Abstract
Background:
Urut Melayu, the traditional Malay massage, had been introduced into three pioneer hospitals in Malaysia, as part of the integrated hospital program. It was introduced primarily for the rehabilitation of poststroke patients. After almost 3 years since it was first implemented, there are currently plans to extend it to other hospitals in the country. Information from this study will contribute toward a better future implementation plan.
Objectives:
This study was conducted to gain an insight into the experiences and views of poststroke patients and their urut Melayu practitioners.
Methods:
A qualitative study design was adopted. A total of 17 semistructured in-depth interviews were carried out with poststroke patients who were undergoing urut Melayu treatment at one of the three integrated hospitals. Information was solicited from their accompanying caregivers whenever necessary. The 2 urut Melayu practitioners at the hospital were also interviewed. All the interviews were carried out in Malay by the authors, at the Traditional and Complementary Medicine unit of the relevant hospital. The interviews were audiotaped, transcribed, and coded into categories through a constant-comparison method of data analysis. Illustrative quotations were identified to supplement the narrative descriptions of the themes.
Results:
It was found that urut Melayu was sought by patients who had experienced stroke brought about by hypertension and postdelivery complications. They reported the unique characteristics of urut Melayu and their positive experiences with it.
Conclusions:
Urut Melayu has potential as a complementary therapy for poststroke patients. It is recommended that the number of practitioners at the Traditional and Complementary Medicine unit be increased to provide the optimum care for poststroke patients.
Introduction
It is known that massage therapy typically enhances relaxation and reduces stress. 3 Urut Melayu is an example of such a therapy. Nevertheless, there are still many aspects of urut Melayu that are yet to be uncovered and understood.
Urut Melayu, like other Malay traditional and complementary medicines (T&CM) in Malaysia, is linked to Islam. 4 In fact, the word “massage” comes from the Arabic word mahasa, meaning “to touch, feel, handle.” 5 Islamic traditional and complementary medicine can be traced to the Middle East and other countries in the region, such as some parts of Indonesia.
Malaysia is a multiethnic country with an exemplary modern health care system. Beyond modern health care, T&CM practitioners of the three main ethnic groups, namely, Malay, Chinese, and Indian, are continuously sought by the population. The Ministry of Health (MOH) formally recognized the importance and contribution of T&CM through the establishment of three integrated MOH hospitals in 2007. All of these hospitals have established a T&CM Unit comprising acupuncture, herbal medicine for patients with cancer, and urut Melayu, the traditional Malay massage. The urut Melayu is introduced primarily to help in the rehabilitation of poststroke patients. Subsequent to this, the urut Melayu services had been extended to address chronic pains and postnatal care. The demand is very encouraging, and there are already plans to extend the service to three other MOH hospitals in the country. This study was thus carried out to gain an insight into the experiences and views of poststroke patients and their urut Melayu practitioners to provide input for the forthcoming plans.
Materials and Methods
This study involved semistructured in-depth interviews with poststroke patients as well as their urut Melayu practitioners. The interviewees were identified by the nurse-in-charge of the T&CM unit in one of the integrated hospitals, based the patients' willingness to participate. The interviews were conducted by the authors using an interview guideline. The guideline included questions on what brought the patients to seek urut Melayu at the unit and what their experience was of urut Melayu, with suitable probes where necessary. The patients were interviewed at the T&CM unit of the hospital, where they were undergoing treatment, either before or after their urut Melayu sessions. Patients who had difficulty in their speech as well as with their memory were supported by their caregivers. The caregivers as well as the practitioners provided clarifications whenever necessary. The interviews were recorded by a notetaker and were also audiotaped. The authors carried out a transcription of the text at the end of each interview. All nonverbal behaviors were also noted to capture the context of the discussion.
Data analysis
The methods used to code and categorize the interview data were adapted from approaches to qualitative content analysis discussed by Granehaim and Lundman 6 and focus group data analysis by Stewart and Shamdasani. 7 For coding the transcript, it was necessary to go through the transcript line by line and paragraph by paragraph, looking for significant statements that were coded according to the topics addressed. The various codes were compared based on differences and similarities and they were sorted into categories. Finally, the categories were formulated into themes. The data analysis was carried out together by all research team members, and a consensus approach was adopted in deciding on codes, categories, and themes. Illustrative quotations were identified to supplement the narrative description of the themes. The final themes and quotations were translated into English by a qualified Malay–English translator for the purpose of this article.
Ethical considerations
Approval to conduct the study was obtained from the Ministry of Health Medical Research Ethics Committee. All interviewees were informed of the objective and design of the study, and a written consent was obtained from them.
