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Effects of Massage Therapy on Clinical Symptoms of Older People

Authors:
  • Mardin Artuklu Üniversity

Abstract

Nurses can improve outcomes of patient care by integrating complementary and alternative therapies with traditional medical practices. Among the non-pharmacological methods that can be used in geriatrics and gerontology are massage, aromatherapy, relaxation, meditation , therapeutic touch, biofeedback (neurotherapy), guided affective imagery (creative psychotherapy), reflexology, acupressure, and naturopathy. Massage therapy attracts the attention of healthcare professionals, patients, and families because it improves many symptoms, it has no side effects, it is easy to learn and apply, and is safe, effective, and economical. Massage therapy is used in geriatric patients for various purposes. For instance, it is effective in the management of pain, agitation, stress, anxiety, worry, and depression, it relieves constipation and improves the range of motion of the joints. Massage therapy together with pharmacological treatments reduces many symptoms of neurological diseases and neurological disease-associated risks, and it has a safe, supportive and positive effect. It is thought that this review, based on the effects of massage therapy, can be a guide especially for nurses working with elderly patients in the neurology clinic.
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Effects of Massage Therapy on Clinical Symptoms of Older People
Abstract
Nurses can improve outcomes of patient care by integrating complementary and alternative
therapies with traditional medical practices. Among the non-pharmacological methods that
can be used in geriatrics and gerontology are massage, aromatherapy, relaxation, medi-
tation, therapeutic touch, biofeedback (neurotherapy), guided affective imagery (creative
psychotherapy), reflexology, acupressure, and naturopathy. Massage therapy attracts the
attention of healthcare professionals, patients, and families because it improves many
symptoms, it has no side effects, it is easy to learn and apply, and is safe, effective, and
economical. Massage therapy is used in geriatric patients for various purposes. For instance,
it is effective in the management of pain, agitation, stress, anxiety, worry, and depression,
it relieves constipation and improves the range of motion of the joints. Massage therapy
together with pharmacological treatments reduces many symptoms of neurological dis-
eases and neurological disease-associated risks, and it has a safe, supportive and positive
effect. It is thought that this review, based on the effects of massage therapy, can be a guide
especially for nurses working with elderly patients in the neurology clinic.
Keywords: Elderly, symptom, massage therapy
Introduction
Aging is a universal and irreversible process of change, starting from birth continuing to
death, which causes a reduction in all functions.1 The aging process is accompanied by
symptoms such as loneliness, depression, physical dysfunction, pain, and helplessness,
and there is a need for a multidisciplinary approach to remove or relieve these symp-
toms. In this regard, the use of complementary and alternative therapies is a supportive
approach to the treatment of symptoms and rehabilitation in old people.2 Nurses can
improve the results of patient care by integrating complementary and alternative thera-
pies with traditional medical interventions.3 Among the non-pharmacological methods
that can be used in geriatrics and gerontology are massage, aromatherapy, relaxation,
meditation, therapeutic touch, biofeedback (neurotherapy), guided affective imagery
(creative psychotherapy), reflexology, acupressure and naturopathy.2
Older adults, compared to young people, are prone to long-term chronic illnesses such
as arthritis, heart and lung diseases, Parkinson’s disease, dementia, Alzheimer’s dis-
ease, and diabetes. This increases the cost of health care, and so increases the use of
complementary therapies.4 In America, 31% of adults aged 50 or overuse complemen-
tary therapies.3,4 Studies found that the frequency of use of massage therapy, herbal
remedies, and acupuncture in elderly women coming for breast and cervical cancer
scans (n = 3660) and in aged individuals with diseases of the musculoskeletal system
(n = 3157) was higher than that of other complementary therapies.5,6
Chronic illnesses, brought by the changing demographics of an aging population,
have forced a long-term and costly care process on nurses. In the management of
the symptoms of chronic diseases, massage therapy should be given a place in nurs-
ing care practice. Massage therapy increases the quality of life by meeting the physical
and psychological needs of old people, and at the same time strengthens the relation-
ship between patient and nurse. This review considers the use of massage therapy
by aged patients, its importance for nurses, its physiology, and its effectiveness on geri-
atric symptoms.
Cite this article as: Utli H. Effects of massage
therapy on clinical symptoms of older people.
J Educ Res Nurs. 2022;19(1):103-107.
