MASSAGE

Massage is an ancient therapy. There is evidence that it was used in China more than 5,000 years
ago (McRee Noble, & Pasvogel, 2003). It is one of the most widely used complementary
therapies and hasbeen a part of the nurse’s armamentarium for centuries. At a time when the
public use of massage is increasing, the nursing profession is decreasing its use of this traditional
intervention. To compensate for this, some health institutions have massage therapists on staff;
patients or family, in most instances, pay for this service. Massage is often combined with other
therapies, such as music, aromatherapy, acupressure, or light touch. Thus, it is difficult to
differentiate the specific effects of massage from those of the other therapies used. Study
findings point to the positive effects of massage with or without other therapies in producing
relaxation, improving sleep, and reducing pain.
DEFINITION
The term massage is derived from the Arabic word mass’h, meaning “to press gently” (Furlan,
Brosseau, Imamura, & Irvin, 2004). Massage, as defined by the American Massage Therapy
Association, is “the application of manual techniques and adjunctive therapies with the intention
of positively affecting the health and well-being of the client” (2004—
http://www.amtamassage.org/about/definition/html). Various strokes are used to produce friction
and pressure on cutaneous and subcutaneous tissues. The types of stroke and the amount of
pressure chosen depend on the desired outcomes and the body part being massaged. There are a
number of types of massage: Swedish (a massage using long, flowing strokes); Esalen (a
meditative massage using light touch); deep tissue or neuromuscular (an intense kneading of the
body); sports massage (a vigorous massage to loosen and ease sore muscles); Shiatsu (a Japanese
pressure-point technique to relieve stress); and reflexology (a deep foot massage that relates to
parts of the body). The different types of massage incorporate a variety of strokes, varying levels
of pressure, and a multitude of procedures. Massage strokes can be administered to the entire
body or to specific areas of the body, such as the back, feet, or hands.
SCIENTIFIC BASIS
The use of massage is a natural healing process that helps to connect the body, mind, and spirit.
Massage produces therapeutic effects on multiple body systems: integumentary, musculoskeletal,
cardiovascular, lymph, and nervous. Manipulating the skin and underlying muscle makes the
skin supple. Massage increases or enhances movement in the musculoskeletal system by
reducing swelling, loosening and stretching contracted tendons, and aiding in the reduction of
soft-tissue adhesions. Friction to the cutaneous and subcutaneous tissues releases histamines that
in turn produce vasodilation of vessels and enhance venous return. Massage has been found to
produce a relaxation response (Hattan, King, & Griffiths, 2002; Holland & Pokorny, 2001;
McNamara, Burnham, Smith, & Carroll, 2003). Investigators report that massage has produced a
decrease in certain physiological parameters (systolic and diastolic blood pressure, heart rate, and
skin temperature), indicative of the relaxation response (Mok & Woo, 2004). Reduction of pain,
a frequent desired outcome of massage, is closely related to the production of the relaxation
response. Studies have validated that patients were more comfortable after the administration of
massage (Frey Law et al., 2008; Simmons, Chabal, Griffith, Rausch, & Steele, 2004; Wang &
Keck, 2004). The positive impact of massage on pain reduction is often posited on the gate
control theory, with massage stimulating the large-diameter nerve fibers that have an inhibitory
input on T-cells (Furlan et al., 2004). According to Wang and Keck, “massaging the hands and
feet stimulates the mechanorecptors that activate the nonpainful nerve fibers, preventing pain
transmission from reaching consciousness” (p. 59). Results from some studies on the use of
massage have shown that massage does not always produce relaxation. One factor that may
contribute to these findings is that massage of short duration may initially cause stimulation of
the sympathetic nervous system and thus cause an increase in blood pressure and heart rate. Few
studies have included information about subjects’ comfort with touch and massage. For some
persons, massage may increase anxiety. The impact of massage on the
psychoneuroimmunological functions of the body and mind is beginning to be explored. Billhult,
Lindholm, Gunnarsson, and Stener-Victoria (2008) explored the effect of massage on CD4+ and
CD8+ T cells in women with cancer. Findings revealed that massage had no effect on these
indices. Anecdotal reports, however, suggest that massage produces positive results in persons
with HIV infection. Massage is a holistic therapy and, as such, promotes overall health.
Improvement in well-being has been shown in the following studies: emotional discomfort
(Currin & Meister, 2008); psychological wellbeing (Chang, Wang, & Chen, 2002); and quality
of life (Williams et al., 2005).
