Original Article Foot Massage: Effectiveness on Postoperative Pain in Breast Surgery Patients ---
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Meral Ucuzal, PhD,* and Nevin Kanan, PhD†
ABSTRACT:
Received September 3, 2011; Revised February 25, 2012; Accepted March 6, 2012.
The aim of this study was to determine the effect of foot massage on pain after breast surgery, and provide guidance for nurses in nonpharmacologic interventions for pain relief. This was a quasiexperimental study with a total of 70 patients who had undergone breast surgery (35 in the experimental group and 35 in the control group). Patients in the control group received only analgesic treatment, whereas those in the experimental group received foot massage in addition to analgesic treatment. Patients received the first dose of analgesics during surgery. As soon as patients came from the operating room, they were evaluated for pain severity. Patients whose pain severity scored $4 according to the Short-Form McGill Pain Questionnaire were accepted into the study. In the experimental group, pain and vital signs (arterial blood pressure, pulse, and respiration) were evaluated before foot massage at the time patients complained about pain (time 0) and then 5, 30, 60, 90, and 120 minutes after foot massage. In the control group, pain and vital signs were also evaluated when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. A patient information form was used to collect descriptive characteristics data of the patients, and the Short-Form McGill Pain Questionnaire was used to determine pain severity. Data were analyzed for frequencies, mean, standard deviation, chi-square, Student t, Pillai trace, and Bonferroni test. The results of the statistical analyses showed that patients in the experimental group experienced significantly less pain (p # .001). Especially notable, patients in the experimental group showed a decrease in all vital signs 5 minutes after foot massage, but patients in the control group showed increases in vital signs except for heart rate at 5 minutes. The data obtained showed that foot massage in breast surgery patients was effective in postoperative pain management. Ó 2012 by the American Society for Pain Management Nursing
1524-9042/$36.00 Ó 2012 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.03.001
Breast cancer remains one of the most important health problems for women. The World Health Organization (WHO) reports that an average of 460,000 people died of breast cancer in the world in 2008 (WHO, 2011). To treat breast cancer, the first
From the *Malatya School of Health, Inonu University, Malatya, Turkey; † Faculty of Nursing, Istanbul University, Istanbul, Turkey. Address correspondence to Meral Ucuzal, PhD, Malatya School of Health, Inonu University, Malatya, Turkey. E-mail: meral.ucuzal@inonu. edu.tr
Pain Management Nursing, Vol -, No - (--), 2012: pp 1-8
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stage of treatment is surgical intervention, especially in patients without distant metastasis. All breast surgery patients experience different levels of pain according to the type of surgery (Akyolcu, 2008; Dirksen, 2004). Qualified postoperative pain control has an important impact on the success of surgical intervention (Dirksen, 2004). Today, however, inadequacies in the treatment and care of postoperative pain continue, despite increases in knowledge about pain pathophysiology, the availability of new drugs, and new developments in methods of drug application (Mac Lellan, 2004; Smith, 2004). Active participation of surgical nurses in the care and treatment of pain, in line with a multidisciplinary team approach, is possible if they are informed on the control of pain through pharmacologic and nonpharmacologic methods and reflect this knowledge in their practices. It should be noted that nonpharmacologic methods should be used to increase the impact of analgesics, but should not be used in their place (Yavuz, 2006). Massage has been used in various cultures and in different styles to control pain for 3000 years (Hayes & Cox, 1999; Quattrin, Zanini, Buchini, Turello, Annunziata, Vidotti, Colombatti, & Brusaferro, 2006). Massage has formed an important part of traditional medicine, and is seen as of value, especially in Eastern countries, as a healing method that has experienced ascents and descents in popularity for centuries. Massage became especially prevalent in Europe during the Renaissance. It is experiencing a rise in its popularity with the demands of patients for special care and the increased interest in alternative therapies (Pienkowski, 2001; Wieting, Andary, Holmes, Rechtien, & Zimmerman, 2005). This circumstance has also led to an increased number of studies to determine the effectiveness and reliability of massage techniques and other nonpharmacologic methods, their effects on patient satisfaction, and their place in nursing practices (Faurot, Gaylord, & Mann, 2007; Grealish, Lomasney, & Whiteman, 2000). The mechanism by which massage decreases pain is explained by the theory of gate control. According to this theory, suggested by Melzack in 1965, fibers of thick tactile sense (A-alpha and A-beta) are faster than the thin fibers (A-delta and C) that transmit the sensation of pain. In this context, the mechanoreceptors and fibers of tactile sense that exist on the skin, and are stimulated through massage, stimulate the substantia gelatinosa cells (the gate closes) and lead to the inhibition of signal transmission to T cells, thus preventing the sensation of pain (Sarıo glu & Dinc¸er 2003; Tuna, 2004). When cells of the substantia gelatinosa are stimulated, they secrete endorphins
called endogenous opioids. Endorphins prevent the secretion of substance p, which plays a role in the transmission of pain, and blocks the transition of pain stimuli (Kanbir, 2005; Pienkowski, 2001; Tuna, 2004). Because foot massage can be applied in a short time and easily without changing the position of the patient, it is a type of massage that is frequently used in pain control (Grealish et al., 2000; Hayes & Cox, 1999). According to the gate control theory of Melzack, the high density of mechanoceptors in the centers of tactile sensory fibers in the hands and feet, which are able to block sensations of pain when they are stimulated, is the reason these sites are preferred (Can, 2012; Wang & Keck, 2004). In the literature, there have been studies to determine the effects of foot massage on pain sensation after various surgical interventions, including laparoscopic sterilization (Hulme, Waterman, & Hillier, 1999), cardiac surgery (Hattan, King, & Griffiths, 2002), abdominal surgery (Kim & Park, 2002), and cesarean section € (Degirmen, Ozerdogan, Sayıner, K€ o¸s geroglu, & Ayrancı, 2010). The present research was intended to determine the effects of foot massage on postoperative pain control in breast surgery patients. The following hypotheses were tested in the research: H0: There is no difference in the postoperative pain severity of breast surgery patients between those receiving foot massage and those who do not. H1: Postoperative breast surgery patients receiving foot massage will have less pain than postoperative breast surgery patients without foot massage.
