REVIEW

The physiological and psychological effects of slow-stroke back

massage and hand massage on relaxation in older people
Melodee Harris and Kathy C Richards

Background and aims. In recent years, the nursing profession used technology and pharmacology to relieve conditions such as
pain, anxiety and insomnia that were once treated with massage. However, interest in massage has grown with the move to
more holistic nursing. This review examines the physiological and psychological effects of slow-stroke back massage and hand
massage on relaxation in older people and identifies effective protocols for massage in older people.
Design. Review.
Methods. Coopers five-stage model was used in the review process. The search strategy included all studies without limiters for
dates through June 2009 in the following databases: Ovid Medline, Cochrane databases, PubMed, EBSCO, CINAHL, Health
Resource, PychINFO and EMB Reviews 1991June 2009. The quality of the research was evaluated using the Research
Appraisal Checklist. Twenty-one studies met the inclusion criteria for massage, relevance to older people and rigorous research.
Results. All studies using slow-stroke back massage and hand massage showed statistically significant improvements on
physiological or psychological indicators of relaxation. The most common protocols were three-minute slow-stroke back
massage and 10-minute hand massage.
Conclusion. Physiological and psychological indicators suggest the effectiveness of slow-stroke back massage and hand massage
in promoting relaxation in older people across all settings.
Relevance to clinical practice. Studies are needed to analyse the feasibility and cost effectiveness of massage to develop best
practices for massage interventions in older people.

Key words: hand massage, hypothalamicpituitary axis, relaxation, slow-stroke back massage

Accepted for publication: 21 July 2009

The practice of massage is regulated in most states through

Introduction
licensing of massage therapists and nurse massage therapists.
In 1910, Isabel Hampton Robb wrote: However, traditional back rubs and hand massage do not
require a licence and can be administered by nurses with
It is not only desirable but absolutely necessary that nurses should
routine training. Although massage is a traditional nursing
have a good general knowledge of the principles of massage, its
intervention and a part of early nursing history, few studies
physical and physiological effects and its general application, because
have examined the benefits of massage for older people.
such knowledge will enable her to do much for the relief and comfort
Older adults in the 66100-year-old age group are more
of almost any kind of patient, (as cited in Fraser & Kerr 1998,
deprived of affective touch than any other population
p. 239).

Authors: Melodee Harris, PhD, APN, GNP-BC, John A. Hartford
Foundation BAGNC Scholar 20072009, College of Nursing,
University of Arkansas for Medical Sciences, Little Rock,
AR; Kathy C Richards, PhD, RN, Director, Madlyn and Leonard
Abramson Center for Jewish Life, Polisher Research Institute, North
Wales, Professor, School of Nursing, University of Pennsylvania,
Philadelphia, PA, USA and Director, Pennsylvania Hartford Center
for Geriatric Nursing Excellence, Pennsylvania State University,
School of Nursing, University Park, PA, USA
Correspondence: Melodee Harris, John A. Hartford Foundation
BAGNC Scholar 20072009, College of Nursing, University of
Arkansas for Medical Sciences, 4301 West Markham Street, Slot
#529, Little Rock, AR 72205, USA. Telephone: +501 230 7269.
E-mail: harrismelodee@uams.edu

