Abstract
Objective
The purpose of this study was to compare the effect of massage and music on fatigue in mothers with preterm newborns in neonatal intensive care units (NICUs).
Methods
This study was a clinical trial with a crossover design which was conducted in Valiye Asr Hospital, Tehran, Iran. A convenience sample of 41 mothers with hospitalized premature neonates in the NICU were randomly assigned to massage-first or music-first groups. Both groups received music and massage, but in different orders. Fatigue was measured using the Multidimensional Fatigue Inventory before and after interventions. Data were analyzed using SPSS version 16 and repeated-measures analysis of variance.
Results
The mean ± SD Multidimensional Fatigue Inventory scores after music, massage, and control measurements were, respectively, 66.90 ± 6.23, 55.78 ± 6.65, and 54.71 ± 6.81. Results of the analysis of variance indicated that there was a significant difference in mean fatigue score between the control group and after both music and massage (P < .001). However, there was no significant difference between the music and massage groups (P = .780).
Conclusion
In this sample of participants, massage and music reduced fatigue in mothers who had preterm newborns in the NICU.
Key Indexing Terms: Fatigue; Massage; Music Therapy; Mothers; Premature Birth; Intensive Care Units, Neonatal
Introduction
Preterm birth is defined by the World Health Organization as a birth that takes place before 37 weeks of gestational age or fewer than 259 days from the first day of the last menstruation.1. It causes a massive burden on health systems and families. According to an estimation of the global birth rate, in 2010, 14.9 million newborns were born prematurely.2 Iranian Ministry of Health estimates that 1 200 000 premature neonates are annually born in Iran, accounting for about 53.1% of neonatal deaths.2 Many premature infants are hospitalized owing to their worsening condition. Hospitalization in the neonatal intensive care unit (NICU) leads to different negative effects on the parents—on mothers in particular—including negative feelings toward the premature neonate, depression, posttraumatic stress, anxiety, and fatigue.3 Fatigue can disturb the psychoemotional balance of the mother.4
The life of premature neonates can be affected by maternal fatigue because these neonates are heavily dependent on maternal care.5 This condition can also disrupt the attachment between mother and child.6 Since these mothers cannot take medication, due to breastfeeding,7 there is a need to find safe and inexpensive interventions to improve their psychophysical condition. Complementary or nonpharmaceutical treatments are increasing in many health care nursing centers because these treatments are low-risk, cost-effective, and easy to use, with limited side effects.8 Music and massage are 2 of these complementary therapies.
Music is a complementary therapy which can affect the nervous system through inducing a sense of relaxation. Massage is also known to be among the oldest and most commonly used forms of complementary treatment. Massage creates feeling of relaxation; it helps relieve stress, reduce muscular tension, and increase speed of recovery from acute and chronic illnesses.9 It increases blood circulation and leads to more absorption of nutrients and elimination of wastes, which directly affect muscle fatigue.9
The effects of music and massage on fatigue have been assessed in different settings. Karbandi et al examined the effectiveness of relaxation with music 72 hours after delivery for 60 mothers with premature newborns and concluded that these mothers experienced better sleep quality and lower fatigue in the following weeks.10 The results of Najafi Ghezeljeh et al indicate that music and back massage cause fatigue reduction, with back massage more effective than music.9 The results of Khachian et al show that effleurage massage with aromatic oil has a positive effect on reducing radiotherapy-induced fatigue in people with cancer.11 Narimani et al studied the effectiveness of muscular relaxation and music therapy on fatigue intensity in women with breast cancer and found that both treatments were effective in reducing fatigue intensity, without a significant difference between the 2 methods.12 In a semiexperimental study, Karagozoglu and Kahve report that back massage reduces fatigue and anxiety in patients undergoing chemotherapy.13 Guo et al studied the effect of music on mental fatigue owing to continuous activity and observed less mental fatigue in the music group than the control group.5 The study results of Surucu et al show that music has a significantly positive effect on the pain and anxiety of women during their first delivery.14
In our literature review, we did not find any study that investigates the effect of massage or music on fatigue in mothers with premature neonates in the NICU. Fatigue is a common problem that usually does not receive enough attention, and most mothers experience it. Since the effectiveness of music and massage have not been studied, and both are cheap and easy, we designed this study to compare the 2 methods with normal rest. We adopted a crossover randomized clinical trial because fatigue is strongly dependent on the person, and many factors can affect it. Personal factors cause lower within-subject variation compared to between-subjects variation, and we needed to be able to use a smaller sample size. To exclude these personal factors, the best method is a crossover design.