Results
The patients who were interviewed were 16 Malay and 1 Chinese poststroke patients, 11 of whom were male and 6 of whom were female. The patients' ages ranged between 28 and 81 years, with a mean age of 56.5 years. All patients were married. The 2 practitioners interviewed were Malay, 1 male aged 29 years and 1 female aged 36 years.
The study resulted in four major categories, namely, patients' poststroke history, characteristics of urut Melayu, patients' assessment of urut Melayu, and patients' assessment of other forms of poststroke treatment in comparison with urut Melayu.
History of poststroke patients prior to urut Melayu
Most of the patients came to the clinic with their caregivers. A few had to travel almost 50 km from their houses to the hospital for their urut Melayu treatment. The time of stroke onset differed among patients. While all the other patients were hypertensive at the onset of stroke, 1 had postdelivery stroke. Three (3) patients were involved in motor vehicle accidents. One (1) of 3 patients had memory loss and needed the help of caregivers in order to walk. Another patient could not even stand when she first came to the T&CM unit. Other patients were either on wheelchairs or used walking frames before starting urut Melayu treatment at the Unit. Nine (9) of 17 patients had slurred speech and numbness on one side of the body. All patients felt numbness in their hands and legs and had difficulty in gripping and lifting objects.
The time frame between stroke onset and receiving urut Melayu varied among patients. While 8 received urut Melayu as soon as they were discharged from the hospital, 9 got it after several months. One reason for the delay was that their stroke onset occurred long before the integrated hospital was established in October 2007. Prior to urut Melayu, some of these patients had been attending physiotherapy sessions as part of their recovery treatment.
Characteristics of urut Melayu for poststroke
Unless the patients requested otherwise, urut Melayu is conducted on the whole body regardless of the part or side of the body that is affected by the stroke. According to the practitioner: All diseases are interconnected. Pain or disorder in one part of the body may have its source in another part. (Practitioner No. 2)
The poststroke urut Melayu is conducted from the feet upward. Almost every inch of the body surface is massaged by the practitioner, including the fingers and toes. A medium such as coconut oil or other medicated oil is used to reduce friction during the treatment.
The practitioners commence urut Melayu by reciting verses from the Al-Quran. The practitioners believe that this is essential as a protection or pendinding for them, as the practitioner has stated: Without pendinding, the patients' pain and ailment will be transferred to us. This is also to protect us from any evil spirit that the patients may harbor. (Practitioner 1)
According to the practitioners, ideally, poststroke patients should get urut Melayu for 3 consecutive days as soon as they are discharged from the hospital, followed by once a week from then on. However, the practitioners reported that they could only perform urut Melayu on a maximum of 8 patients a day. It takes them more than 1 hour to perform a whole-body urut Melayu on 1 patient. With an increase in the number of practitioners, it is expected that appointments for poststroke patients could be given more frequently than the present 2- or 3-week intervals.
According to the practitioners, positive outcomes were more likely if the patients did not wait too long to get urut Melayu after the onset of stroke. They claimed that the longer the patients wait, the more difficult it would be for them to recover: It's best that they come early. We prefer to do urut Melayu on three consecutive days to start with. Then we do once a week. Until they get better. If they come too late, very difficult to get better…All the urat [common term used for muscles, tendons, veins] would have gotten too stiff. Angin [wind] would have entered. (Practitioner 2)
While some patients have just been started on urut Melayu, others had been getting it for more than 6 months. The latter claimed benefit from the urut Melayu to be felt after about 2 months.
Patients' assessment of urut Melayu
All but 1 patient reported significant improvement following urut Melayu. The effects of urut Melayu can be classified into physical, psychologic, and effects on daily living activities. One patient said: I believe I am what I am today, because of urut. My health is now restored. The difference from before…if then my sickness score was 80, it's now only 40. I can now remember things.…It's my nerves. They're much better now. It's the gift of Allah. Alhamdulillah…Now I can ride a motorbike. I can drive…even at night. I used to depend on others to wheelchair me here. Now I drive here myself. You see my legs. All my toes used to be numb. After all the urut they are no longer numb. They are now normal. Praise is to Allah! I cannot even go to the toilet on my own before. (Patient No. 8) Now my fist is not clenched so tight as before. (Patient No. 4)
All the patients expressed their wish to possibly get urut Melayu more frequently as the urut made them feel ringan [relaxed, refreshed, rejuvenated, and re-energized; feeling of replenished energy] 8 .
More than half of the patients reported that other people too had noticed that they had markedly improved following urut Melayu.
My brothers and sisters…they visit once in a while.…I am so much better now, they said. I can do so much more. (Patient No. 2)
All patients had recommended and would continue to recommend, the T&CM Unit to other patients like themselves.
