INTRODUCTION

Cranial surgery can be applied to treat different intracranial diseases1 such as tumors, blood clots, brain abscesses, repair broken cranial bones or clip blood vessels in patients with cerebrovascular aneurysms.2 However, the surgery affects the brain and blood vessels. The brain tissues are damaged, leading to limited activity, decreased mobility3 and different neurological deficits: gait (76.3%) and balance (48.3%).4 Hence, the patients

face the inability to self-care.3 Moreover, the patients need to be positioned correctly to facilitate the surgery. This includes forcing the head to be raised up and stay in an appropriate angle while being pressed by a Mayfield5 for 4-6 hours.6 The patients’ neck and shoulder muscles take the weight, creating taut bands7,8 and aches in the muscles. They have difficulties lowering, raising and turning their heads. The pressure on the blood vessels reduces blood and oxygen circulation to the muscles7,9,

so the patients feel dizzy when changing the position. Moreover, the postoperative pain complicates early ambulation and delays early recovery.10-12

Most patients who have had cranial surgery face limitations in performing daily activities, and only 18% of these patients can resume working normally following surgery.13 Fostering early recovery is very important. In general, 59% of patients who have normal preoperative body movement and receive postoperative recovery promotion show a better body movement function at an 81.5% rate.14 The recovery promotion should start from the patients’ admission.15 Physicians or nurses should provide them with general preoperative knowledge and teach physical exercise, step by step, to prepare the muscles while the patients stay in bed until they can walk.16,17 This is considered nursing therapeutics capable of fostering cranial surgery patients, who are in health and illness transition of Meleis’ transition theory, achieve complete this transition18,19, which contributes in turn to postoperative recovery, improves physical mobility, reduces complications from bed bounding20 and admission days.12 Before starting exercise, the patients will be evaluated in terms of dizziness and wound pain and will be eased of muscle pain in the neck and shoulder areas. Many studies have shown that massaging can reduce pain21 and stress to blood vessels in the muscles, while increasing blood and oxygen circulation to the brain and eliminating dizziness.22 Thus, massage is an appropriate and effective treatment for relieving neck and shoulder muscle stress and promoting early ambulation in patients who have had surgery.

Most of the previous studies were rehabilitation programs for patients who had chronic neurological symptoms and long-term impaired body functions.23-25 In the area of patients who had cranial surgery, a previous study concerning early recovery after surgery (ERAS) programs was found to have encouraged patients to have early mobility from the first 24 hours after surgery. Furthermore, patients who received the ERAS program had early recovery with reduced LOS in hospital.12,17,20,26 However, rehabilitation and ERAS programs in the past did not study massage for relief of muscle pain, massaging to ease muscle pain was done with patients who had a thyroidectomy27, and nurses did not begin exercise from the first 24 hours after surgery when patients were in the ICU. Therefore, to prepare muscles for ambulation with exercise and to prepare patients for transfer from the ICU to the ward on the second day after surgery, patients received massage to relax the neck and shoulder muscles. This role was performed by nurses for comfort, relieve muscle pain and increase blood circulation to the

brain tissues of patients, as a consequence, patients were more likely to have improved physical mobility. Thus, the researcher developed a physical exercise program for patients who had a cranial surgery. The first phase of the exercise started 24 hours after the surgery. Once the patients’ conditions were stable16,26, they were massaged to relieve muscle stress in the neck and shoulder areas before starting active ROM exercise, strengthen the thigh muscles and quadriceps extension until they could get up from the bed and walk. The goal was to promote physical mobility to recover quickly.

MATERIALS AND METHODS

This quasi-experimental research was certified by the Human Research Ethics Committee, Faculty of Medicine, Siriraj Hospital, Mahidol University (Si 065/2020). The research groups were calculated using influence size determination from mean difference of body functions in similar research studies.25 The results were 26 patients for a group. Additional patients were included at a 15% rate in case some dropped out.24 The power of test was 0.80, and confidence in the test (α) was 0.05. The final research groups had 30 patients each.

Population and samples

The population was patients who had cranial surgery at a super tertiary hospital. The samples had the same characteristics as the population. The selection criteria were 1) undergoing cranial surgery; 2) age ≥ 18 years old; 3) Glasgow Coma Scale = 15; 4) Thai Mental State Examination scores > 23; 5) ability to move the body or no limitations in terms of body movement; and

6)understanding and being able to communicate in Thai. The exclusion criteria were 1) having a mental disease history; 2) wearing ventriculostomy drain when starting active exercise; and 3) having a congenital disease which prevents exercising and massaging. The criteria to consider termination from the research were 1) severe postoperative complications; 2) consciousness level decreasing by 2 points in 24 hours; and 3) failing the readiness assessment before starting physical exercise.

