The effect of shoulder massage on shoulder pain and sleep quality in patients after laparoscopic cholecystectomy: a randomized controlled trial

Abstract

Background

Laparoscopic cholecystectomy patients may suffer from sleep disturbances due to this postoperative pain. Postoperative pain and low sleep quality can lead to various unpredictable complications, including anxiety.The aim of this study is to determine the effect of shoulder massage administered to patients after laparoscopic cholecystectomy on pain and sleep quality.

Methods

The study was designed as a randomized controlled trial.This study was carried out with 60 patients who underwent surgery at the General Surgery Department of a university’s Faculty of Medicine between January 2020 and March 2021. The study was completed with 60 patients (30 in the intervention group and 30 in the control group). The patients in the intervention group received shoulder massage twice at 6-hour intervals. The data for the study were collected using the “Individual Introduction Form”, the “VAS”, and the “Richard Campbell Sleep Scale”.

Results

It was found that the pain of the patients in the intervention group significantly decreased compared to the control group 30 min after the massage (p˂0.05). However, 6 h after the massage, the pain levels in both groups were similar. The sleep quality of the patients in the intervention group was significantly higher compared to those in the control group (p˂0.05).

Conclusions

It was determined that the massage therapy yielded a short-term alleviation of shoulder pain among the patients while also enhancing their sleep quality. These results suggest that shoulder massage could be effectively incorporated into nursing practice as a means to ameliorate pain levels and enhance sleep quality in postoperative patients.

Trial registration

ClinicalTrials.gov identifier: NCT06480149 (retrospectively registered, Protocol ID: 2019/06-8Last Update Posted 2024-06-28) https://ctv.veeva.com/study/shoulder-massage-after-cholecystectomy.

Background

Cholelithiasis refers to the condition marked by the presence of stones within the gallbladder and/or the bile ducts. Gallstones represent the most prevalent ailment affecting the gallbladder. The most commonly preferred surgical treatment for cholelithiasis is cholecystectomy [1, 2]. In recent years, the most favored method over open surgical operation is laparoscopic cholecystectomy [3, 4]. This procedure involves the removal of common duct stones by insufflating the cavity with gas (pneumoperitoneum) to separate abdominal cavity organs from each other and from the abdominal wall, aided by a camera for the operation. While this procedure is more comfortable compared to open surgical operations, it can also lead to certain complications [5].

The pain experienced by patients after laparoscopic cholecystectomy can be divided into three categories: parietal, visceral and shoulder pain [6]. While visceral and parietal pain decreases after 24–48 h, it has been reported that shoulder pain may increase gradually [7]. The most severe pain is defined as pain in the right upper quadrant of the back towards the shoulder in the first 24 h. The pain is thought to develop due to increased abdominal pressure, trauma to the abdominal wall, and irritation of the phrenic nerve [8]. Despite early mobilization of patients and the administration of various analgesics to manage these pains, it is observed that the pain is not effectively reduced [9, 10].

The postoperative pain frequently experienced by patients often leads to various discomforts and disrupts daily life activities. One of the most significant among these is the deterioration in the quality of sleep [11, 12]. Studies have reported that, in the hospital setting, pain is the leading factor affecting sleep quality after surgical procedures, accounting for 80% of cases [13, 14]. Laparoscopic cholecystectomy patients may suffer from sleep disturbances due to this postoperative pain [15]. Postoperative pain and low sleep quality can lead to various unpredictable complications, including anxiety [12].

