Reducing Patient's Pain with Post Coronary Artery Bypass Graft (CABG) by Performing Foot Massage: A Systematic Review

Abstract


Coronary Artery Bypass Surgery (CABG) is an
interventional procedure performed to restore coronary perfusion by constructing a bypass on blocked coronary arteries [1], [2].
CABG is considered a compelling procedure to improve the quality of life among patients with cardiovascular issues, both for their physical and mental wellness [3]. CABG surgery is generally suggested due to failure in the previous PCI procedure, impracticability to utilize the coronary arteries in the PCI procedure due to its anatomical structures, or immediate need to do surgical repair [4]. CABG has been widely performed in the clinical practice area, and it has been confirmed by the high incidence rate.
The high incidence of CABG procedure is reported worldwide and also in Indonesia.
CABG procedures are performed at an average of 44 per 100,000 individuals globally [5]. In Indonesia, CABG is the highest number of cardiac surgery, with 516 cases in 2020 based on the annual report of the Harapan Kita Heart Hospital and Blood Vessel Center Hospital [6]. Unfortunately, this high incidence of CABG is not the only issue that requires further attention.
Pain is a typical issue undergone by the majority of patients after the CABG procedure [7]. Postoperative CABG pain occurs in the majority of patients, whereas 75% of patients have reported postoperative pain [8]. On the fourth day after the CABG procedure, 7% and 67% of patients experienced severe and mild to moderate pain, respectively. Only 26% of patients reported no pain symptoms after the surgery [9]. Pain among patients who undergone CABG surgery can persist for one year after the procedure [10].  [18]. Further studies are necessary to obtain a shred of stronger scientific evidence to support foot massage interventions and enrich knowledge in this field [19]. Hence, this study was conducted to explore the effect of foot massage on pain levels among postoperative CABG patients.

Eligibility Criteria
This study employed a systematic review method that discussed the effect of foot

Information Source
Articles were systematically discovered through five journal databases, including ProQuest, ScienceDirect, Google Scholar, ClinicalKey Nursing, and Sage Journal.

Searching Strategy
The literature search was performed using the boolean operators (AND, OR, NOT) and was formulated based on clinical questions.
Boolean operators in this literature search were written as "foot massage OR foot reflexology AND Pain Level AND CABG".

PRISMA (Preferred Reporting Items for
Systematic Review and Meta-Analysis) was employed as a protocol to create a systematic, transparent, and complete analysis. Initially, 11,578 articles were discovered from the journal databases. Five eligible articles filtered by the screening and assessment process were eventually included in the final analysis. The article selection and screening process using PRISMA is shown in Figure 1.

All articles included in the analysis
However, one study conducted foot massage only on the left foot [22]. The frequency of foot massage intervention was also relatively different. One study delivered foot massage intervention only once on the second day after surgery [22]. Another study performed foot massages twice, on the second and fifth day after the surgery [21]. Further, a study explained that foot massages were given in three consecutive days after the surgery, without mentioning which day specifically [24]. A study conducted foot massage intervention in two sessions per day between morning and night [20]. Additionally, a study gave foot massage in three sessions: on the second, third, and fourth day after the surgery [23].  The foot massage was provided between the second and fifth postoperative day for 10 minutes on each foot in a total duration of 20 minutes.
The foot massage was performed in the following steps: (1) lubricating the sole with light oil, (2) creating friction of the sole with the help of the palm by grasping the foot with one hand at the ankle, (3) stretching of the knuckles with the right hand over the sole, (4) giving pressure on the reflex area with the tips of the thumbs of both hands over the entire sole of the foot, (5) creating friction on the instep and side of the foot and from the toes to the heel, (6) pressing the thumb near the heel with the fingertips and finally, (7) pressing the foot inward, grasping the foot between the heels, and pressing the center of the sole.
The experimental group experienced significant decreases in anxiety (p= 0.001), fatigue (p= 0.001), pain (p= 0.001), and increases in selfefficacy (p= 0.001) and also quality of life (p= 0.001). A 20-minute session of foot reflexology therapy was administered, 10 minutes for each foot in each patient. At the end of the procedure, VAS was used to reassess the pain level. On the third postoperative day, before the reflexology procedure, the VAS for foot reflexology was used to measure the pain outcome. On the fourth postoperative day, a VAS examination was performed before the foot reflexology intervention. At the end of the procedure, evaluation was conducted using VAS, STAI, and VASPS.

Author, Place, and Year of Publication
There were statistically significant differences in VAS mean scores on the second, third, and fourth postoperative days (p˂0.001) from both the test (before and after foot reflexology intervention) and the control group. Also, statistically significant differences in pain levels were discovered among postoperative patients in the test and control group on the second (p=0.002), third (p=0.001), and fourth day (p=0.001). Effleurage is a gliding movement on the superficial area done by providing lubrication to create a smooth rhythm of relaxation [26].
The foot massage performed on one side of the foot aimed to stimulate the left foot or lefthand reflex that is closely associated with the heart, which is also located on the left side of the body.
The most significant reduction in pain level was discovered in a study that performed two-foot massage sessions, on the second and fifth day after surgery. However, it is necessary to note that this study did not only use foot massage as an intervention in reducing pain outcomes. This study also provided educational sessions related to selfmanagement after surgery [21]. If only referring to the foot massage intervention, the most significant pain reduction outcomes were found in a study that performed threefoot massage sessions, on the second, third, and fourth days after surgery [23].

ACKNOWLEDGEMENT
We would like to express our deepest gratitude to all those who have contributed to the process of compiling this research.