Corresponding author: Hediye Utli,
E-mail: hediyeutli@hotmail.com
Received: April 3, 2020
Accepted: July 22, 2020
Effects of Massage Therapy on Clinical Symptoms of Older People
Utli
Hediye Utli
Department of Elderly Care, Mardin Artuklu University
Vocational School of Health Services, Mardin, Turkey
1
19
Review
DOI: 10.5152/jern.2021.09327
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JERN 2022; 19(1): 103-107
DOI: 10.5152/jern.2021.09327
Utli
Effects of Massage Therapy on Clinical Symptoms of Older People
The Physiology of Massage Therapy in Geriatrics
Massage therapy, according to the Complementary and Alternative
Medicine Center, is a sub-category of mind-body therapies,7 and is an
important part of physiotherapy. It is a therapy practiced by touching
the muscles of the body to manipulate the soft tissue.8 Massage is a
practice that stimulates the body by the application of still or moving
pressure as effleurage, petrissage, friction, and percussion.9,10 Nurses
can apply back massage to a patient to calm a geriatric patient in the
clinic, to bring on sleep, or to reduce anxiety. Back massage is a tradi-
tional nursing intervention and is also accepted as a complementary
and alternative treatment.9
In massage, when the tissues are stimulated, stimulation is sent to
the brain, providing calming. Massage has benefits such as speeding
up blood circulation and lymphatic drainage so as to reduce muscle
tension, hardness or slackness, pain and stress, and encouraging
mental and physical relaxation, and a feeling of wellbeing.9,11 Massage
prevents the transmission of pain stimuli by secretion of the natu-
ral morphine, endorphin, and in this way reduces the feeling of
pain.12 According to gate control theory, in massage therapy, large-
diameter fibers close the gate to stimuli carried by small-diameter
fibers. Sensory touch (massage) activates mechanoreceptors that
perceive sensory stimuli in the brain and increases the stimulation of
large nerve fibers on small C nerve fibers in the spinothalamic sys-
tem via the spinal cord. In this way, pain and its transmission are
reduced by increasing blood flow to the tisssues.13,14 In the effleurage
technique, the whole plantar surface of the hand and fingers is used
to provide touch stimuli with increasing pressure.15 In old individuals,
the application of a medium level of pressure has positive effects
on back, chest, shoulder and knee pain, osteoarthritis, reduced joint
range of motion, and on symptoms such as worry, anxiety, depres-
sion, and social isolation.16 It is also used to ease the pain caused by
cancer, to reduce stress, to increase relaxation, and to increase men-
tal anxiety.17 Individuals experiencing depression have high levels of
cortisol and low levels of serotonin and dopamine. Application of a
medium level of pressure increases vagal activity, and thereby lowers
cortisol levels in the saliva and urine through an increase in sero-
tonin and endorphin by activation of the parasympathetic nervous
system.16 Saliva cortisol and saliva alpha-amylase enzymes are rec-
ognized as a bioindicator relating to the activity of the sympathetic
nervous system and are accepted as a suitable measure of changes
in stress level.18
Geriatric Symptoms and Massage Therapy
Pain and Massage Therapy
Pain is one of the symptoms most commonly reported by old people.
