IMPACT OF FOOT MASSAGE ON THE LEVEL OF PAIN,

HEART RATE AND BLOOD PRESSURE AMONG

PATIENTS WITH ABDOMINAL SURGERY IN
A SELECTED HOSPITAL
AT MANGALORE

By
LALY CHACKO


Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfilment
of the requirements for the degree of



MASTER OF SCIENCE
in
MEDICAL SURGICAL NURSING



Under the guidance of
Mrs. VICTORIA DALMEIDA, M. SC. (N)

Department of Medical Surgical Nursing
Father Muller College of Nursing
Mangalore


2007
ii


RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA,

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled IMPACT OF
FOOT MASSAGE ON THE LEVEL OF PAIN, HEART RATE AND
BLOOD PRESSURE AMONG PATIENTS WITH ABDOMINAL
SURGERY IN A SELECTED HOSPITAL AT MANGALORE is a
bonafide and genuine research work carried out by me under the guidance of
Mrs. Victoria DAlmeida, Assistant Professor and HOD, Department of
Medical Surgical Nursing , Father Muller College of Nursing, Mangalore.



Date : 26-11-2007
Place : Mangalore Laly Chacko






iii





CERTIFICATE BY THE GUIDE

This is to certify that the dissertation IMPACT OF FOOT
MASSAGE ON THE LEVEL OF PAIN, HEART RATE AND BLOOD
PRESSURE AMONG PATIENTS WITH ABDOMINAL SURGERY IN A
SELECTED HOSPITAL AT MANGALORE is a bonafide research work
done by Laly Chacko in partial fulfilment of the requirement for the degree of
Master of Science in Nursing (Medical Surgical ).



Date : 26-11-2007 Mrs. Victoria DAlmeida, M.Sc. (N)
Place : Mangalore Assistant Professor and HOD
Department of Medical Surgical Nursing
Father Muller College of Nursing






iv

ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF
THE INSTITUTION


This is to certify that the dissertation entitled IMPACT OF FOOT
MASSAGE ON THE LEVEL OF PAIN, HEART RATE AND BLOOD
PRESSURE AMONG PATIENTS WITH ABDOMINAL SURGERY IN A
SELECTED HOSPITAL AT MANGALORE is a bonafide research work
by Laly Chacko under the guidance of Mrs. Victoria DAlmeida, Assistant
Professor and HOD, Department of Medical Surgical Nursing, Father
Muller College of Nursing.




Mrs. Victoria DAlmeida, M.Sc. (N) Sr. Jacintha DSouza,
M.Phil (N)
Assistant Professor and HOD Principal
Department of Medical Surgical Nursing Father Muller College of Nursing
Father Muller College of Nursing



Date : 26-11-2007 Date : 26-11-2007
Place : Mangalore Place : Mangalore

v



COPYRIGHT

Declaration By The Candidate


I hereby declare that the Rajiv Gandhi University of Health Science,
Karnataka shall have the rights to preserve, use and disseminate this
dissertation / thesis in print or electronic format for academic / research
purpose.



Date : 26-11-2007
Place : Mangalore Laly Chacko


Rajiv Gandhi University of Health Sciences, Karnataka




vi



ACKNOWLEDGEMENT
What I am is gods gift to me,
What I become is my gift to God.
St. Augustine.
At the outset, may I thank the Almighty profusely for having showered
His choicest blessings upon me throughout my life.
A hundred times a day I remind myself that my inner and outer life
depends on the labours of other men, living and dead, and that I must exert
myself in order to give in the same measure as I have received and I am still
receiving.
Albert Einstein
I owe a deep sense of gratitude to all those who have contributed to the
successful accomplishment of this endeavour.
The investigator expresses her heartfelt gratitude to her mentor, Mrs.
Victoria D Almeida, Assistant Professor, Father Muller College of Nursing,
for her untiring guidance, sustained patience, constant encouragement, deep
understanding and valuable suggestions.
With profound sense of gratitude I acknowledge the participants
wholehearted cooperation which made this study a real success.
vii

Rev. (Sr.) Jacintha DSouza, Principal, Father Muller College of
Nursing, for the valuable support, constructive suggestions and guidance.
Rev. (Dr.) Baptist Menezes, Former Director, Father Muller Charitable
Institutions, for his good wishes and prayerful support.
Rev. (Fr.) Patrick Rodrigues, Director, Father Muller Charitable
Institutions, for his support.
Prof. (Mrs.) Prema DSouza, Vice Principal and PG programme
coordinator, Father Muller College of Nursing, for her timely help, constant
encouragement and directions.
All the faculty members, especially Prof. Chanu Bhattacharya, for
the constructive criticisms, support, and valuable suggestions.
Mrs. Sucharita Suresh, Statistician, Father Muller Medical College
Hospital, for the expert guidance, valuable corrections, and support in the
statistical analysis.
Rev. (Sr.) Aileen Mathias, Nursing Superintendent, Father Muller
Medical College Hospital, for her support and guidance.
Mr. Kanakaraj, HOD, and Ms. Shervin, Department of Physiotherapy,
Father Muller Medical College Hospital, for their timely help and training in
foot massage techniques.
viii

Doctors, Staffs, and Students of the surgery unit of OBG department
for their timely help and support.
Experts for their recommendations, and suggestions while validating
the tool.
I appreciate the help and services rendered by The authorities, and
library staffs of MAHE; CMC, Vellore; and Father Muller Charitable
Institutions.
Sincere thanks to Mr. Roshan Patrao for his excellent and prompt
services.
Prof. Jacob Devassy, Associate Dean, Bharatamatha College of
Management Studies for meticulously editing the manuscript.
Friend in need is a friend indeed. A word of thanks to All my
classmates for their constant help and support.
My whole hearted thanks and gratitude to one and all who came on my
way to success.
Date : 26-11-2007
Place: Mangalore Laly Chacko
ix

LIST OF ABBREVATIONS
FM- Foot massage
FR Foot Reflexology
TBM Therapeutic Back Massage
SBP Systolic Blood Pressure
DBP Diastolic Blood Pressure
MBP Mean Blood Pressure
HR Heart Rate
VAS Visual analogue Scale
ANOVA Analysis of Variance


x

ABSTRACT
Background
Physiological response to pain creates harmful effects that prolong the
bodys recovery after surgery. Patients routinely report mild to moderate pain
even though pain medications have been administered. Complimentary
strategies based on sound research findings are needed to supplement post
operative pain relief using pharmacological management. Foot massage has the
potential to assist pain relief. Massaging the foot stimulates the
mechanoreceptors that activate nerve fibres to release endorphins, which
prevents pain transmission from reaching consciousness.
The present study aims at assessment of the impact of foot massage on
the level of pain, HR and BP among post operative patients with abdominal
surgery.
The objectives of the study
1. To determine the level of pain of post operative abdominal surgery
patients before implementation of foot massage as measured by a
numerical pain scale and observational check list.
2. To determine the blood pressure and heart rate of post operative
abdominal surgery patients before implementation of foot massage as
measured by sphygmomanometer and stethoscope.
xi

3. To find out the impact of foot massage on the level of pain, heart rate
and blood pressure in terms of reduction in pain, change in blood
pressure and heart rate.
xii

Method
Pre-experimental one group pre test post test design was used for the
present study. Sample consisted of 30 post operative patients with abdominal
surgery, who met the inclusion criteria. Tools used were Observation checklist
and numerical pain scale to assess pain intensity, sphygmomanometer and
stethoscope to assess blood pressure and heart rate.. Data was analyzed using
descriptive and inferential statistics.
Results
The findings of the study showed a significant difference in level of
pain between the pre and post foot massage sessions immediately and after 10
minutes of FM, (t
29
= 12.041, t
29
= 22.71 , t
29
= 12.59 , p<0.05) for the
observation checklist, and (t
29
= 17.02, t
29
= 23.234 , t
29
=9.865, p<0.05) for the
numerical pain scale.
There was significant difference in the HR measured between pre and
post foot massage sessions immediately and 10 minutes of massage (t
29
= 6.630,
t
29
= 7.577, t
29
= 2.442; p<0.05).
There was a significant difference in the systolic blood pressure
measured between pre and post foot massage sessions immediately and 10
minutes of foot massage (t
29
= 11.403, t
29
= 18.793, t
29
= 9.133; p < 0.05).
xiii

Diastolic blood pressure had significant difference between pre and post
foot massage sessions, immediately after 10 minutes of foot massage
(t
29
=9.845, t
29
=11.469, t
29
= 7.388;p <0.05).
There was no significant association between pre foot massage pain and
the selected variables such as age (
2
= 0.109) and type of surgery (
2
= 0.670 ,
p>0.05).
Interpretation
The results showed that foot massage is an effective non
pharmacological method for reducing post operative pain.
Conclusion
Foot massage is a simple non invasive cost effective method that can be
used effectively for the management of post operative pain.
Key words
Impact;foot massage; postoperative patients; level of pain, heart rate
and blood pressure.
xiv

TABLE OF CONTENTS
Chapter
No. Title Page No.
1. Introduction 1 6
2. Objectives 7 15
3. Review of literature 16 26
4. Methodology 27 - 40
5. Results 41 55
6. Discussion 56 60
7. Conclusion 61-66
8. Summary 67-71
9. Bibliography 72-77
10. Annexures 78-99
xv

LIST OF TABLES
Table
No. Title
Page
No.
1. Frequency and Percentage of Sample Characteristics 43
2. Level of pain before foot massage 47
3. Range, mean and SD of heart rate and blood pressure of
Postoperative abdominal surgery patients before foot massage
47
4. Range, mean and SD of level of pain of postoperative patients
before and after implementation of foot massage
48
5. Range mean and SD of heart rate and blood pressure before
and after implementation of foot massage
50
6. Paired t rest showing significant difference between pre- and
post-foot massage pain level
51
7. Paired t rest showing significant difference between pre- and
post-foot massage heart rate and blood pressure
53
8. Association between pre-foot massage pain score and selected
variables such as age and type of surgery
54

xvi

LIST OF FIGURES
Figure
No. Title Page No
1. Non-pharmacological pain relief measures 3
2. Conceptual framework on impact of foot massage on
postoperative abdominal surgery patients based on Roys
Adaptation Model
14
3. Schematic Representation of the Research Design 28
4. Schematic representation of the study design 29
5. Bar Diagram showing the distribution of subjects according to
age
44
6. 3-D Bar diagram showing the distribution of subjects
according to the surgical procedure done
45
7. Level of pain of patients before and after FM assessed by
objective assessment of pain
49
xvii

LIST OF ANNEXURES
Annexure
No. Title Page No
1. Letter requesting permission to conduct research study 78
2. Letter granting permission to conduct the study 79
3. Certificate of attending foot massage training 80
4. Letter requesting opinion and suggestion of experts to
validate the tool
81
5. Acceptance form for tool validation 82
6. Content Validation Certificate 83
7. Consent form (English) 84
8. Consent form of subjects (Kannada) 85
9. Blueprint of the Observation Checklist for the Objective
Assessment of Pain among Postoperative Abdominal
Surgery Patients
86
10. Tool 87
11. Criteria Checklist for Validation of the Tools 92
12. List of validators 94
13. Photographs 95
14. Statistical formulae used in the analysis of data 99
15 Master data sheet 100







INTRODUCTION
1
1. INTRODUCTION
Pain is an elusive and complex phenomenon, and despite its universality its exact
nature remains a mystery.
Pain is a complex, multifaceted phenomenon. It is an individual, unique
experience that may be difficult to describe or explain, and often difficult for others to
recognise, understand, and assess. Pain often leads to debilitation, diminished quality
of life and depression. Pain management challenges every healthcare team member,
for there is no single universal treatment.
1
Pain is much more than a physical sensation caused by a specific stimulus.
The pain experience is complex involving physical, emotional and cognitive
components. Pain is subjective and highly individualised. The stimulus for pain can
be physical and/or mental in nature.
2
Suffering is a frequent consequence of pain and comfort may not be possible
in the presence of pain. Helplessness and suffering are experienced when individuals
have insufficient resources and are unable to cope up.
3
Background of the study
Postoperative pain is one of the most common therapeutic problems in
hospitals. It can increase morbidity leading to reduced breathing and cough
suppression, facilitating retained pulmonary secretions and pneumonia, and delaying
normal gastric and bowel function, and thus contributing to a longer recovery period.
Strategies aimed at reducing postoperative pain increase patients comfort and can
shorten hospital stay.
4, 5
2

