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International Journal of Nursing Practice 2015; 21 (Suppl. 2), 32–37
ORIGINAL ARTICLE
Back massage intervention for relieving lower back pain in puerperal women: A randomized control trial study Hsiu-Jung Lee RN, MSN Vice Head Nurse, Department of Nursing, Taipei City Hospital-Heping Fuyou Branch, Taipei City, Taiwan
Yi-Li Ko RN, EdD Associate Professor, Department of Nursing, College of Medicine, Catholic Fu-Jen University, Taipei, Taiwan
Accepted for publication August 2013 Lee H-J, Ko Y-L. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 32–37 Back massage intervention for relieving lower back pain in puerperal women: A randomized control trial study This study evaluates the effectiveness of a back massage (BM) intervention in relieving lower back pain (LBP) in post-partum women.This is a randomized controlled trial study. Sixty normal spontaneous delivery women (response rate: 96.7%), who gave birth at our hospital, participated in this study from February to May of 2012. We randomly assigned 30 women to the experimental group and 30 women to the control group. During the 1 month post-partum period, the women in the experimental group received a BM for 5 consecutive days, whereas the women in the control group received routine care only. The LBP score was assessed according to a pain visual analog scale. After 5 days of intervention, the experimental group (n = 30) experienced significantly less LBP than did the control group (n = 30) (2.97 ± 1.71 vs. 4.43 ± 1.77, t = 3.26, P = 0.002). BM therapy can effectively reduce LBP during the first post-partum month. Additional studies are required to confirm the effects of BM therapy during extended post-partum periods. Key words: back massage, back pain reduction programme, low back pain, normal spontaneous delivery, post-partum.
INTRODUCTION Minor puerperant discomforts create difficulties for women, and for health-care providers to locate optimal strategies for assisting women to manage these discomforts is challenging. The management of symptoms relies on participant observations and the ability to individualize therapy. Knowledge of alternative complementary thera-
Correspondence: Yili Ko, Nursing Department, Jhongjheng Road,Sinjhuang Branch, New Taipei City 242, Taiwan. Email: [email protected] © 2015 Wiley Publishing Asia Pty Ltd
pies can assist health-care providers and women in selecting the most appropriate treatment. This study is part of a larger study that explores the strategies that Taiwanese women use to manage minor puerperant discomforts. Lower back pain (LBP) is a common post-partum symptom that can be easily neglected. Approximately 84–90% of post-partum women suffer from LBP, and consider it ‘an inevitable’ part of pregnancy, with nearly 40% of incidences lasting 6 months post-partum.1 LBP often appears in the lumbar or sacroiliac joints, and is characterized by soreness, tightness and pain in the lower back above the buttocks.2 During pregnancy, ligaments and joints soften doi:10.1111/ijn.12299
Back massage relieving back pain
to allow more space for the fetus and to facilitate the labour process. The enlarging uterus forces pregnant women to shift their centre of gravity forward (lumbar lordosis), thereby creating pressure on the pelvic and abdominal muscles. LBP in numerous pregnant women often results from a sedentary lifestyle.3 LBP can be so severe that even slight movement when changing positions can cause pain.2,4 Severe LBP can interfere with daily activities for up to 2 years after childbirth.5 Previous studies have investigated the effects of intervention programmes on perinatal women with LBP. A study evaluated the effects of a back pain relief programme (BPRP) on post-partum women in South Korea.6 The BPRP consists of a standardized educational protocol: pamphlets, lectures, DVDs describing exercises, daily exercise records and telephone calls. However, the results of that study showed that the programme did not reach statistical significance in reducing the pain intensity in women at 8 weeks post-partum. Ekdahl and Petersson demonstrated that acupuncture therapy for 6 weeks alleviated LBP in pregnant women, and raised their psychological well-being.7 Bastiaenen et al. conducted a controlled trial study to identify the effects of self-management techniques in women with pregnancyrelated LBP.8 Women in an intervention group attended a 12 week self-management education class to learn about symptom management, post-partum physical and psychosocial effects, lifestyle changes, and specific pain-reduction skills, such as exercises to stabilize the lumbar spine and pelvic girdle and establishing a fitness programme. The results of that study showed no significant differences in pain relief between the intervention and control groups. Taiwan, despite being a Westernized country, has traditional rituals derived from Chinese culture that deeply influence post-partum nursing care. Post-partum women in Taiwan widely practice the 1 month post-partum bedrest period (zuo yeuzi in Chinese) as an approach to rebuilding their health and strength,9 and insufficient bed rest is commonly believed to cause chronic LBP later in life.10 We evaluated the effects of back massage (BM) therapy in early post-partum women experiencing LBP. We hypothesized a reduction in LBP for women in the intervention group who underwent BM therapy compared with women in the control group.