The purpose of this study was to compare the effects of massage and music on fatigue in mothers with preterm newborns in neonatal intensive care units. Our hypotheses were that music would reduce the fatigue of mothers with hospitalized premature neonates in the NICU; massage would reduce the fatigue of mothers with hospitalized premature neonates in the NICU; fatigue reduction would be different between music and massage interventions.
Methods
The present study was a clinical trial with a crossover design registered with the Iran Clinical Trial Registry (IRCT20180626040249N1). Participants were selected from the NICUs of Valiye Asr Hospital, affiliated with Tehran University of Medical Sciences.
Sample Size
The minimum sample size was calculated using a 2-tailed hypothesis, with α = 0.05, a power of 0.80, and, from our pilot study, a standard deviation in fatigue score of 6.4 to discover a minimum difference of 5.5 in fatigue score between the 2 groups. The minimum sample size was calculated to be 36 for each group. Anticipating a 10% dropout for each intervention, we increased the sample size to 40. Because we used a crossover design, 20 participants were enrolled in each group.
Inclusion and Exclusion Criteria
The inclusion criteria were having a newborn in the NICU; newborn age between 30 and 37 weeks; presence of the mother for 3 consecutive days; no history of previous delivery of a premature newborn; no hearing problems, based on the mother's statements and examination; no chronic diseases such as cardiovascular disease, cancer, or neurologic or muscular disorders; and no ulcers at the site of the massage. Exclusion criteria were discharge before completion of all measurements and worsening general condition of the baby or mother.
Study Tools
The data-collection tools were a personal and demographic characteristic form and the Multidimensional Fatigue Inventory (MFI).15 Assessed demographic variables were age, occupation, education, marital status, number of children, and neonate's gestational age, sex, weight, and type of delivery. The data were gathered from the mother and the medical record of the newborn.
Multidimensional Fatigue Inventory
The MFI was used to assess the severity of fatigue. This inventory is a self-reported 20-item tool scored with a 5-point Likert scale ranging from 1 to 5. The total score varies from 20 to 100. Higher MFI scores indicate higher fatigue. The MFI has 5 domains—general fatigue, physical fatigue, mental fatigue, activity-related fatigue, and reduced motivation—with 4 items in each domain. It reports an average Cronbach α of 0.84 for all 5 domains. Its creators’ 5-factor model has a good fit (adjusted goodness-of-fit index > 0.93). The Persian version of the MFI was validated by Hafezi et al, who report an internal consistency reliability of 0.85.16 The reliability of the scale was 0.82 in the current study.
Implementation
The MFI was completed on 3 occasions by each participant. A separate room was provided for interventions, to protect the privacy of mothers in the maternity ward. Enough explanation and training were provided for participants to properly complete the MFI. The MFI scores of participants who met the inclusion criteria were assessed as a control group. Participants were randomly assigned to 2 groups. Random allocation was done by permutated blocks of 4. Group A received music on the second day and massage on the third day; group B received massage on the second day and music on the third day. Each intervention was performed only once a day, over 3 consecutive days. The MFI was completed by participants before and 15 minutes after the interventions. The 15-minute fatigue measurement time after the intervention has also been used in previous studies.17,18
Interventions
Massage
Participants were placed on a bed with a suitable position (lying or sitting) for the massage. After suitable privacy was provided, the participants exposed the area to be massaged. Surface-deep stroking (effleurage) and rolling methods were used. In stroking massage, both palms were placed on the participant's back and superficial and deep pressure on soft tissues were applied in the direction of lymphatic drainage, without using pressure on the bones. In rolling massage, the muscle tissues were rolled between the thumb and index finger at various points.19 Stroking and rolling were repeated 3 to 5 times, with each massage lasting 20 minutes in the evening shifts.
Music
Participants were placed on a bed with a suitable pillow under their head. The intervention was explained to them. Then the sounds of nature—a mixture of the sounds of rain, river, waterfall, and birds—were played for participants through headphones for 20 minutes. The volume was adjusted according to the participant's desire, and headphones were disinfected after each application to prevent the transmission of infection.
Statistical Methods
Data were reported using descriptive statistics (mean, standard deviation, and absolute and relative frequency). The normality of the distribution of MFI scores was tested using the Shapiro-Wilk test (P > .05). The changes in MFI scores were analyzed using repeated-measures analysis of variance using SPSS version 16. Carryover, period, and sequence effects were analyzed and reported. The Bonferroni post hoc test was used to compare the 3 measurements.
Ethical Considerations
The study protocol was approved by the Tehran University of Medical Sciences Committee of Ethics in Research (IR.TUMS.FNM.REC.1397.011, June 13 2018). Ethical considerations included obtaining consent from the participants and assuring them of the confidentiality of all the information, as well as their ability to participate or withdraw from the study at any stage.
