Original Article
Effectiveness of Jaw
From the *Center for Nursing Care
Research, Faculty of Nursing &
Midwifery, Iran University of Medical
Sciences, Tehran, Iran; †Faculty of
Nursing & Midwifery, Iran University
of Medical Sciences, Tehran,
Iran‡Statistics & Mathematics
Department, School of Health
Management and Information
Sciences, Iran University of Medical
Sciences, Tehran, Iran.
Address correspondence to Fahimeh
Mohammadi-Fakhar RN, MSc,
Faculty of Nursing & Midwifery, Iran
University of Medical Sciences,
Rashid Yasemi St., Vali-Asr Ave.,
Tehran, Iran. E-mail:
mohamadifahimeh@yahoo.com
Received November 1, 2012;
Revised October 29, 2013;
Accepted November 12, 2013.
1524-9042/$36.00
Ó 2013 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2013.11.001
Relaxation for Burn
Dressing Pain:
Randomized Clinical
Trial
Forough Rafii, RN, PhD,*
---
Fahimeh Mohammadi-Fakhar, RN, MSc,†
and Roohangiz Jamshidi Orak, PhD‡
- ABSTRACT:
Patients hospitalized for burn injuries experience severe pain, both
immediately after the injury and during daily therapeutic procedures
such as dressing changes. Relaxation is increasingly suggested as a pain
control technique that can be used by nurses in daily practice. Yet the
effects of relaxation on burn pain are not clear. The aim of this study
was to investigate whether jaw relaxation will decrease pain intensity
of burn dressing. Accordingly, a randomized clinical trial (n ¼ 100) was
conducted between 2009 and 2010 to compare jaw relaxation and usual
care. Consenting patients were randomly assigned to either experi-
mental or control groups using minimization. The experimental group
practiced jaw relaxation for 20 minutes before entering the dressing
room. Data were collected by visual analog scale (VAS), and several
structured questions were asked of the experimental group. No sig-
nificant difference was seen between mean pain intensity scores in the
experimental and control groups after dressing (p ¼ .676). Regarding
the ineffectiveness of jaw relaxation for pain intensity of burn dres-
sing, future studies are suggested to concentrate on longer durations of
relaxation time and continuing the procedure in dressing room.
Simultaneous study of the effect of this technique on residual, break-
through, and procedural burn pain is also recommended.
Ó 2013 by the American Society for Pain Management Nursing
INTRODUCTION
Burn injuries are a painful and often disabling form of trauma (Byers, Bridges,
Kijek, & LaBorde, 2001). Pain caused by severe burns is considered the worst
form of pain. Patients describe this pain as a ‘‘living hell’’ or as the most excruci-
ating pain they have ever experienced (De Jong & Gamel, 2006). Burn pain arises
from the injury itself and from the interventions used to treat the burn, such as
Pain Management Nursing, Vol -, No - (--), 2013: pp 1-9
2 Rafii, Mohammadi-Fakhar, and Jamshidi Orak
dressing changes, debridement, and physiotherapy
(Hanafiah, Potparic, & Fernandez, 2008). If left un-
treated, such pain can lead to debilitation, diminished
quality of life, depression (Black & Hokanson Hawks,
2008), dissatisfaction, posttraumatic stress disorder,
and prolonged hospitalization (Byers et al., 2001). In
addition, the adverse effects of pain may contribute
to increased burn hypermetabolism, which is an addi-
tional factor in undernutrition, immunological impair-
ment and sensitivity to infection (Falder et al., 2009).
The typical approach to pain control in burned pa-
tients involves the use of opioid analgesics supple-
mented with anxiolytic drugs. Although opioids and
benzodiazepines tend to diminish the discomfort of
the burn dressing changes, they are usually not suffi-
cient (Frenay, Faymonville, Devlieger, Albert, &
Vanderkelen, 2001). Melzack and Wall explained the
gate control theory in 1965. It was the first theory to
suggest that psychological factors play a role in the
perception of pain (Smeltzer, Bare, Hinkle, &
Cheever, 2008). According to this theory, there is a
gating mechanism in the nervous system that can
