Analgesic Efficacy of Foot and Hand Massage for Laparoscopic Cholecystectomy: A Meta-Analysis

Abstract

Background Foot and hand massage may benefit to alleviate pain for laparoscopic cholecystectomy, and this meta-analysis is intended to study the influence of foot and hand massage on pain intensity after laparoscopic cholecystectomy.

Methods We systematically searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and included randomized controlled trials (RCTs) assessing the effect of foot and hand massage on postoperative pain of laparoscopic cholecystectomy.

Results Six RCTs and 663 patients were included in the meta-analysis. Compared with control intervention for laparoscopic cholecystectomy, massage intervention resulted in significantly decreased pain scores at 60 min (SMD=–0.73; 95% CI=–1.27 to –0.19; P=0.008), pain scores at 90 min (SMD=–0.80; 95% CI=–1.23 to –0.37; P=0.0003), pain scores at 120–150 min (SMD=–1.74; 95% CI=–1.96 to –1.52; P<0.00001) and the need of additional analgesia (OR=0.04; 95% CI=0.02 to 0.07; P<0.00001), but demonstrated no influence on pain scores at 10–30 min (SMD=–0.14; 95% CI=–0.39 to 0.12; P=0.29).

Conclusions Foot and hand massage may be able to reduce pain intensity after laparoscopic cholecystectomy.

Zusammenfassung

Hintergrund Fuß- und Handmassage kann zur Linderung von Schmerzen bei laparoskopischer Cholezystektomie beitragen, und diese Meta-Analyse soll den Einfluss der Fuß- und Handmassage auf die Schmerzintensität nach laparoskopischer Cholezystektomie untersuchen.

Methoden Wir haben systematisch PubMed-, EMbase-, Web of Science-, EBSCO- und Cochrane-Bibliotheksdatenbanken durchsucht und randomisierte kontrollierte Studien (RCTs) einbezogen, die die Wirkung von Fuß- und Handmassage auf postoperative Schmerzen der laparoskopischen Cholezystektomie untersuchten.

Ergebnisse Sechs RCTs und 663 Patienten wurden in die Metaanalyse einbezogen. Im Vergleich zur Kontrollintervention bei laparoskopischer Cholezystektomie führte die Massage zu signifikant verringerten Schmerzwerten bei 60 min (SMD=–0.73; 95% CI=–1.27 bis –0.19; P=0.008), Schmerzwerten bei 90 min (SMD=–0.80; 95% CI=–1.23 bis –0.37; P=0.0003), Schmerzwerte bei 120–150 min (SMD=–1.74; 95% CI=–1.96 bis –1.52; P<0.00001) und die Notwendigkeit einer zusätzlichen Analgesie (OR=0.04; 95% CI=0.02 bis 0.07; P<0.00001), zeigten jedoch keinen Einfluss auf die Schmerzwerte bei 10–30 min (SMD=–0.14; 95% CI=–0.39 bis 0.12; P=0.29).

Schlussfolgerungen Die Fuß- und Handmassage kann die Schmerzintensität nach laparoskopischer Cholezystektomie reduzieren.

Key words

effectiveness - pain - systematic review

Schlüsselwörter

Physikalische Medizin - Ergebnisse - Medizinische Rehabilitation

Introduction

Cholelithiasis has become one of the most common diseases of the gallbladder [1] [2] [3]. As the development of the technology and biomedical developments, cholecystectomy can be treated with the laparoscopic method [4] [5] [6] [7] [8]. However, many patients undergoing laparoscopic cholecystectomy suffer from severe abdominal pain which was caused by surgical manipulation and peritoneal irritation due to CO2 gas dissolved in the abdomen [9] [10] [11]. This obvious pain causes late mobilization, prolonged hospital stay, delayed daily life activities and anxiety [12] [13].

Pharmacological and nonpharmacological supplementary methods are developed to alleviate pain after laparoscopic cholecystectomy [14] [15]. Pharmacological methods commonly lead to negative impact on vital functions like respiratory, nervous, urinary, and gastrointestinal systems [14] [16] [17] [18] [19] [20]. The massage application is one preferred application among nonpharmacological supplementary methods because it is a low-cost, less time consuming, easy-to-apply, and effective method for pain control [21]. For instance, foot massage showed the potential in the relief of pain and anxiety after surgery through reflexology response [9] [22] [23] [24] [25].

Several RCTs reported that foot and hand massage had the capability for pain relief after laparoscopic cholecystectomy, but the results were conflicting [12] [21] [26] [27]. Therefore, we conducted this meta-analysis of RCTs to study the effectiveness of foot and hand massage on pain management after laparoscopic cholecystectomy.

