Keywords
Issue: Volume 51 - Issue 4 - April, 2005
Index: Ostomy Wound Manage. 2005;51(4):70-80.
Touch is a natural human response to alleviate pain in the skin or underlying tissue. Physical contact, particularly involving hands, can be an essential component of the healing process.1 The art of massage was developed long ago based on this knowledge; references to massage can be found in writings earlier than 2000 BC.2,3 Although a considerable amount of information is available on the mechanical, physiological, and relaxing effects of massage, as well as on its indications and contraindications, little is known about its ability to prevent the development of pressure ulcers (PU). Some physiological and therapeutic effects of massage are still questioned4; moreover, the potential for massage to prevent PUs is widely criticized. Some authors believe it actually causes the development of pressure ulcers.3
A literature review was conducted to address existing contradictory opinions about the effects of massage and to provide enhanced insight into the role of massage in the PU development, especially among elderly. This article summarizes the state of the art regarding the effects of different massage techniques, identifies the most important general indications and contraindications for massage, and offers applications for practice in patients prone to developing pressure ulcers. The reviewed literature was obtained through a search of Medline and Pubmed using the keywords pressure ulcer (PU), massage, rubbing, prevention of PU, and by examining the references of all retrieved articles. Conclusions about the effectiveness of massage in preventing PUs are presented following a short description of the etiology and the pathophysiology of PUs and existing information about the mechanical and physiological effects of massage.
Manual Massage Techniques
Manual massage techniques are divided in two general categories — Swedish and Chinese (the latter is discussed elsewhere).2Swedish massage is applied on muscle, tendons, and soft tissue. French terminology is used to differentiate between stroke types.2,5
Effleurage (a stroke that glides). Effleurage consists of slow, rhythmic stroking hand movements molded to the shape of the skin and is frequently used to start and finish a treatment session. The strokes pass from distal to proximal and parallel the long axis of the tissue. Firm pressure is believed to accelerate blood and lymph flow, to improve tissue drainage and, as such, to reduce swelling.5-9
Petrissage (a stroke that kneads). Petrissage or skin rolling is a forceful technique that can only be applied to fleshy regions of the body. A fold of skin, subcutaneous tissue, or muscle is squeezed, lifted, and rolled in a continuous circular motion against the underlying tissues.5-7 This method is particularly useful for stretching contracted or adherent fibrous tissue and to relieve muscle spasm.
Tapotement (striking). Tapotement is the general name given to percussive massage techniques. Vigorous tapping vibrates tissues and triggers cutaneous reflexes such as vasodilatation.5-8 Vasodilatation, in turn, increases muscle tone and promotes interstitial fluid circulation, reduces swelling, and accelerates healing processes.6,7,10
Friction (compression). Friction is an accurately delivered penetrating pressure applied in small areas with the fingertips. It is especially effective for the treatment of adherent or contracted connective tissue5,6; therefore, it is specifically recommended in sports therapy.
Vibration (shaking or vibrating). Vibrations are delivered by trembling both hands held firmly in contact with the skin. Unlike effleurage, this method compresses swollen tissue and can reduce edema with less risk of spreading infection.5 This technique is mostly used in respiratory physiotherapy.
When is Massage Generally Indicated or Contraindicated?