METHODS Study Design and Sample Selection This research was planned as a quasiexperimental study to determine the effects of foot massage on postoperative pain control in breast surgery patients. The research was carried out in the general surgery department breast service of a university hospital, in Istanbul, Turkey, from February 2007 to April 2008. Patients who had undergone excision of the mass and sentinel lymph node biopsy (E-SLNB), excision of the mass and axillary lymph node dissection (E-ALND), simple mastectomy (BM), and modified radical mastectomy (MRM) were included in the study. Seventy patients (35 in the experimental group, and 35 in the control group) as appropriate to research criteria were chosen in the sample. The sample size was calculated by power analysis. It was calculated that ten patients were required in each group to achieve a difficulty value of 0.80, error level of 0.05, effect level of 0.25, and a difference of
Effectiveness of Foot Massage on Postoperative Pain
3
2.0 points. However, in consideration of the minimum number of patients that are recommended for experimental studies, 35 patients each were chosen for the experimental and control groups. The samples of patients invited to join the study consisted of those who were $18 years old, had no difficulties with visual/verbal/audible communication or mental disability that would hinder understanding of the information provided and expressing her pain status accurately, underwent E-SLNB, E-ALND, BM, or MRM with general anesthesia, were not implanted with a breast prothesis during surgery, had no problems with hypertension, did not require blood pressure be taken on the foot, expressed that they had ‘‘medium’’ or ‘‘severe’’ pain levels (pain severity of $4) after surgery, did not experience any complications (severe bleeding, nausea, vomiting, etc.) during the initial period after surgery, did not require patient-controlled analgesia (PCA) for pain control during the postoperative period, and had at least one drain located in the surgery area, because this could affect the pain level. The following conditions were also sought for patients in the experimental group: those who did not experience any infectious disease (zoster, fungus, eczema, callus, etc.), local infections (abscess etc), open lesions/wounds, scar tissue, edema, hematoma, thrombophlebitis, deep vein thrombosis, lymphangitis, clotting disorders, varicose veins, osteoporosis, osteomyelitis, hepatitis, inflammatory or degenerative articular diseases, neuropathy developed as a result of diabetics, or deformity in the toes; also no fractures, or recent dislocation or breaking of muscle fibers, tendons, or fascias. The independent variable of the study was foot massage; dependent variables were postoperative pain severity and vital signs (blood pressure, pulse, and respiration).
The stages of massage were organized according to a special training session which the researcher took from the instructor of the Massage Training Course at the Assocation of Physiotherapy and Rehabilitation. During the massage, a moisturizing body cream (nonherbal and minimally absorbed by skin) suggested by the instructor was used. Because whether surgery was performed on the left or right breast varied from patient to patient, it was impossible to measure blood pressure and pulse from the same arm in all patients. The pulse was evaluated by counting radial artery beats, and respiration was evaluated by counting thorax movements over 1 minute. As soon as patients came from the operating room, their pain severity was evaluated. Patients that scored $4 in pain severity according to the SF-MPQ were accepted into the study. A total of 20 minutes of foot massage was then performed, including 10 minutes for each foot, on patients in the experimental group. To perform the massage in a comfortable environment, and prevent the patient from being influenced by his/her relatives during the pain evaluation, the patient’s relatives were kept away. The environment was brightly lit and there was no music. The patients were made to understand that the information about their pain would be effective for directing their pain management. In the service where the research was carried out, nonsteroidal antiinflammatory drugs (diclofenac sodium, lornoxicam, tenoxicam, methamizole) were used either solely or together with opioids (pethidine HCl, tramadol HCl), with the first dose given during surgery. Patients in the control group received only analgesic treatment, whereas those in the experimental group received foot massage in addition to analgesic treatment.
Data Collection Methods and Instruments As reported in the literature, the effects of foot massage on pain, blood pressure, respiration, and pulse rates have generally been evaluated immediately after the massage, especially at the 5 minute time point (Grealish et al., 2000; Hayes & Cox, 1999; Hulme et al., 1999; Wang & Keck, 2004). We used these times to set the timing of follow-up after massage in our study at 5, 30, 60, 90 and 120 minutes. As a data collection tool, a patient information form, the Short-Form McGill Pain Questionnaire (SF-MPQ), and a calibrated sphygmomanometer with cuff and manometer and a stethoscope were used to measure blood pressure. The application of the patient information form and SF-MPQ, the massage, and the measurements of vital signs were all executed solely by the principal researcher.
Patient Information Form The patient information form developed by the researcher consisted of two sections. There were questions intended to determine sociodemographic variables of patients such as age, sex, and marital status in the first section, and information related to the operation performed in the second section. Before the research, pretests were given to 10 patients, and the form was then revised into its final shape. SF-MPQ The SF-MPQ, developed by Melzack in 1987, is a multidimensional scale that is commonly used for postoper€ ative pain assessment (Ozbayır, 2003; Sloman, Rosen, Rom, & Shir, 2005). The SF-MPQ consists of three sections; the quality of pain is assessed in the first section; the present severity of pain in the second section (with
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Ucuzal and Kanan
the use of a visual analog scale [VAS]); and the general pain severity in the final section. To assess pain severity with VAS, the patient was asked to evaluate the present severity of her pain. There are subjective descriptive expressions at both ends of the VAS, which comprises a 10-cm line drawn either horizontally or vertically (0 cm ¼ no pain; 10 cm ¼ unbearable pain). The patient was told that she was free to mark the point on the line that conforms to the severity of pain. The distance between the lowest VAS level and the point which the patient marked was measured with a ruler, and the numeric value of the pa€ tient’s pain severity quantified in cm (Ozbayır, 2003). Studies of SF-MPQ for validity and reliability were performed by Yakut et al. (2006) in Turkey; The Cronbach alpha value obtained from the scale was 0.705 (Yakut, Yakut, Bayar, & Uygur, 2007). In the present study, the Cronbach alpha value was calculated to be 0.765. Ethical Issues To carry out the research, written permission was acquired from the Ethical Committee of the hospital. Before starting the research, all patients were informed about the research, the disclosure form for volunteers was read out loud, and oral and written permissions were collected from them. They were told that they had the right not to participate in the research, or to leave it at any stage they desired, even though they had previously given written permission. It was stated that the data obtained would be used for scientific purposes without names. Data Analysis To evaluate the data, the Statistical Package for Social Science for Windows (SPSS) version 11.5, licensed to Istanbul University, was used. Descriptive statistical methods (frequency, mean and SD), chi-square (c2), and Yates-corrected c2 test were used in comparisons of qualitative data, and Student t test in comparisons of quantitative data. Pillai trace test was used for variance analysis of repeated measurements, and the Bonferroni test was used for multiple comparison analysis. The results were evaluated in a confidence interval range of 95% and a significance level of p < .05.
RESULTS Of the patients in the sample, 65.7% were 41-60 years of age, 40% had graduated from elementary school, 81.4% were married, and 35.7% had no previous surgery. In addition, 22.9% had undergone E-ALND and 28.5% underwent MRM in each group, 77.1% were using nonsteroidal antiinflammatory analgesics to control pain after surgery, and 51.4% had double
drains placed. No statistically significant differences in these characteristics between the experimental and control groups were seen (p > .05; Table 1). The mean age of patients in the experimental group was 49.40 11.68 years, whereas that of patients in the control group was 54.89 11.69 years; however, there was no statistically significant difference between them (t ¼ 1.963; p ¼ .054). The mean length of operation of patients in the experimental group was 1.88 0.50 hours, and that of the patients in the control group was 1.71 0.53 hours. The difference between these values was not statistically significant (t ¼ 1.320; p ¼ .191). After the first analgesic application (during surgery), patients in the experimental group stated that they felt pain 2.25 0.85 hours later, and those in the control group felt pain after 2.07 0.70 hours; this difference also had no statistical significance (t ¼ 0.943; p ¼ .349). Although the mean pain severity scores of patients in both groups showed decreases at all times, the greater reduction within the experimental group had a high level of statistical significance (F ¼ 24.682; p # .001; Table 2; Figure 1). Changes in the vital signs of patients over time are presented in Table 3. Notably, patients in the experimental group showed a decrease in all vital signs 5 minutes after foot massage, but patients in the control group showed increases in vital signs, except for pulse, at the 5 minute mark.
