Complementary Therapies in Clinical Practice 30 (2018) 122e128

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Does abdominal massage improve gastrointestinal functions of

intensive care patients with an endotracheal tube?: A randomized
clinical trial
Mahlagha Dehghan a, Amanollah Fatehi poor a, *, Roghayeh Mehdipoor a,
Mehdi Ahmadinejad b
a
Nursing Research Center, Kerman University of Medical Sciences, Kerman, Haft Bagh Alavi road, Iran
b
Fellow of Critical Care Medicine, Kerman University of Medical Sciences, Haft Bagh Alavi road, Kerman, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Gastrointestinal dysfunction is one of the most common problems among patients hos-
Received 16 October 2017 pitalized in intensive care units. Currently, medicinal and non-medicinal methods are being used to
Received in revised form prevent gastrointestinal problems. Among non-medicinal methods, abdominal massage is considered as
14 December 2017
a relatively acceptable method. The present study aims to examine the effect of abdominal massage on
Accepted 29 December 2017
gastrointestinal functions of the intensive care patients with an endotracheal tube.
Materials and methods: In this clinical trial, 70 intensive care patients with an endotracheal tube were
Keywords:
chosen by convenience sampling and allocated to an intervention or a control group randomly. In the
Abdominal massage
Digestive function
intervention group, a 15-min abdominal massage was conducted twice a day for three days, while the
Intensive care units control group received only routine cares. The abdominal circumference, gastric residual volume, times
Constipation of defecation, and frequency of constipation were measured.
Gastric residual volume Results: Gastric residual volume decreased significantly in the intervention group and increased signif-
icantly in the control group; however, there was no significant difference between two groups (P ¼ .15).
There was a significant difference between two groups regarding abdominal circumference and it was
decreased in the intervention group (P < .001). The defecation times significantly increased in the
intervention group (P ¼ .002). After the intervention, the prevalence of constipation was significantly
decreased in the intervention group (P ¼ .008).
Conclusion: The results revealed that abdominal massage could improve gastrointestinal functions in
enterally fed patients with an endotracheal tube. It is suggested to use abdominal massage as an adjunct
therapy for improving gastrointestinal functions in intensive care patients.
© 2018 Elsevier Ltd. All rights reserved.

1. Introduction venous nutrition support is applied [2]. Enteral nutrition (EN) is a

The intensive care patients face several digestive problems
including damage to digestive mucosa due to stress, increase of
residual volume, diarrhea, constipation, and malnutrition [1].
Therefore, proper nutrition and nutritional support are important
in caring and treating patients especially ones in intensive care
units. Researches show that appropriate and timely nutritional
support improves outcomes of patients hospitalized in intensive
care units [2]. Based on guidelines and patient's status, enteral or
* Corresponding author.
E-mail address: afatehipoor@gmail.com (A. Fatehi poor).
common method used in patients incapable of having food via
mouth, which reduces infection, catabolic responses, developing
gastric ulcers, and hospital length of stay [3]. The main role of
enteral nutrition is to maintain structure and function of the
gastrointestinal mucosal barrier, to improve the movement of the
digestive system, and to prevent side effects of infection and high
costs of venous nutrition [4].
Although enteral nutrition is appropriate, there are side effects
such as reflux, aspiration, diarrhea, abdominal distention, con-
stipation, and intestinal ischemia. They were reported by 62% of
patients who received this type of nutrition [5,6]. Constipation is a
digestive side effect in intensive care patients which has not been
paid much attention. Immobility, hypotension, use of vasopressors

https://doi.org/10.1016/j.ctcp.2017.12.018
1744-3881/© 2018 Elsevier Ltd. All rights reserved.

