Effects of foot massage on relieving pain, anxiety and improving quality of life of patients undergone a cervical spine surgery

Anterior cervical discectomy and fusion (ACDF) represents one of the most frequently conducted spinal procedures. ACDF is a widely-used procedure to treat several cervical spine pathologies, such as prolapsed intervertebral disc spondylosis, degenerative disc disease and trauma [1]. ACDF is in general associated with optimistic clinical outcomes and the majority of patients demonstrate a substantial reduction in neck pain; nevertheless, this procedure may lead to post-operative complications. For example, dysphagia is found to be present in 38.85% of patients at one month after ACDF [2]. This is concomitant with reports showing that post-operative mental health impairment, psychological distress and anxiety are common consequences of emotional factor following post-operative pain [3, 4]. It is also reported that as high as 47.3% of patients with dysphagia exhibit anxiety and depression [5]. Together, pain and anxiety worsen surgical outcomes and deteriorate quality of life in patients [6]. However, post-operative mental and psychological impairment caused by ACDF has not received enough attention, and strategies for management of pain and anxiety after ACDF surgery are in need for the benefit of these patients.

Massage therapy has increasingly been used as a technique to promote the mobilization of structures such as muscles and subcutaneous tissues, through the appliance of mechanical force to tissues [7]. Massage therapy induces venous return and lymph movement, decreases swelling, meanwhile mobilizes the skin, tendons and muscle fibers. Therefore, the effects of massage therapy include reduction of pain, stress and anxiety, as well as induction of muscle relaxation, which are shown to help improve quality of sleep and speed of recovery. Furthermore, massage therapy could enhance mobility, allowing patients to perform daily activities, which facilitates rehabilitation [8, 9].

Complementary intervention following surgery is increasingly considered effective and acceptable alternative management of pain. Massage therapy is a complementary intervention, which has been shown to relax patients and improve quality of life of patient undergone thoracic surgery or cardiac surgery [9, 10]. Accompanying this, patients showed improved clinical outcomes, reduced pain, less anxiety, fatigue, depression, anger and confusion.

Compared with massage on other body parts, foot message is a form of complementary intervention suitable for patients with ACDF as potential harm imposed by the message on the spine is avoided. To date, limited studies have been reported regarding the effects of foot massage in alleviating anxiety and pain in patients with ACDF. There is a lack of clear evidence on the effectiveness of foot massage, which precludes recommending this routine in the postoperative care of patients undergone ACDF. To clarify the benefit of foot massage in clinical practice, herein we aimed to conduct a randomized clinical trial to evaluate whether patients who received a four-week foot massage experienced less pain and anxiety and improved quality of life. Our results could provide valuable information to guide the clinical management of patients undergone ACDF.

The study was approved by the Ethics Committee of Liaocheng people’s Hospital. Consent forms were acquired from all patients. A total of 118 patients undergone ACDF during the period of 2016–2018 in Liaocheng People’s Hospital were assessed for eligibility. The inclusion criteria were as follows: (1) age over 18 years, (2) administration for over 1 day after surgery, (3) received an open reduction and internal fixation surgery. Since long-term diabetes is thought to have significant negative impact on spinal surgery [11] and cerebrovascular, neurological and psychiatric conditions are important factors to be assessed in our study, subjects with a history of diabetes for over 10 years or had a cerebrovascular, neurological, or psychiatric diseases were excluded. Among the 118 patients, 32 were excluded and 11 did not meet the inclusion criteria. 14 refused to participate and seven were not included for other reasons.

Randomization was performed using block randomization by a research scientist blind to the study. Equal numbers (n = 43 each group) of patients were assigned to either intervention group or control group. In the intervention group, massage treatment lasted four weeks. The treatment time we chose was mainly based on the time in hospital of the patients. In our hospital, the patients with anterior cervical discectomy and fusion are usually discharged one months after operation.

A total of 118 patients were enrolled in this study and 86 patients were assigned randomly to the intervention group (n = 43) and the control group (n = 43) (Fig. 1). As shown in Table 1, the patients in the two groups did not show significant differences in baseline characteristics including gender, age, body mass index (BMI), percentage of patients who smoke, with hypertension, diabetes, coronary artery disease, or hyperlipidemia, as well as education. The average age was 54.2 ± 9.4 years in the intervention group and 52.8 ± 12.4 years in the control group, and the majority of the patients were female.

In the search for a more effective postoperative management of ACDF, psychological factors in addition to pain, such as anxiety should be considered. Postoperative anxiety has been associated with longer hospital stay, higher re-admission rates and dissatisfaction with the received care [4]. However, to our best knowledge, limited studies have been conducted to evaluate postoperative massage on the pain and anxiety management of ACDF.

Here we showed that patient who received foot massage demonstrated markedly alleviated anxiety. Emerging studies have suggested that relaxation, which can be induced in a variety of ways, affects pain. Foot massage is gaining popularity as an approach for pain management. In the present study, we showed that foot massage was associated with decreased neck pain and disability in patients undergone ACDF. Consistent with our study, Eghbali et al. demonstrated that after arthroscopic knee surgery, massage on the healthy foot, hands, and upper shoulder relieved pain [19]. Another report also showed that massage was effective in alleviating acute pain in post-thoracic surgery [10]. Massage has a long history of being used to treat a variety of illnesses. However, empirical and theoretical support in utilizing massage as a complementary intervention to alleviate anxiety, which usually concurs with pain, is thus far limited. In chemotherapy of cancer, complementary relaxation therapy has been shown to reduce anxiety and facilitate the recovery of patients, as well as improve quality of life [20]. A number of clinical studies have also confirmed that postoperative massage is powerful in improving the quality of life in patients undergone cardiac surgery [21‐23].

In contrast to a study by Adogwa et al. on preoperative treatment of anxiety in ACDF management, which showed that preoperative treatment of anxiety did not improve NDI, thereby exerting no functional benefit [24], we showed that postoperative foot massage was associated with significantly improved NDI. Our study is the first one to demonstrate significant reduction in both pain and anxiety following ACDF using foot massage as a complementary therapy. Other possible strategies for pain and anxiety management include the use of anti-depressants [25] or mood-altering drug [26] such as duloxetine [27], which however is inferior in the low-cost and safety of massage.

Our evaluation was based on questionnaires to provide numeric values in the assessment of pain, anxiety, disability and general health state, which nonetheless lacks clinically significant meaning. Thus, in the study by Parker et al. on ACDF, the minimal clinical important difference (MCID) has been introduced to measure the critical threshold of achieving treatment effectiveness [28]. Here we did not associate the clinical outcomes with foot massage intervention, to make definitive conclusions on how foot massage intervention would affect the clinical outcome, the use of MCID may be needed. Further, randomization was not stratified by gender. BMI and the number of smokers in the control group were also higher than those in the intervention group, which, albeit insignificant, may affect the conclusions of the study. Another limitation is that a relatively short follow-up period (four weeks) was used and long-term effects of foot massage in postoperative management of ACDF should be investigated. Further studies are also needed to evaluate whether foot massage would benefit other complications of ACDF, such as sleep disorders.

Here we have demonstrated that postoperative foot massage for four weeks is associated with effectively reduced neck pain and neck disability, relieved anxiety and improved quality of life in patients. These findings suggest that foot massage is worth being used as a complementary care for patients undergone ACDF.