Pain is an expected outcome postoperatively, yet one of the most
frequent postoperative problems is inadequate analgesic administration. All patients
who have just had surgery will experience pain. Pain medication should be given
when needed and prior to pain becoming severe. Pain may be caused by a factor
unrelated to the surgical procedure such as poor positioning; discomfort of a full
bladder can initiate abdominal pain even when appropriate medications have been
administrated.
1
Pain is not an unavoidable consequence of surgery. In the majority of
patients, postoperative pain is preventable with adequate analgesics and by the
appropriate use of newer techniques
5, 6
. Despite this a number of surveys have shown
a high prevalence of significant pain after surgery. The recognition of the inadequacy
of postoperative pain management has promoted the development of corrective efforts
by surgeons, anaesthesiologists and pain management groups
7
. During a patients stay
on a surgical ward, nurses hold a great deal of responsibility for pain management,
especially when analgesics are prescribed on a PRN basis. Despite the availability of
effective analgesics and new technologies for drug administration studies continue to
demonstrate suboptimal pain management.
8

A multi-centre descriptive cross-sectional drug utilisation study in 12
Spanish hospitals showed that a significant proportion of patients suffered severe pain
after abdominal surgery due to inadequate use of analgesics and wide inter-hospital
variability in the management of postoperative pain.
Effective pain control is best achieved through a combination of both
pharmaceutical and non-pharmaceutical therapies. Pharmaceutical management has
been the primary means of providing relief from pain. Although pharmaceutical
3
medications continue to serve as a major contributor to pain management, non-
pharmaceutical techniques are being increasingly used to provide pain relief. Non-
pharmacologic interventions are particularly useful when (a) medications are
inadequate to control pain; (b) client is waiting for medications to take effect; (c)
when side effects or client concerns make the use of medications problematic.
1
Many non-pharmacologic methods relieve pain but are not widely used.
Complementary therapies are attracting attention and patients are interested in
alternatives to biomedicine. In response to patients interests, nurses are exploring
ways to incorporate therapies such as the following:
9








Figure 1: Non-pharmacological pain relief measures
10

4
Pain causes an increase in sympathetic response of the body with
subsequent risk in HR, cardiac work load and O
2
consumption. Prolonged pain can
reduce physical activity and lead to venous stasis and increase risk of deep vein
thrombosis and subsequent pulmonary embolism
12
Need for study
Postoperative pain is a routine poorly controlled by pharmacological means
alone. Complementary strategies based on sound research findings are needed to aid
in postoperative pain relief as patients routinely report mild to moderate pain even
through pain medications have been administered
12
. Analgesics have a maximum
effective dose; increasing the dose cannot increase pain relief, but may increase side
effects. Tolerance also may occur, when larger doses of medicines are needed to
provide the same amount of pain relief as the previous smaller dose.
1
Studies show that pain management following surgery continues to be
inadequate. Consequences of under-treated pain include an increased incidence of
nausea and vomiting, increased predisposition to respiratory and mobility
complications.
11
Pain medicines may be more effective when combined with other
pain relief techniques. The effectiveness of the drug may be increased with change in
the position of the client, back rub, foot rub, or simple interaction with the patient.
Foot and hand massage have the potential to aid pain relief.
12
Massage stimulates cutaneous mechanoreceptors that activate large primary afferents.
Massage is the most widely used complementary therapy in nursing practice. It is one
of the ways nurses use to communicate caring to patients and touch is central to the
5
nurses role in healing. Massage is an extended form of touch, which results in mutual
energy exchange. It soothes pain and produces relaxation. It increases pain thresholds,
and therefore modifies an individuals perception of pain
13
. A ten-minute foot
massage was found to have a significant immediate effect on the perceptions of pain,
nausea and relaxation when measured with visual analogue pain scale.
14

A pre-test post-test single group design with participants serving as their own
controls was conducted in a 39-bed unit at a large teaching hospital in the mid-west
between May 1, 2000 and May 1, 2001 to find out the effect of foot and hand massage
to decrease pain among postoperative patients who had undergone gastro-intestinal,
gynaecological, head neck plastic or urological surgery. A 20-minute foot and hand
massage (5 minutes on each extremity) was given and the pain intensity and distress
were measured by a 0-10 numerical scale in the modified brief pain inventory. The
subjects reported a 56% decrease in pain intensity from 4.65 to 2.35 (t=8.154, P <
0.001). Pain distress decreased from 4.00 to 1.88 (t=5.683, P < 0.001). The
symptomatic response to pain including heart rate and respiratory rate also
significantly decreased (P < 0.05).
12
A quasi-experimental study was conducted at Municipal Hospital,
Mumbai in 1996 to identify the effect of back massage on the pain of postoperative
patients who had under gone closed mitral commissurotomy. The result of the study
showed that on second postoperative day 35% patients in the experimental group
received analgesics, whereas all the patients received analgesics in the control group.
As for the frequency and time of intake was concerned, those who needed analgesics
in the experimental group received it only once whereas in the control group 75%
received twice.
15
6
A study to measure the effect of foot massage on the subjective experience of
pain, nausea and relaxation among cancer patients admitted to a general hospital was
conducted on 62 cancer patients in a cancer hospital in Southern Norway. The result
of the study revealed that the mean pre-treatment pain score was 25 which reduced to
15.3. Mean post-test nausea score decreased from 17.5 to 11; the mean pre-test
relaxation score was 54 which reduced to 31.8.
16
The researcher has come across patients who had inadequate pain relief during
postoperative period with pharmacological measures alone. The difficulty with
introducing complementary therapies such as foot massage into nursing practice is
that there is little empirical evidence to support the use. It is also observed that
published research studies and trials on foot massage in the Indian setting are very
much limited. Hence this study may be considered important in providing empirical
evidence and its efficiency in reducing postoperative pain in patients with abdominal
surgery.
Hence the investigator was interested to the study: Impact of foot massage
on the level of pain, heart rate and blood pressure among postoperative patients with
abdominal surgery. So that complimentary therapies can be incorporated in to pain
relief regimen
Summary
This chapter dealt with the existing problem and need for understanding this
particular research project.






OBJECTIVES

7
2. OBJECTIVES
The objectives include obtaining answers to the research questions or testing
the research hypothesis but may also encompass some broader aims like developing
recommendations for changes in nursing practice based on the study results. Specific
achievable objectives provide the reader with clear criteria against which the proposed
research methods can be assessed.
21
Statement of the problem
Impact of foot massage on the level of pain, heart rate and blood pressure
among patients with abdominal surgery in a selected hospital at Mangalore.
Objectives of the Study
1. To determine the level of pain of postoperative abdominal surgery patients
before implementation of foot massage as measured by a numerical pain scale
and observation checklist.
2. To determine the blood pressure and heart rate of postoperative abdominal
surgery patients before implementation of foot massage as measured by
sphygmomanometer and stethoscope.
3. To find out the impact of foot massage on the level of pain, heart rate and
blood pressure in terms of reduction in pain, change in blood pressure and
heart rate.

8
Operational definitions
1.
Impact: It is the noticeable effect or influence or a change which is a result of
an action or other cause.
17
In this study impact refers to the influence of foot massage on the level of pain,
blood pressure and heart rate as measured by a numerical pain scale, observation
checklist, and sphygmomanometer and stethoscope
2.
Massage: Manipulation, methodical pressure, friction and kneading of the
body.
18
In this study foot massage refers to the low stroke manipulations applied on the
legs by working through the arch of the foot, stop and apply pressure, press a little
harder in between and repeat the activity over the toes, tip of the toes, under and
over the foot for 10 minutes on each foot. Massage will be given when the client
has moderate to severe pain, 4-5 hours after the administration of analgesics.
3. Postoperative patients: In this study it refers to the individuals who have
undergone abdominal surgery of any type including hysterectomy and
caesarean section having pain score more than 3 on the numerical pain scale
which represents moderate to severe pain.
4. Pain: An unpleasant sensation that can range from mild, localised discomfort
to agony.
19




9
In this study level of pain refers to the unpleasant sensation experienced by
the abdominal surgery patients and rated by them against the numerical pain scale and
observed by the investigator using an observation checklist.
Assumptions
1. All postoperative patients will have some amount of pain.
2. Pain is multifactorial.
3. Pain is an individual unique experience.
4. Postoperative pain is poorly controlled by pharmacological means alone.
5. Foot massage is one of the effective non-pharmacological methods of pain
relief.
6. Pain causes increase in heart rate and blood pressure.
Hypotheses
Hypotheses will be tested at 0.05 level of significance.
H
1
: The post-foot massage pain score will be significantly lower than the pre-foot
massage pain score.
H
2
: There will be a significant difference in the heart rate and blood pressure
measured between pre and post-foot care massage sessions.
H
3
: There will be a significant association between pre-foot massage pain score
and the selected variables such as age and type of surgery.

10
Conceptual framework
A conceptual framework is a theoretical approach to study the problems that
are scientifically based, which emphasises the selection, arrangement and
classification of its concepts.
20
A conceptual framework is referred to as the interrelated concepts or abstracts that are
assembled together in some rational scheme by virtue of their relevance to a common
theme. The overall objective of a framework is to make scientific findings meaningful
and generalisable and they also give direction for relevant questions of practical
problems.
21
The conceptual framework for this study is developed by the investigator based on
Roys Adaptation Model. The focus of this theory is the adaptation of the individual
to various stimuli, both from the environment and from within. An individuals
behaviour is based on the input, control process, output, and feedback mechanism.
22
Sister Calista, Roy views people as individuals who are in constant interaction with
the surrounding environment, an integral whole with biological, psychological, and
social components. Individuals have certain needs which they endeavour to meet in
order to maintain integrity. The needs are divided into adaptive needs such as
physiological, self-concept, role function, and interdependence.
23

Input: They are the various stimuli which provoke or stimulate the individual. The
adaptation level of the individual is determined by the different stimuli to which
he/she is exposed. Focal, contextual and residual are the three different stimuli
present. The individual is exposed to a variety of stimuli during the postoperative

11
period. To cope with these stimuli, he/she requires various types of comfortive and
supportive measures like positioning, massage, relaxation techniques, and deviation
techniques.
Focal stimuli: Focal stimuli are those which immediately confront the person. In this
study, it is the postoperative pain experienced by post operative patients with
abdominal surgery
Contextual stimuli: Contextual stimuli are all other internal and external stimuli of the
person that can be identified as having a positive or negative influence on the
situation. In this study, the postoperative abdominal surgery pain will be influenced
by contextual stimuli like altered nutrition, anxiety, fear of the unknown surroundings,
and poor social support.
Residual stimuli: Residual stimuli are those internal factors whose current
effects are unclear. The beliefs, attitudes and traits of an individual developed from
the past, but affecting the current responses
22
. In this study, they are the past
experiences, previous hospitalisation, sociocultural orientation, contact with
healthcare professionals, pain threshold, and lack of knowledge regarding the
outcome.