METHODS Study design and setting This study was a randomized controlled trial that assigned LBP post-partum women randomly into intervention
33
(BM) and control groups (routine care). Randomized and grouped post-partum women with LBP were assigned to one or two groups by a computerized random numbers table, as follows: (i) in the BM group; and (ii) in the control group. Participants in the intervention group received 20 min of back massage once a day for five consecutive days from 5:00 pm to 9:00 pm. Sessions were administered by a certified massage therapist. The setting of the study was at one of the nine branches of the Taipei City Public Hospital of Taiwan, which specializes in obstetric and paediatric care. The average birth rate at this hospital (600 beds specialize in maternalnewborn field) is approximately 250–300 newborns per month. The postpartum maternity centre includes 40 beds. Subsequent to Taiwan’s society changes, one fourth of post-partum women prefer having their 1 month bed rest in a post-partum maternity centre rather than at home.11 According to the practice of the traditional month-long bed-rest period, women are not permitted to bathe, wash their hair or be outdoors to avoid exposure to cold air.12–15 The post-partum maternity centre, which provides facilities for the bed-rest period, is an environment similar to that of a five-star hotel, wherein hot, nourishing meals with Chinese medicine and private rooms for resting are provided, and obstetricians and nursing staff are present to care for the newborn and provide breastfeeding instructions to the mothers. Under the National Health Insurance policy, Taiwanese normal spontaneous delivery mothers are hospitalized for 3 days post-partum and are then usually discharged with their newborns on the fourth day post-partum; they are then directly admitted to the centres. There is no insurance coverage for this service, and post-partum women must pay the fee themselves. The fees range from NT$5000 to NT$7000 (US$1 is equal to NT$30) per day. The women decide the length of stay at the centres, and these typically average 21 days to receive the month-long ritualistic care.
Sample Women who participated in our study were recruited by a researcher, based on the order for their admittance to the post-partum maternity centre. Inclusion criteria included the following: (i) women aged between 20 and 45 years; (ii) term delivery and newborn weight over 2500 g; (iii) complaints of LBP symptoms as defined by a score of ≥ 1 on the pain visual analog scale (PVAS); and (iv) vaginal birth without post-partum complications. © 2015 Wiley Publishing Asia Pty Ltd
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H-J Lee and Y-L Ko
Description of the intervention Sixty-two participants met the inclusion criteria and were enrolled in the study: 31 participants were randomly assigned to the BM group, and 31 to the control group. Each group lost one participant (one participant receiving BM therapy, and the other having been discharged earlier). This resulted in 30 participants in each group. We developed an intervention protocol based on fundamental nursing skills and the findings by Chaitow and Fritz.2 In accordance with the protocol, we consulted the viewpoints of a Chinese physician on acupressure points along the kidney meridian in the back for relieving LBP: The points influence hormonal gland secretions and the reproductive system, stimulate the parasympathetic nervous system, increase blood circulation, reduce respiration and pulse, and enhance muscle tone. Three certified experts (specializing in therapeutic massage) reviewed the protocol, which was revised based on their recommendations. Each woman was asked to lie in a prone position. After body oil was applied, a massage therapist administered a 20 min reflexology session on each woman’s back. The massage techniques involved effleurage, kneading, acupressure and friction. The session was conducted once every evening for 5 consecutive days (post-partum days 9–13).
Data collection A consecutive sample was solicited from one postpartum centre in northern Taiwan. The researcher contacted each participant at the centre and explained the purpose and procedure of the study on the ninth day after admission to the post-partum centre. Once permission was obtained, mothers were assessed LBP by the PVAS. This scale consists of a 10 cm-long vertical line, where 0 cm indicates no pain and 10 cm indicates intolerable pain. The participants were asked to mark on the line the intensity of pain they experienced. The VAS is a convenient, easy and rapid measurement tool for measuring subjective pain. Its reliability and concurrent validity are considered optimal.16 Enrolment and data collection lasted for approximately 3 months, from February 2012 to May 2012.
Ethical considerations Ethical approval was obtained from the Ethical Committee of Taipei City Hospital-Heping Fuyou Branch © 2015 Wiley Publishing Asia Pty Ltd
(TCHIRB-1001205-E). Before data collection, written informed consent was obtained. The participants were informed that their decision to participate would not affect their rights to receiving care. They were also informed that they could withdraw from the study at any time during the intervention.
Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences, version 19 (SPSS Inc., Chicago, IL, USA), to evaluate the effectiveness of the BM therapy. We used a t-test to test the effects of the intervention.
RESULTS Characteristics of participants In total, 62 women were asked to participate in the study, 30 participants were assigned to the experimental group and the other 30 participants to the control group (Fig. 1). Their age ranged from 29 to 40 years. Of the 60 women, 75% (n = 45) had full-time jobs, 97% (n = 58) had a college education, 43% (n = 26) breastfed exclusively and 63.3% (n = 38) gave birth to a boy. Table 1 lists the characteristics of the participants.
Effects of BM therapy in managing LBP during the post-partum period Based on the responses of the 60 women, LBP usually occurred during the third trimester, and often persisted after delivery. Thirty-four (56.7%) participants selfreported LBP, and exhibited a mean LBP intensity of 4.9 on the PVAS (range, 1–8; Table 2). Table 2 shows that the mean intensity score on the VAS for the intervention group (5.02 ± 1.97) did not differ significantly from that of the control group (4.70 ± 1.80) before BM therapy (pretest). However, after 5 days of BM therapy, and at 14 days post-partum, LBP intensity was significantly lower for the intervention group than for the control group (P = 0.002).
DISCUSSION This intervention study is the first in Taiwan designed to manage post-partum LBP. It shows that BMs are an effective part of nursing intervention for relieving lumbar pain in post-partum women. The results show that, after 5 continuous days of BMs, the intensity of pain experienced by the intervention group was significantly lower than in the control group, according to the posttest (VAS score
Back massage relieving back pain
35
Figure 1. Consort diagram.
Table 1 Sociodemographic and obstetric characteristics of participants (N = 60) Variable
Age Education High College or above Occupation Homemaker Full-time occupation Parity Primipara Multipara Feeding Exclusive breast-feeding Mixed formula
All (N = 60)
33.70 ± 3.23 — 2 (3.3) 58 (96.7) — 15 (25.0) 45 (75.0) — 35 (58.3) 25 (41.7) — 26 (43.3) 34 (56.7)
Group Intervention (n = 30)
Control (n = 30)
33.97 ± 2.93 — 0 (0.0) 30 (100) — 7 (23.3) 23 (76.7) — 17 (56.7) 13 (43.3) — 13 (43.3) 17 (56.7)
33.43 ± 3.54 — 2 (6.7) 28 (93.3) — 8 (26.7) 22 (73.3) — 18 (60.0) 12 (40.0) — 13 (43.3) 17 (56.7)
t/χ2
P-value
0.64 — — — — — — — — — 0.00 — —
0.527 0.608 — — 0.979 — — 1.000 — — 1.000 — —
* P < 0.05, ** P < 0.01, *** P < 0.001.
decreased from 5.02 to 2.97 points). This result is consistent with previous studies. Bell evaluated the effectiveness of massage therapy in increasing the range of motion, pain reduction and assisting in healing women with LBP.17 Buttagat et al. evaluated the effectiveness of traditional Thai massage (TTM) therapy on women with LBP.18 They randomly selected 36 women who were assigned to either receive a 30 min session of a TTM or bed rest. Their findings showed that the women received TTM who had less pain intensity, anxiety and muscle tension; and for
women with LBP, the degree of pain declined significantly (the VAS for LBP decreased from 4.7 points in the pretest to 2.3 points in the posttest). Similarly, Dion et al. administered BM therapy and neck and shoulder massage therapy on patients who had undergone pleural effusion surgery, and their results showed a significant reduction in LBP in these patients (the VAS for LBP decreased from 5.5 points in the pretest to 2.1 points in the posttest).19 Thus, BM can block pain messages and reduce the intensity of LBP. © 2015 Wiley Publishing Asia Pty Ltd
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H-J Lee and Y-L Ko
Table 2 LBP score for intervention and control group participants before receiving BM therapy Variable
PVAS (pre-test) PVAS (posttest)
All (N = 60)
4.86 ± 1.88 3.70 ± 1.88
t‡ (P)
Group Intervention (n = 30) M ± SD
Control (n = 30) M ± SD
5.02 ± 1.97 2.97 ± 1.71 t† = 11.71 (P < 0.001***)
4.70 ± 1.80 4.43 ± 1.77 t† = 1.29 (P = 0.208)
3.26 (P = .002**)
** P < .01, *** P < .001. † paired-sample t-test. ‡ independent-sample t-test. BM, back massage; LBP, lower back pain; PVAS, pain visual analog scale.
