Running head: MASSAGE THERAPY POST CARDIAC SURGERY

Reducing Pain, Anxiety and Muscle Tension with Massage Therapy after Cardiac Surgery
Elizabeth Clare Maffett
University of South Florida

MASSAGE THERAPY POST CARDIAC SURGERY

Abstract
Clinical Problem: Post-surgical cardiac patients experience pain, anxiety, and muscle tension
that could lead to post-surgical complications and delayed healing.
Objective: To determine if there is sufficient evidence to support the use of massage therapy
(MT) after cardiac surgery to help alleviate pain, anxiety and muscle tension (PAT) in patients.
Search Engines/Key Words: The search engines CINAHL and PubMed were accessed using
the key words surgery, cardiac surgery, massage therapy, pain management, postoperative, and
cardiac.
Specific Results: Bauer et al. (2010) showed that participants receiving MT experience
significant decreases in PAT (p<.001) on postoperative day two and four. Boiter et al. (2015)
showed a decrease in pain intensity becoming more significant with each session (pS2=.07,
pS3=.008), and pain behaviors were statistically significant after session one (p=.047). Braun et
al. (2012) showed that MT produced a significant reduction in pain (p=.001), anxiety (p<.0001),
and muscular tension (p=.002). Braun et al. (2012) also showed an increase in relaxation
(p<.0001) and overall satisfaction (p=.016). Bagheri-Nesami et al. (2014) showed that the
difference in anxiety before and after foot reflexology was statistically significant (p=.001) on
days one and three after surgery.
Conclusion: MT has been found to decrease pain, anxiety and muscle tension in patients
recovering from cardiac surgery. MT implemented into daily care following cardiac surgery can
decrease symptoms, and increase patient satisfaction.

MASSAGE THERAPY POST CARDIAC SURGERY

Reducing Pain, Anxiety and Muscle Tension with Massage Therapy after Cardiac Surgery
Patients who undergo surgical procedures will experience pain at varying levels of
intensity following their procedure. Cardiac surgical patients experience pain from their incision,
muscle and bone damage, and discomfort from lines and drainage tubes (Boiter, Martorella,
Arbour, Michaud, & Gelinas, 2015). There is an estimated 686,000 cardiac surgeries done in the
United States each year, which is a large population of patients experiencing this kind of pain
(Bagheri-Nesami et al., 2014). The stress patients experience as a result of their pain can lead to
post surgery complications and delayed healing (Dunwoody, Krenzischek, Pasero, Rathmell, &
Polomano, 2008). There is a need for non-pharmacological methods to help manage the postsurgical pain that our patients are experiencing (Bauer et al., 2010). In post-surgical cardiac
patients, how does massage therapy compared to usual care, decrease pain, anxiety, and muscle
tension during hospitalization, for six months?
Literature Search
The CINAHL and PubMed search engines were used to find randomized controlled trials
about pain, anxiety, and muscle tension after cardiac surgery, and symptom management. Key
terms used in the search were surgery, cardiac surgery, postoperative, cardiac, massage therapy,
and pain management. The dates searched ranged from 2009 to 2016.
Literature Review
Four randomized controlled trials (RCT) were examined to assess the effectiveness of
massage therapy (MT) on pain, anxiety and muscle tension (PAT) following cardiac surgery.
Bauer et al. (2010) designed a RCT to evaluate the effectiveness of MT on PAT after cardiac
surgery. They also examined the feasibility of integrating MT into cardiac post-surgical practices.
There were 113 participants randomized into the control or intervention group. The control group