Practitioners using manual massage need to know whether massage is appropriate. In healthy tissues, massage is known to have the following advantageous effects: encouraging hyperemia as a consequence of histamine release, increasing tissue suppleness, relaxing muscle tone, increasing parasympathetic activity, reducing edema, relieving subcutaneous scar tissue, and activating mast cells.2,7-9,11,12 However, massage is contraindicated when tissues are inflamed or when the risk for malignant cells to spread along the skin or through the lymph or blood stream (lymphangitis, malignant melanoma) is increased. Massage is also contraindicated when patients are prone to bleeding (ecchymosis), have disorders of the circulatory system (phlebitis, severe atherosclerosis), and have abnormal sensations due to stroke, diabetes, and medication.2,13 Long-term massage is also known to cause desquamation (the skin peels or comes off in scales) — described by the European Pressure Ulcer Advisory Panel (EPUAP) guidelines as grade 2 pressure ulcers.14
Opinion is divided on the use of massage in patients prone to pressure ulcers. Some authors are convinced that massage prevents the bedridden patient from developing pressure ulcers, particularly if the patient is unable to move.1,2 However, when such patients show signs of acute tissue inflammation, massage treatment can be counterproductive. As such, recognizing early signs of inflammation is important and increasing numbers of clinicians agree that pressure ulcers are related to a form of chronic inflammation.15-17
The literature indicates that effleurage was the preferred technique in the treatment of pressure ulcers and should be applied with moderate pressure because unnecessarily high pressures are harmful to underlying tissues.18-20 Other massage techniques such as tapotement and friction are rather painful, making them disadvantageous for use in the thin, elderly patients. Also, because friction can easily cause mild tissue destruction or provoke an inflammatory reaction, it is contraindicated for people who are not in good health.5,6
Clinical and Physical Aspects of Pressure Ulcers
With the average age of the population on the increase and improved medical care prolonging life, the medical profession is faced with the increasing problem of caring for the elderly and people with disabilities. Pressure ulcers are a common problem in this population, developing locally where soft tissue is compressed between a bony prominence and a firm surface for a prolonged period.16,17 Pressure ulcers occur in superficial as well as deeper layers of the skin or even in the underlying muscles. The EPUAP classification system is the most commonly used international grading system to determine the grade of a PU (see Table 1).14
Physiology of the skin. The skin constitutes the outer boundary of the human body and functions both as a barrier and as a connection between the outer world and the internal organs.15 The skin accounts for 16% of the body’s total weight and has a total surface area of 1.2 to 2.3 m2 in an adult person.21-23 The largest organ in the body, the skin fulfills many essential tasks (see Table 2). Clearly, these functions can be threatened when the skin is damaged by a PU.
Extrinsic factors involved in the development of pressure ulcers. The risk of PU can be provoked by extrinsic and intrinsic factors. The three extrinsic factors related to PU development are pressure on and shear and friction within the tissue.24-27Intrinsic factors include poor blood supply that causes ischemia, reperfusion injury, and inflammation in the affected tissue.
Pressure is created when soft body tissue is compressed between a hard surface and a bony prominence. If this pressure is higher than the capillary pressure, local blood flow is reduced and ischemia may result.16,28 The location of the onset of pressure ulcers is influenced by the nature of the external loading. Pressures applied perpendicularly on the skin above a bony prominence simultaneously compress a small part of subcutaneous fat and muscle tissue above that prominence, potentially causing extensive damage that commences from locations deep within the muscle tissue layer without visible signs at the skin surface.29This effect will be strengthened because the skin is mechanically stronger than underlying tissues and is better equipped to survive periods of ischemia.30 In contrast, superficial pressure ulcers are mainly caused by shearing forces and initiate in the skin with maceration and detachment of the superficial skin layers.31 In addition, deep ulcers develop at a faster rate than superficial ulcers, making them even more harmful.31
Local tissue shear forces are typically problematic when a patient is sitting (chair or wheelchair) for several hours.27 Shearing forces destroy the microcirculation by causing thrombosis of the vessels.32 Preventing the patient from sitting in a tangential way — the position in which most often shear forces occur — is important.33
Friction is a periodic change in shear and occurs when one surface is moving rhythmically over another, such as when the patient is semidependent and semirecumbent and inadequately/infrequently lifted from a bed. Friction can cause stripping of the skin, leading to superficial ulceration.27
A preventive strategy developed to address extrinsic factors provoking pressure ulcers should be based on avoidance or reduction of shearing and friction forces and/or relief of excessive local pressure at all body-support interfaces.34 However, individual susceptibility to pressure ulcers can vary substantially and affect any measure taken to reduce pressure, shear, or friction.35
Intrinsic factors involved in the development of pressure ulcers.
Blood supply to skin and muscle. Interruption of the normal blood supply to skin and muscle by increased localized pressure can result in tissue ischemia and hypoxia when the resultant pressure is greater than capillary pressure and persists over a critical time period.27 Eventually, this can lead to tissue necrosis. Furthermore, when pressure on an ischemic area is relieved, a red area appears on the skin over the bony prominence due to a reactive hyperemia. This phenomenon is typical for tissue that is still viable and characterizes the normal response after temporal flow reduction. In contrast, when the red area does not blanch when light finger pressure is applied, this is termed non-reactive hyperemia. This event is a typical precursor to the development of pressure ulcers.27 The same type of tissue breakdown or necrosis results from pressure-induced muscle ischemia in bedridden patients. Continuous compression interrupts blood and lymph flow and deprives the tissue of access to oxygen and nutrients and toxic waste product removal. Individual cells produce toxic metabolites that cause tissue acidosis, increased capillary permeability, edema, and eventually necrotic cell death.17,27 Pressure ulcerations are localized areas of cellular necrosis. Where normal cell metabolism is dependent on the receipt of nutrients and the elimination of metabolites, compression will interfere with this exchange.16 Because muscle tissue has a lower tolerance to local ischemia than the skin, tissue necrosis conceivably could occur earlier in compressed muscle than in the skin.17
Reperfusion injury. In compressed tissue, blood flow can be restored intermittently, suddenly reperfusing the tissues with oxygenated blood. Paradoxically, this phenomenon also can be harmful, causing occlusion-reperfusion injury.36 Due to the sudden increase in oxygenation and the ischemia-induced suppression of enzyme activity, oxygen-related free radicals can damage cell membranes and initiate the process of cell necrosis.
