By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, August/September 2004.
Pain is an individual experience and, as pain expert Margo McCafferey notes, exists whenever the individual says it does.1 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the governing body of safety and quality in medical care, agrees and has now designated pain as a fifth vital sign, along with heart rate, respiration, blood pressure, and body temperature. Recognizing the patient’s right to effective pain management, the JCAHO issued a mandate, beginning Jan. 1, 2001, that all patients receive thorough assessment of their pain, according to intensity and quality, along with continued reassessment and appropriate treatment.2,3
While this is a step forward in re-establishing the human element in what has become a technologically-oriented medical system, pain management continues to be a major hurdle in postoperative care. According to a recently published study from an Ann Arbor VA hospital in Michigan, there’s more to pain than the sensory markers of quality and intensity. There’s also the personal perception of pain, the affective feeling of unpleasantness that can translate to suffering.
Relieving that suffering through application of massage was the focus of the research team Piotrowski et al. in their prospective randomized clinical trial (RCT) published in Journal of American College of Surgeons (December 2003). Their results show a strong effect for massage on reducing the unpleasantness of pain following surgery, suggesting its usefulness as an adjunct in acute postoperative care.4 Inspiration for this study came from team member Daniel Hinshaw, M.D., who, as a surgeon, is all too aware of the influence of suffering on his patients’ recovery.
“I think the challenge, as a surgeon who’s interested in this and concerned about it, is to emphasize to my surgical colleagues that the act of performing a successful operation is not the whole story,” Hinshaw says. “People have to recover in a context of caring. Oftentimes, we’re so focused on the task we don’t look at a person who’s gone through a major assault. They are also in need of comfort and some kind of reassurance. Their lives were on the line to a certain extent.”
In addition to psychological stress, the study states, “Pain limits physical functioning, including the ability to cough and deep breathe, move, sleep, and perform self-care activities.” These factors can contribute to postoperative complications and delay or threaten recovery. And despite the widespread use of opiates, “pharmacological interventions alone may not effectively address all the sensory and affective factors involved in experiencing pain.” The authors also point to other influences contributing to undertreatment, such as a patient’s fear of chemical dependency or side effects, or hospital staff’s personal beliefs, biases, or knowledge deficits regarding effective management. Pain is reported by surgical patients to be “one of the highest environmental stressors they encounter.”5
With these factors in mind, the Ann Arbor team surmised more effective pain control may be achieved by supplementing opioid care with complementary therapies. Massage has been proven to decrease pain in past studies, and it is this time-honored practice that Hinshaw recounts as having once been at the forefront of nursing care.
“One of the traditional providers of massage in hospitals was the registered nurse (RN). It was my memory of this that intrigued me — why aren’t we doing this? The more senior nurses had done this as part of their routine. They would give massage and patients would sleep better. It was the starting point for me of raising the question again. If you go back far enough, even in medical school curricula, a lot of medical schools would teach students how to do physical manipulations.” As institutional focus shifted to using drugs and what Hinshaw calls the “Holy Grail to stamp out disease,” massage fell by the wayside. Hinshaw says the role of today’s nurse is similar to that of physicians, with a checklist and little time for providing comfort. “There has been more emphasis on curing than providing quality of life.”
Applying the Power of Massage
As Hinshaw notes, the success of palliative care — the alleviation of discomfort — is as critical to recovery as the surgery itself. This study’s focus group was a population undergoing “operations associated with a significant degree of postoperative pain,”6 the majority of which were open heart surgeries. Although the team’s primary objective was to test for effectiveness of massage as an adjuvant to opioid therapy, their emphasis on the patient’s affective experience brings to light the importance of this component in pain assessment and management. The authors state, “The most compelling finding of this investigation was that massage significantly accelerated the rate of decline in pain unpleasantness as perceived by the patients.” From this, they surmise the primary effect of massage is on that affective component that may not respond so readily to opioids.7
To assess both sensory and affective perception of pain, two visual analogue scales (VAS) — one for pain intensity and another for unpleasantness — were utilized, allowing for this distinction in results.8 “If you do pain scales,” Hinshaw says, “they often don’t tease those factors out. It is important in the sense of emotional pain. It relates more to that person’s experience.” The JCAHO mandate for pain assessment, while progressive in intent, makes reference only to sensory markers. According to Hinshaw, this remains a prevalent trend in hospitals.
