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Effect of Relaxation Exercises on Controlling Postoperative Pain
Original Article Effect of Relaxation Exercises on Controlling Postoperative Pain Sacide Yildizeli Topcu, RN, MSc, and Ummu Yildiz Findik, RN, MSc, PhD ---
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ABSTRACT:
This study examines the effect of relaxation exercises on controlling postoperative pain in patients who have undergone upper abdominal surgery. This is a cross-sectional and crossover study conducted on 60 patients who underwent upper abdominal surgery between October 2006 and June 2007, in the General Surgery Department, Health and Research Practice Center, Trakya University, Edirne, Turkey. We assessed the patients’ pain levels before and after the relaxation exercises. Patients’ personal information forms were used to collect data, and pain levels were determined using the verbal pain scale. We used the Wilcoxon T test, nonparametric Spearman correlation analysis, and nominal by interval eta analysis to assess the data, percentage, and frequency analyses. Pain levels were found to be reduced after the relaxation exercises compared with the levels before the relaxation exercises (z ¼ L5.497; p < .001). Relaxation exercises, a nonpharmacologic method, are effective in reducing postoperative pain and should therefore be included in a regimen to control postoperative pain in patients who have undergone upper abdominal surgery. Ó 2012 by the American Society for Pain Management Nursing
From the Trakya University Faculty of Health Science, Edirne, Turkey. Address correspondence to Sacide Yildizeli Topcu, RN, MSc, Teaching Assistant, Trakya University Faculty of Health Science, Aysekadin Campus, 22020, Edirne, Turkey. E-mail: [email protected] Received September 8, 2009; Revised July 12, 2010; Accepted July 14, 2010. 1524-9042/$36.00 Ó 2012 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2010.07.006
Upper abdominal surgery is a painful surgical procedure. Inadequate pain control in these patients can lead to many complications, reduction of participation in treatment and care, patient dissatisfaction, longer hospitalization, and in¨ zyuvacı, Altan, & Yu creased costs (Allred, Byers, & Sole, 2010; O ¨ cel, 2003; Shang & Gan, 2003; Valente, 2006). Although there is no standard method that can be applied to all patients’ pain control, pain management should begin with a preventive approach to pain, and both pharmacologic and nonpharmacologic methods should be used together for the most effective pain control (Allred, Byers, & Sole, 2010; Badır & Aslan, 2003). As a nonpharmacologic method, relaxation exercise helps to reduce postoperative pain and anxiety and thereby prevent complications (Yu ¨ cel, 2000). The use of relaxation exercises in the postoperative period will increase patient satisfaction with nursing care as well as providing effective pain control.
Pain Management Nursing, Vol 13, No 1 (March), 2012: pp 11-17
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Topcu and Findik
REVIEW OF THE LITERATURE Pain, which is defined as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ by the International Association for the Study of Pain (IASP), is the primary area of complaint and fear in postoperative patients (Aslan, 2002; IASP, 2010). Yates, Dewar, Edwards, Fentiman, Najman, and Nash, (1998) reported that 78.6% of patients undergoing treatment in hospitals suffer from pain. Postoperative pain is an acute pain beginning with surgical trauma, tapering off gradually and ending with tissue recovery (Arslan & C ¸ elebio glu, 2004; Green & Trait, 2002; Meeker 1998). Carr and Thomas (1997) observed that all patients expect postoperative pain. It is reported that 46 million people undergo surgery each year in the USA, of whom 77% experience postoperative pain (Centers for Disease Control and Prevention, 2010; Warfield & Kahn, 1995). Kuhn et al. (1990), in their study of 101 patients, found that 40 of them suffered from severe pain and 47 experienced moderate pain. Seventy-five percent of patients undergoing surgery report that they endure moderate to severe pain which on movement causes very severe pain, reaching 85%-100% (Apfelbaum, Chen, Mehta, & Gan, 2003; Good, 1996; McDonald, McNulty, Erickson, & Weiskopf 2000; Sloman, Rosen, Rom, and Shir, 2005; Warfield & Kahn, 1995). In Turkey, 93.7% of the patients undergoing surgery report that they suffer from severe pain (Aslan, 2005). The place and duration of the surgery, the preoperative physical and psychologic preparedness of the patient, the presence of complications, types of anesthetics and analgesics used, and the quality of postoperative care influence the severity of the pain patients experience (Good, Anderson, Ahn, Cong, StantonHicks, 