Medical

Communication

Biosci. Biotech. Res. Comm. 10(4): 645-651 (2017)

The effect of massage therapy on sleep quality in

cardiac care unit patients

Arezoo Khosravi

, Fariba Bolourchifard

*, Mahnaz Ikhani

and Mohamad Amin Pourhoseingholi

Master of Medical Surgical Nursing, Student Research Committee, School of Nursing and Midwifery, Shahid

Beheshti University of Medical Sciences, Tehran, Iran

PhD in Nursing, Assistant Professor, Department of Medical Surgical Nursing, School of Nursing and

Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Doctorate in Clinical Practice, Assistant Professor, Department of Medical Surgical Nursing, School of

Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

PhD in Biostatistics, Associate professor, Gastroenterology and Liver Disease Research Center, Research

Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran

ABSTRACT

Low sleep quality is one of the most common complaints in patients admitted to CCU. This study aimed to determine the

effect of Massage Therapy on Sleep Quality, admitted in the cardiac care unit. This research is a quasi-experimental study.

60 cardiac patients admitted to CCU at Shariati Hospital in Tehran were selected and randomly divided into two interven-

tion and control groups. Members of the intervention group for a week, For one week, in 4 sessions, each session is 12

minutes twice a day, in the morning and in the evening or at least once before bed time were treated by massage, but the

control group did not received the massage. Data collected by demographic characteristics questionnaire and Pittsburg

sleep quality (PSQI) and were analyzed by using of statistical methods such as paired t-test and analysis of covariance.

Results showed improved quality of sleep among the intervention group quality scores in the post-test signi cantly

improved compared to pre-test (P= 0/001) but in the control group was not observed signi cant difference between the

pre-test and post-test (P=0/520). Also, there was a signi cant difference between post-test score in two groups of inter-

vention and control with control of pre-test effects (P=0/001). Therefore, massage therapy has improved the quality of

sleep in the intervention group. According to effectiveness of massage therapy on sleeping quality in patients hospitalized

in the coronary care unit, this method can be used to reduce undesirable effects of decreased sleep quality in patients.

KEY WORDS: MASSAGE THERAPY, SLEEPING QUALITY, CARDIOVASCULAR PATIENTS, CARDIAC CARE UNIT

645

ARTICLE INFORMATION:

*Corresponding Author: bolourchifard@gmail.com,

bolourchi@sbmu.ac.ir

Received 12

Oct, 2017

Accepted after revision 21

Dec, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

DOI: 10.21786/bbrc/10.4/6

646 THE EFFECT OF MASSAGE THERAPY ON SLEEP QUALITY IN CARDIAC CARE UNIT PATIENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Arezoo Khosravi etal.

INTRODUCTION

Cardiovascular diseases have the highest mortality rates

and will continue to be the leading cause of death in the

world by 2020 (Sha e etal., 2013). At present, cardio-

vascular disease accounts for 38% of i the world (Moller,

2010), and the  rst cause of death in Iran. It has also

been anticipated that, by 2030, the order of causes of

death would be included ischemic heart disease, cere-

bro-vascular diseases, AIDS and chronic pulmonary dis-

eases (Azizi, 2008).In spite of increasing awareness of

cardiovascular diseases prevention and planning which

governments have done in this regard, and given the

aging population, the prevalence of cardiovascular dis-

eases, and consequently the need for Coronary care unit

(CCU) and cardiac intensive care beds are on the rise.

As many as 2940 people across the country need to be

admitted to cardiac care units (Talebi etal., 2009). This

indicates an increase in the need for hospitalization

and the number of beds in the cardiac care unit in Iran.

Meanwhile, almost every disease with signi cant pain or

discomfort, such as respiratory, cardiovascular, digestive

and neurological diseases, can negatively affect sleep

quality (Jahne etal., 2012). Sleep problems in patients

with heart failure are more prevalent than those without

this disease, and factors such as respiratory problems,

increased age, medication, anxiety and depression play

a signi cant role in this (Suna, 2015).

