Effect of massage on pain perception after administration of Intramuscular Injection among adult patients

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1 Effect of massage on pain perception after administration of Intramuscular Injection among adult patients Kanika, K Helen Rani, Shobha Prasad Abstract : Pain at the injection site is one of the most commonly-reported local reactions associated with administration of a vaccine. Once the patients experience pain after intramuscular injection because of any of the related factors for causing pain, they become scared of getting the injections via IM route in future. Moreover, multiple practices used or different techniques followed make it difficult to choose a single practice like massaging the site of injection after IM injection to relieve pain or not. The aim of the study was to evaluate the effect of massage on pain perception of patients after administration of intramuscular injection and to assess the correlation between two pain scales i.e. Visual Analogue Scale & Verbal Rating Scale (VAS and VRS) in terms of pain scores with and without massage after administration of intramuscular injection. The study was conducted in medical, surgical, gynae and ortho wards of MMIMSR & Hospital and the design adopted for the study was "Time series with withdrawn and reinstituted treatment design". The population comprised of the patients admitted in selected wards receiving Intramuscular injections and a sample of 30 patients was selected using purposive sampling technique. Each patient was administered repeated intramuscular injections at the gluteal site. The group was a control for itself and the intervention massage was omitted on one occasion after injection administration while instituted on another occasion. The tools developed and used for data collection were performa for identification and demographic data and performa for pain assessment included pain assessment on VAS and VRS. The pain perception of patients in terms of pain scores without massage was found to be significantly higher than pain perception of patients with massage after intramuscular injection administration. Thus it was concluded that massage given after intramuscular injection administration was effective in reducing pain perception of patients. Thus, massage can be used as an intervention to reduce pain after administration of intramuscular injection. Key words : Massage, Intramuscular Injection, Pain Perception, Adult Patients. Correspondence at : Kanika Lecturer, Swift Institute of Nursing Raipura, Patiala Introduction Pain is common in hospitalized patients. It is unknown if any population of hospitalized patients are at low risk for pain. It is estimated that the percentage of pain is anywhere from 50-80% of all hospitalized patients. In one study, nearly 50% of severely ill hospitalized patients reported pain, almost 15% of whom said they had moderately or extremely severe pain, at least half the time 1. Pain at the injection site is one of the most 130

2 commonly-repor ted local reactions associated with administration of a vaccine, but it has not been quantified by a validated instrument for pain measurement 2. The World Health Organization (2006) estimated that 16 billion injections are administered per year 3. Injections are currently the goldstandard for administrating various medications parenterally. The most significant side-effect related to injections is the accompanying pain. Injection pain is related to the penetration of the skin by the needle and to the mechanical and chemical effects of the drug during and after its injection. This pain remains a major obstacle in medication administration in children as well as in other population subject to needle-phobia because of the pain experience. The associated pain may thus prevent optimized medical care for these patients. Current methods to alleviate immediate pain include the utilization of topical anesthesia whereas some patients do not utilize any form of pain relief and simply endure the pain of the injection. Other methods for pain reduction are taking advantage of the applying pressure or vibration to alleviate pain. These methods have resulted in a number of pain relieving devices currently in the market. Such predicate devices primarily involve vibration devices commonly used to alleviate the injection pain 4. There are two main causative groups in which injection pain can be categorized: Pain due to route of administration which includes invasiveness of injection and opening a new IM injection site and another one is pain due to the substance being injected which involves abscess development and solvent concentration of substance. Patients are often afraid of receiving injections because they perceive that it will be painful. The pain of IM injections may be registered in the pain receptors in the skin, or the pressure receptors in the muscle. Pain during an IM injection generally is to be expected. Persistent pain, however, at the injection site is not an expected event. Patients on the receiving end of intramuscular injections are often apprehensive in part due to the potential painfulness of the procedure. One series repor ts that persistent pain may occur in 23 percent of the patients who have complications 5. A number of factors were listed which cause pain and these factors are the needle size, the chemical composition of the drug or its solution, the technique, the speed of injection and the volume of drug 6. It was found in one study that pain receptors are located within the subcutaneous layer and not in muscle tissue, thus needles need to be long enough to reach this muscle layer. The result of the study showed that the rate of redness with the longer needle was two thirds the rate with the smaller needle and rate of swelling with the longer needle was about one third that with the smaller needle. Rates of tenderness were also lower with the longer needle throughout follow up 7. Visual Analogue Scale (VAS) was utilized in one study to measure the intensity of pain 131

