Therapeutic Recreation Interventions for Pain Management

Aromatherapy and Hand Massage: Therapeutic Recreation Interventions for Pain Management

Kunstler, Robin

Chronic pain is a major health problem among the elderly. Therapeutic recreation, with its emphasis on quality of life and its utilization of a range of relaxation interventions, can be an important component of a multidisciplinary pain management program. An investigation was conducted of four older women residing in a skilled nursing facility, with histories of multiple health problems and chronic pain. They received one-to-one sessions of aromatherapy and hand massage from a therapeutic recreation specialist. The design of the study was a multiple single-subject withdrawal design. Pain was self-assessed on a modified Wong-Baker Faces Rating Scale and participants’ comments were recorded. A significant difference between preand post-sessions pain scores was found using an unbalanced randomized block design. Participants reported benefits of relaxation, pain relief, and improved sleep. The results of the study support the role of therapeutic recreation in providing pain management interventions. Implications for professional practice and research are examined.

KEY WORDS: Nursing Homes, Long-Term Care, Pain, Massage, Aromatherapy, Non-Pharmaceutical Pain Management

Pain management is one element of quality of life that has been identified as most important to people as they age (Levine, 2000). Although people over sixty-five are more likely to experience chronic pain than younger adults, pain relief is more elusive for the elderly (Gloth, 2000). Due to the misconception on the parts of both the elderly and their healthcare providers that chronic pain is a normal, unavoidable part of aging (American Geriatrics Society, 1998; Young, 2003), people have been forced to suffer its enormous physiological and psychological effects (Platt & Reed, 2001). Chronic pain, commonly defined as pain that persists longer than the expected time frame for healing, or pain associated with progressive, nonmalignant disease, cannot be eradicated or cured in most cases (Ashburn & Staats, 1999). Chronic pain leads to decreased movement resulting in passivity and dependence; decreased bodily contact that alters relationships; and poor sleep and fatigue that causes decreased concentration and social interaction (Varela-Burstein & Miller, 2003). Other effects include depression, mood swings, social isolation, sleep problems, and difficulty in performing daily activities (Young). Estimates of pain problems in community-dwelling elderly are 25 to 50%, and 45 to 80% among nursing home residents (Gloth). In an extensive study, on pain in nursing homes, Teno (2002) found a “high rate of persistent severe pain in all U.S. nursing homes” (p. 1) with about one-sixth of nursing home residents reporting experiencing daily pain.

Challenges of Pain Management

As improving the quality of life in longterm care becomes the focus of regulatory bodies (Levine, 2000), pain management has received increased attention and emphasis. Recognizing the extent and seriousness of chronic pain in nursing home residents, the Center for Medicare and Medicaid Services (CMS) launched a Nursing Home Quality Initiative in the fall of 2002 to assess all medicare-certified nursing homes in the United States on ten quality indicators. One of those indicators is pain management, measured as the percentage of residents with moderate daily pain or excruciating pain at any time. In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued standards for assessing and managing pain in long-term care facilities, hospitals, home health agencies, and outpatient clinics (Acello, 2000; Platt & Reed, 2001). Under the JCAHO standards, all patients have the right to appropriate pain assessment and management using a pain assessment tool that is appropriate to their age, culture, and medical conditions. Since, in most patients, chronic pain cannot be eliminated or cured, the goal of pain management is to alleviate or reduce pain to a level that is comfortable and acceptable to the patient (Mosby, 1998).

Despite this attention to chronic pain, older adults in nursing homes experience many barriers to pain management, both internal and external. Internal barriers include concern about side effects of treatment, belief that nurses are too busy to help, and fear of being seen as a “complainer,” a malingerer, or a burden to others. External barriers to pain management include lack of good relationships with healthcare providers; and staff’s lack of knowledge about the characteristics of chronic pain, lack of open-mindedness about treatment approaches, and lack of understanding of pain as a treatment priority (Davis, Hiemenz, & White, 2003). Pain treatment is also complicated by the fact that many elders in nursing homes have multiple medical conditions with depression in particular having a tremendous impact on pain management (Gloth, 2000).

Role of Therapeutic Recreation in Pain Management

Along with JCAHO and CMS, the American Geriatrics Society (1998) has also issued guidelines on managing chronic pain in the elderly, emphasizing the importance of an interdisciplinary approach. The society recommended both pharmacological and nonpharmacological strategies. These strategies include behavioral approaches, such as cognitive-behavioral therapy, patient education, exercise, biofeedback, and relaxation techniques, which can foster healthy actions on the part of the patient. Austin (2004) states that the mission of therapeutic recreation (TR) is to use activity, recreation, and leisure to help people overcome barriers to health and achieve their optimal level of well being. As vital members of the interdisciplinary teams in nursing homes (Saul, 1993), recreation therapists actively engage individuals in meaningful activities that give them a sense of control and purpose, with emphasis on the individual’s well-being (McGuire, Boyd, & Tedrick, 1999). Recreation therapists provide interventions such as music, meditation, breathing exercises, guided imagery, aromatherapy, and simple massage activities that promote relaxation and feelings of well-being, as well as relieve pain and tension (Bartalos, 1993).

