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The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial
burns 39 (2013) 61–67
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial Fahimeh Mohammadi Fakhar a, Forough Rafii b,*, Roohangiz Jamshidi Orak c a
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Center for Nursing Care Research, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, East Nosrat St., Tohid square, 6459, Tehran, Iran c Statistic and Mathematics Department, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran b
article info
abstract
Article history:
Aim: The purpose of this randomised clinical trial (RCT) was to determine the effect of jaw
Accepted 16 March 2012
relaxation on pain anxiety related to dressing changes in burn injuries. Introduction: Patients hospitalised with burns experience high levels of anticipatory anxiety
Keywords:
during dressing changes, which cannot be completely managed by anxiolytic drugs. Nurses
Relaxation
as members of the burn care team contribute to pain management by using relaxation
Pain anxiety
techniques as one of the most frequently used approaches to pain anxiety management.
Burn
However, there is not enough information about the effects of these techniques on pain
Dressing
anxiety of patients with burns. The aim of this study was to determine the effect of jaw
Clinical trial
relaxation on pain anxiety related to dressing changes in burn injuries.
Minimisation
Methods: It was a randomised clinical trial with a control group. A total of 100 patients hospitalised in Shahid Motahari Burn Centre affiliated with Tehran University of Medical Sciences were recruited by convenience sampling and were randomly assigned to either experimental or control groups using minimisation. With institutional approval and written consent, the experimental group practiced jaw relaxation for 20 min before entering the dressing room. Data were collected by the Burn Specific Pain Anxiety Scale (BSPAS) during July– December 2009 and analysed using Statistical Package for the Social Sciences (SPSS)-PC (17). Results: An independent t-test showed no significant difference between mean pain anxiety scores in the experimental and control group before intervention ( p = 0.787). A dependent ttest showed significantly less pain anxiety after intervention (before dressing) in the experimental group ( p < 0.05). Moreover, the independent t-test showed that the postdressing pain anxiety of the experimental group was less than the control group ( p < 0.05). However, the dependent t-test showed no significant difference between before and after dressing pain anxiety (after intervention) in the experimental group ( p = 0.303). Conclusion: Nurses can independently decrease the pain anxiety of patients with burns and its subsequent physical and psychological burden by teaching the simple and inexpensive technique of jaw relaxation. Further research is needed to study the effect of this technique on pain anxiety of patients suffering from other painful procedures. # 2012 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +98 21 88671613; fax: +98 21 66904252. E-mail addresses: [email protected], [email protected] (F. Mohammadi Fakhar), [email protected], [email protected] (F. Rafii), [email protected] (R. Jamshidi Orak). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2012.03.005
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burns 39 (2013) 61–67
Burn injuries are a painful and often disabling form of trauma [1]. Patients hospitalised for burn injuries experience severe pain on a daily basis, both immediately after the injury and during therapeutic procedures, such as dressing changes, debridement and physiotherapy [2]. In addition, repetition of these painful procedures often creates anticipatory anxiety for patients with burns [3]. Anxiety induced by a bad acute pain experience risks poor compliance with rehabilitation therapies, increased pain perception and loss of faith in the burn team [4]. If left untreated, anxiety can also intensify into a pathway of fear, sleeplessness, depression and helplessness that may render patients psychologically unable to cope with their illness or in assisting with their treatment [1]. The management of pain anxiety is one of the primary issues in burn care [5]. The typical approach to pain anxiety control in patients with burns involves the use of opioid analgesics supplemented with anxiolytic drugs. While narcotics and benzodiazepines tend to diminish the discomfort of the burn dressing changes, they are usually not sufficient [6]. The gate control theory (1965) was the first theory to suggest that psychological factors play a role in the perception of pain. Thus, the theory guided research towards the cognitive-behavioural approaches to pain management [7]. This concept is supported by the gate control theory of pain, which states that there is a gating mechanism in the nervous system that can block the transmission of sensory and affective components of pain at the level of the spinal cord [3]. According to this theory, information from non-pain fibres or information from the brain can reduce or totally block pain information before it is experienced. Hence, whether the gate is open or closed, it can be influenced by fibres carrying information from many different brain centres down to the spinal cord [8]. Therefore, the gate control theory suggests that cognitive processes such as relaxation can exert control over painful stimuli [3]. Since pain is not only a sensory experience but an affective and cognitive experience as well [9], it is important to use nonpharmacological methods in addition to analgesics to decrease patient discomfort and anxiety [10]. As a treatment strategy, relaxation is very effective for pain and stress-related conditions [11]; and is one of the most widely used methods in management of pain anxiety [12]. The mutual relationship between the brain and muscles is the basic principle of relaxation [13] and its primary purpose is reduction of muscular tension and anxiety [12]. Relaxation reduces pain and anxiety through developing confidence, selfcontrol and by reducing negative feelings. It renews hope by giving patients a tool to manage pain and thus enables patients with burns to learn self-care and to be actively involved in their own recovery [14]. Moreover, it is a workable strategy that can be used at any time [11] and it has minimal side effects [10]. Several studies found that relaxation decreases the sensory and affective components of postoperative pain. In many of these studies, investigators tested the jaw relaxation technique, and this was effective in nearly all of the studies [10,15– 19]. While jaw relaxation has reduced postoperative pain and the related anxiety after abdominal, orthopaedic, gynaecologic and intestinal surgery, evidence for the effectiveness of jaw relaxation for sensory and affective components of burn pain
is sparse. We found no research on jaw relaxation for pain in patients with burns. Moreover, the current climate of providing effective care while reducing nursing time on interventions with unclear effectiveness can be difficult to defend [19]. Hence, this study was done to determine the effectiveness of the jaw relaxation technique on pain anxiety of burn dressing. The following hypotheses were tested in this study: (a) jaw relaxation will significantly decrease pre-dressing pain anxiety of the experimental group; (b) pre- and post-dressing pain anxiety of the experimental group will be significantly different after using jaw relaxation; and (c) patients who receive jaw relaxation will have significantly less pain anxiety than the control group.
