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https://doi.org/10.26911/theijmed.2019.04.01.08
ABSTRACT
Background: Broken bones can cause soft tissue edema, bleeding in the muscles and joints,
tendon rupture, damage to nerve tissue and damage to the vasculer and surgery are ways that are
carried out to restore the movement function of extremitas and the impact that occurs due to these
actions is pain. Acute pain is still found in postoperative non-pathological fracture patients who
have received analgesic ketorolac.
Subjects and Method: This was a quasy experiment study conducted at Dr. Soetomo Hospital,
Surabaya, East Java. A sample of 46 patients post orthopedic surgery was selected for study by
purposive sampling. The dependent variable was pain. The independent variables were range of
motion and deep breathing exercises. Pain was measured by visual analog scale (VAS). The data
were analyzed by t-test.
Results: After treatment, pain level in the intervention group (mean = 2.43; SD = 1.41) was lower
than the control group (mean= 3.48; SD= 1.38) with p= 0.014.
Discussion: Combination of range of motion and deep breathing relaxation therapy effective to
reduce pain among post orthopedic surgery patients.
Correspondence:
Hery Sasongko. Masters Program in Nursing, Universitas Airlangga. Email: herysasongko.ners-
@gmail.com.
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ing to the Royal College of Physicians in legs and 336 people had broken fibular
2012 included six points, i.e. breathing, bone. According to the results of Basic
oxygen saturation, temperature, blood Health Reseacrh (RISKESDAS) the number
pressure, heart rate and level of consciou- of fractures in the Women's Development
sness (National Clinical Effectiveness Com- Institute in 2013 increased compared to the
mittee, 2013). Preliminary study by Ilmia- results in 2007.
sih (2015) showed that postoperative pain The results of the survey and data
can affect hemodynamic stability, can collection from the annual report of the
reduce immunity, thus disrupting the Orthopedic and Traumatology Depart-
healing process. ment/ faculty of medicine, Universitas Air-
Preliminary study conducted at Prof. langga/ Dr. Soetomo Hospital, Surabaya in
Dr.R.D. Kandou hospital, Manado, Indo- 2017 show that those who were performed
nesia, to 30 patients performed 2 days after surgically in the emergency room operation
fracture surgery shows that out of 15 room were 938 patients with 10 most
patients who were not given intervention, diagnoses or (32%) of the total surgery in
there were mild pain as many as 6 patients the emergency room for upper extremity is
(40%), moderate pain as many as people 31 closed fracture of upper humerus pati-
(26.7%), severe pain as many as 3 people ents, 28 upper end closed radius of upper
(20% ) and very severe pain in 2 people fracture, while 29 lower extremity diag-
(13.3%). After intervention in deep breath- noses are closed fracture shaft of tibia,
ing relaxation techniques, there were 2 while surgery in the operating room
patients who said there was no pain, no amounting to 1275 surgery integrated cen-
patients said moderate pain and very severe ter building or (22%) of the total surgeries
pain, there was an effect on the inter- from all surgical departments. Surgical
vention of deep breathing towards the diagnoses at the surgery integrated center
patient's pain response. The study was building for upper extremity were 27
supported by Nurdin et al. (2013) in the patients with closed fracture distal radius,
same place, namely 11 people (55%) with 34 fractures of lower both ulna and radius,
severe pain intensity and severely reduced while lower extremity diagnoses were
to 10 people with moderate pain intensity femur closed fracture as many as 151 pati-
and 1 person without pain. 8 people (40%) ents, from the number of surgical proce-
has the intensity of pain reduced to mild dures performed at the emergency room
pain, mild pain 1 person (5%) which and surgery integrated center building
became painless. operating room with fracture lower extre-
According to the Indonesian Ministry mity diagnosis and upper extremity were
of Health/Kemenkes RI (2015), among obtained by 300 patients on average a
cases of fractures in Indonesia, fractures of month there were 23 patients who under-
the extremities have the highest prevalence went surgical Open Reduction Fixation
among other fractures, which is around (ORIF) to restore motion function and
46.2%. The accident cases were 45,987 reduce fracture pain.