Control process: The control process includes biological and psychological coping
mechanisms. Regulator and cognator are the two sub-system coping mechanisms.
Regulator: A sub-system coping mechanism which responds automatically through
neural-chemical-endocrine processes. In a postoperative abdominal surgery patient,
thoracic, lumbar and sacral nerves transmit pain stimuli to the dorsal root ganglia and

12
to the posterior horn of the spinal cord. From there the impulse will be transmitted to
the thalamus and to the sensory cortex of the brain.
The cognator: Responds through the complex process of perception, information,
processing, learning, judgement and emotion. The individual uses the cognitive
subsystem by perceiving the information given by the caregivers. In this study the
investigator explains the impact of foot massage on postoperative pain and the client
will understand, appreciate and cooperate positively and manifest positive behaviour.
Output: Output is the decreased or increased perception to the stimuli and
corresponding adaptive or maladaptive behavioural responses.
In this study, it is the decreased intensity of postoperative pain BP and heart
rate corresponding adaptive behavioural responses.
Feedback: When the output becomes a non-adaptive behaviour response, it may
contribute as one of the stimuli which require confrontation or intervention.
The adaptive modes: Adaptive or effector modes are a classification of ways of
coping that manifest regulator or cognator activity.
The physiological mode: It involves the bodys basic needs and ways of dealing with
adaptation with regard to fluid and electrolytes, nutrition, circulation, oxygenation,
elimination, exercise and rest, and the regulation of senses, temperature and endocrine
function. Excessive fatigue, fluid electrolyte imbalance, muscular rigidity, irritability,
clenching fists, teeth, biting complaints of pain, and elevated blood pressure and heart
rate are ineffective or maladaptive responses of physiological mode.

13
Self-concept mode: Self-concept is related to the basic need for psychic integrity,
composite of beliefs, and feelings that one holds about oneself at a given time.
In this study, self-concept refers to the maintenance of morale, spiritual self,
and confidence which are adaptive responses; and anxiety, fear, lack of self-control
over pain, and irritated mood which are ineffective responses.
Role function mode: Role function is the performance of duties based on given
positions in the society. Accepting ones own role as head of the family, mother,
teacher, etc are adaptive responses. Restlessness, non-cooperation with care providers,
and indifference are ineffective or maladaptive responses.
Interdependence mode: It is the relationship with significant others and the
supportive system. In this study, cooperation, maintenance of good interpersonal
relationship with the care providers and the investigator are adaptive responses
whereas uncooperative behaviour is the nonadaptive response.
Foot massage will help conserve energy, increase circulation, reduce heat rate
and blood pressure relieve pain, promote comfort and relax muscles of the individual
during postoperative period.

14


Figure 2: Conceptual framework on impact of foot massage on postoperative abdominal surgery patients based on
Roys Adaptation Model
23
Input
STIMULI
Focal stimuli
Postoperative pain
Contextual stimuli
- Surgical procedure done
- Age and gender
- Altered nutrition
- Fear
- Anxiety
- Unknown surroundings
- Social support
Residual stimuli
Pain threshold
Past experience of surgery
Sociocultural orientation
Previous hospitalisation
Contact with healthcare
professionals
Lack of knowledge regarding
outcome
Control process and effectors
No reduction in pain restless-
ness, non-cooperation, irritability
Elevated blood pressure
Elevated heart rate
Cognator
Information
Support from
caregivers
Foot massage
Regulator
Neural pathway
Chemical
change
Endocrine
changes
Maintenance
of vital signs
Relaxation
Rest
Comfort
Pain
perception

Relationship with investi-
gator & support person
Output
Non-adaptive behaviour
Adaptive behaviour
Pain reduction relaxes,
cooperates, follows instructions
Reduced blood pressure
Reduced heart rate
Key
Under study
Intervention
Feedback

15
Delimitations
The study is delimited to:
Postoperative abdominal surgery patients only
Patients who are willing to participate.
Patients above the age of 20 years.
Scope of the study
The results of the study have great scope on nursing education. It can be used
to guide the nurses and nursing students how to provide care that is
independent or in conjunction with medical practice.
Findings of the study can change the nurses perception about pain
management.
An increase in non-pharmacological pain management can significantly
reduce the risk to the client and improve the outcome.
Nurses, clients and other caregivers could easily be trained to apply foot
massage.
This study can stimulate health professionals to conduct further research in
the field.
Summary
This chapter has dealt with the objectives, operational definitions,
assumptions, hypotheses, conceptual framework and scope of the study.








REVIEW OF
LITERATURE

16
3. REVIEW OF LITERATURE
Review of literature is defined as a broad, comprehensive, in depth,
systematic and critical review of scholarly publications, unpublished scholarly print
material, audio visual materials and personal communication.
21
The investigator carried out an extensive review of related literature on
selected topics both research and non research in order to gain maximum relevant
information and to perform the study in a scientific manner.
This literature review has been organized and presented under the following
headings.
- Effect of massage on different variables.
- Effect of foot massage on heart rate, blood pressure and post operative
pain.
- Effect of foot massage on other variables.

Effect of massage on different variables.
A randomised control study comparing massage therapy to a control (rest)
group in patients undergoing alcohol detoxification in which the experimental group
(n = 25) received a seated 15-minute back, shoulder, neck and head massage at the
bed side. Control group (n = 25) rested on their bed for the 15 minutes interval. Both
groups showed reduction in Alcohol Withdrawal Score (AWS) scale. However, the
massage group showed significantly greater reduction than the control group on
Day 1 (F
(1.32)
= 3.29, P < 0.10), Day 2 (F
(1.32)
= 3.29, P < 0.10), and Day 3
(F
(1.29)
= 2.95, P < 0.10). The experimental group reduced pulse following massage
compared with the control group and there was a higher response rate in the massage

17
group (92%) than in the control group (62%) (Yates corrected,
2
= 4.12, P = 0.04)
to the questionnaire.
24
A randomised control study carried out in the University of Miami Medical
School comparing massage therapy to control (viewed relaxing videotapes) group
among children and adolescent psychiatric patients, in which the experimental group
received a 30 minute back massage daily for a 5-day period (N = 52; 26 depressed
and 26 adjustment disorder children) and the control group (N = 20; 10 depressed
and 10 adjustment disorder) who viewed relaxing videotapes revealed more positive
affect after the massage. Activity level decreased during both massage and video
sessions. The verbalisation ratings decreased during the massage, a decrease in
anxiety and fidgeting behaviour, an increase in cooperative behaviour, and indicated
a less depressed mood by the fifth day (the mean score of the depressed group
decreased from 37 to 33; P < 0.05). Urinary cortisol significantly decreased over the
5-day period (Day 1 cortisol mean = 99; Day 5 cortisol mean = 64; P < 0.005).
Similarly, urine norepinephrine decreased (Day 1 norepinephrine mean = 39; Day 5
norepinephrine mean = 29; P < 0.05).
25
A randomised control trial study (Taiwan) was conducted on a population of
98 end-stage renal disease patients with sleep disturbances who were randomly
assigned into an acupressure group (massage on acupressure points), sham
acupressure group (massage on non-acupressure points) and a control group
(without massage). Massages were given three times a week during haemodialysis
treatment for a total of 4 weeks. Result indicated significant difference between the
acupressure and control groups in subjective sleep quality (P=0.009), sleep duration
(P=0.004), habitual sleep efficiency (P=0.001), and sleep sufficiency (P=0.004).

18
Results also showed a significant difference in subjective sleep quality (P=0.003)
between the sham acupressure and control group.
26
A study was conducted to determine the changes in blood pressure in
normotensive and pretensive adults resulting from a therapeutic back massage and
the factors associated with such changes including demographic and massage
characteristics at the National Institute of Health sciences. Massage therapy Clinic,
Lombard, the subjects were 150 current adult massage therapy clients with Bp lower
than 150/95 Bp was measured before and after the theraputic massage. Overall the
systolic Bp decreased by 1.8 mm Hg and diastolic Bp by 0.1 mm Hg. Demographic
factors associated with Bp decrease included young age (P=0.01) and taller stature
(P=0.09).
27
A pre-test post-test experimental study tested the effects of regularly
applied back massage on the BP of patients with clinically diagnosed hypertension.
10 minute back massage was given to the experimental group (n=8) three times a
week for 10 sessions. The control (n=6) relaxed in the same environment for 10
minutes. Analysis of the variance determined that systolic Bp changed significantly
(F1, 12 = 17.0; p=0.001) between groups over time as did the diastolic pressure
(F1,12=8.345; p=0.014). The effects size was 2.25 for systolic pressure and 1.56 for
diastolic pressure (alpha of 0.05 and power at 0.8). This study suggested that regular
massage may lower BP in hypertensive patients.
28


A group experimental design measured the effects of a 20 minute
TBM at three points (pre intervention, immediately post intervention, 20 minutes
post intervention) on spouses of patients with cancer (N=42) randomly assigned to

19
either experimental or control group. The major dependent variables included
natural killer cell activity, HR, SBP and DBP. Two way repeated measures analysis
of variance tests determined the effects of TM over the two post intervention times
and resulted in significant groupXtime interaction on mood. Results of studies
measuring physiologic variables have been mixed. Significant reduction in heart
rate (F5.125=2.06, p=0.08) systolic blood pressure (F5,125=1.21, p=0.31) Diastolic
blood pressure (F5,125=0.61, P=0.69 ) have been shown after massage.
29
A pre test post test repeated measures control group design study was
conducted by the university of Wisconsin on Tellington Touch (TT) as a form of
gentle physical touch to identify the mean blood pressure (MBP) and heart rate in
healthy adults receiving five minute intervention of TT (n=47, random sampling).
There was statistically and clinically significant decrease in the TT group in MBP
and heart rate (F1.9,88=30, 31.6 p<0.01).
30
An experimental study to see the short term effects of myofascial
trigger point massage therapy on 30 randomly allocated healthy subjects (16 females
and 14 males aged 32.4+ 1.55 years; mean standard deviation) A5 minute cardiac
inter-beat interval recording, systolic and diastolic blood pressure and subjective self
evaluations of muscle tension and emotional state were taken before and after
intervention. Following myofascial trigger-point massage therapy there was a
significant decrease in HR (P<0.01) SBP (P=0.02) and DBP (P<0.01). Analysis of
heart rate variability revealed a significant increase in parasympathetic activity
(P<0.01) following myofascial trigger point therapy.
31


20
Effect of Foot Massage on Heart rate, Blood Pressure and post operative pain

A comparative study was conducted in Osaka Japan to find out the
effect of foot massage. Foot bath and Foot massage combined with Foot bath for
relaxation compared with that of a control group. Ten subjects (mean age 72, S.D
2.2) physiological data (H.R and foot skin temperature) were continuously measured
and subjective comfort data were obtained before care, immediately after care, and
120m after care. Analysis done by one way ANOVA, Tukeys test and Fried man
test. Immediately after care, Foot massage resulted in significant decrease in HR in
comparison with control group. (P=0.01).
32
An experimental study was conducted (pre test post test quasi
experimental design) in Japan to investigate the effects of biofeedback using foot
massage. The sample consisted of four men and sixteen women (age range 61-69
years). Four trained researchers massaged the feet of the subjects and measured
vital sign changes. Bio feed back also was investigated before and after the foot
massages. Results showed that the average biofeedback and temperature were lower
before than after the foot massage (P<0.01). The average PR, respiratory rate and
blood pressure however, were found to be lesser after the foot massage (P<0.01)
33
A quasi-experimental repeated measures design study was conducted to find
out the immediate effect of a five-minute foot massage on patients in critical care, at
Miami Japan, reflected that critical care can be considered to be a stressful
environment at both physiological and psychological levels for patients. A five-
minute foot massage was offered to 25 patients, selected by purposive sampling
which showed there was no significant effect from the intervention on peripheral