2005; Ignatavicius, Workman, & Mishler, 1995). Abdominal surgeries are one of the most painful surgical procedures, due to the proximity to the diaphragm and the nerve supply to the area, and 37% of the patients undergoing elective abdominal surgery report that they experience severe pain (Kuhn, Cooke, Collins, Jones, and Mucklow, 1990). Similarly, Good et al. (2001b) observed that postoperative pain during ambulation after abdominal surgery increases by 31%. Postoperative pain exerts several adverse psychologic and physical effects, such as increasing coagulation and fluid retention by raising the stress response, prolonging the recovery process by adversely affecting appetite and sleep, and causing complications in the cardiovascular, gastrointestinal, and urinary systems. In addition, postoperative pain can cause stress and
anxiety. Particularly, severe pain after upper abdominal surgeries can multiply the complications by adversely affecting the respiratory functions and mobilization of the patient owing to the proximity of the incision site to the diaphragm (Agency for Health Care Policy and Research, 1992; Good, 1996; Richards & Hubbert, 2007). Postoperative pain management strives to prevent the side effects of pain, facilitate recovery, and reduce treatment costs by minimizing or eliminating the patient’s distress (Arslan & C ¸ elebioglu, 2004). Despite significant technologic developments and existing research in pain control, postoperative pain cannot be eliminated in most patients (Apfelbaum et al., 2003; Yates et al., 1998). Thus, although various pharmacologic pain control methods have been developed, such as patientcontrolled analgesia, continuous intravenous infusion, and intraspinal application of opioids and/or local anesthetics, analgesic applications cannot sufficiently relieve postoperative pain and may instead precipitate adverse side effects (Carr & Thomas, 1997; Good et al., 1999, Warfield & Kahn, 1995). In their study, Apfelbaum et al. (2003) demonstrated that 23% of patients using postoperative analgesics experienced adverse effects. In postoperative pain control, nonpharmacologic pain control methods can be used to increase the effect of analgesics, in case of insufficient effect of analgesics, or when analgesics cannot be used. Among nonpharmacologic pain control methods, transcutaneous nerve stimulation, application of hot and/or cold compresses, exercises, positioning, and massage are physical techniques commonly used in postoperative pain control, and relaxation, distraction, and hypnosis are cognitive/behavioral techniques (Arslan & C ¸ elebioglu, 2004). In their study on pain prevalence and perception among inpatient individuals, Yates et al. (1998) reported that patients preferred relaxation and distration more than other nonpharmacologic pain control methods. Relaxation is defined as an absence of physical, mental, and emotional tension (Friesner, Curry, & Moddeman, 2006). The resolving of muscle tension caused by anxiety is the mainstay of relaxation exercises. Because skeletal muscles close to the incision site significantly influence postoperative pain, relaxation exercises resolve the tension in the skeletal muscles and thus reduce postoperative pain (Wilkie, 2000; Willens, 2006). The literature demonstrates that relaxation causes a drop in blood pressure, heart rate, and breathing rate, as well as in pain responses and anxiety (Kesler, Patterson, & Dane, 2003). Relaxation exercises first became the subject of nursing research in 1971, when Aiken and Henrichs used systematic relaxation training as a nursing approach for patients scheduled to undergo open-heart surgery. From then on, nurse researchers have used relaxation
Relaxation Exercises for Postoperative Pain
exercises to reduce anxiety, muscle tension, and pain in preoperative and postoperative patients (Demiralp & Oflaz, 2007; Friesner, Curry, & Moddeman, 2006). In their study using relaxation techniques in acute pain control, Seers and Carroll (1998) demonstrated that postoperative pain was reduced by relaxation exercises. Aslan (1998) observed that postoperative pain scores were lower in patients trained in relaxation exercises during the preoperative period. Good et al. (2001a) and Friesner, Curry, and Moddeman (2006) demonstrated that the pain levels in patients using both analgesics and relaxation exercises were lower than in those who used analgesics alone. Relaxation exercises reduce analgesic usage by increasing the comfort of the patient, although it is recommended that they be used along with analgesics for effective pain control (Cheung, Molassiotis, & Chang, 2001; Good et al., 2005). The present research aimed to study the effect of relaxation exercises on controlling postoperative pain in patients undergoing upper abdominal surgery.
