Effect of Foot Reflexology Practice on Acute Pain and Anxiety of Critically ill Patients after Cardiothoracic Surgery

Background: One of complementary therapy is foot reflexology practice which is effortlessly, un-costly and with little risks or complications and can be considered as part of nursing procedures for acute pain and anxiety after cardiothoracic surgery. Objective: evaluate the effect of foot reflexology practice on acute pain and anxiety of critically ill patients after cardiothoracic surgery. Research hypothesis: The pain and anxiety score among the interventional group who receiving the foot reflexology practice is lower than that of the control group. Research design: a quasi-experimental research design was used. Setting: This study was conducted in Cardiothoracic and Post-Operative Intensive Care Units at Assuit University Hospital. Subjects: sixty patients were enrolled in this study and assigned equally to intervention and control groups during the period of data collection from February 2015 to February 2016. Results: There were significant differences between the mean of pain and anxiety score of both groups at immediately, and 45 minutes indicating lower mean of pain and anxiety level among intervention group who received foot reflexology practice than control group. Conclusion: The intervention group who received foot reflexology practice had lower pain and anxiety level than the control group who didn‟t received foot reflexology practice after cardiothoracic surgery.


Introduction
Cardiac and thoracic surgeries are emerging as an important and common categories of critical care surgeries performed worldwide, [1] Regardless of the procedure performed, successful outcomes depend on optimal postoperative care in the ICU. Most preventable complications following operations have been linked to postoperative problems in the ICU. [2] Pain and anxiety are commonly phenomenon following every category of cardiothoracic surgeries. [3] A negative effect on healing and wound repair has been found on patients with pain and/or anxiety. Many physical and mental energy can be exhausted during pain and anxiety that can lead to increase the patient"s tiredness, biochemical activity, stimulation of autonomic nervous system, muscle tension and production of corticosteroids. [4,5] Pain after cardiac surgery is frequently undertreated. In literature the incidence of moderate to severe pain after surgery is 17% to 40%. [6,7] A study in 2013 at Aga Khan University Hospital, Nairobi, found that the prevalence of postoperative pain was 58% within 30minutes, 55.3%after 24 hours, and 34.7% after 48 hours after day care surgery. [8] Persistent postoperative pain is an unpleasant sensory and emotional experience and thought to be related nerve injury, and neuroplastic change in CNS. Optimal therapy of physiological and psychological distress during early recovery phase of heart surgery might Optimal pain and anxiety therapy are mandatory to improve pulmonary function, decrease delirium, increase patient satisfaction, drop the surgical complications and shorten the hospital length of stay. [3,6] Nurses should assess and investigate every cardiothoracic patient for presence of pain and anxiety to provide the necessary cares for preventing and dropping complications with proper measures. [4] As mentioned in literatures, the two categories of relieving pain and anxiety are pharmacological and non-pharmacological ways. Now days, an emphasis on non-pharmacological methods to reduce or eliminate anxiety or/and pain on hospital settings. According to the studies, using medications are effective in relieving both pain and anxiety from one side but from the other side the medications had temporary effects. So, there is a need of applying studies regarding the effect of different interventions of non-pharmacological methods on balancing anxiety and pain. [9,10] Most of these interventions are easy, non-invasive and low cost and have little danger and complications that are used alone or along with other methods. [11] One of the branches of non-pharmacological methods is foot reflexology which is done through apply not only massage but also use a firm thumb-walking motion on the reflexes points that reflect all the parts of the body in the form of a small mirror. [12] Factually, foot reflexology is started in Egypt and used as a useful treatment method as pictures show in Egyptian templates from five-hundreds of years. [13] A randomized controlled study evaluating the effects of foot reflexology massage on anxiety in patients following coronary artery bypass graft surgery demonstrated that a significant decrease in anxiety in the experimental group following foot The critical care nurse is one of professional health team and has role in control, manage and relieve the post-operative acute pain and/or anxiety after cardiothoracic surgery. Both acute pain and anxiety can be managed by pharmacological and nonpharmacological interventions. Undoubtedly, the medications cost a lot of money nowadays particularly with rising the price of everything in the world. Because of this, there is a need to expand the studies about the use and apply the non-pharmacological interventions in nursing practice. One of complementary therapy is foot reflexology practice which is effortlessly, un-costly and with little risks or complications. Therefore, the study was conducting to evaluate the effect of foot reflexology practice on acute pain and anxiety of critically ill patients after cardiothoracic surgery Aim of this study to 1. Compare pain score between the interventional group who received the foot reflexology practice and the control group who did not receive that. 2. Compare level of anxiety between the interventional group who received the foot reflexology practice and the control group who did not receive that.