1.
Method
1.1.
Sample
This study was an experimental randomised clinical trial. A total of 100 patients hospitalised in Shahid Motahari Burn Centre affiliated with Tehran University of Medical Sciences (TUMS) were recruited by convenience sampling over a period of 6 months. Random allocation was achieved by minimisation. Minimisation has the advantage of making small groups closely similar in terms of participant characteristics at all stages of the trial [20]. It controlled the groups for gender, age, educational status, previous hospitalisation for burn injury, substance abuse, previous use of relaxation or similar techniques, sleep disorders and presence of a family member as a caregiver in the ward. There were no significant differences between the groups regarding the above-mentioned factors (Table 1). All patients were fluent Persian speakers; their ages ranged from 18 to 60 years. All sustained 9–35% total body surface area (TBSA) 2nd and/or 3rd degree burns that were not selfinflicted. None of the patients had a history of psychiatric illness. The patients did not undergo any painful procedure or dressing change before the study intervention. Dressings were changed as per ward protocol. The inclusion criteria were: (a) in acute phase of burn injury; (b) thermal burns without face or neck involvement; (c) no history of psychiatric disorders; (d) absence of conditions which alter sensory transmission; (e) no severe visual and/or hearing problems. Exclusion criteria included: inability to do any stage of the procedure and achieve mastery in the jaw relaxation technique; and surgical interventions (e.g., skin graft) and/or biological dressing on the burn wounds. The sample size of 100 patients (50 in each group) was necessary and was included (based on type I error of 0.05 and power of 0.90). The final sample included 72 men and 28 women, with an average TBSA of 22.27% (range, 9–35%). Their mean age was 32.95 years (SD = 11.33) ranging from 18 to 60 years. The majority of the sample was Fars (40%) and married (61%); had not been hospitalised for burn injuries (95%); had completed diploma (43%); had not a substance abuse problem (67%); was in moderate financial status (65%); had sleep disorders (69%); had not received opioids before dressing (88%); and did not have a family member in the ward to help
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burns 39 (2013) 61–67
Table 1 – Characteristics of participants in experimental (n = 50) and control (n = 50) group. Group Variables
Experimental n
Gender 14 Female 36 Male Age <20 3 22 20–29 8 30–39 11 40–49 6 50–60 Educational status 4 Illiterate 4 Elementary 9 High school 23 Diploma 10 University Previous hospitalisation due to burn injury 3 Yes 47 No Substance abuse 16 Yes 34 No Sleep disorder Yes 34 16 No Presence of a family member 12 Yes No 38 Previous use of relaxation 1 Yes 49 No Financial status 4 Good 33 Moderate 13 Bad Receiving opioids before dressing 5 Yes 45 No TBSA 9–15 9 17 16–20 8 21–25 9 26–30 7 31–35 Burn category Flame 39 11 Scald Marital status 18 Single Married 31 0 Dead spouse 1 Divorcee Ethnicity Fars 20 2 Kurd 5 Lur Turk 17 2 Gilak 4 Balouch
Control
Sig.
%
n
%
28 72
14 36
28 72
P=1
6 44 16 22 12
4 21 10 11 4
8 42 20 22 8
P = 0.759
8 8 18 46 20
5 6 10 20 9
10 12 20 40 18
P = 0.935
6 94
2 48
4 96
P=1
32 68
17 33
34 66
P = 0.832
68 32
35 15
70 30
P = 0.829
24 76
11 39
22 78
P = 0.812
2 98
0 50
0 100
P=1
8 66 26
5 32 13
10 64 26
P=1
10 90
7 43
14 86
P = 0.538
18 34 16 18 14
10 17 5 10 8
20 34 10 20 16
P = 0.930
78 22
43 7
86 14
P = 0.436
36 62 0 2
19 30 1 0
38 60 2 0
P = 0.838
40 4 10 34 4 8
20 5 5 15 2 3
40 10 10 30 4 6
P = 0.930
them as a caregiver (77%). Flame and scald burn was observed in 82 and 18 cases, respectively. Except for one patient, none of them had used relaxation or similar techniques before (Table 1).
1.2.
