Title, abstract and type of study
The title is explicit and clearly delineates the key variables though it does not mention the population covered. The abstract summarises the main features of the study report and includes the title, aim, background, methods, findings and conclusion. This randomized controlled study aims at determining the effectiveness of relaxation of jaw and total body relaxation for postoperative pain, anxiety, level of relaxation and the patient expectancy effects if any. The problem statement and research questions have not been defined but the review of literature reveals that very little work has been done on the topic of effectiveness of relaxation for post operative pain and the title mentions the objective of the study. The technique of body relaxation whether total or partial has been indicated as one that can be used by nurses in their daily practice (Schaffer and Yucha, 2004). However the authors have a found a dearth of literature regarding the topic. The question also arises as to whether the precious time of the nursing staff must be spent on this technique of relaxation for post operative pain when there are not many takers or studies to back it.
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A scarcity of literature
It has found that Seers had undertaken a systematic review in 1998 with another researcher Carroll on the effectiveness of relaxation for post operative relief that appears to be the earliest anyone did a study on this topic. Several poorly designed studies followed. They had flaws and did not allow a continuity of conclusions or statistics. Small groups only were involved or power calculations were lacking and the type and frequency of relaxations varied. Moreover these various relaxations had never been compared.
The next well-done review was by Kwekkeboom and Grettarsdottir in 2006. They reviewed randomized trials of relaxation interventions used for the treatment of pain in adults and synthesized evidence regarding the efficacy of specific techniques (Kwekkeboom amd Grettarsdottir, 2006, p.269). The 15 studies reviewed found that 8 had supporters for the relaxation interventions. Progressive muscle relaxation was the most popular. Some support was found for jaw relaxation and systematic relaxation intervention. However autogenic training, rhythmic breathing or other relaxation techniques were not popular.
An integrative review and critique by Good highlighted the effectiveness of relaxation and music on postoperative pain (1996, p. 906). Limitations and gaps were also identified. Relaxation and music were found to reduce postoperative pain but the methodologies that were adopted were not considered feasible (p.912). Marian Good and her group of researchers had conducted a secondary analysis of a randomized controlled trial to investigate the effects of relaxation and music and a combination of both on post-operative pain (2001, p. 208). It was found that the post operative days were all equally influenced by the music and relaxation techniques. There appeared no difference between the first day or other days (p.214). The relaxation interventions were more effective during the ambulant period. However there was no difference noted between the two activities for any particular day whether at rest or ambulatory.
A randomized controlled study by Roykulcharoen and Good examined the effects of systemic relaxation on post operative pain (2004, p. 140). How the systemic relaxation relieved the body of the sensory and affective components of pain, anxiety and opioid intake after the beginning of ambulation had been investigated. Control groups were also used. It was found that postoperative patients who used systemic relaxation had less distress from pain than the control group. No significant effect was seen on anxiety or opioid intake (p.146).
Relaxation was investigated in Good’s study of 2001 where she used the jaw relaxation method while Roykulcharoen used the systemic relaxation. The systemic relaxation was found to reduce pain sensation by 55% and produced less distress by 56% while the jaw relaxation had figures of 11% and 13% less. This study (2008) has compared 4 groups. Total relaxation, jaw relaxation, attention control and usual care postoperative patients formed the groups.
It is to be noticed that only a handful researchers are interested in the topic of relaxation for post operative patients and they have been repeatedly doing research with different colleague researchers. However the number of studies with definite conclusions still remains low.
The total body relaxation in this study used the technique of tensing and relaxing groups of muscles (Bernstein and Borkovec, 1973). The teaching of the interventions at the pre-admission interview was reinforced by supervised training by trained nurses. The participants were requested to start practicing one week before surgery. Total body relaxation was further detailed by using an audio cassette tape with instructions. The study by Seers in 1993 used total body relaxation by concentrating on the feelings accompanying the activities and suggestions made to indirectly enhance the relaxation
(Payne, 1995). The teaching of the interventions there (Seers, 1993) was done at the preadmission interview. Short teaching tapes were used for those with interventions in Good’s study. Jaw relaxation was similar to the method described by Jacobsen (1938). It was as used by Flaherty and Fitzpatrick (1978) and Good et al (2001). One of the control groups in Seer’s study being critiqued was for attention control and the other was just a group of normal postoperative patients getting the usual care. Attention control was also used by Borkovec and Mathews (1988) who gave it another name, ‘non active intervention’. Pre and post intervention questions have been asked and data collected (Seers, 2008). Here absolute privacy was accorded and bias eliminated by having the participants seal the answers before handing over to the researchers. The interventions here were applied and assessed during the rest period, during movement, anxiety and relaxation. Seers in 1993 had used a second researcher blinded to the intervention to reduce bias.
Implication for nursing
Effective management of pain is a significant part of nursing practice. Complete dependence on drugs and sedation may lead to addiction. Systematic relaxation techniques can be easily learnt by nursing staff as they can be recorded and used by them to teach others who need them. It should be done in bed where maximum relaxation is possible. Nurse education programs need to include these interventions in the training of nurses. The techniques for relaxation are self-care procedures which are vital for effective management of pain. Many researchers have spoken for non-pharmacological interventions along with pharmacological treatment of pain (Mandle et al, 1996).
Relaxation has been recommended by the National Health Institute. Technological.
Systemic relaxation is an accepted nursing strategy that gives effective pain relief.