Sleep is a regular, repeatable, and reversible physiologic

event in which a person experiences a decrease in con-

sciousness, a relative loss of skeletal muscle (volitional)

and a signi cant increase in the threshold of response to

external stimuli. More than a third of human life span is

spent in sleep. Therefore, any intermittent hypoxia and

disorder in quantity, quality or pattern of sleep can have

a signi cant negative effect on the person’s physical and

mental health and lead to the development of cardiovas-

cular complications (Wang, 2010). For example, Gvstafsn

writes on the  ndings of his studies: trouble in falling

asleep is an independent risk factor for cardiac events in

men. He also believes that there is a link between inad-

equate sleep and many clinical manifestations of coro-

nary artery disease such as angina, cardiac arrhythmia,

increased blood pressure, respiratory problems, the risk of

developing myocardial infarction and sudden death (Bay-

ley, 2010). Sleep also affects the cardiovascular system

regulation, so that at the time of awakening the heart of

a healthy person, on average, 70 to 80 beats per minute,

while at bedtime it is reduced to 60 times per minute.

Find (Fontana and Pittiglio, 2010). Conversely, sleep dep-

rivation increases heart rate and increases the myocardial

need for oxygen (Matthews etal., 2010).

Nerbass et al. (2010) found that although coronary

artery bypass graft surgery is a common operation (prac-

tice) with a low mortality rate and relieves angina symp-

toms in a desirable manner, but recovery from post-car-

diac surgery is followed by symptoms and signs of pain

and psychological distress, and sleep problems. Consid-

ering all the emphases and warnings about the effects

of sleep deprivation in hospitalized patients, especially

in cardiac care units, many of the patients admitted to

these units experience problems caused by sleep and rest

disturbances (Zolfaghari etal., 2013), and sleep disorders

in patients admitted to intensive care units are highly

prevalent (Habibzade etal., 2011). Although sleep prob-

lems can be somewhat controlled by medication, but

due to the problems and complications of drug therapy

(Cinder, 2007), the use of non-medical methods that can

reduce sleep problems in cardiovascular patients is logi-

cal. In order to solve these problems, various nursing

practices have been used as complementary therapies to

help patients to meet their psychological and physical

needs that among which massage therapy is an effective

nursing intervention in relaxing, reducing stress, relax-

ing the mind and body in patients (Oshundi etal, 2013).

After a preliminary study on cardiac patients, Cut-

shall and colleagues suggested that massage be used as a

complementary therapy to help reduce pain and anxiety

in these patients. Nelson etal. (2008) found that mas-

sage with release of endorphins prevents from the trans-

mission of pain messages and Wilkinson (2009) suggests

that relaxation and eliminating anxiety can be due to

reduced muscle spasm and thus reduce pain (Watson,

2011). Also, Castro and colleagues reported during their

research that massage therapy in patients with  bromy-

algia via decreased muscle tendon restriction, reduces

anxiety and improves sleep quality and physical perfor-

mance in these patients. Some research has shown that

massage therapy is effective in improving sleep qual-

ity and reducing fatigue in patients during the recovery

period after coronary artery bypass graft surgery (Nar-

bass etal., 2010).

Kavehia etal. (2013) investigating the effects of mas-

sage therapy on psychological outcomes in post-cardiac

surgery patients stated that massage therapy is effec-

tive in reducing pain and improving psychological out-

comes in patients undergoing cardiac surgery. Massage

therapy with parasympathetic stimulation can lead to

effects such as lowering heart rate, reducing respiration,

facilitating and returning to normal conditions in car-

diovascular patients (Morskaa et al., 2010). Therefore,

considering the low sleep quality of patients admitted to

CCU, the complications of sleep medications, the need to

use complementary and simple therapies in nursing, safe

and inexpensive methods, it was decided to conducting

a study aimed to determine the effect of massage on

the quality of sleep in the patients admitted to inten-

sive cardiac units, a step toward helping these patients

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS THE EFFECT OF MASSAGE THERAPY ON SLEEP QUALITY IN CARDIAC CARE UNIT PATIENTS 647

Arezoo Khosravi etal.

FIGURE 1. Points in Shiatsu massage

through nursing interventions is taken. For this purpose,

the aim of this study was to evaluate the effect of mas-

sage therapy on the quality of sleep in patients admitted

to cardiac care units (CCU).

MATERIALS AND METHODS

This research is a semi-experimental study with univer-

sity ethics committee approval. 60 patients hospitalized

in the cardiac care units of selected hospitals of Teh-

ran University of Medical Sciences in 2016, according

to inclusion of research (complete consciousness, aged

18 to 85 years, the lack of use of a variety of com-

plementary therapies during the previous three months,

non-use of sedative and narcotic drugs, healthy areas of

massage, and permission from the doctor, lack of severe

neuropathy, mental retardation, blindness and deafness,

lack of history of arthritis, joint rheumatoid arthritis and

joint disorders and absence of coagulation disorders and

diabetes) were selected using convenience and purpose-

ful sampling method and randomly even numbers were

assigned in the experimental group and odd numbers

assigned to control group.

