Ringkasan Jurnal

The effect of combination of spiritual deep breathing exercise therapy on pain and
anxiety in postoperative nonpatological orthopedic fracture patients

Nyeri akut dan kecemasan pada tingkat yang parah karena fraktur ortopedi pasca operasi
nonpatologis menyebabkan permintaan analgesik yang tinggi pada pasien. Menimbulkan
risiko tinggi efek samping obat-obatan seperti gatal-gatal, mual dan muntah, pusing, mulut
kering, perasaan lemah, gangguan penglihatan, dan sebagainya. Efek sampingnya akan
menyebabkan waktu pemulihan yang lama, ambulasi yang tertunda, dan perencanaan
pemulangan. Tujuan penelitian ini adalah untuk menjelaskan pengaruh kombinasi terapi
spiritual deep breathing exercise terhadap nyeri dan kecemasan pada pasien orthopedi post
operasi dengan fraktur nonpatologis. Kombinasi terapi spiritual deep breathing exercise
dapat memanipulasi mekanisme nyeri pada proses modulasi dimana terjadi interaksi antara
sistem analgetik endogen dengan pemasukan nyeri yang masuk ke korpus posterior sehingga
pemasukan nyeri dapat ditekan. Terapi latihan pernapasan dalam spiritual memodulasi rasa
sakit di tingkat tulang belakang dalam pengaturan aferen. Pada tingkat ini, targetnya adalah
modulasi zat agar-agar dengan tujuan memberikan penghambatan pada transmisi impuls
nyeri. Sesuai dengan teori gate control, terapi spiritual latihan nafas dalam dapat merangsang
banyak endorfin menghambat pelepasan zat yang dikeluarkan oleh neuron delta-A dan C
yang mempersepsikan nyeri sehingga input dominan berasal dari serat beta-A, yang akan
menutup mekanisme pertahanan.

Desain penelitian ini adalah penelitian eksperimen semu dengan desain pre-post test control
group design. Sampel dalam penelitian ini adalah pasien ortopedi pasca operasi dengan
fraktur nonpatologis dengan jumlah sampel 28 responden. Teknik pengambilan sampel
menggunakan purposive sampling. Sebanyak 28 responden terbagi menjadi 14 responden
pada kelompok perlakuan dan 14 responden pada kelompok kontrol. Teknik pengambilan
sampel menggunakan nonprobability sampling dengan purposive sampling. Variabel bebas
dalam penelitian ini adalah latihan nafas dalam spiritual. Variabel terikat dalam penelitian
ini adalah skala nyeri dan tingkat kecemasan pada pasien fraktur ortopedi nonpatologis
pascaoperasi. Instrumen yang digunakan adalah kuesioner yang mengukur tingkat nyeri
menggunakan Numeric Rating Scale (NRS) dan untuk mengukur kecemasan menggunakan
Hamilton Anxiety Rating Scale (HARS) Questionnaire. Hasil penelitian dianalisis
menggunakan uji Wilcoxon dan uji Mann-Whitney. Hasil penelitian menunjukkan bahwa
ada pengaruh kombinasi terapi spiritual latihan nafas dalam terhadap tingkat nyeri (p=0,000)
dan tingkat kecemasan (p=0,001) pada pasien fraktur ortopedi nonpatologis pasca operasi.
Terapi spiritual deep breathing exercise terbukti efektif menurunkan tingkat nyeri dan
kecemasan pada pasien orthopedi post operasi sehingga dapat direkomendasikan sebagai
pilihan terapi komplementer dalam penanganan nyeri post operasi yang murah, mudah, dan
aman.
 EurAsian Journal of BioSciences
Eurasia J Biosci 14, 1625-1631 (2020)

The effect of combination of spiritual deep breathing

exercise therapy on pain and anxiety in postoperative
nonpatological orthopedic fracture patients
Ah. Yusuf 1*, Miranti Florencia Iswari 1, Sriyono Sriyono 1, Esti Yunitasari 1
1
Faculty of Nursing, Universitas Airlangga, Surabaya, INDONESIA
*Corresponding author: ah-yusuf@fkp.unair.ac.id

