© Touch for Health Kinesiology Association Journal (year 2001)

Effects of Specific Massage Therapy on Chronic Pain inInstitutionalized Elderly;

Meridian Channel Stimulation(adapted from Meridian Massage, "Touch For Health" Synthesis)

and Hand and Foot Reflexology Introductionby Norma E. Harnack, RN, BSN

Founder MASSAGE AND ENERGY CONNECTION COLLEGE OF APPLICATION7159 Manchester, Maplewood, MO 63143. USA.

Phone: (314) 647-0903 e-mail: meccatfhts'primary.net

Abstract. Little research, in regard to_chronic pain and painmanagement, is doneon the elderly population due to a lack of interest on the natural decline thataccompanies old age and the end stages of life. Our elderly population has multiplemedical conditions that can cause and contribute to chronic pain. The conventionaltreatment, of chronic pain in the elderly, often includes such interventions asmedications, moist heat and physical therapy. This approach produces a less thandesirable effect because of the side effects produced by mixing life supportingmedications with pain medications. Physical therapy treatments are often limiteddue to cost factors although the conditions, which warrant PT, are often chronicand long term. Being institutionalized, as in a nursing home, increases themoribund effect on the elderly population and the need for special consideration.Using more traditional (sometimes labeled complementary or alternative)approaches to pain management and the treatment of chronic pain must be exploredto maximize the quality of life in the elderly and to minimize complications fromdrug reactions as well.

Purpose

The purpose of our study was to examine theeffects of Meridian Channel Stimulation(adapted from Meridian Massage from "TouchFor Health" Synthesis) and Hand and FootReflexology on perceptions of chronic painamong institutionalized elderly.This was a pilot study, conducted byRegistered Nurses and funded by the UnitedWay (St. Louis, MO). This controlled clinicaltrial of massage versus conversation in 18institutionalized elderly residents with chronicpain. A baseline assessment of pain and moodwere obtained two weeks prior to subjectsbeing randomly assigned to one of two groupsof either conversation or massage. Subjectsreceived the intervention (massage orconversation) in the privacy of their room.Subjects wore comfortable clothing but no

socks or shoes. The intervention wasadministered by independent nurses .who werenot employees of the nursing home; and whowere trained in the massage techniques at theMassage & Energy Connection College ofApplications (MECCA). The primary focus ofthe conversations will be reminiscence andsocial interaction.Goalsl.To test the hypothesis that nursing home

residents receiving Meridian ChannelStimulation and Hand and FootReflexology will effect significant reductionin pain perception as measured by adecrease in pain as measured on anobjective pain rating tool (form) ascompared to the nursing home residentswho participate in a conversation group.

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2.To test the hypothesis that receivingMeridian Channel Stimulation and Handand Foot Reflexology effect decreases inpain perception as measured by a reductionin the use of pain medication as comparedto the nursing home residents whoparticipate in a conversation group.

3.To inspire, by example, the staff of thenursing home to replicate the treatment,Meridian Channel Stimulation and Handand Foot Reflexology, on all eligiblenursing horne residents.

BackgroundMassage has been used for pain relief andhealing by various cultures. It is cited as theintervention of choice in several nursingreferences. Other disciplines, such as physicaltherapy also include massage for pain relief.The major role of massage is to improve thecirculation through touch, pressure andstimulation of proprioceptors and receptors ofthe skin and underlying tissues. There is alsomechanical effect upon the superficial venousand lymphatic channels providing mechanicaland reflex pain relief (Jacobs, 1959; Sims,1986; Scull, 1945).There are numerous studies using massagethat focus on pain relief with chronic diseases.Massage has been used with cancer patients,AIDS patients and burn victims. "Slowstroke" massage was studied in healthy middleaged women and showed a decreased level ofanxiety and subjects perceived it as relaxing.(Longworth, 1982)The use of the term massage is considered amanipulation often associated with the act ofrubbing the skin. However, any tactilestimulation within two inches of the skin willstimulate the proprioceptors on the surface ofthe skin causing a measurable change ormanipulation in the response. Because of thefrailty of the population and the physicallimitations often associated with the elderly wewanted to utilize the least aggressive mode ofmanipulation. Using the acupuncture channelsor meridians that already have a specific,established pattern or flow was chosen as themost effective and least invasive type ofmassage.Meridians have been used in East Asianmedicine for centuries. The Meridian Channel

Stimulation is believed to have effect throughthe Meridians in the body. Meridians arereported as specific energy pathways that runthroughout the body and indicate the flow ofenergy. (Austin, 1972, Thie, 1997)Acupuncture points are considered to bepoints of electrical resistance running alongthese energy pathways (Meridians).Theoretically when disease or pain occurs,there is a disruption in this energy pattern andorganization. This disruption may be causedby an excess or a deficiency resulting in ablockage or loss of energy. It is hypothesizedthat stimulation of either the meridians oracupuncture points may improve energy flowand affect organs quite distant from the areabeing stimulated (Harnack, 1990).Specifically, stimulation of the meridiansenhances circulation of lymph and blood andbrings about energy balance and optimalfunction, which gives the patient a sense ofrelaxation and increases the patient's energylevel (Gottesman, 1992; Hare, 1988).