METHODS Ethical Considerations This study was approved by the Ethics Committee of the Trakya University Medical Faculty. Permission to conduct the study was obtained from the Director of Nursing and Clinical Services. All the patients were given information on the study, and informed consent was obtained from each of the participants. Design and Sample This is a cross-sectional and crossover study conducted on 60 patients who had undergone upper abdominal surgery between October 2006 and June 2007 in the General Surgery Clinic, Health and Research Practice Center, Trakya University. A convenience sample method was used in the research. The patients included in the study had undergone upper abdominal surgery, were in the postoperative 1–4-day period, had postoperative mobilization, were >18 years old and literate, had no communication or mental problems, were given an analgesic $2 hours before the exercises, and volunteered to participate in the study and practice the relaxation exercises. Patients who had undergone laparoscopic surgery were not included in the study. Data Collection A personal information form to provide information on the demographic characteristics of the patients, their health histories, and existing diseases and a verbal pain scale to identify the patients’ pain levels were
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used in data collection. A audiotape prepared by the Turkish Psychologists Association was used to teach and apply the relaxation exercises. The personal information form consists of eight questions covering demographic details such as the patient’s age, gender, educational level, health insurance, and health history data such as surgical procedure, chronic diseases, treatment period, and number of postoperative days. The verbal pain scale consists of grades defining the patient’s pain, such as ‘‘no pain,’’ ‘‘mild pain,’’ ‘‘irritating pain,’’ ‘‘severe pain,’’ ‘‘very severe pain,,’’ and ‘‘unbearable pain’’. The training material for relaxation exercises was prepared by the Turkish Psychologists Association. The audiotape used to teach and apply the relaxation exercises includes audible instructions for relaxation exercises, benefits and important points to remember during the practice and application of relaxation exercises. It gives instructions for relaxation exercises with soothing music and the sound of running water in the background. The instructions include correct breathing techniques, focusing on relaxation, as well contracting and relaxing various muscle groups. Procedure Barring clinic visits, meals, visitation, and treatment hours, the patients were verbally informed about the relaxation exercises, based on information gathered from the literature, $2 hours after the analgesic application while at rest in a quiet and calm environment, pain was alleviated by analgesic effect, and the patient had approved participation in the research. All participants were asked to complete the personal information form, and their pain levels were recorded before they began practicing the relaxation exercises. Next, they were taught the relaxation exercises on the tape prepared by Turkish Psychologists Association and encouraged to apply them. The patients used headphones during the training to prevent them from being distracted by the surrounding sounds and to help them concentrate. The patients were encouraged to listen to the tape until they stated that they had learned the exercises fully and could apply them correctly. After that, the patients did the relaxation exercises for 30 minutes, following which the pain levels were reassessed and recorded. Data Analysis The statistical analyses for data assessment were performed using SPSS 10.00. In addition to percentage, frequency, and average analyses, the Wilcoxon T test was used to determine the differences among the pain levels. Then the nonparametric Spearman correlation analysis and nominal by interval eta analysis were
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Topcu and Findik
used to identify the correlation among the patients’ personal characteristics, health history, treatment properties, and pain levels. A p value of <.05 was accepted as the statistical significance limit.
TABLE 1. Pain Sensations Before and After Relaxation Exercises Before Relaxation
After Relaxation
Sensation of pain
n
%
n
%
No pain Mild pain Irritating pain Severe pain Very severe pain Total
1 24 22 8 5 60
1.7 40.0 36.7 13.3 8.3 100
22 22 11 4 1 60
36.7 36.7 18.3 6.7 1.7 100
RESULTS A total of 60 patients undergoing upper abdominal surgery participated in this study. The average age of the patients was 48.38 years. In all, 80% of the patients were primary and secondary school graduates, 51.7% were male, and 55% had undergone open cholecystectomy. It was noted that 66.7% of the patients participating in the study had had no previous surgical procedure, and 63.3% had no chronic disease. No significant correlation was found between the pain levels and these variables. When pain levels before and after the relaxation exercises were examined, the proportion of patients who mentioned no pain had increased from 1.7% to 36.7%, the proportion of patients experiencing irritating pain had decreased from 36.7% to 18.3%, and the proportion of patients who had very severe pain had decreased from 8.3% to 1.7% after the relaxation exercises (Table 1). The fact that the pain was reduced after the relaxation exercises was statistically significant (z ¼ 5.497; p < .001). The study demonstrated that 71.7% of the patients felt less pain after the relaxation exercises (Table 2). Before the relaxation exercises, the correlation between decreasing pain levels and every passing postoperative day was statistically significant (r ¼ 0.267; p < .05; Table 3).