2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926 917
doi: 10.1111/j.1365-2702.2009.03165.x
M Harris and KC Richards
(Barnett 1972). The literature provides evidence of the safety
of back rubs and hand massage in older people with few
contraindications (Bauer & Dracup 1987, DayBreak Geriat-
ric Massage Institute 2006).
In Western culture, massage is often viewed as alternative
medicine, complementary therapies or adjuncts to main-
stream physician-oriented care. In recent years, the nursing
profession has conformed to a highly technological environ-
ment and the use of pharmacology to relieve stressful
physiological and psychological conditions such as pain,
anxiety and insomnia that were once treated with massage.
However, non-pharmacological therapies such as massage
are first-line interventions for relaxation in older people.
Massage may produce relaxation by tactile stimulation in
body tissues causing complex neurohumoral responses in the
hypothalamicpituitary axis (HPA) to circuit through the
central nervous system pathways. The stimulus is distributed
through the cortex, midbrain and lower brain and interpreted
as a relaxation response (Lawton 2003). Adaptation to stress
is regulated by the capacity of the HPA to secrete hormones
such as cortisol and endorphins that decrease sympathetic
nervous system activity and increase responses of the para-
sympathetic nervous system (Moyer et al. 2004). Cortisol is a
major stress hormone and end product of sympathetic
activity. It is thought that tactile stimulation from massage
counteracts the overproduction of cortisol by influencing the
secretion of corticotropin from the HPA. Corticotropin in
turn decreases cortisol and promotes relaxation (Remington
2002). Massage may be the mediating process for the
reduction of physiological and psychological stress in older
people.
Aims and methods
The first aim of this paper is to review the literature on the
physiological and psychological effects of slow-stroke back
massage on relaxation in older people. The second aim is to
identify effective protocols for massage in older people.
Coopers (1998) five-stage model was used in the review
process. The five stages are problem formation, literature
search, data evaluation for the quality of the research,
analysis and interpretation, and presentation of results.
The quality of the research was evaluated according to the
Research Appraisal Checklist (RAC) by Duffy (2001). The
RAC contains 51 items in eight categories that are rated on a
six-point Likert Scale. Quality indicators include values for
the title, abstract, problem, literature review, methodology,
data analysis, discussion, and format and style. Grand totals
for the studies are scored according to Duffys criteria as
superior, average or below average. The RAC has an
918 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
interrater reliability of r = 094. The alpha value for item-
to-item correlations for the total RAC is 091 (Duffy 2001).
To facilitate the review process and provide support for
clinical relevance of massage techniques, study designs were
categorised according to the guidelines for the levels of
quantitative evidence in Evidence-based Geriatric Protocols
for Best Practices (Capezuti et al. 2008).
Definitions of terms
In stage 1 of Coopers model, terms associated with the
concept of massage were developed and defined. Hand
massage and slow-stroke back massage were the terms
included in this review. Common terms found in the
literature for slow-stroke back massage included massage,
back rub or effleurage. However, closer scrutiny was
required to determine a definition of slow-stroke back
massage that was consistent with relaxation. Slow-stroke
back massage in nursing practice differs from massage
practices associated with complementary or alternative
treatments. Slow-stroke back massage in nursing is a type
of Swedish massage known as effleurage (Labyak & Metzger
1997), a massage technique that uses long, firm slow strokes
(Labyak & Metzger 1997). In contrast to massage techniques
that are more stimulating and are used for circulation such as
deep tissue massage, tapotement or pettrisage, effleurage is
used to promote relaxation (Fakouri & Jones 1987). Studies
defining massage as including multiple techniques such as
acupuncture, therapeutic massage or deep tissue massage
were carefully examined and excluded from this review.
Search strategy
The search strategy used for data collection in stage 2 of
Coopers model included databases from Ovid MEDLINE
from 1960June 2009, Ovid old MEDLINE from 1950
1960, EMB Reviews 1991June 2009 and Cochrane data-
bases. All studies without limiters for dates were searched in
the following databases: PubMed, Elton B. Stephens
Company (EBSCO), the Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Health Resource and
PychINFO.
Search terms
The search terms were massage, effleurage, slow-stroke
