Efficacy of Massage on Pain Intensity in Post-Cesarean Women: a Systematic Review and Meta-Analysis

Hammad A. Fadlalmola, RN, MSc, PhD^1,*, Abdelhadi A. Mohammed, MD², Huda H. Abedelwahed, RN, MSc, PhD³, Amani A. Mohammed, RN, MSc, PhD³, Amani A.E. Taha, RN, MSc, PhD³, Rasha A. Ali, RN, MSc, PhD³, Amani M.M. Abdelrahman, RN, MSc, PhD³, Zahra H. Hazazi, RN, MSc, PhD³, Asia S. Mohamed, RN, MSc, PhD³, Manal H. Fatahalrahman, RN, MSc, PhD³, Anwar B. Eltom, RN, MSc, PhD³, Amel E. Banaga, RN, MSc, PhD³, Salwa A.M. Mohmed, RN, MSc, PhD³, Alawia A. Elshaikh, RN, MSc, PhD³, Amna M. Ali, RN, MSc, PhD³, Ashraf A. Elbashir, RN, MSc, PhD³, Randa A. Basheer³, Wargaa H. Taha, RN, MSc, PhD⁴, Eman M. Ebrahim, RN, MSc, PhD³, Elturabi E. Ebrahim, RN, MSc, PhD⁵

¹Nursing College, Department of Community Health Nursing, Taibah University, Madinah, Saudi Arabia
²Soba University Hospital, Khartoum, Sudan
³Nursing College, Jazan University, Jazan, Saudi Arabia
⁴College of Nursing, Department of Maternity and Child Health Nursing, Jouf University, Al-Jawf, Saudi Arabia
⁵Nursing Science Department, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia

Background

Cesarean section is a common surgical procedure that may be considered a safe alternative to natural birth and helps to resolve numerous obstetric conditions. Still, the Cesarean section is painful; relieving pain after a Cesarean section is crucial, therefore analgesia is necessary for the postoperative period. However, analgesia is not free of complications and contraindications, so massage may be a cost-effective method for decreasing pain post-Cesarean. Our study aims to determine the massage role in pain intensity after Cesarean sections.

Methods

We searched five electronic databases for relevant studies. Data were extracted from the included studies after screening procedures. We calculated the pooled mean difference (MD) and standardized mean difference (SMD) for our continuous outcomes, using random or fixed-effect meta-analysis according to heterogenicity status. Interventional studies were assessed for methodological quality using the Cochrane risk-of-bias assessment tool, while observational studies were assessed using the National Institutes of Health’s tools.

Results

Our study included 10 RCTs and five observational studies conducted with over 1,595 post-Cesarean women. The pooled MDs for pain intensity considering baseline values either immediately or post 60–90 minutes were favoring the massagegroup over the control group as follows:(stand. MD = −2.64, 95% CI [−3.80, −1.48], p >.00001; MD = −2.64, 95% CI [−3.80, −1.48], p >.00001, respectively). While pooled MDsregarding post-intervention only eitherimmediately or post 60–90 minutes were:(stand. MD = −2.04, 95% CI [−3.26, −0.82], p =.001; stand. MD = −2.62, 95% CI [−3.52, −1.72],p > .00001, respectively).

Conclusion

Our study found that using massage was superior to the control groups in decreasing pain intensity either when the pain was assessed immediately after or 60–90 minutes post-massage application.

KEYWORDS: massage, post-Cesarean, pain, meta-analysis

INTRODUCTION

A Cesarean section (CS) is a common surgical procedure to deliver a baby through incisions in the abdominal and uterine walls.⁽¹⁾ It is a safe alternative to natural birth and helps resolve obstetric conditions such as cephalopelvic disproportion, fetal malposition, and fetal distress, reducing maternal and neonatal mortality.⁽²⁾

After the surgery, the anesthetic effect wears off, and pain in the lower abdominal incision begins to emerge, usually within 24 hours.⁽³⁾ Anesthesia can cause discomfort and psychological harm.⁽³⁾ Pain is considered the fifth vital sign after body temperature, pulse, respiration, and blood pressure.⁽⁴⁾ Relieving incisional pain after a CS is crucial, so analgesia is necessary for post-operative recovery. The common methods of analgesia include epidural and intravenous analgesia, each with its drawbacks such as epidural catheter displacement and urine retention. ⁽⁵⁾

Additionally, opioid analgesics are associated with respiratory depression, excessive sedation, nausea, vomiting, and other unpleasant responses.⁽⁵⁾ Multimodal analgesia is increasingly used to improve the analgesic effect and reduce adverse reactions, but there is still room for improvement. Even with regular analgesics, pain management is inadequate in some cases.⁽³⁾