The study has several limitations: 1. The participants were all from one post-partum centre in a rural area, and, therefore, the results might not be representative of other areas. 2. If the participants were interested in massage or held positive view of it before the study, this was likely to affect the result of the study. 3. The BM might provide a feeling of relaxation, causing participants to feel less pain, consciously and unconsciously driven by the hope of achieving clinical improvement. 4. The time frame for our study was only 5 days, so we cannot predict whether the therapeutic effect would be maintained over a longer period. 5. In our study, LBP was measured by the simple PVAS; future studies can consider other reliable instruments such as the Brief Pain Inventory Taiwan Form or the American Pain Society pain control questionnaire, both of which can be used to obtain more details on pain symptoms and pain that influence women’s daily lives.20,21 Certain barriers for nurses implementing the intervention also exist in this research. Although a qualified massage therapist (charging US$10 for each 20 min session) provided the BM therapy and effectively relieved LBP, providing women with free BM therapy for coping with LBP is difficult. However, health-care providers, including nurses and midwives, should instruct perinatal clients on physical activity methods that help maintain a neutral spine, which can prevent unnecessary mechanical stress on the lower back. A properly designed fitness programme, including yoga, Pilates and moderate-tointense aerobic workouts, can increase muscle and © 2015 Wiley Publishing Asia Pty Ltd
soft-tissue strength; therefore, such a programme should be advocated.
CONCLUSION This study, which is the first of its kind, examined the effect of BM on women who self-reported post-partum LBP, and found that a BM intervention can effectively relieve LBP. Nurses and midwives should assess LBP symptoms as an integral component of prenatal counselling. In addition, nurses interested in therapeutic massage should be encouraged to obtain training in this technique, and teaching the family of post-partum women should also be integrated into routine care. Additional studies are necessary to confirm the effects of BM therapy postpartum. Longitudinal follow-up studies are required to further investigate the ongoing effects of this type of intervention. Future studies might benefit from approaching multidisciplinary workers as a team, thereby providing accurate, individualized and distinct interventions.
ACKNOWLEDGEMENT The authors would like to thank the 60 women who participated in this study.
REFERENCES 1 Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: Prevalence and risk factors. Spine 2005; 30: 983–991. 2 Chaitow L, Fritz S. A Massage Therapist’s Guide to Lower Back and Pelvic Pain. Oxford, UK: Churchill Livingstone, 2007.
Back massage relieving back pain
3 Noble E. Essential Exercise for the Childbearing Year: A Guide to Health and Comfort before and after Your Baby is Born, 4th edn. Raul Artal. Waltham: New Life Images, 1995. 4 To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstetricia et Gynecologica Scandinavica 2003; 82: 1086–1091. 5 Röst CC, Jacqueline J, Kaiser A, Verhagen AP, Koes BW. Prognosis of women with pelvic pain during pregnancy: A long-term follow-up study. Acta Obstetricia et Gynecologica Scandinavica2006; 85: 771–777. 6 Oh HE, Lee YS, Shim MJ, Kim JS. Effects of a postpartum back pain relief program for Korean women. Taehan Kanho Hakhoe Chi (Journal of Korean Academy of Nursing) 2007; 37: 163–170. 7 Ekdahl L, Petersson K. Acupuncture treatment of pregnant women with low back and pelvic pain-an intervention study. Scandinavian Journal of Caring Sciences 2009; 24: 175– 182. doi: 10.111/j.1471-6712.2009.000704.x. 8 Bastiaenen CHG, Bie RAD, Vlaeyen JWS et al. Long-term effectiveness and costs of brief self-management intervention in women with pregnancy-related low back pain after delivery. BMC Pregnancy and Childbirth 2008; 8: 1471–2393. doi: 10.1186/1471-2393/8/19. 9 Wang X, Wang Y, Wang J. A population-based survey of women’s traditional postpartum behaviors in Northern China. Midwifery 2008; 24: 238–245. 10 Wang X, Wang Y, Zhou S, Wang J, Wang J. Women’s postpartum practices and chronic pain in rural china. Maternal and Child Health Journal 2009; 13: 206–212. 11 Chien LY, Chou YH, Ko YL, Lee CF. Health-related quality of life among 3 to 4-year-old children with very low birthweight. Journal of Advanced Nursing 2006; 56: 9–16. 12 Cheung NF. Chinese ‘zuo yeuzi’ (sitting in for the first month of the postnatal period) in Scotland. Midwifery 1997; 13: 55–65.
