Effects of various coping strategies (Lamaze vs. biofeedback vs. telling) on relaxation as measured by
EMG and finger-tip temperature in nine primiparas
by Margo Marie Caldwell
A thesis submitted in partial fulfillment of the requirement for the degree of MASTER OF NURSING
Montana State University
© Copyright by Margo Marie Caldwell (1979)
Abstract:
The purpose of this study was to determine the effect of various coping strategies for pain
(Biofeedback, Lamaze, and Telling) on relaxation as measured by EMG or finger-tip temperature in
primiparas.
The sample was obtained from a population of volunteers taking either Lamaze Childbirth Education
Classes or Prenatal Education Classes during pregnancy in 1978. The sample consisted of 9 primiparas
ranging from 18 to 38 years of age. The population was Caucasian, English-speaking and free of a past
history of traumatic pain and obstetric complications.
Rotters I-E Scale was administered to all subjects prior to experimentation. Difference scores were
obtained for EMG and fingertip temperature scores.
The data for EMG and finger-tip temperature were subjected to a simple analysis of variance, and
significance was determined at the .05 level. Data from EMG and finger-tip temperature were subjected
also to the Pearson product moment correlation coefficient to measure their relationship.
It was found that subjects using either Lamaze or Biofeedback achieved significantly lower EMG
readings. There was no significant correlation between finger-tip temperature and coping strategy.
The following recommendations were made: 1) Replication with an increased number of subjects.
2) Extension of the research to measurment of pain in the first stage of labor.
3) Extension of the research to explore other techniques said to "help relax" a person such as: yoga,
relaxation response, hypno- tism, and guided imagery. STATEMENT OF PERMISSION TO COPY
In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l l m e n t o f the
re qu ire m e nt s f o r an advanced degree a t Montana S t a t e U n i v e r s i t y ,
I a gr e e t h a t the L i b ra r y s h a l l make i t f r e e l y a v a i l a b l e f o r i n ­
spection.
I f u r t h e r agree t h a t pe rm is si on f o r e x t e n s i v e copying
o f t h i s t h e s i s f o r s c h o l a r l y . p u r p o s e s may be gra nte d by my major
p r o f e s s o r , o r , in h is a bs e nc e, by th e D i r e c t o r o f L i b r a r i e s .
It
i s understood t h a t any copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r
f i n a n c i a l gain s h a l l no t be. all ow ed w it h o u t my w r i t t e n permission
EFFECTS OF VARIOUS COPING STRATEGIES( LAMAZE VS. BIOFEEDBACK VS. TELLING)
ON RELAXATION AS MEASURED BY EMG AND
FINGER-TIP TEMPERATURE IN NINE PRIMIPARAS
by
MARGO MARIE CALDWELL
A t h e s i s su bmitted in p a r t i a l f u l f i l l m e n t
o f the requir em en t f o r th e degree
of
MASTER OF NURSING
Approved:
C ha ir pe r so n, Graduate Committee
— _____
Head, Major Department
Graduate Cftean
MONTANA STATE UNIVERSITY
Bozeman, Montana
J u l y 1979
• ?<
ill
ACKNOWLEDGEMENTS
The g r e a t e s t p o r t i o n of l e a r n i n g t h a t took p la c e from t h i s
r e s e a r c h occured d uri ng t h e i n t e r p e r s o n a l
(and r e s u l t i n g i n t r a p e r s o n a l )
communications with a l l th os e who provided a s s i s t a n c e throu ghout th e
two plu s y e a r s .
The w r i t e r wishes t o ex pre ss s i n c e r e a p p r e c i a t i o n to Dr. Anna
M. Shannon, Dean, School o f Nursing, and c h a i r p e r s o n o f th e examining
committee, f o r her p a t i e n c e , d i r e c t i o n , q u e s t i o n s , su p p o rt and concern
throug hout th e two y e a r s , as well as her s t e a d f a s t commitment to not
pr ov id i n g answers, r a t h e r , r e s o u r c e s and more q u e s t i o n s .
The w r i t e r wishes t o thank Dr. William Jankel f o r his a s s i s t ­
ance as committee member and as a l i a i s o n to the Biofeedback Lab orato ry ,
Department o f Psychology, Montana S t a t e U n i v e r s i t y .
Dr. Ruth Ludeman a l s o r e c e i v e s an e x pr e ss io n o f thanks and a p ­
p r e c i a t i o n from the w r i t e r f o r her a s s i s t a n c e as committee member, c r i ­
t i c a l a n a l y s t , as well as her r e p e a te d d i r e c t i o n to "w r i t e " .
The w r i t e r would l i k e to thank th e fol lo wi ng i n d i v i d u a l s and
the committees o r departments they r e p r e s e n t f o r t h e i r c o o p e r a t i o n :
Dr. George S h r o y e r , Committee on Use of Human S u b je c ts
in Experimental Research.
Dr. Robert Morasky, Head, Department of Psychology
Dr. Laura Walker, p a s t member gra d u a te committee
P r o f e s s o r Montana S t a t e U n i v e r s i t y ( r e t i r e d )
Mrs. Sue B arkle y, P r o f e s s o r , Montana S t a t e U n i v e r s i t y ,
School o f Nursing
A f i n a l thanks goes to the nine women who gave t h e i r conse nt to
become s u b j e c t s in t h i s r e s e a r c h .
TABLE OF CONTENTS
VITA . . ...................................................................................
ACKNOWLEDGEMENTS ...............................................................................
TABLE OF CONTENTS
. . . ...................... ....
LIST OF TABLES . . , . . . .. . . . . .
. . . . '. . : . .
ABSTRACT........................... ........................ ..............................
Chapter
1.
INTRODUCTION......................'
......................
Purpose o f St udy....................................... ' . .
Statement o f the Problem. . .■ .................
D e f i n i t i o n s ................................................ .... .
O b j e c t i v e s . ..........................................................
Hypotheses........................................................ ....
Assumptions . . ............................... ....
2.
REVIEW OF LITERATURE...................• . . . .
Pain T h e o r i e s ...................... ..............................
The Gate-Control Theory Im p l i c a t i o n s f o r
Nursing P r a c t i c e . . . . . .
......................
Independent V a r i a b l e .......................... .... . .
Dependent V a r i a b l e ............................................
I n t e r v e n i n g V a r i a b l e ........................ .. . . .
Summary . ................................... • ......................
3.
RESEARCH DESIGN AND' METHODOLOGY . .
. Sample. . . . . . . . . . . . ...................
Design. . . ............................... ....
Measurement . ............................................
Experimental Procedure. . . . . . . . .
4.
.
ANALYSIS OF THE DATA. . . . . . .
Nature o f th e Sample.......................................
V
5.
.
.
.
CONCLUSIONS, DISCUSSION, RECOMMENDATIONS
AND IMPLICATIONS.
............. , .............................35
Conclusion. . . . ....................................
Discu ssion and Recommendation .
33
36
BIBLIOGRAPHY ...........................................
APPENDIX . . . . . . . . . . . . . ...............................
43
C t CQ O
Q
LU U -
.
46
L i s t o f Texts Reviewed., . . . . . . . . . . . .
P a t i e n t Consent Form. ......................................... . . .
In t e r v i e w Q u e s ti o n n a ir e ..........................
I n s t r u c t i o n s f o r the I-E S c a le . ...............................
I-E Sca le . . . ................................... ....
Biofeedback T r a i n i n g . . . . . . . . .
. . .. . ..
46
48
49
50
51
56
vi
LIST OF TABLES
Table
Page
1.
Demographic C h a r a c t e r i s t i c s o f t h e Sample. . .................. 30
2.
Summary Data For Analysis, o f Variance o f EMG
Readings . . . . . . . . .
..........................................................
3.
31
Summary Data For Anal ysi s o f Variance o f F in g e rTip Te mpe rature...................................................................................... 33
v ii
ABSTRACT
The purpose o f t h i s stu dy was to determine t h e e f f e c t o f
v a r io u s coping s t r a t e g i e s f o r pain (Biofeedback, Lamaze, and T e l ­
l i n g ) on r e l a x a t i o n as measured by EMG o r f i n g e r - t i p te m pe ratu re
in p r i m i p a r a s .
The sample was obt a in e d from a p o p u la tio n o f v o l u n t e e r s
t a k i n g e i t h e r Lamaze C h i l d b i r t h Education Cl ass es or P r e n a ta l Ed­
u c at io n C la sse s d uri ng pregnancy in 1973. The sample c o n s i s t e d of
9 p ri m ip a r a s ranging from 18 to 33 y e a r s o f age. The po pula tio n
was Cau casian, E n g l is h - sp e a k i n g and f r e e . o f a p a s t h i s t o r y o f t r a u ­
matic pain and o b s t e t r i c c o m p l i c a t i o n s .
R o t t e r s I-E Sca le was a d m in is te r e d to a l l s u b j e c t s p r i o r to
e x p e r im e n t a ti o n . D if f e r e n c e s c o r e s were ob ta in e d f o r EMG and f i n g e r ­
t i p te m pe ratu re s c o r e s .
The d a ta f o r EMG and f i n g e r - t i p tem pe rat ure were s u b j e c t e d to
a simple a n a l y s i s o f v a r i a n c e , and s i g n i f i c a n c e was determined a t the
.05 l e v e l . Data from EMG 'and f i n g e r - t i p tem pe rat ure were s u b je c te d
a l s o . t o t h e Pearson pro duct moment c o r r e l a t i o n c o e f f i c i e n t to measure
th eir relationship.
I t was found t h a t s u b j e c t s usi ng e i t h e r Lamaze o r Biofeedback
achieved s i g n i f i c a n t l y lower EMG r e a d i n g s . There was no s i g n i f i c a n t
c o r r e l a t i o n between f i n g e r - t i p te m pe ratu re and coping s t r a t e g y .
The fo ll o w i n g recommendations were made: I ) R e p l i c a t i o n with
an in c r e a s e d number of s u b j e c t s .
2) Extension o f th e r e s e a r c h to measurment o f pain in the
f i r s t stage of labor.
3) Extension o f th e r e s e a r c h to ex p lo re o t h e r t e c h n i q u e s said
to "help r e l a x " a person such a s : yoga, r e l a x a t i o n r e s p o n s e , hypno­
t i s m , and guided imagery.
C hap ter I
INTRODUCTION
A d e s c r i p t i o n o f th e r e l a t i o n s h i p between the amount o f r e ­
l a x a t i o n and th e s t r a t e g i e s o f Lamaze., b io fe e dbac k, and i n s t r u c t i o n ,
or t e l l i n g , was t h e problem s e l e c t e d f o r st udy .
The de sign t e s t e d
th e p o s s i b i l i t y t h a t when a woman i s i n s t r u c t e d in a method of r e ­
l a x a t i o n , she can r e l a x more e f f e c t i v e l y than when j u s t t o l d to r e ­
la x .
Pain i s a u n i v e r s a l phenomena t h a t has e x i s t e d s i n c e rec ord ^
ed time.
The management o f pain s t i l l poses one o f the most c h a l l e n ­
ging problems in n u rs in g ( F i e l d , 1974).
The r e l a t i o n s h i p between
pain p e r c e p t i o n and t h e i n d i v i d u a l ' s s t a t e o f r e l a x a t i o n a r e co nce pt­
u a l i z e d w it h in th e g a t e - c o n t r o l t h e o r y o f pai n.
I t can be hypothe­
s iz e d w it h in t h i s framework t h a t i f a person can r e l a x , h i s p e r c e p t ­
ion o f pain w il l be dim in is he d.
This c o n s t r u c t has th e p o t e n t i a l f o r
an impact on n u r s i n g , f o r nur se s a r e involved with pain management
with c l i e n t s of a l l a ges .
Nurses, f u n c t i o n i n g w ith in t h e framework
o f th e n u r s e - p a t i e n t r e l a t i o n s h i p , a r e in a prime p o s i t i o n to help
the person r e l a x .
The f i r s t s te p toward st udy ing r e l a x a t i o n and pain
r e l i e f i s to look a t a group o f people with the p o t e n t i a l o f ex per­
ie n c i n g p a i n , and the methods used t o reduce pai n.
One such group i s comprised o f pregnant women.
The pain of
c h i l d b i r t h i s so i n t e g r a t e d i n t o our c u l t u r e t h a t th e c o n t r a c t i o n s of
labor are called labor pains.
Pregnant women a l s o c o n s t i t u t e a group
in which r e l a x a t i o n as a pain r e l i e f measure has been e xplo re d.
2
In 1953 G ra n tl y Dick-Read f i r s t i d e n t i f i e d the f e a r - p a i n
t e n s i o n syndrome in pre gna nt women (Gregg, F r a z i e r , N e s b i t t , 1975).
The Lamaze method o f ps ych oprophylaxis u t i l i z e s r e l a x a t i o n te chn iq ues
such as b r e a t h i n g and a focal p o i n t to te ac h the women a s t r a t e g y to
help them r e l a x .
P a r t i c i p a n t s in Lamaze through t h e i r s u b j e c t i v e r e ­
sponse s t a t e d t h a t they f e l t r e l a x e d and t h a t they had some c o n t r o l .
The c l a s s i c te ch niq ue f o r r e l a x a t i o n ( psychoprophala x i s ) when examined
shows t h a t t h e woman has no e x t e r n a l measure to show her t h a t she has
succeeded in her e f f o r t s in r e l a x a t i o n .
Biofeedback i s one way in
which th e woman would know t h a t she has r e l a x e d .
"Bio comes from b i o ­
logy and makes r e f e r e n c e t o t h e n e u ro -p s y c h o - p h y s io l o g ic a l process of
the body." (Gregg, F r a z i e r , N e s b i t t , 1975, p . 3).
Feedback was f i r s t
coined by Norbert Weiner t h e mathematician who de fi n e d feedback as
"a method o f c o n t r o l l i n g a system by r e i n s e r t i n g i n t o i t t h e r e s u l t s
of i t s past performance."
(Gregg, F r a z i e r , N e s b i t t , 1975, p. 3).
A review o f th e n u rs in g t e x t s (see Appendix A) shows t h a t the
n u r s e ’s main r e s p o n s i b i l i t y was i n i t i a l l y th e a d m i n i s t r a t i o n of phar­
macological a g en ts and to "comfort" t h e p a t i e n t .
With th e in c l u s i o n
of th e g a t e - c o n t r o l th e o r y o f pain i n t o t h e nurs ing t e x t s we see more
o f an emphasis on "encouraging" t h e p a t i e n t to r e l a x .