3 following the application of manual pressure to the injection site for 10 seconds before the procedure. More than one-third 37% of subjects included in the study reported less pain 8. Many studies have been conducted on effect of pressure on pain applied prior to administration of injection and technique of administration but still a single practice is not followed to minimize the pain af ter administration of intramuscular injection e.g. some prefer to massage the site after giving injection and some just place the alcohol swab and don t rub or massage the site. Moreover no studies related to pain assessment after intramuscular injection or the effect of massage on pain perception of patients after administration of intramuscular injection could be found in literature in Indian setting which has led to multiple practices being followed to administer intramuscular injection. This has aroused the interest to conduct this study and the researcher is particularly interested to assess the effect of massage on pain perception af ter administration of intramuscular injection. Objectives To find out the effect of massage after administration of intramuscular injection on pain perception of patients. To assess correlation between two scales i.e., visual Analogure scale & verbal Rating Scale Material and Methods The conceptual framework adopted for the study was based on System s Model and Gate s Control Theory of Pain. The research approach adopted for the study was Quasiexperimental research approach using time series with withdrawn and reinstituted treatment design. The independent variable in the study was massage and the dependent variable was the pain perception of patients. The study was conducted in medical, surgical, gynae and ortho wards of MMIMSR & Hospital, Mullana, Ambala and a sample of 30 patients was selected using purposive sampling technique. Formal administrative permission was obtained from the Medical Superintendent of the selected hospital to conduct to study in selected wards of the hospital. The data was collected from 15 th December 2009 to 27 th December The staff of the respective wards was informed to ensure their cooperation during data collection. To obtain cooperation of the patients, the purpose of the study was explained and consent to participate in the study was obtained from the patients. The tools developed and used for data collection were performa for identification and demographic data and per forma for pain assessment including pain assessment on Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS). The VAS indicated the intensity of pain on a straight horizontal line of 10 mm length divided in 10 equal parts and on the scale, 0 indicated no pain and 10 indicated worst possible pain. A table for recording the pain scores was prepared and was filled up to 132

4 assess pain perception of patients at different time inter vals af ter administration of intramuscular injection with or without massage. The pain scores on the table were recorded by the researcher based on the facial expressions of the patient and after palpating the site to note any discomfort on the site of injection administration. On VRS, six adjectives were taken ranging from no pain to worst possible pain and the scale measured scores ranging from 0-5 in which 0 indicated no pain, 1 indicated mild pain (feeble), 2 indicated moderate pain (avoiding extremes, temperate), 3 indicated severe pain (harsh or serious), 4 indicated very severe pain (high degree of forceful pain) and 5 indicated worst possible pain (most bad). The patient was asked to describe his/her pain verbally and it was marked according to his/her own subjective perception of pain on the rating scale. The content validity of the tools was established by eleven experts, including nine nursing experts in the field of Medical Surgical Nursing, Community Health Nursing, one from Psychology and one from Medicine i.e. Cardiologist. The reliability co-efficient for VAS was calculated using Cronbach s alpha and Interrater reliability and the results were 0.75 and 0.80 respectively. The reliability for VRS was calculated by using Cronbach s alpha and it was found to be After selecting the study sample on the basis of inclusion criteria, on day one, intramuscular injection was administered to the patient without massage and the pain scores were recorded both on VAS and VRS at different time intervals i.e. < 5 minutes, 30 minutes and 1 hour inter val after the administration of a single injection. On 2 nd occasion, after administration of intramuscular injection, massage was instituted and pain score readings were taken. The same procedure was followed in all patients with omitting massage on one occasion while instituting it on another. A total of four injections with 12 pain score readings were obtained on both the scales for a single patient. Results Sample Characteristics Out of 30 subjects under study, one fourth of the subjects (26.67%) were in the age group of years. In contrast to this, subjects in the age group were lowest which included 1 (3.33%) subject only. More than half of them (53.33%) were females. Half of the subjects had a general education level up to Secondary (50%) whereas only two (6.67%) had done their Graduation. Four teen (46.67%) out of 30 subjects were not working whereas 13 (43.37%) had private jobs. None of the subjects had Government job. To 30 subjects total 160 intramuscular injections were administered. Injection Voveran was given maximum (74.17%) number of times whereas Injection Vitamin K (1.25%) was given on least number of occasions. 133

