Surgery is a stressful experience for patients, affecting their physiological and psychosocial status (Arora et al, 2010). Study findings indicate that fear of the unknown and of postoperative pain, concerns about anaesthesia, or unintentional movements in unconsciousness, are some of the factors leading to stress and anxiety in surgical patients (Usichenko et al, 2013). Other concerns could be a potential diagnosis of cancer, loss of an organ or limb, and even death. Surgery can prompt concerns regarding loss of occupation and financial safety, changes in social and family roles, disturbance in lifestyle and separation from relatives (Usichenko et al, 2013).
Anxiety affects all biological, psychological, and social domains and also the ways in which human needs are satisfied (Kashdan and Rottenberg, 2010; Shahbazi et al, 2016; De Souza et al, 2017). It causes the heart rate and blood pressure to escalate, which could lead to postoperative complications such as aggravation of renal function and also increased metabolism and oxygen intake (Ghafari et al, 2015; Baradaran, 2017). High levels of anxiety intensify the perceived pain (McEwen et al, 2012), so stressful factors could intensify patient anxiety and, as a result, reduce pain tolerance (Wanzer et al, 2004).
Studies have indicated that patients with lower levels of stress experience fewer problems before and after surgery. Because nurses, compared with other health professionals, spend much more time dealing with patients postoperatively, they can evaluate patients' anxiety and make efforts to prevent and reduce the complications by taking appropriate measures (Rosen, 2011).
Much research has already been conducted to investigate the effect of pharmacotherapy on anxiety disorders (Luqman, 2014). Relief of postoperative pain, stress and anxiety (POPSA) may lead to better recovery, especially in orthopaedic surgery cases (Haleblian et al, 2007). Morphine is one of the strong analgesic drugs used to reduce pain before and after surgery (Luqman, 2014; Maremmani et al, 2016). However, using narcotic and non-narcotic sedative drugs may lead to addiction (Yukawa et al, 2005; Jalali et al, 2015). Thus, stress and anxiety management without the use of narcotic and non-narcotic sedative drugs is a serious issue throughout treatment. Certain techniques are available to manage POPSA, including relaxation, biofeedback, yoga, prompting, artificial sleep, absent-mindedness and nerve-stimulation via skin, acupuncture, exercise, physiotherapy, and emotional support (Naoroibam et al, 2016). Cognitive behavioural therapy (CBT) is a technique that has been shown to be an effective treatment strategy for reducing the need to use narcotic drugs (McHugh et al, 2010).
Obviously, in the light of the nature of anxiety in patients who are candidates for surgery, where the anxiety is mainly related to clinical conditions, it is better to use non-pharmacological approaches, which are less costly and easy to learn. They can be used under any conditions, are not time-consuming and nurses can also teach these easily to patients throughout nursing care (Hunt et al, 2010). One of the approaches to relieving anxiety and stress is progressive muscle relaxation (PMR) (Potthoff et al, 2013; Seifi et al, 2018). Yoga and PMR both help patients to diagnose the physical symptoms and signs of anxiety and their sources, and adopt a suitable method to respond (Bahmani et al, 2014; Hasanpour-Dekhordi et al, 2016). Studies have shown that Benson relaxation therapy (a form of PMR) led to relief of pain, increase in social function and family communication, and promotion of health and quality of life (Choi, 2010; Vancampfort et al, 2013). Given the significance of this issue, this study investigated the effect of PMR combined with narcotic analgesic on psychological status, pain and health promotion in surgical patients.
Materials and methods
In this randomised clinical trial, participants were matched for age, gender, economic status, type of surgery and welfare status (heath insurance status). Seventy patients referred for surgery on the gastrointestinal tract (stomach, duodenum) to the hospital's surgical ward were selected by random allocation. For this purpose, 35 red cards and 35 blue cards were placed in a box, and the patients were randomly asked to remove one card from the box and, according to the definition of the researcher, were assigned to the control or case group.
The case group were prescribed morphine 0.15 mg/kg/day, if it was necessary and according to patient need, in divided dose, and would also undertake PMR. The control group were prescribed morphine 0.15 mg/kg/day, if necessary, in divided dose.