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 M. Dehghan et al. / Complementary Therapies in Clinical Practice 30 (2018) 122e128
and narcotics, and lack of access to appropriate facilities and con-
ditions are among causes of developing constipation. Constipation
increases the time of mechanical ventilation, so it prolongs the
length of stay in intensive care units [1]. Gastroparesis is another
great problem of intensive care patients who are fed by a gastric
tube; 40e60% of patients reported gastroparesis. Gastroparesis
increases residual volume which leads to the limitation of nutrition
and malnutrition of patients [7]. 43% of intensive care patients, due
to receiving low amounts of foods and the increase of residual
volume, suffer from malnutrition [2]. The comparison between the
patients who could not tolerate enteral feeding versus those who
could do showed that the former group received low amounts of
diets and had a poor prognosis of the length of stay and mortality in
intensive care units [8]. In addition, digestive problems in me-
chanically ventilated patients (such as residual volume) had a sig-
nificant correlation with developing hospital infections [9]. As a
matter of fact, it is not common to completely stop enteral nutrition
because of such problems, but such side effects can influence
strictly on sufficient energy and protein uptake [5].
At the moment, many different medicinal and non-medicinal
methods are used to prevent gastrointestinal problems such as
semi-Fowler's position, feeding by naso-jejunum tube, and drug
prescription for stimulating the movements of the digestive system
such as erythromycin and metoclopramide. The last two methods
improve the digestive function and intestinal movements in
intensive care patients. Studies indicated that promotility agents
were not effective enough on the function of the digestive system,
and they caused some side effects as well [7]. 80% of patients with
constipation are taking different types of laxative medications [10].
Use of laxative medications is the most common method in the
management of constipation, but the use of such medications for a
long time will cause some side effects [11].
Recently, massage therapy and other types of complementary
medicine have been taken into consideration especially in palliative
cares [12,13]. Massage is a therapeutic method with a long history
in medicine and it was mostly used in the late 19th century and
early 20th century. Abdominal massage has been addressed as a
method to increase movements of the digestive system and as a
result to reduce constipation [10]. It seems that abdominal massage
increases peristaltism, changes abdominal pressure, and forms a
mechanical and reflexive effect. Therefore, the passage of the foods
and nutrients from the digestive system is accelerated which leads
to the reduction of pain and constipation [3,14].
A few studies have been conducted in different countries with
this regard. Kahraman and Ozdemire conducted a research on
Turkish intensive care patients in 2014. Results showed that
abdominal massage in mechanically ventilated patients fed by a
gastric tube reduced the residual volume and distention [15]. Ayas
et al. studied the effect of abdominal massage on the intestinal
function in patients with spinal cord injury in 2006. Results indi-
cated that constipation, abdominal pain, difficult defecation, and
the time of emptying were not significantly different before and
after the abdominal massage, but a significant difference was seen
in the amount of distention, fecal incontinence, and the average
times of defecation before and after abdominal massage [16]. Uysal
et al. (2012) studied the effect of abdominal massage on the re-
sidual volume in patients hospitalized in the neurosurgical-medical
intensive care unit. Results showed that abdominal massage
reduced the residual volume and distention of patients fed by a
naso-gastric tube. In addition, 4 patients in the control group suf-
fered from vomiting while no patients vomited in the intervention
group [3]. In addition, some other studies revealed that abdominal
massage reduced constipation in patients with multiple sclerosis
[17], chronic constipation [14], and cancer [18] with no adverse
effects [17].
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123
The literature review showed that a few studies examined the
effect of abdominal massage on the gastrointestinal function
[3,14e18]. Most of them focused on constipation [14,17,18] and re-
sidual volume [3,15,16]. Furthermore, the population under study
was different in these studies. Some studies focused on conscious
patients [14,17,18] and few studies focused on unconscious patients
hospitalized in intensive care units [3,15]. The type of interventions,
the process and the number of abdominal massages were various in
different studies [7,9,19e21]. Therefore, according to the literature,
the effect of abdominal massage on the gastrointestinal function
cannot be confirmed or rejected in unconscious patients hospital-