people with cases of limb fractures due to Deep breathing exercise intervention
accidents, 19,629 people had femur frac- has been carried out in hospitals as a
tures, 14,027 people had cruris fractures, relaxation technique to reduce pain inten-
3,775 people had tibia fractures, 9702 sity in all cases, because deep breathing
people had fractures in small bones in the exercise is a therapeutic pharmacology that
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Table 1 showed that the age groups in 0.606), and fracture (p = 0.154) showed
the intervention and control groups were that the general characteristics of sample
mostly 17-40 years old, male gender, and who participated in the study were
had fractures in the lower extremities. homogeneous.
Homogeneity, age (p = 0.342), gender (p =
Table 2. Pain level of patients with orthopedic surgery before treatment
Group Mean SD p
Intervention 4.52 1.04 0.903
Control 4.48 1.16
Table 2 indicated the pain level of given motion range and depth breathing
patients with orthopedic surgery before treatments, the pain level in the inter-
treatment. Table 2 showed that before the vention group (mean = 2.43; SD = 1.41) was
treatment was given, there was almost no lower than the control group (mean= 3.48;
difference in pain levels in the intervention SD= 1.38) with p= 0.014.
group (mean = 4.52; SD = 1.04) and the
control group (mean= 4.48; SD= 1.16) with DISCUSSIONS
p= 0.903. The combination of range of motion and
Table 3 showed the pain level of deep breathing exercise therapies for pati-
patients with orthopedic surgery after ents after orthopedic surgery in Table 2
treatment. Table 3 showed that after being showed different levels of pain. Both groups
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showed different mean pain levels, which type of femoral fracture has closed wounds
were 3.48 (control group) and 2.43 (treat- (71%) and was located in the thigh bone
ment group). Pain scores of samples in both column (46%). The most common cases of
groups had a maximum pain score of 6. femoral fractures occurred in men of pro-
This was in accordance with the theory ductive age due to traffic accident injuries.
which stated that after orthopedic surgery, Pain in patients after orthopedic sur-
the patients had experienced acute pain at a gery was acute pain, which was caused by
severe level. Surgery in the orthopedic unit tissue damage that occurred not only due to
was able to deliver the intensity and dura- surgical incisions but also previous trauma
tion of acute pain that were different com- which was an indication of orthopedic frac-
pared to other care units. This was due to ture operations (Smeltzer and Bare, 2012).
the degree of damage that injured from Nurses have a role to deal with pain, pain
superficial, soft tissue, boned exposed, response and side effects from the adminis-
blood vessels and nerves (Royal College of tration of medication therapy pain relief. It
Physicians, 2012). was one of the efforts in providing compre-
The results of the study in table 1 hensive nursing care services. Pain mana-
showed that most of the study respondents gement was a collaboration of all service
were in the age range of young adults providers for the benefit of patients (Smelt-
(97.8%). This was in accordance with the zer and Bare, 2012)
theory which stated that pain was reported An individual who experienced pain
only if it has become a pathological state with the same type over and over again but
and has impaired function and this was the pain was successfully eliminated, it
often done by adults (Flor et al., 2011). would be easier for the individual to
Table 1 showed that the majority of samples interpret the pain sensation. The impact
were male. The National Health Survey was the client would be ready to take act-
reported that cases of fractures occurred ions to eliminate the pain (Potter and
more in men than women (Novita, 2012). Perry, 2006). Range of motion and deep
The fact showed that the prevalence of breathing exercise combination therapy has
traffic accidents and workplace accidents been shown to significantly reduce pain
was more common in men than in women. levels compared to those who were only
If it was associated with the incidence of given standard therapy in post orthopedic
postoperative orthopedic pain with the patients at Dr. Soetomo Hospital, Surabaya.