massage, massage and elderly, massage and dementia,
massage and Alzheimers disease, touch and elderly, touch
and dementia, touch and Alzheimers disease, back rub
and elderly, back rub and dementia, and back rub and
Review
Alzheimers disease. Terms such as chiropractic, Reiki,
shiatsu, mechanical massage, ice massage, acupuncture, studies met the inclusion criteria for massage, relevance to
healing touch and therapeutic touch were not used because
the focus of the review was on massage for relaxation that is a
part of traditional nursing care and does not require
specialised training.
Inclusion and exclusion criteria
This review was limited using the following inclusion and
exclusion criteria: (1) studies published in the English lan-
guage, (2) participants were men or women with a mean age
of 65 years or older, (3) only studies with slow-stroke back
massage or hand massage as the sole intervention, compared
with control groups or examined in qualitative studies, were
included and (4) studies that included other interventions
such as acupuncture were excluded unless the combined
interventions were compared with a single-intervention
massage group. Reviews or studies without well-defined cri-
teria for rigorous research as below average according to the
RAC (Duffy 2001) were excluded.
Synthesis process
In stage 3 of Coopers model, the titles of all articles with
reference lists for studies that met the inclusion criteria were
hand-searched to identify studies that might have been
excluded from the searches. The American Massage Therapy
Foundation and Touch Massage Institute websites were also
searched for missing data. ProQuest was searched for
doctoral dissertations and non-indexed studies.
Titles and abstracts were screened for the search terms.
Abstracts including studies related to complementary thera-
pies were then reviewed for relevance to massage and older
people. Full-text articles were examined for studies with
participants with a mean age of 65 years and older and for
the use of hand or slow-stroke back massage techniques in
older people. The RAC was used to evaluate the quality of
the research (Duffy 2001).
Twelve studies were repeatedly found in the searches.
When duplicates were removed from all categories and
potentially eligible full-text articles were screened from the
abstracts, 24 articles were scored using the RAC. Of the 24
articles, three studies did not meet the inclusion criteria
because of their failure to comply with massage protocols or
use of a combination of massage techniques. A demonstration
study by Sansone and Schmitt (2000) was excluded because
the authors noted that the protocol was not followed
consistently. Studies by Hirakawa et al. (2005) and Sharpe
et al. (2007) were excluded because massage protocols used
acupuncture, myofascial or other techniques in combination
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
Massage in the elderly
with slow-stroke back massage protocols. Thus, a total of 21
older people and rigorous research (Fig. 1).
Overview of the review
Of the 21 articles reviewed, two were systematic reviews, six
were randomised controlled trials, 12 were quasi-experimen-
tal studies and one was a non-experimental study. The oldest
study was reported in 1987 by Fakouri and Jones. The most
recent published study in 2008 on hand massage was by
Hicks-Moore and Robinson. Of the 19 studies based on
clinical research, seven used hand massage and 12 used slow-
stroke back massage.
Two systematic reviews in this study investigated hand
massage and back massage (Weinrich et al. 1999, Viggo
Hansen et al. 2006). The review by Weinrich et al. (1999)
analysed six of the studies also included in this systematic
review. Articles in the systematic review by Weinrich et al.
(1999) were hand-searched, and three studies in this review,
Dunn et al. (1995), Groer et al. (1994) and Reed and Held
(1988), were excluded based on massage techniques used for
purposes other than relaxation and mean ages of participants
younger than 65 years of age.
Study designs, procedures, instruments, outcome variables
and benefits of back massage on older people were summar-
ised by Weinrich et al. (1999), who reported vital signs as
physiological indicators that associated relaxation with
massage in older people in one randomised controlled trial
(Corley et al. 1995) and two quasi-experimental trials
(Fakouri & Jones 1987, Meek 1993). Vital signs also
21
Studies
Duffys RAC
Full text manuscript
review
Abstract review
Data bases
OVID medline, Cochrane, PubMed, EMB reviews,
EBSCO, CINAHL, Health resource, PsychINFO
Figure 1 Synthesis process.
919
M Harris and KC Richards
indicated psychological benefits of slow-stroke back massage
for decreased anxiety in older people in another well-
designed, randomised controlled trial (Fraser & Kerr 1993).
Vital signs indicated that hand massage decreased morning