ized in intensive care units. As abdominal massage is inexpensive
and has fewer side effects, it could be a good adjunct care with
common medicinal and invasive methods which have many side
effects [11]. Therefore, the present study aims to examine the effect
of abdominal massage on the digestive function of intensive care
patients with an endotracheal tube.
2. Materials and methods
2.1. Study design and setting
This was a randomized clinical trial. The research setting was
trauma intensive care units (4 wards) in Shahid Bahonar Hospital in
Kerman, Iran. This Hospital is the center of trauma intensive care in
the southeast of Iran.
2.2. Sample size and sampling
The study sample size of 52 patients (26 interventions and 26
controls) was powered enough (80%) to detect a mean difference of
gastric residual volume (GRV) of at least 37.9cc; our assumption for
such calculation was the result of the previous study (GRV:
m1 ¼105, m2 ¼ 142.91, S1 ¼15.3, and S2 ¼ 66.75) [3]. However,
regarding the probability of drops out and to increase the power of
our study, 41 samples and 38 samples were assigned in interven-
tion and control group respectively (totally 79 samples).
We conveniently selected intensive care patients with an
endotracheal tube who were being fed by nasogastric tube. Inclu-
sion criteria were: being between 18 and 75 years old [9], not taking
prokinetic medications such as metoclopramide and anticholin-
ergic medications such as atropine [20], not experiencing radio-
therapy and abdominal surgery during recent 6 weeks [15], no
contraindication for abdominal massage such as cellulite, abdom-
inal tumors, peritonitis, abdominal aneurysm, and ascites (ac-
cording to physician diagnosis), and Glasgow Coma Scale (GCS) less
than 9 [9]. Moreover, we excluded patients who were being NPO
due to laboratory tests and surgical procedures, had diarrhea
(having three or more watery defecation with amount of
200e250 cc per day) [15], hyperglycemia (blood sugar above 200)
and hypokalemia (blood potassium below 3.5) [20], were devel-
oped gastrointestinal bleeding (according to physician diagnosis) or
ascites [7], were suffered from spinal cord injury, could not properly
positioned for massage due to severe trauma, and were extubated
or discharged from the ICU during the intervention period [7].
The eligible patients then were allocated into a control or an
intervention group using the stratified random method (using sex,
age (±2), and being addicted as stratums).
2.3. Measures
In the present study, a checklist was used to collect information.
The checklist contained demographic, background information,
and some information about gastrointestinal functions. The form of
demographic and background information included code, age,
124 M. Dehghan et al. / Complementary Therapies in Clinical Practice 30 (2018) 122e128
gender, cause of hospitalization, medical diagnosis, history of
chronic diseases, medications regimen, respiratory status, size of
the nutritional tube, and the gavage volume. In the present study,
the digestive functions were evaluated in terms of residual vol-
umes, distention, constipation, and times of defecation. The gastric
residual volume was controlled immediately before gavage via
aspiration of gastric contents by gavage syringe while patients were
in semi-Fowler position. To determine the amount of distention,
the circumference of the abdomen was measured using a meter
(the same meter used in all measurements). The navel area was the
place of measurement. A waterproof marker was used to mark
some points surrounding the abdomen (navel, right and left sides)
thus the same points were measured at other times. The abdominal
circumference was controlled before and after the intervention in
both groups. The times of defecations was controlled and recorded
daily using nursing flowcharts in both groups. Not having defeca-
tion in the previous three days considered as constipation. The
prevalence of constipation before and after the intervention was
checked using nursing flowcharts. We offered the checklist to 5
members of nursing faculty to check the content validity of the
checklist, and the checklist items were revised according to their
suggestions. Since all items of the checklist were completely
objective and measurable, it did not need to be checked for its
reliability.
2.4. Data collection
To collect the data, first, the demographic information ques-
tionnaire was completed using medical records or patients' family.
Then, samples were allocated randomly into an intervention or a
control group. No action was taken in the control group. Like the
intervention group, gavage was done routinely in intensive care
units via nursing personnel for 7 times per day. In the intervention
group, abdominal massage was performed. First, patient privacy
was provided to do the massage. Half an hour before enteral
nutrition, the massage was done to reduce the risk of aspiration.
The patients positioned on their back while their knees were
slightly bent. The head of the bed was elevated 30e45 . From upper
