If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Post Graduate Nursing Program, Faculty of Nursing, Hasanuddin University, Jl. Perintis Kemerdekaan KM 10, Tamalanrea, Makassar, 90245, IndonesiaWest Sulawesi Regional Hospital, At R.E Marthadinata Street, West Sulawesi, 91512, Indonesia
To determine the effect of foot massage on reducing blood pressure in patients with intradialytic hypertension.
Method
This study is a randomized controlled trial (RCT). Subjects were 32 hemodialyses (HD) patients randomly allocated into two groups: the control group and the intervention group. Foot massage was performed three times in intradialytic phase for 5–10 min in the first, second, and third HD hours. Measurement of blood pressure (BP) used portable sphygmomanometer. The measurement was conducted every hour.
Results
There is a different effect of foot massage on systolic and diastole blood pressure between the control group and intervention group with p < 0.05. The difference in median value for systolic blood pressure between the two groups was 25 mmHg, and diastole was 10 mmHg.
Conclusion
The foot massage is beneficial in controlling intradialytic hypertension and can be applied in the management of hemodialysis patients by nurses.
Patients with chronic kidney disease (CKD) have a relatively high mortality rate. Disclosed in Hallan et al. that the countries in Asia, Europe, and America have a high incidence of CKD with a percentage of 15%, mainly in adults.
Data from the World Health Organization in 2013 put the number of patients with CKD in the world exceeds 500 million, with 1.5 million people undergoing hemodialysis (HD).
As the high prevalence of HD patients keep increasing, it is necessary to focus on one of the most common cardiovascular complications during HD process, the intradialytic hypertension (IDH). (see Fig. 1)
Intradialytic hypertension is defined as 10 mmHg increase in systolic blood pressure which occurs during HD period. The incidence of IDH is 15% of all HD patient population.
The age factor, interdialytic weight gain (IDWG), urea reduction ratio (URR), residual renal function (RRF), duration of HD, psychological conditions, and the amount of anti-hypertensive drugs are allegedly associated with the incidence of IDH.
In HD services, lowering quick blood (Qb) and ultrafiltration (Uf) by stopping the HD, are taken as a precaution to the intradialytic hypertension risk. Because of that, the HD process is not performed as prescribed (inadequate). If IDH is not resolved, it can cause seizures, nausea, cramps, chest pain, loss of consciousness, and headache.
Therefore, it is necessary to apply complementary therapy in reducing complications and improving the quality of HD care so that patients can be freed from the symptoms of uremia.
With the achievement of adequacy, HD nurse can ensure the comfort of the patients as a step to improve the quality of health care and nursing intervention. One of the nursing intervention could be implemented by nurses during HD is foot massage.
Foot massage has been widely used over the last decade in health care and has been known to improve peripheral circulation, mechanically assist the displacement of venous and lymphatic fluid, and manipulate nerve, blood vessels, and cells in the exchange network.
Analysis of Nursing Clinical Practice in Congestive Heart Failure (CHF) Patients with Intervention of Innovation of Back Massage to Weak with Use of INNO. Digital Repository.
The effect of foot massage to control IDH has not been studied, even though based on the theory, with controlled IDH, the risk of life-threatening complications can be minimized. Therefore, the researchers intend to determine the effect of foot massage on intradialytic blood pressure reduction.
2. Method
2.1 Design
This study was conducted in 2019 at Hasanuddin University Hospital, South Sulawesi, Indonesia. Subjects were patients with CKD who were undergoing HD in the HD unit and had intradialytic hypertension. The sampling technique in this study used simple random sampling.
Randomization was conducted by entering the name of the patient based on the day's schedule of HD into a sealed envelope and a draw to determine the intervention group and the control group was conducted. The researchers also used medical records to determine the prognosis of subjects.
2.2 Recruitment of subjects
Thirty-two subjects were recruited and randomized into two groups, the control group, and the intervention group based on their scheduled HD. A flowchart of the participants in this study is provided in Fig. 1. The inclusion criteria of subjects were patients with CKD or end-stage renal disease (ESRD), intradialytic hypertension, ≥ 18 years old, compos mentis, HD > 3 months with a frequency of three times a week, no change in the prescription of HD therapy (Qb, Uf, fluid withdrawal target UFg, and extended dialysis for 4 h), interdialytic weight gain (IDWG) 1–4 Kg, and have no sleeping disorder the previous night. Clinical characteristics of respondents with IDH other than increasing SBP >10 mmHg per HD session is palpitations, headaches, aches, and also accompanied by dry skin appear blackish due to uremia syndrome.