agitation (Snyder et al. 1995a) and increased relaxation
(Snyder et al. 1995b) in two studies using crossover designs.
The systematic review by Viggo Hansen et al. (2006)
analysed the effects of massage and touch in dementia. The
authors recognised only one study by Remington (2002)
using hand massage as meeting the standards for Cochrane
systematic reviews.
Conceptual frameworks
Several theories were used to conceptualise the research
reviewed. Selyes Stress Adaptation Theory and Bensons
Theory of Stress were used to guide the research (Fraser &
Kerr 1993, Richards 1998, Mok & Woo 2004), based on the
view that the parasympathetic nervous system is triggered to
produce relaxation by the effects of massage on the hypo-
thalamus. In one study (Meek 1993), Roys Adaptation
Model rooted in Selyes Theory was used to explain massage
as a physiological interaction with the environment to relieve
pain and promote relaxation. The Theoretical Model for
Aggression in Cognitive Impairment (Rowe & Alfred 1999)
was used to develop implementation of a massage protocol
by caregivers at the first signs of agitation, to diffuse the
progression of behaviours. The Gate Theory (Mok & Woo
2004) was used to explain massage as an intervention to
relieve pain by closing painful stimuli at the dorsal horn of
the spinal cord. One study (Kolcaba et al. 2006) used The
Theory of Comfort to support hand massage as an inter-
vention to provide comfort. The Progressively Lowered Stress
Threshold Theory (PLST) was used in four studies as a
framework for hand massage (Snyder et al. 1995a,b, Snyder
& Olson 1996, Remington 2002). The PLST suggests that
massage is a mechanism that decreases the stress response
by inhibiting the endocrine system from producing stress
hormones.
Sample and setting
Overall, sample sizes were small, ranging from 5102
participants, with an average sample 35 participants. Their
average mean age was 758 years. Participants were predom-
inantly Caucasian women. Three studies included only
women (Madison 1973, Gentner 1980), and one study
included only men (Richards 1998). Of the studies with a
combined sample of men and women, only three (Corley
et al. 1995, Snyder et al. 1995a, Mok & Woo 2004) reported
a gender analysis of the effects of massage. One Australian
920 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
study (Kilstoff & Chenoweth 1998) was multicultural,
including Chinese, Italian, Vietnamese, French and English
participants. One study took place in Hong Kong and two
studies were from Canada. Only the study by Kolcaba et al.
(2006) addressed European ancestry of the participants.
Three studies reported percentages of the sample by race
(Richards 1998, Holland & Pokorny 2001, Kolcaba et al.
2006), but none of the studies, including the multicultural
study (Kilstoff & Chenoweth 1998), addressed the effects of
massage on race or ethnicity of older people. Rowe and
Alfreds (1999) study was the only one using slow-stroke
back massage in dementia. All studies using hand massage
except Kolcaba et al. (2006) conducted research with persons
with dementia. Long-term care was the most frequent
setting used in 12 studies. Six studies were conducted in
other institutionalised settings such as hospice or coronary
care units, and two were based in the community (Tables 1
and 2).
Protocols
Protocols for slow-stroke back massage and hand massage
varied. A three-minute protocol was used in four studies for
slow-stroke back massage. Other protocols ranged from
510 minutes. Four studies used 10-minute protocols for
hand massage. Longer protocols ranged from 1016 minutes.
Fakouri and Jones (1987), Meek (1993), Corley et al.
(1995) and Holland and Pokorny (2001) used three-minute
protocols for slow-stroke back massage. The investigators
cited previous research as support for using this timing. Rowe
and Alfred (1999) used a 75-minute protocol to investigate
the effectiveness of massage in diffusing agitation in older
people. Rowe and Alfred (1999) noted that previous litera-
ture had identified time frames for massage longer than three
minutes were physically stimulating.
A five-minute protocol was used by Fraser and Kerr (1993),
and Richards (1998) used a six-minute protocol for slow-
stroke back massage for sleep. Mok and Woo (2004) used a
30-minute protocol for back massage.
Slow-stroke back massage and physiological indicators of
relaxation
Six studies used physiological indicators of the effects of
slow-stroke back massage on relaxation for older people. The
most important study on relaxation and slow-stroke back
massage was on the exploratory study by Fakouri and Jones
(1987). They conducted a quasi-experimental study (n = 18)
of physiological indicators of relaxation as the proposed
mechanism for slow-stroke back massage. Blood pressure,
heart rate, finger temperature and verbal responses were
Review Massage in the elderly