Abstract
Acute pain and anxiety at the severe level because of postoperative orthopedic fractures of
nonpathological causes high analgesic demand in patients. It causes a high risk of side effects of
drugs such as pruritus, nausea and vomiting, dizziness, dry mouth, weak feelings, visual
disturbances, and so on. The side effects will lead to prolonged recovery time, delayed ambulation,
and discharge planning. The purpose of this study was to explain the effect of a combination of
spiritual deep breathing exercise therapy on pain and anxiety in postoperative orthopedic patients
with nonpathological fractures. The design of this study was a quasi-experimental study design with
a pre-post test control group design. The sample in this study were postoperative orthopedic patients
with nonpathological fractures with a sample of 28 respondents. The sampling technique used
purposive sampling. The variable in this study was spiritual deep breathing exercise therapy for pain
and anxiety. The instrument used was a questionnaire. The results of the study were analyzed using
the Wilcoxon test and the Mann-Whitney test. The results showed that there was an effect of a
combination of deep breathing exercise spiritual therapy on pain levels (p=0.000) and anxiety levels
(p=0.001) in post-operation nonpathological orthopedic fracture patients. Spiritual deep breathing
exercise therapy has proven to be effective in reducing the level of pain and anxiety in postoperative
orthopedic patients so that it can be recommended as a complementary therapy option in the
management of postoperative pain that is cheap, easy, and safe.

Keywords: anxiety, deep breathing exercise, pain, spiritual

Yusuf Ah, Iswari MF, Sriyono S, Yunitasari E (2020) The effect of combination of spiritual deep
breathing exercise therapy on pain and anxiety in postoperative nonpatological orthopedic fracture
patients. Eurasia J Biosci 14: 1625-1631.

© 2020 Yusuf et al.

This is an open-access article distributed under the terms of the Creative Commons Attribution License.

INTRODUCTION Nonpathological fractures are the incidence of

Acute pain is still found in postoperative
nonpathological fracture patients who have received
analgesics. This is because all surgeries in the
orthopedic unit will result the different intensity and
duration of acute pain from other system units due to the
variant degree of damage from the superficial, soft
tissue, bone exposed, blood vessels to nerves (Chelly et
al., 2003; Parvizi et al., 2011; Stein et al., 2012; Chelly
et al., 2010; Moore et al., 2013; Shirkavand et al., 2018;
Sudewi et al., 2015; Ruslin et al., 2019). The high
demand of analgesic to reduce the pain in these patients
is in line with the increasing of side effects of drugs such
as pruritus, nausea, and vomiting, dizziness, dry mouth,
feeling weak, impaired vision, palpitations, sedation,
confusion, agitation, urine retention to constipation
(Zehnder et al., 2009; Günther et al., 2018; Del Vecchio
et al., 2017; Ohlan et al., 2017; Berna et al., 2017;
Beubler, 2015; Cavallone et al., 2020; Mercadante,
2019; La Rochelle et al., 2018).
orthopedic cases of more than 60% and occupy more
than 50% of beds in various hospitals (Helmi, 2012;
Rasjad, 2012; Soleimanha et al., 2018; Helmi, 2012).
Pain in postoperative orthopedic patients has a longer-
lasting pain effect during recovery (Chelly et al., 2003).
Interviews with the head of Muhammadiyah Hospital
room showed that some of the patients requested to be
given analgesics again after 2 hours of the first
administration. Preliminary research conducted at
Muhammadiyah Hospital on three patients on the first
day after orthopedic surgery showed one patient
complained of pain on a scale of 7 and anxious score of
28, 2 patients complained of pain on a scale of 6 and
anxious scores of 27 and 25 respectively. This data is
supported by several studies including 25-50% of
postoperative orthopedic patients reporting pain in
Received: March 2020
Accepted: May 2020
Printed: June 2020