Materials and Methods

Study selection and data collection

Ethical approval and patient consent were not needed because this was a meta-analysis of previously studies. It was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis statement and Cochrane Handbook for Systematic Reviews of Interventions [28] [29]. PubMed, EMbase, Web of science, EBSCO and the Cochrane library have been systematically searched up to April 2023, and we used the search terms “foot massage” OR “hand massage” AND “laparoscopic cholecystectomy”. The inclusion criteria included: (1) study design was RCT; (2) patients underwent laparoscopic cholecystectomy; (3) intervention treatments were foot massage or hand massage versus usual care. Patients with severe bleeding or the injury in their extremities were excluded.

Foot massage was applied to the gallbladder and digestive and musculoskeletal areas of the right foot, and it was conducted only on the areas related to the digestive system and the musculoskeletal system because there was no area belonging to the gallbladder in the left foot. Light pressure was applied to the solar plexus area of the feet for one minute [21]. Hand massage was applied at Hugo point [30].

Quality assessment

The methodological quality of individual RCT was assessed by using the Jadad Scale which included three evaluation elements: randomization (0–2 points), blinding (0–2 points), dropouts and withdrawals (0–1 points) [31]. This score varied from 0 to 5 points. Jadad score≤2 suggested low quality, while Jadad score≥3 indicated high quality [32].

Outcome measures

We extracted the following information from the original articles: first author, publication year, sample size, age, male, smoking and methods of two groups. The primary outcomes were pain scores at 10–30 min and pain scores at 60 min. Secondary outcomes included pain scores at 90 min, pain scores at 120–150 min and additional analgesia.

Statistical analysis

Odd ratio (OR) with 95% confidence interval (CI) was applied to evaluate dichotomous outcomes, while standard mean difference (SMD) with 95% CI was used to calculate continuous outcomes. I ² statistic was used to assess the heterogeneity, and I ² >50% indicated significant heterogeneity [33]. The random-effect model was used when significant heterogeneity was seen, and otherwise fixed-effect model was applied. Sensitivity analysis was conducted by detecting the influence of a single study on the overall estimate via omitting one study in turn or using the subgroup analysis. P≤0.05 suggested statistical significance and statistical analyses were conducted by Review Manager Version 5.3.

Results

Literature search, study characteristics and quality assessment

[Fig. 1] demonstrated the flow chart for the selection process and detailed identification. 148 publications were searched after the initial search of databases. 59 duplicates and 81 papers were excluded after checking the titles/abstracts. Two studies were removed because of the study design and six RCTs were ultimately included in the meta-analysis [12] [21] [22] [26] [30] [34].

Fig. 1 Flow diagram of study searching and selection process.

[Table 1] showed the baseline characteristics of six eligible RCTs in the meta-analysis. These studies were published between 2017 and 2022, and total sample size was 663. There were similar characteristics between massage group and control group at baseline. Five studies reported the foot massage [12] [21] [22] [26] [34], while two studies reported the hand massage [26] [30].

Table 1 Characteristics of included studies.

	Author	Massage group					Control group					Jada scores
		Number	Age (years)	Male (n)	Smoking (n)	Methods	Number	Age (years)	Male (n)	Smoking (n)	Methods
1	Anwar Aly 2022	50	47.93±13.74	27	–	massage intervention on the patient's extremities (5 minutes for each)	50	46.05±12.58	29	–	routine treatment and care	4
2	ABDULLAYEV 2021	30	46.93±14.74	14	7	foot reflexology massage two times after surgery	30	47.06±11.50	10	9	routine treatment and care	4
3	Sözen 2020 (1)	63	–	17	9	foot massage, 10 minutes for each foot	68	–	21	12	routine treatment and care	4
	Sözen 2020 (2)	65	–	26	14	hand massage, 10 minutes for each hand
4	Koraş 2019	85	–	13	–	foot massage	82	–	13	–	routine treatment and care	4
5	Çankaya 2018	44	48.45±14.80	10	–	10 min of classic foot massage	44	51.38±13.88	13	–	routine treatment and care	4
6	Doulatabad 2017	26	47±12.7	–	–	massage of Hugo point three times	26	49.5±10.5	–	–	routine treatment and care	3

ASA, American Anesthesiologists Association.

Among the six RCTs, five studies reported pain scores at 10–30 min [12] [21] [26] [30] [34], three studies reported pain scores at 60 min [21] [22] [34], two studies reported pain scores at 90 min and pain scores at 120–150 min [26] [34], and two studies reported additional analgesia [26] [34]. Jadad scores of the six included studies varied from three to four, and thus all studies were considered to have high quality.