DISCUSSION This study examined the effect of relaxation exercises on pain levels of 60 patients undergoing upper abdominal surgery. Postoperative pain levels were found to be markedly reduced with the use of relaxation exercises. Similarly, Good et al. (2001a, 2005) and Roykulcharoen and Good (2004), in their studies on patients
undergoing abdominal surgery, demonstrated that relaxation exercises effectively reduced postoperative pain. Aslan (1998) also showed that relaxation exercises effectively controlled postoperative pain in patients undergoing upper abdominal surgery. Similar results have been found in different surgical procedures. In their study on patients undergoing gynecologic surgeries, Good et al. (2002) found that relaxation exercises were effective in reducing the pain experienced due to various factors on the first and second postoperative days. In a further study, Good et al. (2006) supported the use of relaxation exercises, as a method supplementary to analgesics, in reducing postoperative pain. Friesner et al. (2006) demonstrated that relaxation exercises positively affected patients whose pain levels were assessed immediately after the removal of the chest tube and 15 minutes later. The results of the present study, as well as the results of the earlier studies, show that relaxation exercises play an effective role in pain control after surgery, not only in the upper abdominal area but also in other parts of the body. There was no correlation between pain levels and individual characteristics, surgical procedure, or chronic disease in the present study. Good et al. (2001a), and Roykulcharoen and Good (2004) also reported no statistically significant correlation between patients’ age, gender, or educational status and their pain levels before and after
TABLE 2. Comparison of Pain Sensations Before and After Relaxation Exercises Difference
n
%
p*
z*
Decreased pain sensation after relaxation exercises Unchanged pain sensations after relaxation exercises Increased pain sensation after relaxation exercises Total
43 13 4 60
71.7 21.7 6.7 100
.000
5.497
*Wilcoxon T test.
1 2.9 0.175 .180 35 100 0 0.0 13 100 0 0,0 9 100 0 0.0 3 100 1 1.7 60 100 4 0 0 0 4 14.3 23.1 22.2 33.3 18.3 14.3 0.267 .039 10 0.0 6 0.0 5 0.0 1 8.3 22
28.6 15 42.9 5 46.2 4 30.8 3 55.5 2 22.2 2 33.3 1 33.3 1 36.7 22 36.7 11
Limitations In the present study, pain was assessed on the first to fourth postoperative day. Postoperative pain decreases in accordance with the healing process, and the duration of pain observed after upper abdominal surgery is 4 days (Aslan, 2006). Therefore, postoperative pain levels were assessed on these days after surgery. Other limitations are that relaxation exercises were taught and applied after analgesic application to facilitate learning and practice by patients. Limited sample size due to the study’s being conducted in a regional hospital was also a limiting factor.
CONCLUSIONS AND RECOMMENDATIONS
45.7 15.4 33.3 33.3 36.7
4 2 1 1 8
11.4 15.4 11.1 33.3 13.3
5 0 0 0 5
The present research findings determined the effectiveness of relaxation exercises in controlling postoperative pain in patients undergoing upper abdominal surgery. The pain levels were reduced after the relaxation exercises in patients using the same analgesics for pain control. Therefore, relaxation exercises are an effective and supplementary nonpharmacologic method of pain control in patients undergoing upper abdominal surgery. Personal and health-related variables have no effect on pain levels. After an evaluation of the conclusions, relaxation exercises should be recommended for use in postoperative nursing care for more effective pain control in patients undergoing upper abdominal surgery. *Spearman correlation.
28.6 16 69.2 2 44.4 3 33.3 1 40.0 22 0 0.0 10 0 0.0 9 1 11.1 4 0 0.0 1 1 1.7 24 Day 1 Day 2 Day 3 Day 4 Total
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relaxation exercises. The results of our study support the findings of those other studies. It was statistically significant that, even before the relaxation exercises, the pain was reduced with each passing postoperative day. Good et al. demonstrated in several studies that patients undergoing abdominal surgery and not using any nonpharmacologic pain control method experienced less pain in the second postoperative day than in the first postoperative day (Good et al., 1999, 2001a, 2005). Research done by Pellino (2005) on patients who had undergone total hip and knee arthroplasty found that pain levels were reduced with each postoperative day, both in the cases under study and in the control group. As a result, it is apparent that postoperative pain reduces with each postoperative day in parallel with tissue recovery.
11.4 0.0 0.0 0.0 6.7
% n % n % n % n % n % n % n % % Postoperative day n
No pain
n
Mild pain
Irritating pain
Severe pain
Very severe pain
r
p*
n
%
n
%
Very severe pain Severe pain Irritating pain Mild pain No pain
Pain Sensation After Relaxation Exercises Pain Sensation Before Relaxation Exercises
TABLE 3. Relationship Between Relaxation Exercises, Postoperative Days, and Pain Sensations
r
p*
Total
Relaxation Exercises for Postoperative Pain
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attitudes among U.S. adults. Anesthesiology, 83(5), 1090–1094. Wilkie, D. J. (2000). Nursing management: Pain. In S. M. Lewis, M. M. Heitkemper, & S. R. Dirksen (Eds.), Medical surgical nursing assesment and management of clinical problems (pp. 126–153). St. Louis, MO: Mosby. Willens, J. S. (2006). Pain management. In S. C. Smeltzer, & B. G. Bare (Eds.), Brunner & Suddarth’s textbook of medical
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surgical nursing (pp. 216–248). Philadelphia, PA: Lippincott Williams & Wilkins. Yates, P., Dewar, A., Edwards, H., Fentiman, B., Najman, J., Nash, R., Richardson, V., & Fraser, J. (1998). The prevalence and perception of pain amongst hospital in patients. Journal of Clinical Nursing, 7, 521–530. Yu grı kontrolu ¨ cel, A. (2000). A ¨ nde hems‚irenin rolu ¨ [Nurse role in pain control]. In S. Erdine (Ed.), A grı [Pain] (pp. 695– 698). I_stanbul: Alemdar.
