Measuring the Effect of Massage Therapy on Anxiety of Heart Failure Patients

Congestive Heart failure (CHF) is one of the most common chronic diseases. The objective of this study was to assess whether back massage could release anxiety in patients with CHF. The study used a quasi-experimental design with one group pretest and posttest. Fifty participants were recruited in study. The modified State Anxiety Inventory was used in this study. The baseline overall mean score of anxiety was 43.52 (10.32) in the intervention group and was decreased to 33.22 (5.19) three days after massage therapy (p=0. 01). The conclusion that back massage can be more helpful to male patients than female patients. This study was conducted without a control group.

be used to promote muscle relaxation and to reduce pain, stress and anxiety (Anderson & Cutshall, 2007).
Although there have been more studies assessing the impacts of massage on the treatment of medical conditions, there has been no research done to assess whether massage therapy reduces anxiety in patients with CHF.

The study design
A quasi-experimental study was conducted with the permission of Jahrom University of Medical Sciences.The study was done in two coronary care unit (CCU) wards of Jahrom University of medical science, Iran.The 50 participants invited to the study after daily reviewing of the patients' files of CCU wards and consulting with their physicians.

Sample Size
On the basis of the previous research the estimated number of samples for study was estimated to be 45 patients (±= 0.05, 1-²=0.80,¼1-¼2= 4.84).However 50 patients were selected to compensate the possible attrition.

Inclusion criteria
The criteria for inclusion: The participants were diagnosed with NYHA Class I-IV heart failure by a cardiac specialist, being literate, being conscious, and a length of stay more than 3 days, and willing to participate in the study.

Exclusion criteria
The participants excluded from study if they have some confounders, such as a thrombosis greater than 1 cm by the Doppler echography, backpressure ulcers, acute pulmonary edema, respiratory failure, or cardiac tamponed, a cardiac arrest in the past 72 hours, severe dyspnea, a cardiac pacemaker, a pulse rate less than 60/min, a dialysis fistula and a history of bone fracture in the past 2 months and a history of receiving massage therapy were excluded.

Procedure
The patients participated in this study within 24 hours after admission to the coronary care unit.
The massages therapy was started 3 days after admission in hospital in order not to disturb their medical regimen plan.
Protocols for this procedure varied in previous studies (Richards, 2010).The intensity and time of massage therapy ranged from one session of 3-45 minutes to 15 sessions over 4 weeks (Jane, Wilkie, & Gallucci, 2008).In this article the time of massage therapy in considered for 10 minutes.Back massage was lasted 10 minutes each day for 3 days consecutively.Back massage intervention included pressing and stroking (effleurage), kneading (petrissage), rubbing with short strokes, tapping (percussion), and rubbing with long strokes (friction).
Back massage was done one hour before a meal or two hours after a meal.Before the massage, each participant was asked to sit up and position himself/herself on a bedside table with a pillow to cushion.
Massage is an intervention that can be implemented in practice, whether by health professionals or parents, but specific guidelines are necessary for its implementation, including the rhythm, pressure, direction, duration, and frequency.All massage treatments will be performed by licensed massage therapists who have at least 5 years' experience.

Instrument
Mahram in 1994 has translated the SAI in Farsi.He has got reliability of 0.94 by Cronbach's Alpha.For validity of the test the comparison of mean of anxiety of the standard community in all age ranges in two levels of 5% and 1% have been achieved.The Farsi inventory has been repeatedly used and evaluated among various groups and its validity and reliability have been measured (Dehghan-nayeri & Adib-Hajbaghery, 2011.Mahram, 1994).
The modified SAI used a 4-point Likert scale.The maximum score was 80 points, and the minimum 20; the higher the score, the higher the anxiety.

Data analysis
The effect of Back massage on anxiety level was assessed with the paired t-test and repeated-measures analysis of variance.

Ethical considerations
This study was approved by the Research Council and the Research Ethics Committee of Jahrom University of Medical Sciences.The researchers also obtained permission from the hospital authorities.All of the subjects informed about being free to participate in the research, nondisclosure of personal information and were offered the written informed consent form to be signed before entering the study.The researchers were mindful of the need to pay close attention to ethical considerations and to the welfare of research participants.

RESULT
The participants consisted of 50 individuals.The proportion of male and female participants was 41.35.The mean age of the total cases was 69.13 (SD=11.82)years.Totally, 89.16% of the patients were married, 68.33% were employed and the others were retired or unemployed.The education of most of patients (58.33%) was at the level of primary school and the rest was at the level of secondary school or higher education.