None o f the
t e x t s reviewed give s a s p e c i f i c methodology f o r encouraging the p a t i e n t
to r e l a x .
A review o f th e l i t e r a t u r e on pain r e l i e f , s p e c i f i c a l l y f o r
noninyasive methods, r e v e a l e d two in which nurs in g i s invo lve d.
methods a r e biofeedback and Lamaze c h i l d b i r t h e d u c a ti o n .
These
3
I t i s c r u c i a l to look a t e x i s t i n g methods o f pain management
w it h in th e g a t e - c o n t r o l th e o ry o f pa in .
I t can be c o n c e p tu a li z e d
w it h in t h i s framework t h a t to help a person cope with pain i t is
n e c e s s a r y to provid e t h e person with a s t r a t e g y which r e s u l t s in
muscle r e l a x a t i o n and m e n t a l - r e l a x a t i o n or de creased a n x i e t y .
The persons s e l e c t e d f o r study in th e r e s e a r c h were p r e g ­
nant women because o f t h e la c k o f i l l n e s s a s s o c i a t e d with pain in
t h i s case (Fagerhaugh and S t r a u s s , 1977).
This la ck o f i l l n e s s and
th e r e q u i r e d b a s ic p r e n a t a l i n s t r u c t i o n served to reduce f e a r in t h i s
group.
This reduced f e a r i s a c r u c i a l v a r i a b l e because i t has been
hypothesized t h a t f e a r a n d / o r a n x i e t y s erve to i n c r e a s e pain pe rc ep ­
t i o n (Melzack, 1970).
Pregnant women a l s o provide a n a t u r a l popula­
t i o n where two methods o f t e a c h in g r e l a x a t i o n - biofeedback and Lamaze were a l r e a d y being t r i e d (C a ld w el l, 1977; Gregg, F r a z i e r , N e s b i t t , 1975).
The i d e n t i f i c a t i o n o f th e s t r a t e g i e s f o r i n s t r u c t i o n and u t i l ­
i z a t i o n o f r e l a x a t i o n te c h n i q u e s f o r t h e co n tr o l of pain pro vides a
more c o n s i s t e n t p a t i e n t response than " t e l l i n g " a lo ne.
The c h i l d b i r t h
regimen in c lu d e s a v e r y c l o s e n u r s e - p a t i e n t r e l a t i o n s h i p which lends
i t s e l f to the Lamaze a n d / o r biofeedback i n s t r u c t i o n .
These methods
have i m p l i c a t i o n s f o r p o t e n t i a l i n t e r v e n t i o n by the p r o f e s s i o n a l nurse
who has t h e d a i l y r e s p o n s i b i l i t y o f comforting the p a t i e n t in pain.
4
PURPOSE OF THE STUDY
This stu dy d e s c r i b e d the r e l a t i o n s h i p between th e amount of
r e l a x a t i o n and the s t r a t e g i e s used by pregnant women to help them cope
with th e pain o f c h i l d b i r t h .
Since th e a b i l i t y to u t i l i z e a s t r a t e g y ,
or e x e r c i s e c o n t r o l over o n e ' s body, may be r e l a t e d to t h e i n d i v i d u a l ' s
locus o f c o n t r o l , t h i s v a r i a b l e was c onsi de re d in r e l a t i o n to r e l a x a ­
t i o n (Johnson and Meyer, 1974).
I t was th e i n t e n t o f t h i s r e s e a r c h e r
to hold o t h e r f a c t o r s known to e f f e c t th e p e rc e p ti o n o f p a i n , such a s ,
p a s t pain e x p e r i e n c e , o b s t e t r i c h i s t o r y , and p r e n a ta l e d u c a t i o n , c o n s t a n t ,
to i s o l a t e t h e v a r i a b l e , r e l a x a t i o n te ch n i q u e.
STATEMENT OF THE PROBLEM
The purpose o f th e study was t o d e s c r i b e the r e l a t i o n s h i p of
va ri ous coping s t r a t e g i e s ( Lamaze vs. Biofeedback vs. T e l l i n g ) to
amount o f r e l a x a t i o n in a sample o f 9 pri m ip ar a women v o l u n t e e r s
(ages 18-38 y e a r s ) who were p a r t i c i p a n t s in e i t h e r Lamaze Ch ildbirth.
Education Classes or P r e n a ta l Education C l a s s e s , and to d e s c r i b e the
r e l a t i o n s h i p between t h e s u b j e c t ' s locus o f co ntro l and r e l a x a t i o n .
The methods used to measure r e l a x a t i o n were f i n g e r - t i p temper­
a t u r e to measure mental r e l a x a t i o n and elec tro m yographic a c t i v i t y to
measure m u s c l e - r e l a x a t i o n .
The method used to measure lo cu s o f con­
t r o l was t h e R o t t e r I n t e r n a l - E x t e r n a l Sc al e.
5
DEFINITIONS
Coping S t r a t e g i e s
Methods used by o r with a pregna nt woman to i n c r e a s e her
relaxation.
Lamaze o r Coping S t r a t e g y I (CSl)
The use of le a r n e d b r e a t h i n g p a t t e r n s and a v i s u a l focal
p o i n t to r e l a x .
Biofeedback or Coping S t r a t e g y 2 (CS2)
The use o f le a r n e d c o n tr o l o f muscle a c t i v i t y t o r e l a x .
T e l l i n g or Coping S t r a t e g y 3 (CS3)
The use of verbal i n s t r u c t i o n as a method o f hel p in g to
relax.
Rel axa tio n
A m a n i f e s t a t i o n o f the psyche and th e soma which can be
d e s c r i b e d by p h y s i o l o g i c a l measures.
Mental Relax at ion
Manifested as he a t on the body s u r f a c e and measured as
f i n g e r - t i p te m p e ra t u re .
Muscle Relax at ion
Manifested as e l e c t r i c a l a c t i v i t y in th e s k e l e t a l muscles
and measured as elec tro m yog raph ic a c t i v i t y .
6
Locus o f Control
"The degree to which the i n d i v i d u a l p e r c e iv e s t h a t the reward
follows from or i s c o n t i n g e n t upon, h i s own behavior o r a t t r i b u t e s
versus t h e degree to which he f e e l s th e reward i s c o n t r o l l e d by f o r c e s
o u t s i d e him se lf" ( R o t t e r , P h a r e s , and Chance, 1972, p. 243).
OBJECTIVES
The o b j e c t i v e s o f th e r e s e a r c h e r were as fo l l o w s :
I)
To e v a l ­
u a te th e t h r e e coping s t r a t e g i e s f o r th e amount o f r e l a x a t i o n provided
as measured by f i n g e r t i p te m pe ratu re re a d in g s and EMG r e a d i n g s .
2)
t o d e s c r i b e th e r e l a t i o n s h i p of r e l a x a t i o n re a din gs o f women
v o l u n t e e r s to t h e i r lo c u s o f c o n tr o l s co r es as measured by th e R o t t e r
I-E S c a le .
HYPOTHESES
Hq = There w i l l be no s i g n i f i c a n t d i f f e r e n c e in EMG reading
among s u b j e c t s who use th e coping s t r a t e g i e s o f Lamaze o r Biofeedback
as compared to th o s e who use th e coping s t r a t e g y , t e l l i n g .
H^ = There w i l l s i g n i f i c a n t l y lower EMG re a d in g s among s u b j e c t s
who use t h e coping s t r a t e g i e s o f Lamaze or Biofeedback as compared to
th os e who use th e coping s t r a t e g y , t e l l i n g .
7
Hq = There w i l l be no s i g n i f i c a n t d i f f e r e n c e in f i n g e r - t i p
te m pe ratu re re a d in g s among s u b j e c t s who use coping s t r a t e g i e s of
Lamaze o r Biofeedback as compared to t h o s e who use th e s t r a t e g y ,
tel ling.
Hj, = There w i l l be s i g n i f i c a n t l y hig he r f i n g e r - t i p temper­
a t u r e re a d in g s among s u b j e c t s who use t h e coping s t r a t e g i e s o f Lamaze
o r Biofeedback as compared to th o s e who use th e s t r a t e g y , t e l l i n g .
Hq = There w il l be no r e l a t i o n s h i p between EMG s c o r e s and
s c o r e s on th e R o t t e r I-E Scal e.
H^ = There w i l l be a p o s i t i v e c o r r e l a t i o n between EMG scores
and s co r es on t h e R o t t e r I-E Scal e.
Hq = There w i l l be no c o r r e l a t i o n between EMG sc or es and f i n g e r ­
t i p te m p e ra t u re s c o r e s .
H^ = There w i l l be a n e g a t i v e c o r r e l a t i o n between EMG scor es and
f i n g e r - t i p te m pe ratu re s c o r e s .
ASSUMPTIONS
The r e s e a r c h e r i d e n t i f i e d t h e fo ll o w i n g assumptions as ba si c to
t h i s stu dy:
1)
T r a n s f e r o f l e a r n i n g occurs in a l l t h r e e coping s t r a t e g i e s .
2)
R el ax at io n can be r e i n f o r c e d and r e t a i n e d .
3)
Al I p a r t i c i p a n t s w i l l be o f equal m o ti v a ti o n and c a p a b i l i t y
to r e l a x .
4)
All women e x p e r ie n c e pain in c h i l d b i r t h and want to reduce
t h e i r p e r c e p t i o n o f t h a t pain.
C h ap ter 2
REVIEW OF LITERATURE
The c o n c e p t u a l i z a t i o n which suggested the problem f o r study
came from a h i s t o r i c a l review o f pain t h e o r i e s i n c lu d in g th e g a t e c o n tr o l th e o r y o f p a in .
This review re v e a le d i m p l i c a t i o n s f o r the
nu rs in g management o f pain and the need f o r e x p l o r a t i o n o f pain manage­
ment.
This review c o n s t i t u t e s th e f i r s t s e c t i o n o f t h i s c h a p t e r .
The second major s e c t i o n c o n t a i n s a review o f s e l e c t e d l i t e r ­
a t u r e p e r t i n e n t to t h e c hoice o f th e dependent and independent v a r i a b l e s .
The t h i r d s e c t i o n d i s c u s s e s t h e in te rv e n in g , v a r i a b l e s t h a t the
l i t e r a t u r e s u g g e s te d , and th e r e s u l t a n t de sign c o n s i d e r a t i o n .
PAIN THEORIES
Pain t h e o r i e s , u n t i l r e c e n t l y , b u i l t upon each o t h e r , the next
always seeking to e x p l a i n th e c l i n i c a l evidence i n e x p l i c a b l e with the
then p r e s e n t t h e o ry .
The t r a d i t i o n a l t h e o r i e s have been s p e c i f i c i t y t h e o r i e s .
Spe­
c i f i c i t y t h e o r y i s d e s c r i b e d in v i r t u a l l y every textb ook on neurophys­
i o l o g y , neu ro lo gy , and n e u r o s u r g e r y , and was so deeply entren che d in
medical school te a c h in g ( u n t i l r e c e n t l y ) t h a t i t was o f t e n ta u g h t as
f a c t r a t h e r than t h e o r y (Melzack, 1973).
Nursing h i s t o r i c a l l y u t i l i z e d
th e medical model and a l s o f e l l prey to t h i s t h e o r y - a s - f a c t assumption
(Appendix A).
9
S p e c i f i c i t y t h e o ry proposes t h a t a s p e c i f i c pain system c a r r i e s
messages from pain r e c e p t o r s in th e skin to a pain c e n t e r in the b r a i n .
Muller in 1842 was th e f i r s t to s t a t e t h i s in s c i e n t i f i c form, and his
s ta t e m e n t has become known as the d o c t r i n e o f s p e c i f i c nerve e n e r g ie s
(Melzack, 1961).
G old sch ei de r (1894) b u i l t upon former pain the ory
with e m p ir ic a l evidence from persons with ta bes d o r s a l i s .
Tabes d o r ­
s a l i s occurs in p a t i e n t s s u f f e r i n g th e l a t e s t a g e s o f s y p h i l i s and is
c h a r a c t e r i z e d by a delayed r e a c t i o n to a pain s t i m u l u s .
The delayed
r e a c t i o n le d G ol dsch ei der to t h e c oncl us io n t h a t mechanisms of summa­
t i o n o f pain s t i m u l i were e s s e n t i a l f o r u nde rs ta ndin g th e mechanisms
o f p a in .
G o l d s c h e i d e r 1s p a t t e r n , o r summation t h e o r y , proposes t h a t
p a r t i c u l a r p a t t e r n s o f nerve impulses t h a t evoke pain a r e produced by
th e summation o f the skin sens ory in p u t a t the dors al horn c e l l s '(Mel­
zack , 1973).
Several t h e o r i e s have emerged from G o l d s c h e i d e r 1s th e o ry .
The
s i m p l e s t form o f p a t t e r n th e o r y d e a l s p r i m a r i l y with p e r i p h e r a l r a t h e r .
than c e n t r a l p a t t e r n i n g ( Buytendij k , 1962).
That i s , pain i s co nsid ered
to be due to e x c e s s i v e p e r i p h e r a l s t i m u l a t i o n t h a t produces a p a t t e r n o f
nerve impulses which i s i n t e r p r e t e d c e n t r a l l y as pa in .
poses t h a t a l l f i b e r s a r e a l i k e ( Buytendij k , 1962).
The the ory p r o ­
The p h y s io lo g ic a l
e v id e n c e , however, r e v e a l s a high degree o f r e c e p t o r f i b e r s p e c i a l i z a ­
t i o n (Melzack, 1973).
10
Central summation th e o r y a l s o emerged from G o l d s c h e i d e r 's
th e o r y .
As the o b s e r v a t i o n s from ta b e s d o r s a l i s lead from s p e c i f i ­
c i t y th e o r y to p a t t e r n t h e o r y , so the a n a l y s i s o f phantom limb p a i n ,
c a u s a l g i a , and n e u r a l g i a s i n d i c a t e t h a t p a r t , a t l e a s t , o f t h e i r under­
ly i n g mechanisms must inv olv e th e c e n t r a l summation th e o r y (Melzack,
1973).
L iv in gs to n (1953) proposed t h a t p a t h o l o g i c a l s t i m u l a t i o n o f
sensory nerves (such as occurs in p e r i p h e r a l nerve damage) i n i t i a t e s
a c t i v i t y in r e v e r b e r a t i n g c i r c u i t s in neuron pools in t h e sp in al cord.
