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Complementary Therapies in Nursing & Midwifery (2004) 10, 209216

The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients
Esther Moka,*, Chin Pang Woob
Department of Nursing, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong b Wong Chuk Hang Hospital, Hong Kong
a

KEYWORDS
Massage; Anxiety; Pain; Stroke patients

Summary This study explores the effect of slow-stroke back massages on anxiety and shoulder pain in hospitalized elderly patients with stroke. An experimental quantitative design was conducted, comparing the scores for self-reported pain, anxiety, blood pressure, heart rate and pain of two groups of patients before and immediately after, and three days after the intervention. The intervention consisted of ten minutes of slow-stroke back massage (SSBM) for seven consecutive evenings. One hundred and two patients participated in the entire study and were randomly assigned to a massage group or a control group. The results revealed that the massage intervention signicantly reduced the patients levels of pain perception and anxiety. In addition to the subjective measures, all physiological measures (systolic and diastolic blood pressures and heart rate) changed positively, indicating relaxation. The prolonged effect of SSBM was also evident, as reected by the maintenance of the psycho-physiological parameters three days after the massage. The patients perceptions of SSBM, determined from a questionnaire, revealed positive support for SSBM for elderly stroke patients. The authors suggest that SSBM is an effective nursing intervention for reducing shoulder pain and anxiety in elderly patients with stroke. From a nursing perspective, this nursing practice provides a challenge and an opportunity for nurses and family caregivers to blend alternative therapies with technology to provide more individualized and holistic patient care. & 2004 Elsevier Ltd. All rights reserved.

Introduction
Stroke, being the fourth most common cause of death in Hong Kong, is one of several chronic diseases that cause the greatest burden in terms of physical disability for individuals and utilization of health services in later life.1 The prevalence of anxiety following stroke is relatively high and long lasting. According to Starkestein et al.2, Castillo
*Corresponding author. Tel.: 852-2766-6410; fax: 8522364-9663. E-mail address: hsemok@inet.polyu.edu.hk (E. Mok).

et al.3, and Astrom4, 2427% of stroke patients suffered from severe anxiety in the acute stage, and the condition can last for more than three years. Shoulder pain is one common complication that may impede the process of rehabilitation as it can interfere with self-care, balance, transfers of patients and ambulation; in addition, greater anxiety and frustration can further lead to failure to respond to rehabilitation.5 The conventional treatments for anxiety and shoulder pain in stroke patients range from medication to psychological support, and can offer some degree of relief under certain circumstances.6

1353-6117/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctnm.2004.05.006

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210 E. Mok, C.P. Woo

Some researchers and clinicians are beginning to promote non-pharmacologic interventions such as the use of massage to relieve of pain and anxiety in a variety of patients. Examples include the reduction of pain and anxiety in cancer patients7 and the reduction of anxiety in elderly patients.8 Dunn et al.9 also found that patients who had received massages in an intensive care unit expressed an improvement in mood, body image, self-esteem and perceived levels of anxiety. Farrow10 examined the physical effects of massage and found that this included relief from pain as a result of muscle relaxation and the release of enkephalins. Massage is one of the most common complementary therapies in nursing practice. It is well documented that massage therapy has been used throughout the world for thousands of years, and that touching, stroking and gentle massage can be a soothing and enjoyable experience.11 Slow-stroke back massages were originally described by Elizabeth12 as a slow rhythmic stroking with the hands, at a rate of 60 strokes per minute and lasting for 310 min. Weinrich and Weinrich7, Meek13, Groer et al.14, and Richards et al.15 have shown that the technique of SSBM is relatively straightforward and simple. It is easy to administer, non-threatening, non-invasive and relatively inexpensive to provide. The effects of SSBM on patients indicate that SSBM is effective in reducing anxiety over pain for cancer patients.7 Corley et al.16 did not nd a signicant decrease in heart rate or blood pressure after the back rub, although the mean values decreased. It seems that the results are inconsistent, ranging from arousal to no effect to relaxed effect.13,17,18 Nevertheless, among the studies, signicant results in the reduction of anxiety and pain were reported. In a critique of massage research methodology, Crawley19 related that future studies should be experimental or quasi-experimental to demonstrate relationships of cause and effect, should have larger sample sizes with equal gender representation, should use a variety of reliable and valid measurement tools, and should provide some consistency in the massage intervention. Thus, additional research is needed with a more rigorous design to test the hypothesis. Moreover, SSBM interventions for elderly stroke patients in a Chinese population have not been previously tested. We therefore assessed the effectiveness of SSMB as a relaxing modality by measuring the patients vital signs and self-reported levels of anxiety and pain before and after the intervention. The measures were taken again three days after the completion of the intervention, to determine the sustainability of the effect of the massage. The study also aims to determine the broader effects of