The protection of participants’ rights
Approval had been obtained from the appropriate ethics committee. Consent from the participants was obtained much before the pre-admission interview so that the possibility of coercion was eliminated at the advice of the committee. The researchers were not permitted to approach participants who did not return the consent form. So the rights of the participants had been protected. A pilot study was done before the actual study to understand the acceptance of the methods proposed to patients and health staff.
Appropriateness of design
The design used is the randomized control study. This is appropriate as the literature review has not revealed many comparative studies and none have used an attention control group yet. The control groups and the attention control group are thereby justified. The weaknesses of earlier studies, flaws and power calculations needed a good study with sufficient randomization. This has been achieved here. Powerful detection of differences, a well-defined sample of participants, standards methods of relaxation, a well-defined setting and reliable outcomes are the strengths of this study.
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Population sample and study limitations
The population was identified and described in fair detail. The 200 participants in this study, recruited from an original group of 813, comprised of patients admitted for total hip replacement or total knee replacement in an orthopaedic hospital in the United Kingdom. Willing patients above the age of 18 and speaking English were selected to participate. Most of the participants were finally lost to follow-up leaving a small balance. Roykulcharoen’s study of 2004 had 102 participants who underwent abdominal surgery in Thailand. Good’s study of 2001 had 468 participants who had abdominal surgery in 5 hospitals in the United States. This was the first study using orthopaedic patients.
The setting was a single hospital and the post -operative patients were all undergoing a replacement surgery of hip or knee. The sample’s representativeness of postoperative patients may not have been adequate because of the confinement to one kind of postoperative patient. The planned power calculation could not be achieved because of difficulty to recruit patients in the setting selected and because these patients had been recruited for another study. Admission dates kept changing making it difficult to track them. 59 per group coming to a total of 236 were required to obtain a mean effect of 15mm. and a standard deviation of 25mm. The number was less and the study was underpowered. To get sufficient numbers, the period of study recruitment was extended for six months which was again to no avail. Patients who did not reply on their own were not to be approached according to the ethics committee. The researchers were therefore not sure as to what the reply of those who failed to do so could have been. It was later understood that many would have liked to be on the study but did not get round to answering.
Data collection, measurement and analysis
The best methods of data collection have been used reducing the possibility of bias. The participants were randomly assigned by interventions used into the groups of total body relaxation, jaw relaxation and the 2 control groups of attention control and usual care. They were taught the intervention for their group at the pre admission clinic before their surgery and asked to begin practicing it one week before the surgery. Written instructions were given to all groups and the total body relaxation group were given an audio cassette too. They were reminded one week prior to the surgery by post to start their intervention. They were visited on the second and third postoperative days. The questions asked before the intervention were repeated and then the intervention given. Bias was reduced by having the answers written by the patients in privacy and placed in an envelope which was sealed and handed over. This method was selected over the blinding of a second researcher to rule out the possibility of the patient revealing the intervention to the second researcher. Each hour the patient had to repeat this process for the next 4 hours after post intervention data was collected.
The instruments used were reliable and accepted. The primary outcome of pain at rest and on movement was measured using the 0-100 mm. Visual Analogue Scale (VAS). The secondary outcome of anxiety was measured using a similar scale and the Spielberger State Trait Anxiety Inventory (STAI). Reliability and validity of VAS has been proved several times (Bijur et al, 2001). It has also been found that VAS meaningfully quantifies differences in efficacy (Myles et al, 1999). Reliability and validity of STAI has also been accepted (Marteau and Bekker, 1992). The instruments have not been described in detail but the scores have been tabulated with results. They probably have been good choices.
Analysis was done with SPSS version 12. The change scores for the four groups were compared using repeat measures ANOVA. Data showed hardly any difference among the four groups for relaxations as an effective intervention for pain. It was also found that orthopaedic patients were already in a great amount of pain before the surgery and that surgery actually alleviated their pain to a great extent. There was no difference between the relaxation group and the attention control group. Since relaxation does not have a significant effect on pain, asking the nurses to offer any intervention for relaxation may not be right as it has been seen to have practically no effect of relief.
However jaw relaxation which is easy to teach and learn may be advocated among the nurses to be used with doubtful expectations to provide short lasting periods of relief along with anti-analgesics as patients consider them worthwhile.
Patients have said that their pain before the surgery was what brought them to the hospital. They had been suffering for years together the intense pain which has been a real problem. The pain is different in the post operative period and it is less intense. Other groups with less or no pre-operative pain may have delivered better results than this group of postoperative orthopaedic patients who have always had severe pain.
However there have been many patients who have accepted the relaxation techniques and taught members of their families. All the members believed that their intervention would relieve them of pain. Even the usual care group believed this. This showed the high level of trust in healthcare interventions.
The paper is well-worded and well organized and has carried the message of this less investigated topic of relaxation for post operative pain. Their credibility is impressive though their study did not produce results as expected. Relaxation was not useful for the orthopaedic postoperative patients. They have shown that systematic studies with powered calculations are the method of ensuring a good resourceful study. The implication of the subject in nursing practice has been detailed. Kate Seers, the main researcher, is the Director of the RCN Research Institute, School of Health and Social Studies, University of Warwick, Coventry, UK. Her colleagues include nursing professionals and a statistician all from UK. Nurses may employ the jaw relaxation method for postoperative patients. Future studies may dwell on other post operative patients who do not have preoperative pain.
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