block the transmission of sensory and affective compo-
nents of pain at the level of spinal cord (Ferguson &
Voll, 2004). Moreover information from nonpain fibers
or information from the brain can reduce or totally
block pain information before it is experienced. So
whether the gate is open or closed, it can be influ-
enced by fibers carrying information from many
different brain centers down to the spinal cord
(Melzack & Katz, 2013). Therefore, the gate control
theory suggests that cognitive processes, such as relax-
ation, can exert control over painful stimuli (Ferguson
& Voll, 2004). Because pain is not only a physiologic
experience, but a psychological one as well, the treat-
ment of burned patients must incorporate a holistic
view of pain management and healing. Cognitive,
behavioral, and pharmacologic interventions all have
a role in pain management (Prensner, Yowler, Smith,
Steele, & Fratianne, 2001).
Relaxation is one of the most frequently used ap-
proaches to pain management (Burke, Mohn-Brown,
& Eby, 2010) and works by (1) reducing tissue oxygen
demand and lowering levels of chemicals such as lactic
acid that can trigger pain, (2) releasing skeletal muscle
tension and anxiety that can exacerbate pain, and (3)
releasing endorphins (Kwekkeboom & Gretarsdottir,
2006). Moreover, relaxation techniques enable pa-
tients to learn self-care and to be actively involved in
their own recovery, which is critical for optimal relief
(Roykulcharoen & Good, 2004).
Clinical and experimental research studies on
pain have shown that relaxation modifies pain percep-
tion and expression (Frenay et al., 2001). In many of
these studies, jaw relaxation was tested for relief
of postoperative pain after abdominal, orthopedic,
gynecologic, and intestinal surgery (Good et al., 1999;
Good et al., 2001; Good, Cranston Anderson, Stanton-
Hicks, Grass, & Makii, 2002; Good, Cranston Anderson,
Ahn, Cong, & Stanton-Hicks, 2005; Roykulcharoen &
Good, 2004; Seers, Crichto, Tutton, Smith, &
Saunders, 2008), but its use has not been reported in
patients who suffer from burn pain. Moreover, the
current state of pain management is not satisfactory to
nurses working in burn care, and research into pain
management is a high priority (De Jong & Gamel,
2006). This study was done to determine the effective-
ness of jaw relaxation technique on pain intensity of
burn dressing. Clarification of this issue is a necessary
prerequisite to make evidence-based decisions about
the possible use and effectiveness of jaw relaxation for
relief of dressing pain with adult patients with burns.
In fact, this study addressed this question: is jaw relaxa-
tion effective in the management of dressing pain in
adult patients with burns?
METHODS
Study Design
This study was an experimental randomized clinical
trial with a control group. Subjects were a convenience
sample of 100 burn-injured men and women treated at
Shahid Motahari Burn Center, affiliated with Iran Uni-
versity of Medical Sciences (IUMS). Random allocation
was achieved by the minimization method.
Minimization ensures balance between groups
for several patient factors at all stages of the trial
(Altman, 2013). Minimization controlled the groups
for gender, age, educational status, previous hospital-
ization 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. No significant differences were found be-
tween the study groups in the above-mentioned fac-
tors (Table 1). The sample size of 100 patients (50
in each group) was based on a ¼ 0.05, power 0.90.
Setting
Shahid Motahari Burn Center is one of the largest in the
country and provides complete care to burn victims of
all ages, whether their burns result from flames, scalds,
chemical, or electrical accidents. Although this center
is located in Tehran, patients treated at the center
come from all over the country for the specialized
burn care that no other area hospital can provide.
This burn center provides inpatient and outpatient
treatment for burn patients and offers different wards
and services that are needed for treating burn patients,
 Effectiveness of Jaw Relaxation 3