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EurAsian Journal of BioSciences 14: 1625-1631 (2020)
severe scales (Huang et al., 2001). Acute pain occurs in
39-97% of patients post orthopedic surgery
(Büyükyılmaz et al., 2011). Of the 60 patients, the
majority complained of pain when interviewed on the
second day after orthopedic surgery (Bergh et al., 2005).
Untreated or mismanaged of pain can cause a decrease
in metabolism. It creates an increase in blood
coagulation, fluid retention, fatigue, anxiety, decreased
of nutritional status, sleep disturbances, and obstructed
discharge planning so that it will affect to the length of
stay, cost management, and patient satisfaction (Good
et al., 1999). As many as 12% of post-orthopedic
surgery, patients experience prolonged ambulation,
which mostly involves pain and anxiety (Chelly et al.,
2003; Moore et al., 2013; Hebl et al., 2008; Jenstrup et
al., 2012; Muenster et al., 2012). It requires nurses to
think critically to develop interventions by integrating the
mind-body-spirit principles and modalities that need
evidence-based practice in providing safety and comfort
to patients (Widyatuti, 2008).
Several studies have been carried out as an effort to
manage the non-pharmacological treatment of post-
orthopedic pain in patients. It includes Deep Breathing
Exercise (DBE), music therapy, and combination
therapies such as DBE and guided imagery, hypnosis
and DBE, also relaxation and back massage techniques
(Engwall & Duppils, 2009; Abd El- Kader, 2018; Lim et
al., 2014; Nelson et al., 2013; Nurdin et al., 2013;
Büyükyılmaz & Aştı, 2013). But the effectiveness of
various therapies in the pain reduction is not significant
because it uses multiple methods, parameters, and
implementation procedures that cannot be applied
universally. So far, acute pain that is still found in
postoperative nonpathological orthopedic fractures after
the administration of ketorolac analgesics has not yet
been resolved. The results of several previous studies
on the use of non-pharmacological interventions in
postoperative orthopedic pain cannot be generalized.
The combination of two or more empirically proven
therapies will be more effective than a single treatment
(Good, 1992). However, the combination of non-
pharmacological treatments in various studies has
varied effectiveness. DBE and guided imagery have not
been able to show significant results, especially in the
pain of postoperative orthopedic patients (Nelson et al.,
2013). Music as a distraction technique to reduce
anxiety used is still varied, not focused on one choice of
music, so it cannot be applied to all samples (Lim et al.,
2014). While the combination of DBE with hypnosis and
back massage, can only be done by a trained
therapist/nurse and the effectiveness precisely in
postoperative orthopedic patients has not been much
studied ((Lim et al., 2014; Büyükyılmaz et al., 2013). In
the above studies, DBE is most often combined with
several other types of therapy because it is a natural,
inexpensive, and safe intervention to be performed in
post orthopedic surgery patients. The combination with
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Yusuf et al.
the spiritual response is believed to reduce pain and
anxiety more optimally because an individual’s spiritual
belief in his religion is more universal and can make
positive perceptions. Zulkurnaini et.al in 2012 proves
that the verses of the Koran can increase the Alpha band
signal which causes a more calming state (more
relaxing) (Zulkurnaini et al., 2012).
In spiritual DBE therapy, before and during DBE,
Murrotal Ar-Rahman will be played beautifully and has a
tempo of 79.8 bpm. The auditory perception of surah Ar-
Rahman works at the auditory center in the frontal lobe,
which then sends signals to the thalamus and prefrontal
cortex (PFC) so that it will affect patient perceptions
positively. Positive perception changes the amygdala. It
will be passed on to the hypothalamus to produce the
Corticotropin-Releasing Factor (CRF). Furthermore,
CRF stimulates the pituitary to secrete endorphins as
neurotransmitters that affect the mood to relax (Black et
al., 2005). Also, when the body does the DBE correctly
and regularly, it will reduce oxygen consumption,
respiratory frequency, heart frequency, and muscle
tension and cause the body to be at high concentrations.
It will activate alpha waves in the brain, which stimulates
endorphin release. In gate control theory, high levels of
endorphins will inhibit the release of substance P by
delta-A and C neurons that perceive pain. The dominant
input comes from beta-A fibers, which will close the
defense mechanism (the gate), so the message
delivered in the cortex is stimulation modulation and not
pain (Potter et al., 2009).
From the background, the researchers decided to
combine two non-pharmacological methods, namely
deep breathing exercise and spiritual therapy, to relieve
pain and anxiety in postoperative orthopedic patients
with nonpathological fractures.
METHODS
This study used a quasi-experimental design with a
pre-post test control group design. A total of 28
respondents divided into 14 respondents in the
treatment group and 14 respondents in the control
group. The sampling technique used nonprobability
sampling with purposive sampling. The independent
variable in this study was spiritual deep breathing
exercises. The dependent variable in this study was the
pain scale and anxiety level in postoperative
nonpathological orthopedic fracture patients. The
instrument used was a questionnaire measuring pain
levels using the Numeric Rating Scale (NRS) and to
measure anxiety using the Hamilton Anxiety Rating
Scale (HARS) Questionnaire. The data analysis to
measure the difference between the mean level of pain
and anxiety before and after the intervention using
Wilcoxon with a degree of significance α <0.05.
Whereas the statistical test used to see the difference in
mean pain levels between the intervention and control
EurAsian Journal of BioSciences 14: 1625-1631 (2020) Yusuf et al.