Experimental intervention
Following random allocation, jaw relaxation was taught to the experimental group and written instruction was provided. Jaw
64
burns 39 (2013) 61–67
relaxation was practiced in a quiet, non-distracting environment. Patients were asked to let the lower jaw drop slightly; keep the tongue quiet and resting in the floor of the mouth; let the lips get soft; breath slowly in a three-rhythm pattern of inhale, exhale and rest; stop forming words; and not even think words [18]. The practice took 20 min and was repeated for the next 2 days. Ability to use the technique was verified using four criteria: (1) face relaxed, (2) no grimace or frown, (3) not talking and (4) slow respirations (2 points each). Mastery was defined as a score of 7 out of 8 points [18]. After 2 days, the patients practiced the method once again with researcher guidance so as to gain sufficient mastery. The patients were also asked to continue jaw relaxation practice until the next dressing.
1.3.
9 excluded Reason: Refused to participate (n=4) Withdrew due to too much pain or illness (n=5) 107 randomized by minimization 55 allocated to experimental group Received jaw relaxation
52 allocated to control group Received usual care
5 lost to follow up Reason: Withdrew due to disinterest in continuing (n=1) No longer eligible due to inability to achieve mastery in jaw relaxation (n=1) No longer eligible as having skin graft (n=2) No longer eligible as had biological dressing on the skin (n=1)
2 lost to follow up Reason: Discharged from wards
50 analysed 5 excluded from analysis Reason: Lost to follow up
50 analysed 2 excluded from analysis Reason: Lost to follow up
Measurements
Anticipatory pain anxiety was measured with the abbreviated version of the Burn Specific Pain Anxiety Scale (BSPAS) introduced by Taal and Faber. This scale is a five-item measure of anxiety specific to the pain anxiety associated with anticipation of pain before, during or after burn-care procedures. It can be completed in about 3 min. Each item in the BSPAS is scored on a 100 mm visual analogue line with two reference points given values of 0 and 100. The reference points are also identified by the expressions ‘‘not at all’’ and ‘‘the worst imaginable way’’. Thus, the BSPAS covers the whole range of dressing change anxiety, from no anxiety at all to extreme anxiety. The BSPAS is scored as the mean of the item responses across all items. The subject is asked to mark the line at a point corresponding to the pain anxiety to be described, and the distance is evaluated to the nearest millimetre [21,22]. For the purpose of this study, forward and back translation of the instrument into a Persian version was used [23]. The internal consistency of BSPAS was also measured (Cronbach’s a = 0.70). For this purpose, the BSPAS was completed by 20 eligible patients and analysed. These patients were excluded from the study. Other studies have reported an internal consistency reliability coefficient (Cronbach’s a) of 0.90 [22]. Ten faculty members of TUMS verified the face and content validity of the translated version of the instrument.
1.4.
116 eligible participants
Procedure
The study was approved by the TUMS ethics committee and burn centre authorities. The study was explained in detail to each eligible participant prior to obtaining consent. Those who then agreed to participate and gave informed consent took part in interviews to collect demographic data. As mentioned earlier, minimisation was used to randomly assign participants to either the control group receiving usual care or the experimental group, jaw relaxation. Fig. 1 shows the number of patients actually recruited and their allocation to the two study groups. To measure their anticipatory anxiety before intervention, we asked patients in the experimental group to rate their pain anxiety on BSPAS, 30–60 min before dressing changes the day after completion of training. Because their burn injuries might have inhibited simple motor movements, the items were read
Fig. 1 – Recruitment and allocation to study groups.
aloud and patients responded verbally to each one. Patients in the experimental group then practiced jaw relaxation technique for 20 min. In this stage, patients who had sufficient mastery of jaw relaxation completed BSPAS again to measure anticipatory anxiety before dressing change. Fifteen to twenty minutes after the dressing change, when patients were resting comfortably in their bed, they were asked to rate their pain anxiety during the dressing change. Patients in the control group completed BSPAS, 30–60 min before the dressing change, and once again, 15–20 min after dressing change to rate before and after dressing pain anxiety, respectively. It is worth mentioning that to prevent diffusion of treatment, room assignments were controlled, so that those in different groups were not assigned to the same room. Data were analysed using descriptive statistics, chi-square test, dependent and independent t-test and Fisher’s exact test by Statistical Package for the Social Sciences (SPSS)-PC. This study has been submitted to www.irct.ir [24].
2.
Results
The mean pain anxiety scores for each group are shown in Table 2 and Fig. 2. The independent t-test showed no
Table 2 – Means and standard deviations of participants pain anxiety in experimental and control group. Group Pain anxiety Before intervention After intervention, before dressing After intervention and/or dressing
Experimental (mm)
Control (mm)
Sig.
M SD
M SD
49.94 22.76 42.56 21.98
51.10 19.90
P = 0.787 P = 0.000
44.77 23.06
53.54 20.67
P = 0.048
burns 39 (2013) 61–67
Fig. 2 – Pain anxiety of participants in experimental and control group.
significant difference between mean pain anxiety scores in the experimental and control groups before intervention (P = 0.787). Regarding the first hypothesis, the dependent ttest showed that there was significant difference between mean pain anxiety scores before and after intervention in the experimental group (P = 0.000). Our second hypothesis (after intervention) demonstrated no significant difference between mean pain anxiety scores, before and after dressing in the experimental group (P = 0.303). There was no significant difference between mean pain anxiety scores before and after dressing in the control group (P = 0.375). Moreover, our third hypothesis independent t-test showed significant difference between the mean post-dressing pain anxiety scores in the experimental and control groups (P = 0.048).