TABLE 1.
Characteristics of Participants in Experimental (n ¼ 50) and Control (n ¼ 50) Groups
Group Experimental Control

Variables n % n % p Value

Gender
Female 14 28 14 28 1
Male 36 72 36 72
Age
<20 3 6 4 8 .759
20-29 22 44 21 42
30-39 8 16 10 20
40-49 11 22 11 22
50-60 6 12 4 8
Educational status
Illiterate 4 8 5 10 .935
Elementary 4 8 6 12
High school 9 18 10 20
Diploma 23 46 20 40
University 10 20 9 18
Previous hospitalization due
to burn injury
Yes 3 6 2 4 1
No 47 94 48 96
Substance abuse
Yes 16 32 17 34 .832
No 34 68 33 66
Sleep disorder
Yes 34 68 35 70 .829
No 16 32 15 30
Presence of a family
member
Yes 12 24 11 22 .812
No 38 76 39 78
Previous use of
relaxation
Yes 1 2 0 0 1
No 49 98 50 100
Financial status
Good 4 8 5 10 1
Moderate 33 66 32 64
Bad 13 26 13 26
Receiving opioids
before dressing
Yes 5 10 7 14 .538
No 45 90 43 86
Total body surface area
9-15 9 18 10 20 .930
16-20 17 34 17 34
21-25 8 16 5 10
26-30 9 18 10 20
31-35 7 14 8 16
Burn category
Flame 39 78 43 86 .436
Scald 11 22 7 14
Marital status
Single 18 36 19 38 .838
Married 31 62 30 60
Dead spouse 0 0 1 2
Divorcee 1 2 0 0
(Continued )
4 Rafii, Mohammadi-Fakhar, and Jamshidi Orak

TABLE 1.
Continued
Group Experimental Control

Variables n % n % p Value

Ethnicity
Fars 20 40 20 40 .930
Kurd 2 4 5 10
Lur 5 10 5 10
Turk 17 34 15 30
Gilak 2 4 2 4
Balouch 4 8 3 6

