Massage therapy for preventing pressure ulcers

  • Review
  • Intervention

Authors

  • Qinhong Zhang,

    1. The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang Province, China
  • Zhongren Sun,

    Corresponding author
    1. The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang Province, China
    • Zhongren Sun, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, No 24 Heping Road, Xiangfang District, Harbin, Heilongjiang Province, 150040, China. sunzhongren2011@163.com.

  • Jinhuan Yue

    1. The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang Province, China

Abstract

Background

Pressure ulcers affect approximately 10% of patients in hospitals and the elderly are at highest risk. Several studies have suggested that massage therapy may help to prevent the development of pressure ulcers, but these results are inconsistent.

Objectives

To assess the evidence for the effects of massage compared with placebo, standard care or other interventions for prevention of pressure ulcers in at-risk populations.

The review sought to answer the following questions:
Does massage reduce the incidence of pressure ulcers of any grade?
Is massage safe in the short- and long-term? If not, what are the adverse events associated with massage?

Search methods

We searched the Cochrane Wounds Group Specialised Register (8 January 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 1), Ovid MEDLINE (1946 to 8 January 2015), Ovid MEDLINE (In-Process Other Non-Indexed Citations 8 January 2015), Ovid EMBASE (1974 to 8 January 2015), and EBSCO CINAHL (1982 to 8 January 2015). We did not apply date or language restrictions.

Selection criteria

We planned to include all randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) that evaluated the effects of massage therapy for the prevention of pressure ulcers. Our primary outcome was the proportion of people developing a new pressure ulcer of any grade.

Data collection and analysis

Two review authors independently carried out trial selection. Disagreements were resolved by discussion.

Main results

No studies (RCTs or Q-RCTs) met the inclusion criteria. Therefore, neither a meta-analysis nor a narrative description of studies was possible.

Authors' conclusions

There are currently no studies eligible for inclusion in this review. It is, therefore, unclear whether massage therapy can prevent pressure ulcers.

Résumé scientifique

Massothérapie dans la prévention des plaies de pression

Contexte

Les plaies de pression touchent environ 10 % des patients hospitalisés, et les personnes âgées sont les plus à risque. Plusieurs études ont suggéré que la massothérapie pourrait aider à prévenir le développement des plaies de pression, mais ces résultats sont incohérents.

Objectifs

Évaluer les données probantes sur les effets du massage par rapport au placebo, aux soins standard ou à d'autres interventions pour la prévention des plaies de pression dans les populations à risque.

Cette revue a cherché à répondre aux questions suivantes :
Le massage réduit-il l'incidence des plaies de pression de tout grade ?
Le massage est-il sûr à court et à long terme ? Si non, quels sont les effets indésirables associés au massage ?

Stratégie de recherche documentaire

Nous avons effectué des recherches dans le registre spécialisé du groupe Cochrane sur les plaies et contusions (8 janvier 2015), le registre Cochrane des essais contrôlés (CENTRAL) (2015, numéro 1), Ovid MEDLINE (de 1946 au 8 janvier 2015), Ovid MEDLINE In-Process & Other Non-Indexed Citations (8 janvier 2015), Ovid EMBASE (de 1974 au 8 janvier 2015) et EBSCO CINAHL (de 1982 au 8 janvier 2015). Nous n’avons appliqué aucune restriction concernant la date ou la langue.

Critères de sélection

Nous avions prévu d'inclure tous les essais contrôlés randomisés (ECR) et quasi randomisés évaluant les effets de la massothérapie pour la prévention des plaies de pression. Notre principal critère de jugement était la proportion de personnes développant une nouvelle plaie de pression de tout grade.

Recueil et analyse des données

Deux auteurs de la revue ont indépendamment effectué la sélection des essais. Les désaccords ont été résolus par la discussion.

Résultats principaux

Aucune étude (ECR ou quasi-ECR) ne répondait aux critères d'inclusion. Ainsi, ni une méta-analyse, ni une description narrative des études n'a été possible.

Conclusions des auteurs

Il n'y a pas, à l'heure actuelle, d'études admissibles pour l'inclusion dans cette revue. Par conséquent, il n'est pas clair si la massothérapie peut prévenir les plaies de pression.

Resumen

Masoterapia para la prevención de las úlceras de decúbito

Antecedentes

Las úlceras de decúbito afectan a cerca del 10% de los pacientes hospitalizados, y las personas de edad avanzada tienen mayor riesgo. Varios estudios han indicado que la masoterapia puede ayudar a prevenir la aparición de las úlceras de decúbito, pero estos resultados no son consistentes.

Objetivos

Evaluar las pruebas sobre los efectos del masaje en comparación con placebo, atención estándar u otras intervenciones para la prevención de las úlceras de decúbito en poblaciones con riesgo.

La revisión intentó responder las siguientes preguntas:
¿El masaje reduce la incidencia de las úlceras de decúbito de cualquier grado?
¿El masaje es seguro a corto y a largo plazo? ¿Si no lo es, cuáles son los eventos adversos asociados con el masaje?

Métodos de búsqueda

Se hicieron búsquedas en el registro especializado del Grupo Cochrane de Heridas (Cochrane Wounds Group) (8 enero 2015), Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL) (2015, número 1), Ovid MEDLINE (1946 hasta 8 enero 2015), Ovid MEDLINE (In-Process Other Non-Indexed Citations 8 enero 2015), Ovid EMBASE (1974 hasta 8 enero 2015) y en EBSCO CINAHL (1982 hasta 8 enero 2015). No se aplicó ninguna restricción de fecha ni de idioma.

Criterios de selección

Se planificó incluir todos los ensayos controlados aleatorios (ECA) y los ensayos controlados cuasialeatorios que evaluaran los efectos de la masoterapia para la prevención de las úlceras de decúbito. El resultado primario fue la proporción de pacientes que desarrollaron una nueva úlcera de decúbito de cualquier grado.

Obtención y análisis de los datos

Dos autores de la revisión realizaron la selección de ensayos de forma independiente. Los desacuerdos se resolvieron mediante discusión.

Resultados principales

Ningún estudio (ECA o cuasi ECA) cumplió los criterios de inclusión. Por lo tanto, no fue posible realizar un metanálisis ni una descripción narrativa de los estudios.

Conclusiones de los autores

Actualmente, no hay estudios elegibles para su inclusión en esta revisión. Por lo tanto, no se conoce si la masoterapia puede prevenir las úlceras de decúbito.

アブストラクト

床擦れ(褥瘡)予防に対するマッサージ治療

背景

床擦れは入院患者の約10%に発症し、高齢者は発症リスクが最も高い。マッサージが床擦れの予防になる可能性があるとする研究が数例あるが、その結果には一貫性が認められない。

目的

床擦れになる可能性のある患者を対象に、プラセボ、標準治療またはその他の介入治療とマッサージ治療の効果を比較したエビデンスを評価すること

本レビューでは以下の問いに対する答えを模索した。マッサージはどのような床擦れにも効果があるか。短期および長期においてマッサージは安全か。安全でない場合、マッサージにはどのような有害事象があるのか。

検索戦略

Cochrane Wounds Group Specialised Register(2015年1月8日)、Cochrane Central Register of Controlled Trials (CENTRAL)(2015年、第1号)、Ovid MEDLINE(1946~2015年1月8日)Ovid MEDLINE(執筆中で未索引のもの2015年1月8日)、Ovid EMBASE(1974~2015年1月8日)、およびEBSCO CINAHL(1982~2015年1月8日)を検索した。年代または言語による制限は行わなかった。

選択基準

床擦れ予防に対するマッサージ治療の効果を検証しているランダム化比較試験(RCT)および準ランダム化比較試験(Q-RCT)を、すべて組み入れるようにした。主要アウトカムは、あらゆるグレードの床擦れを新規に発症した患者の比率であった。

データ収集と分析

2名のレビュー著者がそれぞれに試験の選択を行った。相違点は話し合いにより解決した。

主な結果

選択基準に合う研究(RCTまたは Q-RCT)がなかったので、メタアナリシスまたは文章による記述が 可能であった。

著者の結論

本レビューの選択基準に合致する研究は今のところ存在しない。従って、マッサージ治療により床擦れが予防できるかどうかは不明である。

Plain language summary

Massage therapy for preventing pressure ulcers

What are pressure ulcers?