21
oxygen saturation. However, a significant decrease in heart rate, (p<0.01) blood
pressure, (p=0.02) and respiration (p<0.038) was observed during the foot massage
intervention. Result indicated foot massage had the potential effect of increasing
relaxation as evidenced by physiological changes during the brief intervention
administered to critically ill patients in the intensive care unit.
34
A Non equivalent control group, pre test post test design study was
conduct in a university hospital in seoul Korea on 40 patients who operated under
G/A from July 7, 2000 to Feb 20, 2001 to investigate the effects foot massage on
pain in post abdominal operative patients. Severity of pain was checked with VAS
and vital signs were measured with PR, SBP and DBP. Collected data were
analyzed by the chi-square, Fishes exact test, t-test and repeated measures ANOVA.
The severity of pain decreased significantly in the experimental group as compared
to the control group following foot massage t= -3.37, p=.002. The PR in the
experimental group was lower than that is the control group following foot massage
(F=7.73, P=.008). The SBP in the experimental group was lower than that in control
group following foot massage (F=25.75, P=.000).
35
A quasi-experimental research approach with one group pre-test post-test
with interrupted time series design was conducted in a cardio-thoracic speciality
hospital, Kolkatta (n=30) to determine the effect of ten minutes foot massage on two
phases of postoperative coronary artery bypass graft (CABG) patients on pain, blood
pressure, pulse rate, respiration. There was significant reduction in the heart rate,
respiration and blood pressure measurements between the pre and post-test pain
scores indicating a significant difference (P<0.001) and the opinionniare showed
that most of the patients (80-90%) expressed a positive opinion on foot massage.
36

22
A randomized controlled study conducted at Anaesthetic Department,
Stepping Hill Hospital, Stockport, England, examined the effect of foot massage on
patients perception of care received following laparoscopic sterilisation as day case
patients. Fifty-nine women were randomly allocated into two groups. The
experimental group received a foot massage and analgesia postoperatively; whilst
the control group received only analgesia postoperatively. Each participant was
asked to complete a questionnaire on the day following surgery. This examined
satisfaction, memory and analgesia taken. The 76% percentage response rate was
comparable with other patient satisfaction studies following day case surgery.
Statistical analysis showed no significant overall difference in the pain experienced
by the two groups; however, the mean pain scores recorded following surgery
showed a significantly different pattern over time, such that the experimental group
consistently reported less pain following a foot massage than the control group
(p<0.001). This study has attempted to explore the use of foot massage in a systemic
way and is therefore a basis for further study.
37
An intervention study on foot reflexology (FR) to test if foot reflexology
affects the wellbeing, voiding, bowel movements, pain and sleep in women who
underwent an abdominal operation. One hundred and thirty subjects were
randomised into three groups; 15 minutes foot reflexology/foot massage/talking
were given for 4-5 days respectively. Results show that the women in the foot
reflexology group were more able to void without problems, after the indwelling
catheter had been removed than did women in the comparison groups. There was
also a tendency in the FR group for the indwelling catheter to be removed earlier
than in the other groups. In comparison the FR-group slept worse than the others.

23
The foot massage (FM) group showed significant results in the subjective measures
of wellbeing, pain and sleep.
38
A study conducted to investigate the usefulness of foot reflexology on the
recovery after surgical intervention on 130 abdominal surgery patients (exclusively
gynaecological). Foot reflexology investigated in this study was applied only for a
few days for each patent. The subjective, self-assessed, general condition, pain
intensity, movement of the bowels, micturition, and sleep beginning on the day
before the operation until day 10. Two other treatments served as controls, a simple
foot massage or a personal conversation. The simple massage turned out to be a
relaxing, positive experience, whereas foot reflexology had various effects, some of
them even negative. The conclusion was that foot reflexology is not recommended
for acute abdominal post-surgical situations in gynaecology because it can
occasionally trigger abdominal pain.
39

Effect of Foot massage on other variables

A study was conducted to investigate the effect of pre-operative foot
massage on intra and post operative outcomes in 105 females subjects who had a
laparoscopic gynaecologic surgery procedure done. The subjects received a 30
minute massage (Foot Massage group) or 30 minutes of passive touch (Control
group.) patients in the massage group received significantly less intra operative
narcotics (2.2+ 1.1 versus 2.8 + 2.0mg of fentanyl /kg/hour) Patients in the massage
group had significantly less postoperative anxiety (massage group, 9.83+ 2.9 vs
control group 11.24+ 3.6).
40

24
A study was conducted in Seoul Kyanggi province area of Korea to
investigate the effect of foot massage on sleep, vital sign, and Fatigue in the elderly.
Data were collected from 20 elderly by convenience sampling and analyzed the
change of sleep and sleep satisfaction, vital signs (PR, Respiration, SBP and DBP)
and general fatigue between pre and post foot massage using paired t-test. Result
showed significant difference in the sleep and fatigue between pre and post foot
massage (P=0.05).
41
An experimental study was conducted (pre test post test control group
design) in Gachon, Korea among 50 preoperative patients undergoing total
hysterectomy 25 were in the experimental group (10 mts foot massage) and 25 in the
control group from 10
th
July to 18
th
September 2000 to examine the effect of foot
massage on anxiety response. The levels of anxiety were measured by VAS, state
anxiety scale, BP, PR and respiratory rate. Data analysed using chisquare test, t-
test and ANOVA. The results showed significant reduction in anxiety level systolic
blood pressure, pulse rate and respiration rate of the experimental group after foot
massage. Significant difference were found in anxiety level, systolic blood pressure,
pulse and respiratory rate between the experimental and control groups after foot
massage.
42
A randomised control trial of reflexology for menopausal symptoms
conducted in the Department of Complementary Medicine, School of Sport and
Heath Sciences, University of Exeter, UK, revealed mean (SD) scores for anxiety
fell from 0.43 (0.29) to 0.22 (0.25) in the reflexology group and from 0.37 (0.27) to
0.27 (0.29) in the control group who received foot massage over the same period.
Mean (SD) scores for depression fell from 0.37 (0.25) to 0.20 (0.24) in the

25
reflexology group and from 0.36 (0.23) to 0.20 (0.21) in the control group. The
result revealed foot reflexology was not shown more effective than foot massage in
the treatment of psychological symptoms occurring during menopause.
43
A randomized control trial in a large teaching hospital in England was
conducted on the impact of foot massage and guided relaxation following cardiac
surgery (CABG). Twenty-five subjects were randomly assigned to either a control or
one of the two intervention groups (control group n=7, treatment followed normal
ward protected, guided relaxation group n=9 and foot massage group n =9, both
followed normal ward protocol along with 20 minutes of either guided relaxation or
foot massage). Psychological and physical variables were measured immediately
before and after the intervention using VAS. Results showed no significant effects
on physiological parameters. There was a significant effect of the intervention on the
calm scores among the massage group (x=29.78) (P=0.014). Although not
significant, the guided relaxation group also reported substantially higher levels of
calm than the control group (x=13.89). There was a clear trend across all patient in
the psychological variables for both foot massage and to a lesser extent, guided
relaxation to improve psychological wellbeing. This intervention appears to be
effective non-invasive technique for promoting psychological wellbeing among
CABG patients.
44
An experimental study was conducted at Massachusotts general hospital
Boston on 87 cancer patients on the effects of foot massage and relaxation on
decreasing anxiety, pain and nausea. The subjects were given 10-minutes slow, firm,
gentle stroke towards the heart from the base of the toes up the foot, and lower limb
to the knee. It was found to have significant effect on the perception of pain and

26
nausea when measured with a Visual Analogue Scale. Patients reported pain levels
decreased significantly after the foot massage (p=0.01). The findings for a reduction
in nausea and an increase in relaxation were equally significant; no change occurred
in the control group.
45
Summary
The literature reviewed under different headings enabled the investigator to
have an in depth understanding and deep insight into the problem under study. It
also helped the researcher to establish the need for the study, preparation of tools,
designing the conceptual model and research design, collecting data, planning for
the data analysis and for a good discussion.









METHODOLOGY

27
4. METHODOLOGY
Research methodology is the systematic way of doing a research to solve a
problem. It comprises of the statement of the problem. The objectives of the study,
the hypotheses that have been formulated, the variables under study, the methods
used for data collection and the statistical methods used for analysing the data and
the logic behind it
46
. On the whole it gives a general pattern of gathering and
processing the research data.
The present study aimed at assessing the impact of foot massage on the level
of pain, heart rate and blood pressure among postoperative patients with abdominal
surgery in unit in a selected hospital at Mangalore.
Research Approach
In view of accomplishing the main objective of the study an evaluative
approach was used. An evaluatory research is the utilisation of scientific research
methods and procedures to evaluate a problem, treatment practice or policy. It uses
analytic means to document the worth of an activity.
47

28

Figure 3: Schematic Representation of the Research Design
Population Sample & Sampling
technique
Variables
Data collection
tool & technique
Data analysis
Postoperative
patients with
abdominal surgery
who had moderate
to severe pain
30 postoperative
patients with
abdominal surgery
who had pain
intensity>3
marked on the
numerical pain
scale
Independent
variable
Administration of foot
massage
Techniques
Observation
Client self-
assessment
Recording of
heart rate and
blood pressure
Descriptive statistics
Frequency
Percentage
Mean
Standard Deviation
Spearmans Rank
coefficient
Inferential statistics
Paired t test
Chi square test
Purposive
sampling
Dependent variables
Level of pain
Heart rate
Blood pressure
Tools
Baseline proforma
Observation
checklist
Numerical pain
scale
Stethoscope
Sphygmomanometer
Extraneous variables
Age
Type of surgery
Previous experience
of surgery
Previous use of
analgesics
Experience of non-
pharmacological
pain Relief methods


29
Research Design
Research design is the overall plan for addressing a research question
including specification for enhancing the integrity of the study
48
Pre experimental one group pre-test, post-test design was adopted for the
study. The pre-test was carried out to assess the level of pain, heart rate and blood
pressure of postoperative abdominal surgery patients prior to foot massage.
Subjects
Pre-
treatment Treatment
Post-
treatment
0 minutes
Post-
treatment
10 minutes
Postoperative patients with
abdominal surgery who had
pain score >3 marked on
numerical pain scale
O
1
X O
2
O
3

Figure 4: Schematic representation of the study design
The schematic representation of the research design indicates the following
sequential activities that had been carried out to collect the data.
O
1
: Assessment of level of pain and heart rate blood pressure.
X: Foot massage for 10 minutes.
O
2
: Recording level of pain, heart rate and blood pressure immediately after the
intervention.
O
3
: Recording level of pain, heart rate and blood pressure 10 minutes after the
intervention.

30
Variables Under Study
A variable is an attribute of a person or an object that varies and takes on
different values. In quantitative research an activity is aimed at trying to understand
how or why thing vary and to learn how difference in one variable is related to the
difference in another
49
. There were three types of variables identified in this study.

1. Independent variable
2. Dependent variables
3. Extraneous variables.
Independent Variable
An independent variable is the one that is believed to cause or influence
dependent variable. It stands alone and does not depend on any other.
21
In this study the independent variable is foot massage administered to
postoperative abdominal surgery patients.
Dependent Variables
A dependent variable is the outcome variable of interest; the variable that is
hypothesised to depend on or caused by another variable.
21
In this study dependent variables are level of pain, heart rate and blood
pressure of postoperative abdominal surgery patients.

31
Extraneous Variables
An extraneous variable is an uncontrolled variable that greatly influences the
result of the study.
21
In this study extraneous variables are age, type of operation, previous
experience of surgery, previous use of analgesics, and exposure to non-
pharmacological pain relief methods.
Research Setting
The setting is where the population or portion of that population is being
studied.
The study was conducted at the Father Muller Medical College Hospital,
which is a 1050 bedded general hospital with multi speciality. It is a teaching
institute with research centre which offers both undergraduate and post graduate
courses in medicine, nursing, physiotherapy, medical laboratory technology,
radiology and other paramedical courses. The hospital has well established. Medical
surgical, neuro, paediatrics, orthopaedics, cardiothoracic and gynaecological wards
and ICU. The study was planned to be conducted in the surgical ward but due to
unavoidable circumstance it had to be conducted in the OBG ward.
The setting consisted of the postoperative unit of obstetrics and gynaecology.
On an average 150 abdominal surgeries take place per month which include
hysterectomy, laparotomy, caesarean section and other surgeries.