Data collection method

The research group received a physical exercise program of patients after cranial surgery (CVI 0.9) from the researcher, who is a nurse. The duration of the exercise was approximately 30 - 45 minutes each time. The program included sharing of knowledge from manuals of physical exercise for patients with cranial surgery (CVI 0.8) one day before the operation. Next, one day after the operation in the ICU, the researcher stimulated

the patients via a breathing exercise and passive ROM exercises for both upper and lower extremities (totality 11 positions, 10 times per position, for two sessions) while staying in bed. Two to three days after, the patients could partially move their bodies. The researcher massaged the patients’ upper trapezius and splenius capitis areas to relax muscles by using vibration, stroking, petrissage and friction along with encouraging patients to perform active ROM exercises for both the upper and lower extremities (totality 11 positions, 10 times per position, for 2 sessions). Next, the patients performed an exercise to strengthen the thigh muscles for five times and did quadriceps extensions for five minutes. The researcher then helped the patients step down from the bed to sit by the bedside and stimulated them to stand beside the bed before leading the patients to tread for five minutes, take a break for 2-3 minutes, continue treading for five minutes, then walk around the bed. The exercises depended on the ability of each patient. The researcher assessed the physical readiness and treated wound pain for the patients before starting the program every time. During the exercises, the researcher monitored any changes and pain levels for safety. For the control group, the patients received routine nursing care.

Data collection

Data collection was conducted by a research assistant, starting from the control group and then the experimental group. First data collection: one day before the operation. This data was used as baseline data. Physical mobility data were collected by the Clinical Outcome Variables Scale (COVS). Three points were related: 1) gross motor and gait; 2) mobility; and 3) arm function. The higher the COVS, the better the physical mobility. The COVS assessment revealed inter-rater reliability at 0.9728 and internal consistency at 0.93.23 ROM of the neck and shoulders was measured by a goniometer. The confidence value of goniometer use between the expert and research assistant was 0.97. Second data collection: three days after the operation. Physical mobility was assessed by COVS, and ROM of the neck and shoulder was measured by a goniometer. Third data collection: one day before leaving the hospital physical mobility was assessed by COVS.

Statistical analysis

All of the data were analyzed using SPSS (version 25). Continuous variables were expressed as mean ± standard deviation or median (interquartile range), and were compared using independent t-test or Mann- Whitney U test. Categorical data were expressed as number (percentage), and were compared using the

Pearson chi-square test or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.

RESULTS

The experimental group consisted of 22 female and 6 male patients for a total of 28. The average age was 53.86. The control group consisted of 20 female and 10 male patients for a total of 30. The average age was 50.67. Personal data of the patients are shown in Table 1. There were no differences between both groups. Two patients in the experimental group dropped out as arrhythmia and high blood pressure were identified at the beginning.

One day after the surgery, before starting the program, both the experimental and control groups felt discomfort and muscle stiffness (p = 1.0). There were no differences in the wound pain of both groups (p = 0.074) (Table 1). Three days after the surgery, the discomfort and muscle stiffness of the experimental group was better at a 63.3% rate. Also, easing the wound pain every time before

starting the program differentiated the pain of both
groups significantly (p = 0.003) (Table 2).
The results of the physical exercise program of
patients after cranial surgery and	muscle relief		massage
differentiated COVS scores of both		groups.	Three days
after the operation, the reduction	of	COVS scores of the

experimental group was significantly	less than those of
the control group (p = 0.03). This	meant the physical

mobility of the former was better. The patients resumed walking faster, both three days after and one day before discharge, with statistical significance (p = 0.01, 0.004, respectively) (Fig 1). Furthermore, ROM of the neck and shoulder was significantly better than that of the control group (p = 0.001, 0.001, respectively) (Table 2).

DISCUSSION

Due to cranial surgery, both groups’ physical mobility scores of three days after the operation decreased more than preoperative scores. These findings were in line with many other studies that found issues of reduced postoperative body movement3,4, resulting from the operation, wound pain and muscle overuse at the upper trapezius and splenius capitis areas. The latter led to leakage to Ca2+ from sarcoplasmic reticulum to sarcolemma, combination of Ca2+ and adenosine triphosphate, and attachment of actin to myosin, which created a taut band.9 Pressure to blood vessels and circulation under the muscles produced local hypoxia and anaerobic metabolism. Lactic acid was built up in the muscles and stimulated the nerve endings to feel pain, so the patients felt acute muscle aches and pains. The symptoms could last days or weeks, but no

more than two months.8,27 The motion range of the neck and shoulders was reduced, which slowed the patients’ movement and affected postoperative recovery.