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ABSTRACT:
This study examines the effect of relaxation exercises on controlling postoperative pain in patients who have undergone upper abdominal surgery. This is a cross-sectional and crossover study conducted on 60 patients who underwent upper abdominal surgery between October 2006 and June 2007, in the General Surgery Department, Health and Research Practice Center, Trakya University, Edirne, Turkey. We assessed the patients’ pain levels before and after the relaxation exercises. Patients’ personal information forms were used to collect data, and pain levels were determined using the verbal pain scale. We used the Wilcoxon T test, nonparametric Spearman correlation analysis, and nominal by interval eta analysis to assess the data, percentage, and frequency analyses. Pain levels were found to be reduced after the relaxation exercises compared with the levels before the relaxation exercises (z ¼ L5.497; p < .001). Relaxation exercises, a nonpharmacologic method, are effective in reducing postoperative pain and should therefore be included in a regimen to control postoperative pain in patients who have undergone upper abdominal surgery. Ó 2012 by the American Society for Pain Management Nursing
From the Trakya University Faculty of Health Science, Edirne, Turkey. Address correspondence to Sacide Yildizeli Topcu, RN, MSc, Teaching Assistant, Trakya University Faculty of Health Science, Aysekadin Campus, 22020, Edirne, Turkey. E-mail: [email protected] Received September 8, 2009; Revised July 12, 2010; Accepted July 14, 2010. 1524-9042/$36.00 Ó 2012 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2010.07.006
Upper abdominal surgery is a painful surgical procedure. Inadequate pain control in these patients can lead to many complications, reduction of participation in treatment and care, patient dissatisfaction, longer hospitalization, and in¨ zyuvacı, Altan, & Yu creased costs (Allred, Byers, & Sole, 2010; O ¨ cel, 2003; Shang & Gan, 2003; Valente, 2006). Although there is no standard method that can be applied to all patients’ pain control, pain management should begin with a preventive approach to pain, and both pharmacologic and nonpharmacologic methods should be used together for the most effective pain control (Allred, Byers, & Sole, 2010; Badır & Aslan, 2003). As a nonpharmacologic method, relaxation exercise helps to reduce postoperative pain and anxiety and thereby prevent complications (Yu ¨ cel, 2000). The use of relaxation exercises in the postoperative period will increase patient satisfaction with nursing care as well as providing effective pain control.
Pain Management Nursing, Vol 13, No 1 (March), 2012: pp 11-17
12
Topcu and Findik
REVIEW OF THE LITERATURE Pain, which is defined as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’’ by the International Association for the Study of Pain (IASP), is the primary area of complaint and fear in postoperative patients (Aslan, 2002; IASP, 2010). Yates, Dewar, Edwards, Fentiman, Najman, and Nash, (1998) reported that 78.6% of patients undergoing treatment in hospitals suffer from pain. Postoperative pain is an acute pain beginning with surgical trauma, tapering off gradually and ending with tissue recovery (Arslan & C ¸ elebio glu, 2004; Green & Trait, 2002; Meeker 1998). Carr and Thomas (1997) observed that all patients expect postoperative pain. It is reported that 46 million people undergo surgery each year in the USA, of whom 77% experience postoperative pain (Centers for Disease Control and Prevention, 2010; Warfield & Kahn, 1995). Kuhn et al. (1990), in their study of 101 patients, found that 40 of them suffered from severe pain and 47 experienced moderate pain. Seventy-five percent of patients undergoing surgery report that they endure moderate to severe pain which on movement causes very severe pain, reaching 85%-100% (Apfelbaum, Chen, Mehta, & Gan, 2003; Good, 1996; McDonald, McNulty, Erickson, & Weiskopf 2000; Sloman, Rosen, Rom, and Shir, 2005; Warfield & Kahn, 1995). In Turkey, 93.7% of the patients undergoing surgery report that they suffer from severe pain (Aslan, 2005). The place and duration of the surgery, the preoperative physical and psychologic preparedness of the patient, the presence of complications, types of anesthetics and analgesics used, and the quality of postoperative care influence the severity of the pain patients experience (Good, Anderson, Ahn, Cong, StantonHicks, 2005; Ignatavicius, Workman, & Mishler, 1995). Abdominal surgeries are one of the most painful surgical procedures, due to the proximity to the diaphragm and the nerve supply to the area, and 37% of the patients undergoing elective abdominal surgery report that they experience severe pain (Kuhn, Cooke, Collins, Jones, and Mucklow, 1990). Similarly, Good et al. (2001b) observed that postoperative pain during ambulation after abdominal surgery increases by 31%. Postoperative pain exerts several adverse psychologic and physical effects, such as increasing coagulation and fluid retention by raising the stress response, prolonging the recovery process by adversely affecting appetite and sleep, and causing complications in the cardiovascular, gastrointestinal, and urinary systems. In addition, postoperative pain can cause stress and
