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Effect of Massage With Lavender Oil on Postoperative Pain Level of Patients Who Underwent Gynecologic Surgery

A Randomized, Placebo-Controlled Study

Mizrak Sahin, Berrak PhD, RN; Culha, Ilkay PhD, RN; Gursoy, Elif PhD, RN; Yalcin, Omer Tarik MD

Author Information
doi: 10.1097/HNP.0000000000000400
  • Free

Abstract

INTRODUCTION

Aromatherapy is the use of essential oils acquired from herbal sources in the treatment of various diseases.1 Aromatherapy, used in many fields of medicine, has been drawing attention in the recent years especially for its easy application. Aromatherapy is a noninvasive procedure and can be regularly performed on patients who do not have sensitivity toward odors.2 Today, there are approximately 150 types of essential oils. These oils are prevalently used during massage while they can also be used in patient care via inhalation, steam, bath, and compression.3 Black pepper, clove, ginger, juniper, Portuguese lavender, lavender flower, lemongrass, marjoram, mint, rosemary and ylang oils are among the essential oils used in pain management.4

Lavender, known as a strong aromatic and a medicinal herb, is used in traditional medicine due to its analgesic and anti-inflammatory effects.5 Lavender has 2 components, linalool and linalyl acetate, and also has a stimulating effect on the parasympathetic nervous system. Its linalyl acetate component is known as an analgesic while linalool has a sedative effect.6,7 When used in traditional treatment, lavender oil is used in diuretic, antiepileptic, antirheumatic, and especially nervous system and migraine pains as well as postoperative pain management.8

Postoperative pain management is an important component of postoperative care.9 Especially following abdominal surgery, pain limits physical functions such as coughing, breathing, movement, sleep, and self-care.10 Postoperative pain, if not treated, has effects ranging from patient dissatisfaction and minor complications to extended healing duration, poor quality of life, and postoperative morbidity. Although administration of analgesics as a standard treatment method in postoperative pain management is accepted to be safe, many painkiller medications (especially opioids and nonsteroidal anti-inflammatory drugs) may have some unexpected side effects such as respiratory depression, nausea, itching and bleeding.11,12 In systematic reviews conducted between the years of 1996 and 2002, aromatherapy has been recommended as an effective path for pain management.13 Use of complementary treatments and natural alternatives decreases complications and the need for synthetic analgesics.14 Buckle15 has reported several studies showing that aromatherapy, with or without massage, may decrease pain perception and need for traditional analgesics both in adults and children.15 In the semi-experimental study by Brownfield,16 it has been shown that the massage with lavender oil (Lavandula angustifolia) decreases pain perception of patients and improves sleep quality and well-being perception in those experiencing the effects of chronic rheumatoid arthritis. There are studies in the literature performed on various patient groups, showing the effects of lavender use in postoperative pain. However, there was no study showing the effects of lavender use with massage on the level of pain in patients who underwent gynecologic surgery. Combining the positive effects of aromatherapy and massage in this study is also important in this specific population. Our study has evaluated the effects of hand massage with lavender on postoperative level of pain in patients who underwent gynecologic surgery.

  • Hypothesis 1 (H1): Pain level of the experiment group (massage with lavender oil) is lower than the control group at the 30th minute after massage application.
  • Hypothesis 2 (H2): Pain level of the experimental group (massage with lavender oil) is lower than the control group at the 3rd hour after massage application.
  • Hypothesis 3 (H3): Pain level of the experimental group (massage with lavender oil) is lower than the placebo group (massage only) at the 30th minute after massage application.
  • Hypothesis 4 (H4): Pain level of the experimental group (massage with lavender oil) is lower than the placebo group (massage only) at the 3rd hour after massage application.

METHODS

Study design

This was a randomized, placebo-controlled experimental study. Forty-five patients who were admitted to the obstetrics and gynecology department of a university hospital in the city of Eskişehir between January 20 and July 5, 2019, for gynecologic surgery and who met the sample criteria were included in the study.