The exclusion criteria were patients with an unrecommended condition by the nurses due to shortness of breath, femoral access, peripheral vascular disorders, and mental disorders. The termination in the HD process because of unstable patient conditions was considered to be dropped out of the study. The initial data of patients were collected in three days by tracing medical record information to determine the demographic data. After the initial data collected, foot massage intervention was applied to the intervention group based on their scheduled HD.
2.3 Ethical considerations
The protocol of this study was approved by the Health Research Ethics Commission of the Medical Faculty of Hasanuddin University Indonesia with recommendations number: 412/UN4.6.4.5.31/PP36/2019. All subjects signed informed consents before participating in this study.
2.4 Measurement of blood pressure
Measurement of blood pressure (BP) used portable sphygmomanometer ABN (Padalarang, Indonesia) and a Littmann Classic Stethoscope (3 M Science, St. Paul, Minnesota, USA). Blood pressure measurements performed on pre HD, the 1st, 2nd, an 3rd hours, and post HD.
2.5 Foot massage intervention
Foot massage intervention was performed by researchers who had been certified in performing foot massage after 32 h of training. Foot massage was conducted on the 1st, 2nd, and 3rd hours for 10 min (started at 51st – 60th minutes) followed by observation of blood pressure. Foot massage procedure was adapted from Joachim study and developed by Puthusseril
Place patients in a quiet place while conducting feet inspection to check for foot massage contraindications,
3.
Give a soft touch on both feet, then start with rubbing the right foot from the inside to the outside direction using the palm of hand for ±15 s,
4.
Rotate the ankle clockwise, and then in the opposite direction three times each for ±15 s,
5.
Move the toe back and forth three times for ±15 s,
6.
Move feet to the front and back three times each for ±15 s (both thumbs press the soles and the rest of the fingers on the back foot for ± 15 s)
7.
The left hand support the ankle, and the right-hand massage toes for ±15 s,
8.
Grasp the back of the foot, apply gentle massage for ±15 s,
9.
Support foot, apply pressure and massage on the spaces between with up and down movement for ±15 s,
10.
The right hand hold the toe, and the left hand gently put pressure on the soles for ±15 s,
11.
Do the same on the left foot,
12.
End the intervention by grasping the patient's feet and let it relax for 2 s.
2.6 Statistical analysis
The variables were analyzed using descriptive statistics after the process of data entry and data tabulation. The frequency distribution was tested using Shapiro Wilk using SPSS 24.0 for Windows along with Friedman test and post hoc Wilcoxon test. The comparison between the intervention and control groups used the Mann Whitney test. P ≤ 0.05 is a threshold of significance or degree of freedom (df) with 95% confidence intervals (CI).
3. Results
Table 1 shows the demographic characteristics of subjects. The distribution of subjects based on gender is dominated by women (68.8%). The same number of subjects, i.e., 9 (28.2%) are in the 51–60 year age range and 201–300 times of HD. Almost all subjects (84.4%) consumes the two types of anti-hypertensive drugs. For an interdialytic weight gain, about 14 people (43.8%) of the subjects increased by 2 kg. Half of the subjects have quick target blood of 230 ml/min, and almost half (43.8%) of the subjects have 2 L target ultrafiltration. Homogeneity test shown that each characteristic variables from both groups were homogenic. In addition, p value of those variables were >0,05.
Table 1The frequency distribution based on demographic data of respondents.