DISCUSSION Despite all the advances in pain management, surgical patients continue to experience moderate to severe pain during the postoperative period (Mac Lellan, € 2004; Ritchey, 2006). In a study in Turkey, Ozer and B€ ol€ ukbas¸ (2001) determined that 93.67% of patients experienced pain continuing into the third and fourth days after surgery. The fact is that qualified postoperative pain control can be achieved with the coordinated work of an interdisciplinary team of professional members. Surgical nurses must contribute to pain relief using pharmacologic as well as nonpharmacologic methods as an indispensable part of this team (Sherwood, McNeill, Starck, & Disnard, 2003). In the literature, there have been studies aimed at determining the effects of foot massage on the sensation of pain after different surgeries. Hulme et al. (1999) determined that the pain severity of patients who were both given foot massage and not after outpatient laparoscopic tubal ligation showed a decrease over time (5 minutes after massage, when the patient was ready for discharge, and while being discharged), but patients in the experimental group felt less pain
5
Effectiveness of Foot Massage on Postoperative Pain
TABLE 1. Characteristics of Participants Experimental Group (n ¼ 35) Participant Characteristics Age, y 31-40 41-50 51-60 $61 Educational level Illiterate Elementary school Junior high school Senior high school College and above Marital status Single Married Type of surgery E-SLNB E-ALND BM MRM Analgesics applied NSAID NSAID þ opioid No. of drains Single Double Previous surgical history No Within the past year >1 year before
Control Group (n ¼ 35)
Total (n ¼ 70)
n
%
n
%
n
%
7 11 12 5
20.0 31.4 34.3 14.3
4 10 13 8
11.4 28.6 37.2 22.8
11 21 25 13
15.7 30.0 35.7 18.6
4 13 4 10 4
11.4 37.2 11.4 28.6 11.4
6 15 4 5 5
17.1 42.9 11.4 14.3 14.3
10 28 8 15 9
14.3 40.0 11.4 21.4 12.9
4 31
11.4 88.6
9 26
25.7 74.3
13 57
18.6 81.4
9 8 8 10
25.7 22.9 22.9 28.5
8 8 9 10
22.9 22.9 25.7 28.5
17 16 17 20
24.3 22.9 24.3 28.5
28 7
80 20
26 9
74.3 25.7
54 16
77.1 22.9
15 20
42.9 57.1
19 16
54.3 45.7
34 36
48.6 51.4
12 8 15
34.3 22.8 42.9
13 6 16
37.2 17.1 45.7
25 14 31
35.7 20.0 44.3
Test c2 ¼ 1.598 p ¼ .660
c2 ¼ 2.321 p ¼ .677
c2 ¼ 2.362 p ¼ .124 c2 ¼ 0.118 p ¼ .990
c2 ¼ 0.324 p ¼ .569 c2 ¼ 0.915 p ¼ .339 c2 ¼ 0.358 p ¼ .836
E-SLNB ¼ excision of the mass and sentinel lymph node biopsy; E-ALND ¼ excision of the mass and axillary lymph node dissection; BM ¼ simple mastectomy; MRM ¼ modified radical mastectomy; NSAID ¼ nonsteroidal antiinflammatory drugs.
than patients in the control group. We found in the present study a parallel with the findings of Hulme et al.; patients in the experimental group experienced less pain 5 minutes after massage. This finding of a greater decrease in pain 5 minutes after massage in the experimental group is similar to that in a study by Kim and Park (2002). They applied foot massage after abdominal surgery and found that the severity of the patients’ pain in the experimental group decreased more than that in the control group immediately after massage. In our study, a total of 20 minutes of foot massage were performed, including 10 minutes for each foot. Wang and Keck (2004) applied massage to each hand and foot for 5 minutes for a total of 20 minutes. Pain severity was decreased to a statistically significant degree immediately after massage in their study, and at 5 minutes after massage in our study. De girmen et al. (2010) also determined that the pain severity of the patients who were given foot massage after cesarean
operation decreased immediately after massage but increased slightly after 60 minutes; however, it did not reach the level before the massage. In the same study, pain after 90 minutes was found to be higher than at the first evaluation in the control group. Similar to the study by Degirmen et al. (2010) and our study, the intensity of pain in patients in the experimental group was very low at the 60 minute mark compared with before the massage. It has been stated that the density of mechanoreceptors in the centers of tactile fibres on the hands and feet is very high (Can, 2012; Kennedy & Inglis, 2002; Schicke & R€ oder, 2006); and according to the placebo effect, positive expectations that pain will be eliminated can itself decrease pain (Sagar, Dryden, & Wong, 2007; Smeltzer, Bare, Hinkle, & Cheever, 2008). Koyama, McHaffie, Laurienti, and Coghill (2005) determined through magnetic resonance imaging that the expectancy of a decrease in pain really
6
Ucuzal and Kanan
TABLE 2. Comparison of Pain Severity Over Time, Mean ± SD Follow-Up Times, min* 0 5 30 60 90 120 Test
Experimental Group (n ¼ 35)
Control Group (n ¼ 35)
7.31 1.60 4.26 1.92 3.74 1.58 3.03 1.79 2.17 1.79 1.71 1.62 F ¼ 79.637 p ¼ .000†
6.69 1.25 6.46 1.38 6.09 1.90 5.57 1.96 5.03 2.05 4.60 2.20 F ¼ 6.697 p ¼ .000†
Test F ¼ 24.682 p ¼ .000†
*In the control group, when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. † p < .001; F ¼ variance analysis of repeated measurements, Pillai trace test.
resulted in less pain perception. Although the main pain severity scores of both groups were decreased at all times in the present study, the greater decrease in the pain severity of patients who were given foot massage, compared with those in the control group, might be explained with the gate-control theory of Melzack. Also, it can be said that the expectation of the patients that the massage would get rid of the pain could affect the pain perception by creating a placebo effect. In this context, the results showing that patients who were given foot massage during the postoperative period perceived less pain are in support of the data in the literature. The body adapted to pain in a short time, i.e., changes in vital signs were transient. Besides, because physiologic responses, such as increases in blood pressure, pulse, and respiration, are not similar in all patients with acute pain, the pain expression of the patient is the most reliable indicator (Mc Guire, 2006; Willens, 2008). Hayes and Cox (1999) determined that the mean arterial blood pressure, pulse, and respiratory rate were decreased during foot massage and at 5 minutes after the massage. Those parallel our findings. De girmen Pain Severity (VAS) 8 7 6
cm
5 4 GROUP 3
Control
2 Experimental
1 0 0. min
5. min
30. min
60. min
90. min
120. min
FIGURE 1. - Pain severity scores of experimental and control groups.