Research hypothesis
 The pain score among the interventional group after receiving foot reflexology practice is lower than that of the control group.  The level of anxiety among the interventional group after receiving foot reflexology practice is lower than that of the control group  There are differences between the intervention and control groups at the immediate and after 45 minutes of foot reflexology

Study Design
A quasi-experimental design was used in this study

Setting
The study was conducted in Cardiothoracic and Post-Operative Intensive Care Units at Assuit University Hospital.

Subjects:
A convenience sampling of 60 patients was enrolled in this study were assigned to interventional and control groups (30 patients for each) as illustrated in the flow chart (figure 1) during the period of data collection from February 2015 to February 2016. Tools of the study:

Tool one: Behavioral pain rating scale (BPS)
This tool was adopted from Dehghani H et al (2014). [15] with internal consistency and reliability Cronbach"s alpha was (r= 85). It contains three main items for assessment the level of pain if patient intubated or not intubated. The BPS uses a 4 point rating scale, facial expression ranging from relaxed (score 1) and grimacing (score 4), upper arm from no movement (score 1) and permanently retracted (score 4), for the intubated patient assess the Compliance with ventilation ranging from Tolerating movement (score 1) and Unable to control ventilation (score 4), if patient not intubated assess the vocalization ranging from no pain (score 1) and Crying & sobbing (score 2).


In addition to patient"s data record that includes: age, sex, education level, date of admission to ICU, date of discharge, diagnosis, past history, medications, attached machine and diagnostic lab.

Method
The study design was accomplished as follow:  Official approval was taken from the hospital authority to facilitate the research implementation.  Informed consent of the patients sharing in the study was obtained. The study subjects were assured about the confidentiality. The study subjects were assured about the privacy of their data and the anonymity of the record.  A pilot study was carried out on 6 patients in the previously mentioned settings to test the feasibility of the tools then necessary modifications were carried out and the results were excluded from the study  Control group were received the usual care provided to patients after cardiothoracic surgery.


After an initial foot examination, a traditional foot massages using reflexology techniques were carried out in a sequence of massage strokes and gentle pressure to reflexes points on both feet.  Foot massage was done for three sessions over three days; each session included two sub-sessions; the first one about (5) minutes and the second about (10) minutes for each foot, the actual time the researcher nurse worked on a particular reflex point last from 20 seconds to two minutes or more, the period between the two subsessions is the time needed for obtaining and recording patient pain and anxiety data by behavioral rating scale and brief psychiatric rating scale and minimum time 5 minutes.
 Foot massage protocol was followed in this study to decrease patient pain and anxiety level

Preparation phase:
 Being at patients" bedside at afternoon shift because this shift is less noisy in comparison to the morning shift; bedside curtains were drawn.  External noise and interruptions were decreased as possible.  Comfortable position was assured.  Data about patient pain and anxiety were obtained and recorded as base line data before foot massage by using tool one and two 2. Reflexology phase:   Table 1: Shows the characteristics of the patients assigned to the intervention and control groups. It was found that, 40% and 53.3% of intervention group and control group were in age group between 30 and less than 50 years old with no significant differences between both groups. There was a difference in the gender of the participants in each group, with more patients in the intervention group being female (73.3%). However, differences in level of education, ICU stay, past medical history between both groups were not statistically significant.    4: Present the comparison between the intervention and control groups regarding total score of behavioral pain rating scale at three intervals. According to the current results, there were significant differences between the mean of pain score in both groups immediately, after 15 minutes and 45 minutes (table 4) indicating lower mean of pain score among intervention patients who received foot reflexology practice.