5 Figure 1: Bar graph showing mean pain scores with and without massage on VAS at different time intervals MeanPain Scores WITH MASSAGE WITHOUT MASSAGE < 5minutes 30 minutes 1 hour Time Intervals Figure 1: Bar Graph showing mean pain scores with and without massage on Visual Analogue Scale at different time intervals It is evident from the bar graph shown in figure 1 that the mean pain scores obtained without massage were higher than the mean pain scores with massage on VAS. The graph also reveals that there was consistent decrease in mean pain score with an increase in time inter val both with and without massage after the administration of intramuscular injection. It is evident from the bar graph shown in Figure 2 that the mean pain score obtained without massage were higher than the mean pain scores with massage on VRS. The graph also reveals that there was consistent decrease in mean pain scores with an increase in time inter val both with and without massage after the administration of intramuscular injection. The data presented in Table 1 shows that t value was significant at 0.05 level of significance for df 29.The computed t values at three intervals i.e., 5 minutes t (29)=9.96, 30 minutes t (29)=7.76 and 1 hour t (29)=8.80 indicated that mean score of pain perception of patients without massage were higher than mean score of pain perception of patients with massage after administration of intramuscular injection as measured by VAS. Thus, it is established that the difference obtained in the mean scores of pain perception with and without massage on VAS was a true difference and not by chance. This indicates that massage after administration of intramuscular injection was effective in reducing pain perception of adult patients. Figure 2 : Bar graph showing mean pain scores with and without massage on VRS at different time intervals Mean Pain Scores < 5 minutes 30 minutes 1 hour Time Intervals WITH MASSAGE WITHOUT MASSAGE Figure 2: Bar Graph showing mean pain scores with and without massage on Verbal Rating Scale at different time intervals 134

6 Table 1: Evaluation of effect of massage on pain perception of patients in terms of pain scores on VAS N=30 Mean Mean D SD D SE MD t value Time interval With Without massage massage < 5 minutes * 30 minutes * 1 hour * Table Value of t 29 =2.04, *p<0.05 The data presented in Table 2 shows that t value was significant at 0.05 level of significance for df 29.The computed t values at three intervals i.e. 5 minutes t (29) =6.81, 30 minutes t (29) =5.79 and 1 hour t (29)=6.55 indicated that mean scores of pain perception of patients without massage were higher than mean scores of pain perception with massage at all the three intervals after administration of intramuscular injection as measured by VRS. Therefore, it can be said that the difference obtained in the mean scores of pain perception with and without massage on VRS was true difference and not by chance. This suggests that massage af ter administration of intramuscular injection is effective in reducing pain perception of adult patients. Table 2 : Evaluation of effect of massage on pain perception of patients in terms of pain scores on VRS N=30 Mean Mean D SD D SE MD t value Time interval With Without massage massage < 5 minutes * 30 minutes * 1 hour * t (29)=2.04, *p<

7 The coefficients of correlation between VAS and VRS with massage were 1.00,.746 and.364 at < 5 minutes, 30 minutes and 1 hour interval respectively and without massage were.736,.634 and.780 < 5 minutes, 30 minutes and 1 hour interval respectively, suggesting a significant positive relationship between the pain scores obtained on VAS and VRS at all the three intervals. The findings further revealed that there was marked relationship between VAS and VRS in terms of pain scores obtained at 30 minutes interval with massage and at < 5 minutes and 30 minutes intervals without massage. However, high relationship was present between VAS and VRS in terms of pain scores obtained at < 5 minutes interval with massage and 1 hour interval without massage. There was slight or low correlation present between VAS and VRS in terms of pain scores obtained at 1 hour interval with massage. The findings indicate that pain scores obtained on VAS were consistent with the pain scores obtained on VRS.( table 3) Table 3 : Correlation between VAS and VRS in terms of pain scores obtained at different intervals N=30 Time interval Mean S.D r value With Without With Without With Without massage massage massage massage massage massage VAS VRS VAS VRS VAS VRS VAS VRS < 5 minutes *.736* 30 minutes *.634* 1 hour *.780* r (28) >0.361, p< 0.05 Discussion Several parameters influencing the local tolerance of injectable drugs have been well-documented; however, little attention has been paid to pain following an injectiona common problem in clinical practice. Studies have been conducted on a number of variables associated with injection pain among adults but no study to assess the effect of massage on pain perception of patients af ter the administration of intramuscular injection could be found in literature. Collecting time-series data is an excellent strategy in small, single-group studies as well as in case studies. The present study utilized time series with withdrawn and reinstituted treatment design so as to evaluate and 136