et al. (2010) stated that the systolic and diastolic blood pressure, pulse, and respiratory rates of patients to whom foot massage was applied decreased immediately after massage and did not reach premassage levels again, although they showed some increases after 60 minutes. In the same study, all vital signs of patients to whom massage was not applied were determined to be higher at the 90 minute mark than at the first assessment. Grealish et al. (2000) determined that the pulse rates of massaged cancer patients showed a greater decrease than those who were not given massage immediately after a foot massage applied for 10 minutes. Hattan et al. (2002) also found decreases in systolic and diastolic blood pressure, and increases in pulse and respiratory rates, in patients who had experienced heart surgery, immediately after foot massage was applied for 20 minutes on the second day after the surgery; however, the differences were not statistically significant. In the present study, the decrease in all vital signs of patients in the experimental group after 5 minutes, and the failure of systolic and diastolic blood pressure and respiratory rates to again reach their premassage levels even after 120 minutes can be accepted as a natural reflection of pain decreasing with foot massage. Although the mean pulse rate was decreased at the 5 minute mark, it was increased at the 30, 60, 90, and 120 minute marks; this can be interpreted as an adaptation of the body to the changes in the systolic and diastolic blood pressure. In particular, the changes observed in vital signs 5 minutes after massage significantly support the information in the literature. Patients in the control group, compared with the experimental group, showed a rise in vital signs except for pulse rate at the 5 minute mark. When the effects of pain on vital signs are considered, it can be said that the decrease in pain severity of the patients in the experimental group at the 5 minute mark was higher
7
Effectiveness of Foot Massage on Postoperative Pain
TABLE 3. Comparison of Vital Signs Over Time, Mean ± SD Follow-up times, min* Systolic blood pressure 0 5 30 60 90 120 Test Diastolic blood pressure 0 5 30 60 90 120 Test Pulse 0 5 30 60 90 120 Test Respiration 0 5 30 60 90 120 Test
Experimental Group (n ¼ 35)
Control Group (n ¼ 35)
126.00 14.18 119.71 18.55 119.71 17.90 118.71 16.77 119.86 16.11 120.86 17.55 F ¼ 3.098 p ¼ .023†
129.29 13.94 130.43 16.56 127.86 14.82 124.00 13.11 123.14 12.55 123.71 12.15 F ¼ 4.915 p ¼ .002‡
81.14 8.32 75.71 10.37 77.71 10.87 76.57 11.87 78.86 11.83 77.43 11.97 F ¼ 3.293 p ¼ .017†
80.71 6.20 80.71 8.76 78.86 9.32 76.43 7.82 76.29 8.43 77.43 7.01 F ¼ 5.904 p ¼ .001‡
75.37 11.34 70.43 9.40 72.89 10.15 73.60 10.59 74.80 10.41 75.60 10.54 F ¼ 17.421 p ¼ .000§
70.63 9.82 70.29 10.29 70.00 8.95 70.54 9.21 72.03 9.65 72.74 9.97 F ¼ 3.151 p ¼ .021†
19.23 2.72 17.77 2.78 18.17 2.63 17.83 2.08 18.06 2.14 18.23 2.46 F ¼ 2.850 p: 0.032†
18.11 3.67 18.20 4.04 18.29 4.11 17.71 3.18 18.23 3.07 18.06 3.24 F ¼ 1.340 p ¼ .275
Test F ¼ 3.100 p ¼ .014†
F ¼ 4.845 p ¼ .001‡
F ¼ 5.313 p ¼ .000§
F ¼ 1.953 p ¼ .098
*In the control group, when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. † p < .05; ‡p < .01, §p < .001; F ¼ variance analysis of repeated measurements, Pillai trace test.
than the decrease of those in the control group at the same time point. Study Limitations There are a couple of limitations of the present research which qualify its conclusions. The research was executed with the participation of patients who conformed to the criteria of the sample selection and agreed to participate in research. The first limitation is therefore that the results of the research may only be generalizable to patients with the characteristics of this sampling. The second limitation is that the effects of foot massage on postoperative pain were determined only by analyzing the notification of pain by the patient and the vital signs of the patient.
CONCLUSION The results obtained from the research show that when foot massage is used along with pharmacologic methods after breast surgery, it is effective in decreasing pain severity. Nurses should apply foot massage to patients having no risk for receiving massage. In this way nurses can provide more effective postoperative pain management. Acknowledgments The authors thank all of the patients who accepted the invitation to join the research, colleagues in the Surgical Nursing Department for their valuable contributions, and colleagues who work in the Breast Service, who provided endless support during the research.
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attitudes of nurses toward the patients with pain]. Atat€ urk € Universitesi Hems¸irelik Y€ uksekokulu Dergisi, 4(1), 7–17. Pienkowski, S. (2001). Massage therapy and its complementary therapies. Retrieved February 19, 2012, from http:// www.hawaii.edu/hivandaids/Massage%20Therapy%20and% 20Its%20Complementary%20Therapies.pdf Quattrin, R., Zanini, A., Buchini, S., Turello, D., Annunziata, M. A., Vidotti, C., Colombatti, A., & Brusaferro, S. (2006). Use of reflexology foot massage to reduce anxiety in hospitalized cancer patients in chemotherapy treatment: Methodology and outcomes. Journal of Nursing Management, 14(2), 96–105. Ritchey, M. (2006). Optimizing postoperative pain management. Cleveland Clinic Journal of Medicine, 73(Supp 1), 72–76. Sagar, S. M., Dryden, T., & Wong, R. K. (2007). Massage therapy for cancer patients: A reciprocal relationship between body and mind. Current Oncology, 14(2), 45–56. Sarıo glu, S., & Dinc¸er, G. (2003). Masaj [Massage]. Romatizma, 18(3), 175–181. Sherwood, G. D., McNeill, J. A., Starck, P. L., & Disnard, G. (2003). Changing acute pain management outcomes in surgical patients. Association of Operating Room Nurses, AORN Journal, 77(2), 374–395. Schicke, T., & R€ oder, B. (2006). Spatial remapping of touch: Confusion of perceived stimulus order across hand and foot. Proceedings of the National Academy of Sciences, 103(31), 11808–11813. Sloman, R., Rosen, G., Rom, M., & Shir, Y. (2005). Nurses’ assessment of pain in surgical patients. Journal of Advanced Nursing, 52(2), 125–132. Smith, D. J. (2004). Nursing management postoperative care. In M. S. Lewis, M. M. Heitkemper, & R. S. Dirksen (Eds.), Medical surgical nursing assesment and management of clinical problems (pp. 393–413). St. Louis: Mosby. Tuna, N. (2004). A’dan Z’ye masaj [A to Z massage]. I_stanbul: Nobel Tıp Kitabevleri. Wang, H. L., & Keck, J. F. (2004). Foot and hand massage as an intervention for postoperative pain. Pain Management Nursing, 5(2), 59–65. Wieting, J. M., Andary, M. T., Holmes, T. G., Rechtien, J. J., & Zimmerman, G. (2005). Manipulation, massage and traction. In J. A. DeLisa, B. M. Gans, & N. E. Walsh (Eds.), Physical medicine & rehabilitation: Principles and practice (pp. 285–309). Philadelphia: Lippincott Williams & Wilkins. Willens, J. S. (2008). Pain Management. In S. C. Smeltzer, B. G. Bare, J. L. Hinkle, & K. H. Cheever (Eds.), Textbook of medical surgical nursing (pp. 258–299). Philadelphia: Lippincott, Williams & Wilkins. World Health Organization (2011). Cancer. Retrieved August 25, 2011, from http://www.who.int/mediacentre/ factsheets/fs297/en/ Yakut, Y., Yakut, E., Bayar, K., & Uygur, F. (2007). Reliability and validity of the Turkish version short-form McGill pain questionnaire in patients with rheumatoid arthritis. Clinical Rheumatology, 26(7), 1083–1087. Yavuz, M. (2006). A grıda kullanılan nonfarmakolojik y€ ontemler [Nonpharmacological methods used in pain]. In F. Eti Aslan (Ed.), A grı: Do gası ve kontrol€ u (pp. 135– 147). I_stanbul: Avrupa Tıp Kitapc¸ılık Mart Matbaacılık Sanatları.
