Effect of Whole Body Massage by Patient's Companion on the Level of Blood
Cortisol in Coronary Patients: A Randomized Controlled Trial
Mohsen Adib-Hajbaghery 1, *, Rahman Rajabi-Beheshtabad 2, Ali Abasi 31 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
2 Department of Nursing, Dehdasht Imam Khomeini Hospital, Yasouj University of Medical Sciences, Yasouj, IR Iran
3 Department of Cardiology, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, IR Iran*Corresponding author
: Mohsen Adib-Hajbaghery, Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel.: +98-3615550021, Fax: +98-3615556633,
July 23, 2013; Revised:
July 27, 2013; Accepted:
July 27, 2013
Inconsistent results have been reported on the effect of massage therapy on the blood cortisol levels. Also, no study is
available about the effect of massage done by patient's companions on the level of blood cortisol in patients hospitalized at CCU.
The present study aimed to evaluate the effect of whole body massage performed by patient’s companion on the level of blood
cortisol among the patients admitted in CCU.
Patients and Methods:
A randomized controlled trial was conducted on 60 patients admitted to a CCU ward. Patients were randomly
placed into two groups of massage performed by patient’s companion and the control group. In the intervention group, whole body
massage was administered. The control group did not receive massage. Data analysis was performed using the SPSS 11.5 software.
Independent sample and Paired samples t-test, Chi Square and Fisher's Exact tests were used to analyze the data.
The mean age for the patients was 58.90 ± 15.63 years. None of them had the history of massage therapy. In the group massaged by
the patients' companions, the mean of blood cortisol was 323.6 ± 162.6 nanomoles which decreased to 268.4 ± 141.1 after the intervention (P
< 0.102). The mean of blood cortisol in the control group did not change significantly.
Massage therapy lowered the level of cortisol in the group massaged by the patients' companions. It can be recommended
that massage therapy be used in patients admitted in CCU.
Massage therapy; Relatives; Coronary patients; Cortisol
its aggravation, feeling choked and dyspnea, fear of los-
ing control and fear of death (8). This anxiety increases
Acute coronary syndrome and chronic myocardial in-
the oxygen demand of heart and accordingly increases
farction are among the commonest reasons for hospital-
the risk of cardiac dysfunction, dysrhythmia, ischemia,
ization at coronary care units (CCU) (1). Affliction to these
inefficiency and the likelihood of patient's death (9).
diseases is often accompanied by great fear and anxiety
Some studies have shown that anxiety and stress could
over the likelihood of death (2) and the feeling of anxiety
lead to the activation of the hypothalamus-hypophysis-
remains with patients and their families for some time
adrenal axis and an increase in the secretion of blood
(3). Some studies have shown that hospitalization at
cortisol (10-12). There are different methods for lowering
technologic wards such as CCU is also accompanied with
patients' stress and anxiety; however, medication treat-
anxiety (4). Factors such as lack of familiarity with envi-
ments are extensively used for lowering stress in patients
ronmental conditions, being far from family members,
alarms sounds and other environmental and psycho-
Considering the side effects of medical treatments, al-
logical stimulants increase the level of anxiety among
ternative methods may be used rather than drug therapy
patients at CCU wards (5). One study has indicated that
to decrease anxiety in patients (14). One of the supple-
50% of patients experience signs of anxiety following
mentary therapies recommended for lowering anxiety
acute coronary syndrome and myocardial infarction (6).
is massage therapy (14-17). Some researchers have report-
Another study in Iran has reported that 90% of these pa-
ed that lowering stress and anxiety reduces the level of
tients experience signs and symptoms of anxiety (7).
blood cortisol (18). Lindgren et al. have reported that mas-
Anxiety leads to palpitation, shivering, chest pain and
sage therapy leads to a reduction in salivary cortisol (11).
Implication for health policy/practice/research/medical education:
Massage therapy by the patient’s companions can reduce the blood cortisol level in patients admitted in CCU. Nurses are recommended to involve pa-
tients’ family members in the process of massage therapy for these patients. This may help to make patients calm and reduce the level of anxiety.
Copyright 2013, Kashan University of Medical sciences; Licensee Kowsar Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
Field et al. also examined the effect of massage therapy
Sample size was calculated based on a pilot study on
on the level of cortisol and reported that this method re-
seven samples in which the mean of blood cortisol was
duces the level of cortisol up to 31% (19). In another study,
333.89 and decreased to 278.77 after the massage therapy.
Field et al. reported that psychotherapy alongside mas-
The difference in the response was 55.12 ± 93.25. Then 24
sage therapy for 30 minutes bring about a reduction in
pairs of subjects were estimated to be needed (and we
the level of cortisol (20). Moyer et al. have also reported
selected 30 pairs) to be able to reject the null hypothesis
that massage therapy might increase the activity of the
that this response difference is zero with a power of 0.8.