Results
The characteristics of both groups are presented in Table 1. Among 146 mothers who were assessed for eligibility, 51 enrolled. We replaced each dropout, to maintain the minimum sample size. Data from dropouts were not used in the analysis; only participants who completed all 3 measurements were included in the analysis. Enrollment data are presented in the flow diagram (Fig 1). Based on the diagram, 6 participants dropped out from group A and 5 from group B.
Table 1.
Characteristics of Study Participants
| Variable | Group A: Music-Massage | Group B: Massage-Music |
|---|---|---|
| Age (y) | 31.25 (5.55) | 31.19 (5.83) |
| Marriage duration (y) | 7.33 (3.94) | 7.90 (4.36) |
| Type of pregnancy | ||
| Intended | 18 (90) | 19 (90.5) |
| Unintended | 2 (10) | 2 (9.5) |
| Level of education | ||
| Illiterate | 0 | 1 (4.8) |
| Elementary school | 2 (10) | 1 (4.8) |
| Middle school | 1 (5) | 1 (4.8) |
| High school | 13 (65) | 12 (57.1) |
| Bachelor's degree | 4 (20) | 5 (23.7) |
| Master's degree | 0 (0) | 1 (4.8) |
| Type of deliverya | ||
| Vaginal | 2 (10) | 1 (5) |
| Cesarean | 18 (90) | 19 (95) |
| Occupational statusb | ||
| Employed | 5 (25) | 5 (26.3) |
| Housewife | 15 (75) | 14 (73.7) |
| Place of residence | ||
| Tehran | 12 (60) | 16 (76.2) |
| Suburbs | 6 (30) | 3 (14.3) |
| City | 2 (10) | 2 (9.5) |
| History of admission to NICU | ||
| Yes | 2 (10) | 0 (0) |
| No | 18 (90) | 21 (100) |
| Pregnancy duration (wk) | 32.5 (5) | 34 (6) |
| Newborn sex | ||
| Male | 14 (70) | 11 (52.4) |
| Female | 6 (30) | 10 (47.6) |
| Newborn weight (g) | 1809.5 (777.9) | 2207.52 (249.67) |
Data are given as mean (SD).
NICU, neonatal intensive care unit.
One subject did not respond.
Two subjects did not respond.
Fig 1.
Study flowchart: recruitment and allocation to study groups.
The distribution of the fatigue variable was normal, and data analysis was performed using parametric tests (Table 2).
Table 2.
Determining the Normality of the Fatigue Variable
| Treatment period |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Baseline (Control) |
First period |
Second period |
||||||||||
| Before |
After |
Before |
After |
Before |
After |
|||||||
| Group (Sequence) | Statistic | P | Statistic | P | Statistic | P | Statistic | P | Statistic | P | Statistic | P |
| Music-massage | 0.969 | .731 | 0.921 | .102 | 0.928 | .142 | 0.957 | .494 | 0.926 | .129 | 0.951 | .381 |
| Massage-music | 0.967 | .656 | 0.943 | .250 | 0.908 | .051 | 0.931 | .142 | 0.980 | .927 | 0.951 | .359 |
The carryover, period, and sequence effects are presented in Table 3. As can be seen, they are not statistically significant (P > .05). This means that the effect of the treatment did not carry over from the first measurement to the second one, and the effect of the first measurement was not significantly different from that of the second measurement. The order (priority) of music and massage did not affect fatigue or its components.
Table 3.