Primary outcomes: pain scores at 10–30 min and 60 min

In comparison with control group for laparoscopic cholecystectomy, massage intervention showed no impact on pain scores at 10–30 min (SMD=–0.14; 95% CI=–0.39 to 0.12; P=0.29) with significant heterogeneity among the studies (I²=60%, heterogeneity P=0.03, [Fig. 2]), but was associated with significantly reduced pain scores at 60 min (SMD=–0.73; 95% CI=–1.27 to –0.19; P=0.008) with significant heterogeneity among the studies (I²=83%, heterogeneity P=0.003, [Fig. 3]).

Fig. 2 Forest plot for the meta-analysis of pain scores at 10–30 min.

Fig. 3 Forest plot for the meta-analysis of pain scores at 60 min.

Sensitivity analysis

Significant heterogeneity was seen for primary outcomes. However, there was still significant heterogeneity when performing the sensitivity analysis via omitting one study in turn or subgroup analysis based on foot or hand massage.

Secondary outcomes

Compared to control intervention for laparoscopic cholecystectomy, massage intervention can substantially decrease pain scores at 90 min (SMD=–0.80; 95% CI=–1.23 to -0.37; P=0.0003; [Fig. 4]), pain scores at 120–150 min (SMD=–1.74; 95% CI=–1.96 to –1.52; P<0.00001; [Fig. 5]) and the need of additional analgesia (OR=0.04; 95% CI=0.02 to 0.07; P<0.00001; [Fig. 6]).

Fig. 4 Forest plot for the meta-analysis of pain scores at 90 min.

Fig. 5 Forest plot for the meta-analysis of pain scores at 120–150 min.

Fig. 6 Forest plot for the meta-analysis of additional analgesia.

Discussion

Our meta-analysis included six RCTs and 663 patients undergoing laparoscopic cholecystectomy. The results demonstrated that foot and hand massage was able to significantly decrease the postoperative pain intensity, as evidenced by the substantially reduced pain scores at 60 min, pain scores at 90 min, pain scores at 120–150 min and the need of additional analgesia. In addition, it was very interesting that foot and hand massage can remarkably reduce pain scores at 60 min, pain scores at 90 min and pain scores at 120–150 min after laparoscopic cholecystectomy, but demonstrated no obvious influence on pain scores at 10–30 min. This suggested that the analgesic efficacy of foot and hand massage was significant possibly after at least 60 min after laparoscopic cholecystectomy.

Regarding the sensitivity analysis, there was still significant heterogeneity when performing the sensitivity analysis via omitting one study in turn or subgroup analysis based on foot or hand massage. Several factors may cause the heterogeneity. Firstly, foot massage and hand massage were both included in this meta-analysis. Five studies reported the foot massage [12] [21] [22] [26] [34], while two studies reported the hand massage [26] [30]. Secondly, the detail procedures of massage intervention were not completely same in one massage method, which may affect the efficacy assessment. Thirdly, the laparoscopic cholecystectomy was conducted by different surgeons and needed various operation procedures.

The mechanisms of massage to mediate pain relief after laparoscopic cholecystectomy are explained with the Gate Control Theory of Melzack. When massage is applied, the A-alpha and A-beta thick tactile fibers move faster than the A-delta and C fine fibers which participate in the transmission of the pain, and are able to prevent the impulses in the small-diameter fibers that carry the pain from reaching upper levels [9] [22]. Especially, the mechanoreceptors in the center of the tactile fibers are located in the hands and feet [9]. Foot and hand massage can easily stimulate these mechanoreceptors and alleviate postoperative pain [24] [35].

Several limitations should be taken into consideration. Firstly, our analysis was based on only six RCTs and more studies should be conducted to confirm the analgesic efficacy of foot and hand massage for laparoscopic cholecystectomy. Secondly, the detail procedures of massage intervention were different among the included studies, and may mainly account for the significant heterogeneity. Thirdly, different operation procedures of laparoscopic cholecystectomy may produce various pain intensity due to surgical trauma.

Conclusion

Foot and hand massage may be able to improve the pain control after laparoscopic cholecystectomy.

Notice

This article was changed according to the following correction on August 24^th 2023.

Correction

In the above-mentioned article the affiliation of author Xiaoqiang Wan was wrong. Correct is: Gastroenterology, Chongqing University Central Hospital (Chongqing Emergency Medical Center), Chongqing, China.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publikationsverlauf

Eingereicht: 07. Januar 2023

Angenommen: 17. Juli 2023

Artikel online veröffentlicht:
08. August 2023