Table 1. Frequency distribution of patient respondents of post-surgery nonpathological orthopedic fractures in

Muhammadiyah hospital
Control group Intervention Group Total
Variable
n % n % n %
Age
Teenager (13-16 years old) 1 7.1 2 14.3 3 10.7
Young Adult (17-40 years old) 8 57.1 5 35.8 13 46.4
Middle-aged (41-60 years old) 5 35.8 7 50.0 12 42.9
TOTAL 14 100 14 100 28 100
Gender
Male 11 78.6 11 78.6 22 78.6
Female 3 21.4 3 21.4 6 21.4
TOTAL 14 100 14 100 28 100
Surgical History
Never 8 57.1 7 50.0 15 53.6
Ever 6 42.9 7 50.0 13 46.4
TOTAL 14 100 14 100 28 100

Table 2. Pain and anxiety level of postoperative orthopedic patients with nonpathological fractures before and after
intervention in the intervention group on the first to the second day
Time Control group Intervention Group
measurement Mean Median Elementary school p-value Mean Median Elementary school p-value
Pain level
Pre-1 7.71 8.00 0.469 7.64 8.00 0.497
Post-1 7.21 7.00 0.699 6.64 7.00 0.497
Pre-2 7.43 7.00 0.514 6.64 7.00 0.497
Post-2 6.43 6.00 0.514 5.79 6.00 0.699
0.001 0.000
Pre-3 6.57 7.00 0.514 5.71 6.00 0.611
Post-3 5.79 6.00 0.579 4.50 4.00 0.650
Pre-4 6.43 6.00 0.514 4.57 4.50 0.646
Post-4 5.43 5.00 0.514 3.79 4.00 0.579
Anxiety level
Pre-1 28.21 28:00 2.887 28.36 28.50 2.205
Post-1 28.29 28.50 3.148 27.14 27.50 2.214
Pre-2 27.71 28:00 2.840 26.36 27.00 2.205
Post-2 25.71 25.50 2.758 24.86 25.50 2.656
0.001 0.001
Pre-3 25.14 25.00 2.445 25.00 26.00 2.882
Post-3 24.21 24.00 2.007 10.00 23.00 3.328
Pre-4 23.93 23.00 2.093 21.14 10.00 2.983
Post-4 22.71 10.00 2.128 18.93 8.00 2.921

Table 3. The mean difference in pain and anxiety level after the procedure between the control and the intervention group
Variable n Mean Ranks Sum of Ranks Mann-Whitney U p-value
Pain Level
Control group 14 7.79 109.00
4,000 0.000
Intervention group 14 21.21 297.00
Anxiety Level
Control group 14 9.43 132.00
27,000 0.001
Intervention group 14 19.57 274.00

groups used the Mann-Whitney test. This research has
received research ethics-worthy permits from the
research ethics committee.
RESULTS
Table 1 shows that the most age distribution is the
young adult age group of 8 people (57.1%). The majority
of the sex of the respondents were male, namely 11
people (78.6%), and most of the study respondents had
never experienced a history of surgery before as many
as eight people (57.1%).
Table 2 shows the Wilcoxon test results on the level
of pain in the intervention group obtained p=0.000, which
means that there is a combination of spiritual deep
breathing exercise therapy on pain before and after the
intervention. The test results on the control group
obtained p=0.001. It means that there is an influence of
standard procedures on pain before and after the
intervention.
Wilcoxon test results on the level of anxiety of the
intervention group obtained all p=0.001, which means
that there is an effect of a combination of deep breathing
exercise spiritual therapy on anxiety. Wilcoxon test
results on the level of stress in the control group
obtained p=0.001, which means that there is an
influence of standard procedures on anxiety.
From Table 3, the statistical test results on pain
levels using Mann-Whitney obtained p=0.000, which
means there are significant differences in the mean pain
level of respondents after the procedure between the
intervention and the control group. While the results of
statistical tests on anxiety levels using Mann-Whitney
obtained p=0.001, which means also there is significant
differences in the average of anxiety level of
respondents after the procedure between the

