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burns 39 (2013) 6167

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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: f-mohammadifakhar@tums.ac.ir, mohamadifahimeh@yahoo.com (F. Mohammadi Fakhar),
frafii@tums.ac.ir, foroughrafii@yahoo.com (F. Rafii), jam_orak@yahoo.co.in (R. Jamshidi Orak).
0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2012.03.005

Author's personal copy

62

burns 39 (2013) 6167

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 935% 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, 935%). 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) 6167

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
2029
8
3039
11
4049
6
5060
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
915
9
17
1620
8
2125
9
2630
7
3135
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.

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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burns 39 (2013) 6167

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 (Cronbachs
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 (Cronbachs 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, 3060 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, 3060 min before the dressing
change, and once again, 1520 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 Fishers 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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burns 39 (2013) 6167

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. [1518]. 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 bodys 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 individuals
self-integrity or from outside the psyche, when something in
the individuals 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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burns 39 (2013) 6167

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 clients 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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