INTERVENTION
As noted earlier, numerous types of massage exist. The techniques for hand and shoulder
massage will be presented. The environment in which massage is administered is important. The
room must be warm enough for the person to be comfortable, as shivering could negate the
effects of the massage. In addition, privacy needs to be ensured. Adding music and aromatherapy
to massage session has been thought to increase the effectiveness of massage. Fellowes, Barnes,
and Wilkinson (2004), however, did not find any convincing evidence that aromatherapy
contributed to additional improvement in outcomes. Chapter 6 details intervention with music;
aromatherapy is described in chapter 26.
Massage Strokes
Commonly used strokes in administering massage include effluerage, friction, pressure,
petrissage, vibration, and percussion. Effluerage Effluerage is a slow, rhythmic stroking, with
light skin contact. Effleurage may be applied with varying degrees of pressure, depending on
the part of the body being massaged and the outcome desired. The palmar surface of the hands is
used for larger surfaces, the thumbs and fingers for smaller areas. On large surfaces, long,
gliding strokes about 10 to 20 inches in length are applied.
Friction Movements
In friction movements, moderate, constant pressure to one area is made with the thumbs or
fingers. The fingers may be held in one place or moved in a small circumscribed area.
Pressure Stroke
The pressure stroke is similar to the friction stroke, except pressure strokes are made with the
whole hand.
Petrissage
Petrissage, or kneading, involves lifting a large fold of skin and the underlying muscle and
holding the tissue between the thumb and fingers. The tissues are pushed against the bone, then
raised and squeezed in circular movements. The grasp on the tissues is alternately loosened and
tightened. Tissues are supported by one hand while being kneaded with the other. Variations
include pinching, rolling, wringing, and kneading with fists or fingers. Petrissage is limited to
tissues having a significant muscle mass.
Vibration Strokes
Vibration strokes can be administered with either the entire hand or with the fingers. Rapid,
continuous strokes are used. Because administering vibration strokes requires much energy,
mechanical vibrators are sometimes used.
Percussion Strokes
For percussion strokes, the wrist acts as a fulcrum for the hand, with the hand hitting the tissue.
Strokes are made with a rapid tempo over a large body area. Tapping and clapping are variants of
percussion strokes.
Shoulder Massage
Shoulder massage can be easily performed by nurses and other persons. The person receiving the
massage sits so that the back is accessible to the person administering the massage. The massage
can be administered with the person’s shoulders uncovered or clothed. If clothed, no oil or lotion
is used. The massage begins with some gentle pressure applied on the shoulders using the palm
of the hand. Next, attention is given to stretching the trapezius muscles, moving from the center
of the back to the muscle’s insertion in the scapula at the shoulder joint. Fingers can be used to
massage the fibers in the muscles of the shoulder. Petrissage strokes are used to lift the skin and
muscle fibers so as to massage these tissues between the fingers. Attention is given to the
attachment of the muscles at the base of the skull by massaging up the neck and stretching the
muscles. If a person is unable to hold his or her head upright, a hand can be placed on the
forehead to support the head. The massage is concluded with lighter percussion strokes across
the top of the shoulders (M. O. Martin, March 2005, personal communication).
Hand Massage
A technique for performing hand massage is outlined in Exhibit 22.1. The technique is easy to
use with many populations, including older adults (Kolcaba, Schirm, & Steiner, 2006; Snyder,
Eagan, & Burns, 1995) as well as infants and children (Field, 2002). A suggested period for
administering massage is 21/2 minutes per hand. The length of time is individualized for each
patient, based on his/her response.
Measurement of Outcomes
Both physiological and psychological outcomes have been used to measure the effectiveness of
massage. Indices of relaxation (heart rate, blood pressure, respiration rate, skin temperature,
cortisol level, and muscle tension) have been measured in many studies. Anxiety inventories and
scales to determine pain level and quality of sleep as well as qualityof- life indices have been
used to determine the efficacy of massage. It is important that both short- and long-term effects
of massage be measured.
Precautions
Ernst (2003) reviewed the literature to determine adverse reactions to massage. Although a
number of negative reactions were noted, the majority of these were associated with exotic types
of massage and notwith the Swedish massage technique. Before administering massage, the
nurse explains the intervention, obtains a history, and secures the permission of the patient. The
history provides the nurse with information about past use of massage and any adverse
responses. It is also important to find out the person’s overall response to touch. Some people
may be averse to being touched because of past negative experiences. Others may be
hypersensitive to touch. One method for overcoming this sensitivity is beginning with light touch
and slowly increasing the pressure. The area to be massaged is assessed for redness, bruises,
edema, or rashes. Massage therapists and nurses have been reluctant to use massage with cancer
patients (Gecsedi, 2002) because of the belief that thetherapy may initiate or accelerate
metastases. Guidelines are being developed to govern the use of massage with persons with
cancer. Some therapists request a physician’s order about the body region and technique
to be used. Factors considered are the location of the tumor, the stage of the cancer, and the
location of any metastatic lesions. Pressure in the immediate area of the cancer is to be avoided.