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EurAsian Journal of BioSciences 14: 1625-1631 (2020)
intervention and the control group. Thus, the provision of
a combination of deep breathing exercises spiritual
therapy is more effective in reducing pain and anxiety
levels in post-operative nonpathological orthopedic
patients at Muhammadiyah Hospital.
DISCUSSION
The specificity of pain in patients with
nonpathological orthopedic fractures is acute pain in
which tissue damage occurs not only due to surgical
incision but also the other trauma, which is an indication
of nonpathological orthopedic fracture surgery (Chelly et
al., 2003; Devin et al., 2014; Pasero and McCaffery,
2007; Reuben and Buvanendran, 2007).
The roles of nurses in overcoming pain, pain
response, and side effects from the administration of
pain drugs are one of the efforts in providing
comprehensive nursing care services. The pain
management is the collaboration of the health service
team for the benefit of patients (Rospond, 2008;
Rowlingson, 2003).
Following research conducted by Nurdin, Killing, &
Rottie in 2013 also showed the same thing that Deep
Breathing Exercise (DBE) was effective in reducing pain
in postoperative orthopedic patients with the severe pain
scale (Nurdin et al., 2013). It is in line with this study, the
reduction in pain levels in the intervention group who
received relaxation therapy was greater than in the
control group who only received standard therapy
ketorolac 30 mg intravenous ampoule. Distraction
therapy interventions (music, etc.) were given on the first
and second postoperative days (Good et al., 1999;
Rohmah, 2007). It is an attempt to stimulate endorphin
release as soon as possible. The reduction in pain was
greater in the intervention group compared to the control
group due to an increase in endorphins. These alpha
waves can stimulate the release of β-endorphins and
serotonin, which have a role in the analgesia system. β-
endorphins have a high affinity for μ opioid receptors
(Büyükyılmaz and Aştı, 2013).
The combination of deep breathing exercise spiritual
therapy can manipulate the mechanism of pain in the
modulation process where interaction occurs between
the endogenous analgesic system with the intake of pain
entering the posterior corpus so that the intake of pain
can be suppressed. Spiritual deep breathing exercise
therapy modulates pain at the spinal level in the afferent
arrangement. At this level, the target is the modulation
of the gelatinous substance with the aim of giving
inhibition to the transmission of pain impulses. In
accordance with gate control theory, deep breathing
exercise spiritual therapy can stimulate many
endorphins inhibits the release of substances released
by delta-A and C neurons that perceive pain so that the
dominant input comes from beta-A fibers, which will
close the defense mechanism (the gate). So the
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Yusuf et al.
message delivered in the cortex is the stimulation of
modulation and causes less pain (Potter et al., 2009). In
this study, the side effects of using analgesics can also
be reduced because patients can be recommended to
reduce the dose of analgesic consumption. It will help in
reducing patient costs and increasing patient
satisfaction with nursing services. Analgesic
administration is a standard procedure in postoperative
orthopedics.
Both groups are categorized as severe anxiety. The
same as the level of pain of each group, which is also
classified as severe pain. It is consistent with the theory
that autonomic seizure patterns are the same in pain and
anxiety. Severe pain often causes severe anxiety (Potter
et al., 2009; Pardosi et al., 2018). It is because the
relationship between pain and anxiety is complex.
Anxiety often increases pain perception, but pain can
also cause feelings of anxiety (Nasution et al., 2018;
Aras and Ahmad, 2018; Juanita, 2007). The pain
stimulus activates parts of the limbic system that are
believed to control one’s emotions, especially anxiety.
The limbic system can process emotional reactions to
pain, i.e., worsen or eliminate pain. It’s hard to separate
the two sensations. Spiritual deep breathing exercise
therapy has been shown to reduce anxiety greater and
more significantly than only standard therapy (ketorolac)
in postoperative orthopedic patients.
The results of this study are in line with research
conducted by Elizabeth et al. In 2013 in which a
combination of DBE and guided imagery therapy
techniques can reduce anxiety and depression in
postoperative patients (Nelson et al., 2013). Spiritual
DBE therapy is a combination of therapies that is
believed to reduce pain and anxiety in postoperative
nonpathological orthopedic fractures more effectively. In
fact, in this research, the spiritual element is very
effective in generating positive perceptions that cause a
state of relaxation in post-orthopedic surgery patients. A
study conducted by Nurliana in 2011 found that the
stimulation of Al-Quran verses for mothers by curettage
can reduce anxiety. Qadri’s research in 2003 states that
after reciting Al-Quran to some patients in the hospital,
97% of patients feel peaceful and get faster recovery of
the disease (Qadri, 2003). Respondents after read Al-
Quran readings patients become peaceful and their
brain waves from accelerating motion (12-13 dB per
second) become slower (8-18 dB per second) so that
patients feel more comfortable (Elzaky, 2011). It can be
caused by perception. Pain is strongly influenced by
subjective factors, although the mechanism is unclear.
Pain can last for hours to days. This phase begins at the
time when the nociceptors have sent signals to the
reticular and thalamus formations. The sensation of pain
enters the center of consciousness and effects. This
signal is then continued to the limbic area. This area
contains cells that can regulate emotions. This area will
process emotional reactions to pain. This process takes
EurAsian Journal of BioSciences 14: 1625-1631 (2020) Yusuf et al.