Patients' assessment of urut Melayu in relation to other forms of poststroke treatments
All patients having urut Melayu were also going for physiotherapy sessions at the same hospital. Although some preferred urut Melayu over physiotherapy, most felt that both forms of treatment were equally important: Looking at both…urut Melayu gives you 80%; physio 50%…must use both. (Patient No. 8) At first I only did urut Melayu. After one month I was able to move slightly. Then I registered for physio. (Patient No. 2) To me, physio and urut must go hand in hand… because the way I see it, physio you must do, urut you must also do. I tell you why. Physio is more about aah…what you call it …exercise…when you have to exercise, you need energy. Urut to me helps loosen muscles, loosen tendons. I feel we must get urut first…it makes physio easier. (Patient No. 7) I came first for physiotherapy. I cannot do everything [physiotherapy exercises] on my own. Some things I can do on my own. Some things I cannot. So I registered for urut. Now, I can do better at physio. (Patient No. 9) In my opinion, physio and urut… physio is good, urut [is] also good… more or less. (Patient No. 5) For a year I went for physio…not much improvement. When this Unit opened, I started urut Melayu. Now I can walk faster… I can sit on a chair… I can unclench my fist. (Patient No. 6)
Of all the interviewees, only 3 had experienced acupuncture as well as urut Melayu. However, all had stopped going for acupuncture when they switched to urut Melayu. They felt that acupuncture could benefit from more interpersonal communication such as that present during urut Melayu sessions. One commented: He [the acupuncturist] never talks to me. When the time is up, the siren will sound toot…toot…toot…He will just look in and ask how I feel. That's all. I go 20 times. I said I don't want to do anymore. (Patient No. 9)
Additionally, while urut Melayu was found to be comforting and soothing, patients experienced a considerable amount of discomfort with acupuncture. As was commented by 1 patient: I cannot stand the pain [from acupuncture]…it is too much.…It left me blue black on some parts of my body. (Patient No. 5)
Discussion
This study found that patients sought urut Melayu following stroke, regardless of the etiology of stroke, ethnicity, or age. This is in agreement with other studies in which massage was practiced on different population subgroups 9 including children and infants. 10
Urut Melayu has unique characteristics not found in other traditional modalities. It involved a whole-body massage regardless of the part of the body that is affected. This holistic approach to pain and disease is common among all T&CM modalities. 11 The use of massage oils in urut Melayu as is reported in this study is also common in Indonesian massage 12 even though other forms of massage, such as Swedish and Thai massage, do not include the use of oils or other topical medicines. Additionally, like urut Melayu for other conditions and purposes, urut Melayu for poststroke also involved the use of pendinding, 13 which involves recitals from the holy Al-Quran. 14
The participants in this study believed that their physical functions improved following the urut Melayu. The effects were not only perceived by the patients but were confirmed by the caregivers and also noticed by other family members and friends. The effects were satisfactory enough for the patients to recommend urut Melayu to others like themselves. However, further studies are warranted to confirm this outcome. Following a randomized trial of therapeutic massage for chronic neck pain, Sherman et al. 15 reported the benefits and safety of massage.
In urut Melayu, apart from administering physical body manipulation, the practitioners helped the patients by constantly talking to them throughout the sessions. This can be likened to the psychotherapy provided by professionals, 16 which aims to increase the individual's sense of well-being. This psychotherapy role sets the urut Melayu apart from physiotherapy 17 and acupuncture, 18 where this element is deemed to be limited. Psychotherapy has been reported to have positive psychologic 19 and ultimately physical effect.
Positive psychologic effects may also have been afforded by the touch of the practitioners' fingers and hands. The power of touch had been reported in several other studies. 20,21
Better outcomes were reported to be associated with early initiation of treatment as well as repeating urut Melayu at regular intervals. Since this practice cannot be adhered to at all times due to the limitation of the number of practitioners, it is recommended that more practitioners are trained and positioned at the integrated hospitals.
Conclusions
Urut Melayu has potential as a complementary therapy for poststroke patients. A randomized controlled trial is warranted to see whether this therapy is really cost effective in this group of patients.
Footnotes
Acknowledgments
We thank the Director-General of Health Malaysia for permission to publish this article. We also wish to express our appreciation to all participants for their generous support. This study was funded by the Ministry of Health Research Grant NMRR-09-23-3278 and approved by the Medical Research Ethics Committee, Approval No. P09-33.
Disclosure Statement
There is no commercial association that might create a conflict of interest in connection with this article. All authors are affiliated with the Ministry of Health Malaysia and receive no financial benefit from the publication of this study.