One of the most common and difficult to manage challenges for nurses is pain management [16]. Proper management and control of pain lead to positive outcomes, such as increased sleep quality, reduced hospitalization duration, decreased complications, and improved quality of life for individuals [17, 18]. Pharmacological methods are frequently employed in pain management due to their ease of application and rapid effectiveness. However, it is known that they are not cost-effective and can lead to various adverse physiological outcomes [18, 19]. It is a fact that non-pharmacological methods have been increasingly implemented alongside pharmacological applications in recent times [20]. Guidelines recommend the combined use of non-pharmacological methods with pharmacological approaches [21]. Peripheral cutaneous stimulation techniques, hot-cold applications, TENS (Transcutaneous Electrical Nerve Stimulation), music therapy, acupuncture, aromatherapy, and massage are commonly cited as the most preferred non-pharmacological methods in pain management in conjunction with pharmacological interventions [14, 22]. Massage therapy, as one of these interventions, exerts its effects by targeting soft and connective tissues, facilitates regulation of local blood circulation through biochemical alterations, enhances muscle flexibility, promotes lymphatic movement, and helps loosen adherent connective tissue [23].In this manner, it serves as a mediator that improves local nociceptive and inflammatory resolution [24, 25].It has been reported that massage may reduce secondary injury, nerve sensitivity and collateral sprouting by altering signaling pathways related to the inflammatory process, which may lead to increased healing and reduced or prevented pain [26]. In addition, massage is known to break the pain-spasm-pain cycle. Reduction of pain with massage is achieved by stimulation of peripheral touch sensory receptors with massage applications. Namely, stimulation of thick fibers increases the inhibitory effects of inhibitory intermediate neurons in the substancia gelatinosa. Analgesic effect is provided according to the gate control theory. With the stimulation of thick fibers by massage, nociceptive impulses coming from thin fiberscannot pass to the level of the medulla spinalis and pain is controlled as a result of door closure [27].

While classic shoulder massage is commonly used in daily life for relaxation and stress relief, it also serves as a physiotherapy intervention for the alleviation of various types of pain. During shoulder massage, vagal stimulation increases, leading to an elevation in cortisol release, thereby revealing positive effects on the immune system and pain [24]. Anatomical studies have revealed that during massage, baroreceptors and mechanoreceptors located in the intradermal and subcutaneous tissues send signals to the vagus nerve [2, 28]. In the alleviation of non-specific shoulder pain, including post-operative pain, it has been observed that various types of shoulder massage have a short-term effect [24, 25, 29].

Studies investigating the effectiveness of massage therapy in reducing pain after laparoscopic abdominal surgery have demonstrated the ability of various types of massage to reduce patients’ postoperative pain levels [2, 14, 24, 25, 29]. Upon reviewing the literature, it is observed that there is no study on shoulder massage application for pain management and consequent improvement in sleep quality after laparoscopic surgery. Therefore, this study aimed to investigate the effects of shoulder massage on shoulder pain and sleep quality in patients undergoing laparoscopic cholecystectomy.

Hypotheses

• 1. The study group who receives shoulder massage after cholecystectomy experiences less pain in comparison to control group.

• 2. The pain level of the study group receiving shoulder massage after cholecystectomy is not different from the control group.

• 3. The sleep quality of the study group receiving shoulder massage after cholecystectomy was better compared to the control group.

• 4. The sleep quality of the study group receiving shoulder massage after cholecystectomy did not differ from the control group.

Methods

Study design

This randomized controlled trial was conducted to investigate the effect of traditional shoulder massage on both shoulder pain and sleep quality in patients within the first 24 h after laparoscopic cholecystectomy.

Study population and sample

The research population consisted of 132 patients who underwent laparoscopic cholecystectomy surgery at a private university hospital in Istanbul, Turkey, between 1 January 2020 and 31 March 2021. The sample size was calculated through a power analysis. According to the power analysis conducted, it was determined that a minimum of 52 individuals, with 26 in the experimental group and 26 in the control group, were needed to achieve 80% power at a significance level of 0.05. Considering data losses and after excluding 53 patients who did not meet the inclusion criteria and 19 patients who refused to participate in the study, a total of 60 patients were included in the sample, with 30 in the intervention group and 30 in the control group. The patients admitted to the hospital were assessed for eligibility by the nurse of the same doctor who would perform this surgery. Then, the patients were informed about the research by a nurse and asked to volunteer. Those who met the eligibility criteria were randomly assigned to either the experimental or control groups using a randomization blocking and coin-flip method, with the researcher being informed of the assignments. The study was concluded when the desired number of 30 patients in both experimental and control groups was reached using this method.

Criteria for inclusion in the study

• Patients aged between 18 and 70 years,

• Undergoing general anesthesia,

• Willing to participate in the research.