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Meral Ucuzal, PhD,* and Nevin Kanan, PhD†
ABSTRACT:
Received September 3, 2011; Revised February 25, 2012; Accepted March 6, 2012.
The aim of this study was to determine the effect of foot massage on pain after breast surgery, and provide guidance for nurses in nonpharmacologic interventions for pain relief. This was a quasiexperimental study with a total of 70 patients who had undergone breast surgery (35 in the experimental group and 35 in the control group). Patients in the control group received only analgesic treatment, whereas those in the experimental group received foot massage in addition to analgesic treatment. Patients received the first dose of analgesics during surgery. As soon as patients came from the operating room, they were evaluated for pain severity. Patients whose pain severity scored $4 according to the Short-Form McGill Pain Questionnaire were accepted into the study. In the experimental group, pain and vital signs (arterial blood pressure, pulse, and respiration) were evaluated before foot massage at the time patients complained about pain (time 0) and then 5, 30, 60, 90, and 120 minutes after foot massage. In the control group, pain and vital signs were also evaluated when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. A patient information form was used to collect descriptive characteristics data of the patients, and the Short-Form McGill Pain Questionnaire was used to determine pain severity. Data were analyzed for frequencies, mean, standard deviation, chi-square, Student t, Pillai trace, and Bonferroni test. The results of the statistical analyses showed that patients in the experimental group experienced significantly less pain (p # .001). Especially notable, patients in the experimental group showed a decrease in all vital signs 5 minutes after foot massage, but patients in the control group showed increases in vital signs except for heart rate at 5 minutes. The data obtained showed that foot massage in breast surgery patients was effective in postoperative pain management. Ó 2012 by the American Society for Pain Management Nursing
1524-9042/$36.00 Ó 2012 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.03.001
Breast cancer remains one of the most important health problems for women. The World Health Organization (WHO) reports that an average of 460,000 people died of breast cancer in the world in 2008 (WHO, 2011). To treat breast cancer, the first
From the *Malatya School of Health, Inonu University, Malatya, Turkey; † Faculty of Nursing, Istanbul University, Istanbul, Turkey. Address correspondence to Meral Ucuzal, PhD, Malatya School of Health, Inonu University, Malatya, Turkey. E-mail: meral.ucuzal@inonu. edu.tr
Pain Management Nursing, Vol -, No - (--), 2012: pp 1-8
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Ucuzal and Kanan
stage of treatment is surgical intervention, especially in patients without distant metastasis. All breast surgery patients experience different levels of pain according to the type of surgery (Akyolcu, 2008; Dirksen, 2004). Qualified postoperative pain control has an important impact on the success of surgical intervention (Dirksen, 2004). Today, however, inadequacies in the treatment and care of postoperative pain continue, despite increases in knowledge about pain pathophysiology, the availability of new drugs, and new developments in methods of drug application (Mac Lellan, 2004; Smith, 2004). Active participation of surgical nurses in the care and treatment of pain, in line with a multidisciplinary team approach, is possible if they are informed on the control of pain through pharmacologic and nonpharmacologic methods and reflect this knowledge in their practices. It should be noted that nonpharmacologic methods should be used to increase the impact of analgesics, but should not be used in their place (Yavuz, 2006). Massage has been used in various cultures and in different styles to control pain for 3000 years (Hayes & Cox, 1999; Quattrin, Zanini, Buchini, Turello, Annunziata, Vidotti, Colombatti, & Brusaferro, 2006). Massage has formed an important part of traditional medicine, and is seen as of value, especially in Eastern countries, as a healing method that has experienced ascents and descents in popularity for centuries. Massage became especially prevalent in Europe during the Renaissance. It is experiencing a rise in its popularity with the demands of patients for special care and the increased interest in alternative therapies (Pienkowski, 2001; Wieting, Andary, Holmes, Rechtien, & Zimmerman, 2005). This circumstance has also led to an increased number of studies to determine the effectiveness and reliability of massage techniques and other nonpharmacologic methods, their effects on patient satisfaction, and their place in nursing practices (Faurot, Gaylord, & Mann, 2007; Grealish, Lomasney, & Whiteman, 2000). The mechanism by which massage decreases pain is explained by the theory of gate control. According to this theory, suggested by Melzack in 1965, fibers of thick tactile sense (A-alpha and A-beta) are faster than the thin fibers (A-delta and C) that transmit the sensation of pain. In this context, the mechanoreceptors and fibers of tactile sense that exist on the skin, and are stimulated through massage, stimulate the substantia gelatinosa cells (the gate closes) and lead to the inhibition of signal transmission to T cells, thus preventing the sensation of pain (Sarıo glu & Dinc¸er 2003; Tuna, 2004). When cells of the substantia gelatinosa are stimulated, they secrete endorphins
called endogenous opioids. Endorphins prevent the secretion of substance p, which plays a role in the transmission of pain, and blocks the transition of pain stimuli (Kanbir, 2005; Pienkowski, 2001; Tuna, 2004). Because foot massage can be applied in a short time and easily without changing the position of the patient, it is a type of massage that is frequently used in pain control (Grealish et al., 2000; Hayes & Cox, 1999). According to the gate control theory of Melzack, the high density of mechanoceptors in the centers of tactile sensory fibers in the hands and feet, which are able to block sensations of pain when they are stimulated, is the reason these sites are preferred (Can, 2012; Wang & Keck, 2004). In the literature, there have been studies to determine the effects of foot massage on pain sensation after various surgical interventions, including laparoscopic sterilization (Hulme, Waterman, & Hillier, 1999), cardiac surgery (Hattan, King, & Griffiths, 2002), abdominal surgery (Kim & Park, 2002), and cesarean section € (Degirmen, Ozerdogan, Sayıner, K€ o¸s geroglu, & Ayrancı, 2010). The present research was intended to determine the effects of foot massage on postoperative pain control in breast surgery patients. The following hypotheses were tested in the research: H0: There is no difference in the postoperative pain severity of breast surgery patients between those receiving foot massage and those who do not. H1: Postoperative breast surgery patients receiving foot massage will have less pain than postoperative breast surgery patients without foot massage.