32
Population
Population is the total number of people who meet the criteria that the
researcher has established for a study from whom subjects will be selected and to
whom the finding will be generalised.
In the present study population consisted of postoperative abdominal surgery
patients in admitted during the time of data collection.
Sample
A sample is a small portion of the population selected for observation and
analysis.
In this study sample consisted of 30 patients with abdominal surgery who
met the inclusion criteria.
Sampling Technique
Sampling refers to the process of selecting a portion of the population to
represent the entire population.
In this study purposive sampling technique has been used to select the
sample.
Purposive sampling is based on the belief that a researchers knowledge about
the population can be used to handpick the cases to be included in the sample
8


33
Sampling Criteria
Inclusion Criteria
1. Postoperative patients with abdominal surgery above the age of 20 years.
2. Patients who were willing to participate in the study and to receive foot
massage.
3. Subjects with stable vital parameters.
4. Subjects having pain intensity > 3 marked on the numerical pain scale.
Exclusion Criteria
1. Abdominal surgery patients who were not willing to participate in the study.
2. Patients who had damaged tissue or skin on foot from any cause.
3. Patients having pain intensity < 3 marked on the numerical pain scale.
Selection and Development of Tools
Data collection tools are the procedures or instruments used by the researcher
to observe or measure the key variables in the research problem. Observational
methods are the techniques for acquiring information for research purposes through
direct observation and recording of phenomena.

34
The tools selected for this study were:
1. Baseline proforma.
2. Observation checklist.
3. Numerical pain scale
4. Sphygmomanometer and stethoscope to check blood pressure and heart rate.
The following steps were adopted in the development of the tool:
1. Review of literature provided adequate content for the tool preparation.
2. Direct contact with the patients and significant others during clinical posting.
3. Opinion of experts from medicine, surgery and nursing departments.
4. Development of a blueprint.
5. Construction of a baseline proforma and a chart to record HR and BP.
6. Construction of observation checklist to assess pain intensity.
7. Content validity.
8. Pre-testing of the tool.
9. Reliability of the tool and instruments used was ascertained by rater-
interrater reliability.

35
Preparation of Blueprint
A blueprint was prepared prior to the construction of the observation checklist
(Annexure 9). It depicted the distribution of items according to the content area.
They are:
Affective domain
Psychomotor domain
Cognitive domain
Content Validity
Content validity refers to the degree to which an instrument measures what it
is supposed to measure.
The content validity of the present tool along with the evaluation criteria
checklist was submitted to 11 experts in the field of medical surgical nursing,
surgery and physiotherapy for their opinion on the items in the tool. There was
100% agreement by experts and minimal modifications were made in base line
proforma based on the given suggestion. The observation checklist consisted of 15
items. Seven items had 100% agreement and eight items had 91% agreement.
Pre-testing
Pre-testing is the process of measuring the effectiveness of an instrument.
Pre-testing was done by administering the tools to five postoperative patients with
abdominal surgery in the postoperative wards of the Father Muller Medial College

36
Hospital. The items were found appropriate and easy to use. Hence the instrument
remained as it was without any modification.
Reliability of the tool
Reliability is defined as the extent to which the instrument yields the same
results on repeated measure, it is concerned with consistency, accuracy, stability and
homogeneity.
A new standardised sphygmomanometer and stethoscope were used to check
the blood pressure and heart rate. The reliability of the sphygmomanometer and
stethoscope were checked with other standardised sphygmomanometer and
stethoscope. The readings were matched with the comparative devices used for the
reliability testing. The observation checklist to assess the level of pain intensity was
tested on five postoperative abdominal surgery patients in the postoperative wards of
Father Muller Medical College Hospital. Inter-rater reliability was used to find out
the reliability of the observation checklist; correlation was computed using
Spearmans Rank Correlation Coefficient with a reading of 0.95, which indicated
that the tool was reliable.
Description of the final tool
The data collection instruments consisted of four tools (Annexure 10).
Tool I Baseline Proforma
Baseline proforma of the subjects consisted of the following 8 items: age,
educational qualification, occupation, surgical procedure done, past surgical

37
experience, past experience with analgesia/anaesthesia, experience of non-
pharmacological pain relief methods, and the type of therapy used.
Tool II Observation checklist to assess the pain intensity
The tool (annexure 10 ) consisted of 15 items carrying a total of 15 scores.
An increase in score denotes an increase in pain intensity:
1 4 mild
5- 8 moderate
9 12 severe
> 12 worst pain.
Tool III Numerical pain scale to assess the level of pain intensity
The numerical rating scale (annexure 10 ) comprised of a 10 cm horizontal
line with end points marked as 0 and 10. An increase in score denotes an increase
in pain level and the score ranges from 0 10.
0 - No pain
1- 3 - Mild Pain
4- 6 - Moderate Pain
7 9 - Severe Pain
10 - Worst pain possible
Tool IV Vital parameter monitoring chart
The heart rate and blood pressure were recorded using a sphygmomanometer
and stethoscope.

38
Pilot Study
A pilot study is defined as a small scale version or a trial run of the major
study. Its function is to obtain information for improving the project or for assessing
the feasibility. The principal focus is on the assessment of the adequacy of
measurement. Prior to the study the investigator underwent 14-hour training on foot
massage under an expert in the Physiotherapy Department of the Father Muller
Medical College.
The pilot study was conducted in the postoperative unit of OBG Department,
Father Muller Medical College from July 13, 2007 to July 20, 2007. The investigator
obtained formal permission from the concerned authority prior to the study
(Annexure 2). The study was conducted on 10 postoperative patients with abdominal
surgery who fulfilled the inclusion criteria for the selection of the sample. The
purpose of the study was explained to the subjects and a written consent was
obtained (Annexure 7, 8) after assuring confidentiality. Baseline information was
collected; heart rate and blood pressure were checked after observing the client for
15 minutes to assess the pain intensity. The numerical pain score was obtained and
foot massage (intervention) was given for 10 minutes. Heart rate, blood pressure and
pain intensity were checked immediately after intervention and 10 minutes after the
intervention.
The tools were found feasible and practical. Analysis of the data was done
using descriptive and inferential statistics. No further changes were made in the tool
after the pilot study and the investigator proceeded for the main study.


39
Data Collection Process
Data collection for the main study was done in the postoperative unit of OBG
Department of Father Muller Medical College hospital from August 3, 2007 to
August 29, 2007. Formal permission obtained from the administrator before data
collection (Annexure 2). The purpose of the study was explained to the subjects and
written consent was obtained after assuring confidentiality. Pre-assessment pain
intensity, heart rate and blood pressure were recorded. Foot massage with low stroke
manipulations was applied on each leg of the subject for 10 minutes. Pain intensity,
heart rate and blood pressure were recorded immediately after the intervention and
again after 10 minutes. The data collection process was terminated by thanking the
subjects for their cooperation.
Problems faced during data collection
1. The investigator had to remain with the subjects until the subject developed
moderate pain, which was time consuming.
2. Medication for pain was administered to the patients by the staff nurses as
per the physicians orders, which resulted in the non-availability of patients
with moderate pain leading to sample mortality.
3. Since General surgery patients were taken up by the student doctors for
research the investigator was forced to select OBG patients for the study.



40
Plan for data analysis
Analysis is the systematic organisation and synthesis of research data and the
testing of the research hypothesis using that data.
The data obtained will be analysed using both descriptive and inferential
statistics based on the objectives and hypotheses of the study.
Baseline proforma containing sample characteristics will be analysed by
using frequency and percentage.
Impact of foot massage on pain intensity, heart rate and blood pressure
would be analysed by range, mean and standard deviation. T
est of significance will be determined by using paired t test.
Association between pre-foot massage pain score and the selected variables
such as age and type of surgery would be analysed by chi- square test.
Summary
Research methodology gives a birds eye view of the entire process of
tackling a research problem in a systematic and scientific manner. This chapter dealt
with research approach, research design, sample and sampling technique, research
setting, tool construction, content validity, pilot study, data collection process and
plan for data analysis.







RESULTS

41
5. RESULTS
This chapter presents the analysis and interpretation of the data collected to
determine the impact of foot massage on the level of pain, heart rate and blood
pressure among postoperative patients with abdominal surgery in a selected hospital
at Mangalore.
The analysis of data involves the translation of the information collected
during the course of the research project into interpretable, convenient and
descriptive terms and to draw inferences from them using statistical methods. The
purpose of analysis is to summarise, compare and test the proposed relationships and
infer findings
21
. The collected data was tabulated and analysed using descriptive and
inferential statistical in order to meet the objectives of the study, and to test the
hypotheses.

Organisation of the study findings
The data collected from the postoperative abdominal surgery patients are
organised, analysed and presented under the following headings:
Section I: Sample characteristics.
Section II
a. Assessment of level of pain of postoperative abdominal surgery patients
before implementation of foot massage.
b. Assessment of heart rate and blood pressure of postoperative abdominal
surgery patients before implementation of foot massage.

42
Section III
a. Description of pre- and post-foot massage pain level of postoperative
abdominal surgery patients.
b. Description of pre- and post-foot massage heart rate and blood pressure of
postoperative abdominal surgery patients.
Section IV
a. Significance of difference in the level pain before, immediately after, and 10
minutes after foot massage of postoperative abdominal surgery patients.
b. Significance of difference in heart rate and blood pressure before,
immediately after, and 10 minutes after food massage of postoperative
abdominal surgery patients.
Section V: Association between pre-foot massage pain score and the selected
variables such as age and type of surgery.
Section I: Sample characteristics
This section deals with the analysis of the data collected from 30 abdominal
surgery patients based on their specified inclusion criteria and is explained in
frequency and percentage and represented table 1.


43
Table 1: Frequency and Percentage of Sample Characteristics
N=30
Variable Frequency Percentage
1. Age in years
a. 21 30 13 43.3
b. 31 40 7 23.3
c. 41 50 7 23.3
d. 51 60 2 6.7
e. > 60 1 3.3
2. Education
a. Illiterate 2 6.7
b. Primary education 10 33.3
c. Secondary education 12 40.0
d. Graduate 6 20.0
e. Postgraduate - -
f. Professional - -
3. Occupation
a. Unemployed 18 60.0
b. Employed 5 16.7
c. Professional - -
d. Self-employed 7 23.3
4. Surgical procedure done
a. Laparotomy 3 10.0
b. Hysterectomy 11 36.7
c. Caesarean section 16 53.3
5. Previous surgery
a. Yes 41 33.3
b. No 17 56.7
6. Previous analgesia/anaesthesia
a. Yes 20 66.7
b. No 10 33.3




44
Variable Frequency Percentage
7. Pain relief method other than medications
a. Yes 11 36.7
b. No 19 63.3
8. If yes, type of therapy
a. Acupuncture - -
b. Traditional massage 7 63.6
c. Aroma therapy - -
d. Acupressure - -
e. Yoga 4 36.4
f. Music therapy - -

Age
3.30
6.70
23.30 23.30
43.40
-
10
20
30
40
50
60
70
80
90
100
21-30 years 31-40 years 41-50 years 51-60 years > 60 years
Age (in years)
P
e
r
c
e
n
t
a
g
e

Figure 5: Bar Diagram showing the distribution of subjects according to age
From Table 1 and Figure 4 it is evident that 43.3 of the subjects were in the
age group of 21-30 years and only 3.3% were in the age group more than 60 years.

45
Education
(40%) of the subjects had secondary education followed by primary
education (33.3%), and graduation (20%). Among the subjects only 6.7% were
illiterate.
Occupation
Majority of subjects were unemployed (60%), 23.3% were self-employed
and 16.7% were employed.
Surgical procedure done
10.00
36.70
53.30
-
10
20
30
40
50
60
70
80
90
100
P
e
r
c
e
n
t
a
g
e
Laparotomy Hysterectomy Caesarean Section
Type of surgery

Figure 6: 3-D Bar diagram showing the distribution of subjects according to the
surgical procedure done
Majority of subjects had caesarean section (53.3%), 36.7% had hysterectomy
and 10% had laparotomy.