place so quickly that a pain stimulus can immediately CONCLUSION

produce emotions in the form of anxiety. Relaxation can
stimulate the reward center so that calm arises. Midbrain
will release gamma-aminobutyric acid (GABA),
enkephalin, and beta-endorphin. These substances can
cause analgesia effects that will eliminate pain
neurotransmitters at the center of bodily sensory
perception and interpretation of the brain so that pain will
be reduced/lost. Pain that decreases/disappears directly
will again send a signal to the limbic area, which causes
emotions in the form of anxiety also decrease/disappear.
Spiritual deep breathing exercise therapy can reduce
pain in patients with nonpathological orthopedic fracture
surgery. Pain reduction in patients who received
analgesic therapy (ketorolac) plus mental deep
breathing exercise therapy was greater and significant.
Spiritual deep breathing exercise therapy can reduce
anxiety in postoperative nonpathological orthopedic
fracture patients. The reduction in stress of patients who
received analgesic therapy (ketorolac) plus mental deep
breathing exercise therapy was higher and more
significant.

REFERENCES
Abd El- Kader SM (2018) Impact of respiratory muscle training on blood gases and pulmonary function among
patients with cervical spinal cord injury. Electronic Journal of General Medicine, 15(3): em15.
https://doi.org/10.29333/ejgm/85190
Aras D, Ahmad H (2018) The efficacy of physiotherapy combination technique on pain and functional independence
of people with lumbar disc herniation. Indian Journal of Public Health Research & Development, 9(8): 1524-1529.
https://doi.org/10.5958/0976-5506.2018.00949.X
Bergh I, Gunnarsson M, Allwood J, Oden A, Sjöström B, Steen B (2005) Descriptions of pain in elderly patients
following orthopaedic surgery. Scandinavian journal of caring sciences, 19(2): 110-118.
https://doi.org/10.1111/j.1471-6712.2005.00331.x
Berna C, Kirsch I, Zion SR, Lee YC, Jensen KB, et al. (2017) Side effects can enhance treatment response through
expectancy effects: an experimental analgesic randomized controlled trial. Pain, 158(6): 1014.
Beubler E (2015) Side effects of analgesic drugs. What do we have to consider? . Chir Prax. 80: 141–148.
Black JM, Hawks JH (2005) Medical-surgical nursing. Elsevier Saunders.
Büyükyılmaz F, Aştı T (2013) The effect of relaxation techniques and back massage on pain and anxiety in Turkish
total hip or knee arthroplasty patients. Pain Management Nursing, 14(3): 143-154.
Büyükyılmaz FE, Şendir M, Acaroğlu R (2011) Evaluation of night-time pain characteristics and quality of sleep in
postoperative Turkish orthopedic patients. Clinical nursing research, 20(3): 326-342.
Cavallone LF, Montana MC, Frey K, Kallogjeri D, Wages JM, et al. (2020) The metabotropic glutamate receptor 5
negative allosteric modulator fenobam: pharmacokinetics, side effects, and analgesic effects in healthy human
subjects. Pain, 161(1): 135-146.
Chelly JE, Ben-David B, Williams BA, Kentor ML (2003) Anesthesia and postoperative analgesia: outcomes following
orthopedic surgery. Orthopedics, 26(8): S865-S871.
Chelly JE, Ghisi D, Fanelli A (2010) Continuous peripheral nerve blocks in acute pain management. British journal
of anaesthesia, 105(suppl_1): i86-i96.
Del Vecchio G, Spahn V, Stein C (2017) Novel opioid analgesics and side effects.
https://doi.org/10.1021/acschemneuro.7b00195
Devin CJ, Lee DS, Armaghani SJ, Bible J, et al. (2014) Approach to pain management in chronic opioid users
undergoing orthopaedic surgery. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 22(10):
614-622.
Elzaky J (2011) Buku Induk Mukjizat Kesehatan Ibadah. Jakarta: Zaman.
Engwall M, Duppils GS (2009) Music as a nursing intervention for postoperative pain: a systematic review. Journal
of perianesthesia nursing, 24(6): 370-383.
Good M, Stanton-Hicks M, Grass JA, Anderson GC, Choi C, Schoolmeesters LJ, Salman A (1999) Relief of
postoperative pain with jaw relaxation, music and their combination. Pain, 81(1-2): 163-172.
https://doi.org/10.1016/S0304-3959(99)00002-0
Good MPL (1992) Comparison of the effects of relaxation and music on postoperative pain (Doctoral dissertation,
Case Western Reserve University).