Inflammation. Prolonged ischemia and reperfusion injury both cause serious tissue damage, leading to cell necrosis36 that, in turn, will initiate an inflammatory response characterized by vasodilatation leading to redness of skin and increased temperature. Furthermore, the tissue swells due to increased permeability of blood vessels. This process is associated with pain, probably caused by tissue distortion and production of chemical mediators. Eventually the various events can cause thrombosis in the capillaries.
Time-pressure relationship and the interstitial fluid compartments. Extensive research in animals and humans has shown that the development of pressure ulcers depends on the pressure level, the duration of pressure on the tissue (see Figure 1), and the direction of pressure.30 Increasing the surface of the body in contact with the bottom tissue layer can reduce the intensity of pressure.33 Varying the amount of pressure and the length of time seems to create an inverse relationship between tissue damage and external load magnitude and duration.28,29 Thus, a large-load magnitude applied during a short time and smaller loads applied for prolonged times both result in tissue damage.16,28-30 An explanation for this time-pressure relationship is not immediately at hand. Stagnation of blood flow cannot be the only reason for damage; otherwise, every pressure high enough to cut off a vein would lead to pressure ulcer development. A possible explanation is that pressure and shear lead to a local pressure increase in the interstitial fluid between the cells. Consequently, the fluid will stream slowly away to areas with lower pressure. In these areas, cells will experience a higher pressure, resulting in breakdown through mechanical overloading.28,30
Discussion
Massage on healthy tissues supports adequate tissue blood perfusion; encourages lymphatic drainage, thereby reducing edema; provides gentle stretching of tissue; and relieves subcutaneous scar tissue.2-4,6,37-41 This suggests that massage, and especially effleurages, is effective in the prevention of pressure ulcers because tissue drainage is improved, swelling is reduced, and vascularization is normalized. However, when massage is applied on tissues prone to the development of pressure ulcers, it can have a deleterious effect, provoking further cell damage through the excessive formation of oxygen free radicals as a consequence of hyperemia.36 Nevertheless, this negative effect can be balanced through the restoration of necessary blood flow. Cellular metabolic homeostasis is better preserved and toxic metabolites are better removed through improved blood circulation (see Figure 2). Studies conducted on the effects of massage on skin, immunity, blood flow, and pressure ulcers are summarized in Table 3.
Arguments in favor of massage. In a review of mechanical methods of preventing pressure ulcers in elderly patients, Bliss32claims that purposeful effleurages over threatened areas once or twice daily were effective in preventing the development of pressure ulcers. The additional consequence of rubbing the patient twice daily is a change in position and pressure relief on the compressed areas twice a day. The change of position can cause effect-modification. However, the author of this study did not mention how a possible source of bias was addressed. Célice42 describes positive effects of robust massage for 15 minutes to prevent pressure ulcers in bedridden patients. At the end of each massage session, a slight bloodstained pink color appeared at the treated body part, indicative of hyperemia. No statistically scientific evidence is presented. A pilot study performed by van den Bunt43 shows a positive effect of massage on the prevention of pressure ulcers. The author claims that rubbing the patient prevents the development of PUs but did not mention how. This finding is not supported by any scientific argument; furthermore, the type of massage used is not clear. Although the study found that massage has positive effects, it does not provide more scientific information — specific definitions of “rubbing,” “regularly,” “massage,” and “positive effects” were absent.
Iwama and Ironson8,9 investigated the effect of massage on the immune system by collecting blood before, during, and after completion of massage. They found that massage had a stimulatory effect on the sympathetic nerves (relaxation) and activated and increased the number of natural killer cells. They concluded that massage prevents the occurrence of PUs through the reactivation of the depressed immune system, as observed in elderly bedridden patients. They are convinced that skin rubdown (ie, robust massage) should be recognized as a simple health procedure that improves cellular immunity. Corley39 notes that several physiological measures, such as heart rate and blood pressure, did not change significantly after back rub massage; however, the group of patients studied showed a significant increase in skin temperature. More than half of the persons treated said they felt more relaxed and relieved of pain after the massage. In addition, patients experienced a positive change in mood in comparison with the control group, which for instance, resulted in a better night’s rest.