46
Previous surgery
Majority (56.7%) had no previous surgical experience. And 33.3% had
previous surgical experience.
Previous analgesia or anaesthesia
Majority (66.7%) of the subjects had previous experience of analgesia or
anaesthesia.
Pain relief method other the medications
Majority (63.3%) of subjects had no experience of non-pharmacological pain
management. Of the remaining 36.7% subjects, seven (63.6%) had undergone
traditional massage and the remaining four (36.4%) had undergone Yoga therapy.
Section II
a. Assessment of level of pain postoperative abdominal surgery patients
before implementation of foot massage
Assessment of pain level of 30 post operative abdominal surgery patients
before implementation of foot massage using observational check list and numerical
pain scale and were analysed by descriptive and inferential statistics and presented as
table 2.





47
Table 2: Level of pain before foot massage
N=30
Range Mean Mean % SD
Objective assessment of pain
Using observation check list
8 13 10.67 71.13 1.322
Numerical pain scale 6 10 7.47 72.00 1.042

Table 2 shows that pain level of postoperative abdominal surgery patients
before implementation of foot massage was moderate to severe. According to
observation check list the level of pain was 8-13 and according to numerical pain
scale level of pain was 6-10, which denotes moderate to severe pain which is used as
the control of the study.
c. Assessment of heart rate and blood pressure of postoperative abdominal
surgery patients before implementation of foot massage
Heart rate and BP of 30 post operative abdominal surgery patients were
asses before implementation of foot massage using stethoscope and
sphygmomanometer, analysed by descriptive and inferential statistic.
Table 3: Range, mean and SD of heart rate and blood pressure of Postoperative
abdominal surgery patients before foot massage
N = 30
Range Mean SD
Systolic pressure 100- 140 125.00 9.436
Diastolic pressure 70 92 82.80 7.000
Heart rate 62 92 79.20 4.990


48
The data presented in Table 3 shows the mean and standard deviation of
baseline blood pressure and heart rate which is (1259.436,82.807) and
79.204.990 respectively and is used as control for the study.
Section III
a. Description of pre- and post-foot massage pain level of postoperative
abdominal surgery patients
Pre and post foot massage pain level of 30 post operative abdominal surgery
patients were assessed by using observation check list and numerical pain scale
analysed by descriptive and inferential statistics.
Table 4: Range, mean and SD of level of pain intensity of postoperative patients
before and after implementation of foot massage
N=30
Range Mean SD
Objective assessment of pain
Using observation check list

O
1
(Pre) 8 13 10.67 1.322
O
2
(0
th
minute) 5 11 8.00 1.314
O
3
(10
th
minute) 3 7 4.77 1.165
Numerical pain scale
O
1
(Pre) 6 10 7.47 1.042
O
2
(0
th
minute) 3 7 5.70 0.952
O
3
(10
th
minute) 3 7 4.53 0.937

Data in Table 4 shows that range of mean pre test pain level (8-13 as per
objective assessment and 6-10 as per numerical pain scale) were higher than that of
mean post test pain level (3-7 as per objective assessment and 3-7 as per numerical
pain scale) respectively. It is evident for the table that the mean pre test pain level

49
(X
1
=10.671.322, 7.471.042) was higher than the mean post test pain level
(X
2
=4.4771.165, 4.530.937)

10.67
8.00
4.77
-
2
4
6
8
10
12
14
16
18
20
P
e
r
c
e
n
t
a
g
e
Pre-assessment Immediately after After 10 minutes
Mean pain score

Figure 7: Level of pain of patient before and after assessed by objective
assessment of pain
The pain intensity as measured by the objective pain assessment scale shows
that 10 minutes after foot massage there was significant decrease in the mean pain
score as compared to the pre-assessment mean pain score (4.77 v/s 10.67).
b. Description of pre- and post-foot massage heart rate and blood pressure
of postoperative abdominal surgery patients
pre and post massage heart rate and blood pressure of 30 post operative
abdominal surgery patients were assessed by stethoscope and sphygmomanometer
analysed by descriptive and inferential statistics.

50
Table 5: Range mean and SD of heart rate and blood pressure before and after
implementation of foot massage
N=30
Range Mean SD
Heart rate
O
1
(Pre) 68 92 79.20 4.999
O
2
(0
th
minute) 64 88 76.47 4.569
O
3
(10
th
minute) 62 88 75.40 5.282
Systolic blood pressure
O
1
(Pre) 100 140 125.00 9.436
O
2
(0
th
minute) 94 140 120.53 9.755
O
3
(10
th
minute) 90 130 116.27 8.971
Diastolic blood pressure
O
1
(Pre) 70 92 82.80 7.000
O
2
(0
th
minute) 66 90 79.13 7.040
O
3
(10
th
minute) 66 90 76.07 6.486

Data in Table 5 shows that mean pre test heart rate was higher than that of mean post
test HR immediately after and 10 minutes after foot massage
(X
1
=79.204.999 is higher than X
2
= 76.974.569, X
3
=75.405.282) pre test mean
SBP was higher than that of mean post test SBP immediately and 10 minutes after
foot massage(X
1
= 1259.436 is higher than X
2
=120.539.755, X
3
=116.278.971)
pre test mean DBP was higher than that of mean post test DBP.(X
1
= 82.807
higher than X
2
=79.137.040, X
3
=76.076.486)






51
Section IV
a. Significance of difference in the level of pain before, immediately after,
and 10 minutes after foot massage of postoperative abdominal surgery
patients

In order to find out the significance of difference in the level of postoperative
abdominal surgery patients before, immediately after, and 10 minutes after foot
massage, the following null hypothesis was formulated:
H
01
: The post foot massage pain score will not be significantly lower than the pre
foot massage pain score.
Table 6: Paired ttest showing significant difference between pre- and post-
foot massage pain level
N=30
Mean SD t value
Objective assessment of pain
O
1
- O
2
2.667 1.213 12.041*
O
1
- O
3
5.900 1.423 22.710 *
O
2
O
3
3.233 1.406 12.590 *
Numerical pain scale
O
1
- O
2
1.767 0.568 17.026 *
O
1
- O
3
2.933 0.691 23.230 *
O
2
O
3
1.697 0.648 9.860 *
t
(29)
at 0.05 level = 2.045 *Significant
It is evident from Table 6 that the calculated t values are greater than table
value (t
(29)
= 2.045, P<0.05) showing that there was significant difference in the pre

52
and post-foot massage pain score. Hence the null hypothesis rejected and research
hypothesis accepted.
b. Significant of difference in heart rate and blood pressure before,
immediately after, and 10 minutes after foot massage of postoperative
abdominal surgery patients
In order to find out the significant of difference in the heart rate and blood
pressure of postoperative abdominal surgery patients before, immediately after, and
10 minutes after foot massage, the following null hypothesis was formulated:
H
02
: There will be no significant difference in heart rate and blood pressure
measured between pre- and post-foot massage sessions.

53

Table 7: Paired t test showing significant difference between pre- and post-
foot massage heart rate and blood pressure
N=30
Mean SD t value
Heart rate
O
1
- O
2
2.733 2.258 6.630 *
O
1
- O
3
3.800 2.747 7.577 *
O
2
O
3
1.067 2.392 2.442 *
Systolic blood pressure
O
1
- O
2
4.467 2.145 11.403 *
O
1
- O
3
8.733 2.545 18.793 *
O
2
O
3
4.267 2.559 9.133 *
Diastolic blood pressure
O
1
- O
2
3.667 2.040 9.845 *
O
1
- O
3
6.733 3.216 11.469 *
O
2
O
3
3.067 2.273 7.388 *
t
(29)
at 0.05 level = 2.045 *Significant
It is evident from Table 7 that the calculated t values are greater than table
value (t
(29)
= 2.045, P<0.05) showing that there was significant difference in the pre-
and post-foot massage heart rate and blood pressure. Hence the null hypothesis
rejected and research hypothesis is accepted.

54
Section V
Association between pre-foot massage pain score and the selected variables
such as age and type of surgery
To test the association between pre foot massage pain score and the
selected variables the following hypothesis was formulated.
H
03
: There will be no significant association between pre foot massage pain level,
age and type of surgery.
Table 8: Association between pre-foot massage pain score and selected
variables such as age and type of surgery
N=30
Level of pre-experiment
pain
Variable Moderate Severe Total
2
value
Age (years)
21 30 3 10 13
31 2 15 17
0.109
NS
Type of surgery
Hysterectomy and laparotomy 1 13 14
Caesarean section 4 12 16
0.670
NS

2
= 3.84, P<0.05 NS = Not significant
Table 8 shows that there was no association between pre-foot massage pain
score, age (
2
= 0.109, P = 0.0742), and type of surgery (
2
= 0.670,
P = 0.336) at 0.05 level of significance. There fore null hypothesis was accepted and
the research hypothesis rejected.

55
Summary
This chapter dealt with the results of the data collected from 30 subjects
(postoperative abdominal surgery patients in a selected hospital in Mangalore).
Descriptive and inferential statistics were used to analyse the data based on the
objectives and hypotheses of the study. The findings revealed that foot massage had
impact on the level of pain, heart rate and blood pressure among postoperative
abdominal surgery patients.





DISCUSSION

56

6.DISCUSSION
Thischapterpresentsthemajorfindingsofthestudyanddiscussesthemwith
referencetotheobjectivesandhypothesesstatedandinrelationtothefindingsofsi
milarstudies.
M ajorfindingofthestudy
SectionIsam plecharacteristics
Fortythreepercentofthesubjectbelongedtotheagegroupof21-31
yrs.Findingsregardingagewasconsistentwiththeexperimentalstudytoseethesh
orttermeffectsofmyofacialtriggerpointmassagetherapy(aged32.41.55yrs)
31
an
dthefindingswereinconsistentwithothersimilarstudies.Acomparativestudycon
ductedinOsakatofindouteffectoffootmassageonrelaxation(meanage72,SD2.
2)
32
andexperimentalstudyconductedinJapantofindouttheeffectsofbiofeedback
usingfootmassage(agerange61-69yrs).
Fortypercentofthesubjectshadsecondaryeducationand60% were
unemployed.53% ofthesubjectshadcaesareansectionand37% hadhysterectomy.
Twointerventionalstudiesoffootreflexologytotestthewellbeing,voiding,bowel
movements,painandsleepinwomenunderwentabdominaloperationssupportedsi
milarfindings
38,39
56.7% subjectshadnopreviousexperienceofsurgery.M ajorityo

57
fthesubjects(63.3% )hadnoexperienceinnonpharmacologicalpainreliefmethods

SectionIIAssessm entoflevelofpainheartrateandbloodpressureofpostoper
ativeabdom inalsurgerypatientsbeforeim plem entationoffootm assage.
Thefindingsofthestudyshowedthatthemeanpretestpainlevel(X=10.67,
7.47)higherthanthemeanposttestpainlevelandthemeanpretestSBP(X=125)
washigherthanmeanposttestSBP.Themeanpre-testDBP
(X=82.80)washigherthanthemeanpost-testDBP.Thefindingswereconsistentw
iththatofothersimilarstudies.Anexperimentalstudyconductedin
Japantoinvestigatetheeffectofbiofeedbackusingfootmassageshowedtheaverag
ePR,respiratoryrateandBPwerehigherbeforefootmassage
(p<0.01)
33
.Aquasiexperimentalstudyconductedtofindouttheimmediate
effectofa5minutefootmassageonpatientsincriticalcareshowedhigherlevelsof
HR,BPandrespiratoryrate(p<0.01,p=0.02,p<0.038)respectively
34
.Twointervent
ionalstudiesonfootreflexologyinTaiwanintwodifferentsettingsalsosupportedt
hesamefindings
38,39
.