METHODS Study Design and Sample Selection This research was planned as a quasiexperimental study to determine the effects of foot massage on postoperative pain control in breast surgery patients. The research was carried out in the general surgery department breast service of a university hospital, in Istanbul, Turkey, from February 2007 to April 2008. Patients who had undergone excision of the mass and sentinel lymph node biopsy (E-SLNB), excision of the mass and axillary lymph node dissection (E-ALND), simple mastectomy (BM), and modified radical mastectomy (MRM) were included in the study. Seventy patients (35 in the experimental group, and 35 in the control group) as appropriate to research criteria were chosen in the sample. The sample size was calculated by power analysis. It was calculated that ten patients were required in each group to achieve a difficulty value of 0.80, error level of 0.05, effect level of 0.25, and a difference of
Effectiveness of Foot Massage on Postoperative Pain
3
2.0 points. However, in consideration of the minimum number of patients that are recommended for experimental studies, 35 patients each were chosen for the experimental and control groups. The samples of patients invited to join the study consisted of those who were $18 years old, had no difficulties with visual/verbal/audible communication or mental disability that would hinder understanding of the information provided and expressing her pain status accurately, underwent E-SLNB, E-ALND, BM, or MRM with general anesthesia, were not implanted with a breast prothesis during surgery, had no problems with hypertension, did not require blood pressure be taken on the foot, expressed that they had ‘‘medium’’ or ‘‘severe’’ pain levels (pain severity of $4) after surgery, did not experience any complications (severe bleeding, nausea, vomiting, etc.) during the initial period after surgery, did not require patient-controlled analgesia (PCA) for pain control during the postoperative period, and had at least one drain located in the surgery area, because this could affect the pain level. The following conditions were also sought for patients in the experimental group: those who did not experience any infectious disease (zoster, fungus, eczema, callus, etc.), local infections (abscess etc), open lesions/wounds, scar tissue, edema, hematoma, thrombophlebitis, deep vein thrombosis, lymphangitis, clotting disorders, varicose veins, osteoporosis, osteomyelitis, hepatitis, inflammatory or degenerative articular diseases, neuropathy developed as a result of diabetics, or deformity in the toes; also no fractures, or recent dislocation or breaking of muscle fibers, tendons, or fascias. The independent variable of the study was foot massage; dependent variables were postoperative pain severity and vital signs (blood pressure, pulse, and respiration).
The stages of massage were organized according to a special training session which the researcher took from the instructor of the Massage Training Course at the Assocation of Physiotherapy and Rehabilitation. During the massage, a moisturizing body cream (nonherbal and minimally absorbed by skin) suggested by the instructor was used. Because whether surgery was performed on the left or right breast varied from patient to patient, it was impossible to measure blood pressure and pulse from the same arm in all patients. The pulse was evaluated by counting radial artery beats, and respiration was evaluated by counting thorax movements over 1 minute. As soon as patients came from the operating room, their pain severity was evaluated. Patients that scored $4 in pain severity according to the SF-MPQ were accepted into the study. A total of 20 minutes of foot massage was then performed, including 10 minutes for each foot, on patients in the experimental group. To perform the massage in a comfortable environment, and prevent the patient from being influenced by his/her relatives during the pain evaluation, the patient’s relatives were kept away. The environment was brightly lit and there was no music. The patients were made to understand that the information about their pain would be effective for directing their pain management. In the service where the research was carried out, nonsteroidal antiinflammatory drugs (diclofenac sodium, lornoxicam, tenoxicam, methamizole) were used either solely or together with opioids (pethidine HCl, tramadol HCl), with the first dose given during surgery. Patients in the control group received only analgesic treatment, whereas those in the experimental group received foot massage in addition to analgesic treatment.
Data Collection Methods and Instruments As reported in the literature, the effects of foot massage on pain, blood pressure, respiration, and pulse rates have generally been evaluated immediately after the massage, especially at the 5 minute time point (Grealish et al., 2000; Hayes & Cox, 1999; Hulme et al., 1999; Wang & Keck, 2004). We used these times to set the timing of follow-up after massage in our study at 5, 30, 60, 90 and 120 minutes. As a data collection tool, a patient information form, the Short-Form McGill Pain Questionnaire (SF-MPQ), and a calibrated sphygmomanometer with cuff and manometer and a stethoscope were used to measure blood pressure. The application of the patient information form and SF-MPQ, the massage, and the measurements of vital signs were all executed solely by the principal researcher.
Patient Information Form The patient information form developed by the researcher consisted of two sections. There were questions intended to determine sociodemographic variables of patients such as age, sex, and marital status in the first section, and information related to the operation performed in the second section. Before the research, pretests were given to 10 patients, and the form was then revised into its final shape. SF-MPQ The SF-MPQ, developed by Melzack in 1987, is a multidimensional scale that is commonly used for postoper€ ative pain assessment (Ozbayır, 2003; Sloman, Rosen, Rom, & Shir, 2005). The SF-MPQ consists of three sections; the quality of pain is assessed in the first section; the present severity of pain in the second section (with
4
Ucuzal and Kanan
the use of a visual analog scale [VAS]); and the general pain severity in the final section. To assess pain severity with VAS, the patient was asked to evaluate the present severity of her pain. There are subjective descriptive expressions at both ends of the VAS, which comprises a 10-cm line drawn either horizontally or vertically (0 cm ¼ no pain; 10 cm ¼ unbearable pain). The patient was told that she was free to mark the point on the line that conforms to the severity of pain. The distance between the lowest VAS level and the point which the patient marked was measured with a ruler, and the numeric value of the pa€ tient’s pain severity quantified in cm (Ozbayır, 2003). Studies of SF-MPQ for validity and reliability were performed by Yakut et al. (2006) in Turkey; The Cronbach alpha value obtained from the scale was 0.705 (Yakut, Yakut, Bayar, & Uygur, 2007). In the present study, the Cronbach alpha value was calculated to be 0.765. Ethical Issues To carry out the research, written permission was acquired from the Ethical Committee of the hospital. Before starting the research, all patients were informed about the research, the disclosure form for volunteers was read out loud, and oral and written permissions were collected from them. They were told that they had the right not to participate in the research, or to leave it at any stage they desired, even though they had previously given written permission. It was stated that the data obtained would be used for scientific purposes without names. Data Analysis To evaluate the data, the Statistical Package for Social Science for Windows (SPSS) version 11.5, licensed to Istanbul University, was used. Descriptive statistical methods (frequency, mean and SD), chi-square (c2), and Yates-corrected c2 test were used in comparisons of qualitative data, and Student t test in comparisons of quantitative data. Pillai trace test was used for variance analysis of repeated measurements, and the Bonferroni test was used for multiple comparison analysis. The results were evaluated in a confidence interval range of 95% and a significance level of p < .05.