Reflexology is an acupressure style thatinvolves pressing points on the hand and footthat relate to other parts of the body or internalorgans. A reflexology chart correlates thepoints of stimulation on the hands or feet toother parts of the body (Hare, 1988). It isbelieved that by applying pressure to theseareas, it is possible to effect a change toanother part of the body presumablypromoting well-being and relaxation (Griffith,1996). A study, completed on 52 post-surgical patients, using reflexology post-operatively found the amount of post-operative pain (determined by analgesic use)was reduced for up to 3 days followingreflexology treatment (Griffith, 1996).

Outcome AnalysisThis was a small pilot study. Subjects werefollowed for a period of 10 weeks. Severalassessment tools geared for use in the elderlypopulation were utilized to measure pain andmood. Assessments were taken at thebeginning of the study and at the end of thestudy. Pain surveys were completed twiceweekly for the first two weeks of the study toobtain a pre-treatment baseline, then fourtimes weekly during the intervention and oneadditional time 2 weeks after the interventionwas completed.

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The results indicated that both interventions(conversation and massage) were useful inlowering pain perception indicating the needfor further research on a larger group ofsubjects. The decrease in pain perception inboth the conversation and the massage groupsreinforce the premise that we all need social aswell as physical interaction.

The amount of decrease in pain was onlyslightly higher in the massage group indicatingthe need for further study to analyze theclinical effect of this type of massage in placeof pain medication in the form of drugs. Twoweeks post intervention the pain perception inthe conversation group was equal to thebaseline established prior to the interventions.The effect of massage therapy was onlyslightly different from the baseline establishedprior to the interventions.The staff of the nursing home was notinspired by our efforts. They were much toobusy providing the "routine" care of theresidents and at times considered us (thenurses conducting the study) an interference.The attitude of the nursing staff made datacollecting more difficult. Because the staffnurses were dedicated to routines to maketheir workload less hectic, our request towithhold pain medication unless the patientrequested it was ignored. There was noincentive or bonus to making an additionaltherapy available because there was neithertime nor staff to administer it.Working With The Energy MeridianSystem"Meridian Massage" is a term readilyassociated with the Touch For HealthSynthesis. Students routinely receive thisinformation and practice the application in theLevel 1 Touch For Health class. Inresearching the idea of using the establishedmeridian flow as a technique for reducing painperception and improving mood in the nursinghome residents several questions requiredclarification.

1. Was there any possibility the procedurewould hurt or cause more pain to thesubjects?

The sequence of the Horary or MeridianWheel (or Clock) is the accepted pattern ofenergy flow in acupuncture. (Austin,

1972, Thie, 1997). There are no reportedfindings that indicate using this energyflow pattern (following the timesequencing) is in any way disruptive. Itwas also noted that actually touching thesubjects was not entirely necessary giventhat the desired effect could be realizedwithout ever actually physically touchingthe subject (Thie, 1997).

2. Would the subjects be required to performin any specific way to receive the massage(tum over, stand up etc.)?

It was decided that if unable to turn ontheir sides subjects could remain supine orseated and the nurse would reach underthem to stimulate the meridian.

3. Would the pressure of the touch causepain?Since it was the direction or pattern of themassage that was crucial, minimal touchcould be used. It was desirable to touchthe beginnings and ends of the meridians,however it was not crucial.

Adaptation of the Meridian Massagefrom Touch For Health

The nurses recruited for this study wererequired to take a Level 1 Touch for Healthclass. This was to help them gain someknowledge regarding acupuncture and thesystem they were going to employ with thenursing home residents.

This particular method of utilizing themeridian pathways was first described byRichard Harnack in a workshop he developed,called The Body Energy, to acquaint peoplewith meridians and Touch For Health. Thepattern, adapted for this study, utilizes sixbasic Energy meridians: Stomach, Spleen,Bladder, Kidney, Gall Bladder andLiver. Utilizing these particular meridiansallowed us to cover the front, back and sidesof the body while following the basic time ofday sequencing. Thus, we could encourageand influence the energy flow of the 12meridians by establishing the direction offlow. as indicated by the Meridian Wheel, theestablished pattern.

To help insure our success at meeting the goalof pain reduction and mood enhancing we

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worked with the system in three ways:Scanning, Tracing and Brushing (theEnergy Shower). Each method has aspecific use and advantage.ScanningScanning involves basic awareness of theenergy of the body. Utilizing this as the firstcontact heightened the awareness of both thenurse and the patient. It is not necessary to tryand interpret what you or the subject may feeland it is important not to become discouragedif you have difficulty deciding that you feelanything.

