Original Article

From the Department of Midwifery,

Faculty of Nursing and Midwifery,

Ahvaz Jundishapur University of

Medical Sciences, Ahvaz, Iran.

Address correspondence to

Mrs. Shanaz Najar, MSc, Ahvaz

Jundishapur University of Medical

Sciences, Department of Midwifery,

Faculty of Nursing and Midwifery,

Ahvaz, Iran. E-mail: najarshanaz@

yahoo.com

Received December 26, 2011;

Revised July 16, 2012;

Accepted July 25, 2012.

1524-9042/$36.00

� 2014 by the American Society for

Pain Management Nursing

http://dx.doi.org/10.1016/

j.pmn.2012.07.008

Effect of Foot and HandMassage In Post–CesareanSection Pain Control: ARandomized Control Trial

--- Zahra Abbaspoor, PhD, Malihe Akbari, MSc,

and Shanaz Najar, MSc

- ABSTRACT:One of the problems for mothers in the post–cesarean section period

is pain, which disturbs the early relationship between mothers and

newborns; timely pain management prevents the side effects of pain,

facilitates the recovery of patient, reduces the costs of treatment by

minimizing or eliminating the mother’s distress, and increases

mother-infant interactions. The aim of this study was to determine the

effect of hand and foot massage on post–cesarean section pain. This

study is a randomized and controlled trial which was performed in

Mustafa Khomeini Hospital, Elam, Iran, April 1 to July 30, 2011; it was

carried out on 80 pregnant women who had an elective cesarean sec-

tion and met inclusion criteria for study. The visual analog scale was

used to determine the pain intensity before, immediately, and 90

minutes after conducting 5 minutes of foot and hand massage. Vital

signs weremeasured and recorded. The pain intensity was found to be

reduced after intervention compared with the intensity before the

intervention (p < .001). Also, there was a significant difference be-

tween groups in terms of the pain intensity and requests for analgesic

(p < .001). According to these findings, the foot and hand massage

can be considered as a complementary method to reduce the pain of

cesarean section effectively and to decrease the amount of medica-

tions and their side effects.

� 2014 by the American Society for Pain Management Nursing

Pain has harmful effects that prolong the body’s recovery after surgery and asa main social problem has involved millions of people in the world. Hundreds

of thousands of patients undergo surgery daily in the world and experience dif-

ferent levels of the pain intensity (Kuhn, Cooke, Collins, Jones, & Mucklow,

1990).

Various methods of pharmacologic pain control, such as patient-controlled

analgesia, continuous intravenous infusion, and intraspinal application of opi-

oids and/or local anesthetics, are currently in use; however, in analgesic appli-

cations, postoperative pain relief and patient’ satisfaction are still inadequateand may instead precipitate adverse side effects in many cases (Carr &

Thomas, 1997; Good et al., 1999; Warfield & Kahn, 1995). In one study, 23%

Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 132-136

133Foot and Hand Massage in Post–Cesarean Section Pain

of patients using postoperative analgesics experienced

adverse effects (Apfelbaum, Chen, Mehta, & Gan,

2003).

No pharmacologic pain-control methods or com-

plementary and alternative medicine (CAM) thera-

pies have become a common part of health care for

a number of Americans (Barnes, Bloom, & Nahin,2008). There are many complementary therapies,

such as massage, soothing music, relaxation, mind-

body techniques, reflexology, herbal medicines, hyp-

nosis, and therapeutic touch, that try to help manage

pain (Smith, Collins, Cyna, & Crowther, 2006;

Tournaire & Theau-Yonneau, 2007), but massage

therapy in particular appears to be a reasonable

CAM choice in the postoperative setting (Baueret al., 2010).

Nociceptors are the relatively unspecialized nerve

cell endings that initiate the sensation of pain. Also,

they are sensory receptors that send signals of pain

and are generally located at the surface of internal tis-

sues and beneath the skin, densely so in hands and

feet; therefore, foot and hand massage is considered

to be a significantly appropriate method in pain reduc-tion (Henderson, 2008).