including an emergency ward, adult wards (one female Instrumentation

and two male), a pediatric ward, an intensive care unit,
operation rooms, outpatient clinics, and a physio-
therapy unit. Through center affiliation with IUMS,
this health-educational center offers training to future
health care professionals and provides an on-site facil-
ity for health research activities.
Subjects
All patients were fluent Persian speakers; their ages
ranged from 18 to 60 years. All sustained 9%-35% total
body surface area (TBSA) second and/or third degree
burns that were not self-inflicted. None of the patients
had a history of psychiatric illness. Patients did not un-
dergo any painful procedure or dressing change before
the study intervention. Dressings were changed as per
ward protocol. The inclusion criteria were (1) in acute
phase of burn injury; (2) thermal burns without face or
neck involvement; (3) no history of psychiatric disor-
ders; (4) absence of conditions which alter sensory
transmission; and (5) no severe visual and/or hearing
problems. Exclusion criteria included inability to do
any stage of the procedure and achieve mastery in jaw
relaxation technique; surgical interventions (e.g., skin
graft), and/or biological dressing on the burn wounds.
Ethical Considerations
After the approval of (IUMS) ethics committee, permis-
sion was granted from the manager of Shahid Motahari
Burn Center and its nursing administrator to conduct
the study. Written informed consent was obtained
from each participant. The trial is registered in the
Iranian Registry of Clinical Trials (The effect of jaw
relaxation on pain of burn dressing change in hospital-
ized patients of Shahid Motahari Clinical Educational
Center in 2009, n.d.).
Demographic Questionnaire. This questionnaire
collected basic demographic information about pa-
tients, including (1) gender, (2) age, (3) educational sta-
tus, (4) previous hospitalization due to burn injury, (5)
substance abuse, (6) sleep disorder, (7) presence of a
family member, (8) previous use of relaxation, (9)
financial status, (10) receiving opioids before dressing,
(11) total burned surface area, (12) burn category, (13)
marital status, and (14) ethnicity.
Visual Analog Scale. Pain intensity of burn dressing
was measured with the visual analog scale (VAS). This
scale consists of a 100-mm horizontal line representing
a continuum with the ends marked ‘‘not at all’’ and ‘‘the
worst imaginable way’’ (Hawker, Mian, Kendzerska, &
French, 2011). The subject was asked to mark the
line at a point corresponding to the pain intensity be-
ing experienced, and the distance was evaluated to
the nearest mm.
The VAS is one of the most widely used scales in
experimental and clinical pain research, and numerous
studies have demonstrated its validity and reliability
(Seers et al., 2008).
Data Collection Process
As mentioned earlier, minimization was used to randomly
assign participants either to the control group receiving
usual care or the experimental group (jaw relaxation).
Figure 1 shows the number of patients actually recruited
and their allocation to the two study groups.
Training Session
Data collection was completed at intervals of six
months. After random allocation, jaw relaxation was
taught to experimental group and written instruction
was provided. Jaw relaxation was practiced in a quiet,
nondistracting environment. Patients were asked to let
 Effectiveness of Jaw Relaxation
FIGURE 1. - Study flowchart. Recruitment and allocation to study groups.
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 to not even
think words (Good et al., 2005). The practice took 20
minutes and was repeated for the next two 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 (Good
et al., 2005). After two days, the patients practiced the
method once again with researcher guidance to
gain sufficient mastery. The patients were also asked
to continue jaw relaxation practice until the next
dressing.
Procedure
The day after completion of training, patients in the
experimental group practiced the jaw relaxation tech-
nique for 20 minutes. In this stage, patients who had
sufficient mastery of jaw relaxation went to dressing
room immediately or a few minutes later. Fifteen to
twenty minutes after the dressing change, when pa-
tients were resting comfortably in their bed, they
were asked to rate their pain intensity during the dres-
sing change on VAS. Because their burn injuries might
have inhibited simple motor movements, the scale
were read aloud and patients responded verbally to
it. Patients in the control group also completed VAS,
5
15 to 20 minutes after dressing change to rate dressing
pain intensity. During a final interview, those in the
experimental group were asked several structured
questions: (1) whether they used the assigned inter-
vention to relax, distract, or both; (2) the amount
the intervention helped their pain, rated as not at all,
a little, somewhat, or a lot; (3) whether the inter-
vention reduced sensation, distress, both, or none
(Good et al., 2005); and (4) the amount the jaw relax-
ation technique can reduce pain intensity, rated as
not at all, a little, somewhat, or a lot. It is worth
mentioning that to prevent diffusion of treatment,
those in different groups were not assigned to the
same room.
Data Analysis
All analyses were conducted by SPSS software, version
17. Differences in the baseline demographic character-
istics between the two groups were tested using inde-
pendent t test (for age), c2 test (for gender, marital
status, educational status, receiving opioids before
dressing, substance abuse, sleep disorder, presence
of a family member, burn category, and total burned
surface area), and Fisher’s exact test (for financial sta-
tus, previous hospitalization due to burn injury, previ-
ous use of relaxation, and ethnicity). Moreover,
independent t test was used to test the effect of the
jaw relaxation technique on pain intensity scores. Sta-
tistical significance was set at p < .05.
6 Rafii, Mohammadi-Fakhar, and Jamshidi Orak