3.
Discussion
Data showed that participants of this study suffered from a medium level of pain anxiety. This finding was in accord with the results of similar studies [25,26]. The presence of this emotional reaction is not surprising, given that patients hospitalised for burn care find themselves in a strange environment, often with feelings of loss of control and uncertainty regarding their clinical outcome and that of their families, homes or possessions. Patients also anticipate painful daily wound care and therapies, all of which creates a sense of dread and fear [26]. Consequently, anxiety becomes a part of the experience of pain, particularly if pain medication is not initiated prior to the unpleasant procedures such as dressing changes, which are often repeated for days or even weeks [27]. In this study, we demonstrated that a simple and inexpensive method of jaw relaxation can reduce the pain anxiety related to dressing in patients with burns. This finding is congruent with the findings of Good et al. [15–18]. They measured the effect of jaw relaxation on anxiety and pain after abdominal, gynaecologic and intestinal surgeries at rest and movement on the first and second day after operation. It is also in line with the study conducted by Roykulcharoen and Good that measured the effect of systematic relaxation on the sensory and affective dimensions of pain [10].
65
Based on the gate control theory, when the excitatory input from the inhibitory and descending fibres outnumbers input from the small fibres, the gate will be closed and will not allow information about pain anxiety to be transmitted to the brain [28]. Thus, relaxation can close the gate by the inhibitory impulses of the cortex and thalamus and thereby reduce pain anxiety or completely eliminate it [14]. Moreover, based on this theory, feelings of control over the noxious stimulus can close the gate and decrease the perception of different dimensions of pain by the brain cortex [29]. As a consequence, patients with burns need to feel they have control over the situation [11]. Learning relaxation methods can develop increased feelings of personal control over pain anxiety. In this way, instead of being a merely passive receiver of clinical interventions, patients can play an active role in learning and applying the skills of pain anxiety management [14]. Furthermore, at the time of anxiety, the body’s natural opioids are blocked and pain is experienced with even more intensity [30]. However, relaxation through the secretion of endorphins results in reduced pain and anxiety subsequently. These facts indeed support the claims made by Coldberg on relaxation methods. He believed that the soul is inseparable from the body and thoughts and feelings arise from bodily reactions and each individual is able to reverse physical, emotional and behavioural dimensions of tenseness consciously [31]. The finding that there was no significant difference between pain anxiety of the experimental group (after intervention) before and after dressing could be related to the severe pain that patients with burns usually experience during dressing change and the fact that it frequently causes considerable anxiety. The bi-directional relationship between pain and anxiety has been supported by different studies. Poorly managed pain can increase anxiety and vice versa [32]. Therefore, the presence of increased levels of pain anxiety after dressing is not surprising. Moreover, the stimulus for anxiety can originate either from psychic conflict when ideas, thoughts or feelings threaten the individual’s self-integrity or from outside the psyche, when something in the individual’s biological or social environment threatens self-integrity [28]. Thus, it seems that before dressing, mental conflicts related to anticipation of a painful procedure have triggered anxiety in patients with burns, while external stimulation related to irritated tissues and also dealing with specific issues during dressing change have added to their mental conflicts and intensified the level of their anxiety. In addition, jaw relaxation did not continue in the dressing room, so the descending inhibitory impulses of the brain reduced. All these factors led to increased levels of pain anxiety after dressing. Byers et al. also found that the dressing pain anxiety of patients with burns was higher than their base anxiety. They also found that both pain anxiety and pain intensity were higher than the base state during treatment measures [1].
4.
Conclusion
Daily recurrence of wound care procedures, including removal of dressing, washing, debridement and application of new
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dressing, is the main cause of pain experiences and its anxiety in patients with burns [33]. The exercise of relaxation reinforces the belief in patients with burns that they are not powerless and can exert control over the situation during the periods of pain and stress [14]. Thus, considering the positive effect of jaw relaxation on the reduction of burn pain anxiety and also the simplicity of learning and applying this method, patients with burns can be encouraged to apply the method in times of anxiety and tension. Due to the fact that of all professionals involved in the care for patients with burns, nurses are mostly confronted with the phenomenon of pain and its anxiety [34], and because nurses are the client’s primary advocate for sensory and affective pain reduction and/or relief [35], this study suggests that jaw relaxation be taught to patients with burns so that patients might experience less pain anxiety before, during and after dressing changes. Studying the effect of this relaxation technique on patients going through other painful procedures is recommended.
5.
Limitations
The differences between participants in terms of physiological, emotional, psychosocial and cognitive factors, the different attitudes of dressing room nurses towards patients, and its effect on the method of dressing change and the resultant level of pain anxiety [36] were beyond the scope in this study.
Conflict of interest statement The authors had not any financial or personal relationships with other people or organisations during the study. So there was no conflict of interests in this article.