MASSAGE THERAPY POST CARDIAC SURGERY

(n=62) received 20 minutes of undisturbed rest time. The intervention group (n=51) received 20
minutes of MT day two and day four following surgery. The outcomes showed that participants
in both groups experienced significantly less pain (pIG<.001)(pCG=.003), anxiety (pIG<.001)
(pCG=.04), and muscle tension (pIG<.001),(pCG=.008) on day two. On day four, only the
intervention group experienced significantly less PAT (p<.001). The weaknesses of this trial were
that the participants and researchers were not blind the intervention received, the trial was
specific to cardiac patients and would need further research to apply to other populations, and
only 113 of the 164 randomly assigned participants received the intervention. The strengths of
the trial were that the participants were randomly assigned, baseline characteristics of the two
intervention groups were similar, inclusion and exclusion criteria were clearly defined,
intervention sessions were equal in length in both groups, and they used a visual analog scale for
measurement of MT effectiveness.
Boiter, Martorella, Arbour, Michaud, & Gelinas (2015) designed a RCT to evaluate how
hand massage affects pain following cardiac surgery. There were 40 participants randomized into
the control and intervention groups. The control group (n=19) received a 15-minute handholding
session and then 30 minutes of independent rest. The intervention group (n=21) had a 15-minute
hand massage and then 30 minutes of independent rest. The participants received two or three
sessions depending on when they were discharged from the intensive care unit. All sessions
occurred within the first 24 hours following surgery. The outcomes showed that there was no
statistical significance in reduction of pain intensity after the first session. There was a trend
towards significance after the second session (p=.07), and a statistically significant decrease in
pain intensity following the third session (p=.008). Pain behaviors were observed by video
recording 30 minutes before, during and 30 minutes after sessions. The results revealed

MASSAGE THERAPY POST CARDIAC SURGERY

significantly less pain behaviors after the first session (p=.047), and a trend towards significance
after the second session (p=.115). The weaknesses of the trial include that clinicians were not
blind to interventions, there was a small sample size, not all patients received a third
intervention, and the difference in education levels between the two groups were statistically
significant (p=.021). The strengths of the trial were that participants were randomly assigned to
groups, inclusion and exclusion criteria were clearly defined, all 40 patients that were randomly
assigned received two interventions, intervention sessions were equal in length, demographics
were similar between the two groups with the exception of education levels.
Braun et al. (2012) designed a RCT to evaluate the effectiveness of MT in reducing PAT
after cardiac surgery. There were 146 participants randomized into the control and intervention
group. The control group (n=71) received a prescribed 20 minutes of undisturbed rest time. The
intervention group (n=75) received 20 minutes of MT on day three/four and day five/six
following surgery. The outcomes showed that MT produced a significant reduction in pain
(p=.001), anxiety (p<.0001), and muscular tension (p=.002). This study also showed that
relaxation (p<.0001) and satisfaction (p=.016) increased with MT compared to the undisturbed
rest time. The weakness of this trial were that the participants and practitioners were not blind to
the interventions, 66 of the 152 participants only received one intervention session, and they did
not evaluate the use of analgesic medications over the course of the treatment. The strengths of
the study include that the participants were randomly placed in the intervention and control
groups, inclusion and exclusion criteria were clearly defined, the intervention sessions were
equal in length for each group, there were no voluntary withdrawals from the study, and the
demographics were similar for both groups.

MASSAGE THERAPY POST CARDIAC SURGERY

Bagheri-Nesami et al. (2014) designed a RCT to study how foot reflexology massage
affects patient anxiety after CABG surgery. The 80 participants were assigned randomly to the
control and intervention groups. The groups were balanced by age and gender. The control group
(n=40) had a one-minute foot rub with application of lubricating gel followed by a rest period of
20-minutes while the researcher was present. The intervention group (n=40) had a one-minute
foot rub with application of lubricating gel followed by a 20-minute foot reflexology massage
using a prescribed method. There was a significant difference in anxiety (p=.001) on
postoperative days one, two, and three in both the control and intervention group. The difference
in anxiety before and after foot reflexology was statistically significant (p=.001) on days one and
three. There was statistical significance in anxiety (p=.02) before the massage on day one and
after the massage on day three. The weaknesses of the study include matching for gender and
age, investigators were not blind to the study, they did not reveal if any participants did not
complete the trial, and the trial only evaluated the immediate effects foot reflexology has on
anxiety in CABG patients. The strengths of this trial include random assignment of participants
by drawing of cards, participants were blinded to study interventions, participants were analyzed
within the groups they were originally assigned to, intervention sessions were equal in length for
each group, and demographics were similar for both groups. The two instruments used for
measurement were the Visual Analog Scale for Anxiety (VAS-A) and a shortened version of the
Spielberger State-Trait Anxiety Inventory (STAI).
Synthesis
The literature examined supports the use of MT in decreasing PAT in postoperative
cardiac patients. Bauer et al. (2010) showed that participants receiving MT experience significant
decreases in PAT (p<.001) on postoperative day two and four. Boiter et al. (2015) showed a

