Reverse Abdominal Breathing and Music Intervention on Reducing Pain and Anxiety During Screening Digital Mammography

The purpose of this study was to determine whether the reverse abdominal breathing or music intervention before and during mammography decreases the subjective reports of pain and anxiety during screening mammography. A total of 150 subjects were enrolled in this study: 50 subjects in the reverse abdominal breathing group (52.88 ± 6.67 years old), 50 in the music group (50.42 ± 5.54 years old), and 50 in the control group (51.52 ± 5.17 years old). The measures included State Trait Anxiety Inventory (STAI) questionnaire and 11-point numeric rating scale (NRS) of anxiety and pain. Results showed the NRS score during mammography (NRSduring) of the anxiety was lower than the NRS score before mammography (NRSbefore) of the anxiety in both reverse abdominal breathing (p=0.001) and music intervention groups (p=0.02). No significant difference was found between NRSduring and NRSbefore in anxiety in the control group (p=0.90). No significant differences were found in the NRSduring of pain among the reverse abdominal breathing, music intervention and control group (p=0.79). In conclusion, the reverse abdominal breathing and music intervention before and during mammography decreased the anxiety during mammography. However, there was no reported benefit on pain reduction during mammography. Correspondence Author to: I-Hsin Yeh Department of Medical Imaging, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan No. 482, San-Ming Road, Hsiao-Kang, Kaohsiung 812, Taiwan J Radiol Sci 2012; 37: 153-157 Relaxation techniques for reducing pain and anxiety during mammography 154 J Radiol Sci December 2012 Vol.37 No.4 intervention for the reduction of pain and anxiety has been demonstrated in a variety of medical patients including surgical, cardiac and oncological [12, 15]. TCC is a traditional Oriental mind-body calisthenics that is unique for its slow and carefully controlled movements. TCC consists of a sequence of postures that are smooth, coordinated, and relaxing. TCC training has been shown to be beneficial to cardiopulmonary function, balance, and psychological conditions such as anxiety, depression, chronic pain and the declines associated with aging and inactivity of subjects [17, 18]. In addition, TCC could reduce tension, anxiety, pain and mood disturbance [19]. The reverse abdominal breathing, one of Qi Gong, is one of the basic components of TCC which is relatively easy to perform. Many women suffer from anxiety and pain while undergoing mammography. If a simple, inexpensive, noninvasive intervention could decrease anxiety and pain during mammography, not only would it be of immediate benefit to patients, but also compliance with screening mammography would increase. This study was undertaken to determine whether or not the reverse abdominal breathing and music intervention before and during mammography reduced the subjective reports of anxiety and pain during screening mammography. MAteRiAlS And MethodS This study was approved by our institutional review board. The measures included State Trait Anxiety Inventory (STAI) questionnaire and 11-point numeric rating scale (NRS) of anxiety and pain. STAI questionnaire has two separate components: one is for trait anxiety (TAI); and the other is for state anxiety (SAI). The State STAI questionnaire has been used extensively in intervention research, it is easily completed in a few minutes and its results are reliable in an acute setting [20]. For each NRS, subjects were asked to mark the level of pain or anxiety that they experienced on a scale of 0 (no pain) to 10 (very painful) and 0 (not anxious) to 10 (very anxious), respectively. Exclusion criteria included women having taken pain or anxiety medication before mammography, those with a current psychiatric diagnosis, and those with a history of breast augmentation or surgery. Women were approached by a research assistant after they had changed into a gown and were sitting in the waiting room provided for screening mammography patients only. During the recruiting phase, each potential subject was asked if she would be interested in participating in a brief study to determine the effects of a breathing technique or listening to an audio compact disc (CD) before and during mammography. From January 2010 to December 2010, of the 195 women approached for potential recruitment, 40 declined to participate. One hundred and fifty-five women agreed to be screened for inclusion. The research assistant explained the purpose and procedures of the study to them. The study was designed to be randomized and decoded by secret questionnaire. Informed consent was not needed. Before mammography, the research assistant guided subjects to complete the STAI and NRS of the anxiety in the waiting room. Based on drawing of lots, subjects were randomized into one of three groups: reverse abdominal breathing, music, or control. All subjects were informed of their group assignment and were provided with media players. Five subjects were not included in the data analysis for the following reasons: one changed her mind, another did not want to be in the reverse abdominal breathing group, and three did not have enough time before being called in for the mammographical examination. A total of 150 subjects were therefore enrolled in this study: 50 subjects in the relaxation group (52.88 ± 6.67 years old), 50 in the music group (50.42 ± 5.54 years old), and 50 in the control group (51.52 ± 5.17 years old), respectively. The video CD media of the reverse abdominal breathing contained a TCC practitioner showing the viewer how to practice reverse abdominal breathing. Breathing focused on keeping a smooth and slow gentle movement to relax. When subjects inspire through the nose, they gently contract the muscles of the anus and they visualized the 'chi' or air going into their lungs and upper abdomen. When the lungs are full, they expire through the mouth and relax the anus. They visualized the 'chi' or air went back down to the two inches bellow the umbilical area (dan-tian). This exercise is repeated for at least ten cycles of inhalation and exhalation, filling the lungs to maximum capacity and emptying them out completely with each breath. The music subjects had a choice of audio CD with popular music and ballads. Control subjects received routine examination. Subjects were instructed to watch video CD or listen to their audio CD while in the waiting room before examination. All subjects were asked not to let the radiographers know their group assignment. All mammographies were performed in the standard fashion utilizing craniocaudal (CC) and mediolateral oblique (MLO) views using digital mammography (Lorad Selenia, Lorad/Hologic, Danbury, USA). All radiographers had over 10 years of experience and were certified in mammography by the Society of Radiological Technologists and Bureau of Health Promotion. After undergoing mammography, each subject was met by the research assistant in the waiting room. They were asked to complete the NRS of the anxiety and pain that they experienced during mammography. They returned the media player and were thanked for participating in the study. Statistics Patient age and STAI state scores were compared by one-way ANOVA. Kruskal-Wallis test was used to compare the anxiety and pain of NRS. Wilcoxon signed-rank test was used to compare the anxiety before and during mammography. Two-sided p values of less than 0.05 were considered to be statistically significant. Relaxation techniques for reducing pain and anxiety during mammography 155 J Radiol Sci December 2012 Vol.37 No.4 ReSult As shown in Table 1 and Figure 1, the groups were equivalent before randomization in terms of age and STAI scores. On the anxiety, the NRS score during mammography (NRSduring) was lower than the NRS score before mammography (NRSbefore) in both the reverse abdominal breathing (p=0.001) and music intervention groups (p=0.02). No significant difference was found between NRSduring and NRSbefore of the anxiety in the control group (p=0.90). No significant difference was found in terms of the NRSbefore of the anxiety (p=0.13), the NRSduring of the anxiety (p=0.71) and the NRSduring of the pain during mammography (p=0.79) among the reverse abdominal breathing, music intervention and control groups.