Characteristics
Control group (n = 16)
Intervention group (n = 16)
p *
Mean ± SD
Min-Maks
Mean ± SD
Min-Maks
Age
44.75 + 16279
47.06 + 16 192
0.836
Characteristics
N
%
N
%
p **
Sex
Man
5
31.3
5
31.3
1.000
Woman
11
68.8
11
68.8
HD to
<100
2
12.5
3
18.8
0.312
100–200
5
31.3
2
12.5
201–300
5
31.3
4
25.0
301–400
2
12.5
3
18.8
401–500
0
0
1
6.3
>500
2
12.5
3
18.8
Anti-hypertensive Drugs
Two types
15
93.8
12
75.0
0.154
>3 types
1
6.3
4
25.0
Intradialytic weight gain (IDWG)
1 Kg
4
25.0
4
25.0
1.000
2 Kg
7
43.8
7
43.8
3 Kg
4
25.0
4
25.0
4 Kg
1
6.3
1
6.3
Quick Blood (Qb)
220 ml/min
1
6.3
1
6.3
1.000
230 ml/min
8
50.0
8
50.0
240 ml/min
4
25.0
4
25.0
250 ml/min
2
12.5
2
12.5
280 ml/min
1
6.3
1
6.3
Ultrafiltration goals
1 L
4
25.0
4
25.0
1.000
2 L
7
43.8
7
43.8
3 L
5
31.3
5
31.3
SD (standard deviation), *Mann U Withney test, ** Test of homogeneity of Variances, Chi Square.
Table 2 shows that there is a significant difference of systolic blood pressure between the control group and the intervention group after the first intervention in the 1st hour of HD to post HD (p < 0.05). The difference in diastolic blood pressure is found in the 2nd hour of HD to post HD (p < 0.05). Median range value for systolic blood pressure in both groups during the pre HD increased by 20 mmHg each in the first hour of HD. After the foot massage, the first visible difference in systolic blood pressure is observed 10 mmHg at the intervention group, while the control group increased by 15 mmHg in the second hour. By the application of foot massage every hour, the median value in the intervention group remained stable at 140 mmHg in the 2nd hour of HD to post HD or only increase 10 mmHg of systolic blood pressure compared to pre HD. In the control group, the systolic blood pressure is 175 mmHg in the 2nd and 3rd hours of HD, and in the post HD, the blood pressure declined to 165 mm Hg or increased 25 mmHg of systolic blood pressure compared to pre HD. It can be calculated that the systolic blood pressure difference between the control group and the intervention group is 15 mmHg. The diastolic blood pressure in the intervention group is stable at 80 mmHg from the 1st hour HD to post HD — no change in diastolic blood pressure in the intervention group during the hourly application of foot massage. A different result is observed in the control group with the diastolic blood pressure increase of 10 mmHg–90 mmHg at the post HD.
Table 2Differences in median value (percentile) between the control group and the intervention group.
Variables
pre HD
1st hour
2nd hour
3rd hour
Post HD
Median (min-max)
Median (min-max)
Median (min-max)
Median (min-max)
Median (min-max)
Control (N = 16)
Intervention (N = 16)
p *
Control (N = 16)
Intervention (N = 16)
p *
Control (N = 16)
Intervention (N = 16)
p *
Control (N = 16)
Intervention (N = 16)
p *
Control (N = 16)
Intervention (N = 16)
p *
Systolic
140 (130–180)
130 (120–180)
0.340
160 (150–210)
150 (140–200)
0.022
175 (160–220)
140 (130–200)
0.000
175 (150–220)
140 (130–190)
0.000
165 (150–210)
140 (130–170)
0.000
Diastolic
80 (70–90)
80 (60–90)
0.114
90 (80–120)
85 (70–110)
0.114
90 (80–100)
80 (60–100)
0.003
90 (80–120)
80 (70–90)
0.000
90 (90–100)
80 (70–90)
0.001
*p < 0.05. HD. *Differences between groups using the Mann Whitney test (data is not normally distributed). Blood pressure measurement was performed on pre HD, 1st hour, 2nd hour, 3rd hour, and post HD.
p < 0:05. HD. * Difference between the groups using the Friedman test (data is not normally distributed). Blood pressure measurement was performed on pre HD, 1sthour, 2nd hour, 3rd hour, and post HD.