Between 25% and 65% of old people living independently in the com-
munity, 79% of patients aged over 85, and 45-80% of aged patients
confined to bed have a significant amount of daily pain.19,29
The main reasons for pain in old people are diseases relating to the
muscles, bones, and joints. These include osteoarthritis, spondylosis,
osteoporosis, back and leg pain, rheumatoid arthritis, fibromyalgia,
myofascial pain, tenosynovitis, contractures relating to movement,
unhealed fractures, Paget disease, and secondary myopathies. Other
reasons for chronic pain in old people are malignities, neurological
diseases such as nerve root pain and peripheral neuropathy, vascular
diseases such as angina pectoris and arteritis, and pain of visceral
origin such as peptic ulcers or constipation.11 Pain in old people can
lead to reduced functionality, increased risk of falling, sleep disorder,
anxiety, agitation, delirium, and poor quality of life.19
For many reasons, pain in the geriatric population cannot easily be
treated. The primary reason for this is that both health profession-
als and patients have the mistaken idea that pain is an expected
and natural result of old age. Second, many old people are unable to
report pain because of physical problems such as sight or hearing
loss, or cognitive disorders such as memory loss. Thirdly, old peo-
ple in the terminal period may often conceal pain because of a fear
of more tests and treatments. Finally, health professionals may be
unwilling to act on the effective management of pain because of a
lack of knowledge of pain management strategies, and because of
their perceptions of opioids. Patients may also be afraid of depen-
dence on opioid analgesics, and generally choose to live with pain
rather than take these agents.19,22 America has seen an increase in
the prescription of opioids to treat chronic pain, and this has been
related to increasing opioid and heroin addiction.22 In the treatment
of pain, local treatments and non-pharmacological treatments are
recommended in progressively combined form.19 There has been
no critical evaluation of old people suffering from pain other than
cancer, for non-pharmacological interventions in pain manage-
ment.23 Considering the side effects of pharmacological agents in
old people, the most effective non-pharmacological methods which
can be safely used in the reduction of pain in the geriatric popula-
tion while eliminating sleep disorders and improving the quality of
life include physiotherapy, osteopathic manipulation, transcutane-
ous electrical nerve stimulation, acupuncture, biofeedback, cognitive
behavioral therapy, psychotherapy, and massage therapy.20,21
In a randomized controlled study by Ardigoetal.20 hypnosis (n = 26) and
massage therapy (n = 27) were applied to 53 old people. A reduction
in pain severity was seen in both groups, but this was found to be at
a clearer level in the hypnosis group. Boitoretal24 applied hand mas-
sage for 15 minutes to old people in intensive care who were under-
going elective heart surgery. A significant level of reduction in pain
severity was seen in the experimental group to whom hand massage
was applied (n = 21) compared with the control group, whose hands
were held (n = 19).
A significant increase is expected in the number of geriatric cancer
patients in the next 20 years. Approximately 60% of all cancers and
70% of cancer mortality are in those aged 65 or more.25 Between 83%
and 93% of old people in health institutions with a diagnosis of can-
cer complain of chronic pain, and this limits their activities of daily
life.26 The American Geriatrics Society has reported that pharmaco-
logical pain control methods used along with non-pharmacological
methods may reduce chronic pain in older adults.19 In the national
and international literature, no study was found which examined the
effect of massage therapy on pain in old people with cancer.27,28 In
this regard, studies are recommended with a high level of evidence.
Constipation and Massage Therapy
Constipation is a condition that lowers an individual’s quality of life,
causes exhaustion and loss of work power, increases health care
costs, has adverse effects on the level of health, and is particularly
seen in old people. After the age of 60, the incidence of constipation
increases, and there is a great increase after the age of 70 or 75.29,30
Constipation occurs at a rate of 11-55% among old people worldwide.30
In the UK, 1 in 500 Parkinson’s patients experience constipation
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Utli
Effects of Massage Therapy on Clinical Symptoms of Older People
problems before motor symptoms at a rate of 80-90%. This causes
difficult or painful defecation, a feeling of discomfort, a reduction in
the quality of life, and an increase in the length of hospital stays and
care costs.30,31 The incidence of constipation in Parkinson’s patients
is related to the side effects of medications taken, a reduction in
mobility and poor nutrition.31 Among the risk factors for constipation
in the aged population are gender, medical conditions such as a low
level of physical activity, stress, stroke, heart problems and hemor-
rhoids, and medications such as diuretics, calcium canal blockers,
antidepressants, and hypnotics.30
The side effects and the high cost of the laxatives used in the treat-
ment of constipation show the need for non-pharmacological meth-
ods.29 Among non-pharmacological methods used for constipation
in old people are physical exercise, massage therapy, reflexology,
biofeedback (neurotherapy), and lifestyle modifications.32 Massage
therapy is a non-pharmacological, easily understood, cheap or free,
harmless, non-invasive, and side-effect free method in the manage-
ment of constipation.31 In patients with constipation, massage ther-
apy balances tension of the muscles, fascia, and joints. The definition
of tension is the long-term semi-contraction of muscles, fascia, and
ligaments. Therapy consists of massaging the muscles, fascia, and
joints structurally connected to the painful or excessively tense tis-
sue. In this way, the distribution of tension in the abdominal cavity
will normalize, the abdominal organs will have better conditions to
work, the autonomic nervous system responsible for the smooth
muscle of the colon will be activated, and peristalsis in the colon will
increase.32 Nurses have an important role in the care and treatment
of constipation. In particular, abdominal massage has recently been
widely used by nurses. Abdominal massage is a non-invasive inter-
vention of applying patting, kneading, and vibration in a clockwise
direction to the abdomen, resulting in the stimulation of peristalsis.