Pressure ulcers (also called bed sores or pressure sores) are injuries caused by constant pressure or friction. They usually affect people who are immobilised or find it difficult to move themselves, for example the elderly or paralysed. Pressure ulcers frequently occur on bony parts of the body, such as the heels and hips, and also on the buttocks. Prolonged pressure on these areas leads to poor circulation, followed by cell death, skin breakdown, and the development of an open wound - the pressure ulcer. Pressure ulcers take a long time to heal - and some do not heal – so, if possible, it is important to prevent them from developing.

What is massage therapy?

Massage therapy is a treatment in which parts of the body are manipulated, held, moved and have pressure applied to them. Massage therapy can increase the volume of blood in an area, improve tissue suppleness, reduce swelling due to accumulation of fluid (oedema), and boost the immune system. Some studies have suggested that massage may help prevent the development of pressure ulcers in people who are at risk of developing them, but it is not known whether it really works.

The purpose of this review

This review investigated whether massage therapy is effective when given alone, or as part of a package of care, to prevent the development of pressure ulcers. The review authors were interested in massage therapy compared with sham (pretend) massage, or compared with standard care for prevention of pressure ulcers (that is special mattresses, regular turning and reduction of pressure on the immobile patient).

Findings of this review

The review authors searched the medical literature up to 8 January 2015, but could identify no relevant trials that investigated massage therapy for the prevention of pressure ulcers. Therefore, there is currently no evidence to support or reject massage therapy as a preventative treatment for pressure ulcers. There is an urgent need for trials to investigate this area to establish whether massage therapy works and is safe.

Résumé simplifié

Massothérapie pour prévenir les plaies de pression

Que sont les plaies de pression ?

Les plaies de pression (également appelées escarres ou plaies de lit) sont des lésions causées par une pression ou un frottement constants. Elles touchent généralement des sujets immobilisés ou qui ont des difficultés à se déplacer, par exemple les personnes âgées ou paralysées. Les plaies de pression se forment fréquemment sur les parties osseuses du corps, tels que les talons et les hanches, et aussi sur les fesses. Une pression prolongée sur ces zones conduit à une mauvaise circulation sanguine, suivie par la mort cellulaire, une détérioration de la peau et le développement d'une lésion ouverte - la plaie de pression. Sachant que les plaies de pression mettent beaucoup de temps à guérir - et ne guérissent pas toujours - il est important de les empêcher de se développer, si possible.

Qu'est-ce que la massothérapie ?

La massothérapie est un traitement dans lequel des parties du corps sont manipulées, palpées ou pétries, et une pression leur est appliquée. La massothérapie peut augmenter le volume de sang dans une zone, améliorer la souplesse des tissus, réduire l'enflure due à l'accumulation de liquide (œdème) et stimuler le système immunitaire. Certaines études ont suggéré que le massage pourrait aider à prévenir le développement des plaies de pression chez les personnes à risque, mais son efficacité réelle n'est pas connue.

Objectif de la revue

Dans cette revue, nous avons cherché à savoir si la massothérapie, administrée seule ou dans le cadre d'un ensemble de soins, était efficace pour prévenir le développement des plaies de pression. Les auteurs de la revue se sont intéressés à la massothérapie comparée à un massage factice (placebo) ou aux soins standard pour la prévention des plaies de pression (à savoir, matelas spéciaux, retournement régulier et réduction de la pression sur le patient immobile).

Résultats de la revue

Les auteurs de la revue ont fouillé la littérature médicale jusqu'au 8 janvier 2015, mais n'ont pu identifier aucun essai pertinent examinant la massothérapie pour la prévention des plaies de pression. Par conséquent, aucune preuve n'existe actuellement pour appuyer ou rejeter la massothérapie en traitement préventif des plaies de pression. Des essais dans ce domaine sont nécessaires d'urgence pour déterminer si la massothérapie fonctionne et si elle est sûre.

Notes de traduction

Traduction réalisée par Cochrane France

Laički sažetak

Terapijska masaža za sprječavanje dekubitusa

Što su dekubitusi?

Dekubitus (također se naziva „rane od ležanja“) je naziv za ozljede nastale konstantnim pritiskom ili trljanjem dijela tijela. Oni obično nastaju kod ljudi koji su imobilizirani ili se teško pomiču, na primjer kod starijih ili paraliziranih osoba. Dekubitus se često pojavljuje na koštanim dijelovima tijela kao što su pete, kukovi i stražnjica. Dugotrajan pritisak na ta područja ometa krvni optjecaj, što uzrokuje staničnu smrt, raspadanje kože i razvoj otvorene rane – dekubitusa. Za cijeljenje dekubitusa treba dosta vremena, a neki nikad ne zacijele; stoga je najvažnije sprječavanje njihovog nastanka.

Što je terapijska masaža?

Terapijska masaža je postupak u kojem se dijelovi tijela pomiču, drže i na njih se primjenjuje pritisak. Terapijska masaža može povećati protok krvi u nekom području, poboljšati opskrbu tkiva, smanjiti otok nastao zbog nakupljanja tekućina i povoljno djelovati na imunološki sustav. Neke studije su dale naslutiti da masaža može spriječiti razvoj dekubitusa u ljudi koji imaju rizik za njegov nastanak, ali nije poznato je li to točno ili nije.

Cilj ovog sustavnog pregleda

Ovaj Cochrane sustavni pregled je istražio je li terapijska masaža uspješna u sprječavanju razvoja dekubitusa kad je primjenjujemo samu ili kao dio terapije. Autori sustavnog pregleda bili su zainteresirani za usporedbu terapijske masaže s običnom masažom ili sa standardiziranim postupcima sprječavanja dekubitusa (posebni madraci, redovito okretanje i smanjenje pritiska u nepokretnih pacijenata).

Rezultati sustavnog pregleda

Autori sustavnog pregleda pretražili su medicinsku literaturu objavljenu do 8. siječnja, 2015, ali nisu mogli pronaći pokuse koji su istraživali terapijsku masažu za sprječavanje dekubitusa. Stoga trenutačno nema dokaza koji bi podržali korištenje terapijske masaže kao mjere za sprječavanje nastanka dekubitusa. Potrebno je napraviti istraživanja koji bi ispitala to pitanje kako bi utvrdili sigurnost i djelotvornost terapijske masaže.

Bilješke prijevoda

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Preveo: Ante Bojčić
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எளியமொழிச் சுருக்கம்

அழுத்தப் புண்களை தடுப்பதற்கான நீவுதல் (மசாஜ்) சிகிச்சை

அழுத்தப் புண்கள் என்றால் என்ன?