RESULTS Of the patients in the sample, 65.7% were 41-60 years of age, 40% had graduated from elementary school, 81.4% were married, and 35.7% had no previous surgery. In addition, 22.9% had undergone E-ALND and 28.5% underwent MRM in each group, 77.1% were using nonsteroidal antiinflammatory analgesics to control pain after surgery, and 51.4% had double
drains placed. No statistically significant differences in these characteristics between the experimental and control groups were seen (p > .05; Table 1). The mean age of patients in the experimental group was 49.40 11.68 years, whereas that of patients in the control group was 54.89 11.69 years; however, there was no statistically significant difference between them (t ¼ 1.963; p ¼ .054). The mean length of operation of patients in the experimental group was 1.88 0.50 hours, and that of the patients in the control group was 1.71 0.53 hours. The difference between these values was not statistically significant (t ¼ 1.320; p ¼ .191). After the first analgesic application (during surgery), patients in the experimental group stated that they felt pain 2.25 0.85 hours later, and those in the control group felt pain after 2.07 0.70 hours; this difference also had no statistical significance (t ¼ 0.943; p ¼ .349). Although the mean pain severity scores of patients in both groups showed decreases at all times, the greater reduction within the experimental group had a high level of statistical significance (F ¼ 24.682; p # .001; Table 2; Figure 1). Changes in the vital signs of patients over time are presented in Table 3. Notably, patients in the experimental group showed a decrease in all vital signs 5 minutes after foot massage, but patients in the control group showed increases in vital signs, except for pulse, at the 5 minute mark.
DISCUSSION Despite all the advances in pain management, surgical patients continue to experience moderate to severe pain during the postoperative period (Mac Lellan, € 2004; Ritchey, 2006). In a study in Turkey, Ozer and B€ ol€ ukbas¸ (2001) determined that 93.67% of patients experienced pain continuing into the third and fourth days after surgery. The fact is that qualified postoperative pain control can be achieved with the coordinated work of an interdisciplinary team of professional members. Surgical nurses must contribute to pain relief using pharmacologic as well as nonpharmacologic methods as an indispensable part of this team (Sherwood, McNeill, Starck, & Disnard, 2003). In the literature, there have been studies aimed at determining the effects of foot massage on the sensation of pain after different surgeries. Hulme et al. (1999) determined that the pain severity of patients who were both given foot massage and not after outpatient laparoscopic tubal ligation showed a decrease over time (5 minutes after massage, when the patient was ready for discharge, and while being discharged), but patients in the experimental group felt less pain
5
Effectiveness of Foot Massage on Postoperative Pain
TABLE 1. Characteristics of Participants Experimental Group (n ¼ 35) Participant Characteristics Age, y 31-40 41-50 51-60 $61 Educational level Illiterate Elementary school Junior high school Senior high school College and above Marital status Single Married Type of surgery E-SLNB E-ALND BM MRM Analgesics applied NSAID NSAID þ opioid No. of drains Single Double Previous surgical history No Within the past year >1 year before
Control Group (n ¼ 35)
Total (n ¼ 70)
n
%
n
%
n
%
7 11 12 5
20.0 31.4 34.3 14.3
4 10 13 8
11.4 28.6 37.2 22.8
11 21 25 13
15.7 30.0 35.7 18.6
4 13 4 10 4
11.4 37.2 11.4 28.6 11.4
6 15 4 5 5
17.1 42.9 11.4 14.3 14.3
10 28 8 15 9
14.3 40.0 11.4 21.4 12.9
4 31
11.4 88.6
9 26
25.7 74.3
13 57
18.6 81.4
9 8 8 10
25.7 22.9 22.9 28.5
8 8 9 10
22.9 22.9 25.7 28.5
17 16 17 20
24.3 22.9 24.3 28.5
28 7
80 20
26 9
74.3 25.7
54 16
77.1 22.9
15 20
42.9 57.1
19 16
54.3 45.7
34 36
48.6 51.4
12 8 15
34.3 22.8 42.9
13 6 16
37.2 17.1 45.7
25 14 31
35.7 20.0 44.3
Test c2 ¼ 1.598 p ¼ .660
c2 ¼ 2.321 p ¼ .677
c2 ¼ 2.362 p ¼ .124 c2 ¼ 0.118 p ¼ .990
c2 ¼ 0.324 p ¼ .569 c2 ¼ 0.915 p ¼ .339 c2 ¼ 0.358 p ¼ .836
E-SLNB ¼ excision of the mass and sentinel lymph node biopsy; E-ALND ¼ excision of the mass and axillary lymph node dissection; BM ¼ simple mastectomy; MRM ¼ modified radical mastectomy; NSAID ¼ nonsteroidal antiinflammatory drugs.
than patients in the control group. We found in the present study a parallel with the findings of Hulme et al.; patients in the experimental group experienced less pain 5 minutes after massage. This finding of a greater decrease in pain 5 minutes after massage in the experimental group is similar to that in a study by Kim and Park (2002). They applied foot massage after abdominal surgery and found that the severity of the patients’ pain in the experimental group decreased more than that in the control group immediately after massage. In our study, a total of 20 minutes of foot massage were performed, including 10 minutes for each foot. Wang and Keck (2004) applied massage to each hand and foot for 5 minutes for a total of 20 minutes. Pain severity was decreased to a statistically significant degree immediately after massage in their study, and at 5 minutes after massage in our study. De girmen et al. (2010) also determined that the pain severity of the patients who were given foot massage after cesarean
operation decreased immediately after massage but increased slightly after 60 minutes; however, it did not reach the level before the massage. In the same study, pain after 90 minutes was found to be higher than at the first evaluation in the control group. Similar to the study by Degirmen et al. (2010) and our study, the intensity of pain in patients in the experimental group was very low at the 60 minute mark compared with before the massage. It has been stated that the density of mechanoreceptors in the centers of tactile fibres on the hands and feet is very high (Can, 2012; Kennedy & Inglis, 2002; Schicke & R€ oder, 2006); and according to the placebo effect, positive expectations that pain will be eliminated can itself decrease pain (Sagar, Dryden, & Wong, 2007; Smeltzer, Bare, Hinkle, & Cheever, 2008). Koyama, McHaffie, Laurienti, and Coghill (2005) determined through magnetic resonance imaging that the expectancy of a decrease in pain really
6
Ucuzal and Kanan
TABLE 2. Comparison of Pain Severity Over Time, Mean ± SD Follow-Up Times, min* 0 5 30 60 90 120 Test
Experimental Group (n ¼ 35)
Control Group (n ¼ 35)
7.31 1.60 4.26 1.92 3.74 1.58 3.03 1.79 2.17 1.79 1.71 1.62 F ¼ 79.637 p ¼ .000†
6.69 1.25 6.46 1.38 6.09 1.90 5.57 1.96 5.03 2.05 4.60 2.20 F ¼ 6.697 p ¼ .000†
Test F ¼ 24.682 p ¼ .000†
*In the control group, when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. † p < .001; F ¼ variance analysis of repeated measurements, Pillai trace test.