Table 1 Overview of physiological and psychological effects of slow-stroke back massage (SSBM)

Protocol
Study Level Sample Setting (minutes) Result

Corely et al. (1995) II RCT n = 19 Nursing home 3 Improvement on mood and physiological
variables
Fakouri and III Quasi-experimental n = 18 Nursing home 3 Statistical significant effect on physiological
Jones (1987) variables immediately and 10 minutes after
SSBM
Verbal report-helped with relaxation/sleep
Fraser and Kerr II RCT n = 21 Nursing home 5 Statistical significant effect on anxiety
(1993) Improvement on physiological variables
Verbal Report-helps with relaxation
Holland and III Quasi-experimental n = 24 Rehabilitation 3 Statistical significance effect on physiological
Pokorny (2001) variables
No effect on psychological variables
Verbal report-helped with sleep
Meek (1993) III Quasi-experimental n = 30 Hospice 3 Statistical significant effect on physiological
variables immediately and 10 minutes after SSBM
Mok and Woo II RCT n = 102 Rehabilitation 10 Improvement on physiological variables
(2004) Statistical significant effect on anxiety
Verbal report-helped with relaxation/helped
with pain
Richards (1998) II RCT n = 69 CCU 6 Improvement in sleep
Rowe and Alfred III Quasi-experimental 14 dyads Community 75 Improvements in agitated behaviours
(1999)
Besinger and Payne III Quasi-experimental n = 18 Laboratory 10 Statistical significant effects on physiological
(1986)* variables
Gentner (1980)* III Quasi-experimental n = 30 Nursing home 10 Improvements in loneliness but increase in
depression
Searle (1987)* III Quasi-experimental n = 11 CCU 10 Statistical significant effects on physiological
and psychological variables
Madison (1973)* III Quasi-experimental n = 60 Nursing home 3 Statistical significant effects on physiological variables

*Dissertation study.
RCT, randomised control trial.

analysed using t-test comparisons of mean results to deter-
mine the effects of slow-stroke back massage on relaxation.
Means were compared before, immediately after and 10 min-
utes after treatment using a three-minute protocol for slow-
stroke back massage over three days. Differences in the
means were statistically significant at the 005 level for all
physiological indicators at all intervals except for diastolic
blood pressure on Day 1 and Day 2.
Four subsequent studies modelling the work of Fakouri
and Jones (1987) used vital signs as objective measures for
the effects of massage on relaxation. Two quasi-experi-
mental studies (Meek 1993, Holland & Pokorny 2001)
showed results consistent with those of Fakouri and Jones
(1987).
Holland and Pokorny (2001) used a quasi-experimental
design with a non-randomised convenience sample (n = 24)
on a rehabilitation unit. Participants served as their own
controls and received three-minute slow-stroke back mas-
sages over three days. Respiratory rate, heart rate and blood
pressure readings were recorded before and after the slow-
stroke back massage. Statistically significant improvements
at the 005 level occurred on the mean scores of all vital signs
on all three days.
Meek (1993) investigated the effects of slow-stroke back
massage on relaxation using a sample of elders on a hospice
unit (n = 30). A three-minute slow-stroke back massage was
administered after a five-minute rest. Vital signs were taken
before the rest period, immediately after the intervention and
then five minutes after the intervention. Mean scores on
blood pressure, heart rate and skin temperature revealed
statistically significant improvements in all vital signs at the
0001002 levels.
However, two randomised controlled trials in nursing
home studies (Fraser & Kerr 1993, Corley et al. 1995)
with methodology and settings similar to Fakouri and
Jones revealed conflicting results. In a randomised

2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926 921
M Harris and KC Richards

Table 2 Overview of phsyiological and psychological effects of hand massage (HM)

Sample Protocol
Study Level (n) Setting (minutes) Result

Hicks-Moore and II RCT 41 Nursing home 10 Statistical significance for decrease in

Robinson (2008) verbal agitation and non-aggressive
behaviours immediately and one hour
after HM
Kilstoff and IV Non-experimental 39 Nursing home 1015 Perceived improvements in ADLS and
Chenoweth (1998) alertness
HM promotes relaxation
Kolcaba et al. (2006) III Quasi-experimental 60 Nursing home 1216 Statistical significant effects on comfort
Remington (2002) II RCT 68 Nursing home 5 Statistical significant effects on verbally
agitated behaviours immediately and
at one hour
Snyder and Olson (1996) III Quasi-experimental 5 Nursing home 10 Improvement in aggressive behaviours
Snyder et al. (1995a) III Quasi-experimental 26 Nursing home 5 Improvements in agitated behaviours
Snyder et al. (1995b) III Quasi-experimental 17 Nursing home 10 Statistical significant effects on physiological
variables and anxious behaviours