Acknowledgements We express our sincere gratitude to the patients in the study, who generously provided their time and trust, and to all the nurses and other health-care staff of Shahid Motahari Burn Centre. The authors also thank the Centre for Nursing Care Research affiliated to Tehran University of Medical Sciences for its financial support.
references
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial Fahimeh Mohammadi Fakhar a, Forough Rafii b,*, Roohangiz Jamshidi Orak c a
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Center for Nursing Care Research, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, East Nosrat St., Tohid square, 6459, Tehran, Iran c Statistic and Mathematics Department, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran b
article info
abstract
Article history:
Aim: The purpose of this randomised clinical trial (RCT) was to determine the effect of jaw
Accepted 16 March 2012
relaxation on pain anxiety related to dressing changes in burn injuries. Introduction: Patients hospitalised with burns experience high levels of anticipatory anxiety
Keywords:
during dressing changes, which cannot be completely managed by anxiolytic drugs. Nurses
Relaxation
as members of the burn care team contribute to pain management by using relaxation
Pain anxiety
techniques as one of the most frequently used approaches to pain anxiety management.
Burn
However, there is not enough information about the effects of these techniques on pain
Dressing
anxiety of patients with burns. The aim of this study was to determine the effect of jaw
Clinical trial
relaxation on pain anxiety related to dressing changes in burn injuries.
Minimisation
Methods: It was a randomised clinical trial with a control group. A total of 100 patients hospitalised in Shahid Motahari Burn Centre affiliated with Tehran University of Medical Sciences were recruited by convenience sampling and were randomly assigned to either experimental or control groups using minimisation. With institutional approval and written consent, the experimental group practiced jaw relaxation for 20 min before entering the dressing room. Data were collected by the Burn Specific Pain Anxiety Scale (BSPAS) during July– December 2009 and analysed using Statistical Package for the Social Sciences (SPSS)-PC (17). Results: An independent t-test showed no significant difference between mean pain anxiety scores in the experimental and control group before intervention ( p = 0.787). A dependent ttest showed significantly less pain anxiety after intervention (before dressing) in the experimental group ( p < 0.05). Moreover, the independent t-test showed that the postdressing pain anxiety of the experimental group was less than the control group ( p < 0.05). However, the dependent t-test showed no significant difference between before and after dressing pain anxiety (after intervention) in the experimental group ( p = 0.303). Conclusion: Nurses can independently decrease the pain anxiety of patients with burns and its subsequent physical and psychological burden by teaching the simple and inexpensive technique of jaw relaxation. Further research is needed to study the effect of this technique on pain anxiety of patients suffering from other painful procedures. # 2012 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author. Tel.: +98 21 88671613; fax: +98 21 66904252. E-mail addresses: [email protected], [email protected] (F. Mohammadi Fakhar), [email protected], [email protected] (F. Rafii), [email protected] (R. Jamshidi Orak). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2012.03.005
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Burn injuries are a painful and often disabling form of trauma [1]. Patients hospitalised for burn injuries experience severe pain on a daily basis, both immediately after the injury and during therapeutic procedures, such as dressing changes, debridement and physiotherapy [2]. In addition, repetition of these painful procedures often creates anticipatory anxiety for patients with burns [3]. Anxiety induced by a bad acute pain experience risks poor compliance with rehabilitation therapies, increased pain perception and loss of faith in the burn team [4]. If left untreated, anxiety can also intensify into a pathway of fear, sleeplessness, depression and helplessness that may render patients psychologically unable to cope with their illness or in assisting with their treatment [1]. The management of pain anxiety is one of the primary issues in burn care [5]. The typical approach to pain anxiety control in patients with burns involves the use of opioid analgesics supplemented with anxiolytic drugs. While narcotics and benzodiazepines tend to diminish the discomfort of the burn dressing changes, they are usually not sufficient [6]. The gate control theory (1965) was the first theory to suggest that psychological factors play a role in the perception of pain. Thus, the theory guided research towards the cognitive-behavioural approaches to pain management [7]. This concept is supported by the gate control theory of pain, which states that there is a gating mechanism in the nervous system that can block the transmission of sensory and affective components of pain at the level of the spinal cord [3]. According to this theory, information from non-pain fibres or information from the brain can reduce or totally block pain information before it is experienced. Hence, whether the gate is open or closed, it can be influenced by fibres carrying information from many different brain centres down to the spinal cord [8]. Therefore, the gate control theory suggests that cognitive processes such as relaxation can exert control over painful stimuli [3]. Since pain is not only a sensory experience but an affective and cognitive experience as well [9], it is important to use nonpharmacological methods in addition to analgesics to decrease patient discomfort and anxiety [10]. As a treatment strategy, relaxation is very effective for pain and stress-related conditions [11]; and is one of the most widely used methods in management of pain anxiety [12]. The mutual relationship between the brain and muscles is the basic principle of relaxation [13] and its primary purpose is reduction of muscular tension and anxiety [12]. Relaxation reduces pain and anxiety through developing confidence, selfcontrol and by reducing negative feelings. It renews hope by giving patients a tool to manage pain and thus enables patients with burns to learn self-care and to be actively involved in their own recovery [14]. Moreover, it is a workable strategy that can be used at any time [11] and it has minimal side effects [10]. Several studies found that relaxation decreases the sensory and affective components of postoperative pain. In many of these studies, investigators tested the jaw relaxation technique, and this was effective in nearly all of the studies [10,15– 19]. While jaw relaxation has reduced postoperative pain and the related anxiety after abdominal, orthopaedic, gynaecologic and intestinal surgery, evidence for the effectiveness of jaw relaxation for sensory and affective components of burn pain
is sparse. We found no research on jaw relaxation for pain in patients with burns. Moreover, the current climate of providing effective care while reducing nursing time on interventions with unclear effectiveness can be difficult to defend [19]. Hence, this study was done to determine the effectiveness of the jaw relaxation technique on pain anxiety of burn dressing. The following hypotheses were tested in this study: (a) jaw relaxation will significantly decrease pre-dressing pain anxiety of the experimental group; (b) pre- and post-dressing pain anxiety of the experimental group will be significantly different after using jaw relaxation; and (c) patients who receive jaw relaxation will have significantly less pain anxiety than the control group.