SSBM by asking patients about their perceptions of SSBS as a nursing intervention.

Study design
An experimental quantitative design, the comparing anxiety levels, blood pressure, heart rate and pain scores of two groups of patients immediately before and after, and three days after the massage intervention (i.e., control group and experimental group).

Objectives
The objectives of this study are to 1. Determine whether SSBM has an effect on lowering the subjective level of anxiety of patients immediately and three days after the cessation of SSBM. 2. Determine whether SSBM has an effect on lowering the blood pressure and heart rate of patients immediately and three days after cessation of SSBM. 3. Determine whether SSBM has an effect on lowering the patients subjective perceptions of pain immediately and three days after the cessation of SSBM. 4. Explore perceptions of patients towards SSBM after the intervention.

Conceptual framework
This study hypothesized that slow-stroke back massage would reduce levels of pain and anxiety in the patient. Anxiety is dened as a vague feeling of uneasiness or apprehension. Several explanations have been put forward on the possible mechanism for the effects of massage on the anxiety that patients feel over pain. The gate control theory is the most widely used explanation for the effects of massage.20 The theory proposes that a gating mechanism in the dorsal horn of the spinal cord opens to permit the transmission of the pain stimulus. Massage closes the gate by stimulating the peripheral large bres, thereby inhibiting the transmission of pain. Another theory employed to explain the effectiveness of massage is Selyes stress theory. This is an integrated physiological response originating in the hypothalamus that leads to a generalized increase or decrease in the arousal of the central nervous system. Massage, which produces relaxation by decreasing the tension in the muscles, is the opposite of the stress response. The promotion of relaxation and relief from anxiety

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The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients 211

may work by reducing muscle spasms and, in turn, aiding pain relief.

Methodology of the study

The study was approved by the ethical committee of both The Hong Kong Polytechnic University and the Hospital. The intervention was conducted for six months. Before proceeding to the main study, a pilot study of 12 patients was performed and a medium effect size resulted. The results of the pilot study indicated that an 80% power at the 0.05 level of signicance would require that there be at least 55 subjects in each group (power analysisPASS 6.0).

Study sample
The study took place in a rehabilitation hospital in Hong Kong. The subjects were selected using the following inclusive criteria: (i) Stroke patients experiencing shoulder pain (ii) Patients 65 years of age or older (iii) No history of bradycardia, hypotension, spinal and skin disorders as well as malignancy of the spinal column (iv) Not receiving any types of pain-relieving measures (v) Able to comprehend verbal instructions. . One hundred and thirty patients approached to participate in the study, and 118 patients participated, meaning that 90% of them agreed to participate. The patients were assigned to the experimental group or the control group by a random drawing of lots. Only one researcher collected the data in order to ensure consistency in data collection.

3. Place the palm of one hand at the base of the skull and make a long, smooth stroke all the way down the patients spine to his/her waist. The second hand follows the rst at the base of the skull and strokes down the spine as the rst hand returns to the base of the skull. 4. Place your hands on either side of the neck under the patients ears and stroke down and over the patients collarbones with your thumbs just over the shoulder blades. Repeat the motion several times. 5. Place the thumb of each of your hands beside the spine, beginning with the shoulders, and move the thumbs down the spine to the waist. Repeat several times. 6. Finish by placing your palms on each side of the patients neck and make continuous, long sweeping strokes down the neck, across each shoulder, and down the back near the spine. Repeat the entire pattern several times.