அழுத்தப் புண்கள் (மேலும் படுக்கை ரணங்கள் அல்லது அழுத்த ரணங்கள் என்றழைக்கப்படும்) ஆகியவை தொடர்ந்த அழுத்தம் அல்லது உராய்வின் மூலம் ஏற்படும் காயங்கள் ஆகும். அவை, பொதுவாக அசைவற்று இருக்கும் அல்லது தங்களை நகர்த்துவதற்கு கடினமாக கருதும், உதாரணமாக முதியோர் அல்லது வாதமுடையோர்களை பாதிக்கும். அழுத்தப் புண்கள், அடிக்கடி உடலின் எலும்பு பகுதிகளான குதிகால், இடுப்பு, மற்றும் பிட்டம் போன்ற பாகங்களிலும் ஏற்படும். நீண்ட நேர அழுத்தத்தால், இந்த பகுதிகளில் இரத்த ஓட்டம் குறைவதை தொடர்ந்து, உயிரணுக்கள் இறப்பு, தோல் நசிவு, ஒரு திறந்த காயத்தின் வளர்ச்சி ஆகியவை அழுத்தப் புண்ணிற்கு வழிவகுக்கிறது. அழுத்தப் புண்கள் குணமடைவதற்கு அதிக நாள் எடுத்துக் கொள்ளும்- சிலது குணமடையாது - ஆதலால், முடிந்தால், அவற்றை வளர விடாமல் தடுப்பது முக்கியமாகுகிறது.

நீவுதல் (மசாஜ்) சிகிச்சை என்றால் என்ன?

மசாஜ் சிகிச்சை என்பது, உடலின் பாகங்களை கையாளல், தாங்குதல், நகர்தல் மற்றும் அழுத்தம் கொடுத்தல் போன்ற முறைகளை பயன்படுத்தும் சிகிச்சையாகும். மசாஜ் சிகிச்சை, ஒரு பகுதியில் இரத்த அளவை அதிகரித்து, திசு நெகிழ்ச்சியை மேம்படுத்தி, திரவ தேக்கத்தினால் ஏற்படும் வீக்கத்தை குறைத்து மற்றும் நோய் எதிர்ப்பு சக்தியை அதிகரிக்க முடியும். சில ஆய்வுகள், அழுத்தப் புண்கள் வளர்ச்சி அடையக்கூடிய ஆபத்தை கொண்ட மக்களில், மசாஜ் அத்தகைய வளர்ச்சியை தடுக்க முடியும் என்று கருத்து தெரிவிகின்றன, ஆனால் அது உண்மையில் வேலை செய்யுமா என்று தெரியவில்லை.

திறனாய்வின் நோக்கம்

தனியாக அல்லது பராமரிப்பு தொகுப்பின் ஒரு பகுதியாக அளிக்கப்பட்ட மசாஜ் சிகிச்சை, அழுத்தப் புண்கள் உருவாகுவதை தடுக்க பயனுள்ளதாக இருக்குமா என்பதை இந்த திறனாய்வு விசாரித்தது. திறனாய்வு ஆசிரியர்கள், மசாஜ் சிகிச்சையை போலி (பாவனை) மசாஜ், அல்லது வழக்கமான அழுத்தப் புண்கள் தடுப்பு பராமரிப்பு (ஒரு சிறப்பு மெத்தையில், ஒரு அசைவற்ற நோயாளியை தொடர்ச்சியான திருப்புதல் மற்றும் அழுத்தக் குறைப்பு மூலம்) ஆகியவற்றோடு ஒப்பிடுவதில் ஆர்வம் காட்டினர்.

திறனாய்வின் கண்டுப்பிடிப்புகள்

8, ஜனவரி 2015 வரையான மருத்துவ இலக்கியத்தை திறனாய்வு ஆசிரியர்கள் தேடினர், ஆனால் அழுத்தப் புண்களை தடுப்பதற்கான மசாஜ் சிகிச்சையை பற்றிய தொடர்புடைய சோதனைகளை கண்டறிய முடியவில்லை. எனவே, அழுத்தப் புண்களை தடுப்பதற்கு மசாஜ் சிகிச்சையை ஒரு தடுப்பு சிகிச்சையாக கருதி ஆதரவளிக்க அல்லது நிராகரிக்க தற்போது எந்த ஆதாரமும் இல்லை. மசாஜ் சிகிச்சை வேலை செய்யுமா மற்றும் பாதுகாப்பானதா என்பதை நிலைநாட்ட, இந்த பகுதியினை ஆய்ந்து அறிய வேண்டிய சோதனைகள் அவசரமாக தேவைப்படுகிறது.

மொழிபெயர்ப்பு குறிப்புகள்

மொழி பெயர்ப்பாளர்கள்: சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன், தங்கமணி ராமலிங்கம், ப்ளசிங்டா விஜய், ஸ்ரீகேசவன் சபாபதி.

Laienverständliche Zusammenfassung

Massagetherapie zur Vorbeugung von Druckgeschwüren (Dekubiti)

Was sind Druckgeschwüre?

Druckgeschwüre (auch als Wundliegegeschwüre, Dekubitusgeschwüre oder Dekubiti bezeichnet) sind Wunden, die durch dauerhaften Druck oder Reibung verursacht werden. In der Regel sind davon Menschen betroffen, die nicht selbst mobil sind oder sich nur unter Schwierigkeiten bewegen können, beispielsweise ältere oder gelähmte Menschen. Druckgeschwüre treten häufig an knochigen Körperstellen, wie an den Fersen, der Hüfte oder am Gesäß auf. Anhaltender Druck auf diese Körperstellen führt zu einer Minderdurchblutung, wodurch Zellen absterben, eine Schädigung der Haut eintritt und sich eine offene Wunde entwickelt: ein Druckgeschwür. Druckgeschwüre heilen nur langsam und in manchen Fällen erfolgt gar keine Heilung. Deshalb ist es, falls möglich, von großer Bedeutung, ihrer Entstehung vorzubeugen.

Was versteht man unter Massagetherapie?

Massagetherapie ist eine Behandlung, bei der Körperteile bearbeitet, in einer bestimmten Position gehalten, bewegt und Druck ausgesetzt werden. Dadurch kann die Durchblutung in einer Körperregion gefördert, die Gewebebeweglichkeit verbessert, eine Schwellung infolge von Flüssigkeitsansammlung (Ödem) reduziert und das Immunsystem angeregt werden. In einigen Studien wird vermutet, dass Massagen dazu beitragen könnten, der Entwicklung von Druckgeschwüren bei Risikopatienten vorzubeugen, doch diese Hypothese ist nicht bestätigt.

Zielsetzung dieses Reviews

In diesem Review wurde untersucht, ob Massagetherapie alleine oder als Teil eines Therapiepakets wirksam ist, um der Entstehung von Druckgeschwüren vorzubeugen. Die Autoren des Reviews betrachteten Massagetherapie im Vergleich zu Scheinmassage (nur vorgetäuscht) oder zur Standardbehandlung zur Vorbeugung von Druckgeschwüren (spezielle Matratzen, regelmäßige Umlagerung und Druckreduzierung bei bewegungsunfähigen Patienten).

Ergebnisse dieses Reviews

Für diesen Review wurde die medizinische Literatur bis zum 8. Januar 2015 durchsucht, die Suche ergab jedoch keine relevanten Studien, in denen Massagetherapie zur Vorbeugung von Druckgeschwüren untersucht wurde. Aus diesem Grund liegt derzeit keine Evidenz vor, die den Einsatz von Massagetherapie als Prophylaxemaßnahme gegen Druckgeschwüre befürwortet oder davon abrät. Es besteht dringender Bedarf an Studien zu diesem Bereich, um feststellen zu können, ob Massagetherapie wirksam und ungefährlich ist.

Anmerkungen zur Übersetzung

I. Noack, freigegeben durch Cochrane Schweiz.

Резюме на простом языке

Терапия массажем для профилактики пролежней

Что такое пролежни?

Пролежни (также называемые постельные язвы или язвы от давления) это повреждения, вызванные постоянным давлением или трением. Они, как правило, возникают у людей, которые находятся в неподвижном состоянии или которым трудно двигаться самостоятельно, например, у пожилых людей или парализованных. Пролежни часто встречаются на частях тела с выступающими костями, таких как пятки и бедра, а также на ягодицах. Длительное давление на эти области приводит к плохой циркуляции крови, а затем к гибели клеток, нарушению целостности кожи и развитию открытой раны - язвы от давления. Для заживления пролежней требуется длительное время - и некоторые из них не заживают - поэтому, если это возможно, важно предотвратить их развитие.