With increased attention to quality of life as a legitimate healthcare goal (Van Andel, 1998), and promoting personal responsibility for one’s health by exercising choice and control in the healthcare environment (Austin, 2004), recreation therapists assist clients in choosing treatment that will meet their needs. As pain is always subjective (Darr, 2001), the clients’ role in determining effective pain management techniques is crucial. Patient satisfaction and well-being are important outcomes in healthcare settings today (LaTorre, 2003) and should not be overlooked in planning and implementing pain management programs. One study (Wittink, 2000) found that elderly people themselves preferred massage and informal coping techniques for pain management, such as distraction rather than medication and exercise. Informal techniques, such as massage and distraction, are highly rated by pain specialists because they are inexpensive to offer, easy to teach (Pinkowish, 2000) and are favorably regarded by patients (LaTorre). Although these techniques are not the exclusive domain of recreation therapists, programs related to stress, coping, anxiety, and relaxation are designated within the scope of practice for recreation therapists as denoted by their inclusion in the content areas for the national certification exam as a certified therapeutic recreation specialist (CTRS) (National Council for Therapeutic Recreation Certification, 1999). As quality of life may be the healthcare outcome that recreation therapists have the most potential to influence (Van Andel), TR could play an important role in an interdisciplinary pain management program by offering clients a choice of relaxation techniques to clients to address pain and discomfort.

Relaxation Techniques

Relaxation techniques comprise a group of therapeutic approaches that may be effective in the treatment of chronic pain (Ashburn & Staats, 1999). Relaxation has been described as a process that assists individuals to retreat mentally from their surroundings, while quieting their thoughts, relaxing their muscles, and maintaining a relaxed state for a sufficient period of time to decrease anxiety, tension, and pain (DeMarco-Sinatra, 2000). Relaxation techniques have been found to bring heart rate, blood pressure, and respiration under control (DeMarco-Sinatra).

One relaxation technique that may have both emotional and physical benefits for nursing home residents is aromatherapy (Cerrato, 1998). Aromatherapy is the therapeutic use of essential oils to enhance relaxation, stimulation, and immune response (Jones, 1999). Most current studies show that essential oils are safe and that clients respond to them in a positive, favorable manner (LaTorre, 2003). Elderly patients may benefit from aromatherapy (Brett, 1999) as it eases or reduces the use of sleeping pills and increases patients’ ability to care for themselves (Robinson, 2003). Studies have shown that use of essential oils reduced anxiety and improved quality of life in cancer patients (Cerrato); relieved signs of distress, anxiety, and agitation in nursing home residents with Alzheimer’s disease (Brown University, 1998); significantly reduced agitation, without producing the side effects that may come with the use of drugs, in people with dementia (Futurist, 2003); and helped one very anxious nursing home resident who could not sleep to develop good sleep patterns (Healthcare Review, 2001). Buckle (1999), in her review of nine studies utilizing aromatherapy to address pain in a range of patients, found that subjects reported positive effects including perceptions of reduction in pain, improved sleep patterns, and improved ability to cope. She suggests there is sufficient evidence to demonstrate that aromatherapy can play a complementary role in pain management (Buckle). Within the aromatherapy literature, lavender is considered a good general essential oil to use. Research on lavender has shown some promise in its efficacy in reducing analgesia and heart rate and increasing ability to cope (Buckle). It has also been found to promote an overall sense of well-being (LaTorre).

Massage is another relaxation technique that can address chronic pain, improve sleep, reduce fatigue, and enhance a state of relaxation (Pinkowish, 2000). In a quasi-experimental study of 41 cancer patients, it was found that massage led to significant decreases in pain and symptom distress and improvements in sleep (Smith, Kemp, Hemphill, & Vojir, 2002). Brett (1999) found that hand massage was very therapeutic and beneficial for muscles and joints in the care of older people. Massage has been noted to foster communication among recipient and provider and produce a sense of well-being. This could be particularly valuable for individuals with limited opportunities for physical contact, such as nursing home residents (Vickers, Zollman, & Reinish, 2001). Massage provides the benefits of one-on-one attention and a relaxing and calming effect that produces lessened anxiety and confusion (Healthcare Review, 2001). Brownlee and Dattilo (2002), based on their review of current research on the use of massage, concluded that massage is effective in reducing pain, anxiety, and muscle tension; and that some basic Swedish massage techniques can be learned and easily performed by recreation therapists in order to assist individuals in reducing anxiety, relieving pain, and overcoming barriers to leisure participation.