The method of doing research was that the researcher

received con rmation from the committee of research

and graduate education and the Ethics Committee of

Shahid Beheshti University of Tehran and obtaining

a referral from the university and presenting it to the

management and of ce of nursing at Shariati Hospital

in Tehran, and obtaining permission after their intro-

duction to the head nurse and the staff of the cardiac

care unit and patients, the purpose of the research was

explained to them. Before initiating massage therapy,

the researcher  rst provided the patient and his or her

environment for intervention, in such a way as to pre-

serve the patient’s privacy and not feel insecure. Then,

the subjects completed the questionnaires. For non-lit-

erate students, a researcher or another family member

read the content to the patient and the questionnaire

was completed. For the intervention (experimental)

group, in addition to the routine pharmaceutical and

non-pharmaceutical methods of unit, Shiatsu massage

was performed in the following way:

A total of six points and each point for two minutes

were massaged. The points under massage proposed by

an expert and acupressure specialist, included the point

of ht7, the point at the radial and proximal angles rela-

tive to the wrist line at the plantar and tendon level

of  fth  nger  exor, point kidney 3 point and surface

between the ankles and the achilles tendon in the hori-

zontal direction, the anmien point at the angle between

the mastoid and the mandible is located one centimeter

directly above the hair extension and below the midline

and posterior of the head to cover the important points

of the control of insomnia (Fig. 1).

The massage of every point lasts for two minutes,

which included one minute of vertical and direct pres-

sure, which began with a very gentle pressure, and the

pressure increased to some extent that the patient would

report a pleasant sensation of diffusion of a stream or

lightness, or that the therapist’s nail is discolored due

to pressure, or the patient feel uncomfortable with the

increase in pressure, the process is continued. Then mas-

sage the point is done for one minute. At the time of

acupressure, you need to focus on quiet breathing and

 ngertip pressure. This intervention lasted for one week

in 4 sessions and 24 minutes per session twice daily in

the morning and afternoon, or at least once before bed-

time. After the intervention, the sleep quality question-

naire was completed again. Patients in the control group

had all the conditions of the patients in the experimen-

tal group, but no intervention was provided for them,

and patients received only routine pharmacological and

non-pharmacological care and the questionnaire was

completed on the  rst and last days by them.

The tools used in this study included demographic

questions (age, gender, marital status, duration of ill-

ness, etc.), and the Pittsburgh Sleep Quality Index (PSQI)

which has been designed by Bays etal. in 1989 to assess

Arezoo Khosravi etal.

648 THE EFFECT OF MASSAGE THERAPY ON SLEEP QUALITY IN CARDIAC CARE UNIT PATIENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

the quality of sleep in the psychiatric institution of Pitts-

burgh. This index consists of 19 questions in 7 dimen-

sions (subjective sleep quality, sleep latency, sleep dura-

tion, habitual sleep ef ciency, Sleep disturbances, use

of sleeping medication and daytime dysfunction). Each

part is scored from Zero (No problem) to 3 (there is a

serious problem). The total score is between zero and 21,

with higher scores indicating low sleep quality and vice

versa. Bays et al. (1989) obtained internal consistency

of the questionnaire using Cronbach’s alpha of 0.83. In

the Iranian version of this questionnaire, reliability was

obtained by Cronbach’s alpha of 0.46 and by the split-

half method of 0.52 (Heidari, Ehteshamzade and Mar-

ashi, 2010).

The software SPSS version 19 was used to analyze

the data. Also, paired t-test was used to compare the

mean of the groups. To compare the mean score of sleep

quality before and after the intervention in two groups,

covariance analysis was used. The signi cance level was

considered as p < 0.05.

RESULTS

The mean age of the experimental group was 58.38

with a standard deviation of 19. 21 and the mean age

of the control group 52.36 with a standard deviation

of 17.55. The sample consists of 38 (63.33%) males and

22 females (36.66%) that each experimental and control

group (n = 30) equally includes 19 males and 11 women.

In the experimental group, 3 (10%) were single and 27

(90%) were married. In the control group, 4 (13.3%) were

single and 27 (86.7%) were married. Finally, the mean

duration of the disease was 3.30 months in the experi-

mental group with a standard deviation of 6.25and in

the control group, 5.48 months, with a standard devia-

tion of 5.48.

The mean and standard deviation of the pre-test

and post-test of the studied variables in the interven-

tion (experimental) and control groups are presented in

Table 1.