This abnormal a c t i v i t y can be t r i g g e r e d by normally non-noxious i n ­
put s and g e n e r a t e v o l l e y s o f nerve impulses t h a t a r e i n t e r p r e t e d cen­
t r a l l y as pain ( L i v i n g s t o n , 1953).
Although L i v i n g s t o n ' s concept and
s i m i l a r c e n t r a l summation concepts have c o n s i d e r a b l e power, in e x p l a i n ­
ing phantom limb p a i n , they f a i l to account f o r the f a c t t h a t s u r g i c a l
l e s i o n s o f th e s pin al cord o f t e n do not a b o l i s h pain (Melzack and Casey,
1968).
The n e u r o s u r i g a l (cordotomy and rhizotomy) ev idence p o i n t s to
mechanisms in t h e b r a i n .
A r e l a t e d t h e o r y , th e s en so ry i n t e r a c t i o n t h e o r y , s t a t e s t h a t a
s p e c i a l i z e d in p u t c o n t r o l l i n g system normally p re ve nts summation from
occuring and t h a t d e s t r u c t i o n o f t h i s system le ads to p a th o l o g i c a l pain
s t a t e s (Melzack, 1973).
Noordenbo' s th e o r y r e p r e s e n t s an e s p e c i a l l y im­
p o r t a n t c o n t r i b u t i o n to s e n s o r y - i n t e r a c t i o n co nce pts .
He conceived th e
small nerve f i b e r s as c a r r y i n g impulse p a t t e r n s t h a t produce pain while
the l a r g e f i b e r s i n h i b i t t r a n s m i s s i o n .
He a l s o c o n c e p tu a li z e d the
11
the ide a o f a m u l t i - s y n a p t i c a f f e r e n t system in th e s p in a l cord.
This
i s in c o n t r a s t to the idea o f a s t r a i g h t - t h r o u g h system implied in the
s p e c ific ity theories.
The t h e o ry ( s p e c i f i c i t y or p a t t e r n ) t h a t pain i s a sens ory mod­
a l i t y is r e l a t i v e l y recent.
The a f f e c t th e o ry of pain i s much o l d e r
d a t i n g back t o A r i s t o t l e , who c onsi de re d pain to be an emotion - the
opposite of pleasure.
o f Go ld sch e id e r.
Marshall took an extreme view o f pain a t th e time
He admitte d the e x i s t e n c e i f a p r i c k i n g - c u t t i n g sense
but th oug ht t h a t pain was d i s t i n c t l y d i f f e r e n t .
According to Marshall
a l l sens ory i n p u t s , as well as t h o u g h t s , could have a p a in fu l dimension
to them, and he t a l k e d o f th e pain o f bereavement, and t h e pain of I i s t e n i n g to badly played music (Melzack, 1973).
,
His extreme view was open
to c r i t i c i s m and led to f u r t h e r a f f e c t t h e o r i e s .
Sh e rr in g to n (1900) and
T i t c h n e r (1909) s t a r t e d looking f u r t h e r i n t o the r o l e o f a f f e c t i v e and
m o ti v a ti o n a l p r o c e s s e s in pain (Melzack, 1973).
Sweet summed up th e s t a t e
o f pain th e o r y in 1959, uThe assumption t h a t pain i s a primary s e n s a t i o n
has r e l e g a t e d m o t i v a t i o n a l and c o g n i t i v e p ro c e ss es to t h e r o l e o f r e a c ­
t i o n s to pain and has made them only secondary c o n s i d e r a t i o n s in th e whole
pain p ro ce ss" ( S t e r n b a c h , 1968)..
When one c o n s i d e r s the t h e o r i e s examined so f a r t h e s p e c i f i c mod­
a l i t y and p a t t e r n concepts o f pain both c onta in v a l u a b l e concepts t h a t
supplement each o t h e r .
either.
The a f f e c t i v e q u a l i t y o f pain cannot be ignored
Melzack and Wall (1973) in a n a ly z in g th e s t r e n g t h s and weaknesses
12
o f t h e pre vi ou s t h e o r i e s o f pain l i s t e d f o u r th i n g s any new th e o ry o f
pain must account f o r :
1)
The high degree of p h y s i o l o g i c a l s p e c i a l i z a t i o n o f r e c e p t ­
o r f i b e r u n i t s and o f pathways in th e c e n t r a l nervous system.
2)
The r o l e o f temporal and s p a t i a l p a t t e r n i n g in the t r a n s ­
m is si on o f in f or m at io n in th e nervous system.
3)
The i n f l u e n c e of ps ych olo gic a l p ro c e ss e s on pain p e rc ep ­
t i o n and re s pons e .
4)
The c l i n i c a l phenomena o f s p a t i a l and temporal summation.
Melzack and Wall (.1965) went f u r t h e r , proposing th e g a t e - c o n t r o l
th e o ry which attem pte d to i n t e g r a t e t h e s e re qu ire me nts i n t o a comprehen­
s iv e th e o r y o f p a in .
B a s i c a l l y , th e th e o r y proposes t h a t a neural mech­
anism in th e dors al horns o f th e s p in a l cord a c t s l i k e a g a te which can
i n c r e a s e or d e c r e a s e t h e flow o f nerve impulses from p e r i p h e r a l f i b e r s
to th e c e n t r a l nervous system.
Somatic i n p u t i s t h e r e f o r e s u b je c te d to
the modulating i n f l u e n c e o f th e g a t e b e fo re i t evokes pain pe rc ep ti o n
and re s p o n se .
The degree to which th e g a t e i n c r e a s e s o r d e cr eases
sens ory t r a n s m i s s i o n i s determined by th e r e l a t i v e a c t i v i t y in l a r g e
d ia m e te r (A-beta) and small d ia m e te r (A -d e lt a and C) f i b e r s and by d e ­
scending i n f l u e n c e s from the bra in (Melzack, 1973).
The g a t e - c o n t r o l
th e o ry has im po rt an t i m p l i c a t i o n s f o r t h e tr e a t m e n t o f p a in .
vi de s a conceptual approach to pain management.
I t pro­
13
Melzack (1973) s ugge s ts t h a t th e g a t e - c o n t r o l th e o r y r e q u i r e s
a look a t our o l d e r methods o f t r e a t m e n t (such as s u c c e s s i v e a n e s t h e t i c
blocks and t h e use o f c o u n t e r i r r i t a t i o n ) and a se a rc h f o r tec hn iq ues
to modulate s en so ry i n p u t .
Because s p e c i f i c i t y th e o r y has dominated
th e f i e l d o f pain th e outcome has.been th e development o f te chn iq ues
aimed a t c u t t i n g th e s o - c a l l e d pain pathway.
The g a t e - c o n t r o l th e o ry
lends credence to th e e x p l o r a t i o n o f pain r e l i e f thro ugh:
th e pharma­
c o l o g i c a l c o n t r o l o f pain on 3 l e v e l s , t h e r e c e p t o r l e v e l , th e dorsal
horn and o t h e r hig he r l e v e l s such as th e b r a i n ; the s en so ry co ntro l o f
pain by modulation o f i n p u t ; and t h e psy ch olo gic a l c o n t r o l of p a i n ,
through m a n ip u la ti o n o f a n x i e t y , a t t e n t i o n , and s u g g e s t i o n .
THE GATE-CONTROL THEORY:
IMPLICATIONS FOR NURSING PRACTICE
When pain t h e o r y moved from s p e c i f i c i t y t h e o r i e s , with t h e i r
concomitant t h e r a p i e s , to the g a t e - c o n t r o l t h e o r y , th e door was opened
to th e e x p l o r a t i o n o f new methods o f pain r e l i e f .
The g a t e - c o n t r o l
th e o ry holds much promise f o r t h e e x p l o r a t i o n and e x p l a n a t i o n of nonin v a s i v e nur s in g measures to r e l i e v e p a in .
When pain i s c o n c e p tu a li z e d
as I . p e r c e p t i o n and resp onse r e s u l t i n g from a s tim ulu s which causes the
ne t o u tp u t to exceed a c r i t i c a l l e v e l , and 2. the o u t p u t i s mediated by
a g a te i n g system which i s a f f e c t e d by th e i n d i v i d u a l ' s p r e s e n t and p a s t
e x p e r i e n c e s , the psy ch olo gi ca l component o f pain cannot be ignored.
Within t h i s c o n c e p t u a l i z a t i o n McCaffery (1972) l i s t s th e fo ll ow in g psyche
o l o g i c a l f a c t o r s as i n f l u e n c i n g a p e r s o n ' s pain s e n s a t i o n :
a. emotion­
14
a l l y t r a u m a t i c l i f e e x p e r i e n c e s , b) p a s t e xper ie nc e with p a i n , c) know­
l e d g e , und e rs ta n d in g and c o g n i t i v e l e v e l , d) sense o f p o w e rl e ss n es s ,
e) p r e s e n c e , a t t i t u d e s , and f e e l i n g s o f o t h e r s , and f ) pe rceiv ed t h r e a t
o f pain to l i f e s i t u a t i o n (McCaffery, 1972).
S i e g e l e (1974) s p e c u l a t e d about th e i m p l i c a t i o n s o f the g a t e co n tr o l t h e o r y to n u rs in g p r a c t i c e as f o ll o w s :
" C r e a t i v e approaches have been used in
c a r i n g f o r p a t i e n t s in pain using the g a t e c o n tr o l t h e o r y , e s p e c i a l l y to a l t e r c e r e b r a l
processes."
Siegele points out t h a t :
e s t a b l i s h i n g a t r u s t i n g r e l a t i o n s h i p , de cr ea se
ing a n x i e t y and muscle t e n s i o n , as well as p ro v id i n g t h e p a t i e n t s with
in f or m at io n e n a b li n g them to c o n t r o l t h e i r p a i n , appear to have a concep­
tu a l base w i t h i n Melzack and W a l l 's th e o r y .
A look a t th e f a c t o r s c o n c e p t u a l i z e d as a f f e c t i n g pain p e r c e p ti o n
p o i n t s th e way f o r t h e n u rs in g management o f pain.
Within t h i s framework
i t appears t h a t th e nurs e must a s s e s s a p a t i e n t ' s p a s t e x p e r ie n c e with
p a i n , with emotional trauma, and th e degre e o f t h r e a t t h e p a t i e n t p e r ­
c e iv e s t h i s pain to be to h i s / h e r l i f e .
A h i s t o r y o f n e g a t i v e pain ex­
p e r i e n c e s , a sense of pow e rl e s s n e s s , an emotional trauma an d /o r a high
degree of p e rc ei v e d t h r e a t , e x h i b i t themselves in in c r e a s e d a n x ie t y in
th e p a t i e n t (McCaffery, 1972).
An i n c r e a s e in a n x i e t y w it h in the g a t e -
c o n tr o l t h e o r y i s seen to i n c r e a s e pa in .
The a re as i d e n t i f i e d as i n ­
c r e a s i n g a n x i e t y and p o t e n t i a t i n g pain le ad to a r e a s o f i n t e r v e n t i o n f o r
th e nu rs e .
This c o n c e p t u a l i z a t i o n lends credence t o , one o f th e n u r s e ' s
15
major goals in pain management, t h a t i s , to i n t e r v e n e in a way to p r o ­
duce de cr ea se d t e n s i o n and a n x i e t y in t h e p a t i e n t .
Following t h i s p a t h , t h e next q u e st i o n the nurs e must answer
is:
what p s yc holo gi ca l approaches may be a b l e to produce some pain
r e l i e f through r e l a x a t i o n ?
Sternbach (1968) suggested t h a t some mea- .
s ure o f pain r e l i e f i s achieved through such te ch ni ques a s :
sugges­
t i o n , p r o g r e s s i v e r e l a x a t i o n , th e use o f st rateg em s to d i s t r a c t the
a t t e n t i o n o f th e p a t i e n t , giv in g meaning to the s i t u a t i o n to the
p a t i e n t , o r giv in g c o n t r o l over th e s i t u a t i o n to th e p a t i e n t .
The
mechanisms o f c o g n i t i v e c o n t r o l , phys ic a l and mental r e l a x a t i o n , and
d i s t r a c t i o n , mediate t h e pain s t i m u l i to reduce p e r c e p t i o n .
T h e o re t­
i c a l l y , th e a p p l i c a t i o n o f t h e s e te c h n i q u e s should d e c r e a s e p e rc e p ti o n
o f pain (S te r n b a c h , 1968).
INDEPENDENT VARIABLE
A searc h o f t h e l i t e r a t u r e was made f o r methods o f promoting
r e l a x a t i o n which u t i l i z e d one or more o f th e f a c t o r s d e s c r i b e d by
Sternbach as c o g n i t i v e f a c t o r s to reduce pai n.
Lamaze, or t h e ps y c h o p r o p h y la c ti c c h i l d b i r t h method, was i d e n ­
t i f i e d as one method which appeared to c o n ta i n c o g n i t i v e s tr a te ge m s .
Lamaze i s t a u g h t to pre gna nt women to help them " co nt ro l the pain of
c h i l d b i r t h " through use o f a v i s u a l focal p o i n t , a coach, and a le a r n e d
p attern of breathing.
Lamaze i s p r a c t i c e d to achieve r e l a x a t i o n and re
duce the pain o f l a b o r ( S i e g e l e , 1974, p. 500).
C o n s i s t a n t with the
16
g a t e - c o n t r o l t h e o r y i t appears t h a t th e fo c a l p o i n t could be a " d i s t r a c t o r " , th e coach a " r e i n f o r c e r " and a " p o s i t i v e p resen ce or a t t i ­
tude" (McCaffery, 1972) and the b r e a t h i n g p a t t e r n s could be a method
of reducing t e n s i o n through muscle r e l a x a t i o n .
A review o f th e l i t e r a t u r e on Lamaze and r e l a x a t i o n re v e a le d
one study which c o r r e l a t e d the use o f t h e te chn iq ue and r e s u l t a n t r e ­
laxation.
Klussmon (1975) measured f e a r and a n x i e t y in 42 p ri m ip ar as
be fo re and a f t e r c h i l d b i r t h e du ca tio n c l a s s e s .
Only t h e Lamaze method
o f c h i l d b i r t h e duc a tio n succeeded in red uc in g general a n x i e t y l e v e l ,
as measured by th e IPAT Anxiety Scale.
Benson (1972), F i e l d (1974), Dunn (.1976), and St e rn (1973) a c k ­
nowledge in t h e i r a r t i c l e s the r e l a t i o n s h i p of t e n s i o n to pain in c h i l d ­
birth.