RESULTS
Subject Characteristics
The final sample included 72 men and 28 women, with
an average TBSA of 22.27% (range, 9%-35%). Their
mean age was 32.95 (SD ¼ 11.33), ranging from 18
to 60 years. The primary ethnicity of the sample was
Fars (40%) and most were married (61%), had not
been hospitalized for burn injuries (95%), had
completed diploma (43%), had no substance abuse
problem (67%), were in moderate financial status
(65%), had sleep disorders (69%), had not received opi-
oids before dressing (88%), and did not have a family
member in the ward to help them as a caregiver
(77%). Flame and scald burn was observed in 82 and
18 cases, respectively. Except one patient, none of
them had used relaxation or similar techniques before
(Table 1).
Analyses of the Outcome Measures
Mean pain intensity score was 45.93 (SD ¼ 24.97) in
the experimental group and 48.05 (SD ¼ 25.61) in
the control group. Independent t test showed no sig-
nificant difference between mean pain intensity scores
in the experimental and the control group after dres-
sing (p ¼ .676).
Table 2 depicts the answers to structured questions
provided by the experimental group. Participants used
jaw relaxation in different ways: 42% reported that
they used it to relax, 10% to distract themselves from
the pain, and 48% for both. Most (66%) reported that
the intervention was helpful for pain somewhat. They re-
ported that the intervention reduced sensation (28%),
distress (16%), both sensation and distress (42%), and
none of them (14%). Moreover, 72% said the jaw relaxa-
tion technique can reduce pain intensity somewhat.
DISCUSSION
Data showed that participants of this study suffered
from a moderate level of pain intensity. Numerous in-
vestigators have documented that burn-injured pa-
tients often rate their pain intensity as moderate,
severe, or excruciating (Byers, Bridges, Kijek, &
LaBorde, 2001; Ferguson & Voll, 2004).
Pain is a significant feature of burn injury
(Hanafiah et al., 2008). Procedural pain is the most
intense and most likely type of burn injury pain to be
undertreated. Patients describe procedural pain as hav-
ing an intense burning and stinging quality that may
continue to a lesser degree but may be accompanied
by intermittent sharp pain for minutes to hours
after dressing changes have ended. Dressing changes
that require manipulation of already inflamed tissue
may contribute to increased pain and inflammation in
burn wounds. In addition, dependent positioning of
injured extremities (i.e., below the level of the heart)
can induce excruciating, throbbing pain, thought to
be caused by pressure associated with venous disten-
tion in inflamed, edematous tissue (Summer, Puntillo,
Miaskowski, Green, & Levine, 2007).

TABLE 2.
Experimental Group (N ¼ 50) Answers to the Structured Questions
Structured Questions Answers N %