1.
Method
1.1.
Sample
This study was an experimental randomised clinical trial. A total of 100 patients hospitalised in Shahid Motahari Burn Centre affiliated with Tehran University of Medical Sciences (TUMS) were recruited by convenience sampling over a period of 6 months. Random allocation was achieved by minimisation. Minimisation has the advantage of making small groups closely similar in terms of participant characteristics at all stages of the trial [20]. It controlled the groups for gender, age, educational status, previous hospitalisation for burn injury, substance abuse, previous use of relaxation or similar techniques, sleep disorders and presence of a family member as a caregiver in the ward. There were no significant differences between the groups regarding the above-mentioned factors (Table 1). All patients were fluent Persian speakers; their ages ranged from 18 to 60 years. All sustained 9–35% total body surface area (TBSA) 2nd and/or 3rd degree burns that were not selfinflicted. None of the patients had a history of psychiatric illness. The patients did not undergo any painful procedure or dressing change before the study intervention. Dressings were changed as per ward protocol. The inclusion criteria were: (a) in acute phase of burn injury; (b) thermal burns without face or neck involvement; (c) no history of psychiatric disorders; (d) absence of conditions which alter sensory transmission; (e) no severe visual and/or hearing problems. Exclusion criteria included: inability to do any stage of the procedure and achieve mastery in the jaw relaxation technique; and surgical interventions (e.g., skin graft) and/or biological dressing on the burn wounds. The sample size of 100 patients (50 in each group) was necessary and was included (based on type I error of 0.05 and power of 0.90). The final sample included 72 men and 28 women, with an average TBSA of 22.27% (range, 9–35%). Their mean age was 32.95 years (SD = 11.33) ranging from 18 to 60 years. The majority of the sample was Fars (40%) and married (61%); had not been hospitalised for burn injuries (95%); had completed diploma (43%); had not a substance abuse problem (67%); was in moderate financial status (65%); had sleep disorders (69%); had not received opioids before dressing (88%); and did not have a family member in the ward to help
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Table 1 – Characteristics of participants in experimental (n = 50) and control (n = 50) group. Group Variables
Experimental n
Gender 14 Female 36 Male Age <20 3 22 20–29 8 30–39 11 40–49 6 50–60 Educational status 4 Illiterate 4 Elementary 9 High school 23 Diploma 10 University Previous hospitalisation due to burn injury 3 Yes 47 No Substance abuse 16 Yes 34 No Sleep disorder Yes 34 16 No Presence of a family member 12 Yes No 38 Previous use of relaxation 1 Yes 49 No Financial status 4 Good 33 Moderate 13 Bad Receiving opioids before dressing 5 Yes 45 No TBSA 9–15 9 17 16–20 8 21–25 9 26–30 7 31–35 Burn category Flame 39 11 Scald Marital status 18 Single Married 31 0 Dead spouse 1 Divorcee Ethnicity Fars 20 2 Kurd 5 Lur Turk 17 2 Gilak 4 Balouch
Control
Sig.
%
n
%
28 72
14 36
28 72
P=1
6 44 16 22 12
4 21 10 11 4
8 42 20 22 8
P = 0.759
8 8 18 46 20
5 6 10 20 9
10 12 20 40 18
P = 0.935
6 94
2 48
4 96
P=1
32 68
17 33
34 66
P = 0.832
68 32
35 15
70 30
P = 0.829
24 76
11 39
22 78
P = 0.812
2 98
0 50
0 100
P=1
8 66 26
5 32 13
10 64 26
P=1
10 90
7 43
14 86
P = 0.538
18 34 16 18 14
10 17 5 10 8
20 34 10 20 16
P = 0.930
78 22
43 7
86 14
P = 0.436
36 62 0 2
19 30 1 0
38 60 2 0
P = 0.838
40 4 10 34 4 8
20 5 5 15 2 3
40 10 10 30 4 6
P = 0.930
them as a caregiver (77%). Flame and scald burn was observed in 82 and 18 cases, respectively. Except for one patient, none of them had used relaxation or similar techniques before (Table 1).
1.2.