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13 Holroyd E, Katie FK, Chun LS, Ha SW. Doing the month’: An exploration of postpartum practices in Chinese women. Health Care for Women International 1997; 18: 301–313. 14 Wang X, Wang J, Ou L, Wang Y. The study of woman’s behavior and diet during the puerperium in Laishui County. Chinese Journal of Behavioral Medical Science 2000; 9: 29– 30. 15 Steinbrg S. Child birthing research: A transcultural review. Social Science and Medicine 1996; 12: 1765–1784. 16 Olaogun MOB, Adedoyin RA, Anifaloba RO. Reliability and concurrent validity of visual analogue scale and modified verbal rating scales of pain assessment in adult patients with knee osteoarthritis in Nigeria. South African Journal of Physiotherapy 2003; 59: 12–15. 17 Bell J. Massage therapy helps to increase range of motion, decrease pain and assist in healing a client with low back pain and sciatica symptoms. Journal of Bodywork and Movement Therapies 2008; 12: 281–289. 18 Buttagat V, Eungpinichpong W, Chatchawan U, Kharmwan S. The immediate effects of traditional thai massage on heart rate variability and stress-related parameters in patients with back pain associated with myofascial trigger points. Journal of Bodywork and Movement Therapies. 2011; 15: 15– 23. 19 Dion L, Rodgers N, Cutshall SM, Cordes ME, Bauer B, Cassivi SD. Effect of massage on pain management for thoracic surgery patients. International Journal of Therapeutic Massage and Bodywork 2011; 4: 2–6. 20 Wang XS, Mendosa TR, Gao SZ, Cleeland CS. The Chinese Version of the Brief Pain Inventory (BPI-C): Its development and use in a study of cancer pain. Pain 1996; 67: 407–416. 21 Li SZ, Chang WY, Lu MS, Lin CC, Chen ML. Development and evaluation of the effectiveness of nursing standards for pain management for cancer patients. New Taipei Journal of Nursing 2006; 8: 33–44.
© 2015 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21 (Suppl. 2), 32–37
ORIGINAL ARTICLE
Back massage intervention for relieving lower back pain in puerperal women: A randomized control trial study Hsiu-Jung Lee RN, MSN Vice Head Nurse, Department of Nursing, Taipei City Hospital-Heping Fuyou Branch, Taipei City, Taiwan
Yi-Li Ko RN, EdD Associate Professor, Department of Nursing, College of Medicine, Catholic Fu-Jen University, Taipei, Taiwan
Accepted for publication August 2013 Lee H-J, Ko Y-L. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 32–37 Back massage intervention for relieving lower back pain in puerperal women: A randomized control trial study This study evaluates the effectiveness of a back massage (BM) intervention in relieving lower back pain (LBP) in post-partum women.This is a randomized controlled trial study. Sixty normal spontaneous delivery women (response rate: 96.7%), who gave birth at our hospital, participated in this study from February to May of 2012. We randomly assigned 30 women to the experimental group and 30 women to the control group. During the 1 month post-partum period, the women in the experimental group received a BM for 5 consecutive days, whereas the women in the control group received routine care only. The LBP score was assessed according to a pain visual analog scale. After 5 days of intervention, the experimental group (n = 30) experienced significantly less LBP than did the control group (n = 30) (2.97 ± 1.71 vs. 4.43 ± 1.77, t = 3.26, P = 0.002). BM therapy can effectively reduce LBP during the first post-partum month. Additional studies are required to confirm the effects of BM therapy during extended post-partum periods. Key words: back massage, back pain reduction programme, low back pain, normal spontaneous delivery, post-partum.