Because blood pressure may be lowered during massage, monitoring for light-headedness is
suggested following the initial massage sessions, particularly in older adults. If light-headedness
does occur, allowing the person to remain recumbent for several minutes at the conclusion of the
massage may help to decrease the likelihood of hypotension and falls. Monitoring of blood
pressure and pulse rate are required in persons with cardiac conditions, to determine whether
adverse effects are being experienced.
USES
For a list of conditions for which massage has been used, see Exhibit 22.2. Use of massage to
produce relaxation and reduce pain will now be described.
Relaxation
Many people use a massage therapist to ameliorate their stress. Mokand Woo (2004) reported a
positive response to a slow-stroke back massage in elders who had had a stroke. In a review of
22 studies in which massage had been used, Richards, Gibson, and Overton-McCoy (2000)
found that the most commonly reported outcome was a reduction in anxiety. Using foot massage
with cardiac patients, Hattan et al. (2002) found that subjects receiving this therapy reported
feeling
much calmer. In addition to using massage with patients, massage can also be used with a
patient’s family members who are experiencing high levels of stress. A short hand massage may
help to relax a family member so they can rest or sleep.
Pain
Reduction of pain is another condition for which massage is often used. Numerous studies have
found that massage resulted in a reduction of pain. Ernst (2004), in a meta-analysis of seven
studies, found that use of Swedish massage may be effective in lessening pain. However, the
author also noted that many methodological concerns about the studies existed. In a review of
research on the use of massage and aromatherapy in persons with cancer, Fellowes et al. (2004)
found a reduction in pain in 3 of the 10 studies reviewed in which massage and aromatherapy
had been used with cancer patients. Wang and Keck (2004) reported a lessening of pain in
postoperative patients, and Mok and Woo (2004) found that massage lessened pain in patients
with strokes.
CULTURAL ASPECTS
Nurses may encounter patients who have a reddened area that does not appear to be from
pressure. Cupping is a therapy, used in Asian countries, that originated in traditional Chinese
medicine. A cup (often a plastic cup) is placed over the area and either heat or suction is used to
create a partial vacuum which lifts up the underlying tissue. Stasis of the blood occurs, hence the
reddened skin. The intended purpose of cupping is to “activate” the underlying tissue or organ.
For example, the therapy may be used to release toxins or open up blockages in the colon.
Minimal research has been done on the effectiveness of cupping. Ahmadi, Schwebel, and Rezaei
(2008) tested the efficacy of wet-cupping to treat tension and migraine headaches. A 66%
decrease in severity of pain was reported, and subjects reported 12.6 fewer days of headache per
month. Shiatsu, a pressure-point type of massage, is popular in Japan and other Asian countries.
Its underlying purpose is to rebalance the energy system in the body through pressure on specific
points. Although Shiatsu may not be “comforting” during administration, relaxation is often
felt at the conclusion. Shiatsu may be used to help alleviate other conditions. Tanigaki (2008)
found Shiatsu therapy to be highly efficacious in managing constipation in 6 elderly patients
(from 81 to 93 years of age) who were on bedrest and receiving home care.
FUTURE RESEARCH
Reviews of the studies that have been conducted using massage have identified a number of
methodological issues. One challenge posed in conducting research on massage is having a
comparable control group. McNamara et al. (2003) compared massage and standard care in
patients undergoing a diagnostic test. Some have compared the effects of massage with those of
other therapies such as imagery (Hattan et al., 2002). The following are suggestions for research
that is needed so that practitioners may have more direction in using massage in clinical settings:
1. Few investigators have explored the impact massage has on pyschoneuroimmunologcial
indices. Studies on the use of massage with patients having HIV infection and cancer would
guide nurses in its use with these groups.
2. The period of time for administering massage and the number of sessions that produce the best
results need to be established. There is great variation in these two parameters in published
studies. Because of time constraints in practice settings, this information would be very helpful
to busy practitioners.
3. What, if any, is the effect of the sex of the therapist administering massage on the outcomes
obtained? Few studies have reported on the significance of the sex of the therapist in relation to
that of the patient.