Exclusion criteria from the study

• Patients receiving epidural analgesia after surgery,

• Patients who underwent a conversion from laparoscopic cholecystectomy to open cholecystectomy during the procedure,

• Patients who develop postoperative confusion, need intensive care, or have a secondary complication and are mentally unable to answer the questions correctly,

• Patients who did not develop shoulder pain after surgery,

• Patients in a catabolic state, those aged 70 years and older, those with chronic pain and opioid use, those who experience excessive nausea, vomiting, bleeding or infection in the postoperative period, and those with drains such as Hemovac, which can interfere with the effectiveness of the intervention by negatively affecting pain and sleep quality.

Data collection tools

The research data were collected using the ‘Individual Information Form’, the ‘VAS’ for Pain Assessment, and the ‘Richard-Campbell Sleep Scale’.

Individual information form

The form, prepared by the researcher, includes questions about the patient’s age, gender, height/weight, education level, marital status, previous hospitalizations, history of surgeries, chronic illnesses, medications taken regularly, and past experiences with pain.

Visual analog scale (VAS)

In this scale developed to determine the severity of pain, patients are able to quantify their pain using numbers. It starts from the absence of pain (0) and goes up to the level of unbearable pain [10]. According to the VAS, pain intensity is typically rated as ‘no pain’ with a score of 0 and ‘the worst imaginable pain’ with a score of 10 (on a 10 cm scale) [30].

Richard-campbell sleep scale

The Turkish validity and reliability study of the scale, developed by Richard in 1987, was conducted by Karaman Özlü and Özer in 2015 [31]. It is a 6-item scale used to assess the depth of nocturnal sleep, the time to fall asleep, the frequency of awakening, the duration of wakefulness upon awakening, the quality of sleep, and the level of ambient noise. Each item is evaluated on a chart ranging from 0 to 100 using the visual analog scale technique. Scores between “0–25” on the scale indicate very poor sleep quality, while scores between “76–100” indicate very good sleep quality. The Cronbach’s α coefficient for the scale was determined to be 0.82 [31], whereas in this study, the Cronbach’s α coefficient for the scale was found to be 0.99.

Collection of data

The research data were collected through face-to-face interviews with those patients who agreed to participate in the study. Prior to the surgery, “Informed Consent Forms” were provided to the patients, tailored according to distinct criteria for the intervention and control groups. The patients expressed their voluntary participation in the study by signing these forms, which were overseen by the doctor’s nurse.

The pain levels of the patients in the intervention group were evaluated by the researcher using the Visual Analog Scale (VAS) when they regained consciousness approximately one hour after surgery. The patients were informed about the massage procedure and placed in the semi-fowler position, and olive oil was applied to the hands for lubrication. Classical shoulder massage was applied to both shoulders of the patient for 10–15 min each. 30 min after the massage, the patient’s pain was reassessed using the VAS scale. Then, 6 h later, the patient’s pain was reassessed and shoulder massage was applied using the same techniques, followed by pain assessment 30 min later. Pharmacologic agents continued to be administered under the guidance of a physician throughout this process.

The 30 participants in the control group who agreed to participate in the study received pain treatment using only pharmacologic agents, and pain assessments were performed simultaneously with the intervention group.

The sleep quality of the patients in both intervention and control groups was assessed using the Richard-Campbell Sleep Scale by face-to-face interview on the morning of the first postoperative day.

Shoulder massage application

After providing information to the patients in the intervention group, they were placed in a semi-fowler position with pillow support. Non-sterile gloves were worn on the hands, and olive oil was applied to the hands for lubrication. An expert opinion was obtained from the physiotherapist of the hospital for the application and duration of the classical shoulder massage. The researcher nurse applied classical shoulder massage to both shoulders of the patient for 10–15 min each. The application started with effleurage and proceeded sequentially with petrissage and percussion techniques.

• Effleurage was performed in a rubbing motion with the palm of the hand from distal to proximal, aiming to promote increased blood circulation.

• Petrissage was applied as deep as possible, in a rubbing motion from distal to proximal on the shoulder. Deep touches, especially with the thumb, were emphasized. Patients were told to indicate if they felt discomfort and softer touch was applied.

• Percussion was administered with superficial strikes, again from distal to proximal on the shoulder [32].

All of these procedures were applied to both shoulders for 10–15 min.

