrative massage session consisted of the assessment (15 min),
which included comfortable positioning of the patient, and
massage with the hands (20 min) that focused on the areas of
primary concern as indicated by the patient.
A sign on the door alerted other healthcare providers or visitors
that a massage session was in progress. Music was offered and
played in the patients room, if desired. Patients sat at the edge of
the bed or in a chair or lay in bed supine or on one side. Positioning
depended on the patients preference, mobility, and tube and
equipment placement. Patients were clothed in hospital gowns,
and areas not massaged were covered with a sheet and blankets.
The therapist focused on using and adjusting massage techniques to help the patient release tension, promote scapular glides,
and regain normal movement. Massage techniques were selected
by the therapist and individualized on the basis of the patients
medical status, positioning tolerance, symptoms, and symptom
location. The massage incorporated techniques such as deep tissue
massage, neuromuscular techniques, trigger point therapy,
myofascial release, manual lymphatic drainage, reexology,
acupressure, and some Swedish massage techniques. The therapist
modied massage techniques to avoid a bruising pace or pressure,
to avoid a negative impact on low or high blood pressure and heart
rate, to not pull on the incision site, and to not push the patient
against something solid because of the sternotomy. Angle of the
massage stroke, pace, and amount of pressure were articulated
carefully. Massage was provided to the head, neck, shoulders, arms,
hands, back, legs, or feet, depending on the patients primary
concern.
2.3.2. Control therapy
For patients in the control arm, relaxation sessions occurred on
postoperative days 2 and 4. They continued receiving standard care
(eg, medication was administered) and were instructed to relax for
20 min while lying in bed or sitting in a chair. A sign was posted on
the door indicating a relaxation session was in progress. The patient
was offered dimmed lights.
2.4. Evaluation

2.2. Randomization
Patients were randomly assigned to 1 of 2 treatment arms:
massage therapy or standard care with quiet relaxation (control).
To assure balanced allocation throughout the course of the study,
we used a randomized block design with 55 blocks of 4 and 55
blocks of 2; these 110 blocks also were permuted into a random
order to ensure that patients were distributed evenly among
treatment arms (the difference in patient numbers for each arm
was always 2). Randomizing with mixed blocks and using cards in
sealed envelopes masked the administrators who enrolled patients.
To account for potentially nonrandom withdrawal from the study,
the randomization scheme was determined in advance for 300
patients, and enrollment continued until at least 50 patients in each
study arm had completed day 4 of treatment. The large number of
randomizations was determined in advance because we anticipated a high proportion of patients remaining intubated on day 2 or
withdrawing from the study because of high pain levels before the
rst intervention.
2.3. Intervention
2.3.1. Massage therapy
Integrative massage was provided on postoperative day 2 (the
day after surgery) and day 4. The massage was given by a Certied

Patients reported measures of pain, anxiety, tension, relaxation,


and overall satisfaction before and after interventions on days 2 and
4 and also on day 3 (a day without an intervention) to identify any
potential carryover effects from day 2 to day 3. Visual analog scales,
where 0 indicated none and 10 indicated most, were used for
outcome evaluation. For pain, anxiety, and tension, negative
changes indicated improvement, whereas for relaxation and
satisfaction, positive changes indicated improvement. Vital signs of
heart rate, blood pressure, and breaths per minute also were
collected by a study coordinator before and after each 20-min
session and on day 3. The amount of sleep and length of hospital
stay were recorded.
2.5. Sample size
Results of the pilot study indicated that a minimum of 50
patients in each group would have 80% power to detect a difference
of 1.6 points or more between the massage and standard care
groups. It also would be powered sufciently to detect a difference
of 1.3 points or more within a group when comparing measures
before and after therapy. These calculations assumed a signicance
level of a 0.05 and 2-sided statistical tests. Calculations were
performed using nQuery version 6.0 (Statistical Solutions, Saugus,
Massachusetts).