Apart from consent to participate in the study, the inclusion criteria were: hospitalisation in the hospitals affiliated with Shahrekord University of Medical Sciences, lack of previous participation in a similar study, lack of previous psychological diseases, being a candidate for gastrointestinal surgery (stomach, duodenum) and not taking anti-anxiety drugs. The exclusion criteria were: lack of patient safety and lack of willingness to participate in the study.
First, the researcher contacted the wards of the hospitals affiliated with Shahrekord University of Medical Sciences, southwest Iran, on a daily basis, investigated the list of the patients who were candidates for gastrointestinal surgery, interviewed them and asked them to participate in the study, then, if they consented, enrolled them. Ethical approval no. 1-4-87 was obtained from the Ethics Committee of Shahrekord University of Medical Sciences. The study protocol was registered as IRCT2013121813768N5 in Iranian Registry of Clinical Trials.
Before any interventions, vital signs were taken (blood pressure, pulse rate, respiration rate and temperature) and anxiety intensity measured using the Spielberger scale (the State Anxiety Scale from the State-Trait Anxiety Inventory). All patients then underwent the intervention according to group assignment. The measurements were repeated at 3, 12, and 24 hours after the surgery for all patients. Blood pressure and pulse rate were measured while the patient was in a supine position, by means of a single calibrated manometer and stethoscope. The accuracy of the manometer was 0.2 mmHg to the nearest 0.1. The pulse rate was counted from the radial artery for 1 minute. Body temperature was measured using a single oral thermometer. The accuracy of the temperature measurement was 0.2°C to the nearest 0.1°C.
In the group receiving the PMR intervention, training on the method of using Benson's relaxation technique was delivered. Each patient was monitored before the operation. In each patient, the PMR intervention would be performed for 20 minutes every 6 hours for 2 days until 2 hours before the operation (Potthoff et al, 2013).
First, a private, calm and light environment inside the surgical ward was provided for use by patients in the PMR group. Then, a researcher specialised in Benson's relaxation technique taught the technique to the patient during a 30 to 45-minute, face-to-face session, and simultaneously answered the patient's questions and clarified any ambiguities. An audio recording talking patients through the technique was provided to the case group on an MP3 player with headphones, after training and explanations. The PMR technique was practised by the case group repeatedly so that the researcher was satisfied that the recorded relaxation recommendations were followed and the technique would be practised correctly.
The technique was performed comfortably in a supine position with hands to the side of the body, so that the person, after adopting the position, closed his/her eyes slowly and, while breathing consciously, slowly and sequentially loosened all the muscles of the body, from the soles of the feet up, according to the advice given on the audio recording. After all the muscles of the body had been extended, the patient was asked to maintain this relaxed state for some time. Throughout Benson's relaxation technique, the patient was also asked to set aside disturbing thoughts from his/her mind and choose a word (such as ‘God’ or ‘love’) that always reminded him/her of calmness, and to begin to breathe deeply and regularly (inhale through nose and exhale through mouth), repeating the word while relaxing.
The audio file was provided to the case group, and then they were asked to perform relaxation at least three times (Seifi et al, 2018).
On the day of the operation, immediately before surgery and the administration of premedication, pain, anxiety and vital signs were measured and recorded again. Routine procedures of the ward were freely undertaken.
The data collection instrument consisted of four sections. The first section recorded items on demographic characteristics, including age, sex, education level, place of residence and economic status; the second section was the 20-item Spielberger state anxiety scale, with a minimum score of 20 and a maximum of 80, administered before and after the intervention (Seifi et al, 2018). The third section of the questionnaire included physiological indices (blood pressure, respiratory rate, pulse rate and temperature). For scientific consistency a sphygmomanometer, stethoscope and thermometer manufactured by a reliable company were used and their precision was checked. The fourth section was a Bayer numerical scale to measure pain, including a graph ranging from 0 (the lowest level) to 10 (the highest level) plotted by pain intensity. Scientific rigour was determined by content validity and the reliability of measures was 0.95 using Cronbach's alpha. The data were analysed by paired t-test, analysis of variance, and chi-square in SPSS version 18.