Что такое терапия/лечение массажем?

Терапия массажем это лечение, при котором части тела подвергаются манипуляциям с применением передвижения, давления и удерживания (фиксации). Терапия массажем может увеличить приток крови в определенной области, улучшить эластичность тканей, уменьшить отек из-за скопления жидкости, а также укрепить иммунную систему. Некоторые исследования показали, что терапия массажем может помочь предотвратить развитие пролежней у людей с риском их развития, но неизвестно, действительно ли это работает.

Цель этого обзора

В этом обзоре исследовали, эффективна ли терапия массажем при использовании ее в качестве монотерапии или как части оказания комплексной помощи, в предотвращении развития пролежней. Авторы обзора хотели сравнить терапию массажем с имитацией массажа, или сравнить со стандартной помощью, оказываемой для профилактики пролежней (то есть специальные матрасы, регулярные повороты и уменьшение давления на неподвижного пациента).

Результаты этого обзора

Авторы обзора провели поиск медицинской литературы, опубликованной до 8 января 2015 года, но не смогли выявить соответствующих испытаний, в которых изучали терапию массажем для профилактики пролежней. Таким образом, в настоящее время нет доказательств в поддержку терапии массажем или отказа от его использования в качестве профилактики пролежней. Существует острая необходимость в проведении клинических испытаний, чтобы исследовать эту область и установить, работает ли терапия массажем и безопасна ли она.

Заметки по переводу

Перевод: Потапов Александр Сергеевич. Редактирование: Юдина Екатерина Викторовна. Координация проекта по переводу на русский язык: Cochrane Russia - Кокрейн Россия (филиал Северного Кокрейновского Центра на базе Казанского федерального университета). По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: lezign@gmail.com

Streszczenie prostym językiem

Stosowanie masażu leczniczego w zapobieganiu odleżynom

Co to są odleżyny?

Odleżyny to urazy spowodowane stałym uciskiem lub tarciem. Zazwyczaj powstają u osób unieruchomionych lub mających trudności z poruszaniem się na przykład u osób starszych lub sparaliżowanych. Odleżyny najczęściej pojawiają się na miejscach na ciele, gdzie kości są wydatne, takich jak biodra, pięty a także na pośladkach. Długotrwały ucisk w tych miejscach powoduje osłabienie krążenia, prowadząc do obumarcia komórek, uszkodzenia skóry i rozwoju otwartej rany zwanej odleżyną. Odleżyny to rany, które długo się goją a nawet niektóre nie goją się – dlatego, jeśli to możliwe, istotne jest zapobieganie ich powstawaniu.

Czym jest masaż leczniczy?

Masaż leczniczy to zabiegi polegające na ugniataniu, rozcieraniu i uciskaniu określonych części ciała. Masaż leczniczy może zwiększyć przepływ krwi w tym obszarze, poprawiać jędrność tkanek, zmniejszyć obrzęki spowodowane nagromadzeniem płynów oraz wzmocnić układ odpornościowy. Niektóre badania sugerują, że masaż może być pomocny w zapobieganiu powstawaniu odleżyn u osób znajdujących się w grupie ryzyka ich rozwoju, jednakże nie do końca jest jasnym, czy to leczenie jest rzeczywiście skuteczne.

Cel przeglądu

W niniejszym przeglądzie oceniano czy masaż leczniczy jest skuteczny w zapobieganiu rozwojowi odleżyn, gdy stosowany jest jako jedyna interwencja lub gdy jest częścią całościowej opieki. Celem autorów niniejszego przeglądu było porównanie skuteczności masażu leczniczego z masażem pozorowanym lub ze standardową opieką (tj. stosowaniem specjalnych materacy, regularną zmianą pozycji oraz zmniejszaniem ucisku u pacjentów unieruchomionych) w zapobieganiu powstawaniu odleżyn.

Wyniki przeglądu

Autorzy przeglądu przeszukali literaturę medyczną do 8 stycznia 2015 r., jednak nie zidentyfikowali żadnych istotnych badań, w których oceniano masaż leczniczy w zapobieganiu odleżynom. Tym samym, obecnie nie ma dostępnych danych naukowych pozwalających na potwierdzenie lub zaprzeczenie czy masaż leczniczy jest skutecznym postępowaniem zapobiegającym. Niezbędne są badania w powyższym zakresie w celu ustalenia czy stosowanie masażu leczniczego jest efektywne i bezpieczne.

Uwagi do tłumaczenia

Tłumaczenie: Magdalena Koperny Redakcja: Joanna Zając

Resumen en términos sencillos

Masoterapia para la prevención de las úlceras de decúbito

¿Que son las úlceras de decúbito?

Las úlceras de decúbito (también llamadas escaras o úlceras por presión) son heridas causadas por la presión o la fricción constantes. Generalmente, afectan a los pacientes inmovilizados o que tienen dificultades para moverse por sí solos, por ejemplo, personas de edad avanzadas o con parálisis. Las úlceras de decúbito aparecen con frecuencia en partes óseas del cuerpo como el talón y la cadera, y también en los glúteos. La presión prolongada sobre estas áreas da lugar a una circulación deficiente, seguida de la muerte celular, el deterioro de la piel y el desarrollo de una herida abierta, la úlcera de decúbito. Las úlceras de decúbito toman mucho tiempo para curar (y algunas no lo hacen) por lo que, de ser posible, es importante prevenir su desarrollo.

¿Qué es la masoterapia?

La masoterapia es un tratamiento en el cual partes del cuerpo se manipulan, se sostienen, se mueven y se les aplica presión. La masoterapia puede aumentar el volumen de sangre en un área, mejorar la flexibilidad tisular, reducir el edema debido a la acumulación de líquido y estimular el sistema inmunológico. Algunos estudios han indicado que el masaje puede ayudar a prevenir el desarrollo de úlceras de decúbito en los pacientes con riesgo de desarrollarlas, aunque no se conoce si realmente funciona.

Propósito de esta revisión

Esta revisión investigó si la masoterapia es efectiva cuando se administra de forma aislada, o como parte de un paquete de atención, para prevenir el desarrollo de úlceras de decúbito. Los revisores estaban interesados en la masoterapia en comparación con masaje simulado (fingido), o en comparación con atención estándar para la prevención de las úlceras de decúbito (es decir, colchones especiales, cambio regular de posición y reducción de la presión sobre el paciente inmóvil).

Hallazgos de esta revisión

Los revisores realizaron búsquedas en la bibliografía médica hasta el 8 de enero de 2015, aunque no pudieron identificar ensayos relevantes que investigaran el tratamiento con masaje para la prevención de las úlceras de decúbito. Por lo tanto, actualmente no hay pruebas para apoyar o rechazar la masoterapia como un tratamiento preventivo para las úlceras de decúbito. Hay una necesidad urgente de ensayos para investigar esta área y establecer si la masoterapia funciona y es segura.

Notas de traducción

La traducción y edición de las revisiones Cochrane han sido realizadas bajo la responsabilidad del Centro Cochrane Iberoamericano, gracias a la suscripción efectuada por el Ministerio de Sanidad, Servicios Sociales e Igualdad del Gobierno español. Si detecta algún problema con la traducción, por favor, contacte con Infoglobal Suport, cochrane@infoglobal-suport.com.

平易な要約

床擦れ(褥瘡)予防に対するマッサージ治療

「床擦れ」とは?