MASSAGE THERAPY POST CARDIAC SURGERY

decrease in pain intensity becoming more significant with each session (pS2=.07, pS3=.008), and
pain behaviors were statistically significant after session one (p=.047). Braun et al. (2012)
showed that MT produced a significant reduction in pain (p=.001), anxiety (p<.0001), and
muscular tension (p=.002). Braun et al. (2012) also showed an increase in relaxation (p<.0001)
and overall satisfaction (p=.016). Bagheri-Nesami et al. (2014) showed that the difference in
anxiety before and after foot reflexology was statistically significant (p=.001) on days one and
three after surgery.
The studies reviewed all included a type of massage therapy treatment to measure
improvements in pain, anxiety, and/or muscle tension in postoperative cardiac patients. The types
and locations of massage varied from patient preference, to hand massage, to foot reflexology.
Additional research is needed to determine which method and location of massage is most
beneficial in relieving symptoms after surgery. The lengths of the sessions were similar in all of
the studies ranging from 15 to 20 minutes. The intervention sessions were conducted at different
times in the post surgery period. Additional research is needed to determine the most optimal
time to implement MT following surgical procedures. These studies focused on patients that had
undergone cardiac surgery. Additional research is needed to determine the affect of MT in
reducing PAT after other types of surgery. Additional research is also needed to determine the
effectiveness of MT in reducing the use of narcotics after cardiac surgery.
Clinical Recommendations
Cardiac surgical patients experience PAT during their hospital stay, and there is a need for
non-pharmacological methods to aid in decreasing these symptoms. Decreasing PAT will help to
increase patient satisfaction. Evidence shows that MT can promote patient comfort following

MASSAGE THERAPY POST CARDIAC SURGERY

cardiac surgery using a variety of techniques. Nurses and assistive personnel could implement
MT into daily care following cardiac surgery to decrease PAT in their patients.

MASSAGE THERAPY POST CARDIAC SURGERY

References
Bagheri-Nesami, M., Shorofi, S. A., Zargar, N., Sohrabi, M., Gholipour-Baradari, A., & Halilian,
A. (2014). The effects of foot reflexology massage on anxiety in patients following
coronary artery bypass graft surgery: A randomized controlled trial. Complementary
Therapies in Clinical Practice, 20(1), 42-47. Doi: 10.1016/j.ctcp.2013.10.006
Bauer, B. A., Cutshall, S. M., Wentworth, L. J., Engen, D., Messner, P. K., Wood, C. M.,
Sundt III, T. M. (2010). Effect of massage therapy on pain, anxiety, and tension after
cardiac surgery. Complementary Therapies in Clinical Practice 16(2), 70-75. doi:
10.1016/j.ctcp.2009.06.012
Boitor, M., Martorella, G., Arbour, C., Michaud, C., & Gelinas, C. (2015). Evaluation of the
preliminary effectiveness of hand massage therapy on postoperative pain of adults in the
intensive care unit after cardiac surgery: A pilot randomized controlled trial. Pain
Management Nursing, 16(3), 354-366. doi: 10.1016/ j.pmn.2014.08.014
Braun, L.A., Stanguts, C., Casanelia, L., Spitzer, O., Paul, E., Vardaxis, N. J., & Rosenfeldt, F.
(2012). Massage therapy for cardiac surgery patients a randomized trial. The Journal
for Thoracic and Cardiovascular Surgery, 144(6), 1453-1459.e1.doi:
10.1016/j.jtcvs.2012.04.027
Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., & Polomano, R. C. (2008).
Assessment, physiological monitoring, and consequences of inadequately treated acute
pain. Journal of PeriAnesthesia Nursing 23(1A), S15-S27. doi:
10.1016/j.jopan.2007.11.007