Although published as a preliminary study of men, the project included seven women among the total of 202 subjects. The disproportionate low number of female subjects does not allow for generalized application of results to this gender. The majority of participants were age 60 or older. Subjects were randomly assigned to groups receiving massage, focused attention, or routine care (control group). For both massage and focused attention, intervention administered by RNs took place on inpatient units for 10 minutes, twice a day, beginning 24 hours postoperatively and continuing through the seventh day. RNs trained by a certified massage therapist delivered effleurage back massage, while those providing focused attention allowed time for uninterrupted patient/nurse interaction, or silence if the patient preferred.9
In gathering data on focused attention, researchers were also interested in the impact of emotional support on pain relief independent of massage. Although results were not as pronounced as those for massage intervention, there was a slightly greater decrease (nonsignificant) in perceived pain for the focused attention group as compared to the control group. Decrease in pain intensity was greater for the massage group, but not statistically significant. In addition, data collected on daily use of opioids showed no differential decrease across the groups.10
At the conclusion of participation, subjects were also asked to rate satisfaction with the intervention received regarding its impact on pain experience. Both experimental groups reported a perceived improvement in pain control, with the highest rating in the massage group. That the massage group experienced a greater decline in perceived pain unpleasantness, as compared to focused attention, “suggests that physiologic responses to the massage may also be important,” the authors say.11
It appears that timing of intervention is a critical factor for integrating massage into postoperative pain care. While the focus of evaluation covered postoperative days two through seven, the authors write, “The greatest impact of both massage and focused attention was noted during the first 72 hours after an operation, suggesting that adjuvant interventions should begin as soon as feasible postoperatively.” After that, the impact may be decreased.12
“Postoperative pain is at its very peak when the patient is awake and out of anesthesia,” Hinshaw says. It then falls off, reaching a plateau by the fourth or fifth day. It’s not clear whether the fall off is clearly linear or hyperbolic. By obtaining information closer to the actual insult, researchers may have a better sense of the slope of that decline. While the team did say the rate of decline over time was more rapid in subjects receiving massage, Hinshaw says they are interested in honing in on the initial rate during the first few days. This aspect is being addressed in Ann Arbor’s larger-scale RCT now underway.
In the preliminary study, the authors cite a “frequent absence of preintervention pain data.” Noting more than half of the subjects missed their first pain evaluation before intervention was initiated, the team points to several factors involved including “patient sleeping, still on ventilatory support, or not yet enrolled in the study.”13 Hinshaw says the optimal situation would be to have subjects signed up prior to surgery, affording the opportunity to establish baseline pain levels. With the fair amount of emergency work involved in surgical units, that’s not always possible. “When patients are awake enough, it’s usually by 24 hours later. This impacts on the earliest scores, and that’s been a problem,” he says.
It should be noted that, through some happenstance of randomization, baseline levels of pain were slightly higher in the massage group at the outset,14 although Hinshaw says this did not impact statistical results. The randomization process itself resulted in a larger number of subjects assigned to massage (n=81) than the focused attention (n=66) and control (n=55) groups.15 Hinshaw explains that replacement of the original statistical consultant in mid-project, and a resultant switch in approach, was likely the cause of this imbalance of numbers.
Comfort, Care, and Cost
With the positive results of their preliminary study in hand, the team has embarked on a larger RCT, focusing on the first five days of postoperative care. Recruitment of subjects has been increased to two sites, including Ann Arbor and an Indianapolis hospital. Provision has been made to hire certified massage therapists for administering treatment, and enrollment numbers have reached mid-point of the projected goal. The new study also includes the use of devices worn by patients to measure sleep and waking activity, providing researchers with more objective information than nurses’ notes. Hinshaw predicts a possible completion of the project by 2006.
Part of the rationale for expanding the study is to further confirm the impact of massage on the affective component of pain, Hinshaw says. “Can we achieve better pain relief? At the first pass, it appears massage may be making a difference. The primary effect of massage appears to be on the affective (emotional) component of pain which may be less responsive to opiates. Thus, massage may add an additional element of pain relief not typically addressed by standard pharmacological approaches.”
The current study examines both acute and enduring effects of massage. “It’s very common for patients to fall asleep during massage,” Hinshaw says. Likely, they are experiencing great pain relief in the moment. But the team is also concerned with more lasting effects. “We’re trying to see at some point during the day, remote to intervention, what was their overall pain perception.
“We don’t really do a lot to comfort our patients,” Hinshaw says, noting the “hands-off” quality of current postoperative care. “But we have to be careful with massage. It is culturally driven, and some patients may view it as too much of an intrusion.” Even though cautionary, he says, “Massage creates a space and time in their care where the focus is entirely on the person and their comfort, and that’s what would be very unique about introducing it into healthcare.
“The challenge is that a hospital or healthcare system wouldn’t implement something like this unless there’s a marketing advantage,” Hinshaw says. “We’re gathering enough data where we might be able to speculate with some reason that perhaps patients get out of the hospital faster if they had massage introduced. We have a large population of patients receiving open heart surgery. The majority of open heart programs follow clinical pathways with designated clinical care. A lot of those landmarks relate to increasing return to function.” A proven shortened recovery period could be the incentive to introduce massage as a standard in postoperative pain management.