Experimental intervention
Following random allocation, jaw relaxation was taught to the experimental group and written instruction was provided. Jaw
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relaxation was practiced in a quiet, non-distracting environment. Patients were asked to let the lower jaw drop slightly; keep the tongue quiet and resting in the floor of the mouth; let the lips get soft; breath slowly in a three-rhythm pattern of inhale, exhale and rest; stop forming words; and not even think words [18]. The practice took 20 min and was repeated for the next 2 days. Ability to use the technique was verified using four criteria: (1) face relaxed, (2) no grimace or frown, (3) not talking and (4) slow respirations (2 points each). Mastery was defined as a score of 7 out of 8 points [18]. After 2 days, the patients practiced the method once again with researcher guidance so as to gain sufficient mastery. The patients were also asked to continue jaw relaxation practice until the next dressing.
1.3.
9 excluded Reason: Refused to participate (n=4) Withdrew due to too much pain or illness (n=5) 107 randomized by minimization 55 allocated to experimental group Received jaw relaxation
52 allocated to control group Received usual care
5 lost to follow up Reason: Withdrew due to disinterest in continuing (n=1) No longer eligible due to inability to achieve mastery in jaw relaxation (n=1) No longer eligible as having skin graft (n=2) No longer eligible as had biological dressing on the skin (n=1)
2 lost to follow up Reason: Discharged from wards
50 analysed 5 excluded from analysis Reason: Lost to follow up
50 analysed 2 excluded from analysis Reason: Lost to follow up
Measurements
Anticipatory pain anxiety was measured with the abbreviated version of the Burn Specific Pain Anxiety Scale (BSPAS) introduced by Taal and Faber. This scale is a five-item measure of anxiety specific to the pain anxiety associated with anticipation of pain before, during or after burn-care procedures. It can be completed in about 3 min. Each item in the BSPAS is scored on a 100 mm visual analogue line with two reference points given values of 0 and 100. The reference points are also identified by the expressions ‘‘not at all’’ and ‘‘the worst imaginable way’’. Thus, the BSPAS covers the whole range of dressing change anxiety, from no anxiety at all to extreme anxiety. The BSPAS is scored as the mean of the item responses across all items. The subject is asked to mark the line at a point corresponding to the pain anxiety to be described, and the distance is evaluated to the nearest millimetre [21,22]. For the purpose of this study, forward and back translation of the instrument into a Persian version was used [23]. The internal consistency of BSPAS was also measured (Cronbach’s a = 0.70). For this purpose, the BSPAS was completed by 20 eligible patients and analysed. These patients were excluded from the study. Other studies have reported an internal consistency reliability coefficient (Cronbach’s a) of 0.90 [22]. Ten faculty members of TUMS verified the face and content validity of the translated version of the instrument.
1.4.
116 eligible participants
Procedure
The study was approved by the TUMS ethics committee and burn centre authorities. The study was explained in detail to each eligible participant prior to obtaining consent. Those who then agreed to participate and gave informed consent took part in interviews to collect demographic data. As mentioned earlier, minimisation was used to randomly assign participants to either the control group receiving usual care or the experimental group, jaw relaxation. Fig. 1 shows the number of patients actually recruited and their allocation to the two study groups. To measure their anticipatory anxiety before intervention, we asked patients in the experimental group to rate their pain anxiety on BSPAS, 30–60 min before dressing changes the day after completion of training. Because their burn injuries might have inhibited simple motor movements, the items were read
Fig. 1 – Recruitment and allocation to study groups.
aloud and patients responded verbally to each one. Patients in the experimental group then practiced jaw relaxation technique for 20 min. In this stage, patients who had sufficient mastery of jaw relaxation completed BSPAS again to measure anticipatory anxiety before dressing change. Fifteen to twenty minutes after the dressing change, when patients were resting comfortably in their bed, they were asked to rate their pain anxiety during the dressing change. Patients in the control group completed BSPAS, 30–60 min before the dressing change, and once again, 15–20 min after dressing change to rate before and after dressing pain anxiety, respectively. It is worth mentioning that to prevent diffusion of treatment, room assignments were controlled, so that those in different groups were not assigned to the same room. Data were analysed using descriptive statistics, chi-square test, dependent and independent t-test and Fisher’s exact test by Statistical Package for the Social Sciences (SPSS)-PC. This study has been submitted to www.irct.ir [24].
2.
Results
The mean pain anxiety scores for each group are shown in Table 2 and Fig. 2. The independent t-test showed no
Table 2 – Means and standard deviations of participants pain anxiety in experimental and control group. Group Pain anxiety Before intervention After intervention, before dressing After intervention and/or dressing
Experimental (mm)
Control (mm)
Sig.
M SD
M SD
49.94 22.76 42.56 21.98
51.10 19.90
P = 0.787 P = 0.000
44.77 23.06
53.54 20.67
P = 0.048
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Fig. 2 – Pain anxiety of participants in experimental and control group.
significant difference between mean pain anxiety scores in the experimental and control groups before intervention (P = 0.787). Regarding the first hypothesis, the dependent ttest showed that there was significant difference between mean pain anxiety scores before and after intervention in the experimental group (P = 0.000). Our second hypothesis (after intervention) demonstrated no significant difference between mean pain anxiety scores, before and after dressing in the experimental group (P = 0.303). There was no significant difference between mean pain anxiety scores before and after dressing in the control group (P = 0.375). Moreover, our third hypothesis independent t-test showed significant difference between the mean post-dressing pain anxiety scores in the experimental and control groups (P = 0.048).