Postoperative cesarean section pain is a common

cause of acute pain in obstetrics (Granot, Lowenstein,

Yarnitsky, Tamir, & Zimmer, 2003). According to a

ministry of health report in Iran, cesarean section is

one of the most common surgical operations, com-

prising 41.6% of all births with an increasing rate as

time goes by (Ministy of Health of Iran, 2006). Studiesin Iran show that several factors, over 4 decades, have

increased a general tendency among pregnant women

and health care providers to perform cesarean sec-

tion. Also, by expansion of specialized services and

the growing trend of hospital deliveries in Iran, deliv-

ery is considered as a medical problem and unneces-

sary medical interventions, such as cesarean section,

are offered for it.Owing to the high rate of problems in pain man-

agement in obstetrical settings and massage being

a cost-effective and safe method of postoperative

pain control, the present study was conducted to ana-

lyze effectiveness of foot and hand massage as a non-

pharmacologic method in post–cesarean section pain

management.

METHODS

SettingThis randomized controlled study was conducted at

the obstetrics ward of Mustafa Khomeini University

Education and Training Hospital in Elam City, Iran,

from April 1 to July 30, 2011.

SubjectsAmong 244 pregnant women attended for elective ce-

sarean section to the obstetrics ward of Mustafa Kho-

meini Hospital, we included a total 80 women whowere medically able to participate in massage therapy

after surgery.

Patients were selected by a random sampling

method; and they were evenly ordered and assigned

to one of two treatment arms: massage therapy and

control group, each of which included 40 patients.

Inclusion and Exclusion CriteriaWe includedonly thosewhogaveconsent toparticipate

in each groups of study, had been scheduled for electivecesarean operation by their obstetrician, and were

18-35 years old, 37-42 weeks’ gestational age, and

were on their second pregnancy with previous cesar-

ean section, estimated birth weight 2,500-4,000 g, and

transverse incision on uterus and abdomen in the previ-

ous cesarean section. The excluding criteria were as

follows: thosewho had not been able to verbally or non-

verbally report their pain intensity (n¼ 82), those whowere at risk of taking general anesthesia (n ¼ 8), fetal

death or discomfort in neonates (n ¼ 1), abnormal

body mass index in first trimester (n ¼ 4); those who

had damaged tissue and skin on their hands or feet or

acute phlebitis (n ¼ 4); those who had operating

room accidents (n ¼ 3), and those who had a different

surgeon for the operation (n ¼ 92); and 10 patients

were excluded from the study because of an uncomfort-able feeling about letting other people touch their feet.

Patients in the two groups were matched regarding an-

esthesia method,medication name and its dosage, same

surgeon, type of uterus and abdominal incision, and du-

ration of operation.

Data CollectionDatawere collected through a review of the medical re-

cords. Demographic characteristics included age, gesta-

tional age, body mass index, and diagnosis; and surgical

characteristics included type and date of operation andsurgeon’s name, which were collected via a patient in-

formation form. The history of analgesic use included

medication name, its dosage, and the last time it was

given. Patients reported measures of pain and overall

satisfaction before and after 90minutes of intervention.

The pain intensity was measured with the use of an 11-

point numeric rating scale (NRS). The intensity scale

ranged from 0 (no pain) to 10 (pain as bad as you canimagine). Patients circled a number on the scale indicat-

ing the intensity of pain experienced. The validity

and reliability of NRSs have been supported for mea-

suring pain intensity (Duncan, Catherine Bushnell, &

Lavigne, 1989; Wang & Keck, 2004). Vital signs of heart

134 Abbaspoor, Akbari, and Najar

rate, blood pressure, pulse, and breaths per minute also

were collected by the investigator before and after the

90-minute session.

Study ProceduresThe investigator explained the purposes and proce-

dures of study for patients who met the inclusion crite-

ria before obtaining written informed consent. Patientswere matched regarding anesthesia method, type of

medication and its dosage, same surgeon, type of inci-

sion on uterus and abdomen, and duration of operation.