INTRODUCTION Minor puerperant discomforts create difficulties for women, and for health-care providers to locate optimal strategies for assisting women to manage these discomforts is challenging. The management of symptoms relies on participant observations and the ability to individualize therapy. Knowledge of alternative complementary thera-
Correspondence: Yili Ko, Nursing Department, Jhongjheng Road,Sinjhuang Branch, New Taipei City 242, Taiwan. Email: [email protected] © 2015 Wiley Publishing Asia Pty Ltd
pies can assist health-care providers and women in selecting the most appropriate treatment. This study is part of a larger study that explores the strategies that Taiwanese women use to manage minor puerperant discomforts. Lower back pain (LBP) is a common post-partum symptom that can be easily neglected. Approximately 84–90% of post-partum women suffer from LBP, and consider it ‘an inevitable’ part of pregnancy, with nearly 40% of incidences lasting 6 months post-partum.1 LBP often appears in the lumbar or sacroiliac joints, and is characterized by soreness, tightness and pain in the lower back above the buttocks.2 During pregnancy, ligaments and joints soften doi:10.1111/ijn.12299
Back massage relieving back pain
to allow more space for the fetus and to facilitate the labour process. The enlarging uterus forces pregnant women to shift their centre of gravity forward (lumbar lordosis), thereby creating pressure on the pelvic and abdominal muscles. LBP in numerous pregnant women often results from a sedentary lifestyle.3 LBP can be so severe that even slight movement when changing positions can cause pain.2,4 Severe LBP can interfere with daily activities for up to 2 years after childbirth.5 Previous studies have investigated the effects of intervention programmes on perinatal women with LBP. A study evaluated the effects of a back pain relief programme (BPRP) on post-partum women in South Korea.6 The BPRP consists of a standardized educational protocol: pamphlets, lectures, DVDs describing exercises, daily exercise records and telephone calls. However, the results of that study showed that the programme did not reach statistical significance in reducing the pain intensity in women at 8 weeks post-partum. Ekdahl and Petersson demonstrated that acupuncture therapy for 6 weeks alleviated LBP in pregnant women, and raised their psychological well-being.7 Bastiaenen et al. conducted a controlled trial study to identify the effects of self-management techniques in women with pregnancyrelated LBP.8 Women in an intervention group attended a 12 week self-management education class to learn about symptom management, post-partum physical and psychosocial effects, lifestyle changes, and specific pain-reduction skills, such as exercises to stabilize the lumbar spine and pelvic girdle and establishing a fitness programme. The results of that study showed no significant differences in pain relief between the intervention and control groups. Taiwan, despite being a Westernized country, has traditional rituals derived from Chinese culture that deeply influence post-partum nursing care. Post-partum women in Taiwan widely practice the 1 month post-partum bedrest period (zuo yeuzi in Chinese) as an approach to rebuilding their health and strength,9 and insufficient bed rest is commonly believed to cause chronic LBP later in life.10 We evaluated the effects of back massage (BM) therapy in early post-partum women experiencing LBP. We hypothesized a reduction in LBP for women in the intervention group who underwent BM therapy compared with women in the control group.
METHODS Study design and setting This study was a randomized controlled trial that assigned LBP post-partum women randomly into intervention
33
(BM) and control groups (routine care). Randomized and grouped post-partum women with LBP were assigned to one or two groups by a computerized random numbers table, as follows: (i) in the BM group; and (ii) in the control group. Participants in the intervention group received 20 min of back massage once a day for five consecutive days from 5:00 pm to 9:00 pm. Sessions were administered by a certified massage therapist. The setting of the study was at one of the nine branches of the Taipei City Public Hospital of Taiwan, which specializes in obstetric and paediatric care. The average birth rate at this hospital (600 beds specialize in maternalnewborn field) is approximately 250–300 newborns per month. The postpartum maternity centre includes 40 beds. Subsequent to Taiwan’s society changes, one fourth of post-partum women prefer having their 1 month bed rest in a post-partum maternity centre rather than at home.11 According to the practice of the traditional month-long bed-rest period, women are not permitted to bathe, wash their hair or be outdoors to avoid exposure to cold air.12–15 The post-partum maternity centre, which provides facilities for the bed-rest period, is an environment similar to that of a five-star hotel, wherein hot, nourishing meals with Chinese medicine and private rooms for resting are provided, and obstetricians and nursing staff are present to care for the newborn and provide breastfeeding instructions to the mothers. Under the National Health Insurance policy, Taiwanese normal spontaneous delivery mothers are hospitalized for 3 days post-partum and are then usually discharged with their newborns on the fourth day post-partum; they are then directly admitted to the centres. There is no insurance coverage for this service, and post-partum women must pay the fee themselves. The fees range from NT$5000 to NT$7000 (US$1 is equal to NT$30) per day. The women decide the length of stay at the centres, and these typically average 21 days to receive the month-long ritualistic care.