Test of Carryover, Period, and Sequence Effects on the Study Variables
| Carryover Effect |
Period Dffect |
Sequence Effect |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variable | Mean (SD) | t | P | Mean (SD) | t | P | Mean (SD) | t | P | |||
| Fatigue | Baseline (before) | 67.61 (6.47) | 1.787 | .081 | First period (after) | 55.02 (6.58) | −0.461 | .647 | First group | 0.65 (5.80) | −0.435 | .666 |
| Second period (before) | 65.39 (7.25) | Second period (after) | 55.46 (6.91) | Second group | 1.47 (6.33) | |||||||
| General fatigue | Baseline (before) | 15.19 (2.09) | 0.062 | .951 | First period (after) | 13.17 (1.84) | −1.296 | .202 | First group | −0.25 (2.38) | −1.271 | .211 |
| Second period (before) | 15.17 (1.97) | Second period (after) | 13.66 (2.01) | Second group | 0.71 (2.47) | |||||||
| Physical fatigue | Baseline (before) | 14.19 (2.43) | 0.179 | .895 | First period (after) | 12.07 (2.50) | 0.919 | .364 | First group | 1.50 (3.41) | 1.023 | .315 |
| Second period (before) | 14.12 (1.94) | Second period (after) | 11.66 (2.21) | Second group | 0.62 (1.83) | |||||||
| Activity-related fatigue | Baseline (before) | 11.97 (1.94) | 1.599 | .118 | First period (after) | 8.95 (2.99) | 0.792 | .433 | First group | 0.45 (2.80) | 0.787 | .436 |
| Second period (before) | 11.10 (3.40) | Second period (after) | 8.58 (2.70) | Second group | −0.28 (3.16) | |||||||
| Reduced motivation | Baseline (before) | 11.80 (2.23) | 1.337 | .189 | First period (after) | 8.83 (1.98) | −0.654 | .517 | First group | −0.25 (2.27) | −0.644 | .523 |
| Second period (before) | 11.27 (2.01) | Second period (after) | 9.10 (1.78) | Second group | 0.28 (2.98) | |||||||
| Mental fatigue | Baseline (before) | 14.44 (2.39) | 1.417 | .164 | First period (after) | 12.00 (2.20) | −1.226 | .227 | First group | −0.80 (2.14) | −1.243 | .221 |
| Second period (before) | 13.73 (2.46) | Second period (after) | 12.46 (2.19) | Second group | 0.14 (2.67) | |||||||
Because carryover, period, and sequence effects were not significant, the ANOVA was used to compare the 3 measurements (Table 4).
Table 4.
Repeated-Measures Analysis of Variance (ANOVA) to Study the Mean Differences in Variables
| Mean (SD) |
Repeated-Measures ANOVA |
||||||
|---|---|---|---|---|---|---|---|
| Variable | Baseline | Music | Massage | Mauchly W (P) | SSE (df) | F | P |
| Fatigue | 66.90 (6.23) | 55.78 (6.65) | 54.71 (6.81) | 0.796 (.012) | 3738.796 (1.66) | 56.709 | .000 |
| General fatigue | 14.53 (2.19) | 13.53 (1.75) | 13.29 (2.11) | 0.931 (.247) | 35.626 (2) | 4.467 | .014 |
| Physical fatigue | 13.88 (1.88) | 12.39 (2.37) | 11.34 (2.24) | 0.950 (.365) | 133.220 (2) | 17.037 | .000 |
| Activity-related fatigue | 12.00 (2.26) | 8.80 (2.65) | 8.73 (3.05) | 0.883 (.088) | 285.577 (2) | 23.613 | .000 |
| Reduced motivation | 12.29 (2.12) | 8.97 (1.97) | 8.95 (1.81) | 0.953 (.389) | 302.976 (2) | 36.759 | .000 |
| Mental fatigue | 14.19 (2.44) | 12.07 (2.12) | 12.39 (2.28) | 0.923 (.208) | 107.431 (2) | 13.322 | .000 |
SSE, error sum of squares.
The results indicate a significant difference in mean fatigue scores (and their components) among the 3 different measurements (P < .05). Therefore, the Bonferroni post hoc test was used to examine which intervention was more effective (Table 5).
Table 5.
Results of the Bonferroni Post Hoc Test
| Variable | Stage | Mean Difference | P | 95% CI for Difference |
|---|---|---|---|---|
| Fatigue | Baseline-music | 11.12 | .000 | (7.63-14.62) |
| Baseline-massage | 12.19 | .000 | (8.67-15.72) | |
| Music-massage | 1.07 | .780 | (−1.27 to 3.42) | |
| General fatigue | Baseline-music | 1.00 | .134 | (−0.21 to 2.21) |
| Baseline-massage | 1.24 | .027 | (0.11-2.37) | |
| Music-massage | 0.24 | 1.000 | (−0.71 to 1.20) | |
| Physical fatigue | Baseline-music | 1.49 | .011 | (0.28-2.69) |
| Baseline-massage | 2.54 | .000 | (1.54-3.54) | |
| Music-massage | 1.05 | .054 | (−0.01 to 2.11) | |
| Activity-related fatigue | Baseline-music | 3.20 | .000 | (1.87-4.52) |
| Baseline-massage | 3.27 | .000 | (1.71-4.83) | |
| Music-massage | 0.07 | 1.000 | (−1.09 to 1.23) | |
| Reduced motivation | Baseline-music | 3.32 | .000 | (2.08-4.55) |
| Baseline-massage | 3.34 | .000 | (2.25-4.43) | |
| Music-massage | 0.02 | 1.000 | (−1.01 to 1.05) | |
| Mental fatigue | Baseline-music | 2.12 | .000 | (0.99-3.25) |
| Baseline-massage | 1.80 | .002 | (0.58-3.03) | |
| Music-massage | −0.32 | 1.000 | (−1.27 to 0.64) |
CI, confidence interval.