58
SectionIIIAssessm entofpainlevel,heartrateandbloodpressureaftertheim
plem entationoffootm assage.
Themeanpainlevelimmediatelyafter(x=85.70)and10minute
safter(x=4.77,4.53)footmassagewaslowerthanthemeanpre-testresults.Theme
anpost-test(footmassage)heartrates(76.47,75.40),SBP(120.53,116.27)andDB
P(79.13,76.07)immediatelyandtenminutesafter.Thefindingswereconsistentwit
hthefindingsofothersimilarstudies
31-37
.
SectionIVSignificanceofdifferencebetweenthem eanpre-testandpost-testpa
inlevel,H eartrateandBloodpressuream ongpostoperativeabdom inalsurge
rypatients.
Thefindingsofthestudydemonstratedsignificantdecreaseinp
osttestpainlevel[t
29
=12.041(O
1
-O
2
),t
29
=22.710(O
1
-O
3
),t
29
=12.590(O
2
-O
3
),p<0.0
5]fortheobjectiveassessment,and(t
29
=17.026,t
29
=23.230,t
29
=9.860)respectivelyf
ornumericalpainscale.Significantreductioninpost-testheartrate[t
29
=6.630(O
1
-O
2
),t
29
=7.577(O
1
-O
3
),t
29
=2.442(O
2
-O
3
)],SBP[t
29
=11.403(O
1
-O
2
),t
29
=18.793(O
1
-O
3
),t
2
9
=9.133(O
2
-O
3
)]andDBP[t
29
=9.845(O
1
-O
2
),t
29
=11.469(O
1
-O
3
),t
29
=7.388(O
2
-O
3
)].Fi
ndingsweresupportedbyothersimilarstudies.AcomparativestudyconductedinO
sakaJapantofindouttheeffectoffootmassageonrelaxationshowedsignificantre
ductioninHR(p=0.01)
32
.AnexperimentalstudyconductedinJapantoinvestigatet

59
heeffectofbiofeedbackusingfootmassageshowedtheaveragePR,respiratoryrate
,Bpwerelesser(p<0.01)afterfootmassage
33
.AstudyconductedinJapantofindou
ttheimmediateeffectofafiveminutefootmassageonpatientsoncriticalcaresho
wedsignificantdecreaseinHR(p<0.01),BP(p=0.02)andrespiration(p<0.038)
34
.An
on-equivalentpre-testpost-testcontrolgroupstudyconductedinKoreatoinvestigat
etheeffectsoffootmassageonpaininpostabdominaloperativepatientsshowedsi
gnificantreductioninpainfollowingfootmassage(t=-3.37,p=0.002),decreaseinPR
(F=7.73,p=0008)anddecreasedSBP(F=25.75,p=0.002)
35
.Aquasi-experimentalst
udyconductedincardiothoracichospital,Kolkatatodeterminetheeffectof10min
utefootmassageonCABGpatientspain,BP,PRandrespirationshowedsignifican
treduction(p<0.001)
36
.ArandomizedcontrolstudyconductedinEnglandtoexamin
etheeffectoffootmassageonpatientsperceptionofcarereceivedfollowinglaprosc
opicsterilizationshowedsignificantreductioninpain(p<0.001)
37
.SectionVAssociationbetweenprefootm assagepainscoreandthesele
ctedvariablessuchasage,andtypeofsurgery.
Findingsofthestudyshowednoassociationbetweenprefootmassagepa
inscore,age(
2
=0.109,p=0.0742)andtypeofsurgery(
2
=0.670,p=0.336)at0.05l
evelofsignificance.

60
Sum m ary
Thefindingsofthepresentstudywereanalysedanddiscussedwiththefindi
ngsofsimilarstudiesconductedinthepast.Thishelpedtheinvestigatortoprovetha
tthefindingsaretrueandfootmassagewaseffectiveinreducingpaininpatientswit
habdominalsurgery.

CONCLUSION

61


7. CONCLUSION
The chapter presents the conclusions drawn based on the present study. This
study attempted to find out the impact of foot massage on the level pain, heart rate,
and blood pressure of postoperative patients with abdominal surgery.
The pre-foot massage pain level was significantly higher than the post-foot
massage pain level.
The highest significance of difference in pain level was found between pre-
foot massage and 10 minutes after foot massage.
There was significant difference between pre-foot massage heart rate and
post-foot massage heart rate.
There was significant difference between pre-foot massage blood pressure
and post-foot massage blood pressure.
There was no significant association between pre-foot massage pain score,
age, and type of surgery.

62
Nursing Implications
The findings of this study have brought out certain facts that have far-
reaching implication for nursing in the area of practice, education, administration
and research.
Nursing Practice
Today, more than ever, healthcare reform calls nursing to provide cost
effective care. Concern about possible side effects of drug treatment and heavy
expenses on medical care are the reasons why people seek complimentary and
alternative medicine, because the dimensions of pain involve physical,
psychological, social and spiritual health. There will be a potential reduction in the
quality of life. Pain related anxiety, and sleeplessness release stress hormones, which
have deleterious effects upon post-surgical outcome.
Using the current research findings nurses can use foot massage as an
effective intervention in their practice. Foot massage is cost effective, easy to learn,
and has no adverse effects. It does not require additional equipment, extra
preparation, or expenditure. Foot massage as a means of touch can be used by the
nurses to communicate care and concern for the patients.
The findings of this study can be incorporated in the training of other
healthcare personnel and family members in providing healthcare.
Nursing Education
Alternative and complementary therapies are increasing in popularity
(British Medical Association, 1993). Nurses seem to be equipped to act as advocates

63
with regard to pain management in order to assess and alleviate pain of the patients.
The use of non-pharmacological measures like foot massage can be easily
incorporated in nursing education along with other complementary therapies. To
equip nurses to provide holistic care the nursing curriculum needs to cover non-
pharmacological measures such as foot massage for pain management. Nurse
educators need to highlight the non-pharmacological pain relief measures like foot
massage in the curriculum of basic nursing education as part of pain assessment and
management. Ongoing education can be planned for graduate students. Students can
be given a project work to experiment the need for foot massage in pain
management. Foot message as a non-pharmacological pain management method can
be highlighted as a part of in-service education programme. Family members should
also be educated on foot massage techniques which will enable them to help and
care for the individual who is in pain and thereby making these measures beneficial
to common people.
Nursing Administration
Today, there is an increasing need for quality and holistic care. The findings
of this study could be made use of by nursing and non-nursing personnel. Nursing
administrators are in the key position to formulate policies and the execution of
quality nursing based on research findings with necessary changes in nursing
education and practice. They should develop nursing practice standards, protocols,
and manuals for pain assessment and management. Awareness programmes could be
organised and information could be disseminated through media, like newspapers,
magazines, television and internet. In-service education for the staff nurses could be

64
provided with special emphasis on the use of foot massage to relieve pain in
postoperative patients.
Nursing Research
A profession seeking to improve the practice of its members and to enhance
its professional stature strives for the continuous development of a relevant body of
knowledge. It is apparent that there are significant gaps in research with regard to
foot massage and pain management. It is also observed that the published research
studies and trials on foot massage in the Indian setting are very limited.
Nurse researchers should be aware of the new trends in the existing
healthcare system. Emphasis should be laid on research in the area of non-
pharmacological measures of pain management in postoperative patients. The
findings of the research need to be disseminated through publications so that the
utilization of such research findings is encouraged.
Limitation
Since the study was confined to the postoperative patients with abdominal
surgery in the OBG unit of one hospital, generalisation of the study is limited.
Intervention was limited only for 10 minutes.

65
Recommendations
1. The study can be replicated on a larger sample with general surgery to have
generalisation.
2. A similar study can be replicated on a larger sample having a control group.
3. The study could be undertaken during chronic painful experience like cancer
pain.
4. Study could be conducted with a control group to assess the effect of other
complimentary therapies such as acupressure, progressive muscle relaxation,
and guided imagery.
5. A comparative study can be conducted with more than one intervention.
Suggestions
1. Complementary therapy cell could be arranged in the institution and
multidisciplinary team could be introduced.
2. Pain assessment and management should be given emphasis in postoperative
nursing care practices
3. Non-pharmacological methods of pain management should be emphasised in
nursing curriculum.
4. Nurses can be given training programmes on non-pharmacological pain
management.

66
5. Findings of this study can be utilised to educate family members and non-
nursing personnel to provide quality services in hospitals.
Summary
On the whole, conducting this study was a learning experience for the
investigator. The result of this study shows that foot massage is an effective non-
pharmacologic measure in reducing postoperative pain. Foot massage is an effective,
simple, non-invasive, cost-effective method that can be used easily without any side
effects or extra efforts from the part of practitioners.





SUMMARY

67

8. SUMMARY
Pain is an expected outcome postoperatively. The inadequacy of
postoperative pain management was shown in many studies and the pain is often
underestimated and untreated. Routinely postoperative pain is poorly controlled by
pharmacological means alone and the patients report mild to moderate pain even
though pain medications have been administered.
Effective postoperative pain control can be achieved through combination of
both pharmacological and non-pharmacological therapies. Massage is one of the
most widely used complimentary therapies in nursing practice. In spite of all the
advancement in the knowledge and complexes of techniques massage therapy
retains its usefulness and significance even in the steps for saving life from
immediate death as in cardiopulmonary arrest.
Throughout history, caregivers have used massage techniques to soothe a
painful body part. However, scientific evidence for the effectiveness of massage as a
non-pharmacological method of pain relief is recent. Foot massage can certainly
reduce pain because cutaneous stimulation stimulates nerve fibres which encourage
the release of endorphins that have analgesic properties and produces relaxation.
Relaxation may increase pain threshold and modify an individuals pain perception.
Foot massage reduces pain based on Gate Control Theory also.
Foot massage as a non-pharmacological pain relief measure is safe, easy to
administer, cost effective and simple.

68
The objectives of the study
1. To determine the level of pain of postoperative abdominal surgery patients
before implementation of foot massage as measured by a numerical pain
scale and observation checklist.
2. To determine the blood pressure and heart rate of postoperative abdominal
surgery patients before implementation of foot massage as measured by
sphygmomanometer and stethoscope.
3. To find out the impact of foot massage on the level of pain, heart rate and
blood pressure in terms of reduction in pain, change in blood pressure and
heart rate.
Assumptions
1. All postoperative patients will have some amount of pain.
2. Pain is multifactorial.
3. Pain is an individual unique experience.
4. Postoperative pain is poorly controlled by pharmacological means alone.
5. Foot massage is one of the effective non-pharmacological methods of pain
relief.
6. Foot massage is one of the best methods for relaxation.