RCT, randomised control trial.

controlled trial (n = 21), Fraser and Kerr (1993) measured
blood pressure, heart rate, skin temperature and electro-
myography (EMG). When analysis of variance (ANOVA )
data were analysed, EMG testing was the only variable
that showed statistically significant improvements (p <
005) after a five-minute slow-stroke back massage. Several
years later, Corley et al. (1995) measured blood pressure,
heart rate, skin temperature and EMG readings after a
three-minute slow-stroke back massage. The results showed
trends, but no statistically significant improvements for all
variables.
Finally, a study by Richards (1998) investigated the effects
of slow-stroke back massage on relaxation in older people,
but using polysomnography data as an objective measure for
sleep. A randomised controlled posttest only design was used
to test the effects of slow-stroke back massage on a sample of
hospitalised men (n = 69). Participants were randomly
assigned to a six-minute slow-stroke back massage interven-
tion, a teaching session with a 75-minute audio tape with
relaxing background music, muscle relaxation and mental
imagery, or a control group who received usual nursing care.
The analysis of the data showed trends, but no statistically
significant results (p = 006).
Slow-stroke back massage and psychological indicators of
relaxation
Three published studies (Fraser & Kerr 1993, Rowe & Alfred
1999, Mok & Woo 2004) and three dissertation studies
(Madison 1973, Gentner 1980, Searle 1987) have investi-
gated psychological indicators of the effects of slow-stroke
back massage on relaxation using several psychometric
instruments.
Two studies (Fraser & Kerr 1993, Mok & Woo 2004) used
results from a 20-question Spielberger Self-Evaluation
Questionnaire (STAI) to analyse the psychological effects of
slow-stroke back massage on older people. A randomised
controlled trial (n = 21) by Fraser and Kerr (1993) found a
statistically significant improvement in the mean anxiety
score on the STAI after a five-minute slow-stroke back
massage. Mok and Woo (2004) also used the STAI in a
randomised controlled trial (n = 102) with hospitalised
Chinese elders. After a 10-minute slow-stroke back massage,
results from the STAI showed statistically significant
increases in relaxation (p < 005).
A study by Rowe and Alfred (1999) used the Brief
Noncognitive Symptom Rating Scale (BSRS) to measure the
level of agitation in community dwelling elders with dementia
(n = 14) before and after a slow-stroke back massage
administered by caregivers. An analysis did not reveal any
statistically significant decreases in physically agitated behav-
iours. The BSRS did indicate that physical expressions of
agitation, including pacing, wandering and resisting care,
decreased with slow-stroke back massage in five out of nine
participants.
A dissertation study by Gentner (1980) used a non-
randomised pretest/posttest design with an intervention and
control group to test the psychological effects of slow-stroke
back massage on a convenience sample (n = 30) of older
women. Gentner used the Zung Depression Scale, the UCLA
Loneliness Scale and the Rosenburg Self-Esteem Scale to
measure the effects of slow-stroke back massage on