Median (min-max)
Median (min-max)
Median (min-max)
Median (min-max)
Median (min-max)
The control group (n = 16)
Systolic
140
(130–180)
160
(150–210)
175
(160–220)
175
(150–220)
165
(150–210)
0.000
Diastolic
85
(70–90)
90
(80–120)
90
(80–120)
90
(80–120)
90
(80–100)
0.000
The intervention group (n = 16)
Systolic
130
(120–180)
150
(140–200)
140
(130–200)
140
(130–190)
140
(130–170)
0.000
Diastolic
80
(60–90)
85
(70–100)
80
(60–100)
80
(70–90)
80
(70–90)
0.038
a p < 0:05. HD. * Difference between the groups using the Friedman test (data is not normally distributed). Blood pressure measurement was performed on pre HD, 1sthour, 2nd hour, 3rd hour, and post HD.
The aim of this study is to determine the effect of foot massage on intradialytic blood pressure reduction. Foot massage intervention was significantly effective in lowering blood pressure, both systolic and diastolic. This reduction was higher than a study by Ju et al. that found a significant decrease in blood pressure by 15 mmHg for systolic and 4 mmHg for diastolic.
However, the decrease of diastolic blood pressure in this study occurred only once in the 2nd hour and remained stable until post HD. The similar intervention was carried out by Malekshahi, Aryamanesh, & Fallahi by investigating the application of foot massage for 10 min, three times, during HD in patients with ESRD.
The duration of the 10-min foot massage can give a significant change in blood pressure. A study by Moyle et al. showed significant results in lowering systolic and diastolic blood pressure with the same duration.
During HD, the withdrawal of excess fluid that causes the Renin-Angiotensin System (RAS) induced peripheral resistance and thus, an increase in blood pressure occurs.
The mechanism of lowering blood pressure with foot massage occurs through the activation of the parasympathetic nervous system during the massage that induces the relaxation response.
foot massage can improve muscle tone and provide a relaxing effect. The pressures given on the feet will stimulate the peripheral nervous system through the neural grooves and go toward the central nervous system and stimulate the adrenal hormones to make vessels dilate and calm the body (relaxation). Foot massage is an intervention that can be performed by nurses, as Joachim has compiled simple steps to make it easier to be conducted by nurses.
On the research process, HD nurses on duty have learned FM techniques, indications, contraindications, as well as applying them to research respondents. To carry out foot massage in daily routine requires at least 10 min every hour or a total of 30–40 min in a HD session for each IDH patient. The HD unit in this study had 3-4 nurses for each HD session, so possible to apply foot massage because not all patients experience IDH.
It was noted from the subject statement that foot massage intervention had a soothing effect on them. It will be beneficial to learn more about the nursing comfort plan in nursing education. The foot massage is one of the nursing interventions for patients with CKD to improve the quality of HD therapy. Another nursing education to prevent the poor prognosis of IDH and primary hypertension can also be applied salt-reduction and efficacy-maintenance.
Patients will feel comfortable and give a pleasant impression during the therapy session, as their health condition is getting better. Patient comfort is an indicator of the success of hospital services and development. Initially there were respondents who did not believe that foot massage can reduce IDH, but after knowing the results of the blood pressure measurements on hourly observations, respondents felt that FM provided was very comfortable, make it easy to sleep and enjoy the HD process. Some even involve their families to learn FM movements so that they can be done independently.
5. Conclusions
This study showed that foot massage for 10 min every hour for 4 h of HD resulted in improving systole and diastole blood pressure on people with intradialytic hypertension during HD.
Strengths and weaknesses of the study
FM is an efficient, easy, inexpensive, no-risk, simple but proven intervention for its benefits in controlling IDH. Controlling IDH also means that the risk of complications during HD can be suppressed. But the majority of respondents in this study were female so their effects could not be generalized for men, and blood pressure measurements were carried out without similiar on just one leg.
Declaration of competing interest
The authors declare that the publication of this paper has no conflict of interests.
Acknowledgments
Authors would like to thank the Human Resource Development Center of the Indonesian Ministry of Health for funding this project and the Hemodialyses Unit of Hasanuddin University Hospital, Indonesia.
References
Hallan S.I.
Matsushita K.
Sang Y.
et al.
Age and association of kidney measures with mortality and end-stage renal disease.
Analysis of Nursing Clinical Practice in Congestive Heart Failure (CHF) Patients with Intervention of Innovation of Back Massage to Weak with Use of INNO. Digital Repository.
30122-6&id=gr1.jpg){kind=link}