3.
Discussion
Data showed that participants of this study suffered from a medium level of pain anxiety. This finding was in accord with the results of similar studies [25,26]. The presence of this emotional reaction is not surprising, given that patients hospitalised for burn care find themselves in a strange environment, often with feelings of loss of control and uncertainty regarding their clinical outcome and that of their families, homes or possessions. Patients also anticipate painful daily wound care and therapies, all of which creates a sense of dread and fear [26]. Consequently, anxiety becomes a part of the experience of pain, particularly if pain medication is not initiated prior to the unpleasant procedures such as dressing changes, which are often repeated for days or even weeks [27]. In this study, we demonstrated that a simple and inexpensive method of jaw relaxation can reduce the pain anxiety related to dressing in patients with burns. This finding is congruent with the findings of Good et al. [15–18]. They measured the effect of jaw relaxation on anxiety and pain after abdominal, gynaecologic and intestinal surgeries at rest and movement on the first and second day after operation. It is also in line with the study conducted by Roykulcharoen and Good that measured the effect of systematic relaxation on the sensory and affective dimensions of pain [10].
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Based on the gate control theory, when the excitatory input from the inhibitory and descending fibres outnumbers input from the small fibres, the gate will be closed and will not allow information about pain anxiety to be transmitted to the brain [28]. Thus, relaxation can close the gate by the inhibitory impulses of the cortex and thalamus and thereby reduce pain anxiety or completely eliminate it [14]. Moreover, based on this theory, feelings of control over the noxious stimulus can close the gate and decrease the perception of different dimensions of pain by the brain cortex [29]. As a consequence, patients with burns need to feel they have control over the situation [11]. Learning relaxation methods can develop increased feelings of personal control over pain anxiety. In this way, instead of being a merely passive receiver of clinical interventions, patients can play an active role in learning and applying the skills of pain anxiety management [14]. Furthermore, at the time of anxiety, the body’s natural opioids are blocked and pain is experienced with even more intensity [30]. However, relaxation through the secretion of endorphins results in reduced pain and anxiety subsequently. These facts indeed support the claims made by Coldberg on relaxation methods. He believed that the soul is inseparable from the body and thoughts and feelings arise from bodily reactions and each individual is able to reverse physical, emotional and behavioural dimensions of tenseness consciously [31]. The finding that there was no significant difference between pain anxiety of the experimental group (after intervention) before and after dressing could be related to the severe pain that patients with burns usually experience during dressing change and the fact that it frequently causes considerable anxiety. The bi-directional relationship between pain and anxiety has been supported by different studies. Poorly managed pain can increase anxiety and vice versa [32]. Therefore, the presence of increased levels of pain anxiety after dressing is not surprising. Moreover, the stimulus for anxiety can originate either from psychic conflict when ideas, thoughts or feelings threaten the individual’s self-integrity or from outside the psyche, when something in the individual’s biological or social environment threatens self-integrity [28]. Thus, it seems that before dressing, mental conflicts related to anticipation of a painful procedure have triggered anxiety in patients with burns, while external stimulation related to irritated tissues and also dealing with specific issues during dressing change have added to their mental conflicts and intensified the level of their anxiety. In addition, jaw relaxation did not continue in the dressing room, so the descending inhibitory impulses of the brain reduced. All these factors led to increased levels of pain anxiety after dressing. Byers et al. also found that the dressing pain anxiety of patients with burns was higher than their base anxiety. They also found that both pain anxiety and pain intensity were higher than the base state during treatment measures [1].
4.
Conclusion
Daily recurrence of wound care procedures, including removal of dressing, washing, debridement and application of new
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dressing, is the main cause of pain experiences and its anxiety in patients with burns [33]. The exercise of relaxation reinforces the belief in patients with burns that they are not powerless and can exert control over the situation during the periods of pain and stress [14]. Thus, considering the positive effect of jaw relaxation on the reduction of burn pain anxiety and also the simplicity of learning and applying this method, patients with burns can be encouraged to apply the method in times of anxiety and tension. Due to the fact that of all professionals involved in the care for patients with burns, nurses are mostly confronted with the phenomenon of pain and its anxiety [34], and because nurses are the client’s primary advocate for sensory and affective pain reduction and/or relief [35], this study suggests that jaw relaxation be taught to patients with burns so that patients might experience less pain anxiety before, during and after dressing changes. Studying the effect of this relaxation technique on patients going through other painful procedures is recommended.
5.
Limitations
The differences between participants in terms of physiological, emotional, psychosocial and cognitive factors, the different attitudes of dressing room nurses towards patients, and its effect on the method of dressing change and the resultant level of pain anxiety [36] were beyond the scope in this study.
Conflict of interest statement The authors had not any financial or personal relationships with other people or organisations during the study. So there was no conflict of interests in this article.
Acknowledgements We express our sincere gratitude to the patients in the study, who generously provided their time and trust, and to all the nurses and other health-care staff of Shahid Motahari Burn Centre. The authors also thank the Centre for Nursing Care Research affiliated to Tehran University of Medical Sciences for its financial support.
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