Whether they used the assigned intervention to relax, distract, or both Relax 21 42
Distract 5 10
Both of them 24 48
Total 50 100
The amount the intervention helped their pain Not at all 2 4
A little 8 16
Somewhat 33 66
A lot 7 14
Total 50 100
Whether the intervention reduced sensation, distress, both, or none Sensation 14 28
Distress 8 16
Both of them 21 42
None of them 7 14
Total 50 100
The amount the jaw relaxation technique can reduce pain intensity Not at all 0 0
A little 3 6
Somewhat 36 72
A lot 11 22
Total 50 100
 Effectiveness of Jaw Relaxation
Although pain intensity of burn dressing was
less in the experimental group than the control
group; it was not statistically significant. This finding
is congruent with the findings of Good et al. (1999,
2002, & 2005) who measured the effect of jaw relaxa-
tion on anxiety and pain after abdominal, gynecologic,
and intestinal surgeries at rest and movement on the
first and second day after operation (Good et al.,
1999; Good et al., 2002; Good et al., 2005). It is also
in line with the study conducted by Seers et al.
(2008) that measured the effect of jaw and total
body relaxation for influencing postoperative pain,
anxiety, and level of relaxation after elective total hip
replacement or total knee replacement surgery. Yet
this finding is not congruent with the findings of
Roykulcharoen and Good (2004), which examined
the effects of systematic relaxation on the sensory
and affective components of pain.
According to the gate control theory, pain is not a
simple, sensory experience but a complex integration
of sensory, affective, and cognitive dimensions; both
physical and psychosocial factors will influence
it (Phipps, Monahan, Sands, Marek, & Neighbors,
2003). Thus, Melzack and Wall suggested that factors,
such as anxiety, knowledge and consciousness, previ-
ous pain experience, affect, motivation, cognitive ac-
tivities, individual expectations, and importance of
the situation that pain has occurred in, have enormous
influence on pain perception (Black & Hokanson
Hawks, 2008).
Burn patients experience different psychological
reactions during their hospitalization period that all
influence pain perception; for example, anxiety
(Jeschke, Kamolz, Sjoberg, & Wolf, 2012), depression
(Hanafiah et al., 2008), posttraumatic stress syndrome
(Wisely, Wilson, Duncan, & Tarrier, 2010), and fear of
the future (consists of clinical outcome such as survival
or improved health, complications or sequel of the
injury, coping with environmental factors, fear of the
unfamiliar stimuli encountered, stress related to the
injury and hospitalization, and outside stressors seem-
ingly unrelated to the actual illness) (Prensner et al.,
2001).
Moreover, consistent with this theory, previous
experience of burn patients with pain related to dres-
sing changes influences how patients react to a next
pain episode. Duration, frequency of repetition, diffi-
culties in the performance of the dressing change,
and previous experiences with dressing room staffs
will influence pain perception (De Jong, Middelkoop,
Faber, & Van Long, 2007). A patient who has had
repeated painful experiences may have developed suc-
cessful ways of coping. On the other hand, if frequent
painful procedures and attempts at coping have been
7
unsuccessful, the heightened fear and anxiety over
having to endure them again may elicit an entirely
different response (Timby & Smith, 2006).
Individual expectations also play an important
role in pain perception and effectiveness of therapeu-
tic interventions in reduction or optimal relief of pain
(Black & Hokanson Hawks, 2008). Optimistic expecta-
tions lead to positive results and pessimistic expecta-
tions lead to negative results. In the present study,
data showed that 66% of the experimental group re-
ported the intervention was somewhat helpful for
pain relief and 72% said the jaw relaxation technique
can reduce pain intensity somewhat. In fact, the exper-
imental group did not believe jaw relaxation could
decrease pain intensity, and this belief influenced the
results of the study.
In addition, jaw relaxation was not continued in
dressing rooms. Moreover, stimulation of irritated tis-
sues in dressing rooms leads to more pain and irritation
in burn wounds and increases pain intensity related to
dressing changes in burn injuries.
Based on the gate control theory, there is a gating
mechanism in the nervous system that acts as a calcu-
lator to sum information from the small fibers, the large
fibers, and the descending fibers. When the excitatory
input from the small fibers outnumbers input from the
inhibitory and descending fibers, the gate will be
opened and will allow information about pain to be
transmitted to the brain (Timby & Smith, 2006).
Thus, stimulation of irritated tissues during dressing,
psychological reactions of burn patients (such as anxi-
ety, pessimistic expectations toward jaw relaxation ef-
fects, previous experiences with dressing pain, and
other issues previously stated) led to stimulation of
small fibers more than large and descending fibers, so
the gating mechanism in the spinal cord was opened,
pain of burn dressing was transmitted to the brain,
and it was perceived.
Limitations
The differences between participants in terms of phys-
iological, emotional, psychosocial, and cognitive fac-
tors, the different attitudes of dressing room nurses
toward patients, and the resulting effect on the method
of dressing change and the resultant level of pain inten-
sity (Rafii, Oskouie, & Nikravesh, 2007) were beyond
the control in this study.
CONCLUSION
Controlling burn pain presents a challenge from initial
emergency room care through the rehabilitation phase
of care (Patterson, Hoflund, Espey, & Sharar, 2004).
Although burn injury pain was well-described as a
8 Rafii, Mohammadi-Fakhar, and Jamshidi Orak
major clinical problem more than two decades ago, re-
searchers continue to report that burn pain remains
undertreated (Summer et al., 2007). Despite many ef-
forts, jaw relaxation technique had no significant effect
on pain intensity of burn dressing and unrelieved mod-
erate to severe pain continued to be reported after
dressing changes.
Implications for Nursing
Although jaw relaxation had no significant effect
on pain intensity of burn dressing, it was an appro-
priate technique to reduce pain anxiety related
to dressing in patients with burns (Mohammadi
Fakhar, Rafii & Jamshidi Orak, 2013). Nonpharmaco-
logical interventions have different effects on multi-
ple components of pain, including pain sensation
(intensity) and psychological components (pain
anxiety), and it seems that management of proce-
dural pain intensity during dressing change in
patients with burns is a more complex and chal-
lenging issue, and cooperation of all multidisci-
plinary team members is necessary for relief of it.
Because most participants of the study had little in
the effectiveness of jaw relaxation for reduction of
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