RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS. SHALU SUNNY PHILIPDAYANANDA SAGAR COLLEGE OF NURSING
KUMARASWAMY LAYOUT, BANGALORE- 560078
2 / NAME OF THE INSTITUTION / DAYANANDA SAGAR COLLEGE OF NURSING
3 / COURSE OF THE STUDY / DEGREE OF MASTER OF SCIENCE IN NURSING, MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION / 14/06/2010
5 / TITLE OF THE STUDY / SYNOPSIS ON “A STUDY TO ASSESS THE EFFECTIVENESS OF SLOW STROKE BACK MASSAGE ON QUALITY OF SLEEP AMONG CRITICALLY ILL PATIENTS IN SELECTED HOSPITALS, BANGALORE”
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
A good laugh and a long sleep are the best cures in the doctor’s book.
~Irish Proverb
Sleep is a behavioral state characterized by the temporary suspension of the state of watchful consciousness. The particular subjective nature of sleep has always stimulated philosophical thought, but the actual behavior of the sleeping organism has also attracted wide interest across all cultures. Sleep isessentialfor the normal, healthy functioning of the human body. The physiological phenomenon of sleep is much complicated and is defined as a state of unconsciousness from which a person can be aroused. During this state, thebrainis relatively more responsive to internal stimuli than external stimuli.1
In order to evaluate and truly respect the importance of sleep, it is relevant to consider the symptoms that occur with the absence of proper sleep. First of all, the average duration of sleep should be around eight hours. Studies have shown that certain individuals are able to function with less sleep, with as little as six hours; however others are unable to function unless they have reached as many as ten hours of rest.2
A lack of sleep will quickly cause irritability, grogginess, the inability to make decisions or follow through with cognitive functions. It will cause hallucinations, dozing off during activities and even throughout the day, etc. A continued lack of sleep can contribute to weight gain, anxiety, depression, lethargy and fatigue. These inevitabilities clearly show the importance of sleep. Although one day ofsleepdeprivationis not fatal, it will indeed cause alterations in mood,physicalwell being, and overall cognitive function. Severe sleep deprivation can ultimately lead to death.2
Sleep disturbances are common problems among individuals in hospitals and institutions. A search was carried out in June 2009 in the following databases, Academic Search Elite, CINAHL, the Cochrane Library and MedLine/ PubMed. Large size effects of some interventions were found when using massage, acupuncture and music, natural sounds or music videos. The lack of high evidence strength for the nursing interventions such as massage together with the uncertainty about their effects calls for more research before implementing these interventions into clinical practice.3
Many studies show that 50 percent of critically ill patients suffer from sleep disturbances. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutic interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogram is used to objectify sleep architecture. To improve sleep in ICU patients measures are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and massage and music for relaxation. In order to define non-pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations.4
Therapeutic massage is an ideal way to deal with stress and health disorders naturally. A massage provides both physical and emotional wellness. The massage sessions can vary from single sessions to a regular massage for a short span, over a period of time. Therapeutic massage is usually rendered to treat certain health conditions, boost overall immunity or as a distressing mechanism. Therapeutic massage provides varied benefits such as improved blood circulation, release of endorphins that reduce pain, speedy recovery from injuries or chronic illness and improvement in sleep.5
Therapeutic massage employs various features such as use of essential or aromatherapy oils, different types of strokes and massage technique to help the person receiving the massage achieve the expected benefits from massage. Massage techniques vary from a single type to a combination of different strokes. The key movements in massage are effleurage (stroking), petrissage (kneading), percussion, friction and vibration techniques to relieve the stressed muscles. The pressure applied varies from light, moderate to heavy depending on the objective of the massage and type of massage. Certified and qualified massage therapists can provide 200 odd techniques in therapeutic massage.5
The various movements or techniques used in massage therapy physically stretch muscles, tendons, ligaments and fascia. The therapist’s hands can also boost blood circulation through the tissues inhibiting muscular spasms. The most popular types of therapeutic massage are deep tissue massage, shiatsu, Swedish massage, Thai massage, cranio sacral massage and sports massage usually done on the back, neck, shoulder, chest and abdomen.5