anxiety. Particularly, severe pain after upper abdominal surgeries can multiply the complications by adversely affecting the respiratory functions and mobilization of the patient owing to the proximity of the incision site to the diaphragm (Agency for Health Care Policy and Research, 1992; Good, 1996; Richards & Hubbert, 2007). Postoperative pain management strives to prevent the side effects of pain, facilitate recovery, and reduce treatment costs by minimizing or eliminating the patient’s distress (Arslan & C ¸ elebioglu, 2004). Despite significant technologic developments and existing research in pain control, postoperative pain cannot be eliminated in most patients (Apfelbaum et al., 2003; Yates et al., 1998). Thus, although various pharmacologic pain control methods have been developed, such as patientcontrolled analgesia, continuous intravenous infusion, and intraspinal application of opioids and/or local anesthetics, analgesic applications cannot sufficiently relieve postoperative pain and may instead precipitate adverse side effects (Carr & Thomas, 1997; Good et al., 1999, Warfield & Kahn, 1995). In their study, Apfelbaum et al. (2003) demonstrated that 23% of patients using postoperative analgesics experienced adverse effects. In postoperative pain control, nonpharmacologic pain control methods can be used to increase the effect of analgesics, in case of insufficient effect of analgesics, or when analgesics cannot be used. Among nonpharmacologic pain control methods, transcutaneous nerve stimulation, application of hot and/or cold compresses, exercises, positioning, and massage are physical techniques commonly used in postoperative pain control, and relaxation, distraction, and hypnosis are cognitive/behavioral techniques (Arslan & C ¸ elebioglu, 2004). In their study on pain prevalence and perception among inpatient individuals, Yates et al. (1998) reported that patients preferred relaxation and distration more than other nonpharmacologic pain control methods. Relaxation is defined as an absence of physical, mental, and emotional tension (Friesner, Curry, & Moddeman, 2006). The resolving of muscle tension caused by anxiety is the mainstay of relaxation exercises. Because skeletal muscles close to the incision site significantly influence postoperative pain, relaxation exercises resolve the tension in the skeletal muscles and thus reduce postoperative pain (Wilkie, 2000; Willens, 2006). The literature demonstrates that relaxation causes a drop in blood pressure, heart rate, and breathing rate, as well as in pain responses and anxiety (Kesler, Patterson, & Dane, 2003). Relaxation exercises first became the subject of nursing research in 1971, when Aiken and Henrichs used systematic relaxation training as a nursing approach for patients scheduled to undergo open-heart surgery. From then on, nurse researchers have used relaxation
Relaxation Exercises for Postoperative Pain
exercises to reduce anxiety, muscle tension, and pain in preoperative and postoperative patients (Demiralp & Oflaz, 2007; Friesner, Curry, & Moddeman, 2006). In their study using relaxation techniques in acute pain control, Seers and Carroll (1998) demonstrated that postoperative pain was reduced by relaxation exercises. Aslan (1998) observed that postoperative pain scores were lower in patients trained in relaxation exercises during the preoperative period. Good et al. (2001a) and Friesner, Curry, and Moddeman (2006) demonstrated that the pain levels in patients using both analgesics and relaxation exercises were lower than in those who used analgesics alone. Relaxation exercises reduce analgesic usage by increasing the comfort of the patient, although it is recommended that they be used along with analgesics for effective pain control (Cheung, Molassiotis, & Chang, 2001; Good et al., 2005). The present research aimed to study the effect of relaxation exercises on controlling postoperative pain in patients undergoing upper abdominal surgery.