As the results of the table above reveal, the post-test

score of the intervention group was reduced by 2.93 in

comparison with the pre-test score. In the intervention

group, the post-test score increased by about 40% com-

pared to the pre-test score.

The calculated Z to evaluate the normal distribution

of data for pre-test and post-test of the sleep quality

score was 1.29 and 1.07, respectively, which was not

statistically signi cant (Table 2). Therefore, parametric

tests can be used to examine the research hypotheses.

Paired t-test was used to evaluate the effect of mas-

sage therapy on the quality of sleep in patients admitted

in cardiac care units (Table 3).

As shown in table (3), the sleep quality score of the

intervention group in the post-test has been decreased

and according to the scoring of the questionnaire, the

decrease in score means improving sleep quality. The

t-value calculated for changes in the mean in post-test

of the intervention group compared to the pre-test score

was 4.82, which was statistically signi cant (p = 0.001).

In contrast, the calculated t value for the comparison of

Table 1. Mean and standard deviation of pre-test and post-test of sleep quality score

in two groups of intervention (experimental) and control

variable Group Number test periods mean and standard deviation

Sleep

quality

Intervention 30

Pre-test 13.96(2.930

Post-test 11.03(1.27)

control 30

Pre-test 13.06(2.75)

Post-test 13.46(1.77)

Table 2. Kolmogorov-Smirnov test for data normalization

Variable Mean (SD) Z Kolmogorov-Smirnov p-value

Pre-test score of sleep quality 13.51 (2.58) 1.29 0.069

Post-test score of sleep quality 12.25 (1.96) 1.07 0.20

Table 3. Paired t-test results to examine the intra-group mean changes of

intervention and control groups in the quality of life score

Variable Group Pre-test Post-test

Mean SD Mean SD t p-value

Intervention 13.96 2.93 11.033 1.27 4.82 0.001

Control 13.06 2.75 13.46 1.77 0.64 0.52

Arezoo Khosravi etal.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS THE EFFECT OF MASSAGE THERAPY ON SLEEP QUALITY IN CARDIAC CARE UNIT PATIENTS 649

the pre-test and post-test mean of the control group was

0.64, which was not statistically signi cant (p = 0.52).

To evaluate the consistency of variances between two

groups, Levin test was used (F = 0.73, df1 = 1, 58 =

df2, p = 0.08). The insigni cancy of Levine’s test is that

the variance in sleep quality score is identical in both

groups and covariance can be used.

One-way covariance analysis was used to compare the

mean of intervention and control groups. The results of

one-way covariance analysis are presented in Table (4).

The results of one-way covariance analysis showed

that the calculated f value for the comparison of the

means in the intervention and control groups is 34.56,

which is statistically signi cant (p = 0.001). Therefore,

the results of this analysis showed that the intervention,

namely, massage therapy, is effective on the quality of

sleep in patients admitted to cardiac care units.

DISCUSSION

The aim of this study was to determine the effect of mas-

sage therapy on sleep quality of patients hospitalized

in intensive care units. The  ndings showed that sleep

quality in the intervention group improved after mas-

sage therapy. This  nding is consistent with the results

obtained in some previous studies. For example, Sha ee

etal. (2013) examined the effects of massage therapy on

the quality of sleep after surgery in patients undergoing

coronary artery bypass graft surgery. The mean of qual-

ity of life scores in the experimental group and control

group was 22.5 ± 3.6 and 22.3 ± 3.8, respectively. The

difference was not statistically signi cant. After inter-

vention, mean of quality of life scores of the patients in

the experimental (intervention) group and control group

was 5.5 ± 4.7 and 11 ± 2.15, respectively, which showed

a signi cant difference (p < 0.001). Also, the results

showed that the use of massage therapy can improve the

quality of sleep after surgery in patients undergoing cor-

onary artery bypass graft surgery and considering the

simplicity and low cost of this method, this method may

be considered as a suitable supplement for medication

and postoperative interventions in these patients. The

differences between this study and the present study can

be explained by the difference in the type of massage,

the place where the work was carried out, the society

and the research environment and the disease. The aim

of this study was to investigate the effect of massage

on the quality of sleep in patients with heart disease. In

addition, the lack of improvement in sleep quality in the

control group in the post-test compared with the pre-test

is consistent with Arab and colleagues (2012), in a study

entitled “the effect of acupressure on quality of life in

patients undergoing hemodialysis”.