Discussion
Foot Massage therapy is an ancient therapeutic technique that has been used in most major healing traditions. Recent interest in its role as an adjunct to conventional medical therapy has resulted in an extensive number of clinical trials, with many showing improvement in outcomes such as pain anxiety and muscle tension.
Recently, several studies have focused on the role of foot massage therapy in the hospital setting. Of interest is the effect of massage on patients postoperatively, since pain and anxiety may be especially problematic in this group. Therefor the study was conducted to compare the pain score and anxiety level between the interventional group who receive foot reflexology practice and the control group who did not receive that.
Results of the current study revealed that a statistical significant difference between the mean of pain score in interventional group and the control group immediately, after 15 minutes and 45 minutes indicating. The study shows lower mean of pain score among intervention patients who received foot reflexology practice. The same result was found in the study of Cutshall SM. et al (2010) [17] who documented that foot massage therapy improved relaxation in a group of cardiovascular surgery patients who received both foot massage and guided relaxation, and a more recent trial of 104 cardiovascular surgery patients showed reductions in pain and tension for those patients receiving massage therapy. Because of the unique challenges faced by cardiovascular surgery patients (ie, prolonged operative time, considerable musculoskeletal shifting, and positioning requirements), we hypothesized that massage therapy might be particularly beneficial in this patient group.
The result in line with Mohammed HM et al. (2010) [18] who examined the effect of foot and hand massage on anxiety and physiological indicators on 60 patients before the cataract surgery. A reduction of anxiety and an improvement of physiological indices prior the surgeries were reported. Nazari, Ahmadzadeh (2012) [19] examined the effect of foot and hand massage on the reduction of anxiety among patients undergoing the ophthalmology surgery using local anesthesia. Brand, Munroe (2013) [20)] using a quasi-experimental study assessed the effect of foot and hand massage on patients" anxiety among patients undergoing the outpatient surgery. They showed a significant difference in the level of anxiety between hand massage and control groups and believed that hand massage effectively reduced anxiety.
In contrast to the finding of the current study, Gronzales et al (2010) [21] failed to show a reduction in the use of narcotics postoperatively but did show a reduction in the unpleasantness of pain. Taylor et al (2003) [22] evaluated 105 women who underwent abdominal laparotomy and received massage and vibration therapy postoperatively. In this study, mild improvements in pain scores did not reach statistical significance.
Most patients with cardiovascular diseases experience many emotional and psychological problems in the early days of admission to the cardiac care unit (CCU). One of the nursing diagnoses for such patients is anxiety, which is considered a risk factor for coronary artery diseases. The findings of the present study demonstrate that statistical significant differences between the frequencies of anxiety score in both groups and decreased the level of anxiety in intervention group at immediate time, after 15 minutes and 45 minutes from foot reflexology. Most studies showed that reflexology caused deep relaxation, body and mind balance, reduced stress symptoms and created good feelings in patients. The theory of reflexology is based on the principle that energy flows through vertical zones throughout body from organs toward the head. Therefore, massage and stimulation of nerves cause relaxation, reduce tension and as a result returns balance in the body. Kahangi, Moeini(2012) [23] supported the finding of the current study and confirmed the effect of reflexology on decrease the anxiety level before coronary artery bypass graft surgery.  [26] found that hand reflexology had no significant effect on patients" anxiety.
Cardiothoracic diseases have been emerging and are becoming a major health problem worldwide. Patients with cardiothoracic disease who do not respond to routine medical treatment will end up with cardiothoracic surgery. Although surgery is beneficial and very essential, it is a highly stressful situation for patient. Foot reflexology is one example of complementary therapies that are cost effective and simple with fewer side effects when compared with drugs. These therapies have been used by nurses to alleviate anxiety, minimize or relieve pain and promote the optimum level of well-being and comfort.

Equations
The raw data were coded and transformed into coding sheets. The results were checked. Then, the data were entered into SPSS system files (SPSS package version 18) using personal computer. Output drafts were checked against the revised coded data for typing and spelling mistakes. Finally, analysis and interpretation of data were conducted.
The following statistical measures were used:  Descriptive statistics including frequency, distribution, mean, and standard deviation were used to describe different characteristics.  Univarate analyses including: T-test, and Z-test were used to test the significance of results of quantitative variables.