anterior iliac projection to beneath ribs of the chest was uncovered
while other parts were covered. The researcher or his colleague
stood on the right side opposite the patient's pelvis and started
massage after checking the abdomen for contraindications. The 15-
min Swedish massage was done twice a day at 8.30AM and 20.30PM
for three days [15]. Massage hours were adjusted in a way that it is
done in constant intervals and it would not disrupt patient's sleep.
The researcher and his colleague referred to one of physiotherapy
professors of Kerman University of Medical Sciences and were
trained how to massage. Massage training was continued until both
researchers could massage similarly. The study variables were
measured by the researcher and his colleague before, during, and at
the end of the study. Sampling lasted from April 2017 to August
2017.
2.5. Data analysis
To analyze data, SPSS 18 was used. Descriptive statistics (fre-
quency, percent, mean, and standard deviation) was used to
describe demographic and background characteristics of both
groups. T independent, Mann-Whitney U (for non-parametric
variables), c2, and Fisher exact tests were used to compare two
groups in terms of background and confounding variables at the
beginning of the study. To determine the mean difference of the
gastric residual volume within and between two groups, repeated
measure ANOVA was used. To compare the mean gastric residual
volume between two groups, independent T test was used. To
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determine the mean difference of abdominal circumference
(distension) in each group, paired t-test was used. To compare the
mean of abdominal circumference between two groups, indepen-
dent T test was used. To compare the mean times of defecation
between two groups, independent t-test was used. To compare the
prevalence of constipation within and between two groups before
and after the study, McNemar and c2 tests were used respectively.
2.6. Ethical consideration
The present research was conducted after taking ethical code
(No. IR.KMU.REC.95.89131) from the ethical committee of Kerman
University of Medical Sciences and the clinical trial code
(IRCT2017030531972N2) from Iranian Registry of Clinical Trials
(IRCT). The researcher explained the research goal and method to
personnel of the intensive care units, patients' family, and guard-
ians. The patients' families were ensured of information confiden-
tiality and that they can be aware of research results. The patients'
families were ensured that the study was safe and their patients
could participate in the study voluntarily and their families were
free to withdraw patients from the study. Written consents were
taken from patients' guardians.
3. Results
Six patients in the intervention group and 3 in the control group
could not complete the study due to death, discharging from the
ICU, getting NPO, and being extubated. Finally, 35 patients in both
groups completed the study. 91.4% of patients in both groups were
under mechanical ventilation. At the beginning of the study, both
groups were matched regarding all demographic and background
information (Table 1). In addition, the medication regimen of pa-
tients did not differ between the intervention and the control group
during the study (P > .05). All patients received regular diet during
the study.
The results showed that the ordered gavage volume did not
differ between two groups during the study; however, the gavage
volume significantly increased during the study in both groups
(Table 2). The administered gavage volume did not differ between
two groups during the study; however, the administered gavage
volume significantly increased during the study in the massage
group. The Gastric residual volume significantly increased in the
control group and significantly decreased in the massage group
during the study, but these changes were not significantly different
between two groups (Table 2).
The mean times of defecation were 1.26 ± 1.31 and 0.43 ± 0.74 in
the massage and the control group respectively. The defecation
times were significantly different between two groups (Mann-
Whiteny U test ¼ 3.17; P ¼ .002). The difference of abdominal
circumference before and after the study were 0.59 ± 1.58 and
0.91 ± 1.62 in massage and control group respectively. The
abdominal circumference significantly decreased after the study in
the massage group and significantly increased in the control group.
There was a significant difference between two groups with this
regard (Table 3). Before the study, the frequency of constipation was
88.6% (n ¼ 31) in both groups, but after the study, the frequency of
constipation was 37.1% (n ¼ 13) in the massage group and 68.6%
(n ¼ 24) in the control group. After the study, the prevalence of
constipation was significantly lower in the massage group than in
the control group (c2 ¼ 6.94; P ¼ .008). In addition, no adverese
effect has been manifested during the massage period in the
intervention group.
 M. Dehghan et al. / Complementary Therapies in Clinical Practice 30 (2018) 122e128 125