Statistical analysis

The data were analyzed using the SPSS for Windows 22 software package. The data analysis process included descriptive statistics such as numbers, percentages, minimum and maximum values, as well as means and standard deviations. Additionally, the data were analyzed using various statistical tests. In the comparison of binary groups, the t-test was used when the data showed a normal distribution, while the Mann-Whitney U and Wilcoxon tests were employed for non-normally distributed measurements. For the comparison of multiple groups, Analysis of Variance (ANOVA) was used for repeated measurements, and as an advanced analysis, the LSD test was applied. In the assessment of internal validity, Cronbach’s α coefficient was used, along with Kurtosis and Skewness coefficients to indicate the normality of the data distribution [33].

Ethical considerations

Prior to commencing the research, the necessary research approval was obtained from the Ethics Committee of Maltepe University (Approval no: 2019/06–8). Institutional approval to conduct the research in the General Surgery Clinic of the Faculty of Medicine Education and Research Hospital of Maltepe University was also obtained from the Office of the Chief Physician. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants were informed of the voluntary nature of their participation and the commitment to confidentiality and anonymity. Signed informed consent was obtained from all participants prior to the start of data collection, which explained the purpose of the study, the nature of their participation and their right to withdraw at any time. Before the interviews, the ‘Informed Consent Form’ was prepared with separate content for the intervention and control groups, and theparticipants who voluntarily expressed their willingness to participate in the study signed the form.

Results

In this study, which was conducted to investigate the effect of shoulder massage on shoulder pain and sleep quality in patients undergoing laparoscopic cholecystectomy surgery, in the intervention group, 36.7% of the participants were in the 26–40 age group, 50% were male (Table 1), 46.7% were in the height range of 156–170 cm, and 43.3% were in the weight range of 71–85 kg. Furthermore, 70% of the participants had been hospitalized before, and 56.7% had not undergone surgery previously. Among the participants, 73.3% did not have a chronic illness, 70% did not use medication regularly, 80% had no allergies, and 66.7% had experienced pain before (Table 2). In the control group, 66.6% of participants were in the 41–55 or 46–70 age group, 60% were female (Table 1), 50% were in the height range of 156–170 cm, and 56.7% were in the weight range of 56–70 kg. Among them, 76.7% had been hospitalized before, and 53.3% had undergone surgery previously (Table 2). The intervention and control groups were similar in terms of all variables.

Table 1 Demographic characteristics of participants

Table 2 Medical information of the participants

There was no statistically significant difference in the average pain score between the intervention (7.67 ± 1.54) and control groups (8.23 ± 0.82) (p > .05). However, there was a statistically significant difference in the average pain score 30 min after the first massage between the intervention (3.03 ± 1.07) and control groups (8.10 ± 0.71) (p < .05). The control group had a higher mean score. While there was no statistically significant difference in the average pain score 6 h after the first massage between the intervention (6.13 ± 1.22) and control groups (6.43 ± 1.30) (p > .05), there was a statistically significant difference in the average pain score 30 min after the second massage between the intervention (1.53 ± 0.68) and control groups (5.93 ± 0.98) (p < .05). Again, the control group had a higher mean score.

In the intervention group, there was a statistically significant difference in the average pain score at four different time points (p < .05). In the post hoc analysis conducted to determine the source of the difference (LSD), it was found that all measurements were significantly different from each other. This can be summarized as follows: a > c > b > d (Table 3).

Table 3 Comparison of Pain score averages within and between groups

In the control group, there was a statistically significant difference in the average pain score at four different time points (p < .05). In the post hoc analysis conducted to determine the source of the difference (Z), it was determined that the average score 30 min after the second massage was lower than the scores immediately upon regaining consciousness, 30 min after the first massage, and 6 h after the first massage. Additionally, it was found that the average score 6 h after the first massage was lower than the score immediately upon regaining consciousness but higher than the score 30 min after the first massage. This can be summarized as follows: d < a, b, c; c < a, c > b (Table 3).

When comparing the average sleep quality scores on postoperative day 1 (Table 4), there was a statistically significant difference in the average sleep quality scores between the intervention (94.00 ± 3.92) and control (64.90 ± 12.14) groups on postoperative day 1 (p < .05). The intervention group had a higher average sleep quality score.

