Emamkhomeini.yums.ac.ir

Research Article
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, Received: July 23, 2013; Revised: July 27, 2013; Accepted: July 27, 2013
Background: 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.
Objective: 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.
Results: 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.
Conclusions: 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.
Keywords: Massage therapy; Relatives; Coronary patients; Cortisol 1. Background
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- 2. Objective
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 Figure 1. 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.
4. Results
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- Table 1. The Patients’ Characteristics
Intervention, No. (%)
Control, No. (%)
Age, Mean ± SD
Medical diagnosis
Patients’ level of education
Companions’ level of education
History of hospitalization
Satisfaction of massage
Table 2. Changes in the Blood Cortisol Level
Cortisola
Intervention, Mean ± SD Control, Mean ± SD 95% confidence interval of the difference Test Results
P = 0.61
t = 0.499
P = 0.36
t = 0.915
P value of Paired t Test
5. Discussion
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 3. Kulkarni HS, Kulkarni KR, Mallampalli A, Parkar SR, Karnad DR, on the level of blood cortisol among the male patients Guntupalli KK. Comparison of anxiety, depression, and post- hospitalized at the CCU wards. It was indicated that after traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital. Indian J Crit Care Med. massage therapy, the level of cortisol had been lowered in 2011;15(3):147-56.
the intervention group. Although the resultant decrease 4. Abolhasani S. [Effects of sensuous stimulation on anxiety in the was not found to be significant. Regarding the effects of patients hospitalized in coronary care unit]. Sci J Kurdistan Univ Med Sci. 2007;12(2):46-52.
the massage therapy on lowering anxiety and cortisol 5. Marianne C, Burns SM. AACN Essentials of Progressive Care Nursing. levels and also its tranquilizing effect, it could be recom- New York: Mc GrawHill Companies; 2007. p. 13.
mended that massage therapy be used in patients admit- 6. Huffman JC, Smith FA, Blais MA, Januzzi JL, Fricchione GL. Anxi- ety, independent of depressive symptoms, is associated with in-hospital cardiac complications after acute myocardial infarc- The individual characteristics of researcher and wear- tion. J Psychosom Res. 2008;65(6):557-63.
ing white uniform might have been effective on the level 7. Beyraghi N, Tonekaboni SH, Vakili G. [Anxiety and depression in of anxiety and blood cortisol which was an issue out of patients admitted in cardiac care unit, Taleghani hospital, Teh- ran, Iran]. Hormozganm Med J. 2005;9(4):261-4.
the researchers' control. Regarding this point that mea- 8. Bastard J, Tiran D. Aromatherapy and massage for antena- suring the levels of blood cortisol was performed 15 min- tal anxiety: its effect on the fetus. Complement Ther Clin Pract. utes after the application of massage, it is recommended 2006;12(1):48-54.
to conduct further investigations to examine the level of 9. Ulvic B, Bjelland I, Hanestad B, Omenaas E, Wentzel - Larsen T, Nygard O. Comparison of the short form 36 and the Hospital blood cortisol in a longer interval after taking massage anxiety and depression scale measuring emotional distress in- so that the durability of blood cortisol reduction is pin- patients admitted for elective coronary angiography. Heart Lung. 2008;37(4):286-95.
10. Moraska A, Pollini RA, Boulanger K, Brooks MZ, Teitlebaum L. Physiological adjustments to stress measures following mas- Acknowledgements
sage therapy: a review of the literature. Evid Based Complement Alternat Med. 2010;7(4):409-18.
The researchers would like to express their gratitude to 11. Lindgren L, Rundgren S, Winso O, Lehtipalo S, Wiklund U, Karls- the directors and personnel of CCUs of Shahid Beheshti son M, et al. Physiological responses to touch massage in healthy Hospital of the Kashan University of Medical Sciences. volunteers. Auton Neurosci. 2010;158(1-2):105-10.