Table 1
Demographic and background information in the massage and control groups.

Variables Abdominal massage Control group Statistical test P value

group

Mean SD Mean SD

Age (yr) 40.94 19.44 42.97 23.08 t ¼ 0.4 .69

Glasgow coma scale 6.06 1.65 6.18 2.02 Z ¼ 0.46 .64
Body temperature 37.78 0.58 37.64 0.48 t ¼ 1.12 .27
Systolic blood pressure 103.96 9.82 101.87 12.39 t ¼ 0.5 .62

n % n %

Sex
Male 28 80 29 82.9 c2 ¼ 0.09 .76
Female 7 20 6 17.1

Marital status
Single 14 40 8 23.5 c2 ¼ 2.15 .14
Married 21 60 26 76.5

Education
Illiterate 7 21.2 6 17. 1 c2 ¼ 5.48 .14
Under diploma 8 24.2 7 20
Diploma 11 33.4 20 57.2
Academic 7 21.2 2 5.7

Cause of hospitalization
Trauma 21 60 16 45.7 c2 ¼ 3.56 .5
Surgery 5 14.3 4 11.4
Trauma and surgery 5 14.3 9 25.7
Other 4 11.4 6 17.2

Diagnosis
Diffused Acsonal Injury 4 11.4 10 28.6 Fisher exact test ¼ 10.56 .06
Head injury and multiple trauma 11 31.4 3 8.6
Brain tumor 6 17.2 10 28.6
Sub Doral Hemorrhage 5 14.3 8 22.8
Intra Cranial Hemorrhage 5 14.3 2 5.7
Others 4 11.1 2 5.7

Chronic disease
No 21 60 25 71.4 c2 ¼ 1.01 .31
Yes 14 40 10 28.6

History of addiction
No 27 77.1 28 80 c2 ¼ 0.09 .77
Yes 8 22.9 7 20

Naso-gastric tube size

14 16 45.7 14 40 c2 ¼ 0.59 .74
16 16 45.7 19 54.3
Other 3 8.6 2 5.7

Opioid medications
Infusion 25 71.4 18 51.4 c2 ¼ 2.95 .09
Per needed 10 28.6 17 48.6

Non-opioid medications
NO 31 88.6 25 71.4 c2 ¼ 3.21 .07
Yes 4 11.4 10 28.6

4. Discussion
Our results revealed that gastrointestinal functions in enterally
fed patients with an endotracheal tube were improved after
administering abdominal massage. The abdominal circumference
and constipation prevalence significantly decreased and the defe-
cation times significantly increased in the abdominal massage
group in comparison with those in the control group. In addition,
gastric residual volume decreased significantly in the intervention
group and it significantly increased in the control group; however,
there was no significant difference between two groups. The
different gastric residual volume between two groups could be
clinically important especially in intensive care patients who are at
high risk of developing multiorgan dysfunction.
The results of this study revealed that, in both abdominal
massage and control groups, the mean ordered and administered
gavage volume at the end of the third day of the study, in com-
parison with the time before the study, significantly increased.
However, there was no significant difference between two groups
in terms of ordered and administered gavage volume. Also, the
mean gastric residual volume in the abdominal massage group
from 20 cc before the study significantly decreased to 11 cc at the
end of the third day of the study. In control group, the mean gastric
residual volume from 13.86 cc before the study significantly
increased to 34.37 cc at the end of the third day of the study.
Nevertheless, the gastric residual volume between two groups did
not have a significant difference. In contrast to the results of the
present study, Uysal et al.'s. (2012) study showed that in the mas-
sage group, the high residual volume was observed at 2 times and
the mean residual volume was 105 ml (minimum 80 ml and
maximum 130 ml), while in the control group, the high residual
volume was observed at 8 times and the mean residual volume in

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Table 2
The comparison between the Abdominal massage group and the control group regarding the gastric gavage volume and the gastric residual volume.

Variable Group

Abdominal massage group Control group Repeated measures ANOVA P value

Mean Standard diviation Mean Standard diviation

Ordered Gavage volume (cc)

Befor the study 123.71 84.4 153.43 83.52
At the end of first day 122.57 80.93 153.1 81.12 2.59 .11
At the end of second day 123.8 81.15 161.35 86.51
At the end of third day 143.02 76.84 168.94 86.0
Repeated measures ANOVA 5.48 6.11
P value .006 .006

Administered Gavage volume (cc)

Befor the study 119.43 85.09 152.0 85.74
At the end of first day 118.28 83.69 152.86 81.45 2.09 .15
At the end of second day 123.8 81.15 151.75 91.71
At the end of third day 143.02 76.84 160.37 90.79
Repeated measures ANOVA 7.61 0.71
P value .001 .45

Gastric Residual volume (cc)

Befor the study 20 22.05 13.86 22.95
At the end of first day 26.17 20.7 22.56 17.3 2.14 .15
At the end of second day 17.32 14.1 26.97 23.13
At the end of third day 11 11.58 34.37 25.77
Repeated measures ANOVA 7.84 13.29
P value <.001 .001