Dunn (1976) speaks o f t h e p r o c e s s :
pain in l a b o r i s i n c re a s e d
by f e a r o f the unknown which m a n i f e s t s i t s e l f in l a c k o f c on fi d e n c e ,
l o n e l i n e s s , w a i t i n g f o r th e p a i n , and muscle t e n s i o n .
He sugg est s t h a t ,
in o r d e r to modify p a i n , t r e a t m e n t should be aimed a t d e c r e a s i n g muscle
t e n s i o n , i n c r e a s i n g c o n f id e n c e , i n c r e a s i n g knowledge, and prov idin g d i s ­
t r a c t i o n (Dunn, 1976).
A review of th e l i t e r a t u r e r e v e a l e d no s t u d i e s
e v a l u a t i n g t h e s e v a r i a b l e s in r e l a t i o n to pa in.
Biofeedback was a n o th e r method i d e n t i f i e d by t h e r e s e a r c h e r
as c o n t a i n i n g some o f t h e te ch ni ques Sternbach (1968) suggested as pro ­
vid in g a measure o f pain r e l i e f .
Biofeedback is d e fi n e d as prov idi ng a
person with immediate in fo rm at io n about h i s / h e r on-going p h y s i o l o g i c a l
17
p r o c e s s e s (Ryan, 1975).
The in f o r m a t i o n , o r feedback, i s provided to.
th e s u b j e c t by means o f a l i g h t or to ne .
This method appea rs to have
a focal p o i n t o r d i s t r a c t i o n , the l i g h t o r the tone.
Biofeedback a l s o
pr ov id e s the i n d i v i d u a l with in fo rm at io n or "gives meaning to th e s i t ­
u a ti o n " .. Biofeedback i s u t i l i z e d to produce r e l a x a t i o n by fee din g back
elec tro m yog raphi c a c t i v i t y a n d / o r skin s u r f a c e te m p e ra t u re as a measure
o f the degree o f r e l a x a t i o n ( H a u r i , 1975).
A review o f t h e l i t e r a t u r e
produced one study u t i l i z i n g biofeedback as a method, t o reduce t e n s i o n ,
and thus reduce p a i n , in l a b o r .
Gregg, F r a z i e r , and N e s b i t t (1975) had as s u b j e c t s women who had
taken Lamaze and i n s t r u c t e d them in t h e use of a home EMG feedback u n i t ,
th e women were to p r a c t i c e two hours a day.
The women in t h e i r study
used fewer a n a l g e s i c s , a n e s t h e t i c s , and had s h o r t e r l a b o r s .
They a ls o
had s u b j e c t i v e r e p o r t s o f p o s i t i v e b i r t h e x p e r i e n c e s .
A t h i r d "method" was implied in th e l i t e r a t u r e .
Benson (1972),
Stern (1973), F i e l d (1974) as well as a v a r i e t y o f n u rs in g t e x t s (Appen­
dix A) r e p e a t e d l y s u g g e s te d , "encouraging the p a t i e n t to r e l a x , " " t e l l
the p a t i e n t to r e l a x " .
This "method" does f i t one c r i t e r i a o f Melzack's
(1973) v a r i a b l e s known to a f f e c t p e r c e p t i o n .
This t e l l i n g i s "su gge st io n
In summary, a l i t e r a t u r e s e a r c h r e s u l t e d in s u p p o rt of r e l a x a t i o n
as a pain r e l i e f measure and r e v e a le d t h r e e methods t h a t cont ai ned one
o r more o f t h e f a c t o r s i d e n t i f i e d by Sternbach (1968) and Melzack (1973)
as pr ov id i n g pain r e l i e f .
I t appeared t h a t an e x p l o r a t i o n o f th e amount
18
o f r e l a x a t i o n provided by t h e s e methods was needed.
q u e s t i o n took shape:
Thus, th e r e s e a r c h
I f d i s t r a c t i o n , s u gge s tio n and muscle r e l a x a t i o n
a r e known to reduce p a i n , and Lamaze, Biofeedback, and T e l l i n g , are
methods which c o n ta i n one o r more o f t h e s e f a c t o r s , does r e l a x a t i o n o c ­
cu r with each?
Is t h e r e a d i f f e r e n c e in rega rd to r e l a x a t i o n among
them?
The d e c i s i o n to ex p lo re e x i s t i n g methods of producing r e l a x a ­
t i o n to reduce pain led to Lamaze which has as i t s p o p u la ti o n pregnant
women.
I f r e l a x a t i o n , as a pain r e l i e f measure, was to be s t u d i e d in
pr eg na nt women was t h e r e any th in g unusual about t h e i r pain as compared
t o o t h e r pain?
Fagerhaugh and S t r a u s s (1977) d i s c u s s th e c h a r a c t e r i s t i c s of
b i r t h pain and how i t d i f f e r s from o t h e r pa in :
th e pain i s e xpect ed ,
has n ot hi ng to do with i l l n e s s , and i s f i n i t e .
Pain which i s a s s o c i a t e d
with a high degree o f p e rc ei v e d t h r e a t to l i f e and which i s u n p r e d i c t a b l e ,
i n c r e a s e s a n x i e t y and pain (McCaffery, 1972).
So t h e c h a r a c t e r i s t i c s o f
b i r t h pain appear to make i t a pain t h a t i s la ck in g some of the f a c t o r s
know to i n c r e a s e a n x i e t y .
D i f f i c u l t and h i g h - r i s k b i r t h s a r e known to
i n c r e a s e f e a r and a n x i e t y as does th e p a s t h i s t o r y or p e r c e p t i o n t h a t
b i r t h w i l l be d i f f i c u l t or high r i s k (Fagerhaugh and S t r a u s s , 1977).
In summary, pre gna nt women p r e s e n t a p o p u la tio n whose pain has
l e s s o f an a n x i e t y component i f t h o s e , with a p a s t h i s t o r y , or f e a r ,
of a d i f f i c u l t o r h i g h - r i s k b i r t h , a r e omi tte d from th e p o p u la ti o n .
19
DEPENDENT VARIABLE
I f th e t h r e e pre vio us s t r a t e g i e s (Lamaze, Biofeedback, T e l l i n g )
were to be e v a l u a t e d f o r t h e amount o f r e l a x a t i o n , i t was ne ce s sa ry to
c o n c e p t u a l i z e r e l a x a t i o n in a way t h a t po in te d to methods o f measurement
Rel axa tio n has been c o n c e p t u a l i z e d as having two components,
muscle r e l a x a t i o n and mental r e l a x a t i o n ( K a u r i , 1975).
The measurement o f t e n s i o n in a muscle i s done by e l e c t r o ­
myography (EMG).
EMG induced r e l a x a t i o n has been used in the t r e a t m e n t
o f a wide range o f a n x i e t y and t e n s i o n r e l a t e d problems such as:
ten­
sion headache, ch ro n ic alcohol abu se, ch ro n ic a n x i e t y and b i r t h pain
( K a u r i , 1975; Haynes, e t . a l . , 1975; Townsend, e t . a l . , 1975; Gregg, e t . a l
1975; S t e r n n o n , 1975; Breeden, e t . a l . , 1975; P u t t , 1979).
Mental t e n s i o n , or c o n v e r s e l y , mental r e l a x a t i o n , a l s o has a phy
s i o l o g i c a l measure, s kin te m p e ra t u re .
The c a r d i o v a s c u l a r mechanisms
which r e g u l a t e skin te m p e ra t u re in th e hands a re c l o s e l y t i e d with th e
a c t i v i t y o f th e sy mpathetic d i v i s i o n o f th e autonomic nervous system
(Ganong, 1975).
The fe e d in g back o f te m pe ra tu re re a d in g s and r e i n f o r c e ­
ment o f i n c r e a s e s in te m pe ratu re have been used as a method to achieve
r e l a x a t i o n (Reinking, e t . a l . , 1975; H a u r i , 1975).
French, Leeb and
Boernes (1973) su p p o rt th e use o f f i n g e r - t i p te m pe ratu re feedback with
prepared c h i l d b i r t h t r a i n i n g as a method to produce r e l a x a t i o n .
Work
in t h e i r l a b o r a t o r y i n d i c a t e d t h a t a s i g n i f i c a n t d e cr ea se in tem pe rat ure
was a s s o c i a t e d with a d e c r e a s e in r e l a x a t i o n .
20
In summary, a review o f th e l i t e r a t u r e supported th e co n ce p t­
u a l i z a t i o n o f t h e dependent v a r i a b l e , r e l a x a t i o n , as being ma nife st ed
in muscle r e l a x a t i o n (EMG) and mental r e l a x a t i o n ( f i n g e r - t i p tempera­
t u r e ) , and f u r t h e r , po in te d out methods f o r measurement.
INTERVENING VARIABLES
C e r t a i n s p e c i f i c v a r i a b l e s have been c i t e d in the l i t e r a t u r e
as f a c t o r s a f f e c t i n g a p e r s o n ' s p e r c e p t i o n of pain and th e co ntro l of
t h e s e v a r i a b l e s d i c t a t e d design c o n s i d e r a t i o n s .
Melzack (1973) proposed t h a t t h e c o g n i t i v e a c t i v i t i e s which
ta k e p la c e as a r e s u l t o f s u gge s tio n can i n f l u e n c e pain by a c t i n g a t
th e l e v e l o f sens ory t r a n s m i s s i o n .
This i n d i c a t e d t h e need to pro ­
vide s u g g e s t i o n s to a l l groups to e l i m i n a t e the p o s s i b i l i t y t h a t r e ­
l a x a t i o n was achieved as a r e s u l t o f su gges tio n a lo ne.
C u lt u ra l va lu es and age a r e a l s o known to pla y an important r o l e
in th e way a person p e r c e i v e s p a i n , and t h e r e f o r e c o n s i d e r a t i o n needed
to be given to c u l t u r e in s u b j e c t s e l e c t i o n through sampling or o t h e r
means o f c o n t r o l (Melzack, 1973; Z b o r o s k i , 1952).
The v a r i a b l e age was a c r i t i c a l one because p e rc ei v e d r i s k may
i n c r e a s e a woman's a n x i e t y , t e n s i o n , o r f e a r and thu s her pain (Fagerhaugh and S t r a u s s , 1977; McCaffery, 1972).
McCaffery (1972) l i s t s th e fo ll ow in g f a c t o r s as being v a r i a b l e s ,
known to a f f e c t pain p e r c e p t i o n and l e v e l o f a n x i e t y in a p a t i e n t :
21
e m o ti o n a ll y t r a u m a t i c l i f e e x p e r i e n c e s , personal p a s t e xp e r ie n c e s with
p a i n , knowledge and u n d e r s t a n d i n g , and c o g n i t i v e l e v e l , s u g g e s ti n g the
need to c o n tr o l t h e s e v a r i a b l e s through s u b j e c t s e l e c t i o n or measurement
of differences.
The word, " c o n t r o l ", a ro s e f r e q u e n t l y in the l i t e r a t u r e on pain
(MeC a f f e r y , 1972; Melzack, 1973; Fagerhaugh and S t r a u s s , 1977).
The
biofeedback l i t e r a t u r e a l s o spoke to c o n t r o l as a p o t e n t i a l v a r i a b l e a f ­
f e c t i n g th e a b i l i t y to c o n tr o l o n e ' s body and use a s t r a t e g y ( O l i v e r ,
1972; DeGood, 1975; G a t c h e l , 1975; Johnson and Meyer, 1974).
The pain
t h e o r i s t s saw a sense of c o n t r o l as reduci ng pain p e r c e p t i o n (McCaffery,
1972).
The biofeed bac k r e s e a r c h e r s used locus of c o n t r o l t e s t s to mea­
su re t h i s v a r i a b l e and e quate i t to the a b i l i t y to use a s t r a t e g y .
r e s u l t s were mixed.
The
Gatchel (1975), Raymond (1972), and O li v e r (1972)
found no s i g n i f i c a n t e f f e c t between locus o f co n tr o l and a b i l i t y to con­
t r o l body p r o c e s s e s .
DeGood (1975) found no s i g n i f i c a n t e f f e c t between
locus o f c o n tr o l and resp onse to s t r e s s .
Johnson and Meyer (1974)
found t h a t i n t e r n a l s seek more i n f o r m a t i o n and adopt behav ior s t h a t
f a c ilita te control.
The R o t t e r I-E Scale was used in a l l the above mentioned r e ­
searc h and was s e l e c t e d f o r t h i s r e s e a r c h .
The r e l a t i o n s h i p between l o ­
cus of c o n t r o l and a b i l i t y to use a s t r a t e g y could then be examined.
22
SUMMARY
A review o f the l i t e r a t u r e in r e l a t i o n to i n t e r v e n i n g v a r i a ­
b le s i n f l u e n c e d th e d e c i s i o n to e s t a b l i s h c r i t e r i a t h a t would s e l e c t
a u n i c u l t u r a l p o p u l a t i o n , o f s i m i l a r age and p a s t h i s t o r y in an at te m p t
to measure t h r e e s t r a t e g i e s i d e n t i f i e d from the l i t e r a t u r e as having
a p o t e n t i a l to reduce t e n s i o n .
These s t r a t e g i e s were t h e o r e t i c a l l y ex ­
p l a i n e d by th e g a t e - c o n t r o l t h e o ry o f p a i n .
S e l e c t i o n o f the dependent
v a r i a b l e s and t h e i r measurement was guided by a review o f the l i t e r a t u r e
P o t e n t i a l Iy i n t e r v e n i n g v a r i a b l e s were i d e n t i f i e d from th e l i t e r a t u r e .
C h ap ter 3
RESEARCH DESIGN AND METHODOLOGY
SAMPLE
A sample was s e l e c t e d to study t h e r e l a t i o n s h i p o f amount of
r e l a x a t i o n to coping s t r a t e g i e s .
The l i t e r a t u r e su ggested t h a t an ap ­
p r o p r i a t e sample would be pre gnan t women w ith ou t a h i s t o r y o f p r e n a t a l
a n d / o r b i r t h c o m p li c a ti o n s (Fagerhaugh and S t r a u s s , 1977).
The age
range (18-38 y e a r s ) was chosen f o r sample s e l e c t i o n due to th e de ­
c re as ed r i s k o f p r e n a t a l and b i r t h c o m p lic at io ns in t h o s e y e a r s (Eager
haugh and S t r a u s s , 1977).
The i n t e r v e n i n g v a r i a b l e , c u l t u r e , was con­
t r o l l e d by sampling from th e predominate s u b c u l t u r e o f t h e area (Cau­
casian , English-speaking, college stu d en ts).