Table 4 Comparison of Sleep Quality score averages on postoperative day 1

Discussion

It is commonly believed that carbon dioxide gas, which is commonly used during laparoscopic surgery, often causes shoulder pain due to irritation of the diaphragm. The incidence of shoulder pain ranges from 35 to 80% and has been reported to persist for up to 72 h after surgery [8, 9]. Ineffective management of postoperative pain is associated with increased morbidity, reduced quality of life and decreased functional recovery. Most patients require analgesics or non-pharmacologic treatment to relieve pain.

Laparoscopic cholecystectomy is one of the most preferred minimal invasive surgical methods, with the majority of patients being middle-aged individuals and females [3, 4, 34, 35]. In this study, it was also found that the majority of the patients were over 40 years old and female. It is thought that the reason why gallbladder inflammation is more common in women and people over the age of 40 may be due to conditions such as sex hormones, diet with fatty foods, sedentary life, and the more frequent occurrence of conditions that may cause inflammation in older ages.

Postoperative pain is one of the significant issues that can negatively affect patients’ recovery process and quality of life [36]. Although various studies have reported that patients experience less pain after laparoscopic surgery [37, 38], in this study, the pain of the patients was found to be severe in the initial measurement. Pain experienced during laparoscopic surgery can develop due to the insufflation of carbon dioxide gas, intraabdominal trauma, and trocar site incisions [39,40,41]. Postoperative shoulder pain is a significant issue observed in a large proportion of patients after laparoscopic cholecystectomy (approximately 80%) and can affect the patient’s comfort, presenting as referred pain during the post-laparoscopic period [10, 14]. Within the scope of invasive procedures, pain management is an important parameter in the nursing care process. In another study involving patients who underwent laparoscopic cholecystectomy, patient-specific nursing care plans were examined, and it was determined that the most common nursing diagnoses were anxiety, pain, and knowledge deficit [42]. Therefore, following minimal invasive procedure applications, pain should be included among nursing diagnoses, and necessary nursing interventions should be implemented to control it.

When pain assessments were conducted 30 min after the shoulder massage applied on postoperative day 0, it was observed that the pain of the patients in the intervention group significantly decreased (p = .000), while at the sixth hour measurement, there was no difference in pain between the intervention and control groups (p = .362) (Table 3). It can be suggested that the massage application in the intervention group had a short-term effect on patients’ shoulder pain, and that the pain, however, increased again after the massage’s effect wore off due to the continued intraperitoneal pressure. It has also been reported that shoulder pain after laparoscopic surgery gradually decreases and continues for up to 7–10 days [28]. In the intervention group, with two massage applications at 6-hour intervals, it was found that pain gradually decreased in repeated measurements within itself. As for the control group, there was a slight decrease in pain levels in the second measurement compared to the first measurement, but this change was not statistically significant. To the best of our knowledge, there has not yet been a direct assessment of the impact of duration. Therefore, more research is needed to evaluate the effectiveness of massage for a minimum period of time. In a comprehensive meta-analysis study examining the effect of massage therapy on postoperative pain, it was reported that massage was effective in reducing postoperative pain both in the short and long term [43]. According to this result, if we consider that pain affects sleep in the first degree, it can be thought that the better sleep quality of the intervention group compared to the control group may be due to the reduction of pain with the effect of massage.

Kılınç and Karaman Özlü (2022) was reported that 62% of patients experienced shoulder pain at 12 h after laparoscopic cholecystectomy, and that it continued to decrease until postoperative day 10 [44]. In this study, shoulder massage, combining effleurage, petrissage, and percussion, was applied for postoperative shoulder pain. It was found that the patients experienced a short-term reduction in their pain. When looking at studies regarding the use of massage for pain control, a short-term relief in patients was observed, but it was concluded that their pain persisted afterwards [44, 45].

Zerkle and Gates (2020), investigating the effect of massage on postlaparoscopic shoulder pain in a pediatric patient, it was reported that massage was an effective method to reduce pain in a short time [29]. Although massage applications have a short-term effect by enhancing the therapeutic touch and the action of analgesics, it has been reported that they promote patient relaxation, reduce pain through muscle relaxation and the secretion of enkephalins, and prevent the transmission of pain by affecting myelin sheaths [22, 46, 47]. It is thought that the massage performed to the patients both provides relaxation to the patient through relaxation and helps the nurse to make the patient feel better through therapeutic touch. Accordingly, it can be said that back massage has a therapeutic effect on the patient, provides physical and psychological relaxation and can be applied easily and costlessly in patient care.