922 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
Review
depression, loneliness and self-esteem. Analysis of covariance
revealed statistically significant decreases in loneliness
(p < 003) and an increase in self-esteem (mean score
3156; the highest rating is 40). One-way analysis of
covariance found a statistically significant increase in depres-
sion in the experimental group.
A dissertation study by Searle (1987) used the Resting
Measure Scale (RMS) to test the effects of slow-stroke back
massage on hospitalised elders (n = 11) in a coronary care
unit (n = 11) in Canada. The study used a repeated-measures,
quasi-experimental design. The RMS is a 13-item question-
naire requiring a subjective response that rates relaxation
effects of slow-stroke back massage. The RMS showed a
statistically significant improvement in relaxation (p < 001
005), indicating that participants perceived slow-stroke back
massage as restful or relaxing.
Using a random, repeated-measures design, a dissertation
study by Madison (1973) used vital signs to measure the
psychological effects of slow-stroke back massage on older
women in the nursing home. A statistically significant
decrease in heart rate at the 005 level indicated the
effectiveness of slow-stroke back massage for relaxation.
Subjective verbal reports of participants from five studies of
slow-stroke back massage indicated that the intervention was
relaxing, relieved pain (Fraser & Kerr 1993, Mok & Woo
2004) and promoted sleep (Fakouri & Jones 1987, Richards
1998, Holland & Pokorny 2001). Only one study by
Richards (1998) investigated the relaxing effects of slow-
stroke back massage using polysomnography as an objective
measurement for sleep. That study showed trends towards
improved sleep consistent with verbal reports.
Hand massage and indicators of relaxation
Seven studies of hand massage used vital signs and psycho-
metric instruments to examine the psychological effects of slow-
stroke back massage for relaxation. Only two of these studies
(Snyder et al. 1995b, Snyder & Olson 1996) used vital signs as
psychological indicators of relaxation. Decreased heart rate
was a statistically significant (p = 00010002) with hand
massage reducing anxious behaviours (Snyder et al. 1995b).
The Cohen Mansfield Agitation Index (CMAI) was used
in two randomised controlled trials to test the effects of
hand massage on agitated behaviours. Statistically significant
reductions in verbal (p < 0001) and non-aggressive behav-
iours (p < 0001) were found in the study by Hicks-Moore
and Robinson (2008) in 41 participants immediately and
one hour after hand massage. Remington (2002) found
statistically significant reductions in behaviours that are not
physically aggressive (p < 001) one hour after hand
massage in 68 participants.
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
Massage in the elderly
In a quasi-experimental study of 17 participants, by Snyder
et al. (1995b), the Luiselli Checklist showed statistically
significant (p = 00010005) reductions on anxious behav-
iours immediately after hand massage. Sustained effects were
not explored in this study. A multivariate analysis of data in a
quasi-experimental trial by Kolcaba et al. (2006) revealed
statistically significant effects of hand massage on comfort in
a quasi-experimental study of 70 participants in the nursing
home.
Six experimental studies and one qualitative study inves-
tigated the effects of hand massage on relaxation among
older people with dementia. The studies investigated depen-
dent variables for verbal agitation, non-aggressive agitated
behaviours, comfort and anxious behaviours. All experimen-
tal studies of hand massage showed statistically significant
improvements on dependent variables. Also, the qualitative
study by Kilstoff and Chenoweth (1998) concluded that hand
massage was a beneficial intervention for dementia. The
studies on hand massage reported a consistent reduction in
verbal aggression and non-aggressive behaviours in persons
with dementia.
Discussion
Outcomes on psychological indicators are consistent with
strong physiological indicators for slow-stroke back mas-
sage on relaxation in older people. Statistically significant
results and improvements for physiological and psycholog-
ical indicators are associated with decreasing agitation and
promoting relaxation using hand massage in older people.
Stronger correlations were found between slow-stroke back
massage and psychological responses in older people. The
effects of massage for reducing anxiety and increasing
relaxation were recurring themes suggesting that slow-
stroke back massage reduces psychological stress. The
studies on hand massage reported a consistent reduction
in verbal aggression and non-aggressive behaviours in
persons with dementia.
In the investigations into the physiological indicators of
the effects of massage, heart rate was the strongest
indicator of relaxation. All studies showed either statisti-
cally significant improvements or trends towards improve-
ments in vital signs. More studies are needed to compare
massage with pharmacological therapy using objective
measures for such conditions as pain and sleep to
develop evidence-based practices for non-pharmacological
interventions.
Four of the studies reviewed used widely recognised
instruments such as the Cohen Mansfield Agitation Inventory
(Remington 2002, Hicks-Moore & Robinson 2008) to
923
M Harris and KC Richards
measure agitated behaviours and the STAI (Fraser & Kerr
1993, Mok & Woo 2004) to measure anxiety. Psychometric
instruments with reported validity and reliability are needed