characteristics of acute and severe pain, Therefore, this therapy can be used as a
then this was not in accordance with the complementary therapy that helped the
theory which stated that women focused process of wound healing and recovery of
more on pain so that the pain sensation was the general condition of post-orthopedic
higher in women because clients who surgery patients.
focused their attention on pain can affect This was in accordance with Nurdin et
pain perception (Smeltzer et al., 2013). al. (2013) who also showed that deep
The analysis showed that the type of breathing exercise was effecttive in redu-
fracture found at the study site was fracture cing pain in postoperative orthopedic pati-
that occurred in the lower extremity of ents with severe pain scale. This proved
52.2% of all cases, this was in accordance that the reduction in pain level in the
with the study conducted by Noorisa et al. intervention group who received relaxation
(2017) which stated that the most common therapy was greater than the control group
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who only received standard ketorolac including β-endorphins have a direct effect
therapy 30 mg of intravenous ampoule on neurons, namely: (1) closing the gate
preparation. A greater reduction in pain in Ca2 + at the presynaptic nerve end, so that
the intervention group compared to the the infusion of Ca2 + decreased, thereby
control group was caused by an increase in reducing the release of pain transmitters
endorphins in the intervention group. such as glutamate, acetylcholine, norepine-
Range of motion and deep breathing com- phrine, and substance P; and (2) caused
bination therapy exercises combined the hyperpolarization of the neurons, thus
range of motion therapy with deep breath- inhibiting postsynaptic neurons by opening
ing relaxation technique. the gate of K + (potassium) ions, causing K
Range of motion can lead to positive + influx. Receptors μ, δ, and κ reduce the
perception. Positive perceptions that release of transmitters from the end of the
affected the amygdala would be forwarded presinaps, whereas the μ receptor also
to the hypothalamus to produce Cortico- caused hyperpolarization at the post-
tropin Releasing Factor (CRF). Further- synaptic end.
more, CRF stimulated the pituitary gland The combination of range of motion
(hypophise) to secrete endorphins as neu- therapy and deep breathing exercise can
rotransmitters that affect the mood to relax. manipulate the pain mechanism in the
The effect of relaxation obtained from modulation process where there was an
doing range of motion was strengthened by interaction between the endogenous anal-
deep breathing exercise. If people did the gesic system and the intake of pain that
DBE correctly, it would reduce oxygen enter the posterior body so that pain intake
consumption, respiratory frequency, heart can be suppressed. Range of motion and
frequency and muscle tension. This would deep breathing exercise combination thera-
help the body to be at a high concentration py modulated pain at the spinal level in
so that it would activate alpha waves in the afferent arrangements. At this level, the
brain. Buyukyilmaz and Asti (2013) stated modulation target in the gelatinose subs-
that these alpha waves can stimulate the tance in order to provide inhibition to the
release of β-endorphins and serotonin transmission of pain impulses. In accord-
which have a role in the analgesia. β-endo- ance with gate control theory, combination
phine system had a high affinity for the μ of range of motion and deep breathing
opioid receptor. Opioid receptors were exercise therapy can stimulate many endor-
related to G proteins, which were proteins phins that inhibit the release of substances
found on the cytoplasmic surface of the released by delta-A and C neurons that
plasma membrane. G protein was activated perceive the pain so that the dominant
by an increase in cAMP (cyclic adenosine input came from beta-A fibers which would
monophosphate), Ca2 + (calcium), or phos- close the defense mechanism (gate). So the
phoinositid ions. The bond between opioid message conveyed in the cortex was
receptors and G proteins, specifically the Gi modulation stimulation and it can decrease
protein, caused a decrease in the enzyme the pain (Potter and Perry, 2006).
adenylatecyclase, an enzyme that converted Changes in perceptions that have not
ATP (adenosine triphosphate) to cAMP, been formed can be caused by several
resulting in a decrease in cAMP. The factors. Rustianawati (2013) stated that
decrease in cAMP caused a reduction in there were two factors that influence
membrane permeability to ions. Opioids perceptions, namely internal factors and
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