8 compare the pain perception of patients with and without massage after administration of IM injection. A study conducted by one author 9 used a time-series design in a pilot study of developmentally disabled children with oral feeding problems. The preintervention baseline data was collected for four to six sessions, and then the data during two to four control sessions was collected in which subjects heard music that did not contain Hemi-Sync sounds. Thus, more definitive conclusions could be drawn about the impor tance of Hemi-Sync tones by comparing results to both the baseline and the soothing music treatment periods. The present study was taken up with the objective to assess and evaluate the effect of massage on pain perception of patients after the administration of intramuscular injection. The findings of the study give a baseline to the nursing personnel and student nurses to develop an understanding of the effect of massaging the site to reduce pain after intramuscular injection. The results of the present study clearly indicated the effectiveness of massaging the site after administration of IM injection in reducing pain perception of adult patients. Some of the studies conducted by different authors 2, 10, 11 also highlighted the significance of applying pressure/ massage prior to the administration of IM injection in reducing pain perception of patients. In contrast, massage was given af ter administering IM injection to evaluate its effect on pain perception of patients in the present study. The correlation between VAS and VRS was calculated in the present study and the findings indicate that there is significant positive relationship between pain scores obtained with and without massage at different intervals after the administration of intramuscular injection. A study was taken up to compare VAS and VNRS, whose results showed a strong correlation between the two scales but not perfect agreement and VNRS was preferred over VAS 12. Similarly one study was carried out to test the agreement between the Visual Analogue Scale (VAS) and a Verbal Numerical Rating Scale (VNRS) in measuring acute pain, and measure the minimum clinically significant change in VNRS. The results showed that VAS and VNRS were highly correlated but VNRS scores were higher than the VAS scores 13. The findings of the present study indicated that massage was effective in reducing pain perception of adult patients after the administration of intramuscular injection. Hence, it can be said that massage can be used as an intervention to reduce pain after administration of intramuscular injection. The application of manual pressure has an effect on patients perception of pain associated with intramuscular injections though the sample taken up for the study was a smaller one but based on the findings of the study, it is recommended that the nurses working in clinical areas as well as community settings may follow the practice of massaging 137

9 the injection site after administration of intramuscular injection in order to reduce pain related to injection. Intramuscular injection administration is the most common procedure performed by the nurses in clinical setting. Research should be directed to explore nurses knowledge and skills of intramuscular injection administration, minimizing pain and assessing post injection pain. The present study clearly gives an insight into the common problem i.e. pain associated with intramuscular injection and further studies can be conducted in different setting and large sample to generalize the results. A comparative study can be done to assess the effect of two different interventions i.e. massage applied prior to and after the administration of IM injection on pain perception of patients. References 1. Won A, Lapane K, Gambassi G, Bernabei R, Mor V, Lipsitz LA. Correlates and management of nonmalignant pain in the nursing home. Journal of the American Geriatrics Society 1999; 47: Su L, Tucker R, Frey SE, Gress JO, Chan IS, Kuter BJ. et al. Measuring injection-site pain associated with vaccine administration in adults: a randomized, double-blind, placebocontrolled clinical trial. Journal of Epidemiology and Biostatistics 2000; 5(6): WHO Repor t findar ticles.com/p/ ar ticles/mi_m0fs S/ i s _ 4 _ 1 7 / a i _ n / p g _ 2 /?tag=content;col1site accessed in October Pinchas Halpern, Tatiana Levit. Evaluation of pain reduction in the administration of saline injections by the usage of pneumatic skin flattening: a study available from clinicaltrials.gov/ct2/show/nct Site accessed in March Greenblatt D, Divoll-Allen M. Intramuscular injection-site complications. JAMA 1978; 240(6): Torrance C. Intramuscular Injection Part 1 Surgical Nurse 1989; 2(5): Diggle L, Deeks J. Effect of needle length on incidence of local reactions to routine immunization in infants aged 4 months; randomized controlled trial. British Medical Journal 2000; 321: Barnhill BJ, Holbert MD, Jackson NM, Erickson RS. Using pressure to decrease the pain on intramuscular injections. Journal of Pain Management 1996; 12(1): Morris S. E. Opening the door with Metamusic. Hemi-Sync Journal 1998; 16 (3): Chung JW, Ng WM, Wong TK. An experimental study on the use of manual pressure to reduce pain in intramuscular injections. Journal of Clinical Nursing 2002; 11(4): Negin MasoudiAlavi. Effectiveness of acupressure to reduce pain in intramuscular injections. International Journal of Acute Pain Management 2007;9(4): Mohan H, Ryan J, Whelan B, Wakai A. The end of the line? The VAS and verbal numerical rating scale as pain assessment tools in the emergency department. Emergency Medicine Journal 2010; 27(5): Holdgate A, Asha S. Comparison of a verbal numeric rating scale with the VAS for the measurement of acute pain. Emergency Medicine 2003; 15(5-6):

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