To c o n t r o l f o r the i n t e r
vening v a r i a b l e s i d e n t i f i e d by th e l i t e r a t u r e ( l e v e l o f a n x i e t y , emo­
t i o n a l l y tr a u m a t i c l i f e e x p e r i e n c e s , pe rsonal p a s t e x p e r ie n c e s with
p a i n , knowledge and u n d e r s t a n d i n g , and c o g n i t i v e l e v e l ) t h e s u b j e c t s
were scr eened through use o f a q u e s t i o n n a i r e (Appendix C).
C r i t e r i a f o r Sample S e l e c t i o n
The fo ll ow in g s p e c i f i c c r i t e r i a were s e l e c t e d t o co n tr o l f o r
t h e i n t e r v e n i n g v a r i a b l e s i d e n t i f i e d by th e l i t e r a t u r e :
1)
Being in th e t h i r d t r i m e s t e r o f pregnancy
2)
Being between the ages o f 18 and 38 y e ar s
3)
Being a p rim ip ar a
24
4)
Having no h i s t o r y o f m i s c a r r i a g e .
5)
Having no n e g a t i v e p hys ic a l r e p o r t , i . e . , "high r i s k "
pregnancy, o r " t r o u b l e " r e p o r t s .
6)
Having no s e l f r e p o r t o f a pre vious t r a u m a t i c a l l y . p a i n ­
ful e x p e r ie n c e .
7)
Being e n r o l l e d in one type o f p r e n a t a l i n s t r u c t i o n c l a s s
8)
Using Engl ish as a primary language.
9)
Having completed high scho ol.
only.
10)
Being Caucasian.
Sample s e l e c t i o n was made from two p o p u l a t i o n s .
The f i r s t group
or CSl, (n=3) was a random sample o f v o l u n t e e r s from Lamaze C h i l d b i r t h
Education C la s s e s .
The second two groups:
CS2 (n=3) and CS3, (n=3)
were composed o f women s e l e c t e d a t random from a l i s t o f v o l u n t e e r s who
had or were t a k i n g P r e n a ta l Education C l a s s e s .
then a s s ig n e d randomly to e i t h e r CS2 o r CS3.
ural occurence in grouping.
These v o l u n t e e r s were
The r e s e a r c h e r used n a t ­
T h e r e f o r e , t h e assignment o f th e s u b j e c t s
could be c o n t r o l l e d in two o f the t h r e e groups.
The f i r s t two g ro u p s ,
CSl and CS2, were t h e experimental groups composed o f women who had p r e ­
v i o u s l y le a r n e d one o f two s t r a t e g i e s , biofeedback or Lamaze.
The
t h i r d group, or CS3, was the c o nt ro l group, and was composed of women
who had no pre vio us i n s t r u c t i o n in a r e l a x a t i o n s t r a t e g y .
25
All t h r e e groups had re c e iv e d b a s i c c h i l d b i r t h e d u c a ti o n .
This
r e q u i r e d e d u c a t i o n , as well as th e c r i t e r i a f o r i n c l u s i o n , was designed
to c o n tr o l f o r th e e xtra neo us v a r i a b l e , h i s t o r y (Campbell and S t a n l e y ,
1963).
A sample c r i t e r i a n scr eened out women who had p r e v i o u s l y had
c h i l d r e n o r a " t r a u m a t i c a l ly" p a in fu l e x p e r ie n c e .
This sc r e e n in g out
o f n e g a t i v e p a s t pain was e s s e n t i a l to i n s u r e a homogeneous group (Melz ac k, 1970).
An a c c e p t a b l e s t a t i s t i c a l t e s t f o r t h i s design was simple
a n a l y s i s o f v a r i a n c e u t i l i z i n g d i f f e r e n c e s c o r e s (Ferguson, 1977).
DESIGN
The de sign chosen to t e s t the h ypoth e si s co rresponds with:
th e
q u a s i - e x p e r i m e n t a l ; s e p a r a t e sample; p r e - t e s t , p o s t - t e s t , designed by
Campbell and S t a n l e y (1963).
I t r e p r e s e n t s a 2 x 3 m a t r i x with r e p e a te d
measures.
MEASUREMENT
The methods used to measure the dependent v a r i a b l e s were as
f o ll o w s :
I)
M usc le -R el a xa tio n:
An Autogen 1700 Electromyogram was used
to measure t h e a c t i v i t y o f t h e s k e l e t a l muscles.
This a c t i v i t y i s t r i g ­
gered by a complex p a t t e r n o f e l e c t r i c a l impulses o r i g i n a t i n g in th e c e n ­
t r a l nervous system.
Muscular r e l a x a t i o n occurs when t h e e l e c t r i c a l d i s ­
charge f a t e o f th e motor nerve d e c r e a s e s .
Muscle r e l a x a t i o n was d i s p l a y e d
as a de cr ea se d m i c r o v o l t l e v e l on the Autogen 5600 Data A c q u i s i t i o n Center
26
2)
M e n ta l- R e la x a ti o n :
An Autogen 2000b Temperature Feedback
Thermometer was used to measure th e skin te mp erat ure o f th e hand, an i n ­
d i c a t o r which i s c l o s e l y r e l a t e d to th e a c t i v i t y o f th e autonomic n e r ­
vous system (French, Leeb9 and B oe rn es , 1973).
P s y c h i c - r e l a x a t i o n was
d i s p l a y e d as in in c r e a s e d f i n g e r - t i p te m pe ratu re on t h e Autogen 5600
Data A c q u i s i t i o n Center.
3)
Locus o f C o n t r o l :
the s u b j e c t ' s locus o f c o n t r o l .
in c l u d i n g 6 f i l l e r items .
The R o t t e r I-E Scale was used to measure
This was a for ce d c hoic e 29 item s c a l e
Item a n a l y s i s and f a c t o r a n a l y s i s show r e a s o n ­
ably high c o n s i s t e n c y f o r an a d d i t i v e s c a l e ( R o t t e r , 1972).
D is crim in­
a n t v a l i d i t y i s i n d i c a t e d by the low r e l a t i o n s h i p with such v a r i a b l e s as
i n t e l l i g e n c e , s o c i a l d e s i r a b i l i t y , and p o l i t i c a l l i b e r a l i s m .
The most
s i g n i f i c a n t e v id e n c e , o f t h e c o n s t r u c t v a l i d i t y , o f th e I-E Scale comes
from th e p r e d i c t e d d i f f e r e n c e s in be hav io r f o r i n d i v i d u a l s above and be ­
low t h e median s c a l e and from c o r r e l a t i o n s with beh av io ral c r i t e r i a
( Phares and Chance, 1972).
Scoring o f th e s c a l e c o n s i s t e d o f marking
t h e e x t e r n a l re s p o n s e s .
EXPERIMENTAL PROCEDURE
Setting
The s e t t i n g f o r th e study was t h e Montana S t a t e U n i v e r s i t y De­
partment o f Psychology, Biofeedback La b o ra to ry , Bozeman, Montana.
Vo lun te ers were s o l i c i t e d by f l y e r s and c o n t a c t through e x i s t i n g
classes.
They were scr eened by i n t e r v i e w acc ording to th e c r i t e r i a on
t h e q u e s t i o n n a i r e (Appendix B).
27
Procedure
An informed c onse nt was o b ta in e d from the s u b j e c t s s e l e c t e d f o r
participation.
The s u b j e c t ' s c o n f i d e n t i a l i t y was p r o t e c t e d by a number
coding system f o r a l l d a t a .
d iv id u a l appo int me nts .
The s u b j e c t s were scheduled, f o r t h r e e i n ­
Those p a r t i c i p a t i n g in Lamaze i n s t r u c t i o n were
scheduled f o r appointments upon completion o f th e f o u r t h week o f c l a s s .
Those s e l e c t e d f o r biofeedback were scheduled f o r appointments upon com­
p l e t i o n o f th e biofeed bac k t r a i n i n g s e s s i o n s (Appendix F ) .
The s u b j e c t s
s e l e c t e d f o r th e c o n t r o l , o r T e l l i n g , group were scheduled f o r a p p o i n t ­
ments upon completion o f th e f o u r t h week o f P r en a ta l C la s s e s .
Experimental Se ssi ons
During each s e s s i o n t h e s u b j e c t was s ea te d in a r e c l i n e r in a
darkened room.
dix F ) .
Appartus was a t t a c h e d as in biofeedback t r a i n i n g (Appen- .
The tone w a s n ' t used in any group.
Su bje ct s were i n s t r u c t e d
t h a t " th e f i r s t 5 minutes a r e f o r you t o g e t used, to th e equipment.
a r e to j u s t s i t q u i e t l y , "
You
B a s e li n e EMG and te m pe ratu re re a d in g s were
taken a t 30 second i n t e r v a l s in th e form o f i n t e r v a l means.
The e x p e r i ­
m e nt e r then e n t e r e d t h e room and t h e s u b j e c t s were i n s t r u c t e d to r e l a x
as f o ll o w s :
Lamaze (C S l) labor.
"As you have l e a r n e d , r e l a x a t i o n reduces pain in
So f o r t h e nex t 25 minutes you a r e to r e l a x as you have l e ar ne d
in your Lamaze c l a s s . "
28
Biofeedback (CS2)pain in l a b o r .
"As you have l e a r n e d , r e l a x a t i o n reduces
So f o r th e nex t 25 min ute s you a r e to r e l a x as you have
l e a r n e d in your biofeedback t r a i n i n g . "
T e l l i n g (CS3)labor.
"As you have l e a r n e d , r e l a x a t i o n reduc es pain in
So f o r th e next 25 minutes you a r e to r e l a x as you were t o l e in
class."
During th e r e l a x a t i o n t i m e s , EMG and te m pe ra tu re re a d in g s were
taken a t 30 second i n t e r v a l s in th e form o f i n t e r v a l means.
At the end
o f th e r e l a x a t i o n s e s s i o n t h e e x pe r im en te r r e - e n t e r e d th e room and t o l d
th e s u b j e c t s to " j u s t s i t q u i e t l y f o r th e next 5 m i n u t e s . "
Post-treat­
ment re a d in g s were taken in t h e same manner as th e o t h e r r e a d i n g s .
At t h e end o f t h e t h i r d s e s s i o n t h e s u b j e c t s were thanked f o r
t h e i r p a r t i c i p a t i o n and t h e i r q u e s t i o n s were answered.
Chapter 4
ANALYSIS OF THE DATA
The a n a l y s i s c h a p t e r i s div id e d i n t o two s e c t i o n s .
s e c t i o n i s a d e s c r i p t i o n o f the sample t e s t e d .
The f i r s t
The second s e c t i o n con­
t a i n s th e r e s u l t s of th e s t a t i s t i c a l a n a l y s i s , used to t e s t the four
null hypotheses in Chapter I and to a ddre ss the o b j e c t i v e s which were:
I)
To d e s c r i b e t h e r e l a t i o n s h i p between t h e amount of r e l a x a t i o n and
the s t r a t e g i e s o f Lamaze, Biofeedback, and i n s t r u c t i o n or t e l l i n g .
2)
To d e s c r i b e t h e r e l a t i o n s h i p o f r e l a x a t i o n re a d in g s of
women v o l u n t e e r s t o t h e i f locus o f c o n t r o l s cor es as measured by the
R o t t e r I-E S c a le .
NATURE OF THE SAMPLE
S u b je c ts were a cce pt ed f o r t e s t i n g on the b a s i s o f being p r i m i pa ras between t h e ages o f 18 and 38 y e a r s , having no pre v io u s h i s t o r y
o f m i s c a r r i a g e or a b o r t i o n , and no s u b j e c t i v e r e p o r t o f " tr a u m a ti c pain
Al I s u b j e c t s were m a rr ie d and had gra dua ted from high school
The c r i ­
t e r i o n q u e s t i o n i n g was done be fo re a d m i n i s t e r i n g any f u r t h e r t e s t i n g .
Twelve women v o l u n t e e r e d f o r t e s t i n g and nine were acc e pte d following
c r ite r io n questioning.
C h a r a c t e r i s t i c s o f th e Three Groups
The c h a r a c t e r i s t i c s o f th e t h r e e groups (CS1, CS2, CS3) are
p r e s e n t e d in Table I .
The d a t a in t h i s t a b l e show t h e sample dis p la y e d
homogeneity w i t h i n and between th e groups in r e l a t i o n to age and l e n g th
30
of gestation.
The mean age f o r th e nine s u b j e c t s (24.6 y e a r s ) i s
h i g h e r than t h e n a t i o n a l average (2 1.7 ) f o r p r i m i p a r a s .
This f i n d i n g
i s most l i k e l y due to t h e v o l u n t e e r s being s o l i c i t e d from a community
of college students.
Lamaze c l a s s e s in t h i s community have an o l d e r
p ri m ip a r a a c c or din g to t h e i n s t r u c t o r ' s o b s e r v a t i o n .
l e n g t h o f . g e s t a t i o n was 25-31 weeks.
The range of the
I n s p e c t i o n o f t h e d a t a showed
th e t h r e e groups d e v i a t e d l i t t l e from each o t h e r on th e v a r i a b l e ,
length of g e sta tio n :
Table I .
Demographic C h a r a c t e r i s t i c s (Age and Length o f G e st a ti on)
o f t h e Sample.
Group
CSl
(n=3)
Biofeedback
CS2
(n=3)
Lamaze
CS3
Total
(n=3)
Tel l i n g
Age (Years)
Range
Mean
S.D.
22-29
24.6
3.0919
22-27
24
2.1602
23-28
25
2.1602
22-29
24.56
2.5435
Range
Mean
S.D.
26-30 .
27-31
27.6
1.6653
25-30
27.3
2.0551
25-31
G e s t a t i o n (Weeks)
28.3
1.8859
27.78
1.9309
To t e s t t h e n u ll hy p o th e si s o f no d i f f e r e n c e in EMG r e a din gs
among s u b j e c t s us in g coping s t r a t e g i e s o f Lamaze or Biofeedback as com­
pared to th o s e us in g t h e coping s t r a t e g y , t e l l i n g , a simple a n a l y s i s of
v a r i a n c e ( Roscoe, 1969) was a p p l i e d to d a ta and i s r e p o r t e d in Table 2.
31
The simple a n a l y s i s o f v a r i a n c e i s used f o r t e s t i n g t h e hy poth e si s t h a t
: two or more independent samples were drawn from p o p u l a t i o n s having the
same mean ( Roscoe, 1969).
