1. Rebekah Sweeney COHP 450 Ferris State University
PICO Presentation
Rebekah Sweeney
COHP 450
Ferris State University

2. Introduction PICO Question
In surgical operations lasting over two hours, is massaging bony prominences like elbows and ankles vs. not doing anything at all, an effective way to decrease the rate of occurrence of Level I pressure ulcers?

3. Rationale for asking question
There is not a lot of literature out there.
Practices in the operating room are not consistent and differ greatly.
Need for empirical evidence that massage works or doesn’t.

4. Definition of Pressure Ulcer
Level I pressure ulcer (PU)= Is an area of intact skin that is unblanching, usually localized over a bony prominence, and caused by prolonged pressure. Risk factors include; Age, poor nutrition, decreased mobility, exposure to skin irritants like urine, and impaired wound healing. These ulcers cause pain and can escalate to the next level of ulceration if left untreated. They are expensive to treat depending on the stage and can take a long time to heal. [4]

5. Definition of Massage
Massage is when body parts are manipulated and moved around to increase blood flow to the area.[4]

7. Research Results
Key Words: Incidence of pressure ulcers from surgery, surgical pressure ulcers, preventing ulcers, surgical positioning, massage, massage for ulcers, treatment of ulcers, wound prevention, bony prominence, risk factors for pressure ulcers, risk of long surgery.
Search Engines:MEDLINE/ PubMed, CINAHL
Data Collected: I found little data for massage intra-operatively. Although I was able to find 152 articles that spoke to massage for preventing pressure ulcers.

8. Information Used
Study 1: Shahin, E., Dassen, T., & Halfens, R. (2008, February 14). Pressure Ulcer Prevention in Intensive Care Patients: Guidelines and Practice. Retrieved November 1, 2015, from onlinelibrary.wiley.com.libcat.ferris.edu/doi/ /j x/epdf
Study 2: Duimel-Peeters, I., Halfens, R., Ambergen, A., Houwing, R., Berger, M., & Snoeckx, L. (2007). The effectiveness of massage with and without dimethyl sulfoxide in preventing pressure ulcers: A randomized, double-blind cross-over trial in patients prone to pressure ulcers. International Journal of Nursing Studies, 44(8), doi: /j.ijnurstu

9. Rationale For Using Studies
Because I was unable to find studies specifically for intra-operative massage, I searched for the benefits of massage in the prevention of PUs in other departments of the hospitals.
Study 1: I chose this study because it shows other interventions for PU’s in addition to massage. It was conducted by qualified PhDs and was published by a peer reviewed journal. It looked at prevention and occurrence.
Study 2: I used this study because it has multiple qualified authors and is in a nursing journal. It speaks to the effectiveness of massage on pressure ulcers. It also gives insight into different massage styles and their effectiveness. The researchers want to know how to prevent PU’s.

10. Study 1 Type of study: Quantitative cross-sectional.
Design and method: Questionnaires were given out to adult intensive care workers in German hospitals. The questionnaire measured early interventions and outcomes for pressure ulcers in 169 adult patients. Interventions included: Positioning devices, massage, special mattresses, avoiding nutritional and fluid deficits, and repositioning. Data was analysed using spss version 15 and Dassen et al. [3]
Conclusion: The researchers claim that massage is contraindicated when the tissue is inflamed. Because it’s hard to assess when the underlying tissue is inflamed, massage is not recommended. This could lead to damaged tissue. They also suggest it should be avoided based on the recommendations from the Agency for Healthcare Policy and Research (AHCPR).[3]

11. Study 2 Type of Study: Randomized
Design and method: Double- blinded quantitative study that used nursing home patients as subjects. They used three types of therapies to see what the best practice would be: Change positions, use of cream/lotion, use of cream/lotion with 5% dimethyl sulfoxide (antioxidant).[2]
Conclusion: There was NO significant difference between the three treatments when comes to pressure ulcer prevention and treatment. Neither treatment was effective in prevention. Because there was no evidence to suggest massage was prefered, the researchers offer repositioning the patient as the best choice of treatment. You would have to do skin biopsies to prove underlying tissue benefited from the massage.[2]

12. Ethical Considerations
Study 1: Permission to do this study was given by the Berlin Medical Ethics Committee and all subjects gave informed consent.
Study 2: Nursing home subjects and medical workers didn’t know they were being studied.

13. Strength, Quality, and Credibility
Study 1
Strength: Small sample size is not very strong.
Quality: High quality cross-sectional study that came up with proof that certain interventions worked better than others.
Credibility: The researchers were all PhD’s and qualified to work on this project.
Study 2
Strength: Could have been better with biopsies of tissue to prove the theory that massage doesn’t really work.
Quality: High quality double blinded study that was used quantitative analysis.
Credibility: Written by a group of doctors and nurses working in the healthcare field.

14. Relevant to Practice Decrease pressure ulcer development.
Improve surgical patient comfort.
Decrease mortality due to complications of pressure ulcers
Lower healthcare costs.

15. Conclusion
Most of the studies I reviewed suggested that massage may not be the best practice in reducing the occurrence of PVs. I thought if I could find studies outside of the Operating Room showing value to massage then I would incorporate the intervention in my nursing practice. I wanted to learn about this area of research because I work in surgery and know that surgical patients have many risk factors for PUs including long hours in one position on a surgical table. I had a hard time finding strong evidence for or against the use of massage therapy to prevent the occurrence of pressure ulcers. There were many studies that concluded positioning the patient on a gel mattresses and change of position were the best interventions. This leaves a huge gap in the literature on this subject and we are in need of true studies. I will be sure to spend extra time padding up and positioning my patients properly in the future.

16. References
Blessing, J. D., & Forister, J. G. (2013). Introduction to research and medical literature for health professionals. Burlington, MA: Jones & Bartlett Learning.
Duimel-Peeters, I., Halfens, R., Ambergen, A., Houwing, R., Berger, M., & Snoeckx, L. (2007). The effectiveness of massage with and without dimethyl sulfoxide in preventing pressure ulcers: A randomized, double-blind cross-over trial in patients prone to pressure ulcers. International Journal of Nursing Studies, 44(8), doi: /j.ijnurstu
Shahin, E., Dassen, T., & Halfens, R. (2008, February 14). Pressure Ulcer Prevention in Intensive Care Patients: Guidelines and Practice. Retrieved November 8, 2015, from onlinelibrary.wiley.com.libcat.ferris.edu/doi/ /j x/epdf
Zhang, Q., Sue, Z., & Yue, J. (2015, June 17). Massage therapy for preventing pressure ulcers Retrieved November 5, 2015, from therapy-for-preventing-pressure-ulcers