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B.A. Bauer et al. / Complementary Therapies in Clinical Practice 16 (2010) 7075

2.6. Statistical method


Data are described using summary statistics: mean  SD or
median (interquartile range) for continuous measures and count
(percent) for categorical variables. Patient characteristics and
baseline clinical variables were compared using the Wilcoxon rank
sum test or c2 test, as appropriate. Changes in vital signs were
compared between groups; linear regression was used to adjust for
pretreatment levels. Changes in pain, anxiety, tension, relaxation,
and satisfaction with care were compared within each group,
before and after treatment, using the Wilcoxon signed rank test.
These before-to-after changes between groups were compared
with linear regression models. Initially, models that adjusted only
for treatment group and respective pretreatment levels of pain,
tension, relaxation, and satisfaction with care were constructed,
and then multivariable models that additionally adjusted for age,
sex, and day-3 opioid use (when examining day-4 measurements)
were created. Opioid use within 1 day was compared between
treatment groups using Wilcoxon signed rank tests. Change in
amount of sleep from day 2 to day 3, and from day 3 to day 4, was
compared between treatment groups, adjusting for the earlier days
sleep time. Change in satisfaction with care from day 2 before
treatment to day 4 after treatment was compared between treatment groups with a multivariable linear regression model that also
adjusted for age, sex, and day-2 pretreatment satisfaction level.
Length of hospital stay was compared between groups using linear
regression, adjusting for age and sex. All tests were 2-sided, and
P-values less than .05 were considered statistically signicant.
Analysis was performed with SAS version 9.0 (SAS Institute, Cary,
North Carolina).
3. Results
3.1. Patients
In total, 295 patients scheduled for CABG surgery with or
without cardiac valve surgery were approached the day before the
procedure. Of these patients, 113 completed the trial; 62 received
massage therapy and 51 received standard care. Fig. 1 shows the
ow of participants through each stage of the trial. Baseline patient
characteristics were similar between the 2 groups (Table 1).
The most common areas of musculoskeletal discomfort were at
the medial biceps, the shoulder girdle (particularly the anterior
region), back of the neck, and between the shoulder blades. For
patients receiving massage therapy, most were supine, although
some preferred lying on their side or sitting in a chair on day 2. If
the patient requested a change to the side-lying position, the
request was accommodated. On day 4, patients showed no clear
positioning preference; patients chose side lying, sitting on the
edge of bed or in the chair, and laying supine with equal frequency.
3.2. Outcomes
Patients receiving massage therapy had signicantly less pain
(1.5  2.0, P < .001), anxiety (1.4  2.4, P < .001), and tension
(2.4  2.0, P < .001) on day 2 after the massage compared with
before the massage. Similarly, this same group also had signicantly less pain (1.5  1.7, P < .001), anxiety (1.7  2.2, P < .001),
and tension (2.2  2.2, P < .001) after the massage on day 4.
Patients who received standard care also had signicantly less
pain (0.8  1.8, P .003), anxiety (0.6  2.1, P .04), and tension
(1.0  3.1, P .008) on day 2 after the intervention. However, on
day 4, pain, anxiety, and tension levels were not signicantly
different after the standard care intervention than before the
intervention (data not shown).

Comparison between groups rst was performed after adjusting


only for respective pretreatment measures. On day 2, patients who
received a massage had signicantly improved tension levels (1.0,
P .006) than patients who received standard care. On day 4,
patients who received a massage had signicantly improved levels
of pain (1.0, P < .001), anxiety (1.3, P < .001), and tension (1.5,
P<.001) compared with patients who received standard care.
On day 3, patients were assessed to determine whether the
massage from the previous day had any carryover effects. When
day-3 data were compared with day-2 posttreatment values,
patients who had received a massage had signicant worsening of
pain (0.7  2.7, P .05), anxiety (0.7  2.4, P .03), and tension
(0.9  2.3, P .003). Patients receiving standard care did not have
signicant changes in any measures from day 2 to day 3 (data not
shown). However, when comparing patients who received massage
with those who received standard care, the change in pain (0.7,
P .08), anxiety (0.2, P .72), and tension (0.3, P .50) from day 2
to day 3 was not signicantly different.
Multivariable models of changes in pain, tension, and anxiety
were constructed for day 2 (comparing pretreatment and posttreatment levels), for day-2 posttreatment to day 3 (to identify any
carryover effect), and for day 4 (pretreatment to posttreatment).
These models were adjusted for age, sex, and the earlier of the 2
measurements (day-2 pretreatment, day-2 posttreatment, and day4 pretreatment, as applicable). Day-4 models were also adjusted for
use of opioid medications on day 3. Compared with patients
receiving standard care, patients who received massage therapy
had a signicantly greater improvement in day-4 levels of pain
(1.1, P < .001) and anxiety (1.2, P < .001), and they also showed
greater improvement in tension levels on day 2 (1.0, P .01) and
on day 4 (1.6, P < .001) (Table 2).
Opioid use was slightly greater in the massage group compared
with the standard care group only on day 3 (median difference,
5 mg; P .03) (Table 3). No signicant differences were noted
between groups for the change from day-2 pretreatment to day-4
posttreatment in overall satisfaction with the treatment (0.02  1.1
vs 0.5  1.5; P .44) or mean length of stay (8  3 vs 7  2 days;
P .18). Groups also were similar with regard to change in blood
pressure and heart rate from day-2 pretreatment to day-4 posttreatment. Compared with standard care patients, massage
patients had a signicantly greater decrease in respiratory rate on
day 2 (1.7, P .03) and on day 4 (1.2, P .05). Changes in hours of
sleep between day 2 to day 3 and day 3 to day 4 were not signicantly different between the 2 groups (Table 4). Allied health staff
did not report any problems incorporating massage therapy into
daily care routines.
4. Discussion
The ndings of the current study build on those of our pilot trial
and show that massage therapy is effective for reducing pain,
anxiety, and tension in patients after cardiac surgery. The program
that provided this care was implemented within the context of
a busy clinical service and did not disrupt workow. The therapy
was well received by patients and caregivers. These results, which
demonstrate how complementary therapy can be integrated into
clinical practice, suggest that further study of its effect on return to
wellness is warranted.
Although we observed a signicant reduction in patientreported pain in the massage intervention group, we did not
observe a corresponding reduction in the use of narcotic medication. This may have been partially due to considerable variation in
the opioid-prescribing practice of individual surgical teams. The
use of standing orders and protocol-based pain management
strategies may have obscured the effect of massage on individual