DISCUSSION
In the current study, after massage therapy the male participants showed a significantly greater reduction in anxiety than the female participants.
Females reported significantly higher levels of test anxiety than males.This is consistent with the previous researches on gender effects on test anxiety (Lashkaripour,2006. Mousavi, Haghshenas, & Alishahi, 2008).
Moser et al. reported that patients' anxiety levels were correlated with their gender, age, and educational level (Moser, Dracup, & Evangelista, 2010).
Massage seems to relax the muscles (Buttagat, Eungpinichpong, Chatchawan, & Kharmwan, 2011) and decreases norepinephrine (Braun & Simonson, 2014) that consequently will result in reduced anxiety.Our results showed that massage therapy reduces anxiety in patients admitted to CCU.In a previous study it has reported that massage therapy after heart surgery may be pleasant but is not effective on anxiety (Baxter & Albert ,2011.Kargar Jahromi et al,2016).But in a study at the Mayo Clinic, in which 58 cardiac surgery patients postoperatively received 1 -3 massage therapy ses-sions of 20 minutes each, created evidence compelling enough for the Mayo Clinic to hire a full-time massage therapist to be available on the inpatient unit (Cutshall et al,2007).
In adults, MT has been shown to reduce anxiety, depression, and delayed assessment of pain (Moyer ,Rounds, & Hannum ,2004 ).The reported cardiopulmonary effects of MT in adult populations include reduction in blood pressure (BP) and heart rate (HR) and improvement in comfort, pain, anxiety, and tension after cardiac surgery (Beeken, Parks, Cory,& Montopoli ,1998.

Bauer, 2010. Cutshall et al,2010
).There is evidence to suggest that post-exercise massage may be helpful in reducing delayed-onset muscle soreness (Hilbert, Sforzo, & Swenson,2003).In addition, Hemmings et al. reported that massage is effective in enhancing perception of recovery after boxing (Hemmings, Smith, Graydon,& Dyson ,2000), which may lead to improvement in subsequent performance.
It has also been shown that massage therapy reduces pain and anxiety and improves sleep quality of patients' undergone cardiovascular surgeries (Nerbass, Feltrim, Souza, Ykeda, & Lorenzi-Filho,2010.Poorgholami et al,2016).Field and colleagues (2002) observed that MT decreased anxiety and depressed mood and increased the number of sleep hours in patients with fibromyalgia (Field et al ,2002).
Other study has also shown that massage can relax muscles, produce calmness, reduces pain, fatigue and drowsiness and eventually leads to reduction of anxiety (Cutshall et al, 2010).
Back massage can help CHF patients be less anxious.After 1 day of massage, anxiety significantly improved.The changes in anxiety level after massage among male participants were significantly greater than those among female participants (p<001).Table 3.
Rose Adams, et al in their study on title of the effects of massage therapy on pain management in the acute care setting is shown that integration of massage therapy into the acute care setting creates overall positive results in the patient's ability to deal with the challenging physical and psychological aspects of their health condition(Rose, Barb, & Cynthia, 2010 ).In Shay Beider, et al study, peak heart rate, peak VO2, and peak minute ventilation were higher when children received a massage before exercise testing(Shay Beider, Boulanger, Yann, & Ruey, 2010).
In the present study, there were limitations inherent to the investigation itself .limitation of the present study is the lack of collection of physiological data, including heart rate, blood pressure, and oxygen levels.The absence of data on the physiological indicators means that the study relied on participant perceptions without additional external measures to verify participant responses to massage therapy.Another limitation was the lack of control of all of confounders.
The current project, designed to gather prelimi-nary data on the research hypothesis, did not use a control group.The selection of additional patients in units throughout the hospital, combined with randomization to groups, would have required sub-stantial additional resources.However, future stud-ies on massage therapy in coronary care setting may benefit from the addition of a control group.

CONCLUSION
The conclusion that back massage can be more helpful to male patients than female patients.It needs to be confirmed in an additional study with a large randomized sample size.

Table 1 .
Demographic Data of Research Participants

Table 2 .
Mean scores of anxiety before and after the intervention (n= 50)

Table 3 .
Comparisons of Mean Differences in Pre-and Post-intervention Between aM, mean difference = mean (post-test III) -mean (pretest).bF, F value analyzed by using multivariate analysis of variance.cZ, Z value analyzed by using Mann-Whitney U test.