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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 11-16

The effects of jaw relaxation on stress and physiological indicators in patients with acute coronary syndrome: A randomized controlled trial


1 School of Nursing and Midwifery, Isfahan University of Medical Sciences, Iran
2 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission08-May-2021
Date of Acceptance08-Jun-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Hojatollah Yousefi
School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nms.nms_40_21

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  Abstract 


Backgrounds: Relaxation techniques can help reduce stress. However, few studies are available on the effects of jaw relaxation on stress and physiological indicators of patients with acute coronary syndrome (ACS). Objectives: This study aimed to examine the effect of jaw relaxation on stress and physiological indicators of patients with ACS. Methods: A randomized controlled trial was conducted on 64 patients with ACS hospitalized in two hospitals affiliated with Isfahan University of Medical Sciences, Iran. The patients were selected using consecutive sampling and were randomly assigned to an intervention (n = 32) and a control (n = 32) group. Jaw relaxation was performed for the subjects in the intervention group twice a day and for 3 days. The subjects in the control group received their routine care. The data were collected using Cohen's Perceived Stress Scale and a checklist for recording physiological indicators. Data analysis was performed using descriptive statistics, the chi-square, and the independent samples t test. Results: The mean stress score in the intervention group decreased from 26.03 ± 15.97 to 11.45 ± 14.75 (P < 0.001). However, the difference was not significant in the control group. The mean diastolic blood pressure, systolic blood pressure, heart rate, respiratory rate, and arterial oxygen saturation were not significantly different between the two groups before the intervention (P > 0.05). However, after interaction, the mean of these variables was significantly different between the two groups (P < 0.05). Conclusion: The use of jaw relaxation together with medical treatments has a positive effect on the recovery of patients with ACS and helps them manage their stress.

Keywords: Acute coronary syndrome, Jaw relaxation, Physiological indicators, Stress


How to cite this article:
Ghanbari Z, Yousefi H, Moeini M. The effects of jaw relaxation on stress and physiological indicators in patients with acute coronary syndrome: A randomized controlled trial. Nurs Midwifery Stud 2022;11:11-6

How to cite this URL:
Ghanbari Z, Yousefi H, Moeini M. The effects of jaw relaxation on stress and physiological indicators in patients with acute coronary syndrome: A randomized controlled trial. Nurs Midwifery Stud [serial online] 2022 [cited 2022 Aug 15];11:11-6. Available from: https://www.nmsjournal.com/text.asp?2022/11/1/11/340537




  Introduction Top


Despite being a setting with sophisticated technologies for providing quality patient care, intensive care units are stress-inducing places.[1] Stress causes a lot of changes in one's life. It changes the patients' vital signs and induces anxiety in them. Changes in vital signs, anxiety, and feeling of suffocation and the imminent death are also among the most prominent symptoms of acute coronary syndrome (ACS).[2] Increased blood pressure can increase cardiac workload, which consequently increases the extent of myocardial injury in patients with ACS.[3] Stress, in turn, can increase the patient's blood pressure and the severity of the injury.[4] Therefore, reducing stress can play an important role in reducing the risk of myocardial injury.

In addition to anxiolytic medications, a number of behavioral treatments can be used to overcome stress. Meditation, yoga, muscle relaxation, massage, and biofeedback are among the behavioral methods that are used to decrease stress.[5],[6] Relaxation is defined as any state of releasing stress, anxiety, and musculoskeletal pressure.[2],[7] As a therapeutic strategy, relaxation is widely used in stressful situations. Relaxation induces a feeling of peace and diminishes stress and anxiety through reducing oxygen demand of the tissues, decreasing the level of chemicals such as lactic acid, eliminating skeletal muscle tension, and secretion of endorphins.[4] Relaxation has different types including jaw relaxation (JR) and can be used at any time.

Many studies have evaluated the effects of different relaxation methods in different groups of people. For instance, a study has reported that Benson's relaxation technique could effectively reduce the anxiety of patients undergoing coronary angiography.[8] Another study also assessed the effect of muscle relaxation on vital signs of patients with myocardial infarction and reported that muscle relaxation could modify, adjust, and improve vital signs of patients suffering from myocardial infarction.[9] A study also reported that progressive muscle relaxation was effective in alleviating stress, anxiety, and depression after hysterectomy.[10]

JR technique was first presented by Jacobson in 1938[11] and has been reported to be effective in reducing postoperative pain.[12] However, few studies are available on its effects on other problems. In one of these few studies, the effect of JR was examined on anxiety in patients with myocardial infarction and it was found that this method was effective in reducing the level of anxiety in these patients.[13] In another study, the effects of JR were examined in a sample of Egyptian nurses and it was found that JR could significantly decrease the nurses' low back pain, systolic and diastolic blood pressures, heart rate, and respiratory rate.[11] A study also reported that JR was effective in the reduction of pain anxiety during burn dressings.[14] However, a study examined the effects of meditation and JR on postoperative pain, anxiety, and vital signs of patients undergoing abdominal surgery. The findings showed that both methods were effective on pain and anxiety; however, neither meditation nor JR could significantly affect the vital signs.[15] Considering the nurses' responsibility to provide quality care, decrease stress, and stabilize the vital signs in critical patients such as those with ACS, and due to the few and controversial studies available on the effects of JR on stress, anxiety, and vital signs, and that no study is available on the effects of this relaxation method in patients with ACS, the question remained that can JR affect the stress and physiological indicators such as vital signs and blood oxygen saturation in patients with ACS?