Abdominal massage of the rising, transverse, and descending colons
when carried out daily improves intestinal mobility and is effective in
reducing medications used for constipation and in regulating bowel
movements.37
It was determined by Ceviketal34 that abdominal massage applied
to 22 old people with constipation increased bowel movements and
the weight of feces, improved consistency, and reduced mean scores
for abdominal tension, and also that on days when it was not applied,
the bowels were not completely emptied. In a randomized controlled
study by Mcclurgetal.31 abdominal massage was applied once a day
for 10 weeks to 32 old patients with Parkinson’s disease. However,
despite an improvement in signs of constipation in the experimental
group (n = 16), to whom abdominal massage was applied, compared
with the control group (n = 16), the difference was not found to be
significant. Although the time spent on defecation fell from 10 min-
utes to 4.5 minutes, no difference was found between the groups
in frequency of defecation. In a study by Yıldırım35 with 204 patients
taking opioid analgesics for cancer and non-cancer pain and who had
a problem with constipation, 15 minutes of abdominal massage was
given twice a day 30 minutes after breakfast and supper for 4 weeks
to the experimental group. It was found that the severity of consti-
pation, the feeling of incomplete voiding, the severity of straining,
pain felt in the anus and the severity of gas were statistically signifi-
cantly reduced, the consistency of feces improved, and the number
of defecations and the quality of life scores statistically significantly
increased. In conclusion, abdominal massage is recommended in the
management of constipation and constipation-related symptoms
and the reduction of their severity.
Behavioral and Psychological Symptoms and Massage Therapy
With the aging of the world’s population, it is expected that the prev-
alence and incidence of dementia, delirium, and Alzheimer’s disease
will increase. Alzheimer’s disease is the most frequently seen type of
dementia in old people. More than 55 million people in the world are
living with dementia, and every year, approximately 10 million new
cases are seen. By 2030, there will be more than 78 million people
with Alzheimer’s disease, and by 2050 there will be 139 million.36
Delirium is resistant to drug treatment; every year, it affects more
than 2.3 million hospitalized old people and increases health care
costs. It also increases the possibility of readmission to hospital and
health care costs.15 These aged patients have behavioral and psy-
chological symptoms such as agitation, aggressiveness, anxiety, and
depression.37,38
According to family members and nurses, agitation is one of the
most difficult behaviors seen in Alzheimer’s patients. The prevalence
of agitation or aggressive behavior in individuals with dementia is
13-50.4%. The treatment of agitation is difficult because patients
refuse to take the medications.39 Families and caregivers experience
mental and material stress because of the reducing cognitive func-
tion in dementia patients. Because the psychotropic drugs used in
the treatment of dementia and Alzheimer’s disease increase the risk
of falling, interest has recently increased in non-pharmacological
methods as a support to increase cognitive function and to improve
morale and the quality of life.37,38 Among the non-pharmacological
methods which can be applied to individuals with dementia are bright
light therapy (phototherapy), physical exercise, music therapy, aro-
matherapy and massage therapy.39 With aging, while tactile sensitiv-
ity is reduced, sensitivity to sensory touch increases. It is thought
that persons with dementia retain the ability to distinguish the thera-
peutic and compassionate intentions of stimuli which include physi-
cal contact such as touch and massage through the preservation of
limbic systems.18
Schaubetal18 applied hand massage for 16-20 minutes for 3 weeks
to 40 old people with dementia. It was found that stress and agi-
tation levels were significantly lower in the experimental group
(n = 20) to whom hand massage was applied than in the control group
(n = 20) who received no intervention. In a randomized controlled
study, Dimitriouetal39 applied 1 of 3 non-pharmacological methods
(physical activity, music therapy, and massage therapy) every night
for 5 days for 20 minutes before going to bed to reduce the level of
agitation or aggressive behavior in 60 old people with dementia. In
the same study, it was found that the non-pharmacological method
that had the most effect in reducing agitation and aggressive behav-
ior was music therapy, followed by massage therapy, and the least
effective was physical exercise. In a randomized controlled study by
Ardigoetal20 with 53 old people with chronic pain, the depression
scores of a hypnosis group (n = 26) showed a significant improvement
compared with those of a massage group (n = 27). In a semi-experi-