The major difference between stroking and effleurage relates to the depth of pressure applied. Stroking is usually performed slowly with gentle pressure that is firm enough from the client to feel yet light enough so that there is minimal deformation of subcutaneous tissue.6It is believed that stroking offers little direct mechanical effect, as the depth of technique is too superficial. However, significant reflexive effects have been observed with the application of stroking. Effleurage by contrast has a greater mechanical effect and may also produce the same reflexive effects as stroking. Throughout the stroke, the contoured and sculpted palms and hands, fingers or fingertips mould and form to the shape of the body region being treated. The hands are relaxed and the stroke is performed in a smooth and rhythmic fashion. The pressure employed is derived from the therapist leaning their body weight into the stroke. Effleurage is derived from the French verb effleurage meaning ‘to brush against, to skim over or to touch lightly’. Some authors equally refer to this manipulation as stroking or gliding.7
A study was done to examine the physiological and psychological effects of slow-stroke back massage and hand massage on relaxation in older people and identifies effective protocols for massage. All studies using slow-stroke back massage and hand massage showed statistically significant improvements on physiological or psychological indicators of relaxation. The most common protocols were three-minute slow-stroke back massage and 10-minute hand massage.Results of the review show the effectiveness of slow-stroke back massage and hand massage in promoting relaxation across all settings.It was concluded that studies are needed to analyze the feasibility and cost effectiveness of massage to develop best practices for massage interventions in older people.8
ASwedish research studyinvestigated the importance of slow stroke back massage for the recovery and well being of stroke patients. It was a smaller-scale randomized controlled study carried out at a Swedish geriatric clinic from 1998 to 1999. The patients who received slow stroke back massage experienced a significantly higher quality of life, showed an improvement in general hygiene and mobility, and used less medication, in particular for pain, sleep and depression.9
Another research study was conducted in June 2004 with 102 subjects on “The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients.” It was conducted by staff at the Hong Kong Polytechnic University Department of Nursing and Wong Chuk Hang Hospital, in Hung Hom, Kowloon, Hong Kong. Themassage group received 10 minutes of slow-stroke back massagebefore bedtime for seven nights. Subjects in the control group received standard care. Results of this study showed that 10 minutes of nightly slow-stroke back massage had significantly reduced pain, anxiety, blood pressure and heart rate and improved sleep, as compared to subjects in the control group. Massage can also help to increase circulation to areas in the body that have been affected by a stroke.10
6.1 NEED FOR THE STUDY
Sleep disruption has been recognized as a complication of acute. It is characterized by reduced nocturnal sleep efficiency and altered sleep architecture with increased wakefulness and stage 1 Non–Rapid Eye Movement (NREM) sleep, together with reduced slow wave and rapid eye movement (REM) sleep. Sleep disruption in critically ill and mechanically ventilated patients may have a multi factorial cause. Acute illnesses are associated with abnormal sleep architecture. The ICU environment, in which loud noisesand frequent care-related interruptionsare prevalent, may interfere with continuity of sleep. Medications commonly prescribed for patient comfort also have marked effects on sleep.It is possible that dyssynchronous patient–ventilator interactions may result in sleep disruption.11
Few epidemiologic studies evaluated the relative contribution of different risk factors on sleep problems. The main aim of the study was to assess demographics, co morbid characteristics, and health outcomes in patients with sleep problems. The information was collected from 12,437 patients with a new sleep disorder diagnosis during the year 1996 and 18,350 age- and sex-matched controls. The incidence of a new sleep disorder diagnosis was 12.5 per 1000 person-years. There was a clear association of sleep disorders with prior circulatory diseases, including heart failure and coronary heart disease; and prior gastrointestinal diseases, including gastro esophageal reflux disease and irritable bowel syndrome.12
Lack of sleep in the hospital environment is a well-known phenomenon and can delay a patient’s recovery. Hospital-induced sleep deprivation is generally remedied with medications.11 Critically ill and elderly patients are a vulnerable population and benefits from non-pharmacologic methods to promote sleep.13 By studying the amount of REM and NREM sleep in 69 elderly men, Richards found that sleep efficiency was 14.7% higher in patients who received a 6-minute back massage than in a control group.14 This study was comparable with another that followed 30 patients with fibromyalgia who received 30 minutes of massage therapy twice weekly for 5 weeks. The patients experienced decreased depression, improved sleep (a greater number of sleep hours and fewer sleep movements) and decreased symptoms, including pain, fatigue, and stiffness.15Another study on 41 hospitalized oncology patients illustrated that sleep quality, pain, symptom distress, and anxiety all improved when massage therapy was given during the hospital stay.16
Studies on the exact incidence and prevalence of insomnia, one of the commonest sleep disorders in India, are lacking. Clinicians such as Kumar and Gitanjali said that they are increasingly finding insomnia as a “major problem” per se as well as in relation to medical disorders such as heart disease, stroke, diabetes and depression and claim it accounts for up to 50% of sleep-related complaints that require intervention.17