Vagus nerve and decrease stress-related hormones (18).
The Type I error probability associated with this test was
Nonetheless, Billhult et al. and McVicar et al. did not find
0.05. Sampling was performed via the convenience sam-
a significant difference in the level of salivary cortisol
pling method and the patients were randomly assigned
level between massage therapy group and control group
into control and experiment groups, so that the sample
size was completed for each group. The process of sam-
The data collection instrument consisted of two parts.
Regarding the existing controversies about the effect of
The first part included a demographic data form (age,
massage therapy on the level of cortisol and the fact that
marital status, occupation, number of children, patient’s
no study is available about the effect of massage therapy
level of education, and patient’s companion level of edu-
by patient companions on the level of blood cortisol in
cation). Also, the medical diagnosis as inscribed in the
the patients hospitalized at CCU, and also because of high
file, and the history of hospitalization were extracted
workloads of nurses and this issue that patients might be
from the patient’s file. The second part of the instrument
more comfortable to receive massage by their relatives,
consisted of one form for recording the amount of corti-
and relatives also might feel more active in patients care,
sol both before and after getting massage.
the present study was conducted with the aim of evaluat-
In the intervention group, massage therapy was ad-
ing the effect of massage therapy performed by patients`
ministered in a private setting (in a private room or after
companion on the level of blood cortisol among patients
pulling curtains around the patient) in the third day of
hospitalization (due to going through the acute phases
of the disease and training the patient’s companion for
3. Patients and Methods
performing massage) after getting permission from the
treating physician and obtaining the patient’s consent.
A randomized controlled trial was conducted on 60 pa-
After the selection of patients and filling in the consent
tients admitted to the CCU wards of the Kashan university
form in the intervention group, the patients’ demo-
of Medical sciences. The eligible subjects for this research
graphic and clinical data were recorded in a special form
were identified through daily referring to the CCU wards
and also their blood samples were analyzed for the level
of Shahid Beheshti Hospital, Kashan, Iran, and going over
of cortisol and the results were recorded in the form.
their hospitalization records alongside consulting with
For each individual in the intervention group, one
60-minute session of massage therapy was performed by
The inclusion criteria included of being male, hospi-
one of his relatives. One of the male companions or rela-
talization at CCU ward, having the medical diagnosis of
tives of patient was selected by consulting with the pa-
acute coronary syndrome or myocardial infarction, be-
tient and was trained the manner of performing massage
ing literate, being completely conscious, having a three-
and accordingly evaluated. In case of being accepted, he
day record of hospitalization, willingness to participate
was allowed to give massage to his patient. Training each
in the study. Also not having the following conditions
of the companions was performed on an individual basis
were selected as additional inclusion criteria: a history
in a 2-hour session in the practice room at the nursing de-
of cardiac arrest during the recent 72 hours, being un-
partment on a human manikin by the second research-
der treatment by warfarin, any coagulation disorder, a
er who had a specialized degree in the field of massage
known psychological disorder, a cardiac pacemaker, a
history of second degree burn in more than 25% of the
Almond oil was used for facilitating whole body mas-
body surface, a known infectious disease or hepatitis and
sage in back, buttocks, shoulders, deltoid muscles, arms,
jaundice, a known adrenal gland disorder, a known skin
forearms, palm of both hands and fingers, the poste-
problem, fever, limb amputation, bone fracture in recent
rior part of thighs and ankles, foot soles, the front part
two months, deep vein thrombosis, a dialysis fistula in
of thighs and back of feet and toes, patient’s abdomen
limbs, and a history of massage therapy. Exclusion crite-
and chest, axillaries and neck muscles. The techniques
ria included of a reduction in the level of consciousness,
used in massage therapy included static massage, super-
bradycardia (less than 60 beats per minute), severe or ex-
ficial stretching technique, stretching massage, lymph
ertional dyspnea and any hemodynamic instability.
vacuuming technique, latitudinal rubbing technique,
and myofacial releasing technique (23), which were ac-
transferred to lab. All patients were massaged in the
companied with effleurage (gentle and light press while
evening shift and their blood samples were accord-
rubbing oil on body) (24). Massage was not performed in
ingly taken. The level of blood cortisol was identified
painful areas and areas with burn, bruise, inflammation,
by using the Immunotech Kits (Beckman Coulter Co.
thrombosis, ecchymosis, and skin wounds.