Findings
Most participants in the PMR and control groups were married (70% and 75%, respectively). The mean age of participants in the PMR and control groups was 43.64±9.65 and 44.37±10.56 years, respectively. Most participants in both groups were from middle income families and were covered by health insurance (77%) (Table 1). For physiological indices, t-test indicated no significant difference between the two groups before the intervention. Comparison of the mean values of the physiological indices in the PMR group before and after the intervention indicated a significant difference in pulse rate, blood pressure and respiratory rate.
| Demographic item* | Cases (n=35) % | Controls (n=35) % | |
|---|---|---|---|
| Gender | Male | 52 | 41 |
| Female | 48 | 60 | |
| Marital status | Single | 30 | 25 |
| Married | 70 | 75 | |
| Educational level | Illiterate | 19 | 19 |
| High school diploma | 69 | 72 | |
| > High school diploma | 12 | 9 | |
| Job | Self-employment | 22 | 22 |
| Official | 27 | 25 | |
| Worker | 23 | 25 | |
| Jobless | 29 | 28 | |
| Monthly income (US$) | ≤500 | 29 | 28 |
| 501–2000 | 44 | 47 | |
| ≥2001 | 27 | 25 | |
| Insurance | Has health insurance | 77 | 77 |
T-test results indicated that there was a significant difference between the anxiety levels before and after the intervention in the case group but not in the controls. In addition, the mean anxiety score was not significantly different for the patients in the case and control groups before the interventions, but after the surgery the mean score of obvious anxiety was statistically significantly different in the two groups (Table 2).
| Case (n=35) (mean ± SD) | Control (n=35) (mean ± SD) | Independent p value | ||
|---|---|---|---|---|
| Vital sign | ||||
| Systolic blood pressure | pre | 13.1 ± 20.40 | 13.5 ± 19.15 | > 0.05 |
| post | 11.22 ± 17.66 | 12.83 ± 15.23 | < 0.05 | |
| p value | < 0.05 | > 0.05 | ||
| Diastolic blood pressure | pre | 86.33 ± 16.12 | 87.81 ± 15.65 | > 0.05 |
| post | 71.07 ± 12.42 | 86.13 ± 18.69 | < 0.05 | |
| p value | < 0.05 | > 0.05 | ||
| Pulse rate | pre | 91.5 ± 16.23 | 92.03 ± 17.80 | > 0.05 |
| post | 80.61 ± 15.12 | 91.22 ± 19.51 | < 0.05 | |
| p value | < 0.05 | > 0.05 | ||
| Respiration rate | pre | 18.1 ± 4.36 | 19.53 ± 3.36 | > 0.05 |
| post | 15.80 ± 4.27 | 18.94 ± 2.34 | < 0.05 | |
| p value | < 0.05 | > 0.05 | ||
| Temperature (°C) | pre | 37 ± 0.31 | 36.90 ± 0.36 | > 0.05 |
| post | 37.5 ± 0.65 | 37.63 ± 0.29 | > 0.05 | |
| p-value | > 0.05 | > 0.05 | ||
| Spielberger state anxiety ratings | ||||
| pre operation | 42.5 ± 10.57 | 41.3 ± 13 | > 0.05 | |
| post operation | 35.4 ± 4.58 | 40.05 ± 4.96 | < 0.05 | |
There was no statistically significant difference in age, gender, and anxiety between the two groups, but the results showed that the individuals with higher economic status and covered by health insurance experienced lower anxiety and worry.