The samples may be c o n s t i t u t e d by drawing
independent random samples from a s i n g l e p o p u l a t i o n , s u b j e c t i n g them
to e x p e r im e n t a ti o n and then comparing them on a s i n g l e c r i t e r i a n v a r ­
iable.
The samples in t h i s stu dy were obta in e d through sc r e e n in g v o l ­
u n t e e r s t o o b t a i n a p o p u la ti o n s i m i l a r in ag e, p a r a , h i s t o r y , and
length of g e sta tio n .
case o f Lamaze.
A n a t u r a l Iy o c cu r in g group was s e l e c t e d in the
Assignment t o th e Biofeedback o r th e T e l l i n g group
was done randomly.
External v a l i d i t y was a f f e c t e d and i s addressed in
Chapter 5.
The summary d a t a f o r the a n a l y s i s o f v a r i a n c e a r e p re s e n te d in
Table 2.
A one-way a n a l y s i s o f v a r i a n c e was run with 3 groups (Lamaze,
Biofeedback and T e l l i n g ) and 9 s u b j e c t s .
The degrees o f freedom a s s o ­
c i a t e d with t h e de sign a re 2 ( d f = 3-1=2) and 6 ( d f = 9-3=6).
Table 2.
Summary Data f o r the Anal ysi s o f Variance o f EMG Readings
Source o f V a r i a t i o n
df
Between groups
2
.8718
.4359
Within groups
6
.4824
. 0804
Total
8
1.3542
P < .05
Sum o f Squares
Mean Squares
— — —
________________________ (F = 5.42)
In e v a l u a t i n g th e r e s u l t s o f th e experiment to determine whether
F v a lu e f o r tr e a t m e n t e f f e c t s was s i g n i f i c a n t the .05 p e r c e n t le vel of
s i g n i f i c a n c e was a p p l i e d .
32
The F r a t i o r e q u i r e d f o r s i g n i f i c a n c e with 2 and 6 degrees of
freedom was 5.14 a t th e .05 l e v e l .
which i s above th e .05 l e v e l .
The F va lu e f o r th e d a t a was 5.42
The nu ll hy poth e si s i s t h e r e f o r e r e ­
jected.
When usi ng the a n a l y s i s of v a r i a n c e with more than two groups
t h e r e i s a q u e s t i o n o f t h e source o f t h e s i g n i f i c a n t d i f f e r e n c e .
M ulti­
p l e comparisons with simple a n a l y s i s o f v a r i a n c e i s a c o n t r o v e r s i a l s ub­
j e c t among s t a t i s t i c i a n s and one f o r which t h e r e i s a t p r e s e n t no com ple te ­
l y s a t i s f a c t o r y s o l u t i o n (Roscoe, 1969; Ferguson, 1976).
The r e s e a r c h
h yp ot he si s t e s t e d th e q u e s t i o n o f whether 2 groups ( Lamaze and Biofeedback)
which le a r n e d s p e c i f i c s t r a t e g i e s have lower EMG s c o r e s than a group ( T e l l ­
ing) t h a t did not l e a r n a s t r a t e g y .
The F value f o r main e f f e c t along
with t h e a p p r e c i a b l y l a r g e r means o f t h e Lamaze (. 8 0 ) and Biofeedback ( .7 8 )
groups as compared t o t h e mean o f t h e group T e l l i n g ( . 1 6 ) i n d i c a t e d t h a t
no f u r t h e r t e s t o f s i g n i f i c a n c e was ne c e s s a ry .
The second nu ll h y p o t h e s i s :
There w ill be no d i f f e r e n c e in f i n g e r ­
t i p te m p e ra t u re r e a d i n g s among s u b j e c t s who use coping s t r a t e g i e s o f Lamaze o r Biofeedback as compared to th o s e who use th e s t r a t e g y of T e l l i n g
was t e s t e d with th e simple a n a l y s i s o f v a r i a n c e .
The summary da ta f o r
t h e simple a n a l y s i s o f v a r i a n c e f o r f i n g e r - t i p te m p e ra t u re are. p r e s e n t ­
ed in Table 3.
33
Table 3. Summary Data f o r th e A nal ys is o f Variance o f Fi n g e r- T ip
Temperature Readings
Source o f V a r i a t i o n
df
Sum o f Squares
Mean Squares
Between groups
2
1.1862
.5931
Within groups
6
.8016
.1336
Total
8
1.9878
■ ^ w.
________ P < .05__________ ;__________________(F = 4.44)______________________
The F r a t i o
r e q u i r e d f o r s i g n i f i c a n c e with 2 and 6 degrees of
freedom was 5.14 a t the .05 p e r c e n t l e v e l .
was 4.44 which i s below th e .05 l e v e l .
The F val ue f o r t h e s e da ta
The null h y p o th e s i s i s t h e r e f o r e
acc e pt ed .
To t e s t th e t h i r d null hy p o th e si s s t a t i n g t h e r e i s no r e l a t i o n ­
s hip between EMG s c o r e s and s co r es on th e R o t t e r I-E Sc a le th e Pearson
pr odu ct moment t e s t o f c o r r e l a t i o n was performed on th e d a ta in Table 2
(see page. 31).
The r f o r th e d a ta i s .1991.
When two v a r i a b l e s a re
s a i d to be not c o r r e l a t e d t h e c o e f f i c i e n t i s z e r o , a p e r f e c t c o r r e l a t i o n
i s equal to plu s or minus one.
The si gn o f the r i n d i c a t e s the d i r e c t i o n
o f t h e c o r r e l a t i o n (Roscoe, 1969).
relation.
An r o f .1991 shows l i t t l e or no c o r ­
" P o s s i b l y t h e most v a l i d and use fu l i n t e r p r e t a t i o n of the c o r ­
r e l a t i o n c o e f f i c i e n t i s achieved by s q u a r in g i t " (Roscoe, 1969, p. 191).
The p r o p o r t i o n o f th e v a r i a n c e or th e v a r i a n c e o f one measure (EMG)
2
which i s accounted f o r by th e o t h e r (I- E Scale Score) i s equal to r .
2
Thus, r = .0396 o r f o u r p e r c e n t o f t h e v a r i a t i o n in EMG i s accounted
f o r o r a t t r i b u t a b l e to the p e r s o n ' s lo cu s o f c o n t r o l .
The squared r of
34
fo u r p e r c e n t i s a l s o i n d i c a t i v e o f l i t t l e o r no c o r r e l a t i o n .
The null
hy p o th e si s i s a c c e pt ed in t h i s case.
The Pearson r was a l s o used to t e s t th e f o u r t h nu ll hypothe si s
o f no c o r r e l a t i o n between EMG r e a d i n g s and f i n g e r - t i p te m pe ratu re r e a d ings.
The r = - . 1 9 6 8 , and r
2
= .0387.
The n e g a t i v e sign i n d i c a t e d a
n e g a t i v e c o r r e l a t i o n o r d i r e c t i o n , but only 4 p e r c e n t o f the v a r i a t i o n
in EMG can be accounted f o r by t h e v a r i a t i o n in te m p e r a t u r e .
The null
hy p o th e si s was a cce pt ed f o r t h i s h y p o t h e s i s .
In summary, th e nin e s u b j e c t s r e p r e s e n t a sample o f m a r r i e d ,
p r im ip a r a s with no h i s t o r y o f m i s c a r r i a g e a n d /o r a b o r t i o n , and no sub­
j e c t i v e re p o rt o f "traumatic pain".
d e v i a t e l i t t l e among th e groups.
The mean age, and g e s t a t i o n a l age
The t h r e e groups show a high degree
o f s i m i l a r i t y on t h e v a r i a b l e s known to a f f e c t p e r c e p t i o n o f pain in
general and p e r c e p t i o n o f pain in c h i l d b i r t h in p a r t i c u l a r .
The r e s e a r c h f i n d i n g s su pp ort th e acc e pta nc e o f tb e fol lo wi ng
hypothesis:
1)
There were s i g n i f i c a n t l y lower EMG re a d in g s among s u b j e c t s
who used t h e coping s t r a t e g i e s o f Lamaze o r Biofeedback as compared to
th o s e who used th e coping s t r a t e g y . T e l l i n g .
2)
There was no s i g n i f i c a n t d i f f e r e n c e in f i n g e r - t i p te m p e ra t u re
r e a d i n g s among s u b j e c t s who used coping s t r a t e g i e s Lamaze or Biofeedback,
as compared t o th o s e who used th e s t r a t e g y , T e l l i n g .
scores.
3)
There was no c o r r e l a t i o n between locus o f c o n t r o l and EMG s c o r e s .
4)
There was no c o r r e l a t i o n between EMG s co r es and f i n g e r - t i p
Chapter 5
CONCLUSIONS, DISCUSSION, RECOMMENDATIONS, AND IMPLICATIONS
CONCLUSIONS
Four hypotheses were t e s t e d in t h i s r e s e a r c h .
The r e s u l t s of
app ly in g a simple a n a l y s i s o f v a r i a n c e to th e da ta c o l l e c t e d on the d e ­
pendent v a r i a b l e s EMG and f i n g e r - t i p te m p e ra t u re lead to the following
c on c lu s io n s in t e s t i n g th e f i r s t two hypotheses:
1)
There were s i g n i f i c a n t l y lower EMG r e a d i n g s among s u b j e c t s
who used coping s t r a t e g i e s o f Lamaze or Biofeedback as compared to th os e
who used t h e s t r a t e g y T e l l i n g .
2)
There was no s i g n i f i c a n t d i f f e r e n c e in f i n g e r - t i p t e m p e ra t u re
re a d in g s among s u b j e c t s who used coping s t r a t e g i e s o f Lamaze or Biofe ed­
back as compared t o th o s e who used th e s t r a t e g y T e l l i n g .
The t h i r d h ypot he si s was t e s t e d by a p pl yin g th e Pearson p r o ­
duc t moment c o r r e l a t i o n c o e f f i c i e n t to t h e d a ta c o l l e c t e d on th e v a r i a b l e ,
locus o f c o n t r o l , which led to th e fo ll o w i n g c o n c lu s io n :
There was no
s i g n i f i c a n t r e l a t i o n s h i p between a s u b j e c t ' s EMG re a d i n g and t h e i r s co re
on th e R o t t e r I-E S c a le .
The amount o f v a r i a n c e in EMG r e a d i n g s which
can be r e l a t e d to th e s u b j e c t ' s locus o f c o nt ro l was f o u r p e r c e n t.
The f o u r t h hy poth esi s was t e s t e d by a p p l i c a t i o n of the P e a r ­
son p ro duc t moment c o r r e l a t i o n c o e f f i c i e n t to th e EMG and tem pe rat ure
r e a di ng s to d e s c r i b e t h e i r r e l a t i o n s h i p .
The fo ll o w i n g con clu si on was
36
rea che d:
There was no c o r r e l a t i o n between EMG a n d , f i n g e r - t i p temper­
ature readings.
DISCUSSION AND RECOMMENDATIONS
The comparison o f th e r e l a x a t i o n s co r es (muscle-EMG, m e n t a l f i n g e r - t i p te m p e r a t u r e ) o b ta in e d by two groups o f s u b j e c t s t r a i n e d to
use a s t r a t e g y to r e l a x (Biofeedback, Lamaze) as compared to a group
t o l d to r e l a x ( T e l l i n g ) r e s u l t e d in s i g n i f i c a n t l y lower EMG s co r es (mus
c l e r e l a x a t i o n ) and no s i g n i f i c a n t d i f f e r e n c e s in f i n g e r - t i p tempera­
t u r e (mental r e l a x a t i o n ) .
The methodology f o r o b t a i n i n g EMG and f i n g e r - t i p te mp erat ure
re a d in g s c o n s i s t e d o f measuring a b a s e l i n e on each i n d i v i d u a l p r i o r to
measuring t h e i r " r e l a x a t i o n " .
This provided th e i n v e s t i g a t o r with the
change in r e l a x a t i o n s c o r e s t h a t t h e s u b j e c t gained as compared with
t h e i r b a s e l i n e , r a t h e r than th e s u b j e c t ' s i n d i v i d u a l s t a t e o f r e l a x a ­
tion.
This was done to c o n t r o l f o r t h e i n t r i n s i c v a r i a b l e o f th e r e ­
laxed pe rs on .
This along with o t h e r methodological and desi gn c r i t e r i a
lends c r e d i b i l i t y to t h e c onc lu s io n t h a t t h e r e s u l t s a r e indeed depend­
e n t on t h e t r e a t m e n t s t r a t e g i e s (Lamaze and Biofeedback).
The d a t a o b ta in e d on EMG were c o n s i s t e n t with t h e l i t e r a t u r e .
I t was expected t h a t t h e use o f e i t h e r Lamaze or Biofeedback would r e ­
s u l t in de cr ea se d muscle t e n s i o n or lower EMG s c o r e s .
I t was observed
by th e i n v e s t i g a t o r , w hil e c o l l e c t i n g t h i r t y - s e c o n d EMG re a d in g s over
the t r e a t m e n t s e s s i o n s t h a t t h e Biofeedback group m a in ta in ed low scor es
37
dur ing t h e t r e a t m e n t s e s s i o n s .
Although th e Lamaze g r o u p ' s s co r es would
drop , the y tended to f l u c t u a t e d urin g th e t r e a t m e n t s e s s i o n .
Because o f
t h e s e o b s e r v a t i o n s , f u r t h e r r e s e a r c h could in c lu de a graph p r i n t - o u t o f
EMG, o b ta in e d d uri ng t h e r e l a x a t i o n p e r io d s and c u r v e - f i t t i n g could be
done t o t h e d a t a .
This would look a t th e q u a l i t a t i v e a s p e c t o f th e r e ­
l a x a t i o n o b ta in e d as well as the q u a n t i t a t i v e dimension.
For example,
perhaps t h e r e were two ty pes o f " r e l a x a t i o n " t a k in g p l a c e —one in the
Lamaze and a n o t h e r in the Biofeedback groups.
.
A f u r t h e r recommendation would be to measure EMG re a d in g s a t
o t h e r s i t e s to deter mine i f th e r e l a x a t i o n achieved was t o t a l - b o d y r e ­
laxation.
The l i t e r a t u r e on EMG as a t o t a l - b o d y r e l a x a t i o n method i s
i n c o n c l u s i v e and t h i s r e s e a r c h would shed l i g h t on t h a t q u e s ti o n ( C o u r - ,
sey , 1975; Alexander, 1975; H a y n e s , e t . a l . , 1975; C o x , e t . a l . , 1975).