Regarding the comparison of sleep quality of patients

admitted to CCU in intervention and control groups, the

 ndings showed that the intervention, namely, massage

therapy, was effective on the quality of sleep in patients

admitted to intensive care units. This  nding is consist-

ent with the study conducted by Narbas entitled “the

effects of massage therapy on the quality of sleep after

coronary artery bypass graft surgery. This research was

performed on 57 patients undergoing coronary artery

bypass surgery that were divided into two groups of con-

trol and massage group after discharge from the inten-

sive care unit. Participants in the control group and the

massage group were three nights without massage and

three nights under the massage therapy. Patients were

evaluated the next morning. The results of the study in

the experimental group showed that sleep quality in the

intervention group has been increased.

Some of the theories that look at massage offer

assumptions (hypotheses) about the effectiveness of this

method. For example, according to the gate control the-

ory of pain, this method has been shown to increase the

secretion of endorphins and enkephalins, thereby con-

trolling pain, as well as improving the function of the

immune system and eliminating toxins from the body.

Also, based on the theory of nerve impulses, massage

can inhibiting the afferent nervous messages and clo-

sure of nerve valve on the posterior horn of the spi-

nal cord, inhibits the transmission of pain. It seems that

by massage, the pituitary and hypothalamus glands are

stimulated and endorphin is secreted as an intravenous

narcotic similar to morphine by them, thus these neural

mediators reduce the pain (Rigi etal., 2015).

Other researchers also believe that increased blood

supply (increased intake of food, oxygen, and removal

of cellular waste) and sensitization of muscles in relation

to neural waves, of direct effects of massage therapy on

the body. On the other hand, this technology can indi-

rectly affect fatigue by reducing pain, improving depres-

sion and relaxation (Domingos & Barg, 2015). Massage

reduces anxiety and tension, relieves pain and causes

Table 4. One-way covariance analysis to compare the mean score of sleep quality in two intervention groups with control

Source sum of squares degree of freedom mean square F P eta coef cient observed power

Sleep

quality

Group 83.07 1 83.07 34.56 0.001 0.377 0.99

Error 137.003 57 2.40

Total 9231.00 60

Arezoo Khosravi etal.

650 THE EFFECT OF MASSAGE THERAPY ON SLEEP QUALITY IN CARDIAC CARE UNIT PATIENTS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

physical relaxation, leading to two-way energy transfer

between the patient and the therapist, and as a general

manipulation of the soft tissues of the body for restoring

the metabolic balance of these tissues is used. The short-

term use of massage for hands, feet, neck and shoul-

ders can have therapeutic effects. But many massage

therapists focus on foot massage because of the lack

of enough time to massage the whole body, which has

the bene ts of physical and mental relaxation, reducing

anxiety and improving sleep (Shabani et al., 2005).In

general, based on the literature on the effects of massage

therapy, it seems that the effect of this treatment on the

quality of sleep can be the direct and indirect effects of

massage therapy. Its direct effects are due to changes

in the hormonal and neuro-transmitter, and its indirect

effects are due to the reduction of some of the variables

affecting the quality of sleep such as reduced fatigue,

stress and ... as a result of massage therapy.

Each research has limitations that can in uence its

outcomes. Some of the limitations of this research are: 1)

lack of complete control of disturbing variables such as

personality, physical and psychological variables as well

as social, economic and cultural variables; 2) lack of suit-

able research facilities such as research room, proper chair

and other necessary facilities in the hospital and thera-

peutic center; and 3) the limited power of generalizing the

results due to the limited research sample group.

It is suggested that in future researches the effective-

ness of massage therapy on other groups of patients with

problems in sleep quality and other variables such as

stress and anxiety of heart patients be investigated. It is

also suggested that the effectiveness of massage therapy

on the quality of sleep is compared with other therapies

that are available to improve the quality of sleep, so that

therapies with greater ef cacy can be used to improve

sleep quality. In addition, teaching this method of treat-

ment to nurses, using this treatment to improve the

quality of sleep in patients admitted to intensive cardiac

units and preventing the negative consequences of poor

sleep, such as heart problems, are some of the practical

suggestions of the present study.

CONCLUSION

According to the results of this study and the effect of mas-

sage therapy on the sleep quality of patients admitted to

the cardiac care unit, this method can be used to reduce the

adverse effects of decreased sleep quality in these patients.

ACKNOWLEDEMENTS

This article was part of a Master of Medical Surgical

Nursing Thesis and approved research plan of Shahid

Beheshti University of Medical Sciences, Tehran, Iran.

An acknowledgement comes to action of all patients of

hospitals af liated to Tehran Universities of Medical Sci-

ences that assisted in this study.

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