This study showed that the physical exercise program of patients after cranial surgery including preoperative exercise knowledge sharing, early body movement stimulation and muscle preparation within the first 24 hours after the operation such as passive and active ROM exercises of both the upper and lower extremities, strengthen the thigh muscles and quadriceps extension, caused striated a skeletal muscle to contract harder. Consequently, the muscles used more energy, converting chemical energy

into kinetic energy and increasing the cross-sectional area of Type 2 muscle fibers and resulting in muscle hypertrophy. With full growth of muscle fibers, the muscles became stronger, enabling patients to exercise more and move better, respectively.29 This also prepared the patients’ muscles before they could step down from the bed until walk around. Overall recovery was faster. More than three-quarters of the patients were able to walk by the bedside three days after surgery at a rate of 86.7%. The physical mobility of the experimental group decreased less than the physical mobility of those without the support program. Therefore, the patients in

the experimental group had complete health and illness transition.18 The study of Wang et al. (2018) found that the elective craniotomy patients who received the ERAS program could do early off-bed activities and ambulation by the third day after the surgery. The success rate was 95%, which was significantly more than another group that did not have the program (p < 0.0001).12

In terms of the assessment of body readiness and management of localized wound pain from injuries at brain tissues, cortex nerves and blood vessels, which could be relieved pain by medication30, both study groups had similar levels of wound pain before they were forced to step down from the bed, and they received similar amounts of painkiller. However, the experimental group had lower wound pain scores in POD3 than the control group (Table 2). The results were similar to those of the study of Qu et al. (2020) who found that pain management after cranial surgery in the patients receiving ERAS programs generated significantly lower wound pain scores in POD3 than the other group (p < 0.001).26 Moreover, massaging was an alternative medicine that had a mechanism to send nerve currents along a beta or alpha nerve fiber to signal and stimulate S.G. cells to inhibit the function of transmission cells. The mechanism controlling the gate at the spinal cord level was thus closed. No nerval signal was sent to the brain, so the patients felt no pain.31 Also, there was endorphins and enkephalins secretion to defy Substance P. This caused the gate to close and inhibited the transmission of nerve pain from the brain. The perception of pain was reduced. The patients felt relaxed, which enhanced pain relief.

The patients’ ameliorated body movement was partially from discomfort management and massaging to relax the muscles. After receiving massages, two- thirds of the patients felt more comfort and less muscle stress. Furthermore, ROM of the neck and shoulders was better than the control group, and the experimental group could recover close to the normal state. Thus, they could exercise and move their bodies actively. The results were similar to those of Gemmell et al. (2008) who used post-isometric relaxation, which is similar to massage. The study found that the pain decreased immediately, and ROM was increased significantly (p < 0.05).21 Increased ROM is related to decreased pain32, the results after massaging by Doppler ultrasound showed increased blood and lymph circulation.22 This circulation led to nutrient and oxygen supplies to the muscles, waste removal from the tissue cells and signal stimulation of focal adhesion kinase enzyme and extracellular signal- regulated kinase enzyme to reduce the contracture of sarcomere. The trigger points were relaxed with less

cytokine and more mitochondria synthesis.33 The muscles were stimulated to recover from fatigue more quickly.34 Moreover, massaging relaxed the upper trapezius muscle, loosened the pressure of the vertebral artery under the muscle and increased blood circulation to the cerebral and basilar arteries. The brain tissues gained more oxygen so the patients’ headache and dizziness were eased.35,22 The experimental group could move their bodies more comfortably than the other group.

The physical exercise program of patients after cranial surgery was important in terms of promoting body movements such as sitting and standing, stepping down to sit beside the bed, performing various activities to help the patients resume walking faster (Fig 1) and leaving the hospital earlier than the other group (Table 2). The nursing method helped enhance recovery after surgery.

CONCLUSION

The physical exercise program of patients after cranial surgery including body exercise, muscle relaxing massage, knowledge sharing and management of symptoms affecting postoperative recovery improved the patients’ physical mobility. As a result, nurses who take care of cranial surgery patients should use this program as a guideline to promote early movement of patients after surgery.

ACKNOWLEDGEMENTS

I would like to thank the Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, for supporting the neurosurgery research funding from the Siriraj Foundation, and Associate Professor Doctor Wattana Jalayondeja, specialist from the Faculty of Physical Therapy, Mahidol University, who taught muscle relaxing massage techniques and how to use a goniometer. I also would like to thank the head of the patient ward, staffs and research participants who cooperated and helped with data collection.

Abbreviations: ERAS = enhance recovery after surgery, LOS = length of stay, ICU = Intensive Care Unit, CVI = content validity index, ROM = range of motion, COVS

=Clinical Outcome Variable Scale, BMI = body mass index, NRS = numeric rating scale, POD = postoperative day, S.G. cell = Substantia gelatinosa cell,

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