this group was 142.91(minimum 85 and maximum 300 ml) and
there was a significant difference between two groups [3]. Also, the
results of the Kahraman and Ozdemir study (2014) showed that, in
the intervention group in 4 patients (25%) the residual volume of
the last day in comparison to the first day increased and in 12 pa-
tients (75%), the residual volume of the last day in comparison to
the first day decreased or was equal. Also, in the control group, the
residual volume in 12 patients on the last day in comparison to the
first day increased and in 4 patients the residual volume decreased.
There was also a significant difference between two groups in
terms of residual volume [15]. In addition, the study results of
Aslani et al. (2014) somewhat was in contrast to the results of the
present study. The results of their study showed that the mean
gastric residual volume in the intervention group, on the first day
after intervention was 18.68, the second day 12, the third day 11.95
and the fourth day after intervention was 11.35 cc and in the control
group the mean gastric residual volume on the first day was 18.71,
the second day 17.36, the third day 19.60 and the fourth day was
19.87. The mean gastric residual volume in 4 consecutive days in
the control group statistically wasn't significant. Also, the com-
parison of the mean gastric residual volume in 4 consecutive days
between two groups of intervention and control, showed that two
groups had a significant difference [7]. The results of Tekgunduz
et al. study showed that the residual volume difference of the first
and the last day of study in the abdominal massage group was
statistically significant, and the residual volume of last day in
comparison to the first day decreased. However, the residual vol-
ume of the first and the last day in the control group did not
significantly differ. Also, there was a significant difference between
two groups in terms of residual volume [22]. Similar to the results
of the studies mentioned, also in the present study after abdominal
massage, the gastric residual volume reduced. But in contrast to the
results of these studies, there wasn't a significant difference be-
tween the abdominal massage and control groups in terms of
gastric residual volume. The reasons for the differences in the re-
sults of the present study with other studies, can be due to low
sample volume in some studies [15,22], the type of society under
study (neonates and elderly people) [15,22], as well as the time
duration of massage (more than 3 days) [7,20,22]. Another possible
reason for this difference can be related to the low residual volume
at the beginning of the study in the present study samples. It should
be mentioned that the mean residual volume depends on ordered
and administered gavage volume, but in some studies, the amount
of ordered and administered gavage volume has not been reported.
Not paying attention to this matter in the studies above could be as
a limitation that makes it difficult to interpret and compare the
results.
The results of the current study showed that the average of
abdomen circumference in the abdominal massage group after the
intervention in comparison to the time before the intervention
significantly decreased. Also, the average of abdomen circumfer-
ence in the control group after the intervention in comparison to

Table 3
The comparison of abdominal circumference between the massage and the control group.

Time Abdomen circumference Abdomen circumference at Paired t-test P value Difference of abdomen
before the study the end of the study circumference before and after
the study

Mean Standard diviation Mean Standard diviation Mean Standard diviation

Abdominal massage group 82.84 15.25 82.26 15.08 2.2 .035 0.59 1.58
Control group 83.4 12.21 84.31 11.69 3.35 .002 0.91 1.62