The Foot and Hand Massage ProceduresFoot and hand massage include petrissage, kneading,

and friction applied to the patient’s hands and feet

with the use of classical massage techniques. Petrissageis the movement of the balls of the fingers and thumbs

to apply direct pressure in a slow and rhythmic fashion

to the soft tissue underlying the skin. Kneading is very

similar in action to wringing and usually follows in se-

quence. Compression on the muscle is achieved by al-

tering the direction in which the hands knead. Friction

is used only on small areas and is applied by pressing

with small circular movements using the pad of thehand or the fingers. When compressing and relaxing

the muscle tissue, blood and lymph circulation in-

creases, which removes lactic acid between the mus-

cle fibers and reduces fatigue and stress. Kneading

also has a mild toning effect on the muscles, improv-

ing muscle condition (Degirmen, Ozerdogan, Sayiner,

Kosgeroglu, & Ayranci, 2010).

InterventionMassage Therapy. Foot and hand massage was initi-

ated 1.5-2 hours after spinal anesthesia medication. Be-

fore the massage, the preintervention pain measures

and vital signs were conducted.

The massage was given to all of the patients by one

investigator, who had been given theoretical and practi-

cal training and was certified by a physiotherapist be-

fore the study. Patients were provided a comfortableposition and were asked to avoid talking during the in-

tervention unless necessary. Handmassagewas applied

to each hand for 5 minutes, avoiding the intravenous

catheter insertion area if present. Following hand mas-

sage, the patient’s foot was elevated by supporting it

with a pillow. The solewas spread and rubbed by the in-

vestigator’s fingers. The thumbwasused tomake circles

over the entire sole of the foot. The knuckles of onehand stroked the sole with an up-and-down motion.

The heel and ankle were kneaded between the investi-

gator’s thumb and forefinger. The pillow support was

removed to finish the massage. In total, each patient re-

ceived 20 minutes’ massage (Wang & Keck, 2004).

Control Therapy. Patients in the control group con-

tinued receiving standard care (e.g., medicationwas ad-

ministered) and the investigator stood near the patient

bed and talked to her for 20 minutes without any otherintervention. For deleting the psychologic effect, the

control group were located in a separate room. The

pain intensity of the patients was measured and re-

corded after the massage in both groups. The measure-

ments were repeated 90 minutes after the intervention

to determine the efficacy duration. In both groups, at

the request of a patient for pain relief, analgesics were

used and the analgesic name, dosage and times of usingwere recorded.

Statistical AnalysisStatistical analysiswas carried outwith SPSS software ver-

sion 13. Statistical analysis was performed using chi-

square test to compare patients’ characteristics in the

two groups. Repeated-measures analysis of variance test

was used to compare pain intensity scores before andright after and 90 minutes after intervention; and paired

t test was used for the comparison of each two time pe-

riods in two groups. Postmassage pain intensity scores

of both groups were compared using independent-

samples test. The difference between the pain intensity

measurements of the control group was verified with

t test.Data are expressed asmean andSD; the significance

level was set up at p < .05.

RESULTS

The mean age of patients was 28.28 years (SD 3). Base-

line patient characteristics were similar between themassage and control groups (Table 1). In the massage

group, there was a statistically meaningful difference

between pain intensity scores before and right after

the massage (p< .001) and pain intensity scores before

and 90 minutes after the massage (p < .001). A de-

crease of 3.47 points was indicated for the women in

the foot and hand massage group (premassage score

7.05 � 0.83, 90 minutes after massage 3.58 � 0.64).Also, in the massage group, there was a significant dif-

ference between pain scores right after massage and

90 minutes later.

In the control group, the pain intensity scores

were not significantly different before and after the

time of massage, but after 90 minutes, the patients

had a significant decrease in the pain intensity scores

(p ¼ .003). There was a decrease of 0.72 points inpain intensity after 90 minutes in the control group

(Table 2), which may be due to using more analgesic

in control group. All patients in both groups could

use analgesic for the pain relief if they had a request.

But the control group used analgesic more (Table 3).

TABLE 1.