The authors are also thankful to all patients and their 12. Lenze EJ, Dixon D, Mantella RC, Dore PM, Andreescu C, Reynolds CF, 3rd, et al. Treatment-related alteration of cortisol predicts relatives who participated in this study. This study was change in neuropsychological function during acute treatment registered at Iranian registry for clinical trials with the of late-life anxiety disorder. Int J Geriatr Psychiatry. 2012;27(5):454-
13. Rincon HG, Granados M, Unutzer J, Gomez M, Duran R, Badiel M, et al. Prevalence, detection and treatment of anxiety, depres- Authors’ Contribution
sion, and delirium in the adult critical care unit. Psychosomatics. 2001;42(5):391-6.
Adib-Hajbaghery M and Rajabi-Beheshtabad R were re- 14. Wang AT, Sundt TM, 3rd, Cutshall SM, Bauer BA. Massage sponsible for the study conception and design; Ali Abasi therapy after cardiac surgery. Semin Thorac Cardiovasc Surg. helped in the process of sampling; Adib-Hajbaghery M 2010;22(3):225-9.
prepared the draft of the manuscript, made critical re- 15. Castro-Sanchez AM, Mataran-Penarrocha GA, Granero-Molina J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo visions to the paper for important intellectual content, C. Benefits of massage-myofascial release therapy on pain, performed the data analysis and supervised the study. anxiety, quality of sleep, depression, and quality of life in pa- Rajabi-Beheshtabad R performed the data collection.
tients with fibromyalgia. Evid Based Complement Alternat Med. 2011;2011:561753.
16. Frazier SK, Moser DK, Daley LK, McKinley S, Riegel B, Garvin BJ, et Financial Disclosure
al. Critical care nurses' beliefs about and reported management of anxiety. Am J Crit Care. 2003;12(1):19-27.
The authors declare that they have no competing inter- 17. Nerbass FB, Feltrim MI, Souza SA, Ykeda DS, Lorenzi-Filho G. Ef- fects of massage therapy on sleep quality after coronary artery bypass graft surgery. Clinics (Sao Paulo). 2010;65(11):1105-10.
Funding/Support
18. Moyer CA, Seefeldt L, Mann ES, Jackley LM. Does massage therapy reduce cortisol? A comprehensive quantitative review. J Bodyw This project was funded by the research deputy of Mov Ther. 2011;15(1):3-14.
19. Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C. Corti- Kashan University of Medical Sciences and specified as sol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115(10):1397-413.
20. Field T, Deeds O, Diego M, Hernandez-Reif M, Gauler A, Sullivan S, References
et al. Benefits of combining massage therapy with group inter- personal psychotherapy in prenatally depressed women. J Bodyw 1. Michalopoulou A, Tsios A, Vitos M, Liapi P, Mpizas L. Admissions Mov Ther. 2009;13(4):297-303.
to the Coronary Care Unit (CCU): Comparison with international 21. Billhult A, Lindholm C, Gunnarsson R, Stener-Victorin E. The ef- data. Hosp Chronic. 2008;3(4):182–6.
fect of massage on cellular immunity, endocrine and psycho- 2. Stromberg A, Jaarsma T. Thoughts about death and perceived logical factors in women with breast cancer -- a randomized con- health status in elderly patients with heart failure. Eur J Heart trolled clinical trial. Auton Neurosci. 2008;140(1-2):88-95.
Fail. 2008;10(6):608-13.
22. McVicar A, Greenwood C, Fewell F, D'Arcy V, Chandrasekharan S, Alldridge L. Evaluation of anxiety, salivary cortisol and melato- rage massage in recovery from fatigue in the adductor muscles nin secretion following reflexology treatment: a pilot study in of the thumb. J Manipulative Physiol Ther. 2005;28(9):696-701.
healthy individuals. Complement Ther Clin Pract. 2007;13(3):137-45.
25. McEwen BS. Central effects of stress hormones in health and 23. Shiri M. Massage Therapy. 2nd ed. Tehran: Aeeizh; 2010.
disease: Understanding the protective and damaging effects of 24. Young R, Gutnik B, Moran RW, Thomson RW. The effect of effleu- stress and stress mediators. Eur J Pharmacol. 2008;583(2-3):174-85.

Source: http://emamkhomeini.yums.ac.ir/uploads/nms-02-13781_11044.pdf