The r e s u l t s o f t h e measurement a r e c o n s i s t e n t with t h e l i t e r a ­
t u r e on f i n g e r - t i p te m p e ra t u re as a measurement o f autonomic nervous
system r e l a x a t i o n , in t h a t th e l i t e r a t u r e was i n c o n c l u s i v e .
Theoreti­
c a l l y , f i n g e r - t i p te m p e ra t u re should be a measure and be n e g a t i v e l y c o r ­
r e l a t e d with EMG.
Anal ysi s o f th e d a t a r e s u l t e d in a n e g a t i v e sign on
the c o e f f i c i e n t as th e l i t e r a t u r e su gg est ed .
too weak ( f o u r p e r c e n t ) to be c o n c l u s i v e .
in th e measurement t e c h n i q u e .
But the c o r r e l a t i o n was
P a r t of th e problem may be
I t was observed by th e i n v e s t i g a t o r t h a t
the s u b j e c t s ' t h e r m i s t o r probes o f t e n were lo os e or about to f a l l o f f
a t th e end o f a s e s s i o n .
i t y o f the readings.
This led t h e r e s e a r c h e r to q u e s t i o n the v a l i d ­
Also, i f the muscle r e l a x a t i o n i s o f a s i t e r a t h e r
38
than thp t o t a l body, then s i t e may be warmer r a t h e r than th e f i n g e r - t i p .
I t would be a recommendation o f th e i n v e s t i g a t o r t h a t r e a d i n g s be taken
a t v a r i o u s s i t e s on the. body, some c o r r e l a t e d with e l e c t r o d e placement.
This would e nab le th e r e s e a r c h e r to deter mine whether, or not low EMG
sc or es c o r r e l a t e d with high f i n g e r - t i p te m pe ratu re o r high skin tempera­
t u r e a t t h e s i t e o f e l e c t r o d e placement.
I t i s a f u r t h e r recommendation t h a t a s u b j e c t i v e measure of p e r ­
ceived r e l a x a t i o n be taken from s u b j e c t s fo ll ow in g t r e a t m e n t s e s s i o n s .
The i n fo r m a t io n would shed some l i g h t on th e qu e st i o n o f whether the
Biofeedback and th e Lamaze s t r a t e g i e s produce r e l a x a t i o n only when being
pe rfo rm ed , or whether, the y produce a s t a t e o f r e l a x a t i o n which l a s t s
p a s t t h e time o f a c t u a l performance.
The d a t a o b ta in e d on the c o r r e l a t i o n of locus o f c o n tr o l (as
measured by R o t t e r I-E Sc al e) and EMG i s a l s o c o n s i s t e n t with th e work
o f DeGood (1975), Raymond (1972), Fox (1972), and Gatchel (1975).
De-
Good (1975) s t u d i e d t h e i n t e r a c t i o n o f locus o f c o n t r o l , and th e use o f
a coping be hav io r or s t r a t e g y .
He found no s i g n i f i c a n t r e l a t i o n s h i p
between s co r es on th e R o t t e r I-E Sca le and the a b i l i t y to c o n tr o l through
avoidance.
He s t a t e d :
The e x t e n s i o n o f a model o f coping b e ha vio r to humans
r e q u i r e s a c o n s i d e r a t i o n o f r e l e v a n t a t t i t u d e s and e xpect an ces .
Given th e wide range o f i n d i v i d u a l l e a r n i n g e x p e r ie n c e among
human s u b j e c t s , i t seems r e a s o n a b l e t h a t e f f e c t i v e coping s t r a ­
t e g i e s might in vol ve an i n t e r p l a y between p e r s o n a l i t y and s i t u ­
a t i o n a l phenomena.
39
I t i s a recommendation t h a t a locus o f c o n tr o l t e s t t h a t measures p e r ceived c o n t r o l over o n e ' s body be us ed , r a t h e r than th e R o t t e r I-E Sca le
which measures p e rc e iv e d s o c i a l c o n t r o l .
In a d d i t i o n to d i s c u s s i o n and recommendations on th e dependent
v a r i a b l e s and t h e i r m e a s u r e s , th e i n v e s t i g a t o r would make t h r e e o t h e r
recommendations.
The f i r s t r e l a t e s to sample s i z e (n =9) .
The recommendation f o r
f u r t h e r study would be t o i n c r e a s e th e number to a minimum o f 30 sub­
jects.
The id e al would be to i n c r e a s e th e age range o f th e sample,
and to randomly a s s i g n them to groups.
The second recommendation would be t h a t th e s u b j e c t s be measured
f o r amounts o f r e l a x a t i o n duri ng th e f i r s t phase o f l a b o r with The McGill
pain q u e s t i o n n a i r e (Melzack and Debuisson, 1976; Melzack, 1975).
This
would f a c i l i t a t e measuring t h e e f f e c t s o f l e a r n i n g a s t r a t e g y , perform^
ing i t du rin g l a b o r , and th e r e s u l t a n t a b i l i t y o f th e s t r a t e g y to a f ­
f e c t pain p e r c e p t i o n .
The t h i r d recommendation would b u i l d on a r e p l i c a t i o n o f t h i s
study.
As a body o f d a t a i s compiled on th e a b i l i t y o f Lamaze and Bio­
feedback t o reduce muscle t e n s i o n and thu s pain p e r c e p t i o n , measures
should be made o f o t h e r te c h n i q u e s s a i d to "help r e l a x " such, as y o g a ,
r e l a x a t i o n r e s p o n s e , hypnotism and guided imagery.
This would provid e
th e l i n k needed to move on t o e v a l u a t i n g th e a b i l i t y o f r e l a x a t i o n to
reduce pain p e r c e p t i o n .
40
IMPLICATIONS
The r e s e a r c h de sign t e s t e d th e p o s s i b i l i t y t h a t when a woman i s
i n s t r u c t e d in a r e l a x a t i o n s t r a t e g y she can r e l a x more e f f e c t i v e l y than
when j u s t t o l d to r e l a x .
The dat a su pported t h i s premise.
Women who
were i n s t r u c t e d in Lamaze or Biofeedback did achieve more r e l a x a t i o n
(as measured) than women who were simply t o l d to r e l a x .
The i m p l i c a t i o n s f o r c l i e n t s a r e many and th e need i s g r e a t .
The f e a r o f pain i s s a i d to rank second only to the f e a r o f death
(Zborowski, 1969).
Pain i s the most f r e q u e n t and compelling reason
why a person seeks h e a l t h a s s i s t a n c e (Zborowski, 1969).
The f a c t t h a t
a s t r a t e g y e n a b li n g a person to r e l a x can be t a u g h t , and t h a t r e l a x a t i o n
d e c r e a s e s pain pro v id e s a conceptual umbrella f o r a l t e r n a t i v e nonin v a s i v e pain r e l i e f measures.
Pain i s a dynamic t h r e a t and a coping
s t r a t e g y must lend i t s e l f to th e complexity of t r e a t i n g p a in .
R el ax at io n
s t r a t e g i e s can be a p p l i e d to a l l th e phases o f p a i n , a n t i c i p a t i o n , p r e s ­
en ce , and a f t e r m a t h .
P a t i e n t s about to undergo pain producing t r e a t m e n t s
can be ai ded duri ng t h e i r r e c over y phase by previous i n s t r u c t i o n on s e l f induced r e l a x a t i o n and how to use i t to r e l i e v e p a in .
T h e ir a n x ie t y can
a l s o be reduced in t h e a n t i c i p a t i o n phase through th e use o f a s p e c i f i c
s t r a t e g y such as imagery, and group p a t i e n t e duca tio n c l a s s e s aimed a t
p r o v id i n g r e a l i s t i c e x p e c t a t i o n s .
Both, r e a l i s t i c e x p e c t a t i o n s and group
su p p o rt a r e known t o d e c r e a s e a n x i e t y o r t e n s i o n , th u s red uc in g pain
(Melzack, 1973).
41
P a t i e n t s who have ch ro nic pain can a l s o b e n e f i t from r e l a x a t i o n
as a pain r e l i e f measure.
Cancer v i c t i m s can supplement t h e i r a n a l g e s i a s
or u t i l i z e r e l a x a t i o n as a pain r e l i e v e r while aw ai ti n g t h e i r next pain
medication.
During debridement (p r es en c e ) a burn p a t i e n t can u t i l i z e r e ­
l a x a t i o n ( s p e c i f i c a l l y d i s t r a c t i o n ) to reduce th e pain o f th e t r e a t m e n t
a n d / o r supplement a pain m e d ic a ti o n .
S e v e r a l , as o f y e t u n t e s t e d , q u e s t i o n s a r i s e from t h e idea of
using r e l a x a t i o n as a pain r e l i e v e r .
F i r s t , in some c a s e s , burns f o r e x ­
ample, h e a l i n g may be speeded up by t h e r e l a x a t i o n due to t h e concomitant
vasodilation.
Second, in cases o f ch ro nic severe i n t e r m i t t a n t p a i n ,
h y p e rt e n s io n e x i s t s along with th e pe rsonal te n s i o n from t h e a n t i c i p a t i o n
of th e nex t p a i n f u l e p is o d e .
I t can be s p e c u la te d t h a t t h e s e c l i e n t s
would a l s o b e n e f i t from l e a r n i n g a s t r a t e g y and pre s en c e phase.
I t can
be f u r t h e r s p e c u l a t e d t h a t th e h y p e rt e nsi on would d e c r e a s e .
The l i s t could go on as to the u s e f u l n e s s o f r e l a x a t i o n in t h e '
phases o f p a i n , as well as a l l s ta g e s o f i l l n e s s .
But a n o t h e r f e a t u r e
o f t h i s dynamic t h e r a p y , r e l a x a t i o n , i s t h e way i t le nds i t s e l f to the
p r o f e s s i o n o f n u r s in g .
The i m p l i c a t i o n s f o r n u r s i n g a r e a l s o many.
In h e r e n t in the
n u r s e - c l i e n t e n co unt e r i s a r e l a t i o n s h i p b u i l t o f t r u s t , time and aimed
a t individualized care.
The nurs e who te ac he s r e l a x a t i o n the ra py to her
c l i e n t p ro v id e s th e c l i e n t with a f l e x i b l e th e ra p y because i t would a l ­
low t h e c l i e n t to u t i l i z e i t when h e /s h e needs i t (McCaffery, 1972).
42
This n u r s e - c l i e n t r e l a t i o n s h i p with i t s q u a l i t y o t t r u s t provides a
t h e r a p e u t i c c o n t e x t f o r optimum pain r e l i e f (Melzack, 1973).
The
t e a c h i n g f u n c t i o n o f th e p r o f e s s i o n a l nurs e a l s o helps to r e i n f o r c e th e
idea o f t h e nurse as a q u a l i f i e d p r o v i d e r in the use o f r e l a x a t i o n s t r a ­
t e g i e s with c l i e n t s .
This te a c h i n g f u n c t i o n i s not only a p r o f e s s i o n a l one, but a l s o
a perso nal one.
I f t h e t e a c h i n g o f s t r a t e g i e s to p ro vi de r e l a x a t i o n is.
to reach t h e c l i e n t , nur se s a t a l l l e v e l s must, f i r s t , become knowledge­
a b l e in th e s t r a t e g i e s a v a i l a b l e f o r pain r e l i e f .
Second, the nurses
must become r e s p o n s i b l e f o r e d u c a ti n g t h e i r c l i e n t s , whether s t u d e n t s ,
p e e r s , or p a t i e n t s , about th e use o f r e l a x a t i o n s t r a t e g i e s to reduce
pa in.
T h i r d , f u r t h e r r e s e a r c h i n t o the v a r i o u s r e l a x a t i o n s t r a t e g i e s
(yoga, T.M., d i s t r a c t i o n , massage) i s needed to e l a b o r a t e on how they
work, how the y a r e l e a r n e d , and how th e y a r e r e t a i n e d .
The v a s t number
o f c l i e n t s needing pain r e l i e f , as well as th e nurs in g p r o f e s s i o n , can
b e n e f i t from t h e s e s t e p s to become knowledgeable about such a promising
t r e a t m e n t mode.
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Journal o f
APPENDIX A
LIST OF TEXTS REVIEWED
The f o ll o w i n g t e x t books were reviewed f o r the u t i l i z a t i o n of
r e l a x a t i o n s t r a t e g i e s as a pain r e l i e f measure.
a t i o n were not mentioned in any o f them.
Strategies for relax ­
The g a t e - c o n t r o l the ory was
not u t i l i z e d e xc e pt in l i s t i n g s with an a s t e r i s k .
Advanced Concepts in C l i n i c a l Nu rs in g. Ed. Kay Corman K i n t z e l .
P h i l a d e l p h i a : J . B . L i p p i n c o t t , 1971.
A Text Book o f M ed ic a l- S ur gic a l N urs in g.
York: Putman, 1964.
B a r b a t a , Jean C.
New
C l i n i c a l Nursing: P a th o p h y s io lo g ic a l and Ps yc hological Approaches.
Ir en e L. Beland. New York: Macmillan, 1970.
*The C l i n i c a l P r a c t i c e o f M ed ic a l- Su r gic a l Nurs ing. M a r j o r i e Beyers,
Susan Dadas, Boston: L i t t l e and Brown, 1977.
Textbook o f M ed ic a l- Su r gi ca l N urs in g. L i l l i a n S h o l t i s B urnner.
P h i l a d e l p h i a : J .B . L i p p i n c o t t , 1970.
Promotion o f Phy sical Comfort and S a f e t y . V.G. F i s c h e r and A.F. Cono l l y . Dubuque: W.C. Brown Company, 1970.
Fundamentals o f Nursing: the human!sties and th e s c i e n c e s in n u r s i n g .
E.V. F u e r s t , L. Wolff, and MH. W e i t z e l . P h i l a d e l p h i a : J. B.
L i p p i n c o t t , 1974.
*Medica1-Surgica1 Nursing: A Conceptual Approach.
New York: McGraw-Hill, 1978.
Concepts Basic to N urs in g.
P. M i t c h e l l .
Nursing Concepts o f P r a c t i c e .
D. Orem.
Ed D.A. Jones.
New York:
New York:
McGraw-Hill, 1978
McGraw-Hill, 1971.
Care o f . t h e Adult P a t i e n t : M ed ic a l- Su r gic a l Nu rs in g.
P h i l a d e l p h i a : J . B . L i p p i n c o t t , 1971.