Objective

This study aimed to examine the effect of JR on stress and physiological indicators in patients with ACS.


  Methods Top


Study design and participants

A clinical trial was conducted in 2018 on patients with ACS admitted to cardiac care units (CCUs) of Al-Zahra and Shahid Chamran hospitals affiliated with the Isfahan University of Medical Sciences. Sample size was calculated using the results of an earlier study into the effect of JR on anxiety in patients with myocardial infarction. The mean postintervention anxiety scores in the control and the experimental groups were 48.41 ± 6.35 and 42.47 ± 7.12, respectively.[13] Subsequently, with a type-I error of 0.05, a type-II error of 0.2, a S1 of 6.35, a S2 of 7.12, a μ1 of 48.41, and a μ2 of 42.47, sample size was calculated to be 21 per group. However, the sample size per group was increased to 32 due to participants' probable withdrawal from the study.

Subjects who met the eligibility criteria were recruited using a consecutive sampling method and then were randomly allocated to a JR (n = 32) or a control (n = 32) group based on the even (intervention group) and odd (control group) numbers. Sampling continued until the sample size reached the predetermined size [Figure 1].
Figure 1: Consort flow diagram of the study

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The inclusion criteria of the study were age of 20 years and over, a definite medical diagnosis of ACS, the physician's permission for JR, the patient's alertness to time, place and person, a willingness to participate in the study, hemodynamic stability on the day of study, having no specific problem such as fracture at the site of JR, lack of any active mental and anxiety disorders or drug addiction. The exclusion criteria of the study included a patient's decision to withdraw from the study, discharge or death of the patient, participation in another study during this one, and need for an emergency nursing or medical intervention during the study.

Instruments

A three-part instrument was used in this study. The first part contained questions on demographic variables such as age, gender, education level, marital status, job, and disease history. The second part was a checklist for recording the physiological indices. The third part was the Perceived Stress Scale (PSS) developed by Cohen et al. This scale has 14 items designed to assess “the degree to which situations in one's life are appraised as stressful.” All items are responded on a 5-point Likert scale ranging from zero: “never” to 4: “very often”. The overall score range between 0-56. This scale had previously been translated into Farsi by Safaei and Shokri,[16] and its internal consistency coefficient was 0.76.

Procedure

The first author provided every patient in the intervention group with 5-min individual and verbal training about the method of JR. In addition to verbal educations, she practically showed patients how to perform the JR correctly and responded to their questions, if any. All subjects were taught to perform JR twice daily (between 15 and 17 Pm) and for 3 days as follows, whereas they are free from tension, and resting in bed (lying down on their back while the head of the bed is 30° high): “Let the lower jaw drop slowly as if a small yawn is going to start;” “keep the tongue relax and motionless at the floor of the mouth;” “loosen your lips;” “breath out slowly and regularly (inhale, exhale and relax);” “do not talk and do not even think about words.”[14]After training, the patients were asked to practice and repeat this procedure several times to gain sufficient skill in this regard. The skills of the subjects in performing JR were evaluated by the researcher using a relaxation skill checklist that included four criteria of (a) face relaxation, (b) no grimace or frown, (c) no talk, and (d) slow respiration.[12] Each item had 2 points. Mastery was defined as a score of 7 out of 8.

All patients in the intervention group performed JR in a quiet setting and as instructed (i.e., twice a day, for 3 days, and 20 min per session). Then, on the afternoon of the intervention days, the patients' physiological indicators (i.e., systolic and diastolic blood pressure, heart rate, arterial blood oxygen saturation, and respiration rate) were measured10 min before and 10 min after the intervention. The stress level was also measured 10 min before the first session and 30 min after the last session. Blood pressure was measured using a mercury manometer, oxygen saturation was measured via a pulse oximeter connected to the patient's index finger, heart rate was measured via a monitor, and the respiration rate was measured through direct observation by the first researcher. The level of stress was also measured using the PSS.

Patients in the control group received no intervention but their stress and physiological indicators were measured at times similar to the intervention group. All patients received their routine medical treatment during the study.