METHODS Ethical Considerations This study was approved by the Ethics Committee of the Trakya University Medical Faculty. Permission to conduct the study was obtained from the Director of Nursing and Clinical Services. All the patients were given information on the study, and informed consent was obtained from each of the participants. Design and Sample This is a cross-sectional and crossover study conducted on 60 patients who had undergone upper abdominal surgery between October 2006 and June 2007 in the General Surgery Clinic, Health and Research Practice Center, Trakya University. A convenience sample method was used in the research. The patients included in the study had undergone upper abdominal surgery, were in the postoperative 1–4-day period, had postoperative mobilization, were >18 years old and literate, had no communication or mental problems, were given an analgesic $2 hours before the exercises, and volunteered to participate in the study and practice the relaxation exercises. Patients who had undergone laparoscopic surgery were not included in the study. Data Collection A personal information form to provide information on the demographic characteristics of the patients, their health histories, and existing diseases and a verbal pain scale to identify the patients’ pain levels were
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used in data collection. A audiotape prepared by the Turkish Psychologists Association was used to teach and apply the relaxation exercises. The personal information form consists of eight questions covering demographic details such as the patient’s age, gender, educational level, health insurance, and health history data such as surgical procedure, chronic diseases, treatment period, and number of postoperative days. The verbal pain scale consists of grades defining the patient’s pain, such as ‘‘no pain,’’ ‘‘mild pain,’’ ‘‘irritating pain,’’ ‘‘severe pain,’’ ‘‘very severe pain,,’’ and ‘‘unbearable pain’’. The training material for relaxation exercises was prepared by the Turkish Psychologists Association. The audiotape used to teach and apply the relaxation exercises includes audible instructions for relaxation exercises, benefits and important points to remember during the practice and application of relaxation exercises. It gives instructions for relaxation exercises with soothing music and the sound of running water in the background. The instructions include correct breathing techniques, focusing on relaxation, as well contracting and relaxing various muscle groups. Procedure Barring clinic visits, meals, visitation, and treatment hours, the patients were verbally informed about the relaxation exercises, based on information gathered from the literature, $2 hours after the analgesic application while at rest in a quiet and calm environment, pain was alleviated by analgesic effect, and the patient had approved participation in the research. All participants were asked to complete the personal information form, and their pain levels were recorded before they began practicing the relaxation exercises. Next, they were taught the relaxation exercises on the tape prepared by Turkish Psychologists Association and encouraged to apply them. The patients used headphones during the training to prevent them from being distracted by the surrounding sounds and to help them concentrate. The patients were encouraged to listen to the tape until they stated that they had learned the exercises fully and could apply them correctly. After that, the patients did the relaxation exercises for 30 minutes, following which the pain levels were reassessed and recorded. Data Analysis The statistical analyses for data assessment were performed using SPSS 10.00. In addition to percentage, frequency, and average analyses, the Wilcoxon T test was used to determine the differences among the pain levels. Then the nonparametric Spearman correlation analysis and nominal by interval eta analysis were
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used to identify the correlation among the patients’ personal characteristics, health history, treatment properties, and pain levels. A p value of <.05 was accepted as the statistical significance limit.
TABLE 1. Pain Sensations Before and After Relaxation Exercises Before Relaxation
After Relaxation
Sensation of pain
n
%
n
%
No pain Mild pain Irritating pain Severe pain Very severe pain Total
1 24 22 8 5 60
1.7 40.0 36.7 13.3 8.3 100
22 22 11 4 1 60
36.7 36.7 18.3 6.7 1.7 100
RESULTS A total of 60 patients undergoing upper abdominal surgery participated in this study. The average age of the patients was 48.38 years. In all, 80% of the patients were primary and secondary school graduates, 51.7% were male, and 55% had undergone open cholecystectomy. It was noted that 66.7% of the patients participating in the study had had no previous surgical procedure, and 63.3% had no chronic disease. No significant correlation was found between the pain levels and these variables. When pain levels before and after the relaxation exercises were examined, the proportion of patients who mentioned no pain had increased from 1.7% to 36.7%, the proportion of patients experiencing irritating pain had decreased from 36.7% to 18.3%, and the proportion of patients who had very severe pain had decreased from 8.3% to 1.7% after the relaxation exercises (Table 1). The fact that the pain was reduced after the relaxation exercises was statistically significant (z ¼ 5.497; p < .001). The study demonstrated that 71.7% of the patients felt less pain after the relaxation exercises (Table 2). Before the relaxation exercises, the correlation between decreasing pain levels and every passing postoperative day was statistically significant (r ¼ 0.267; p < .05; Table 3).