For the domains of physical fatigue, activity-related fatigue, reduced motivation, and mental fatigue, the mean was significantly reduced in the music and massage measurements compared to the control (P < .05). Although there is a significant difference in mean general-fatigue score between the control and massage groups (P < .05), there is no significant difference between the control and music groups or between the music and massage groups (P > .05). Finally, the difference in mean fatigue score was significant between the control group and both music and massage (P < .001). However, there was no significant difference between the music and massage groups (P = .780).
Discussion
Regarding the first hypothesis, the results indicate that the mean fatigue score was significantly lower after the music intervention compared with the control group. This result is in line with some previous studies in various groups. Karbandi et al evaluated the effectiveness of relaxation with music at 72 hours after delivery in 60 mothers of premature newborns and concluded that these mothers experienced better sleep quality and lower fatigue in the following weeks.10 Guo et al studied the effect of music on mental fatigue due to continuous activity and observed less mental fatigue in the music group compared with the control group.5 Music affects the health, comfort, and well-being of individuals in several ways, including prevention and reduction of stress caused by injuries and posttraumatic stress, side effects of drugs, and length of hospitalization; it also decreases muscle tone and improve muscle function.20
Regarding the second hypothesis, the results indicate a significant difference in the mean fatigue score between the control and massage groups. Therefore, it can be concluded that massage can reduce fatigue in mothers of preterm newborns. Khachian et al report that effleurage massage with aromatic oil, along with conventional treatments, has a positive effect on the reduction of radiotherapy-induced fatigue in individuals with cancer.11 Ghasemi et al have shown that massage and rest are effective in improving chronic fatigue, and massage is able to improve muscle function after fatigue; however, rest does not have such effects, and massage is more effective than rest in improving fatigue.21 In line with the results of the present study, it is to be noted that resting and sleeping alone cannot improve fatigue. The results suggest that complementary therapies such as massage can accelerate the recovery process and eliminate boredom and fatigue.
Regarding the third hypothesis, the difference between music and massage measurements was not significant. Mean comparisons show that mean fatigue was significantly reduced by music and massage compared with the control group, and their effectiveness in reducing fatigue was comparable. The results of this study are consistent with those of Najafi Ghezeljeh et al, who studied the effect of back massage and music on fatigue in individuals with chronic heart failure and reported that both music and back massage were effective on fatigue reduction.9 Akbari observes no difference between massage and music concerning the severity of chemotherapy-induced nausea in children with cancer.22 The results show that in addition to the effect of music and massage on general fatigue, they significantly effect the improvement of fatigue components including physical fatigue, activity-related fatigue, reduced motivation, and mental fatigue. This result is in line with those of Narimani et al,21 where both massage and music significantly affect fatigue components. While the results of the 2 studies are similar with regard to the effectiveness of music and massage, in the present study only massage had a significant effect on general fatigue.
Limitations
One of the limitations of the present study was that we were not able to create an equipped space for interventions. It was also impossible to set time for each participant with respect to breastfeeding and newborn care, a limitation reduced by coordination between the researchers and participants. Yet another limitation was participants listening to other types of music outside of the music intervention.
Conclusion
The results of the present study show that for this sample of participants, music and massage reduced fatigue in mothers with neonates hospitalized in the NICU. We did not find any difference in fatigue reduction between the 2 therapies. Both methods could be considered for use in the NICU setting to relieve mothers’ fatigue, based on time and mothers’ preferences. Music was not as effective as massage in the reduction of general fatigue. Both methods had a significant effect on other components of fatigue.
Funding Sources and Conflicts of Interest
The present study is the result of a research project, master's thesis No. 39009, approved by Tehran University of Medical Sciences on January 21, 2019. It was supported by the Tehran University of Medical Sciences research deputy and the Maternal, Fetal & Neonatal Research Center. No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): B.P.
Design (planned the methods to generate the results): H.R.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): L.A., B.P.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): L.A., H.R.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): H.R.
Literature search (performed the literature search): L.A., B.P.
Writing (responsible for writing a substantive part of the manuscript): L.A., B.P., H.R., K.O.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): M.S., N.A.N.
Practical Applications.
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Music and massage were found to reduce the fatigue of mothers whose babies were hospitalized.
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Massage was a more effective way to reduce fatigue than music.
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Nurses can consider using both methods, depending on their facilities and training.
Alt-text: Unlabelled box
References
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