Sample Women who participated in our study were recruited by a researcher, based on the order for their admittance to the post-partum maternity centre. Inclusion criteria included the following: (i) women aged between 20 and 45 years; (ii) term delivery and newborn weight over 2500 g; (iii) complaints of LBP symptoms as defined by a score of ≥ 1 on the pain visual analog scale (PVAS); and (iv) vaginal birth without post-partum complications. © 2015 Wiley Publishing Asia Pty Ltd
34
H-J Lee and Y-L Ko
Description of the intervention Sixty-two participants met the inclusion criteria and were enrolled in the study: 31 participants were randomly assigned to the BM group, and 31 to the control group. Each group lost one participant (one participant receiving BM therapy, and the other having been discharged earlier). This resulted in 30 participants in each group. We developed an intervention protocol based on fundamental nursing skills and the findings by Chaitow and Fritz.2 In accordance with the protocol, we consulted the viewpoints of a Chinese physician on acupressure points along the kidney meridian in the back for relieving LBP: The points influence hormonal gland secretions and the reproductive system, stimulate the parasympathetic nervous system, increase blood circulation, reduce respiration and pulse, and enhance muscle tone. Three certified experts (specializing in therapeutic massage) reviewed the protocol, which was revised based on their recommendations. Each woman was asked to lie in a prone position. After body oil was applied, a massage therapist administered a 20 min reflexology session on each woman’s back. The massage techniques involved effleurage, kneading, acupressure and friction. The session was conducted once every evening for 5 consecutive days (post-partum days 9–13).
Data collection A consecutive sample was solicited from one postpartum centre in northern Taiwan. The researcher contacted each participant at the centre and explained the purpose and procedure of the study on the ninth day after admission to the post-partum centre. Once permission was obtained, mothers were assessed LBP by the PVAS. This scale consists of a 10 cm-long vertical line, where 0 cm indicates no pain and 10 cm indicates intolerable pain. The participants were asked to mark on the line the intensity of pain they experienced. The VAS is a convenient, easy and rapid measurement tool for measuring subjective pain. Its reliability and concurrent validity are considered optimal.16 Enrolment and data collection lasted for approximately 3 months, from February 2012 to May 2012.
Ethical considerations Ethical approval was obtained from the Ethical Committee of Taipei City Hospital-Heping Fuyou Branch © 2015 Wiley Publishing Asia Pty Ltd
(TCHIRB-1001205-E). Before data collection, written informed consent was obtained. The participants were informed that their decision to participate would not affect their rights to receiving care. They were also informed that they could withdraw from the study at any time during the intervention.
Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences, version 19 (SPSS Inc., Chicago, IL, USA), to evaluate the effectiveness of the BM therapy. We used a t-test to test the effects of the intervention.
RESULTS Characteristics of participants In total, 62 women were asked to participate in the study, 30 participants were assigned to the experimental group and the other 30 participants to the control group (Fig. 1). Their age ranged from 29 to 40 years. Of the 60 women, 75% (n = 45) had full-time jobs, 97% (n = 58) had a college education, 43% (n = 26) breastfed exclusively and 63.3% (n = 38) gave birth to a boy. Table 1 lists the characteristics of the participants.
Effects of BM therapy in managing LBP during the post-partum period Based on the responses of the 60 women, LBP usually occurred during the third trimester, and often persisted after delivery. Thirty-four (56.7%) participants selfreported LBP, and exhibited a mean LBP intensity of 4.9 on the PVAS (range, 1–8; Table 2). Table 2 shows that the mean intensity score on the VAS for the intervention group (5.02 ± 1.97) did not differ significantly from that of the control group (4.70 ± 1.80) before BM therapy (pretest). However, after 5 days of BM therapy, and at 14 days post-partum, LBP intensity was significantly lower for the intervention group than for the control group (P = 0.002).
DISCUSSION This intervention study is the first in Taiwan designed to manage post-partum LBP. It shows that BMs are an effective part of nursing intervention for relieving lumbar pain in post-partum women. The results show that, after 5 continuous days of BMs, the intensity of pain experienced by the intervention group was significantly lower than in the control group, according to the posttest (VAS score
Back massage relieving back pain
35
Figure 1. Consort diagram.