Massage is a low-cost, widely used alternative therapy that benefits various biological systems and promotes local and general circulation, immune function, natural healing, and homeostasis.⁽⁶⁾ Local massage can also reduce pain by stimulating non-painful nerve fibers and interfering with pain transmission in the spinal cord.⁽⁶⁾ Foot and hand massage has effectively reduced post-operative incision pain.⁽⁷⁾ They are ideal locations for massage because they have many mechanoreceptors stimulating non-painful nerve fibers and reducing pain.⁽⁷⁾

Many studies have been published since the last meta-analysis, which discussed the effect of massage on decreasing pain after CS.^(7–11) In our study, we aim mainly to assess the efficacy of massage on pain post-CS to determine its role in everyday practice. Additionally, we aim to include all massage types, not only hand and foot massage.

METHODS

The study was designed according to the Cochrane Handbook for Systematic Reviews of Interventions and reported under the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.^(12,13)

Literature Search

We searched Web of Science, PubMed, Scopus, Cochrane CENTRAL, and EMBASE from inception until February 2023. Additionally, all references listed in all eligible articles and prior meta-analyses on the same topic were retrieved to identify any other missed relevant citations. The following search terms were used: (“Cesarean section” OR “abdominal Deliver*” OR “caesarean Section” OR cesarian OR cesarean OR “c-section” OR csection OR “c section” OR “surgical delivery” OR “surgical birth”) AND (massage OR massages OR “zone therapy” OR Qigong OR “Ch’i Kung” OR “Tui na”).

Eligibility Criteria

Two reviewers independently screened the retrieved references according to the eligibility criteria. The following criteria were applied to include the studies in our systematic review: 1) studies whose patients are post-CS females; 2) studies whose intervention was massage (any type); 3) studies in which the comparator or a control group did not receive any type of massage; 4) studies that assessed any of the following outcomes: pain (the primary outcome), systolic blood pressure, diastolic blood pressure, and respiratory rate; and 5) any study design comparing massage versus control group. We excluded different studies for the following reasons: 1) animal studies; 2) studies that were not in English; 3) abstracts only; and 4) study data that were not published yet.

Data Extraction

Data extraction was performed using an offline data extraction sheet. The following data were extracted: study ID (first author and publication year), country, study design, age of participants, description of massage, the protocol for tacking additional pain killer, inclusion criteria, conclusions, and main outcomes, which were as follows: pain intensity, sleep quality, fatigue severity, Post-partum Comfort Questionnaire Anxiety, opioid and NSAID use, stress, relaxation, the effect of massage on abdominal pain, Self-Rating Anxiety Scale, the effect of massage on breastfeeding, headache, need for breastfeeding support, breastfeeding success score, breastfeeding self-efficacy, and prevent urinary retention after Cesarean delivery.

Risk of Bias Evaluation

Two authors independently assessed observational studies for their methodological quality using the National Institutes of Health’s (NIH) tool.⁽¹⁴⁾ The authors’ opinion is classified as “good”, “fair”, or “poor” according to scores obtained during the assessment. As for RCTs, the quality of the included trials was assessed using the Cochrane risk-of-bias assessment tool (ROB) for interventional studies.⁽¹⁵⁾ This tool comprises the following parameters: selection, performance, detection, attrition, reporting, and other possible sources of bias. The authors’ judgment was categorized as “high”, “low”, and “unclear” risk of bias. Discrepancies were resolved through discussion or by a third assessor.

Data Synthesis

Our assessed outcomes were continuous and were pooled as mean differences (MDs) between the two groups with 95% CIs using the inverse variance method. When applicable, we calculated and pooled the change between before and after the massage or the control; otherwise, we analyzed the post-intervention only when the pre-intervention data were unavailable. We also used standardized MD when different scales were used to assess the same outcome. The fixed effects model was first applied if the effect estimate was pooled from homogenous studies; otherwise, the random effects model was applied. We investigated the statistical heterogeneity between studies using the I2 statistics chi-squared test, with p < .1 considered heterogeneous and I² ≥ 50% suggestive of high heterogeneity. The Review Manager Software (RevMan) version 5.4 (London, UK; www.cochrane.org ) was used for all statistical analyses.

RESULTS

Results of Literature Search

Our search method using four databases resulted in 1,363 studies. After duplicate elimination, 904 studies were eligible for screening. After title and abstract screening, 46 articles were found reliable for full-text screening. We rejected 31 of these; eventually, 10 articles met our criteria and were included in our meta-analysis, while five studies were only included as a systematic review.^{(8,9, 10,11,16–21,22–26)}Figure 1 shows the PRISMA flow diagram for the study selection.