Instruments
We assessed the effectiveness of the massage by measuring the patients vital signs, self-reported anxiety and perceptions of pain before and after the intervention, and three days following the completion of the intervention. The research nurse measured the blood pressure and heart rate of the patients using the automated portable Dinamap blood pressure and heart rate monitor. Prior to the experiment, the machine was calibrated according to the manufacturers set tolerance level. The patients reported their levels of anxiety by completing the state portion of the State-Trait Anxiety Inventory (STAI). Only the state anxiety portion of the Chinese STAI (C-STAI) version was used to measure the patients anxiety because it is a transitory emotional state, and can provide a measure of an individuals level of anxiety in that current situation. The reliability and validity of this inventory have been well-documented and the alpha reliability coefcients range from 0.83 to 0.92 for state anxiety scores. The C-STAI was tested in Hong Kong and was found to possess high reliability.21 The Vertical Visual Analogue Scale (VAS) with the phases no pain and worst pain placed at the bottom and top of the line, respectively, was used to measure the patients perceptions of pain. The convergent validity of the VAS was tested with a Geriatric Depression Scale; strong and positive correlations between pain and anxiety were found17. VAS has also been validated by Aun

Slow-stroke back massage

Slow-stroke back massage was originally described by Elizabeth12 as a slow rhythmic stroking with the hands. The procedure of the massage consists of the following steps: 1. The patient should be either seated in a chair leaning over a table on to a pillow or lying in a prone position. 2. Firmly grasp the top of the patients shoulders with both hands and place the thumbs of each hand just below the base of the skull, making tiny circular movements on the upper neck.

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212 et al.22, by Sze et al.23 and by Tian24 and has been found to be a valid tool. E. Mok, C.P. Woo

Results
Of the 118 subjects who started the study, 102 (86%) remained in the study and two (1.7%) withdrew during the initial process of data collection for personal reasons. Fourteen (12%) were excluded because they were incapable of assigning scores to items in the VAS despite having been given clear instructions prior to being exposed to the VAS. The failure to score could be attributed to their poor abstract conceptualization of the intensity of pain along a line. Impaired mobility and poor visual acuity may have also limited their ability to mark the appropriate spot on the line. The failure to score was comparable to the ndings of Aun et al.22 that about 14% of the Chinese patients in their study were not capable of using the VAS. Among the 102 subjects who participated the entire study, fty-one (50%) were males and ftyone (50%) were females. The ages of the subjects ranged from 65 to 85 years, with a mean age of 73.2 years (SD 6.60). Apart from the diagnosis of stroke, the subjects were also suffering from diabetes mellitus (n 28; 27%), urinary tract infection (n 35; 34%), chest infection (n 19; 19%) and mild anaemia (n 8; 8%.). A two-sample t-test for independent groups to detect any baseline differences in each of the pretest variables was performed, and a p value of o0.05 was established as the level of signicance. The test revealed that there were no signicant differences in age, anxiety level, heart rate, and systolic and diastolic blood pressure and pain score at pre-assessment (Table 1). A two-sample t-test for independent groups was conducted to detect differences in the aforesaid variables after the massage intervention by immediate rating. It revealed that the patients who had received the massage intervention had signicant lower values in all ve variables than patients in the control group (Table 2). A two-sample t-test for independent groups was conducted to detect differences in the aforesaid variables three days after the completion of the massage intervention. The test revealed that the patients who had received a massage intervention had signicantly lower values in all ve variables than patients in the control group three days after cessation of massage intervention (Table 3). Repeated measures ANOVA with one withinsubject factor (time of measurement: three levels) and one between-subject factor (experimental vs. control groups: two levels) was used to compare the mean A-State scores, the systolic and diastolic blood pressure and the pain scores of the two groups over the three time periods. In the test, the

Evaluation questionnaire
A semi-structured questionnaire with open-ended questions related to the patients perceptions of the massage was given to the experimental group three days following the completion of the massage intervention.