「床擦れ(褥瘡)」は圧力と摩擦の継続により起こる傷害である。身体を動かせない、または動かすことが困難な患者、例えば高齢者や身障者が通常発症する。床擦れは、踵や腰、臀部などの身体の骨張った部分に頻繁に発症する。これらの部位への長期的加圧は血行不良を引き起こし、細胞の壊死、皮膚組織の破壊、および開放創-つまり「床擦れ」-につながる。床擦れは治癒までに時間がかかり、中には完治しないものもある。従って、可能であれば予防することが重要となる。

マッサージ治療とは?

マッサージ治療は、身体の部分に触れ、持ち上げ、動かして圧力をかける治療である。マッサージ治療により身体のある部位の血量を増やし、組織の柔軟性を改善し、体液の充満によるむくみ(浮腫)を減少し、免疫機能を増進することができる。床擦れを発症する可能性が高い患者における床擦れ予防にマッサージが効く可能性があるとする研究があるが、その真偽は定かではない。

本レビューの目的

本レビューは、マッサージが単独で、または治療の一環として床擦れ予防に効果があるかどうかを調査したものである。レビュー著者は、床擦れ予防に対するマッサージと偽マッサージとの比較、マッサージと標準治療(特製マットレス、定期的な寝返りおよび動けない患者への減圧)との比較に注目した。

本レビューの所見

レビュー著者は2015年1月8日までの医学文献を検索したが、床擦れ予防に対するマッサージの効能に関連する試験が同定できなかった。従って、床擦れの予防的治療としてのマッサージを支持または否定するエビデンスは今のところない。マッサージが有効であり安全であることを証明するための試験実施が急務である。

訳注

《実施組織》厚生労働省「「統合医療」に係る情報発信等推進事業」(eJIM:http://www.ejim.ncgg.go.jp/)[2018.1.21]
《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。
 CD010518 Pub2

Background

Description of the condition

Pressure ulcers, also known as bedsores or pressure sores, are regions of localised damage to the skin and deeper tissue layers affecting muscle, tendon, and bone as a result of constant pressure due to impaired mobility (Reddy 2008; Whitney 2006). Pressure on the affected area leads to poor circulation and eventually contributes to cell death, skin breakdown, and the development of an open wound. If not adequately treated, open ulcers can become a source of pain and disability, and can become infected.

Pressure ulcers are widespread in the very old, the immobile and people of any age with medical conditions that impair sensation and /or mobility (e.g., spinal cord injury) (Moore 2014; Reddy 2006; Torpy 2003; Woodbury 2004; Zeller 2006). Reported prevalence rates for pressure ulceration vary from 8.8% to 53.2% (Davis 2001; Tannen 2006), and incidence rates from 7% to 71.6% (Scott 2006; Whittington 2004; Zhang 2013). This variability in reported prevalence and incidence rates may be partly explained by the fact that studies are conducted in different clinical settings (for example care homes or hospital), and populations (for example differences in baseline risk of ulceration. Development of pressure ulcers has been associated with a 4.5-times greater risk of death than that for persons with the risk factors but without pressure ulcers (Staas 1991). Common sites for pressure ulcers include the sacrum (tailbone), back, buttocks, heels, back of the head and elbows (Torpy 2003; Zeller 2006) (Figure 1). Pressure ulcers are generally graded 1, 2, 3 and 4, according to the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel guidelines (EPUAP/NPUAP 2009) (see Appendix 1).

Figure 1.

From Pressure ulcers, JAMA, January 8, 2003: Vol 289, No.2

The treatment of pressure ulcers can represent a financial burden on healthcare systems, and a Dutch study found that costs associated with the care of pressure ulcers were the third highest after those for cancer and cardiovascular diseases (HCN 1999). The annual treatment cost of pressure ulcers has been estimated to range from GBP £1.4 to 2.1 billion; this is broadly equal to total UK National Health Service expenditure on mental illness, or the total cost of community health services (Bennett 2004). In the US in 2006 there were 503,300 hospital stays during which pressure ulcers were noted. In adults, the total hospital costs of these stays was USD 11 billion (Russo 2008). A study examining economic losses from pressure ulcers among hospitalised adult patients in Australia, estimated that annual opportunity costs totaled AUD 285 million (Graves 2005). Effective and adequate prevention is an important issue for patients, clinicians and policy makers.

Description of the intervention

Massage can be defined as manual soft tissue manipulation, and includes holding, causing movement, and/or applying pressure to the body (Kenny 2009). This kind of therapy is practised by accredited professionals to achieve positive physical, functional, and psychological outcomes in clients (AAMT 2012). As a complementary and alternative medical (CAM) practice, massage therapy encompasses different types of massage originating from different parts of the world (Ernst 2005). The two most common techniques are Swedish and Chinese massage (Duimel-Peeters 2005a).

Swedish massage

Swedish massage is based on the Western concepts of anatomy and physiology, as opposed to energy work on 'meridians' in Chinese massage systems. Swedish massage involves the following techniques (Duimel-Peeters 2005b; Ernst 2005; Moraska 2005):

  • Effleurage (stroking): performed using either the padded parts of the finger tips or the palm of the hand; it can be firm or light without dragging the skin. It consists of slow, rhythmic stroking hand movements moulded to the shape of the skin. It is believed to accelerate blood and lymph flow to improve tissue drainage and to reduce swelling (Duimel-Peeters 2005b; Goats 1994; Huber 1981; Ironson 1996; Iwama 2002; Wakim 1976). Effleurage is thought to be the least harmful massage technique (Duimel-Peeters 2005a).

  • Petrissage (kneading): performed with the palm of the hand and the surface of the fingers and the thumbs; this technique can only be applied to the fleshy regions of the body. In pétrissage a fold of skin, subcutaneous tissue, or muscle is squeezed, lifted, and rolled in a continuous circular motion against the underlying tissues (Goats 1994; Huber 1981; Wakim 1976). It is particularly useful for stretching contracted or adherent fibrous tissue and to relieve muscle spasm (Wakim 1976).

  • Tapotement (striking): consists of a rhythmic percussion, most frequently administered with the edge of the hand, a cupped hand, or the tips of the fingers. It is a stimulating movement in which the fingers, sides, or palms of the hands produce light tapping, quick pinching, or gentle slapping movements. It vibrates tissues and triggers cutaneous reflexes such as vasodilatation (widening of blood vessels), resulting in increasing muscle tone and promoting circulation of interstitial fluid (fluid surrounding tissue cells), reducing swelling and accelerating healing processes (Huber 1981; Wakim 1976).

  • Friction (compression): consists of an accurately-delivered penetrating pressure applied in a small, localised area with the hands or fingers. It is a very effective way to break up adhesions or contracted connective tissue (Goats 1994; Wakim 1976).

  • Vibration (shaking): consists of a fine, gentle trembling movement of the tissues, and is performed by the hand or fingers in contact with the skin. In this technique the palm of the hand is often used on the part of the body or limb being treated.The purpose of vibration is to facilitate muscle relaxation and increase circulation (Benjamin 1996; Fritz 1995).

Chinese massage

Chinese massage therapy, also called Tui na, is believed to have originated around 2700 BC. It was practiced in tandem with acupuncture, acupressure and use of various Chinese medicinal herbs, and, therefore, formed one of the essential parts of Traditional Chinese Medicine (TCM). The techniques involve compression, swing, friction, vibration, percussion, pinching and grasping and joint manipulation (CMT 2013).

  • Compression (pressure): applied by the fingers, limbs and palms to execute motions like nipping, pressing, stepping and twisting.

  • Friction (also known as rubbing, pushing, gliding and wiping): carried out to create heat on the body surface and improve the circulation underneath. Small, rhythmic circular movements are used for abdominal problems and gross scrubbing motions are used for the chest, limbs and back.

  • Swing (also named finger-pushing, kneading and rolling): this is a common technique in TCM massage by pushing with one finger operation.