Study Characteristics

Our study included 10 RCTs and five observational studies conducted in six countries with over 1,595 post-CS women.^{(8,9,10,11,16,17–20,23,25)} The main outcome in most of the studies was pain intensity. Table 1 shows the baseline characteristics and summary of included studies.

Table 1 Summary and Baseline Characteristics of the Included Studies

Risk of Bias Assessment

According to the NIH tool, observational studies showed a fair risk of bias. As for trials, the overall authors’ judgment was high to moderate quality according to the Cochrane risk of bias assessment tool. Although all of the trials showed a low risk of bias regarding random sequence generation (except Abdel-Ghani et al.⁽¹⁶⁾ which did not declare their randomization status), blinding in most of them was unclear, and it is considered here a key domain for potential bias. Figure 2 shows the summary of the risk of bias in interventional trials, while the summary of observational studies is shown in Table 2.

Table 2 Quality assessment of RCTs by Cochrane tool

Primary Outcomes

Pain intensity assessed right after massage

Pain intensity pre and post-massage were reported in six studies with 688 patients included.^{(9,11,16,18,19,21)} The pooled standardized MD showed a significant difference, favoring the massage group (stand. MD = −2.64, 95% CI [−3.80, −1.48], p > .00001). The pooled studies were heterogenous (χ² p > .00001, I² = 97%); however, we could not resolve heterogenicity by the sensitivity analyses (Figure 3).

Pain intensity post-massage only was reported in seven studies with 798 patients included.^{(8–11,16,18,19)} The pooled standardized MD showed a significant difference, favoring the massage group (stand. MD = −2.04, 95% CI [−3.26, −0.82], p = .001). The pooled studies were heterogenous (χ²p > .00001, I² = 98%); we could not resolve heterogenicity by the sensitivity analyses (Figure 4).

Pain intensity assessed 60–90 minutes after massage

Pain intensity pre- and post-60–90 minutes after massage was reported in six studies with 518 patients included.^{(9,11,17–20)} The pooled MD favored the massage group over the control (MD = −2.50, 95% CI [−2.73, −2.27], p > .00001). The pooled studies were homogenous (χ²p = .60, I² = 0%) (Figure 5).

Pain intensity post-60–90 minutes after massage only was reported in six studies with 518 patients included. ^{(9,11,17–20)} The pooled standardized MD showed a significant difference in favor of the massage group (stand. MD = −2.62, 95% CI [−3.52, −1.72], p > .00001). The pooled studies were heterogenous (χ²p > .00001, I² = 93%); nevertheless, we could not resolve heterogenicity by any means of sensitivity analyses (Figure 6).

Secondary Outcomes

Change of systolic blood pressure, diastolic blood pressure, pulse, and respiratory rate from the baseline was assessed after 60–90 minutes of massage in three studies with 256 patients included; the pooled MDs showed significant difference (p > .05) favoring the massage group, as follows: (MD = −9.10, −7.25, −3.93, and −2.21, respectively) (Figures 7–10).

Additionally, we analyzed the latter secondary outcomes regarding post-massage values only, and the pooled MDs were as follows: (−3.91, −4.00, −1.69, and −1.57, respectively). They all showed significantly different outcomes towards massage groups, except for respiratory rate (Figures 11–14).

DISCUSSION

Our study included 15 studies; 10 RCTs and five observational studies with 1,595 post-CS women who underwent different types and sites of massages. We excluded different populations as dialysis patients, which led to homogeneity of the population. Only 10 of our included studies were included in the quantitative analysis. The main outcome of our study is pain intensity. All of our pooled results showed significant improvement in the massage over the control groups regarding decreasing pain post-CS, whether the assessment was immediately after the massage or 60–90 minutes post-massage.

Our findings could be justified by the holistic nature of that massage therapy that incorporates several theories, such as the meridian theory, modern pathophysiology, bio-holographic embryo theory, and the reflection theory.^(27,28) Suppose we applied some of these theories to Cesarean delivery as an example. In that case, the blood after the procedure is mainly outside the veins and remains in the skin, causing stagnation, blood stasis, and obstructed channels, which result in pain according to traditional Chinese medicine.^(27,28) Massage can help promote blood circulation, clear the meridians, and alleviate pain. Pain receptors are found primarily in the skin and subcutaneous tissue, with a high concentration in the hands and feet.^(27,28) These receptors are mechanically stimulated and send signals to the brain through the spinal cord, which excites the vagus nerve influencing the hypothalamus.^(27,28) This leads to an increase use of painkillers, such as enkephalins and dynorphins, and a decrease in pain-causing substances, which affects the secretion and metabolism of pain-related neurotransmitters and hormones, resulting in an analgesic effect.^(27,28) Furthermore, massage therapy provides relaxation for the patient, allowing them to focus on the sensations caused by the massage and reducing pain by distracting their attention from it.^(11,27,28)

Zimpel et al., in their recent meta-analysis, compared many complementariness and alternative therapies for post-CS pain, including hand and foot massage, and they were in line with our results regarding the efficacy of massage in decreasing pain.⁽²⁹⁾ Still, many studies were conducted afterward that were not included in their study.^(8–11,23) They also were restricted in their analysis on hand foot massage, unlike our study, which comprised different types of massages. Furthermore, they did not standardize their MD, although their included studies used different scales to assess pain intensity.