1629
EurAsian Journal of BioSciences 14: 1625-1631 (2020) Yusuf et al.

Günther T, Dasgupta P, Mann A, Miess E, et al. (2018) Targeting multiple opioid receptors–improved analgesics
with reduced side effects?. British journal of pharmacology, 175(14): 2857-2868.
Hebl JR, Dilger JA, Byer DE, Kopp SL, et al. (2008). A pre-emptive multimodal pathway featuring peripheral nerve
block improves perioperative outcomes after major orthopedic surgery. Regional Anesthesia & Pain Medicine,
33(6): 510-517. https://doi.org/10.1016/j.rapm.2008.04.008
Helmi ZN (2012) Buku ajar gangguan muskuloskeletal. Jakarta: Salemba Medika, 296.
Huang N, Cunningham F, Laurito CE, Chen C (2001) Can we do better with postoperative pain management?. The
American Journal of Surgery, 182(5): 440-448.
Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, et al. (2012) Effects of A dductor‐C anal‐B lockade on pain and
ambulation after total knee arthroplasty: a randomized study. Acta anaesthesiologica Scandinavica, 56(3): 357-
364.
Juanita F (2007) Teknik Distraksi Audio Visual Menurunkan Tingkat Kecemasan Anak Usia Sekolah yang Menjalani
Sirkumsisi. Jurnal Ners, 2(2): 95-99.
La Rochelle AD, Guillemyn K, Dumitrascuta M, Martin C, et al. (2018) A bifunctional-biased mu-opioid agonist–
neuropeptide FF receptor antagonist as analgesic with improved acute and chronic side effects. Pain, 159(9):
1705-1718.
Lim YC, Yobas P, Chen HC (2014) Efficacy of relaxation intervention on pain, self-efficacy, and stress-related
variables in patients following total knee replacement surgery. Pain Management Nursing, 15(4): 888-896.
https://doi.org/10.1016/j.pmn.2014.02.001
Mercadante S (2019) Opioid Analgesics Adverse Effects: The Other Side of the Coin. Current Pharmaceutical
Design, 25(30): 3197-3202.
Moore JG, Ross SM, Williams BA (2013) Regional anesthesia and ambulatory surgery. Current Opinion in
Anesthesiology, 26(6): 652-660.
Muenster T, Mueller C, Forst J, Huber H, Schmitt HJ (2012) Anaesthetic management in patients with Duchenne
muscular dystrophy undergoing orthopaedic surgery: a review of 232 cases. European Journal of
Anaesthesiology (EJA), 29(10): 489-494. https://doi.org/10.1097/EJA.0b013e3283566789
Nasution IK, Lubis NDA, Amelia S (2018) The correlation of pain intensity and quality of life in chronic LBP patients
in Adam Malik general hospital. In: L. W, D. W, W. M, et al. (eds). Neurology Department, Faculty of Medicine,
Universitas Sumatera Utara, Medan, Indonesia: Institute of Physics Publishing, 2018.
https://doi.org/10.1088/1755-1315/125/1/012183
Nelson EA, Dowsey MM, Knowles SR, Castle DJ, et al. (2013) Systematic review of the efficacy of pre-surgical
mind-body based therapies on post-operative outcome measures. Complementary therapies in medicine, 21(6):
697-711.
Nurdin S, Kiling M, Rottie J (2013) Pengaruh teknik relaksasi terhadap intensitas nyeri pada pasien post operasi
fraktur di ruang Irina A BLU RSUP Prof Dr. RD Kandou Manado. Jurnal Keperawatan, 1(1).
Ohlan R, Nanda S, Pathak D (2017) Analgesic prodrugs for combating their side-effects: rational approach. Current
Drug Delivery, 14(1): 16-26. https://doi.org/10.2174/1567201813666160504100705
Pardosi MC, Loebis B, Husada MS (2018) The level of depression in lower back pain patient at outpatient of
neurology Haji Adam Malik hospital Medan (RS HAM). E&ES, 125(1): 012182.
Parvizi J, Miller AG, Gandhi K (2011) Multimodal pain management after total joint arthroplasty. JBJS, 93(11): 1075-
1084. https://doi.org/10.2106/JBJS.J.01095
Pasero C, McCaffery M (2007) Orthopaedic postoperative pain management. Journal of PeriAnesthesia Nursing,
22(3): 160-174.
Potter PA, Perry AGE, Hall AE, Stockert PA (2009) Fundamentals of nursing. Elsevier mosby.
Qadri MA (2003) Quranic therapy heal yourself. USA: Islamic Educational Cultural Research Center of North
America.
Rasjad C (2012) Pengantar ilmu bedah ortopedi: Kelainan degeneratif tulang dan sendi. Ed III Jakarta PT Yars
Watampone: 196–204.
Reuben SS, Buvanendran A (2007) Preventing the development of chronic pain after orthopaedic surgery with
preventive multimodal analgesic techniques. JBJS, 89(6): 1343-1358. https://doi.org/10.2106/JBJS.F.00906
Rohmah N (2007) Efektifitas Distraksi Visual dan Pernafasan Irama Lambat dalam Menurunkan Nyeri Akibat Injeksi
Intra Kutan. Jurnal Ners, 2(1).