Table 1 Sociodemographic and obstetric characteristics of participants (N = 60) Variable
Age Education High College or above Occupation Homemaker Full-time occupation Parity Primipara Multipara Feeding Exclusive breast-feeding Mixed formula
All (N = 60)
33.70 ± 3.23 — 2 (3.3) 58 (96.7) — 15 (25.0) 45 (75.0) — 35 (58.3) 25 (41.7) — 26 (43.3) 34 (56.7)
Group Intervention (n = 30)
Control (n = 30)
33.97 ± 2.93 — 0 (0.0) 30 (100) — 7 (23.3) 23 (76.7) — 17 (56.7) 13 (43.3) — 13 (43.3) 17 (56.7)
33.43 ± 3.54 — 2 (6.7) 28 (93.3) — 8 (26.7) 22 (73.3) — 18 (60.0) 12 (40.0) — 13 (43.3) 17 (56.7)
t/χ2
P-value
0.64 — — — — — — — — — 0.00 — —
0.527 0.608 — — 0.979 — — 1.000 — — 1.000 — —
* P < 0.05, ** P < 0.01, *** P < 0.001.
decreased from 5.02 to 2.97 points). This result is consistent with previous studies. Bell evaluated the effectiveness of massage therapy in increasing the range of motion, pain reduction and assisting in healing women with LBP.17 Buttagat et al. evaluated the effectiveness of traditional Thai massage (TTM) therapy on women with LBP.18 They randomly selected 36 women who were assigned to either receive a 30 min session of a TTM or bed rest. Their findings showed that the women received TTM who had less pain intensity, anxiety and muscle tension; and for
women with LBP, the degree of pain declined significantly (the VAS for LBP decreased from 4.7 points in the pretest to 2.3 points in the posttest). Similarly, Dion et al. administered BM therapy and neck and shoulder massage therapy on patients who had undergone pleural effusion surgery, and their results showed a significant reduction in LBP in these patients (the VAS for LBP decreased from 5.5 points in the pretest to 2.1 points in the posttest).19 Thus, BM can block pain messages and reduce the intensity of LBP. © 2015 Wiley Publishing Asia Pty Ltd
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H-J Lee and Y-L Ko
Table 2 LBP score for intervention and control group participants before receiving BM therapy Variable
PVAS (pre-test) PVAS (posttest)
All (N = 60)
4.86 ± 1.88 3.70 ± 1.88
t‡ (P)
Group Intervention (n = 30) M ± SD
Control (n = 30) M ± SD
5.02 ± 1.97 2.97 ± 1.71 t† = 11.71 (P < 0.001***)
4.70 ± 1.80 4.43 ± 1.77 t† = 1.29 (P = 0.208)
3.26 (P = .002**)
** P < .01, *** P < .001. † paired-sample t-test. ‡ independent-sample t-test. BM, back massage; LBP, lower back pain; PVAS, pain visual analog scale.
The study has several limitations: 1. The participants were all from one post-partum centre in a rural area, and, therefore, the results might not be representative of other areas. 2. If the participants were interested in massage or held positive view of it before the study, this was likely to affect the result of the study. 3. The BM might provide a feeling of relaxation, causing participants to feel less pain, consciously and unconsciously driven by the hope of achieving clinical improvement. 4. The time frame for our study was only 5 days, so we cannot predict whether the therapeutic effect would be maintained over a longer period. 5. In our study, LBP was measured by the simple PVAS; future studies can consider other reliable instruments such as the Brief Pain Inventory Taiwan Form or the American Pain Society pain control questionnaire, both of which can be used to obtain more details on pain symptoms and pain that influence women’s daily lives.20,21 Certain barriers for nurses implementing the intervention also exist in this research. Although a qualified massage therapist (charging US$10 for each 20 min session) provided the BM therapy and effectively relieved LBP, providing women with free BM therapy for coping with LBP is difficult. However, health-care providers, including nurses and midwives, should instruct perinatal clients on physical activity methods that help maintain a neutral spine, which can prevent unnecessary mechanical stress on the lower back. A properly designed fitness programme, including yoga, Pilates and moderate-tointense aerobic workouts, can increase muscle and © 2015 Wiley Publishing Asia Pty Ltd
soft-tissue strength; therefore, such a programme should be advocated.
CONCLUSION This study, which is the first of its kind, examined the effect of BM on women who self-reported post-partum LBP, and found that a BM intervention can effectively relieve LBP. Nurses and midwives should assess LBP symptoms as an integral component of prenatal counselling. In addition, nurses interested in therapeutic massage should be encouraged to obtain training in this technique, and teaching the family of post-partum women should also be integrated into routine care. Additional studies are necessary to confirm the effects of BM therapy postpartum. Longitudinal follow-up studies are required to further investigate the ongoing effects of this type of intervention. Future studies might benefit from approaching multidisciplinary workers as a team, thereby providing accurate, individualized and distinct interventions.
ACKNOWLEDGEMENT The authors would like to thank the 60 women who participated in this study.
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