Participants

Patients included in the study were in the 19- to 65-year age group, did not have asthma/allergic asthma or chronic pulmonary disease problems, were not allergic to any odors, did not have any dermatologic diseases or any mental health problems such as anxiety, depression, panic attack, bipolar, affective disorder, or schizophrenia, were able to smell the odors according to the odor detection threshold test, and were not undergoing chemotherapy. As it was considered that the difference between the performed surgeries could change the level of pain and analgesic effectiveness, a single surgical type was selected for standardization. Accordingly, patients who underwent total abdominal hysterectomy and salpingo-oophorectomy, which are B type surgical procedures, stated in the Health Practices Statement published in Turkey, were included in the study. Patients who had lymph node dissection out of the patients who were taken into surgery due to endometrium cancer suspicion were excluded from the study.

Sample size

The sample consisted of 3 groups of patients: the experiment group, the placebo group, and the control group. Power analysis was performed by using Minitab16 Package software. As a result of the power analysis performed with the 1-way variance analysis, considering the descriptive statistics used in the study by Nasiri et al,17 it was concluded that the difference would be found with 90% power by including at least 11 people in each group. Fifteen patients were included in each group considering the data losses. The flowchart of the study design is shown in the Figure.

FIGURE.
FIGURE.:
CONSORT diagram.

Instruments

The data were collected using a questionnaire and a Verbal Rating Scale (VRS)—a questionnaire form consisting of questions related to the sociodemographic characteristics (age, education status, and marital status) and the characteristics regarding the disease (diagnosis, treatment, and disease duration) of the patients. Use of a visual analog scale (VAS) was planned at the beginning of the study. VAS scores range from 0 (no pain) to 10 (unbearable pain). However, due to the high mean age of the sample group and reasons caused by postoperative discomfort, this scale was not adequately understood by the patients. While difficulties were reported regarding the graphic tools such as the VAS among the older patients, it was reported that the VRS has lower error rates. We used a 5-point VRS with the phrases “no pain,” “slight pain,” “moderate pain,” “severe pain,” and “unbearable pain.”18 Patients evaluated with the VAS were not included in the sample group.

Interventions

As the date and times of surgery of the patients were determined 1 day before the surgery in the hospital where the study was conducted, the patients were listed. Patients who met the sampling criteria were assigned to the experiment, placebo and control groups according to the randomization table. Groups were randomized using the SAS University Edition package software (SAS, USA) with the criterion sample method. The listed patients were visited in their rooms, a preinterview was conducted with the patients by one of the researchers, information was given regarding the study, and written consent was taken. The researcher, who conducted a preliminary interview with the patient, followed the patient's entry and exit time on the day of surgery. Patients were followed up to 24 hours in an intensive care unit of the obstetrics and gynecology clinic after surgery. For this reason, the application stage of the research was carried out in the intensive care unit. In the intensive unit, analgesics (pethidine/Aldolan 100 mg) are routinely applied to patients undergoing gynecologic surgery immediately after the operation and at the 6th hour postoperatively depending on the patient's request. Pain levels of all patients groups were evaluated using the VRS by the researcher who conducted the preinterview 3 hours after the initial analgesic administration following the surgery. Massage application was performed 3 hours after analgesic application, as the effect of pethidine/Aldolan decreased in about 3 hours.19 While hand massage was performed on the experiment group with lavender, hand massage was performed on the placebo group with ultrasound gel. There was no application performed by the researcher on the control group. Due to the waiting of the 30-minute rest period of the muscle after massage application, the pain evaluation was made 30 minutes after the application and just before the second analgesic administration, that is, at the 3rd hour after the massage application. Pain levels of the patients in the experiment and placebo groups were evaluated with the VRS by a different researcher than the one who performed the application at the 30th minute and the 3rd hour after the application. The researcher who performed the application did not inform the other researcher regarding group assignments of patients. Similarly, the pain level of patients in the control group was also evaluated with the VRS at 3 hours after the initial analgesic administration and at the following 30th minute and the 3rd hour. Routine analgesic administration was performed on patients who had pain at the 6th hour after the initial analgesic administration. Whether the patients requested analgesics was also recorded in addition to the evaluation of pain with the VRS at the 6th hour after the initial analgesic administration (at the 3rd hour after the massage application). The patients in the groups were not informed regarding the application performed on the patients in the other groups. Thus, bias was prevented during patient evaluation.