Arguments against massage. Opponents of massage as a method to prevent the development of pressure ulcers claim it has no effect or inflicts more harm than benefits. The outcome of Ek’s12 study show that massage on normal skin had an inconsistent and nonsignificant effect on blood flow as measured by laser Doppler flowmetry. Furthermore, patients with skin discoloration reacted with a reduced blood flow after the massage was implemented. Frantz40 found the same inconsistencies when looking at the single effects of prolonged pressure on skin blood flow over the trochanters of 16 elderly patients at risk for pressure ulcers. Blood flow tracings in the skin during a 60-minute period of continuous pressure revealed an inconsistent pattern of response; the flow increased, decreased, or showed no change. Although this study involved a relatively small number of patients undergoing pressure for a single 1-hour session, results implied that additional studies with larger populations over longer periods of time are warranted. Braden19 states that massage to prevent pressure ulcers is no longer considered appropriate skin care and is harmful if ischemic injury is already present. Massaging a nonblanchable skin discoloration to prevent further damage is pointless because the blood vessels already are dilated; thus, massage may force toxic substances to leak into the interstitial space, which, in turn, may cause tissue damage. Olson20 also does not recommend extensive massage to a formerly compressed area because circulation would be further compromised; however, the small sample size, lack of a control group (ie, group without massage), and the participation of a unique population (patients with fractured hips) limits the generalization of the results. Meaume44 states no confirmed reports of efficacy support the widespread usage of massage in France and further argues that rubbing pressure ulcers, especially Stage I ulcers, should be contraindicated because underlying tissues are damaged by decreased blood flow and, consequently, elevated skin temperature.
Dyson18 studied the effects of massage on geriatric patients over a 6-month period and found the incidence of pressure ulcers was greatly reduced if patients were not rubbed at all; on post-mortem examination, massaged areas exhibited macerated and degenerated tissue, while unmassaged tissue remained healthy with no signs of tearing. The author did not stipulate the massage technique used — only the term vigorous is mentioned. However, in the past massage meant strong rub and pinch — this is not the way effleurages are performed today. Dyson’s findings are interesting but lack scientific documentation on the methods and conditions of the research.
The questionable usefulness of petrissage, tapotement, friction, and vibration in the treatment of elderly patients prone to pressure ulcers has met with considerable agreement.5-7,10,11,20,38,44 Petrissage (skin rolling) is a forceful technique. Because of its effects and means of application, it is completely contraindicated in the prevention and treatment of pressure ulcers. Petrissage is harmful to underlying tissues, especially when they are in a compromised condition. Meaume44 reports that this technique has been abandoned in France and replaced by effleurage. Hovind and Nielsen38 conclude that petrissage has a variable and inconsistent effect on blood flow but that hyperemia is absent.
Physiologically, tapotement provides an immediate increase in blood flow during the treatment, reaching values 35% higher than normal.38 However, because it is rather painful, the technique is deleterious, especially in thin, elderly patients. The same may be said for friction, which can be painful and stimulates a marked local hyperemia or inflammatory reaction.2,5 Vibrations are also not recommended in the prevention of PUs because of the extended and robust way of performing this type of massage. Several authors have suggested that vigorous massage over bony prominences should be avoided because it provokes muscle damage not visually apparent.18,20
Conclusion
According to data presented in the literature, massage has some advantageous effects on the skin. It increases blood flow, stimulates skin suppleness, and relaxes the tissue. In addition, massage reduces certain types of edema. An important disadvantage is the potential to cause damage to underlying tissues, a consequence of using the wrong type of massage or of not taking into consideration that pressure ulcer-related damage is already present.
This review shows that the effect of massage on the prevention of pressure ulcers varies between different studies and authors with regard to local skin blood flow and temperature, individual differences, and normal versus injured skin. Although healthcare workers often believe in the preventive effect of massage,45 no clear scientific evidence has yet been presented in terms of the beneficial effects of massage in the prevention of pressure ulcers, particularly among the elderly and people at risk.
However, because of the relatively small number of participants and questionable methodological quality of the studies, contraindications may, in some cases, be worthy of the benefit of the doubt. Massage (ie, effleurages) may be beneficial in some instances after careful consideration of the patient’s physical condition and medical history and respecting individual variability in administering massages. The mechanism behind the effects of massage is an important field for research.