  • Joint manipulation (rotation, pulling): actions assist in increasing the range of joint motion and flexibility of the limbs and spine.

  • Percussion with finger tapping: this technique is used on the head, abdomen and chest regions; fist striking is used for the back, and palm patting for the waist, hip and limbs.

  • Pinching and grasping (rhythmic picking up and squeezing of the soft tissues): consists of twisting, holding, kneading and pinching with the operator's fingers.

  • Vibration (rapid vibration, shaking and rocking a selected region): resumes Qi movement, to get rid of stagnation and to enhance gastrointestinal functioning.

The cost of massage therapy is minimal when compared with the cost of some medications and other conventional treatments (Corbin 2005). Massage is widely considered to be safe for use in the general population, although adverse events have been reported. For example, one study reported that massage had caused some minor discomfort, but no major side-effects occurred during the treatment session (Cambron 2007).

For the purposes of this review the term 'massage therapy' incorporates both western (Swedish) and Chinese techniques.

How the intervention might work

Massage is known to have the following advantageous effects that may help to prevent pressure ulcers; encouraging hyperaemia (localised increase in amount of blood) as a consequence of histamine release; increasing tissue suppleness; relaxing muscle tone; increasing parasympathetic activity; reducing oedema; relieving subcutaneous scar tissue; and activating mast cells (Olson 1989; Duimel-Peeters 2005a; Duimel-Peeters 2005b). However other authors have pointed out that massage might have adverse effects through the application of shear forces on vulnerable skin (NICE 2014).

Why it is important to do this review

Several investigators have suggested that massage therapy might be helpful in preventing pressure ulcers (Duimel-Peeters 2005a; Olson 1989), therefore, it is important to undertake a comprehensive assessment of all the available high level data on the benefits and harms of massage intervention for the prevention of pressure ulcers. Furthermore, the inclusion of massage therapy as part of a prevention strategy adds to the overall cost of the strategy, so it is important to explore whether use of this therapy provides potential benefit to patients.

Objectives

To assess the evidence for the effects of massage compared with placebo, standard care or other interventions for prevention of pressure ulcers in at-risk populations.

The review sought to answer the following questions:

  • Does massage reduce the incidence of pressure ulcers of any grade?

  • Is massage safe in the short- and long-term? If not, what are the adverse events associated with massage?

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) were eligible for inclusion. We excluded cluster RCTs and cross-over designs.

Types of participants

We planned to include trials involving people in any care setting, of any age or sex, without a pressure ulcer.

Types of interventions

The primary intervention was massage therapy applied to the skin with the aim of preventing the development of a pressure ulcer. Likely comparisons were with sham massage or no massage.

Types of outcome measures

Primary outcomes

The proportion of people developing a new pressure ulcer of any grade at any point during the study (pressure ulcers are defined as a localised injury to the skin, underlying tissue, or both, usually over a bony prominence) (EPUAP/NPUAP 2009; Moore 2014).

Secondary outcomes
  • The severity of the new pressure ulcer (ulcer grade and volume).

  • Costs of intervention.

  • Pain (assessed using any validated pain scales).

  • Quality of life (assessed using any validated assessment tool, such as the Nottingham Health Profile scales (McKenna 1981)).

  • Adverse events associated with massage.

Search methods for identification of studies

Electronic searches

We searched the following databases in January 2015:

  • The Cochrane Wounds Group Specialised Register (searched 8 January 2015);

  • The Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 1);

  • Ovid MEDLINE (1946 to 8 January 2015);

  • Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 January 2015);

  • Ovid EMBASE (1974 to 8 January 2015); and

  • EBSCO CINAHL (1982 to 8 January 2015).

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) using the following search strategy:

#1 MeSH descriptor: [Massage] explode all trees
#2 massag*:ti,ab,kw
#3 #1 or #2
#4 MeSH descriptor: [Pressure Ulcer] explode all trees
#5 (pressure next (ulcer* or sore* or injur*)):ti,ab,kw
#6 (decubitus next (ulcer* or sore*)):ti,ab,kw
#7 ((bed next sore*) or bedsore):ti,ab,kw
#8 #4 or #5 or #6 or #7
#9 #3 and #8

We adapted this strategy to search Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL. We combined the Ovid MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity- and precision-maximising version (2008 revision) (Lefebvre 2011). We combined the EMBASE search with the Ovid EMBASE filter developed by the UK Cochrane Centre (Lefebvre 2011). We combined the CINAHL searches with the trial filters developed by the Scottish Intercollegiate Guidelines Network (SIGN 2013). We did not restrict studies with respect to language, date of publication or study setting.

We searched the following clinical trials registries:

Searching other resources

We searched the bibliographies of all retrieved, potentially-relevant publications for reports of any potentially-relevant trials and contacted experts in the field to ask for information relevant to this review.

Data collection and analysis

Selection of studies

Independently, two review authors reviewed titles and abstracts identified by the searches. We retrieved full reports of all potentially relevant trials for further assessment of eligibility based on the inclusion criteria. The first two review authors independently assessed all full text reports against the inclusion criteria; those reports not meeting the inclusion criteria were added to the table of excluded studies with full reasons for their exclusion noted. Any differences in opinion were resolved by discussion with a third review author.

Data extraction and management

Two review authors planned to extract data independently using a data extraction sheet; differences in opinion were to be resolved through discussion or consultation with a third review author if consensus could not be reached. Extraction of the following information was planned:

  • authors; title; year of publication;

  • country of study; setting of study (e.g. primary care);

  • characteristics of participants;

  • number of participants with new pressure ulcers; stage of new pressure ulcers;

  • inclusion criteria and exclusion criteria for participants;

  • number of participants randomised to each trial arm; method of randomisation; allocation concealment; blinding of participants and trial personnel;

  • setting of treatment;

  • details of the intervention (treatment and comparator); co-intervention(s);

  • details of personnel delivering the intervention;

  • duration of intervention; frequency of intervention; duration of follow-up;

  • outcome data for primary and secondary outcomes;

  • number of participants completing; number of withdrawals; reasons for participant withdrawal;

  • statistical methods used in the analysis; methods for handling missing data (per-protocol or intention-to-treat (ITT) analysis).

Assessment of risk of bias in included studies

Two review authors planned to assess the methodological quality of the included studies independently using the Cochrane Collaboration risk of bias tool (Higgins 2011a). This tool covers six specific domains namely; sequence generation, allocation concealment, blinding of participants and outcome assessors, incomplete outcome data, selective outcome reporting and other issues (see Appendix 2). We planned to assess blinding and completeness of outcome data for each outcome separately. Disagreements were to be resolved by consultation with a third review author

Measures of treatment effect

We planned to perform meta-analyses according to the recommendations of the Cochrane Collaboration, depending on the available data and event rate (Higgins 2011a), using the software package Review Manager (RevMan) 5.2 provided by the Cochrane Collaboration (RevMan 2011). For dichotomous data, we planned to calculate the risk ratio (RR) with 95% confidence intervals (CI). For continuous variables, we planned to present mean differences (MD) with corresponding 95% CIs, or standardised mean difference (SMD) with 95% CIs, depending upon the measures used across the studies. We planned to analyse time-to-event data (e.g. time to ulcer development) as survival data. The most appropriate way of summarizing time-to-event data is to use methods of survival analysis and express the intervention effect as a hazard ratio. (Deeks 2011).

Unit of analysis issues

We did not include cluster-randomised trials (C-RCTs) and studies with cross-over designs because these are not appropriate designs to use in answering this research question. C-RCTs are commonly used when it is appropriate or necessary to randomise groups of individuals and cross-over designs are only appropriate when the intervention has a temporary effect and is used in the treatment of a stable condition.

Dealing with missing data

If data were missing from reports, we planned to attempt to contact the study authors to obtain missing information. If this was not successful, we would decide whether the data were missing 'at random' or 'not at random'.