mental study by Tannouset al9 conducted with 50 male geriatric
patients who had suffered a stroke, anxiety levels were 13.3 ± 8.9,
but fell to 8.2 ± 5.6 after light back massage. It was found that the
mean depression score improved significantly by 26.41 ± 25.33 after
back massage. In conclusion, back massage significantly reduces the
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DOI: 10.5152/jern.2021.09327
Utli
Effects of Massage Therapy on Clinical Symptoms of Older People
levels of depression and anxiety in geriatric patients in the clinic and is
an effective nursing intervention. In a study by Keshavarzetal38 with
70 geriatric patients with Alzheimer’s disease (experimental group
n = 35, control group n = 35), agitation scores before head and
face massage were found to be 77.2 ± 14.4 and 82.1 ± 17.3 in the
2 groups respectively, while after head and face massage they were
49.7 ± 6.0 and 80.8 ± 18.3. As a result, no significant difference was
found between the 2 groups after head and face massage. However,
Basiriet al40 carried out 15 minutes of medium intensity back mas-
sage for 3 days in a study with 80 elderly women with breast can-
cer, and a reduction in levels of anxiety was seen in the experimental
group (n = 40) compared to the control group (n = 40). In both studies,
the use of back massage was recommended by nurses in clinics to
relieve agitation and anxiety. Also, Makinianetal15 applied face and
head massage twice a day (at 10:00 am and 6:00 pm) to 88 old people
in a coronary intensive care unit. There was no significant difference
between the study groups (experimental = 44, control = 44) in pre-
test total delirium scores, but after the massage therapy, the delirium
total mean score of the experimental group was seen to be signifi-
cantly higher than that of the control group.
Contractures and Massage Therapy
Contractures can occur in old people because of chronic diseases,
particularly Parkinson’s disease, or because of being confined to bed.
These decrease the patient’s activities of daily life, affect the quality
of life, and increase health burden.15,41
Souhetal41 applied 30-40 minutes of shoulder, neck, chest, and back
massage once a day for 7 weeks to 11 old people with Parkinson’s dis-
ease, using petrissage and tapotement movements. One week after
the treatment was completed, the range of motion (ROM) of shoulder
joints was measured. It was observed that shoulder abduction was
improved by performing ROM exercises on the shoulder joints. As a
result, it is felt that there is a need for studies with larger sample
groups and high evidence levels in order to determine the effective-
ness of massage therapy on the range of motion of joints in individu-
als with Parkinson’s disease.
Conclusion
The changing sociodemographic structure in Turkey and the rest of
the world focuses attention on the aged population. Old people may
have more than 1 chronic disease, and this makes their care long-
term, costly and tiring. In Turkey, place should be given to the nursing
use of massage therapy in the management of care of old people
with chronic diseases, as it is cheap, safe, and of proven effective-
ness. The use of massage therapy with old people is effective on the
symptoms of neurological diseases, especially pain, constipation,
agitation, stress, worry, depression, and joint range of motion, but
research is needed on its effectiveness with symptoms relating to
other chronic diseases, such as diseases of the cardiovascular sys-
tem, cancer, diseases of the respiratory system and endocrine sys-
tem diseases. In particular, there is a need for studies to contribute
to the literature, as no studies were found examining the effect of
massage therapy on pain in old people with cancer.
Patients with neurological illnesses form the group with the most
need for autonomy and self-care. There is a complex process neces-
sitating the use of a number of different methods at the same time
which can help in symptom management of neurological diseases.
Massage therapy can secure improvement in many neurological
symptoms, and so it is recommended that it can be used safely with
old people by nurses in neurology clinics.
Ethics Committee Approval: Ethical committee approval was received from the
Ethics Committee of XXXXX University (approval No: XXXXXX).
Informed Consent: Written informed consent was obtained from all participants
who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – H.U.; Design – H.U.; Supervision – H.U.;
Resources – H.U.; Materials – H.U.; Data Collection and/or Processing – H.U.;
Analysis and/or Interpretation – H.U.; Literature Search – H.U.; Writing Manuscript
– H.U.; Critical Review – H.U.
Acknowledgments: XXX.
Declaration of Interests: The authors declare that there was no conflict of
interest.
Funding: The authors declare that this study has received no financial support.
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