to provide more objective data consistent with subjective
verbal reports of the effects of slow-stroke back massage and
hand massage on relaxation.
Viggo Hansen et al. (2006) have identified several
limitations of studies in Massage and Touch for Dementia.
These authors found a lack of description of the randomi-
sation process, concealed allocation and failure to identify
side effects and benefits of massage as common limitations
of the studies in their review. They recommended more
focused studies to answer single research questions that
yield high-quality evidence and controls for environmental
factors such as room temperature, noise and interruptions
in care. The authors also cited the many sociocultural
implications of massage, suggesting a need for exploration
of differences in preferences of massage by gender, culture,
race and ethnicity.
Conclusion
Small sample sizes were consistent limitations cited by the
authors of these studies. Weaknesses in study designs for
randomisation, sham control groups, blinding and reporting
of power analysis are limitations of the studies in this review.
Standard techniques for massage and protocols tailoring
massage interventions for older people are needed for
evidence-based practices.
Some variability in the results of these studies has been
because of the massage protocols. Fakouri and Jones
(1987), Meek (1993) and Holland and Pokorny (2001)
followed three-minute slow-stroke back massage protocols
and showed statistically significant improvements in phys-
iological indicators of relaxation. In the randomised con-
trolled trials that revealed trends rather than statistically
significant improvements, Fraser and Kerr (1993) followed
a five-minute protocol and Richards (1998) adhered to a
six-minute slow-stroke back massage protocol. The only
three-minute protocol for slow-stroke back massage that
did not reveal statistically significant improvements for
relaxation in older people was the study by Corley et al.
(1995). Clearly, standardised protocols are necessary to
analyse the effects of slow-stroke back massage on relax-
ation in older people.
Relevance to clinical practice
Slow-stroke back massage is a traditional nursing interven-
tion that was once used to relieve pain and promote
924 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 917926
relaxation and sleep. Although slow-stroke back massage
has a remote place in nursing history because of the adoption
of pharmacological interventions, non-pharmacological
interventions such as massage are first-line interventions for
older people. Compared with pharmacological interventions,
slow-stroke back massage and hand massage have fewer
contraindications for older people and can be used easily by
trained formal and informal caregivers.
Statistically significant improvements in physiological and
psychological indicators in these studies provide support for
the use of slow-stroke back massage and hand massage in
clinical practice across all settings including family caregivers
for persons with dementia, older people in hospice settings
and long-term care. More studies are needed on the imple-
mentation of slow-stroke back massage by caregivers.
Further, the current literature provides support for the use
of hand massage for relaxation in older people only in the
nursing home setting.
Relaxation and sleep are important issues for older adults.
Subjective verbal reports on the effects of slow-stroke back
massage on sleep found in these studies are data from
polysomnography in the coronary care unit (Richards 1998).
However, more research is needed to test the effects of slow-
stroke back massage and hand massage on the sleep of older
adults using objective measures such as polysomnography or
actigraphy.
The statistically significant improvements for physiological
and psychological indicators in studies on three-minute slow-
stroke back massage and 10-minute hand massage provide a
reasonable basis for the introduction of these interventions in
clinical practice. Kolcaba et al. (2006) cited administrative
support as barriers to the use of hand massage in the nursing
home, and clearly demands placed on nursing staff need to be
considered. To make the implementation of hand massage
more appealing to nursing staff, Snyder et al. (1995a)
reduced their hand massage protocol from 10 minutes in a
previous study (Snyder et al. 1995b) to five minutes. How-
ever, Remington (2002) noted that five-minute protocols may
not be long enough to produce an effect from hand massage.
Research on protocols for slow-stroke back massage and
hand massage is needed to determine the amount of pressure
to be applied, the time of day, the length and the lasting
effects of massage.
Nurses can be trained in the knowledge and skill required
to administer and educate caregivers on the use of slow-
stroke back massage and hand massage. Slow-stroke back
massage and hand massage for relaxation may be an effective
alternative to pharmacological therapy in reducing physio-
logical and psychological stress and improving the quality of
life in older people.
Review
Acknowledgements
This study was made possible through generous support from
The John A. Hartford Foundation Building Academic Geri-
atric Nursing Excellence Capacity Predoctoral Scholarship
Program; Sigma Theta Tau Gamma XI; National
Gerontological Nurses Association Mary Wolanin Graduate
Scholarship.
Contributions
Study design: MH; data collection and analysis: MH, KR;
manuscript preparation: MH.
Conflict of interest
None.
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