Czech) and according to the instructions given by the
Half an hour before and 15 minutes after the termi-
manufacturing company and using Gama Counter
nation of massage therapy (while patient was relax at
sets, model Genesys Gamma-1TM, made by LTI Com-
least for 15 minutes), the blood sample was obtained
pany (Laboratory Technologies INE) in America. In ad-
for measuring the level of cortisol. To this aim, four
dition, patients were monitored during the massage
milliliters of blood was taken from the patient’s arm
in a lab tube which was then placed in an ice box and
• Not meeting inclusion criteria (n= 18)
• Received allocated intervention (n= 35)
• Received allocated intervention (n= 35)
• Did not receive allocated intervention
• Did not receive allocated intervention
The Study Follow Diagram
No intervention was performed for the control group and
two groups. Paired samples t-test was used for comparing
the patients in this group merely received the routine care
the pre and post-intervention cortisol in each group, and
of the ward. Blood sample was taken in this group for identi-
the Chi Square test and the Fisher's Exact test were used to
fying the level of blood cortisol after filling in the informed
analyze the nominal and categorized data. In all tests, the
consent form and collecting the patients' demographic and
level of significance was considered to be 0.05.
clinical data in two rounds with a 105 minutes interval.
The mean of age for the research subjects was 58.90 ±
This study was approved by the Research Council and the
15.63 years. Among them, 90% were married and 10% were
Research Ethics Committee of Kashan University of Medi-
single or widowed. Also, 65% of patients currently had a
cal Sciences, Kashan, Iran. All the participants in this study
job and 35% were either jobless or had been retired. None
signed the informed consent form and were assured of the
of them had the history of massage therapy. Regarding
confidentiality of their individual information and of the
education, 70% were at elementary level and 30% were at
lack of coercion for taking part in the study. Data collec-
the high school or over. Most of the selected companions
tion was performed after making coordination with the
(76.7%) were the patients’ sons and the others were their
head-nurse at ward and the treating doctor. The research
brothers or friends. Most of the companions (86.7%) were
objective was explained to all the study subjects.
at high school education level. In total, 95% of patients in
the intervention group were very much or highly satis-
The mean of blood cortisol level before the intervention
After entering the data into the SPSS 11.5 software, the de-
was 323.6 ± 162.6 nanomoles in the intervention group
scriptive and analytical tests were used. Independent sam-
which was decreased to 268.4 ± 141.1 after the intervention
ple t test was used to compare the mean of cortisol in the
(P < 0.102). The mean of blood cortisol level in the control
group both before and after massage did not change sig-
The Patients’ Characteristics
Intervention, No. (%)
Control, No. (%)
Age, Mean ± SD
Patients’ level of education
Companions’ level of education
History of hospitalization
Satisfaction of massage
Changes in the Blood Cortisol Level
Intervention, Mean ± SD Control, Mean ± SD 95% confidence interval of the difference Test Results
P = 0.61t = 0.499
P = 0.36t = 0.915
P value of Paired t Test
tisol (18). Although the changes in the blood cortisol level
were not statistically significant in the present study,
The findings of this research indicated that whole body
the observed decrease may be clinically important and
massage therapy performed by patient's companion de-
signifies the effect of massage therapy. The small sample
creased the blood cortisol level more than 55 nanomoles.
size may be influenced on the statistical significance of
Field et al. have reported that massage leads to a decrease
the results. It is also likely that the duration of massage
in the level of blood cortisol(19). Besides, Lindgren et al.
in the present study was not sufficient enough to yield a
examined the physiological responses to massage among
significant difference among the two groups. Also other
healthy individuals and reported that salivary cortisol
variables might have been presented which were out of
was significantly decreased after massage compared to
the researcher's control and were effective on the level of
the pre-massage and one hour after massaging (11). How-
ever, there are some conflicting reports. Billhult et al.
All in all, the findings indicate that massage as an exter-
studied the effect of massage on cellular immunity, en-
nal stimulant may decrease anxiety and cortisol levels.
docrine and psychological factors in women with breast
Previous studies have also reported that hypothalamus-
cancer and reported no significant difference between
hypophysis-adrenal axis is activated during stress and
the level of salivary cortisol in the control and interven-
reacts to internal and external stimulants (25). Thus, it
tion groups (21). Also, by examining the effect of massage
could be supposed that massaging may alleviate anxiety
therapy on blood cortisol, Moyer et al. have reported that
which then may lead to a decrease in the blood cortisol
massage therapy has little effect on the level of blood cor-
This research examined the effect of massage therapy
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the directors and personnel of CCUs of Shahid Beheshti
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The authors are also thankful to all patients and their
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CF, 3rd, et al. Treatment-related alteration of cortisol predicts
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prepared the draft of the manuscript, made critical re-
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J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo
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performed the data analysis and supervised the study.
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Rajabi-Beheshtabad R performed the data collection.
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MRI to assess the contribution of gastric peristaltic activity and tone to the rate of liquid gastric emptying in health A. Steingoetter1, M. A. Kwiatek2, A. Pal3, G. Hebbard4, M. Thumshirn2, M. Fried2, J. Brasseur3, W. Schwizer2, P. Boesiger1 1University and ETH Zurich, Institute for Biomedical Engineering, Zurich, Switzerland, 2University Hospital, Division of Gastroenterology, Zurich, Swit