D.W. Smith.
Comprehensive P e d i a t r i c Nurs ing. G. S c i p i e n , M.U. Barnard, M. Chard,
J . Huve, P. P h i l l i p s . New York: McGraw-Hill, 1975.
47
Behavioral Concepts and Nursing I n t e r v e n t i o n s .
P h i l a d e l p h i a : J . B . L i p p i n c o t t , 1978.
Nursing:
Levels o f Health. I n t e r v e n t i o n .
P r e n t i c e - H a l l , 1978.
C . ' C ar ls o n , B. Blackwell.
A. Burgess.
\
New J e r s e y :
APPENDIX B
PATIENT CONSENT FORM
I am w i l l i n g to p a r t i c i p a t e in t h i s r e s e a r c h p r o j e c t concerned
with r e l a x a t i o n and pain p e r c e p t i o n .
Ms. Margo Cal dwe ll, a nurse and
a gr a d u a te s t u d e n t has ex p la i n ed th e procedures f o r the r e l a x a t i o n
s e s s i o n s , i n c l u d i n g th e use o f th e in s tr u m e n ts t h a t m onito r muscular
r e l a x a t i o n and te m p e r a t u r e .
I t i s my u n d e rs ta n d in g t h a t . b y p a r t i c i p a ­
t i n g in t h i s s t u d y , I w i l l meet with Ms. Caldwell f o r t h i r t y minute
r e l a x a t i o n s e s s i o n s , have a h i s t o r y t a k e n , and ta k e a s t a n d a r d i z e d
p s yc ho lo gic a l t e s t .
I am c l e a r l y aware t h a t t h e r e w i l l be no f i n a n ­
c i a l charge and my c o n f i d e n t i a l i t y w i l l be m a in ta in e d .
Although I have
signed t h i s c onsen t form, I may withdraw from t h i s stu dy a t any time
w it h o u t a d v e r s e l y a f f e c t i n g any o t h e r a s p e c t o f my p r e n a t a l c l a s s e s .
Signed:
Wit n e s s :
Date:
APPENDIX C
INTERVIEW. QUESTIONNAIRE
CL
I
ID:
AGE:
MARITAL STATUS:
EDC:
GRADE COMPLETED IN SCHOOL:
LANGUAGE:
RACE:
TYPE OF CHILDBIRTH EDUCATION:_____________________________
HISTORY
Have you e ver had a spontaneous a b o r t i o n o r m i s c a r r i a g e ?
Has yo ur d o c t o r e v e r t o l d you t h a t you a r e a t r i s k or a high r i s k ?
Do you have.any f e a r s t h a t t h i s pregnancy or l a b o r w i l l be e x c e p t i o n a l l y
difficult?
Have you ever e xper ien ce d what you would c o n s i d e r an extre mely pa in fu l
e xp er ie nc e ?
COMMENTS
APPENDIX D
INSTRUCTIONS FOR THE I-E SCALE
This i s a q u e s t i o n n a i r e t o f i n d out th e way in which c e r t a i n
im po rt an t e v e n ts in our s o c i e t y a f f e c t d i f f e r e n t p e i p l e .
c o n s i s t s o f a p a i r o f a l t e r n a t i v e s l e t t e r e d a o r b.
Each item
P le a s e s e l e c t
th e one s t a t e m e n t o f each pain (and only one) which you more s t r o n g l y
b e l i e v e to be th e case as f a r as y o u ' r e concerned.
Be s u re to s e l e c t
t h e one you a c t u a l l y b e l i e v e to be more t r u e r a t h e r than t h e one you
t h i n k you should choose o r th e one you would l i k e to be t r u e .
i s a measure o f perso nal b e l i e f :
This
obv io u s ly t h e r e a r e no r i g h t or
wrong answers.
P le a s e answer t h e s e items c a r e f u l l y but do not spend too much
time on any one item.
Be su re to f i n d an answer f o r ev ery cho ice.
Find t h e number o f t h e item on th e answer s h e e t and b l a c k - i n th e space
under t h e number I o r 2 which you choose as th e s t a t e m e n t more t r u e .
In some i n s t a n c e s you may d i s c o v e r t h a t you b e l i e v e both s t a t e ­
ments o r n e i t h e r one.
In such c a s e s , be su re to s e l e c t th e one you more
s t r o n g l y b e l i e v e t o be th e case as f a r as y o u ' r e concerned.
Also t r y
to respond to each item i n d e p e n d e n tl y when making your c h o i c e ; do not
be i n f l u e n c e d by your pre vio us c h o i c e s .
APPENDIX E
I-E SCALE
1.
a.
Children g e t i n t o t r o u b l e because t h e i r p a r e n t s punish them
too much.
b.
The t r o u b l e w ith most c h i l d r e n nowdays i s t h a t t h e i r p a r e n t s
a r e too easy with. them.
2.
a.
Many o f t h e unhappy th i n g s in p e o p l e ' s l i v e s a r e p a r t l y due to
bad luc k.
3.
b.
P e o p l e ' s m i s f o r t u n e s r e s u l t from th e m is ta k e s the y make.
a.
One o f t h e major re a so ns why we have wars i s because people
d o n ' t ta k e enough i n t e r e s t in p o l i t i c s ,
b.
There w i l l always be wars, no m a t t e r how hard people t r y to
p r e v e n t them.
4.
a.
In t h e long run people g e t the r e s p e c t th e y d e se rv e in t h i s .
world.
b.
U n f o r t u n a t e l y , an i n d i v i d u a l ' s worth o f t e n p a s s e s unrecognized
no m a t t e r how hard he t r i e s .
5.
a.
The idea t h a t t e a c h e r s a r e u n f a i r to s t u d e n t s i s nonsense.
b.
Most s t u d e n t s d o n ' t r e a l i z e t h e e x t e n t to which t h e i r grades
a r e i n f l u e n c e d by a c c i d e n t a l happenings.
6.
a.
Without t h e r i g h t breaks one cannot be an e f f e c t i v e l e a d e r ,
b.
Capable people who f a i l to become l e a d e r s have no t taken
advantage o f t h e i r o p p o r t u n i t i e s .
52
7.
a.
No m a t t e r how hard you t r y some people j u s t d o n ' t l i k e you.
b.
People who c a n ' t ge t o t h e r s to l i k e them d o n ' t understand
how t o g e t along with o t h e r s .
8.
a.
H e re d i ty pla ys t h e major r o l e in de te rm in in g o n e ' s p e r s o n a l i t y .
b.
I t i s o n e ' s e x p e r ie n c e s in l i f e which determine what t h e y ' r e
like.
9.
a.
I have o f t e n found t h a t what was going to happen w i l l happen.
b.
T r u s t i n g f a t e has never tu rn e d ou t as well f o r me as making a
d e c i s i o n to t a k i n g a d e f i n i t e co urs e o f a c t i o n .
10 .
a.
In t h e case o f t h e well prepa red s t u d e n t t h e r e i s r a r e l y i f
e v e r such a t h i n g as an u n f a i r t e s t .
b.
Many times exam q u e s t i o n s tend to be so u n r e l a t e d to course
work t h a t st ud y in g i s r e a l l y u s e l e s s .
11 .
a.
Becoming a su cc e ss i s m a t t e r o f hard work, luck has l i t t l e or
not hin g to do with i t .
b.
G e t t i n g a good j o b depends m ai nly on being in t h e f i g h t pla ce
a t t h e r i g h t time.
12.
a.
The average c i t i z e n can have an in f l u e n c e in government d e c i s i o n s
b.
This world i s run by th e few people in power, and t h e r e i s not
much t h e l i t t l e guy can do about i t .
13.
a.
When I make p l a n s , I am almost c e r t a i n t h a t I can make them ■
work.
b.
I t i s not always wise t o plan too f a r ahead because many th i n g s
t u r n o u t to be a m a t t e r o f good or bad f o r t u n e anyhow.
53
14.
15.
a.
There a r e c e r t a i n people who a r e j u s t no good,
b.
There i s some good in everybody.
a.
In my ca s e g e t t i n g what I want has l i t t l e o r n o th in g to do
with luc k.
b.
Many times we might j u s t as well de cide what to do by f l i p p i n g
a c oi n.
16.
a.
Who g e t s t o be t h e boss o f t e n depends on who was lucky enough
to be in t h e r i g h t pla ce f i r s t .
b.
G e tt in g to do t h e r i g h t t h i n g depends on a b i l i t y , luck has
l i t t l e o r not hin g to do with i t .
17.
a.
As f a r as world a f f a i r s a r e co ncerned, most o f us a r e v ic ti m s
o f f o r c e s we can n e i t h e r u n d e r s t a n d , or c o n t r o l ,
b.
By t a k i n g an a c t i v e p a r t in p o l i t i c a l and s o c i a l a f f a i r s the
people can c o n t r o l world e v e n t s .
18.
a.
Most people d o n ' t r e a l i z e t h e e x t e n t to which t h e i r l i v e s a re
c o n t r o l l e d by a c c i d e n t a l happenings,
19.
20.
b.
There i s r e a l l y no such t h i n g as "luck ".
a.
One should always be w i l l i n g to admit m i s t a k e s ,
b.
I t i s u s u a l l y b e s t to cover up o n e ' s m i s t a k e s .
a . . I t i s r e a l l y hard t o know whether o r not a person l i k e s you.
b.
How many f r i e n d s you have depends upon how n i c e a person you
are.
54
21 .
a.
In the long run t h e bad th i n g s t h a t happen to us a re balanced
by t h e good ones.
b.
Most m i s f o r t u n e s a re the. r e s u l t o f la ck o f a b i l i t y , ign or a nc e,
la z in e s s, or all three.
22.
a.
With enough e f f o r t we can wipe out p o l i t i c a l c o r r u p t i o n .
b.
I t i s d i f f i c u l t f o r people to have much c o n t r o l over the
t h i n g s p o l i t i c i a n s do in o f f i c e .
23.
a.
Sometimes I c a n ' t unde rstan d how t e a c h e r s a r r i v e a t the
grades t h e y giv e .
b.
There i s a d i r e c t conn ectio n between how hard I study and th e
grades I g e t .
24.
a.
A good l e a d e r e x p e c ts people to deci de f o r themselves what they
should do.
25.
b.
A good l e a d e r makes i t c l e a r t o everybody what t h e i r jo b s a r e .
a.
Many times I f e e l t h a t I have l i t t l e i n f l u e n c e over th e t h i n g s
t h a t happen to me.
b.
I t i s i m p o s si b le f o r me to b e l i e v e t h a t chance o r luck plays
an im po rt an t r o l e in my l i f e .
26.
a.
People a r e l o n e l y because the y d o n ' t t r y t o . b e f r i e n d l y .
b.
There i s no t much use in t r y i n g hard to p l e a s e p e o p le , i f
they l i k e y o u , they l i k e you.
27.
a.
There i s too much emphasis on a t h l e t i c s in high s c h o o l .
b.
Team s p o r t s a r e an e x c e l l e n t way to b u il d c h a r a c t e r .
55
a.
What happens to me i s my own doing.
b.
Sometimes I fe e l t h a t ! . d o n ' t have enough c o n t r o l over, the
d i r e c t i o n my l i f e i s t a k i n g .
a.
Most o f t h e time I c a n ' t underst and why p o l i t i c i a n s behave, the
way they do.
b.
.
.
.
In th e long run th e people a r e r e s p o n s i b l e f o r bad government
on a n a t i o n a l as well as on a l o c a l l e v e l .
.
APPENDIX F
BIOFEEDBACK TRAINING
Al I s u b j e c t s r e c e i v e d 5 s e s s i o n s o f 35 m in ute s .
Each se s si on
c o n s i s t e d o f a 5 minute b a s e l i n e , a 25 minute pe rio d o f feedback t r a i n ­
ing and a 5 minute b a s e l i n e .
darkened room.
S u b je c ts were s ea te d in r e c l i n e r s in a
Two a c t i v e and one ground s u r f a c e e l e c t r o d e (withi n 6
inches o f each o t h e r ) were pla ced on t h e r i g h t i n t e r c o s t a l muscle on
th e m idi nguin al l i n e below th e s ub co s ta l pla ne.
A porcelain thermistor
was a t t a c h e d to t h e t i p o f th e second f i n g e r on the r i g h t with n o n - a l l e r gic ta p e .
The e xpe r im e n t e r t o l d th e s u b j e c t s t h a t "the nex t 5 minutes you
a r e to j u s t q u i e t l y . "
EMG and te m p e ra t u re r e c o r d i n g s were monitored a t
30 second i n t e r v a l s .
A f t e r 5 minutes o f b a s e l i n e r e a d i n g s , th e e x p e r i ­
menter e n t e r e d t h e room and t o l d t h e s u b j e c t s they would g e t feedback f o r
relaxing.
"The tone you a r e going to hear means you a r e r e l a x i n g .
Your
t a s k du rin g the nex t 25 mi nutes i s t o t u r n th e tone on, t h a t means you
are relaxing.
Next you a r e to slow i t down, which means you a re becoming
more r e l a x e d . "
EMG and te m p e ra t u re re a d in g s were monito red a t 30 second
intervals.
A f t e r 25.m inutes th e e xper im en t er e n te r e d t h e room and tur ne d
o f f th e feedback.
next 5 m i n u t e s . "
The s u b j e c t s were t o l d to j u s t " s i t q u i e t l y f o r the
EMG and te m pe ratu re r e a d i n g s were monitored a t 30
second i n t e r v a l s f o r 5 minutes.
57
Feedback c o n s i s t e d o f a p r o p o r t i o n a l tone and was d e l i v e r e d
on a co nti nuo us sch ed ule .
The m i c r o v o l t t h r e s h o l d l e v e l f o r feedback
was lowered by ten p e r c e n t o f t h a t o f t h e previous s e s s i o n .
i t r e q u i r e d lower EMG s c o r e s to g e t feedback.
Thusi
At th e completion of
t h e s e f i v e s e s s i o n s th e s u b j e c t s were scheduled f o r th e t h r e e e x p e r i ­
mental s e s s i o n s .
MONTANA STATE UNIVERSITY LIBRARIES
762 1001 3165 3
Caldwell , ^ a r r o M arie
C12?
c o o .2
E f f e c t s o f v a r io u s c o p in r
s t r a t e g i e s ( lamaze v s . b i o ­
fe e lb ack v s . t e l l i n c ) on
r e l a x a t i o n as m e a su re ! by
and f i n g e r - t i p te m o e ra -