Experimental group: Massage application with lavender oil (L. angustifolia) (n = 15)

Odor and allergy tests were performed on the patients to be included in the study during the interview before the surgery. Sensitivity of the patients to lavender oil was tested with lavender oil dripped on the wrist of the patient (rested for 5 minutes), and the sense of odor was tested with an alcohol-soaked stick applied on each nostril.20 Patients who liked the lavender odor and who did not develop sensitivity toward lavender were included in this group.12 The massage protocol is inspired by the procedure by Boitor et al.21 The massage was performed on both hands using moderate pressure, stroking, and kneading techniques by the researchers with lavender oil. Massage application duration was 10 minutes for each hand.21

Placebo group: Massage application with ultrasound gel (n = 15)

A placebo group was used in the study to evaluate the effects of lavender oil. Massage was performed on the placebo group with the use of ultrasound gel, which is known to not have an analgesic effect. The ultrasound gel, which is used by the hospital where the study was conducted and safety of which was tested by the hospital, was used in the study. The massage technique and duration applied on the placebo group were the same as the experimental group.

Control group (n = 15)

In the hospital where the study was conducted, patients are kept under monitoring in the intensive care unit for approximately 24 hours following gynecologic surgeries. Following surgery, 100-mg pethidine/Aldolan is administered to the patients admitted to the intensive care. Following the initial analgesic administration, during the time spent in the intensive care unit, analgesic is administered in 6-hour intervals. Standard treatment of the hospital for postoperative pain management was given to this group.

Statistical methods

Statistical analysis was performed using statistics package software. The normality test was performed with the Shapiro-Wilk test. Descriptive statistical methods (mean, standard deviation/standard error, and percentages) were used for evaluation. Fisher's exact χ2 test and Pearson's exact tests were used to evaluate the distribution of the descriptive characteristics of the groups. Two-way variance analysis (single-factor repetition) was used to evaluate the differences in the groups according to the variables between the measurement time points. The Bonferroni test was used in the comparison of the subgroups of factors, which were significant based on the evaluation of the main effects (group and measurement times) and the interaction term. Statistical significance level was accepted as P < .05.

Ethical consideration

The study protocol was approved by the Clinical Research Ethics Committee of Eskisehir Osmangazi University. Written informed consent was obtained from all patients.

RESULTS

Information including the sociodemographic characteristics and the characteristics regarding the surgical operation of the participants is presented in Table 1. There was no significant difference detected between the groups in terms of the stated characteristics.

TABLE 1. - Characteristics of Participants
Experiment Group Placebo Group Control Group Analysis
Characteristics Mean ± SD Mean ± SD Mean ± SD P
Age, y 51.86 ± 8.70 52.33 ± 9.55 51.33 ± 7.32 .950
n (%) n (%) n (%)
Educational level
Literate 2 (13.3) 2 (13.3) 3 (20.0) .239a
Primary school 9 (60.0) 10 (66.7) 6 (40.0)
High school 2 (13.3) 1 (6.7) 6 (40.0)
University 2 (13.3) 2 (13.3) 0 (0)
Marital status
Married 14 (93.3) 13 (86.7) 15 (100) .343a
Single 1 (6.7) 2 (13.3) 0 (0)
Diagnosis
Endometrial cancer 3 (20.0) 2 (13.3) 5 (33.3) .208a
Pelvic mass 8 (53.3) 3 (20.0) 4 (26.7)
Endometrial hyperplasia 1 (6.7) 2 (13.3) 0 (0)
Myoma uteri 3 (20.0) 8 (53.3) 6 (40.0)
Surgical procedure
Total abdominal hysterectomy + bilateral salpingo-oophorectomy 3 (20.0) 8 (53.3) 7 (46.7) .143a
Total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy 12 (80.0) 7 (46.7) 8 (53.3)
Information about the surgical procedure
Yes 11 (73.3) 10 (66.7) 14 (93.3) .280a
No 4 (26.7) 5 (33.3) 1 (6.7)
Previous surgery
Yes 13 (86.7) 12 (80.0) 12 (80.0) .859a
No 2 (13.3) 3 (20.0) 3 (20.0)
Type of operation
Urgent 12 (80) 10 (66.7) 11 (73.3) .912a
Planned 3 (20) 5 (33.3) 4 (26.7)
aPearson χ2.