Procedure for sampling

The participation of the patients in this research study was entirely voluntary. The purpose of the investigation was explained to the patients prior to the study, and their written informed consent was obtained.

Data collection for the experimental group

Patients in the experimental group were given a massage near the side of their bed, with a curtain screened both to provide privacy and to minimize unnecessary movement, and thus, change in the physiological parameters. The temperature of the room was maintained at 221C. Systolic and diastolic blood pressure, and the heart rate of each subject were measured by an independent assessor. Patients were also asked to complete the C-STAI scale and VAS before undergoing the massage intervention. The massage intervention was given before bedtime for 10 min as described above for seven consecutive days, in addition to the routine nursing care. On the seventh day, after the massage intervention, the patients were asked to rate the items on the state portion of the STAI and on the pain score, and the same physiological measurements were taken. The same measurements were repeated three days following the cessation of the massage. In addition, the patients were asked to comment on their perceptions of the SSBM intervention by completing a questionnaire.

Data collection for the control group

Patients in the control group were not offered the SSBM intervention. Their vital signs were taken before and after the intervention as well as three days after the intervention. The patients also completed the state portion of STAI and the VAS, but were not required to ll in the evaluation questionnaire.

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Table 1 Two-sample t-test for Independent groups comparing the pre-test scores of the experimental and control groups. Variable Control group(n 51) Mean Age Anxiety level Heart rate Systolic BP Diastolic BP Pain score 73.1 40.7 80.0 139.6 78.2 44.2 Standard deviation 6.64 6.06 6.07 8.65 5.47 7.03 Experimental group(n 51) Mean 73.3 42.8 82.2 142.0 80.5 44.2 Standard deviation 6.62 6.66 5.11 7.50 6.34 6.06 Pre-test comparison t Value 0.16 1.66 1.98 1.49 1.94 0.02 p Value 0.870 0.099 0.051 0.139 0.055 0.988

Table 2 Two-sample t-test for independent groups comparing the post-test scores of the experimental and control groups. Variable Control group Mean Anxiety level Heart rate Systolic BP Diastolic BP Pain score 40.9 80.5 140.2 78.4 44.4 Standard deviation 5.86 6.38 8.54 5.64 6.86 Experimental Group Mean 28.6 71.6 129.3 68.5 29.6 Standard deviation 4.34 5.38 8.51 5.87 7.56 Post-test comparison t Value 12.02 7.66 6.46 8.67 10.35 p Value o0.05 o0.05 o0.05 o0.05 o0.05

Table 3 Two-sample t-test for independent groups comparing the results of the experimental and control groups three days after the completion of the massage intervention. Variable Control group Mean Anxiety level Heart rate Systolic BP Diastolic BP Pain score 40.9 80.4 139.2 78.2 44.3 Standard deviation 5.98 6.46 8.11 5.46 6.97 Experimental group Mean 28.1 72.2 129.6 68.6 29.6 Standard deviation 3.62 5.45 8.59 5.75 6.53 Three days post-test comparison t Value 13.8 6.93 5.80 8.62 10.10 p value o0.05 o0.05 o0.05 o0.05 o0.05

patients in the experimental group demonstrated a signicant decrease from pre-test to post-test in all ve variables (Table 4). The results also provided evidence that the effect of the massage intervention could be sustained three days after the massage. However, patients in the control group demonstrated no signicant differences from pre-test to post-test and three days after the post-test in anxiety level, heart rate, diastolic and systolic blood pressure, and pain scores (Table 4).

level and pain intensity over time in the experimental group were analysed by repeated measures ANOVA with one within-subject factor (time of measurement: three levels). It revealed no signicant gender and age differences for the effect of SSBM on these variables over time with p40:05 (Table 5).