Stressors experienced by hospital patients include excessive noise, lack of sleep, social isolation, enforced immobility, and pain from procedures. Anxiety and stress during cardiac catheterization can lengthen the hospital stay and increase the use of sedative medication before and during the procedure.19 Hamel’s did a randomized clinical trial with 46 participants demonstrated that a 20-minute back massage successfully reduced blood pressure before cardiac catheterization and improves sleep.18 When patients have higher postoperative mobility due to massage, they may also have fewer serious postoperative complications, as demonstrated by Mitchinson and his colleagues in a randomized controlled trial of 605 veterans undergoing major surgery at Department of Veterans Affairs hospitals.20
Massage therapy can produce a reaction response that creates a calm state and enhances the ability to rest, qualities that are so essential for healing to occur.14 “The majority of studies show that back massage induces a physiological or psychological relaxation response and that it is not injurious for critically ill patients with heart disease”.13
Massage therapy is becoming more widely accepted in the medical community as a credible treatment for many types of back pain and insomnia and/or as an adjunct to other medical treatments. Research shows that massage therapy has several potential health benefits for back pain sufferers, including increased blood flow and circulation, which brings needed nutrition to muscles and tissues. This aids in recovery of muscle soreness from physical activity or soft tissue injury (such as muscle strain) and decreased tension in the muscles. This muscle relaxation can improve flexibility, reduce pain caused by tight muscles and even improve sleep. Increased endorphin levels--the "feel good" chemicals in the brain. This mood enhancer can ease depression and anxiety, which can help reduce pain and speed recovery--particularly important for those suffering from chronic back or neck problems.21
Another study shows how critically ill patients reported having improved sleep patterns, both in the quality and quantity of sleep, due to slow stroke back massage compared to those who received only relaxation exercises. Many people report that they have much deeper and more restful sleep after receiving a massage or reflexology session.9
Superficial stroking is reported to stimulate and relax mood, relieve anxiety, reduce muscle tension and facilitate regression of sensory analgesia. Stroking is often used as an introductory or closing technique during a massage routine. Its effect on arousal in reportedly dependent upon the speed of the stroke: a slow stroke may have a more relaxing effect whereas a fast stroke tends to stimulate.6
One particular method of superficial stroking is known as the slow stroke back massage. The slow stroke back massage is a specific nursing protocol which consists of slow, gentle, rhythmical strokes using two hands simultaneously over the client approximately 5 centimeter out from the spine, from the crown of the head to the sacral area and has been used in nursing care since the mid 1960s. Several studies have used slow stroke back massage and have found it to be a successful nursing intervention for promoting relaxation and thus promoting sleep.35
Slow-stroke back massage is a non-pharmacological intervention that has been used since the time of Florence Nightingale to relieve physiological and psychological stressors and promote restorative sleep, although evidence for its effectiveness is sparse. One pilot randomized controlled trial examined the effects of a 3-minute Slow Stroke Back Massage on minutes of nighttime sleep in persons with dementia (n = 40) in the nursing home. The hypothesis was that participants receiving slow-stroke back massage will have increased minutes of nighttime sleep compared to participants receiving a usual care/control condition. The primary aim of this study was to compare the effects of slow-stroke back massage to a usual care/control condition on minutes of nighttime sleep. Secondary aims were to explore the effects of slow-stroke back massage compared to a usual care/control condition on minutes of nighttime sleep latency, sleep efficiency, wake after sleep onset, daytime sleep, and the day/night sleep ratio. Participants were randomized to an intervention group (n = 20) who received the 3-minute Slow Stroke Back Massage intervention or a control group (n = 20) who received usual bedtime care. Actigraphy was used to record data on sleep variables at baseline and post intervention. Descriptive statistics showed a 36 minute increase on minutes of nighttime sleep in the Slow Stroke Back Massage intervention group (46.1 minutes) compared with the control group (10.32 minutes). ANCOVA did not reveal any statistically significant differences between the intervention and control groups on minutes of nighttime sleep [F(1, 37) = 1.90, p = 0.18, effect = 0.05)] or on exploratory sleep variables. Long hours in bed, poor sleep hygiene practices and environmental factors contributed to poor sleep patterns. Findings from this pilot study suggest that Slow Stroke Back Massage may be an effective nursing intervention to promote sleep in persons with dementia in the nursing home, but further testing is needed to provide definitive results.8