Data are said to be 'missing at random' if the reason for being missing is unrelated to actual values of the missing data. For instance, if some quality-of-life questionnaires were lost in a postal system, this would be unlikely to be related to the quality of life of the trial participants who completed the forms. Data are said to be 'not missing at random' if the reason that they are missing is related to the actual missing data. For instance, in a trial if participants do not attend the final follow-up interview because they have developed a pressure ulcer or are in pain, they are more likely to contribute to missing outcome data. Such data are 'non-ignorable' in the sense that an analysis of the available data alone will typically be biased. Publication bias and selective reporting bias lead by definition to data that are 'not missing at random', and attrition and exclusions of individuals within studies often do as well (Higgins 2011b).

If data turned out to be missing at random, we planned to analyse the available information (completer analysis). If data were regarded as not missing at random, we planned to make explicit the assumptions of any methods we used to deal with the missing data, for example if the missing values were assumed to indicate a poor outcome. We planned to undertake a sensitivity analysis to assess the impact of the assumptions we made. We planned to address the potential impact of any missing data on the findings of the review in the Discussion section (Higgins 2011b).

Assessment of heterogeneity

Heterogeneity would be explored by the Chi2 and I2 tests. We planned to interpret Q test data with P values less than 0.10 as indicating significant statistical heterogeneity. In order to assess and quantify the possible magnitude of inconsistency (i.e. heterogeneity) across studies, we also planned to use the I2 statistic as a rough guide for interpretation (Higgins 2003); an I2 of 30% or under would indicate a low level of heterogeneity, 31% to 59% would indicate moderate heterogeneity, and values of 60% or over would indicate considerable heterogeneity.

Assessment of reporting biases

We planned to investigate reporting biases using appropriate techniques (for example, examining funnel plot asymmetry).

Data synthesis

In future updates of this review, if suitable trials are identified for inclusion, we would undertake analysis of the data using RevMan software (RevMan 2011). We would plan to present the results with 95% confidence intervals (95% CI) and report estimates for dichotomous outcomes as RR, and continuous outcomes as MD or SMD. Data synthesis would depend on the quality, design and heterogeneity of the included trials. If data were not appropriate for pooling or analysis, we would undertake a narrative overview, which would be structured according to the study design that had been used. We would use a fixed-effect model for the meta-analysis where I2 is 30% or under, and a random-effects model when I2 values lie between 31% to 59% we would not undertake meta-analysis when I2 values are 60% or above.

Subgroup analysis and investigation of heterogeneity

We planned to analyse potential sources of heterogeneity as follows: if sufficient data were available and significant heterogeneity were identified, we would undertake the following subgroup analysis: type of setting (community, inpatient, outpatient), as we hypothesized that the characteristics of patients seen in these settings may be different, and hence a source of heterogeneity.If substantial statistical or clinical heterogeneity were detected either by the I2 statistic or by observation, and could not be explained, we would not combine study results, but would present them in a descriptive summary.

Sensitivity analysis

If there were sufficient studies, we planned to undertake a sensitivity analysis to determine the effect of study risk of bias on our results.

Results

Description of studies

We did not find any RCTs or Q-RCTs that met the inclusion criteria.

Results of the search

We excluded most of the citations retrieved by the searches at the title and abstract stage on the basis that the primary focus was not massage therapy for preventing pressure ulcers. We obtained full-text papers for five studies for further assessment. None of these studies met the inclusion criteria and were added to the Characteristics of excluded studies table (Figure 2).

Figure 2.

Study flow diagram.

Included studies

No studies (RCTs or Q-RCTs) were included.

Excluded studies

The Characteristics of excluded studies table lists the reasons for the exclusion of five potentially eligible studies. In summary, one study was not a clinical trial (Duimel-Peeters 2005); one study was not an RCT or a Q-RCT (Acaroglu 2005); In addition, the other two studies were both cross-over trials with a cluster randomisation (Duimel-Peeters 2007; Duimel-Peeters 2003). Finally Olson 1989 did not measure any of the primary or secondary outcomes of the review, being limited to the impact of massage on skin temperature.

Risk of bias in included studies

It was not possible to undertake a risk of bias assessment, because no studies met the inclusion criteria.

Effects of interventions

No studies met the inclusion criteria. Thus, neither a meta-analysis nor a narrative synthesis of studies was possible.

Discussion

Our review highlights the lack of robust evidence for the use of massage in the prevention of pressure ulcers. We found no randomised controlled trials (RCTs) or quasi-randomised trials comparing massage with placebo, standard care or with other therapies amongst people at risk of developing a pressure ulcer. We found a narrative study discussing the potential benefits of massage for this purpose (Acaroglu 2005), and three related randomised controlled trials, none of which met our inclusion criteria (Duimel-Peeters 2003; Duimel-Peeters 2007; Olson 1989). Two of these trials were cross-over trials with a cluster randomisation (Duimel-Peeters 2003; Duimel-Peeters 2007), and one evaluated the effects of massage by measuring skin temperature at the sacral site (Olson 1989).

Consequently, although guidelines advise against the use of massage (Shahin 2009; EPUAP/NPUAP 2009; NICE 2014), there is a lack of evidence in this area. This means that we still do not know if massage has an effect when used as an intervention to prevent pressure ulcers. It is important to have an answer to this question, because massage is an intervention that is widely used by nurses to prevent pressure ulcers (Acaroglu 2005). Accordingly, an opportunity exists to trial some of the more common massage techniques against standard care to investigate whether massage is effective in the prevention of pressure ulcers.

Authors' conclusions

Implications for practice

We did not find any eligible randomised controlled trials (RCTs) or quasi-RCTs. At present, there is no evidence for either the effectiveness, or potential harms, of massage therapy when used to prevent the development of pressure ulcers. Therefore, until good quality evidence emerges, no definitive conclusions regarding massage therapy for prevention of pressure ulcers can be drawn.

Implications for research

There is an urgent need for methodologically robust RCTs to compare massage with placebo, or standard care (such as mattresses, regular turning, and pressure relief of immobile patients) for prevention of pressure ulcers. Multicentre RCTs that can recruit larger sample sizes would be most desirable. In these trials it will be important to investigate the potential harms of massage therapy, as well as the potential benefits.

Acknowledgements

We would like to express our thanks to Sally Bell-Syer for editorial advice during the preparation of this protocol. We would also like to thank the Wounds Group Editors and the peer referee for their comments (Patricia Danielsen; Hugh Macpherson; Anita Raspovic; Marialena Trivella; Joan Webster), and to the copy editor Elizabeth Royle.

This work was supported by the National Natural Science Foundation of China (Grant No. 81273823), Doctoral Fund of Ministry of Education of China (Grant No. 20122327110007), Foundation of Outstanding Innovative Talents Support Plan of Heilongjiang University of Chinese Medicine (Grant No. 2012RCL01; 2012RCQ64).

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. NPUAP/EPUAP pressure ulcer classification

Introductory statements

This classification starts from the premise that the use of the terms 'Stage' and 'Grade' implies a natural progression from Stage/Grade 1 through to 4, which is not generally the case. The use of the term 'Category' is intended to be a neutral term, however, it is recognised that in the United States it may be more difficult to change from the use of 'Stages' to 'Categories' because of some regulations and legislation.

◆ Category I: Non-blanchable redness of intact skin

Intact skin with non-blanchable erythema (redness) of a localised area usually over a bony prominence. Discoloration of the skin, warmth, oedema (swelling), hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching.
Further description: the area may be painful, firm, soft, warmer, or cooler than adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' persons.

◆ Category II: Partial-thickness skin loss or blister

Partial-thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled or serosanguineous-filled (fluid-filled) blister.
Further description: presents as a shiny, or dry shallow, ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation (destruction of skin by scraping or chemicals).

