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 24th 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.