On the morning of the first postoperative day, the sleep quality of the intervention group was significantly better than the control group. It has been noted that the total sleep duration in patients undergoing surgical procedures can decrease by up to 80% on the first postoperative night [48]. Pain is indicated as one of the most significant factors contributing to the reduction in sleep quality [49, 50]. In this study, non-pharmacological pain management was aimed at providing good sleep quality for the patient in parallel. The findings of the study suggest that classical shoulder massage on the night of postoperative day 0 leads to high sleep quality (p = .000) (Table 4). It was reported that acupressure applied to the PC6 (inner wrist) point had a positive effect on post-laparoscopic cholecystectomy pain and sleep quality [44]. Besides its short-term effect on pain, massage was found to have a positive impact on sleep quality. In an interventional study examining the main effects of massage therapy, patients in the intervention group received massage twice a week for five weeks, and it was determined that anxiety and sleep problems were less prevalent in addition to pain reduction [22].

The quality of sleep is also related to the absence of pain, which is why our study findings indicate that it provides quality sleep for patients in the intervention group. The average sleep quality score evaluated on the morning of postoperative day 1 was higher in the intervention group and lower in the control group, with a statistically significant difference between them (p = .000) (Table 4). In another study, acupressure was applied to patients after cardiac surgery, and it was determined to be 64% effective in improving sleep quality [51]. Another study involving patients undergoing colorectal surgery reported that aromatherapy massage with lavender oil in the preoperative period reduced anxiety and improved sleep quality [52]. The importance of therapeutic touch in sleep quality, as emphasized in our study, is supported by these findings. Furthermore, the better sleep quality in the intervention group compared to the control group indicates that massage therapy also reduces pain.

In this current study, it can be considered that our aim was not only to create a mechanical effect through massage but also to make the patient feel safe and provide comfort [53]. In a descriptive study, it was also noted that massage played a significant role in pain management as it is part of independent nursing interventions and provides therapeutic touch to the patient [40]. Therefore, the quality of sleep of patients whose shoulder pain lasting almost 72 h decreases will increase accordingly. It is thought that increased sleep quality will also contribute to the improvement of the patient’s physiologic processes.

In today’s context where short-stay surgeries like laparoscopic surgery have gained importance, ensuring pain control and sleep comfort for patients is crucial in nursing care. In such procedures with a short hospital stay, personalized nursing interventions tailored to meet the needs of patients should be implemented to facilitate early recovery, prevent complications, and expedite the process of regaining independence for patients.

Strengths and limitations

Strengths

Independent nursing interventions, such as massage, play a vital role in nursing autonomy. They not only foster positive patient-nurse relationships but also contribute to efforts aimed at enhancing non-pharmacological interventions, which, in turn, helps mitigate the side effects associated with medications. Patient selection in the study was done by the doctor’s nurse to avoid bias, while only the nurse who was the researcher performed the massage. In this study, the fact that the patients were selected by another nurse and not by the researcher was a strong feature in terms of bias.

Limitations

Some of our patients refused to undergo the massage intervention, which requires close physical contact during the study period due to the pandemic. As the study was limited to the patients undergoing inpatient laparoscopic cholecystectomy at the General Surgery Clinic of xxx Hospital, the results cannot be generalized to all patients undergoing laparoscopic cholecystectomy but can be used to compare with the results in the study. In addition, the fact that the study was not double-blind is another limitation.

Conclusions

In this study, the study revealed that a 15-20-minute classical shoulder massage administered to the intervention group resulted in reduced pain levels 30 min after application and significantly improved sleep quality on the first postoperative day compared to the control group. However, there was no significant difference in pain levels between the intervention and control groups during the second measurement. Therefore, it can be said that classical shoulder massage reduces patients’ pain and has a more positive effect on sleep quality in the short term after laparoscopic cholecystectomy. As a result, we think that classical shoulder massage administered after laparoscopic surgeries could be added to nursing care protocols as an alternative treatment method to reduce pain and improve sleep quality. It is also recommended that randomized controlled trials be conducted with larger sample sizes to further investigate the effectiveness of classical shoulder massage application, particularly in terms of how long it remains effective after such surgeries.