Patients perceptions of the massage intervention

Thirty-seven participants (72.5%) in the experimental group responded to the open-ended questions on their perceptions and preferences towards massage. All of the participants said that the massage intervention helped to relieve their pain,

Gender and age differences

The potential impact of gender and age differences for the effect of SSBM on mean systolic and diastolic blood pressure, heart rate, state anxiety

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Table 4 Repeated measures ANOVA of the different variables at pre-test, post-test and post-test T2 (three days after the completion of the intervention) between the control and experimental groups. Variable Control group Mean7SD Anxiety level Pre-test vs. post-test Post-test vs. post-test T2 Pre-test vs. post-test T2 Heart rate Pre-test vs. post-test Post-test vs. post-test T2 Pre-test vs. post-test T2 40.776.06 40.975.86 40.776.06 80.876.07 80.576.38 80.076.07 F p Experimental group Mean7SD 42.876.66 28.674.34 42.876.66 82.275.11 71.675.38 82.275.11 F 28.674.34 232.06 28.173.62 2.26 28.173.62 299.94 71.675.38 269.10 72.275.45 3.39 72.275.45 249.27 p 0.000 0.139 0.000

40.975.86 1.07 0.306 40.975.98 0.08 0.785 40.975.98 3.77 0.058 80.576.38 2.88 0.096 80.476.46 0.19 0.667 80.476.46 2.32 0.134

0.000 0.072 0.000

Systolic BP Pre-test vs. post-test 139.678.65 140.278.54 2.02 0.162 142.077.50 129.378.51 372.25 Post-test vs. post-test T2 140.278.54 139.278.11 2.62 0.112 129.378.51 129.678.59 3.22 Pre-test vs. post-test T2 139.678.65 139.278.11 0.75 0.391 142.077.50 129.678.59 334.74 Diastolic BP Pre-test vs. post-test Post-test vs. post-test T2 Pre-test vs. post-test T2 Pain score Pre-test vs. post-test Post-test vs. post-test T2 Pre-test vs. post-test T2 78.275.47 78.475.64 78.275.47 44.277.03 44.276.86 44.277.03 78.475.64 0.82 0.371 78.275.46 1.08 0.303 78.275.46 0.20 0.659 44.476.86 0.88 0.354 44.376.97 0.13 0.723 44.376.97 0.86 0.357 80.576.34 68.575.87 80.576.34 44.276.06 29.677.56 44.276.06 68.575.87 298.09 68.675.75 1.14 68.675.75 296.45

0.000 0.079 0.000

0.000 0.29 0.000

29.677.56 331.64 0.000 29.676.53 0.000 0.971 29.676.53 444.17 0.000

Table 5 Variables

Gender and age interactions with other variables. Interaction with gender df F 60.22 72.56 54.98 52.88 88.47 1.07 0.14 2.82 0.36 0.35 p 0.321 0.813 0.094 0.571 0.688 Interaction with age df 1.26, 1.51, 1.15, 1.10, 1.84, 60.22 72.56 54.98 52.88 88.47 F 1.72 1.72 0.59 2.12 3.28 p 0.195 0.192 0.466 0.149 0.064

Anxiety level Heart rate Systolic BP Diastolic BP Pain score

1.26, 1.51, 1.15, 1.10, 1.84,

helped them relax, and enabled them to sleep better. One participant stated: I was not able to sleep for a long time after the illness. I looked at the clock every hour during the night, waiting for the time to pass. Since I had the massage last week, I was able to sleep well, which I had not done for weeks. The massage helped me to relax, which enabled me to have good sleep. However, ve participants expressed the view that they were initially apprehensive about the intervention. As one of them stated: The rst time I had the massage, I was quite apprehensive as I was not sure whether the back

massage would work or not y and I found it hard to relax. However, as time went by, I found the massage really relaxing and comfortable. Some participants said that massage was a means through which nurses expressed their caring attitude. One participant said: The nurses are all very busy, and because they are so busy that they dont have time to touch me. They touch us only when they are performing their nursing tasks. I understand there is shortage of nurses; however, I still wish they could sit down, pat my shoulder and chat with me. I am very satised with the nurses massage; I only wish they could do it more often.