Independent t-test 0.17 0.64 3.93

P value .87 .53 <.001

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 M. Dehghan et al. / Complementary Therapies in Clinical Practice 30 (2018) 122e128
the time before the intervention had a significant increase. There
was also a significant difference in this view, and the amount of
distention in the intervention group was less than the control
group. In line with the results of the current study, the results of
Uysal et al. showed that the abdomen circumference in both
intervention and control groups on the last day, in comparison to
the first day, did not have a significant difference. However, there
was a significant difference between the two groups in this view,
and abdomen circumference in the intervention group, in com-
parison to the control group, decreased [3]. Also, the study of
Kahraman and Ozdemir (2014) showed that abdomen circumfer-
ence in the intervention group at the end of the study in compar-
ison to the beginning of the study has decreased in 87.5% of cases,
but it has not decreased in the control group. This difference was
significant between two groups [15].
The results of the present study showed that the average
numbers of defecation in the abdominal massage group after the
intervention was 1.26 times, while the average numbers of defe-
cation after the intervention in the control group was 0.43 times.
There was a significant statistical difference between two groups in
this view. Similar to the results of the present study, Ayas et al., in
2006 showed that the average numbers of defecation after
receiving a high-fiber diet plus abdominal massage in comparison
to just receiving a high-fiber diet was more. The average numbers
of defecation in the first intervention was 4.61 and in the second
intervention was 3.79 times. There was a significant difference
between two methods [16]. The results of Lai et al. showed that the
average numbers of defecation during 5 days in the massage group
with aromatic substances, the massage group, and the control
group was 3.69, 1.73 and 0.63, respectively. Also, the average
numbers of defecation over a day in 3 groups of the massage with
aromatic substances, massage group, and control group was 0.8,
0.34 and 0.12, respectively. There was a significant difference
among 3 groups for the numbers of defecation, so that the numbers
of defecation in the aromatic massage group, was more than the
massage group and the massage group was more than the control
group [18]. The results of these studies are in line with the present
study and confirm the results of the present study based on the
effectiveness of abdominal massage on increasing the numbers of
defecation.
The results of the present study showed that 88.6% of samples
under the study, before the intervention in both groups of
abdominal massage and control, had constipation. After the inter-
vention, this rate significantly had decreased in the intervention
group and reached to 37.1%. Also, in the control group after study,
the constipation rate reduced and reached to 68.6%, but this rate
wasn't statistically significant. After the intervention, the preva-
lence of constipation in the abdominal massage group was signif-
icantly less than the control group. The study results of Lai et al.
showed that the intensity of constipation in the aromatic massage
group decreased from 5.62 before the study to 1.46 after the study.
Also, the intensity of constipation in the massage group from 4.8
reached to 1.55, but the score of constipation intensity in the con-
trol group increased from 5.63 to 6.63 [18]. The results of Lamas
et al. study indicated that abdominal massage significantly reduced
digestive symptoms according to Gastrointestinal Symptom Rating
Scale and reduced constipation syndrome. Based on this study, the
intensity of constipation syndrome significantly decreased in the
intervention group at week 8 in comparison to the beginning of the
study and the week 4, and there was a significant difference be-
tween two groups [23]. McClurg et al. in a study evaluated the in-
tensity of constipation after performing abdominal massage in
patients with multiple sclerosis. The results of this study indicated
that in both groups, the score of constipation intensity decreased
from week zero to week 4, which this reduction was significantly
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127
higher in the intervention group. However, the score of con-
stipation intensity did not have a significant difference in two
groups from week zero until the eighth week [17]. In these studies,
the prevalence of constipation was not evaluated, because the pa-
tients participating in this study was conscious and had the ability
of responsiveness to a more precise tool. However, in the current
study, the constipation prevalence was evaluated by checking the
nursing flowchart for having defecation in the 3 recent days.
Although the constipation prevalence and constipation intensity
are two different variables, they are essentially the same and
comparing the results of this study with the present studies isn't far
from mind. Thus, the results of the mentioned studies confirm the
findings of the present study based on the effectiveness of
abdominal massage in the reduction of constipation. In addition, in
the present study no adverse effect was reported. This was in
agreement with McClurg et al. study. Therefore, it seems that
abdominal massage has few side effects.
Our study had three limitations. First, we measured constipation
using having or not having defecation during last three days. There
are some precise scales for assessing constipation which consider
different aspects of defecation such as times of defecation, difficulty
in defecation, stool consistency, obstructive defecation, and so on;
however, these scales are not practicable to use in unconscious
patients. Second, this study was conducted in a trauma intensive
care center, thus the findings might generalized to the other
intensive care units with caution. Finally, the researcher colleague
was not blinded to the samples assignment. This may influence his
evaluation while assessing variables. However, the researcher
colleague was not a research team member and had no conflict of
interest.
In the present study, we made a short communication with
patients before the abdominal massage. It is proposed that the
unconscious patients can hear, so it is the patients right to get
complete explanation of massage before the intervention. If we
completely communicated with patient before the study, it would
influenced on the study outcomes. Thus, we were not able to
distinguish between the exact effect of abdominal massage and the
communication. It should be mentioned that in our ICU units,
nurses do not communicate with unconscious patients regularly
before providing any procedures for them. Although this ethical
challenge was existed, KUMS ethical commite has approved the
procedure.
5. Conclusion
Our results revealed that abdominal massage could improve the
gastrointestinal functions in enterally fed patients with an endo-
tracheal tube. The abdominal circumference and constipation
prevalence were decreased, while the defecation times were
increased after administering abdominal massage. In addition,
gastric residual volume was decreased in the abdominal massage
group, while it was increased in the control group. As there are few
studies on using abdominal massage in intensive care patients, the
adequate duration and the best time of applying abdominal mas-
sage in enterally fed patients remain unclear. Therefore, further
studies in this field are necessary. Further studies are also needed to
compare abdominal massage with other complementary methods
for improving the gastrointestinal functions in intensive care
patients.
Conflicts of interest
The authors declare that they have no competing interests.
128 M. Dehghan et al. / Complementary Therapies in Clinical Practice 30 (2018) 122e128
Acknowledgements
This paper has been extracted from the M.S thesis of intensive
care nursing approved by Kerman University of Medical Science.
The authors appreciate all staff of Intensive care center of Shahid
Bahonar Hospital for their cooperation.
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