B.A. Bauer et al. / Complementary Therapies in Clinical Practice 16 (2010) 7075

73

Fig. 1. CONSORT ow diagram.

narcotic use. Finally, the apparent increase in opioid use on day 3 of


the massage intervention suggests that the timing of massage may
have been suboptimal.
We observed that day-2 massage increased pain on day 3; this
change may have been caused by the soft-tissue releases and
increased mobility after the rst massage, which subsequently
increased achiness and pain the following day. This conclusion

Table 1
Baseline patient characteristics (N 113).
Characteristic

Massage (n 62)

Standard care (n 51)

P-value

Age, y, mean (SD)


Men, No. (%)
Surgical procedure, No. (%)
CABG
Valve
CABG Valve

65 (12)
42 (68)

66 (14)
36 (71)

.33
.74
.38

17 (27)
31 (50)
14 (23)

10 (20)
24 (47)
17 (33)

Abbreviation: CABG, coronary artery bypass graft.

supports deferring massage until later in the hospital stay (day 3 or


4 instead of day 2). Such a deferral would also obviate the need for
the massage therapist to maneuver around multiple central intravenous lines and chest drainage tubes. Furthermore, patients often
were groggy on postoperative day 2, which minimized their ability
to receive maximal benet from the massage intervention. By days
3 and 4, many lines and tubes have been removed and patients are
more mobile. Interestingly, Ayurvedic medicine principles also
suggest deferring massage until bowel and bladder function have
resumed; this typically occurs on day 3 or 4.
The signicant reduction of anxiety and tension after massage
therapy is an important nding. Studies have repeatedly conrmed
that patients under stress have depressed immune function and
delayed wound healing,4850 and pain has been shown to delay
postsurgical healing.51 Thus, introducing a safe and relatively
inexpensive therapeutic modality such as massage into the postoperative care of patients after cardiac surgery may have substantial effects on outcomes such as infection rate and time to full
recovery. This study did not include a prolonged follow-up

74

B.A. Bauer et al. / Complementary Therapies in Clinical Practice 16 (2010) 7075

Table 2
Changes in pain, anxiety, tension, and relaxation after each intervention.
Outcome
measure
Pain
Day 2
Day 3c
Day 4
Anxiety
Day 2
Day 3c
Day 4
Tension
Day 2
Day 3c
Day 4
Relaxation
Day 2
Day 3c
Day 4

Table 4
Changes in vital signs, hours of sleep, and length of hospitalization.