DISCUSSION This study examined the effect of relaxation exercises on pain levels of 60 patients undergoing upper abdominal surgery. Postoperative pain levels were found to be markedly reduced with the use of relaxation exercises. Similarly, Good et al. (2001a, 2005) and Roykulcharoen and Good (2004), in their studies on patients
undergoing abdominal surgery, demonstrated that relaxation exercises effectively reduced postoperative pain. Aslan (1998) also showed that relaxation exercises effectively controlled postoperative pain in patients undergoing upper abdominal surgery. Similar results have been found in different surgical procedures. In their study on patients undergoing gynecologic surgeries, Good et al. (2002) found that relaxation exercises were effective in reducing the pain experienced due to various factors on the first and second postoperative days. In a further study, Good et al. (2006) supported the use of relaxation exercises, as a method supplementary to analgesics, in reducing postoperative pain. Friesner et al. (2006) demonstrated that relaxation exercises positively affected patients whose pain levels were assessed immediately after the removal of the chest tube and 15 minutes later. The results of the present study, as well as the results of the earlier studies, show that relaxation exercises play an effective role in pain control after surgery, not only in the upper abdominal area but also in other parts of the body. There was no correlation between pain levels and individual characteristics, surgical procedure, or chronic disease in the present study. Good et al. (2001a), and Roykulcharoen and Good (2004) also reported no statistically significant correlation between patients’ age, gender, or educational status and their pain levels before and after
TABLE 2. Comparison of Pain Sensations Before and After Relaxation Exercises Difference
n
%
p*
z*
Decreased pain sensation after relaxation exercises Unchanged pain sensations after relaxation exercises Increased pain sensation after relaxation exercises Total
43 13 4 60
71.7 21.7 6.7 100
.000
5.497
*Wilcoxon T test.
1 2.9 0.175 .180 35 100 0 0.0 13 100 0 0,0 9 100 0 0.0 3 100 1 1.7 60 100 4 0 0 0 4 14.3 23.1 22.2 33.3 18.3 14.3 0.267 .039 10 0.0 6 0.0 5 0.0 1 8.3 22
28.6 15 42.9 5 46.2 4 30.8 3 55.5 2 22.2 2 33.3 1 33.3 1 36.7 22 36.7 11
Limitations In the present study, pain was assessed on the first to fourth postoperative day. Postoperative pain decreases in accordance with the healing process, and the duration of pain observed after upper abdominal surgery is 4 days (Aslan, 2006). Therefore, postoperative pain levels were assessed on these days after surgery. Other limitations are that relaxation exercises were taught and applied after analgesic application to facilitate learning and practice by patients. Limited sample size due to the study’s being conducted in a regional hospital was also a limiting factor.
CONCLUSIONS AND RECOMMENDATIONS
45.7 15.4 33.3 33.3 36.7
4 2 1 1 8
11.4 15.4 11.1 33.3 13.3
5 0 0 0 5
The present research findings determined the effectiveness of relaxation exercises in controlling postoperative pain in patients undergoing upper abdominal surgery. The pain levels were reduced after the relaxation exercises in patients using the same analgesics for pain control. Therefore, relaxation exercises are an effective and supplementary nonpharmacologic method of pain control in patients undergoing upper abdominal surgery. Personal and health-related variables have no effect on pain levels. After an evaluation of the conclusions, relaxation exercises should be recommended for use in postoperative nursing care for more effective pain control in patients undergoing upper abdominal surgery. *Spearman correlation.
28.6 16 69.2 2 44.4 3 33.3 1 40.0 22 0 0.0 10 0 0.0 9 1 11.1 4 0 0.0 1 1 1.7 24 Day 1 Day 2 Day 3 Day 4 Total
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relaxation exercises. The results of our study support the findings of those other studies. It was statistically significant that, even before the relaxation exercises, the pain was reduced with each passing postoperative day. Good et al. demonstrated in several studies that patients undergoing abdominal surgery and not using any nonpharmacologic pain control method experienced less pain in the second postoperative day than in the first postoperative day (Good et al., 1999, 2001a, 2005). Research done by Pellino (2005) on patients who had undergone total hip and knee arthroplasty found that pain levels were reduced with each postoperative day, both in the cases under study and in the control group. As a result, it is apparent that postoperative pain reduces with each postoperative day in parallel with tissue recovery.
11.4 0.0 0.0 0.0 6.7
% n % n % n % n % n % n % n % % Postoperative day n
No pain
n
Mild pain
Irritating pain
Severe pain
Very severe pain
r
p*
n
%
n
%
Very severe pain Severe pain Irritating pain Mild pain No pain
Pain Sensation After Relaxation Exercises Pain Sensation Before Relaxation Exercises
TABLE 3. Relationship Between Relaxation Exercises, Postoperative Days, and Pain Sensations
r
p*
Total
Relaxation Exercises for Postoperative Pain
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