1630
EurAsian Journal of BioSciences 14: 1625-1631 (2020) Yusuf et al.

Rospond MR (2008). Pemeriksaan dan Penilaian Nyeri. Diambil dari URL: lyrawati. files. wordpress.
com/2008/.../pemeriksan-dan-penilaian-nyeri. pd.
Rowlingson JC (2003) Acute pain management revisited. Anesthesia and Analgesia, 14: 87-95.
Ruslin M, Brucoli M, Boffano P, Forouzanfar T, Benech A (2019) Maxillofacial fractures associated with sport injuries:
a review of the current literature. Otorinolaringologia, 69(3): 165-170. https://doi.org/10.23736/S0392-
6621.19.02215-X
Shirkavand L, Abbaszadeh A, Borhani F, Momenyan S (2018) Correlation between spiritual well-being with
satisfaction with life and death anxiety among elderlies suffering from cancer. Electronic Journal of General
Medicine, 15(3): em20. https://doi.org/10.29333/ejgm/85501
Soleimanha M, Salari A, Khosousi D, Karimi A, Hemmati M (2018) Comparison of the anxiety and satisfaction level
of the patients under fracture plating treatment type c1 and c2 of distal femur in the two groups of combination
drugs (gabapentin, celecoxib, and acetaminophen) and placebo. Electronic Journal of General Medicine, 15(4):
em45. https://doi.org/10.29333/ejgm/85678
Stein BE, Srikumaran U, Tan EW, Freehill MT, Wilckens JH (2012) Lower-extremity peripheral nerve blocks in the
perioperative pain management of orthopaedic patients: AAOS exhibit selection. JBJS, 94(22): e167.
Sudewi, Harahap U, Arifin H (2015) Prospective study effect of drug related problems (DRPs) reduction of drug
effects on pain patients remover ward in post surgery ortopedi haji adam malik general hospitals in Medan. Int J
PharmTech Res. 8: 189–192.
Widyatuti W (2008) Terapi komplementer dalam keperawatan. Jurnal Keperawatan Indonesia, 12(1): 53-57.
https://doi.org/10.7454/jki.v12i1.200
Zehnder J, Katzung SM, Trevor A (2009) Basic and clinical pharmacology. McGraw-Hill Medical, New York.
Zulkurnaini NA, Kadir RSSA, Murat ZH, Isa RM (2012, February) The comparison between listening to Al-Quran
and listening to classical music on the brainwave signal for the alpha band. In 2012 Third International
Conference on Intelligent Systems Modelling and Simulation (pp. 181-186). IEEE.
https://doi.org/10.1109/ISMS.2012.60

www.ejobios.org

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