Our study included all types of massage—foot and hand, all-body, deep-tissue, and massage with olive oil—in the analysis, trying to declare its role in decreasing pain and consequently improving the quality of life of women post-CS. Several studies have come to the same conclusions as ours, reinforcing our results; for example, researchers who utilized olive oil for post-Cesarean section massages showed a statistically significant difference between the study group and the control group.^(9,16) Additionally, Pruyadarsini demonstrated a significant difference between the pre-and post-test results. Over half of the women studied had a severe pain level in the pre-test, but after receiving an olive oil massage, this pain level decreased to zero in the post-test.⁽³⁰⁾

A qualitative study was conducted to investigate the impact of therapeutic massage therapy on pain levels after obstetric surgery. During the study, therapeutic massage was administered to the patient’s head, neck, shoulder, and back. The patients reported decreased pain levels at the end of the study.⁽³¹⁾ These results, along with those of Güney et al., demonstrated that massage treatments in general, and deep tissue massage specifically, can effectively reduce pain levels among various patient groups.⁽¹⁰⁾

Additionally, our findings could be supported by other studies that did not target post-CS women but assessed the effect of massage on pain. A randomized controlled trial was conducted on participants with chronic low back pain; deep-tissue massage was just as effective as non-steroidal anti-inflammatory drugs.⁽³²⁾ In a case study of a pregnant woman, deep-tissue massage was used to alleviate low back pain and improve functional capacity. The study reported that massage therapy was associated with a reduction in low back pain and an improvement in functional capacity.⁽³³⁾ All the massage therapies discussed earlier are believed to improve circulation and lymphatic flow, which could potentially quicken the elimination of metabolic waste products and reduce fatigue.⁽³⁴⁾

Our study had some limitations. 1) The assessment of the main outcome in the study is subjective, and this may make the same outcome varies, so we suggest coming studies choose another objective method to assess the efficacy of massage in decreasing pain as trying to measure the level of endogenous endorphins before and after massage or link between massage and the levels of inflammatory mediators. 2) The duration of massage varies across the studies, so it needs to be more stratification in further analyses when become available with sufficient data. 3) Also, in our study, we could not consider the analgesia in our analysis, and this is a major confounder that may affect the results, so future studies should stratify analgesia in their analyses with massage to exclude the confounding bias that may result from analgesia. 4) There was heterogenicity between the pooled studies and this may be mainly to different scales used, different study designs and the type of analgesia used among participants. 5) Lack of data sufficient for subgroup analysis according to the type of massage. 6) There were not enough studies available with longer follow-up durations to consider the true effectiveness of massage therapy not influenced by the negative effects of massage therapy as it is common that the patient may feel muscle soreness at the following day, lasting for two to four days as a result of the massage treatment itself, especially if the pressure was deep. 7) We found only one paper on the prevention of urinary retention after Cesarian section which wasn’t considered a clear indicator of the effectiveness of massage therapy. So, future studies should be done to prove this point.

Despite these previous limitations, we included all relevant published studies in the literature and all types of massage (all-body, hand and foot, deep-tissue, with olive oil) in our analyses. We also do subgroups according to the time of pain assessment post-massage, either immediately or 60–90 minutes post-massage, and we consider the change in MD from baseline whenever it was applicable in the analysis. Also, we limited our study to post-CS women to make the population as homogenous as possible.

CONCLUSION

In our study, we tried to clarify the role of massage on pain intensity in post-CS women. Our results favored massage over the control in decreasing post-CS pain immediately after the massage or 60–90 minutes post-massage application. We recommend further studies to stratify confounding associated with assessment and standardize measuring tools across studies, and the use of more objective tools to detect the role of massage in pain post-CS to build stronger evidence that could be generalized to improve everyday health practice and post-partum period management.

ACKNOWLEDGMENTS

Not applicable.

CONFLICT OF INTEREST NOTIFICATION

The authors declare that they have no financial or personal relationships with other individuals or organizations that could inappropriately influence, or be perceived to influence, their work.

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INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK, VOLUME 16, NUMBER 3, SEPTEMBER 2023