In the study, pain levels of the women in all 3 groups were evaluated at different times by the use of the VRS. Generally, the VRS scores of the 3 groups did not show a significant difference in terms of group and time interaction (P = .221). However, there was a significant difference in VRS scores between the experimental and control groups at the 30th minute after the massage (P = .036). This difference was caused by the lower pain level of the group, which had massage with lavender (2.66 ± .89) compared with the control group (3.80 ± 1.01). Although there was no statistically significant difference between the experimental and the placebo groups, it was determined that the pain score of the experimental group was lower compared with the placebo group. When all 3 groups were compared in terms of the pain levels at the 3rd hour after the massage application, there was no significant difference between their pain levels (P > .05) (Table 2). VRS scores of 3 different times from each group were evaluated within the group. When the VRS scores of different times were evaluated in the control group, it was determined that the VRS scores at the 30th minute (3.80 ± 1.01) and the 3rd hour (3.86 ± 0.91) were higher than the VRS score at the initial measurement (3.60 ± 0.91) (P > .05). In the placebo group, while the VRS score at the 30th minute (3.06 ± 1.53) decreased compared with the initial measurement (3.13 ± 1.18), the VRS score at the 3rd hour (3.86 ± 0.91) was higher compared with the previous measurements (P > .05). In the experimental group, the VRS scores measured at the 30th minute (2.66 ± 0.89) and the 3rd hour (3.06 ± 1.27) after the massage application were lower than the VRS score before the application (3.60 ± 0.91) (P < .001; P = .034, respectively) (Table 2).

TABLE 2. - Means of VRS Scores of the Groups With Respect to Time
VRS Experiment Group Placebo Group Control Group Multiple ComparisonsaP
Before massage application
(a) 3 h after the initial analgesic administration
3.60 ± 0.91 3.13 ± 1.18 3.60 ± .91 1-2: P = .640
1-3: P = >.05
2-3: P = .640
(b) 30th min after the massage 2.66 ± 0.89 3.06 ± 1.53 3.80 ± 1.01 1-2: P = >.05
1-3: P = .036
2-3: P = .290
(c) 3rd h after the massage 3.06 ± 1.27 3.40 ± 1.50 3.86 ± 0.91 1-2: P = >.05
1-3: P = .265
2-3: P = .944
Multiple comparisonsa
a-b P < .001 P > .05 P = .660 P = .221b
a-c P = .034 P = .579 P = .579
b-c P = .089 P = .202 P = >.05
Abbreviation: VRS, Verbal Rating Scale.
aBonferroni correction
bTwo-way analysis of variance

When the patients in groups were asked whether they wanted analgesics at the postoperative 6th hour, there was no significant difference between the groups (P = .565) (Table 3).

TABLE 3. - Analgesic Application Status by Groups
Analgesic Application Status at the Postoperative 6th h (3rd h After Massage) Experimental Group n (%) Placebo Group n (%) Control Group n (%) Pa
Yes 10 (29.4) 11 (32.4) 13 (v) .565
No 5 (45.5) 4 (36.4) 2 (18.2)
aPearson χ2.

DISCUSSION

Massage performed on patients after surgical interventions stimulates A-β fibers and decreases pain by suppressing the transmission of nociceptive stimuli. Nociceptors are found more in the surface of the skin in hands and feet compared with the other regions of the body. Thus, hand and/or foot massage is effective in decreasing pain.22 Especially hand massage is recommended after surgical interventions due to its positive effects such as providing psychological relaxation and decreasing anxiety and pain.23 When the study results are examined in light of this information from the literature, there was a decrease in the pain level, although not significant, at the 30th minute after the massage applied with the ultrasound gel while the massage did not have any effect on the pain level at the 3rd hour in the present study (Table 1). In the present study, massage application was effective in short-term decrease of pain. There are studies in literature applying hand and foot massage together. In the study by Chithra and D'Almeida,24 hand and foot massage was performed for a total of 20 minutes on women after abdominal hysterectomy, and a decrease at a significant level was detected in the level of pain at the 60th and 90th minutes. In 2 different studies performing hand-foot massage after abdominal surgery, it was determined that massage is effective in short-term decrease of pain.10,25 In studies aiming to determine the effect of hand-foot massage in pain management in cesarean section, a significant decrease was detected in the pain levels immediately after and 90 minutes after the massage.26,27 The study results, which have demonstrated that massage is effective in short-term management of postoperative pain, are similar to our results.