Ethical considerations

This study was approved by the ethics committee of Isfahan University of Medical Sciences (ethics code: IR.MUI.REC.1397.376) and was registered on the Iranian Registry of Clinical Trials (IRCT ID: IRCT20190102042210N1). All participants were informed that they are under investigation, were assured of the confidentiality of the data, and signed the informed consent form. They also were told that they could withdraw from the study whenever they wished.

Data analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program, version 13.0 (SPSS, Chicago, Illinois); normality was tested by the Kolmogorov–Smirnov test, and descriptive statistics (frequency, mean, and standard deviation) were calculated for the demographic data. Moreover, the demographic characteristics of the two groups were compared using the chi-square and Mann–Whitney U tests. The independent samples t tests were used for the comparison of the mean of quantitative variables in the two groups. Statistical significance was considered to be P < 0.05.


  Results Top


The mean age of the participants in the control and the intervention groups was 57.6 ± 10.08 and 57.3 ± 10.95 years, respectively. Respectively, 56.25% and 46.78% of the patients in the control and the intervention groups were males. The study groups were homogeneous in terms of all demographic characteristics [Table 1].
Table 1: Demographic characteristics of the study participants

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The mean diastolic blood pressure, systolic blood pressure, heart rate, respiratory rate, and arterial oxygen saturation were not significantly different between the two groups before the intervention (P > 0.05). However, after interaction, the mean diastolic blood pressure, systolic blood pressure, heart rate, respiratory rate, and arterial oxygen saturation were significantly different between the two groups [Table 2].
Table 2: Comparison of the mean vital signs and O2 saturation, before and after the intervention between two groups

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Furthermore, after the intervention, the mean stress score in the intervention group decreased significantly (P = 0.001) but it did not change significantly in the control group. In addition, the independent t-test showed that the mean score of stress was significantly different between the two groups after the intervention (P = 0.001) [Table 3].
Table 3: Comparison of the mean score of stress before and after the intervention in two groups

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  Discussion Top


The results of this study showed that JR can reduce stress and improve some physiological indicators in patients with ACS. JR could decrease diastolic and systolic blood pressure, heart rate, respiratory rate, and increase arterial oxygen saturation. In line with our results, earlier studies have also shown that this technique was effective in reducing anxiety in patients with myocardial infarction[13] and before burn dressings.[14] Several other studies have also shown that relaxation methods are effective in reducing depression, anxiety, and pain in patients with cardiovascular disorders[17] and before coronary angiography,[18] hip or knee arthroplasty,[19] and chemotherapy.[20] A study also showed that relaxation could effectively reduce anxiety and improve the quality of life of patients undergoing coronary artery bypass graft surgery.[21] Accordingly, it can be concluded that relaxation, as a complementary therapy, can be used to reduce the anxiety and stress of patients with various disorders. Patients with ACS are usually anxious due to fear of death. Some of these patients experience anxiety even several months after the heart attack due to fear of recurrence of the attack, forgetting the medications, diminished physical abilities, and sleep disorders.[22],[23] Although depending on the type of technique, the duration of the intervention, the population, and the research setting, the impact of relaxation techniques may vary somewhat, simple relaxation methods, especially JR can be taught to patients with ACS to help them manage their own anxiety and stress, which consequently can improve their quality of life and reduce the risk of attack recurrence.

This study showed that JR could improve the patients' physiological indicators such as systolic and diastolic blood pressure, heart rate, arterial blood oxygen saturation, and respiration rate. A study on patients undergoing abdominal surgery has reported that JR did not significantly affect vital signs.[15] Two other studies on patients with ACS[24] and those undergoing cesarean section[25] also reported that relaxation could not significantly affect the hemodynamic parameters. However, a number of studies on patients with myocardial infarction[9] and healthy nurses[11] confirmed that relaxation methods such as JR could modify, adjust, and improve vital signs. Some other studies have also shown that relaxation methods such as muscle relaxation, can decrease heart rate, respiration rate, and dyspnea,[26],[27] which in turn reduces the patients' anxiety and stress. These effects might be attributed to a set of changes such as improved cerebral blood flow, deviation of thought, secretion of endorphins, and a feeling of well-being, that occurs during the relaxation session.[24],[25],[28]

This study was conducted on a small number of patients and in a short period. Therefore, further studies with larger sample sizes and longer intervention and follow-up are suggested.


  Conclusion Top


The results of this study showed that JR can affect the physiological and psychological indicators of patients with ACS over a short period of time. Therefore, JR, as a complementary therapy, can be used along with other medical treatments in order to accelerate the recovery of patients with ACS. Nurses can apply this simple method in their patients and also teach them to perform this technique to manage their anxiety and stress and improve their physiological functions.

Acknowledgement

The authors would like to express their gratitude to the research deputy of the university and the cooperation of the patients who participated in this study.

Financial support and sponsorship

This article is the result of a thesis for the fulfillment of a master's degree in nursing No. 397202, approved by the Faculty of Nursing and Midwifery of Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
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