Procedure: Beginning at the head, mentallydivide the face into halves. From the hairlinemove your hand down to the shoulder.Slowly, with hand outstretched, move downtoward the fingers then back toward the torso.From the shoulder use both hands to scandown the side of the body to the foot thenback up the front of the body to the shoulder.Repeat on the opposite side. Repeat the entiresequence three times. This is a very slowmovement.TracingTracing the Energy System involves lightlytouching the body with a tracing motion whilemoving your hands in the same direction ofthe flow of the Scanning technique. Thismethod can also be done just above the body,in case the person is ticklish or sensitive.The main use of the Tracing technique is toincrease the energy flow in the system. It hasthe effects of increasing both energy andrelaxation. The speed used to do this can bevaried. If you move slowly the greater therelaxation seems to be, while the fastermovement seems to energize

Energy ShowerTo do the Energy Shower you touchthe body using a continuous brushingand scooping motion following thepattern described below:

1. Following the diagrams above start at thebeginning of the stomach meridian, brush inthe direction of the meridian (down the body)to the foot to the 2nd toe. Hold the tip of the2nd toe about 2 seconds.2. Hold at the nail root of the big toe on the

. .side closest to the middle of the body for twoseconds then brush upward along the inside ofthe foot curving upward in front of the ankle;continuing up the leg just behind the shin bone(tibia), curve slightly forward at the knee andcontinue along the inside of the thigh up theabdomen to the outside the chest toward thearm pit.3. From the arrn pit, brush down the inside ofthe arm to the palm of the hand.4. BlUShup the back hand and arm to the ear.5. Starting at the inner corner of the eye abovethe eyebrow, press firmly on these points fortwo seconds then brush over the top of theskull, down the back of the head, down theneck move in close along the spine down tothe lower lumbars, following the gluteal foldoutward. Return to the shoulder and brush outtowards the edge of the shoulder, downthrough the middle of the buttocks, down theback of the thigh, to the back of- the knee,following the curve of the calf outside downalong the outside of the foot and end at theoutside nail root of the little toe. Hold the littletoe for two seconds.6. Begin on the ball of the foot, brushupwards following the arch of the foot up andinside; continue back behind the ankle makinga small circle, then up the inside of the legpassing on either side of the pubic bone andnavel. At the base of the sternum, flare outslightly and continues on either side of thesternum ending just below the collar bone.Hold the notches at the collar bone for twoseconds.7. From the top of the shoulder brush downthe inside of the arm to the palm of the hand.

8. BlUShup the back of the arm to the ear.

9. Begin at the outer corner of the eye, brushdown and back toward the opening of the ear,make a circle forward then back behind theear. Continue brushing forward toward themid-point of the eyebrow (about one finger'swidth above the eyebrow) continuing backover the top of the skull along the outsidedown to the back of the shoulders. From theshoulders brush forward on the chest andback under the arms, follow the curve of thechest back at the waist, brush forward on thehips. Continue down the outside mid-point of

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the thigh and lower leg onto the 4th toe. Holdthe 4th for two seconds.10. Begin on the lateral side of the nail root ofthe big toe (hold for two seconds) then brushup the foot in front of the ankle on the insideof the leg. Follow the inside edge of the shinbone (tibia) then slightly back at the knee,upward on the inside of the thigh, followingthe curve of the hips back and up to the side ofthe abdomen, ending on the rib cage in linewith the nipple (in the sixth intercostal space).11. Brush up the rib cage and down the insideof the rum to the palm of the hand.12. Brush up the back of the arm to the ear.Repeat the sequence at least threetimes. Sequence may be repeated asoften as needed.References

Austin, Mary (1972), The Textbook ofAcupuncture Therapy, ASI PublishersInc.

Ferrell, B. (1995). Pain evaluation andmanagement in the nursing home.American College of Physicians, 68 1-687.

Ferrell, B. (1991). Pain management inelderly people. Journal of AmericanGeriatrics Society. 39ill, 64-72.

Fenell, B., Ferrell, B., & Rivera, L. (1995).Pain in cognitively impaired nursinghome patients. Journal of Pain andSymptom Management, 10(8), 591-598.

FelTell-TOlTY,A. & Glick, O. (1993). The useof therapeutic massage as a nursingintervention to modify anxiety and theperception of cancer pain. Can c e rNursing, 16(i), 93-101.

Field, T., Peck, M., Krugman, S., Tuchel,T., Schanberg, S., Kuhn, C. & Burman,I. (1998). Burn injuries benefit frommassage therapy. Journal of Burn Care& Rehabilitation. 19(3), 241-244.

Fraser, J. & Ross, J. (1993). Psycho-physiological effects of back massage onelderly institutionalized patients. Journalof Advanced Nursing 18, 238-.245.

Harnack, Norma (1990),Getting in Touchwith Your Patients. Touch For HealthInternational Journal, 10.....64-69

Ironson, G. & Field, T. (1996). Massagetherapy is associated with enhancement ofthe immune system's cytotoxic capacity.International Journal of Neuroscience,84, 205-2 17.

Jacobs, M. (1959). Massage for the relief ofpain: Anatomical and physiologicalconsiderations. The Physical TherapyReview, 40(2), 93-98.

Longworth, J. (1982). Psychophysiologicaleffects of slow stroke back massage innormotensive females. Advances inNursing Science, (July), 44-6 I.

Thie, John F., D.C., (1997) To.uch ForHealth, DeVons Publishers

Westwater,1.,Marshall,B.,(l982) Color ForHealth, THEnterprise

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