Massage is a method frequently applied in addition to medication treatment in the management of postoperative pain. In recent years, massage is performed using essential oils and odors acquired from plants, such as rose and lavender, due to effect of pleasant scents in aromatherapy on relaxation as well as pain.28 Aromatherapy massage performed with lavender and similar essential oils provides relaxation by increasing parasympathetic activity as a result of stimulating the sense of touch and thus changing pain perception.3 In this study, hand massage with lavender has provided significant decrease in the pain levels at the 30th minute and the 3rd hour, which supports the literature data, thus the H1 and H2 hypotheses were accepted. The massage performed on the placebo group also provided decrease in the postoperative pain, but the hand massage performed with the use of lavender oil had a longer lasting effect on pain management compared with only hand massage (Table 1). The H3 and H4 hypotheses were accepted. The effectiveness of massage on pain management increased with the help of the aromatic effect of lavender. In the literature, there are studies reporting that aromatherapy massages performed using lavender are effective on pain caused by cancer,29 decrease migraine pain30 as well as pain induced by osteoarthritis17 and rheumatoid arthritis16 and decrease pain during the fistula injection in hemodialysis patients.14 There are also studies related to primary dysmenorrhea in the field of gynecology. In a study using lavender as the massage oil with experimental and placebo groups, it was determined that the decrease in the experimental group, which had lavender massage, was higher compared with the other group.31 There were no studies found in the literature determining the effects of aromatherapy massage with lavender in pain management after gynecologic surgery. Thus, our results will have a positive contribution to the literature. Study results, which have determined that aromatherapy massage with lavender is more effective in pain management compared to the normal massage, support our results.

In the present study, lavender was used in the massage application. There are studies in the literature using lavender with the inhalation method in postoperative pain management. Lavender inhalation provided a decrease in pain at the first 30 minutes32 up to 16 hours33,34 after the initial application in patients who underwent cesarean section and at the first 60 minutes in patients who underwent coronary artery bypass surgery.35 Lavender inhalation following open heart surgery,9 breast biopsy,12 and tonsillectomy2 was not effective in pain management.

Medication treatment is generally used in decreasing pain/pain management during the postoperative period.36,37 Due to conditions such as high analgesic consumption and inadequacy of routine procedures in pain management, nonpharmacologic methods such as massage are utilized.38 Moreover, the decrease of medication use is also important in terms of decrease of health care expenditures and thus contribution to the country's economy. In this study, it was determined that massage with ultrasound gel and aromatherapy massage with lavender oil did not have a significant effect on analgesic use (Table 3). Lack of a difference between the groups in terms of analgesic use may be caused by analgesic use being a routine procedure in the clinic in pain management at the postoperative first day, the patients fearing experiencing pain and wishing to use analgesic for comfort. Contrary to the results of this study, in a study by Abbaspoor et al,26 it was determined that hand and foot massage decreases pain-related medication use in the period after cesarean section. In the literature, there were no studies determining the effects of aromatherapy massage using lavender on analgesic use while there are studies in which lavender is applied via inhalation.2,12,34,39

Limitations

The present study had some limitations. First, due to the smell of lavender oil, the study could not be performed in a double-blind manner, and only the researcher evaluating pain did not know which patient had which application (single-blind application). Second, while the postoperative analgesic administration was usually given at the same time for all patients, analgesic administration times differed in certain conditions due to the physician's request, and these patients were excluded from the study. Third, to observe the affected duration of the massage application, it could have been used for a longer time. Fourth, the small sample size is another limitation factor for this study.

CONCLUSIONS

According to the study results, while only hand massage application after gynecologic surgery was effective for a short period in decreasing postoperative pain, it was determined that massage application with lavender had a longer effect in decreasing postoperative pain. This result supports the combination use of the effects of massage and aromatherapy together in pain management, which is an important issue for nurses as well as for patients' outcomes. It is known that pain-related nursing practice is a process of care as a response to the patients' needs. The results of this study showed that this inexpensive and easy-to-apply method, which does not have any side effects, can be safely performed by nurses on postoperative patients and can support pain management of patients in the first hours after gynecologic surgery. To support research findings, studies with a larger sample and a longer massage application are needed.

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Keywords:

gynecologic surgery; hand massage; lavender; nursing; pain

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