Baseline Patient Characteristics

Characteristic Massage Group (n ¼ 40) Control Group (n ¼ 40) p Value

Age, y, mean (SD) 28.1 (2.9) 28.4 (3.2) .74BMI, (1st trimester) 22.6 (1.5) 23.02 (.74) .13Unwanted pregnancy, n (%) 8 (20%) 4 (10%) .34Birth weight, g, mean (SD) 3,170 (277.3) 3,188 (247.1) .79Previous surgery, n (%) 6 (15%) 7 (17.5%) .46Previous acute pain, n (%) 34 (85%) 36 (90%) .73Previous chronic pain, n (%) 0 (0%) 5 (2%) .49

135Foot and Hand Massage in Post–Cesarean Section Pain

DISCUSSION

The results indicated that 20 minutes of foot and

hand massage therapy is effective for reducing post–

cesarean section pain intensity within the first 90

minutes.

In a study conducted by Degirmen et al. (2010)

a decrease of 2.76 points was reported for the womenin the foot and hand massage group (Degirmen et al.,

2010). Nixon, Teschendorff, Finney, and Karnilowicz

(1997) and Brewer (1997) published similar findings.

Also, in a study conducted by Wang and Keck

(2004), 20 minutes foot and hand massages were

proved to be efficient in reducing postoperative pain,

indicating that pain intensity scores were reduced after

invention (Wang & Keck, 2004), but Hulme,Waterman, and Hillier (1999) did not obtain significant

results on pain intensity scores from a 5-minute foot

massage, which suggests that the duration of massage

may play an important role in its effect on postopera-

tive pain.

Findings of the measurements recorded 90 min-

utes after the massage were assessed to be lower than

those right after the massage, which implied that theefficacy of performing the once-only massage remains

after 90 minutes. In our study, patients could use an-

algesic if they made a request. However, the study by

Hattan, King, and Griffiths (2002) indicated that per-

forming the massage only once would not be as effec-

tive as regular performances. This intervention may

TABLE 2.

Comparison of the Pain Intensity Levels [mean (SD)] oon NRS as Measured Before, Right after and 90 Minu

Massage Group (n ¼ 40)

Before the massage 7.05 (83)Right after massage 4.9 (.7)90 min after massage 3.58 (.64)

have potentially more effective clinical pain control

when it is combined with other regimens.

It was further reported that performing the mas-

sage intervention resulted in a considerable decreasein the use of analgesic in the massage group compared

with the control group during the first 90 minutes.

There was a significant different between massage

and control groups in all analgesic types, including

Diclophenac (supp or amp) and Petedine.

CONCLUSION ANDRECOMMENDATIONS

Based on the findings of this study, foot and hand mas-

sage, a nonpharmacologic intervention, appears to be

a useful, economic, and effective method in reducing

post–cesarean section pain level.

The massage skills do not require extensive train-ing, and they can easily be used. Massage may be a ben-

eficial noninvasive pain management strategy for

patients whose pain is not adequately controlled by

medication. Finally, it is advised that further trials are

required to monitor pain for a longer period and to as-

sess the impact of massage frequency on the efficacy

of the massage in pain reduction after cesarean

section.

Strengths and LimitationsA strength of this study compared with other reportswas that patients were randomized to control and

f Women in Massage and Control Groups Basedtes after the Massage Intervention

Control Group (n ¼ 40) p Value

6.97 (.89) <.0016.91 (.84) <.0016.23 (.68) <.001

TABLE 3.

Comparison of the Use of Analgesic and Opioid Medication [n (%)] of Women in Massage and ControlGroups During the 90 Minutes after the Massage Intervention

Massage Group (n ¼ 40) Control Group (n ¼ 40) p Value

Diclophenac (supp. or amp.) 6 (15%) 28 (70%) <.001Petedine 0 (0%) 3 (7/5%) <.001Without drug 34 (85%) 9 (22.5%) <.001

136 Abbaspoor, Akbari, and Najar

massage therapy groups. Massage was performed for

all of the women by one trained massage therapist as

a second investigator.Based on the results, and evidence available, effec-

tiveness of pain control massage when it is combined

with other regimens and the duration and frequency

of the intervention are debatable.

Acknowledgments

The authors are indebted to those who commented on early

drafts of this article, in particular, M. H. Haghighizadeh, MSc,

Department of Statistics and Epidemiology, for his full and

helpful comments and doing statistical analysis. The authors

also acknowledge the deputy vice-chancellor for research af-

fairs, especially the Research Consultant Center.

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