resulted in less pain perception. Although the main pain severity scores of both groups were decreased at all times in the present study, the greater decrease in the pain severity of patients who were given foot massage, compared with those in the control group, might be explained with the gate-control theory of Melzack. Also, it can be said that the expectation of the patients that the massage would get rid of the pain could affect the pain perception by creating a placebo effect. In this context, the results showing that patients who were given foot massage during the postoperative period perceived less pain are in support of the data in the literature. The body adapted to pain in a short time, i.e., changes in vital signs were transient. Besides, because physiologic responses, such as increases in blood pressure, pulse, and respiration, are not similar in all patients with acute pain, the pain expression of the patient is the most reliable indicator (Mc Guire, 2006; Willens, 2008). Hayes and Cox (1999) determined that the mean arterial blood pressure, pulse, and respiratory rate were decreased during foot massage and at 5 minutes after the massage. Those parallel our findings. De girmen Pain Severity (VAS) 8 7 6
cm
5 4 GROUP 3
Control
2 Experimental
1 0 0. min
5. min
30. min
60. min
90. min
120. min
FIGURE 1. - Pain severity scores of experimental and control groups.
et al. (2010) stated that the systolic and diastolic blood pressure, pulse, and respiratory rates of patients to whom foot massage was applied decreased immediately after massage and did not reach premassage levels again, although they showed some increases after 60 minutes. In the same study, all vital signs of patients to whom massage was not applied were determined to be higher at the 90 minute mark than at the first assessment. Grealish et al. (2000) determined that the pulse rates of massaged cancer patients showed a greater decrease than those who were not given massage immediately after a foot massage applied for 10 minutes. Hattan et al. (2002) also found decreases in systolic and diastolic blood pressure, and increases in pulse and respiratory rates, in patients who had experienced heart surgery, immediately after foot massage was applied for 20 minutes on the second day after the surgery; however, the differences were not statistically significant. In the present study, the decrease in all vital signs of patients in the experimental group after 5 minutes, and the failure of systolic and diastolic blood pressure and respiratory rates to again reach their premassage levels even after 120 minutes can be accepted as a natural reflection of pain decreasing with foot massage. Although the mean pulse rate was decreased at the 5 minute mark, it was increased at the 30, 60, 90, and 120 minute marks; this can be interpreted as an adaptation of the body to the changes in the systolic and diastolic blood pressure. In particular, the changes observed in vital signs 5 minutes after massage significantly support the information in the literature. Patients in the control group, compared with the experimental group, showed a rise in vital signs except for pulse rate at the 5 minute mark. When the effects of pain on vital signs are considered, it can be said that the decrease in pain severity of the patients in the experimental group at the 5 minute mark was higher
7
Effectiveness of Foot Massage on Postoperative Pain
TABLE 3. Comparison of Vital Signs Over Time, Mean ± SD Follow-up times, min* Systolic blood pressure 0 5 30 60 90 120 Test Diastolic blood pressure 0 5 30 60 90 120 Test Pulse 0 5 30 60 90 120 Test Respiration 0 5 30 60 90 120 Test
Experimental Group (n ¼ 35)
Control Group (n ¼ 35)
126.00 14.18 119.71 18.55 119.71 17.90 118.71 16.77 119.86 16.11 120.86 17.55 F ¼ 3.098 p ¼ .023†
129.29 13.94 130.43 16.56 127.86 14.82 124.00 13.11 123.14 12.55 123.71 12.15 F ¼ 4.915 p ¼ .002‡
81.14 8.32 75.71 10.37 77.71 10.87 76.57 11.87 78.86 11.83 77.43 11.97 F ¼ 3.293 p ¼ .017†
80.71 6.20 80.71 8.76 78.86 9.32 76.43 7.82 76.29 8.43 77.43 7.01 F ¼ 5.904 p ¼ .001‡
75.37 11.34 70.43 9.40 72.89 10.15 73.60 10.59 74.80 10.41 75.60 10.54 F ¼ 17.421 p ¼ .000§
70.63 9.82 70.29 10.29 70.00 8.95 70.54 9.21 72.03 9.65 72.74 9.97 F ¼ 3.151 p ¼ .021†
19.23 2.72 17.77 2.78 18.17 2.63 17.83 2.08 18.06 2.14 18.23 2.46 F ¼ 2.850 p: 0.032†
18.11 3.67 18.20 4.04 18.29 4.11 17.71 3.18 18.23 3.07 18.06 3.24 F ¼ 1.340 p ¼ .275
Test F ¼ 3.100 p ¼ .014†
F ¼ 4.845 p ¼ .001‡
F ¼ 5.313 p ¼ .000§
F ¼ 1.953 p ¼ .098
*In the control group, when the patients complained about pain (time 0) and again at 5, 30, 60, 90, and 120 minutes, in sync with the times when foot massage was completed in the experimental group. † p < .05; ‡p < .01, §p < .001; F ¼ variance analysis of repeated measurements, Pillai trace test.
than the decrease of those in the control group at the same time point. Study Limitations There are a couple of limitations of the present research which qualify its conclusions. The research was executed with the participation of patients who conformed to the criteria of the sample selection and agreed to participate in research. The first limitation is therefore that the results of the research may only be generalizable to patients with the characteristics of this sampling. The second limitation is that the effects of foot massage on postoperative pain were determined only by analyzing the notification of pain by the patient and the vital signs of the patient.
CONCLUSION The results obtained from the research show that when foot massage is used along with pharmacologic methods after breast surgery, it is effective in decreasing pain severity. Nurses should apply foot massage to patients having no risk for receiving massage. In this way nurses can provide more effective postoperative pain management. Acknowledgments The authors thank all of the patients who accepted the invitation to join the research, colleagues in the Surgical Nursing Department for their valuable contributions, and colleagues who work in the Breast Service, who provided endless support during the research.
8
Ucuzal and Kanan
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