Massagea

Standard carea

Estimated difference
P-valueb
between treatment groups

1.5 (2.0)
0.7 (2.7)
1.5 (1.7)

0.8 (1.8)
0.3 (2.8)
0.4 (1.4)

0.5
0.6
1.1

.10
.11
<.001

1.4 (2.4)
0.7 (2.4)
1.7 (2.2)

0.6 (2.1)
0.6 (2.9)
0.2 (1.8)

0.5
0.2
1.2

.09
.62
<.001

2.4 (2.0)
0.9 (2.3)
2.2 (2.2)

1.0 (3.0)
0.1 (3.2)
0.3 (2.0)

1.0
0.3
1.6

.01
.52
<.001

2.1 (3.2)
1.2 (3.1)
1.8 (2.2)

1.2 (3.5)
0.8 (3.8)
0.4 (2.1)

0.5
0.0
1.3

.27
>.99
<.001

Measures are visual analog scale values, where 0 none, 10 most. For pain,
anxiety, and tension, negative changes indicated improvement; for relaxation,
positive changes indicated improvement. Data are shown as mean (SD).
b
Linear regression models were used to calculate the difference in outcomes after
adjusting for pretreatment values, age, and sex. Day-4 models also adjusted for
medications administered on day 3.
c
Results were calculated by subtracting day-2 posttreatment scores from day 3
scores.

Characteristic

Diastolic blood
pressure, mm Hga
Day 2
Day 4
Systolic blood
pressure, mm Hga
Day 2
Day 4
Heart rate,
beats/mina
Day 2
Day 4
Respiratory rate,
breaths/mina
Day 2
Day 4
Amount of sleep, hb
Day 2 vs 3
Day 3 vs 4
Length of
hospitalization, dc
a
b
c

assessment in which wound healing, infections, and time to full


recovery could be evaluated. Such outcomes may be addressed in
future studies that include periodic follow-up assessments (eg, 1
month and 3 months after surgery).
Several theories have been proposed that describe the mechanisms underlying the effects of massage therapy. One is the gatecontrol theory of pain reduction, which suggests that massage
therapy has an analgesic effect.52 Another theory, albeit one with
inconsistent support, is that massage therapy benets are derived
from the parasympathetic response associated with decreased
cardiovascular activity, decreased production of stress hormones,
and feelings of calmness and well being.17 A third suggests that
manipulating and elongating the musculoskeletal system releases
tension from muscle bers and connective tissue.3 Future studies
investigating potential mechanisms of action of massage are
needed.
We acknowledge the limitations of the study. The chief limitation was the inability to mask participants to the treatment
method. However, we were able to control for the time that the
massage therapist spent with each patient. We also provided
a complementary massage to each patient in the control group
after all study data were collected; this was intended to reduce
any disappointment that might have resulted from being
randomized into the relaxation-only study arm. Finally, this study
was specic to patients who had undergone cardiac surgery, and
the results cannot necessarily be generalized to other surgical
patient groups.
In conclusion, massage therapy appears to be a useful method of
reducing pain, tension, and anxiety in patients recovering after
Table 3
Opioid use.
Postoperative day Massage, median (IQR)a Standard care, median (IQR)a P-valueb
Day 2
Day 3
Day 4

54 (3477)
24 (1656)
8 (115)

Abbreviation: IQR, interquartile range.


a
Opioid use is reported as mg/d.
b
Wilcoxon rank sum test.

47 (3274)
19 (742)
5 (020)

.38
.03
.39

Massage,
mean  SD

Standard
care,
mean  SD

Estimated
difference between
treatment groups

P-value

0.8  7.8
1.8  9.5

0.2  10.3
0.6  8.3

0.6
0.4

.70
.80

0.7  7.8
2.3  10.9

1.7  8.7
2.3  12.7

2.2
0.3

.16
.87

0.5  6.0
0.6  6.6

1.3  9.3
0.6  7.1

1.1
0.3

.42
.81

0.9  5.6
0.0  5.1

0.6  4.1
0.5  4.6

1.7
1.2

.03
.05

0.8  5.9
0.1  4.7
7.4  2.1

1.1  5.6
0.2  3.1
7.9  2.6

0.2
0.1
0.6

.81
.90
.18

Adjusted for pretreatment status.


Adjusted for day-2 and day-3 sleep time, respectively.
Adjusted for age and sex.

cardiac surgery. The optimal time to deliver massage therapy most


likely is after postoperative day 2. Planned future trials are required
to determine the optimal frequency, techniques, and duration of
massage therapy in the postoperative setting.
Conict of interest
None of the authors report any conict of interest with this
work.
Acknowledgements
This research was supported by the Mayo Clinic Sponsorship
Board, the Mayo Clinic Nursing Research Division, and a generous
donation from Richard J. and Sharon M. Mroek. We further
acknowledge the participation of the Healing Enhancement Team
members in assisting and supporting all efforts of the Healing
Enhancement Program. Perhaps this was excluded according to
Elsevier policy and if so, that is ne. If it was inadvertently dropped
somewhere in the process and could be added back in, that would
be most appreciated. Either way, we are happy to endorse the
current version.
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