◆ Category III: Full-thickness skin loss (fat visible)

With full-thickness skin loss subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Some slough may be present. May include undermining and tunnelling.
Further description: the depth of a Category III pressure ulcer varies according to anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose, i.e. fat) subcutaneous tissue and Category III ulcers in these locations can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category III pressure ulcers. Bone/tendon is not visible or directly palpable.

◆ Category IV: Full-thickness tissue loss (muscle/bone visible)

Full-thickness tissue loss that exposes bone, tendon, or muscle; slough or eschar (scab) may be present. These ulcers often include undermining and tunnelling.
Further description: the depth of a Category IV pressure ulcer varies according to its anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and ulcers in these areas can be shallow. Category IV ulcers can extend into muscle or supporting structures, or both (e.g. fascia, tendon, or joint capsule) making osteomyelitis or osteitis (inflammations of bone due to infection) likely to occur. Exposed bone/muscle is visible or directly palpable.

Additional categories for the United States of America

◆ Unstageable/unclassified: Full-thickness skin or tissue loss-depth unknown

Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green, or brown) or eschar (tan, brown, or black), or both, in the wound bed.
Further description: until enough slough, eschar, or both, are removed to expose the base of the wound, the true depth cannot be determined; but the ulcer will be either a Category III or IV. Stable (dry, adherent, intact without erythema or fluctuance, i.e. indication of infection), eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

◆ Suspected deep tissue injury

Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure, shear or both.
Further description: the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than the adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may evolve further and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue, even with treatment.

Source: National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel. Clinical practice guidelines for the prevention and treatment of pressure ulcers. (in press)

Appendix 2. The Cochrane Collaboration's tool for assessing risk of bias

1. Was the allocation sequence randomly generated?

Low risk of bias

The investigators describe a random component in the sequence generation process such as: referring to a random number table; using a computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots.

High risk of bias

The investigators describe a non-random component in the sequence generation process. Usually, the description would involve some systematic, non-random approach, for example: sequence generated by odd or even date of birth; sequence generated by some rule based on date (or day) of admission; sequence generated by some rule based on hospital or clinic record number.

Unclear

Insufficient information provided about the sequence generation process to permit a judgement of low or high risk of bias.

2. Was the treatment allocation adequately concealed?

Low risk of bias

Participants and investigators enrolling participants could not foresee assignment because one of the following, or an equivalent method, was used to conceal allocation: central allocation (including telephone, web-based and pharmacy-controlled randomisation); sequentially-numbered drug containers of identical appearance; sequentially-numbered, opaque, sealed envelopes.

High risk of bias

Participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection bias, such as allocation based on: using an open random allocation schedule (e.g. a list of random numbers); assignment envelopes were used without appropriate safeguards (e.g. if envelopes were unsealed or non opaque or not sequentially-numbered); alternation or rotation; date of birth; case record number; any other explicitly unconcealed procedure.

Unclear

Insufficient information provided to permit a judgement of low or high risk of bias. This is usually the case if the method of concealment is not described or not described in sufficient detail to allow a definite judgement, for example if the use of assignment envelopes is described, but it remains unclear whether envelopes were sequentially-numbered, opaque and sealed.

3. Blinding - was knowledge of the allocated interventions adequately prevented during the study?

Low risk of bias

Any one of the following.

  • No blinding, but the review authors judge that the outcome and the outcome measurement are not likely to be influenced by lack of blinding.

  • Blinding of participants and key study personnel ensured, and unlikely that the blinding could have been broken.

  • Either participants or some key study personnel were not blinded, but outcome assessment was blinded and the non-blinding of others unlikely to introduce bias.

High risk of bias

Any one of the following.

  • No blinding or incomplete blinding, and the outcome or outcome measurement was likely to be influenced by lack of blinding.

  • Blinding of key study participants and personnel attempted, but likely that the blinding could have been broken.

  • Either participants or some key study personnel were not blinded, and the non-blinding of others was likely to introduce bias.

Unclear

Either of the following.

  • Insufficient information provided to permit a judgement of low or high risk of bias.

  • The study did not address this outcome.

4. Were incomplete outcome data adequately addressed?

Low risk of bias

Any one of the following.

  • No missing outcome data.

  • Reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias).

  • Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups.

  • For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk were not enough to have a clinically relevant impact on the intervention effect estimate.

  • For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes was not enough to have a clinically relevant impact on observed effect size.

  • Missing data have been imputed using appropriate methods.

High risk of bias

Any one of the following.

  • Reason for missing outcome data are likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups.

  • For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk is enough to induce clinically relevant bias in intervention effect estimate.

  • For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes is enough to induce clinically relevant bias in observed effect size.

  • ‘As-treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation.

  • Potentially inappropriate application of simple imputation.

Unclear

Either of the following.

  • Insufficient reporting of attrition/exclusions to permit judgement of low or high risk of bias (e.g. number randomised not stated, no reasons for missing data provided).

  • The study did not address this outcome.

5. Are reports of the study free of suggestion of selective outcome reporting?

Low risk of bias

Either of the following.

  • The study protocol is available and all of the study’s pre-specified (primary and secondary) outcomes that are of interest in the review have been reported in the pre-specified way.

  • The study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were pre-specified (convincing text of this nature may be uncommon)

High risk of bias

Any one of the following.

  • Not all of the study’s pre-specified primary outcomes have been reported.

  • One or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not pre-specified.

  • One or more reported primary outcomes were not pre-specified (unless clear justification for their reporting is provided, such as an unexpected adverse effect).

  • One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta-analysis.

  • The study report fails to include results for a key outcome that would be expected to have been reported for such a study.

Unclear

Insufficient information provided to permit a judgement of low or high risk of bias. It is likely that the majority of studies will fall into this category.

6. Other sources of potential bias

Low risk of bias

The study appears to be free of other sources of bias.

High risk of bias

There is at least one important risk of bias. For example, the study:

  • had a potential source of bias related to the specific study design used; or

  • has been claimed to have been fraudulent; or

  • had some other problem.

Unclear

There may be a risk of bias, but there is either:

  • insufficient information provided to assess whether an important risk of bias exists; or

  • insufficient rationale or evidence that an identified problem will introduce bias.

History

DateEventDescription
21 October 2008AmendedConverted to new review format.

Contributions of authors

Zhang Qinhong: developed, completed the first draft of, made an intellectual contribution to and approved the final version of the protocol prior to submission.
Yue Jinhuan: conceived the review question, co-ordinated the protocol development, performed part of writing or editing and advised on the protocol.
Sun Zhongren: secured funding for, edited, advised on and acted as guarantor for the protocol.

Contributions of editorial base

Nicky Cullum: edited the protocol; advised on methodology, interpretation and review content and approved the final version of the review.
Liz McInnes, Editor: approved the final protocol and review prior to submission.
Sally Bell-Syer: co-ordinated the editorial process. Advised on methodology, interpretation and content. Edited the protocol and the review.
Ruth Foxlee: designed the search strategy and edited the search methods section.
Rachel Richardson: edited the review.

Declarations of interest

Zhang Qinhong: none known
Yue Jinhuan: none known
Sun Zhongren: none known

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to Cochrane Wounds. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Healthp, UK.

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    Abbreviations

    DMSO = dimethyl sulfoxide cream
    Q-RCT = quasi-randomised controlled trial
    RCT = randomised controlled trial

Acaroglu 2005Not a RCT or a Q-RCT
Duimel-Peeters 2003Cross over trial design
Duimel-Peeters 2005Not clinical trial
Duimel-Peeters 2007Cross over trial design
Olson 1989Did not address any of the reviews' primary or secondary outcomes, but considered only skin temperature

Ancillary