A significant difference in pain intensity at 3, 12, and 24 hours after the operation was observed between the case and control groups (Table 3). In addition, the results demonstrated that the quantity and type of analgesic drugs administered (morphine) were significantly different in the case and control groups. The amount of the analgesic for the control group was 2.5 times more than that for the case group.
| Pain severity at 3 hours post operation | Very low | Low | Intermediate | Severe |
| Group | % | % | % | % |
| Case | 0 | 38.5 | 45 | 16.5 |
| Control | 0 | 2.5 | 20 | 77.5 |
| Chi-square test results | p-value < 0.000, df = 2, d = 26.169 | |||
| Pain severity at 12 hours post operation | Very low | Low | Intermediate | Severe |
| Group | % | % | % | % |
| Case | 27 | 35 | 28 | 10 |
| Control | 7.5 | 47.5 | 42.5 | 2.5 |
| Chi-square test results | p-value < 0.000, df = 2, d = 12.284 | |||
| Pain severity at 24 hours post operation | Very low | Low | Intermediate | Severe |
| Group | % | % | % | % |
| Case | 77 | 23 | 0 | 0 |
| Control | 65 | 35 | 0 | 0 |
| Chi-square test results | p-value < 0.003, df = 1, d = 9.08 | |||
Discussion
In this study, there were no significant differences in age, gender, socioeconomic status, and insurance between case and control groups, and therefore the groups were matched for these variables, which is consistent with other studies (Good et al, 1999; Arora et al, 2010). Comparison of the mean values of physiological indices in the patients in the PMR group before and after the intervention indicated a statistically significant difference in pulse rate, blood pressure and respiratory rate, but not body temperature, which is consistent with other studies (Potthoff et al, 2013). A study by Sheu et al (2003) showed that after 1 week of PMR, heart rate decreased by 2.35 beats per minute (BPM), systolic blood pressure by 5.44 mmHg and diastolic blood pressure by 3.48 mmHg, and after 4 weeks of PMR, heart rate decreased by 2.9 BPM, systolic blood pressure by 5.1 mmHg and diastolic blood pressure by 3.1 mmHg. PMR significantly reduced the patients' stress and enhanced their understanding of health (Sheu et al, 2003).
One of the problems affecting patients undergoing surgery is anxiety, which sometimes makes them withdraw from the procedure. This study also indicated a statistically significant difference in anxiety levels in the patients in the PMR group before and after the intervention. In this regard, Choi (2010) reported that Benson relaxation led to relief of pain and promotion of quality of life and health. A study by Charalambous et al (2016) showed that PMR training helped cancer patients achieve a lower stress response; they experienced less depression, fatigue and pain, and it provided an important basis for stress control. Lolak et al (2008) showed that PMR relieved anxiety and depression. In addition, use of a combination of approaches such as pharmacotherapy and behavioural therapy can lead to feelings of calm, promotion of physical and mental status, and enhancement of intellectual capabilities (Walkup et al, 2008).
When caring for patients and individuals with stress-related problems the use of PMR should be considered, because this method is convenient and economical. A study involving people with schizophrenia indicated that PMR led to improvement in social, mental and sexual function, self-satisfaction and enhanced quality of life—the patients undergoing PMR had a shorter incapacity episode and hospital stay compared with controls (Vancampfort et al, 2013). Zhou et al (2015) observed that music therapy and PMR training could reduce depression, anxiety and length of hospital stay in female breast cancer patients after radical mastectomy, while Good et al (1999) showed that jaw relaxation, music and a combination of these reduced pain and anxiety in patients after abdominal surgery. A study by Kwekkeboom and Grettarsdottir (2006) showed that muscle relaxation and analgesic imagery interventions reduced the severity and extent of pain and stress in patients. Friesner et al (2006) showed that the use of PMR with morphine was more effective at reducing pain intensity than use of morphine alone.
Enhancing mental powers and increasing self-confidence leads to increased efficiency and awakening of inner talents, strength of reasoning and creativity; therefore, training in methods of coping with stress and anxiety is necessary for patients because a reduction in anxiety and stress improves concentration and memory, as well as learning, the ability to study, and physical and mental wellbeing. Furthermore, it contributes to patients' recovery and cooperation.
Conclusion
Given the findings of the present study and the severe complications of stress and anxiety in patients undergoing surgery, the authors would recommend that teaching and encouraging patients to perform PMR presents one way of promoting their health and wellbeing. It is an economical and convenient method through which patients can manage stress related to surgery more efficiently.