69
Hypotheses
Hypotheses will be tested at 0.05 level of significance.
H
1
: The post-foot massage pain score will be significantly lower than the pre-
foot massage pain score.
H
2
: There will be a significant difference in the heart rate and blood pressure
measured between pre and post-foot care massage sessions.
H
3
: There will be significant association between pre-foot massage pain score
and selected variables such as age and type of surgery.
The conceptual framework used for the present study was based on Roys
Adaptation Model. The focus of this theory is the adaptation of the individual to
various stimui both from the environment and from within.
The variables of the present study were: independent variable foot
massage, and dependent variable heart rate and blood pressure.
The investigator used an evaluatory research approach to assess the impact of
foot massage on level of pain, heart rate and blood pressure among postoperative
patients with abdominal surgery. The research design selected was pre-experimental
(one group pre-test post-test) design.
The study was conducted at The Father Muller Medical College Hospital,
Mangalore. The population of the study included postoperative patients with
abdominal surgery. Purposive sampling technique was used to select 30 subjects
with pre determined criteria from the population

70
Tools for data collection were:
Tool I: Baseline proforma.
Tool II: Observation checklist to assess pain.
Tool III: Numerical pain scale to assess pain.
Tool IV: Sphygmomanometer and stethoscope to check blood pressure and heart
rate.
The content validity of the tool was established with the help of 11 experts
and reliability was established using inter-rater reliability for observation checklist.
Spearman Rank Correlation was used to test the reliability and the tool was found to
be reliable (r=0.95). Since numerical pain scale, sphygmomanometer and
stethoscope are already standardised tools; reliability test was not established for the
same. A pilot study was conducted to confirm the feasibility for conducting the main
study.
The main study was conducted between August 3, 2007 and August 29,
2007. The data obtained were analysed using both descriptive and inferential
statistics. The level of significance for testing hypotheses was set at 0.05.
The findings of the study showed significant difference in pain between the
pre- and post-foot massage pain score immediately, and after 10 minutes of foot
massage (t
29
= 12.041, t
29
= 22.71, t
29
= 12.59, p<0.05) for the observation checklist,
and (t
29
= 17.02, t
29
= 23.234, t
29
=9.865, p<0.05) for the numerical pain scale.

71
There was significant difference in the heart rate measured between pre- and
post-foot massage immediately and after 10 minutes after massage (t= 6.630,
t
29
= 7.577, t
29
= 2.442, p<0.05).
There was significant difference in the systolic blood pressure measured
between pre- and post-foot massage immediately and 10 minutes after foot massage
(t
29
= 11.403, t
29
= 18.793, t
29
= 9.133, p < 0.05).
Diastolic blood pressure has significant difference between pre-and post-foot
massage sessions immediately and 10 minutes after foot massage (t=9.845,
t
29
= 11.469, t
29
= 7.388, p <0.05).
There was no significant association between pre foot massage pain and
selected variables such as age (
2
= 0.109, p > 0.05) and type of surgery (
2
= 0.670,
p > 0.05).
On the whole, carrying out present study was really an enriching experience
to the investigator. The constant encouragement and guidance by the guide,
cooperation and interest of respondents to participate in the study contributed to the
fruitful completion of the study.


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72
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Publishers; 1999.








ANNEXURES

78
Annexure 1
Letter requesting permission to conduct research study


From,
Laly Chacko.
II year M. Sc. Nursing
Father Muller College of Nursing
Kankanady, Mangalore.
To,
The Director
Father Muller College of Nursing and Medical College
Mangalore 575 002.
Respected Reverend Father
I have selected the below mentioned topic for my dissertation to be
submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka,
as a requirement for the award of Masters Degree in Nursing.
Topic: Impact of foot massage on the level of pain, Heart rate and Blood
pressure among patient with abdominal surgery in a selected
hospital at Mangalore
I am interested in conducting this study in your esteemed institution. I assure
that this study will not cause any inconvenience to the normal routine of the wards.
Kindly permit me to conduct the proposed study and do the needful.
Thanking you.
Yours sincerely,
Place: Mangalore
Date:
Laly Chacko.













79
Annexure 2
Letter granting permission to conduct the study


80
Annexure 3
Certificate of attending foot massage training



81
Annexure 4
Letter requesting opinion and suggestion of experts to validate the tool
From,
Laly Chacko
I Year M. Sc. Nursing
Father Muller College of Nursing
Kankanady
Mangalore-575002.
To,


Respected Sir/Madam/Sister,
Subject: Request for expert opinion and suggestions to establish content
validity of the research tool.
I, Laly Chacko, I Year M. Sc. Nursing student at Father Muller College
of Nursing have selected the following topic for my dissertation to be
submitted to Rajiv Gandhi University of Health Sciences in partial fulfilment
for the requirement for award of Master of Science in Nursing.
Topic: Impact of foot massage on the level of pain, heart rate and
blood pressure among patients with abdominal surgery in OBG
unit in a selected hospital at Mangalore.
Herewith I have enclosed
1. Objectives of the study, operational definitions and hypotheses
2. Baseline proforma
3. Blueprint of the observation checklist
4. Observation checklist for pain
5. Criteria checklist
6. Numerical pain scale
7. Vital parameter monitoring chart
I request you to go through the items and give your valuable
suggestions and opinions to develop the content validity of the tool. Kindly
suggest modifications, additions and deletions, if any, in the Remark column.
Thanking you.
Yours sincerely
Place: Mangalore
Date:
Laly Chacko

82
Annexure 5
Acceptance form for tool validation

Name: ________________________________
Designation: ________________________________
Name of the college/ hospital: ________________________________

Statement of acceptance or non acceptance
I give my acceptance/non-acceptance to validate the tool.


Topic: Impact of foot massage on the level of pain, heart rate and
blood pressure among patients with abdominal surgery in OBG
unit in a selected hospital at Mangalore


Place:
Date:
Signature

83
Annexure 6
Content Validation Certificate

I hereby certify that I have validated the tool of Laly Chacko, I Year
M. Sc. Nursing student, Father Muller College of Nursing who is undertaking
the following study:
Impact of foot massage on the level of pain, heart rate and blood
pressure among patients with abdominal surgery in OBG unit in a
selected hospital at Mangalore

Place: Signature of the expert
Date:
Designation and address

84
Annexure 7
Consent form (English)

Dear respondent,
I am a final year M. Sc. Nursing student of Father Muller College of
Nursing. As a partial fulfilment of the course, I am conducting a research
study on the following topic:
Impact of foot massage on the level of pain, heart rate and blood
pressure among patients with abdominal surgery in OBG unit in a
selected hospital at Mangalore
As part of the study, I would like to ask you a few questions. I assure
you that the information obtained from you will be kept strictly confidential
and will be used for the study purpose.
I expect your whole-hearted cooperation and will be grateful to you for
the same.
Yours sincerely,

Signature of the participant Laly Chacko



85
Annexure 8
Consent form of subjects (Kannada)
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PUwz:
AUjD0iDv0iAzgG zgzaQvUUzgVU
l, Jz rv U gPzvqz PU
ziqzjAzG AmUju
F Czs0izsUVPUP0iv.rz
iw0iUVlPCzs0iPgivG 0iVUzJAz
F PDqwz.
F 0iAtPg0iv.
Ewv

sUg jhee

86
Annexure 9
Blueprint of the Observation Checklist for the Objective Assessment of
Pain among Postoperative Abdominal Surgery Patients
Sl.
No. Content Items Total Percentage
1. Physical domain 3, 9, 13, 14 4 26.67
2. Psychological
domain
2, 4, 5, 7, 8, 11, 15 7 46.66
3. Physiological
domain
1, 6, 10, 12 4 26.67
Total 15 100.00

Scoring key
Score
Items Yes No
Positive score 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15
1 0
Negative score 2, 3 0 1


87
Annexure 10
Tool
Baseline Proforma
Instruction: The investigator places a tick mark () in the space provided
against the relevant answer.
1. Age (in years)
1.1 21 30 [ ]
1.2 31 40 [ ]
1.3 41 50 [ ]
1.4 51 60 [ ]
1.5 > 60 [ ]
2. Educational qualification
2.1 Illiterate [ ]
2.2 Primary education [ ]
2.3 Secondary education [ ]
2.4 Graduate [ ]
2.5 Postgraduate [ ]
2.6 Professional [ ]
3. Occupation
3.1 Unemployed [ ]
3.2 Employed [ ]
3.3 Professional [ ]
3.4 Self-employed [ ]
4. Surgical procedure done
4.1 Laparotomy [ ]
4.2 Hysterectomy [ ]
4.3 Caesarean section [ ]
4.4 Any other [ ]
5. Have you undergone any surgery in the past?
5.1 Yes [ ]
5.2 No [ ]

88
6. Have you received any type of analgesia or anaesthesia in the past?
6.1 Yes [ ]
6.2 No [ ]
7. Have you had any pain relief method other than medications for pain in
the past?
7.1 Yes [ ]
7.2 No [ ]
8. If yes, type of therapy
8.1 Acupuncture [ ]
8.2 Traditional massage [ ]
8.3 Aroma therapy [ ]
8.4 Acupressure [ ]
8.5 Yoga [ ]
8.6 Music therapy [ ]

89
Numerical Rating Scale for Pain
Instruction
Please place a tick mark according to the level of your pain on the
scale given below.
XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX
0 1 2 3 4 5 6 7 8 9 10

0 No pain
1 3 Mild pain
4 6 Moderate pain
7 9 Severe pain
10 Worst pain possible

90
Chart to Monitor Vital Parameters
Blood pressure Pulse
No.
Before foot
massage
Immediately
after foot
massage
10 minutes
after foot
massage
Before foot
massage
Immediately
after foot
massage
10 minutes
after foot
massage
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

91
Observation Checklist for Objective Assessment of Pain among
Postoperative Abdominal Surgery Patients
The investigator observes the behaviour responses of the client and
places a tick mark () in the appropriate column.
Sl.
No. Behaviour response Yes No
1. Remains restless in bed
2. Sleeps
3. Awake and relaxed
4. Expresses pain verbally
5. Holds breath/shallow breath
6. Groans with pain
7. Guards operated site
8. Holds cough
9. Shows painful facial expression
10. Unwilling to change position
11. Frowns
12. Clenches the fist
13. Expresses irritation and intolerance
14. Sheds tears
15. Asks for analgesics

Maximum score = 15; Minimum score = 0
Grading
Score Level of pain
0 3 Mild
4 7 Moderate
8 11 Severe
12 15 Unbearable

92
Annexure 11

Criteria Checklist for Validation of the Tools
Instructions: Please review the items in the tool and give your suggestions
regarding accuracy, relevance and appropriateness of the content. Kindly
place a tick mark () in the appropriate column. If there are any suggestions
or comments please mention in the Remarks column.
Q. No. Agree Disagree Remarks
Baseline Proforma
1.
2.
3.
4.
5.
6.
7.
8.
Observation Checklist for Objective Assessment of Pain among Postoperative
Abdominal Surgery Patients
1.
2.
3.
4.
5.

93
Q. No. Agree Disagree Remarks
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.


94

Annexure 12
List of validators
1. Mrs. Ratna Prakash
Principal
Manipal College of Nursing

2. Rev. Sr. Rubeena, SD
Principal
Samaritan College of Nursing
Aluva, Ernakulam

3. Mrs. Elsa Sanatombi Devi
Associate Professor
Manipal College of Nursing

4. Sr. Lucy Rodrigues
Principal
St. Anns College of Nursing

5. Sr. Ann Rose DAlmeida
Principal
Athena College of Nursing

6. Mrs. Asha DSa
Lecturer
St. Anns College of Nursing

7. Mrs. Larissa Martha Sams
Principal
Laxmi College of Nursing

8. Mrs. Diana Lobo
Lecturer
Laxmi College of Nursing

9. Mrs. B. V. Kathyayani
Principal
M. V. Shetty IHS

10. Mrs. Molly Pinto
Assistant Professor
Nitte Usha Institute of Nursing
Sciences

11. Mr. Kanagaraj
HOD, Dept. of Physiotherapy
Father Muller Medical College
Hospital




95
Annexure 13
Photographs
























Preparation of patient
















Observational assessment of pain


96



















Patient recording pain level on a numerical pain scale




















Foot massage Step 1 Low stroke friction movement

97



















Foot massage Step 2 Effleurage


















Foot massage Step 3 Low stroke manipulation below the toes



98

















Foot massage Step 4 Thumb rotation


99
Annexure 14
Statistical formulae used in the analysis of data
1. Spearman Rank Correlation Coefficient

=

) 1 (
6
1
2
2
n n
d

2. Chi square with Yates correction

2
=
) )( )( )( (
)
2
| (|
2
d b c a d c b a
N
bc ab N
+ + + +


3. Paired t test
t=
n
d
d
2

n
d
d

=
n
d d
d


=
2
) (

4. Standard deviation
SD =
n
x x

2
) (




100