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Discussion
It was hypothesized that patients who had the massage intervention would experience signicant lower levels of anxiety and have lower blood pressure, heart rates and pain scores than those who had not had the massage intervention. The results supported the hypothesis and revealed that patients in the experimental group had signicant lower anxiety levels, blood pressure, heart rates and pain scores than patients in the control group. For the within-group analysis, patients in the experimental group demonstrated a signicant decrease from pre-test to post-test in anxiety levels, blood pressure, heart rates and pain scores; while the patients in the control group did not show any differences. These ndings were consistent with the results by Longworth25, Fakouri and Jones26, Ferrell-Torry and Glick27, and Meek13, who found that massage promotes relaxation, comfort and sleep. In contrast, the results differ from those of Bauer and Dracup28 and Dunn et al.9, who showed that there was no decrease in the blood pressure and heart rate of the participants after the massage, although there was decrease in perceptions of anxiety. Possible explanations for the inconsistencies might be differences in methodology and sample. For instance, the massage administered in this study was 10 min daily for 7 consecutive days, vs. 3 30 min in a single session in other studies. Other factors affecting the results are gender differences, stage of the illness, age of the patients, as well as whether the patients pain is acute or chronic. Moreover, the ndings from the descriptive data support the conclusion that, from the patients perspective, massage is considered helpful. It helps patients relax, lessens their pain and helps them to sleep. Moreover, some participants stated that they considered massage to be an expression of the nurses care and concern. It seems that the patients identify massage as something different from the task-oriented or procedural touch. The massage intervention serves to reassure and calm the patient. It represents a nurses response to a patient needs that is not treatment-related. It can be characterized as a personalized approach to giving assistance, which gives the patient a sense of connection. However, it is important for nurses to fully understand the indications and contraindications for massage. In addition, nurses should thoroughly assess and evaluate each patients response to massage, particularly those patients whose haemodynamic status is unstable.

Limitations of study
The generalizability of the study is limited by the fact that all of the data were collected in one hospital; therefore, any conclusions and generalizations that are reached may be applicable only to this particular population. Another important factor that might have affected the results that, when the participants lled in the S-STAI scale, although the term anxiety in Chinese does not appear in the scale, other descriptors related to anxiety might have caused the participants to guess the hypothesis of the research study and alter their behavior accordingly. The study is limited by the lack of control over the Hawthorne effect. As the nal measurement took place after three days, it is not known if the benets could be further sustained. Its clinical signicance is therefore limited. The resource implications of the intervention (a 10-min daily massage) are considerable and as the technique of SSBM is relatively simple, it is suggested that it can be taught to family caregivers. Additional research is warranted to examine the extent to which SSSBM can control pain and relieve anxiety when the intervention is given by family members. It would also be interesting to examine how SSBM changes the levels of relaxation and anxiety associated with other stroke-related pain conditions in elderly patients. Does the effectiveness of SSBM for pain control and anxiety reduction in elderly stroke patients extend beyond three days after its cessation?

Conclusion
This study supported the view that SSBM can reduce anxiety and pain in elderly stroke patients in a rehabilitative setting. In addition, its lasting effect were also been demonstrated through the maintenance of psychophysiological parameters for three days following the message. The effectiveness of SSBM was substantiated by the participants, who felt that SSBM helped them to relax, relieved their pain and helped them fall asleep. The results of this study supports the view that SSBM, as an alternative adjunct to pharmacological treatment, is a clinically effective nursing intervention for reducing anxiety and shoulder pain in elderly stroke patients.

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Facts do not cease to exist because they are ignored. (Aldous Huxley)