Combining two or more relaxation techniques has been found to be very beneficial in pain management. “Often it is the blend of smell, touch, and human interchange that appear to create the best outcome” in the treatment of pain (Buckle, 1999, p. 44). For instance, Jones (1999) reported that aromatherapy can be combined with massage to reduce anxiety, depression and stress, and alter pain perceptions. Likewise, a relaxation group that used combined modalities (i.e., aromatherapy, exercise, music, and stretching) and which was co-led by a recreation therapist and a social worker led to reduced confusion and frustration in elderly nursing home residents with Alzheimer’s disease (Brown University, 1998).

While research has validated the use of relaxation techniques in addressing chronic pain and related problems, there is a need for further research to validate the effectiveness of various techniques (DeMarco-Sinatra, 2000), especially with the elderly in whom chronic pain is excessive. Little has been reported in the therapeutic recreation literature on pain management in nursing home residents or on the use of aromatherapy and hand massage. The purpose of this study, therefore, was to investigate the use of the relaxation techniques of aromatherapy and hand massage as pain management interventions for nursing home residents with chronic pain.


Research Design

The design of the study was a multiple single-subject ABABA research design. According to Dattilo, Gast, and Schleien (1993), potential benefits of single-subject research are providing data that can result in the development of more effective treatment and increased accountability of TR service provision. A single-subject design allow the researcher to examine the impact of an intervention on one person’s behavior and is a useful alternative to experimental design in clinical settings where it is difficult to form experimental and control groups (Voelkl & Negley, 2001). Single-subject design “complements the ability of TR specialists to meet the individual needs of participants” (Dattilo, Gast, Loy, & Malley, 2000, p. 254).

Participant Selection and Informed Consent Procedures

The current study was conducted at an 816-bed, not-for-profit, long-term care facility that provides a continuum of comprehensive care including skilled nursing, sub-acute care, and community outreach services in New York City. Selection criteria for participation limited involvement in this study to the clients who had the following characteristics: (a) resident of one of the skilled nursing units at the facility, (b) a report of chronic pain on their most recent pain assessment conducted by the nursing staff, and (c) a minimum score of 24 out of 30 on the Mini-Mental Status Exam (MMSE). The MMSE is a quick screening tool used to evaluate cognitive functioning and evidence of dementia in people over sixty years of age. A score of 24 out of 30 is considered normal on the MMSE and was the qualifying score mandated by the facility’s Institutional Review Board for participation in this study. This score was mandated to assure that those who expressed interest in participating were “legally” capable of understanding and providing informed consent to participate in a research study.

Participant Recruitment

Flyers that clearly outlined the purpose, procedures, benefits, and risks associated with the study were posted and distributed throughout the skilled nursing units. The flyer was designed to be both culturally appropriate and accommodating to the participants based on their disability (e.g., large print flyers, Spanish versions). Those interested in participating were directed to contact the Director of Therapeutic Recreation. Upon expressing their interest in participating, they were given the MMSE to verity their eligibility. Informed consent was obtained from those who scored 24 or higher.

Pain Assessment Procedures

Patient self-reports of pain is considered the single most reliable assessment tool available to quantify the existence and intensity of pain (Platt & Reed, 2001). The facility’s pain assessment includes a modified Wong-Baker Faces Rating Scale (Mayer, Torma, Byock, & Norris, 2001). This scale features a series of facial expressions, accompanied by a four-point numeric rating, and serves as a basic method of communication about pain. Elderly nursing home residents indicated that a pain rating scale allowed them to more effectively describe their pain to nursing staff and that the Faces Scale was easier to use than other scales (Carey et al., 1997). The Faces Scale has been found to be an effective measure of pain in cognitively intact elderly (Agarwal, 2002) as has the use of a four-point pain scale (Smith et al., 2002). Wong (2002) demonstrated initial construct validity of the scale with an adult population, ages 21 to 67, as compared to a well established numeric pain rating scale.

General Description of Participants

Four residents, who met the eligibility criteria, agreed to participate in the research. All participants were female, reflecting the composition of the residents of the facility. The predominance of females in the intervention is also consistent with the fact that older women are more likely than older men to report pain (Varela-Burstein & Miller, 2003). Their ages were 60, 63, 63, and 90. All four were active participants in a wide range of recreation programs in the facility, both on and off unit. Two participated off-unit on a daily basis, and two approximately every other day. Although three of the women were under 65 years of age, they were typical of most older nursing home residents, in having at least one chronic condition, such as arthritis, hypertension, heart disease, visual difficulties, cerebrovascular disease, and diabetes (Gloth, 2000). Two of the participants reported chronic pain, one reported acute head and back pain and sinus problems, and one participant complained of pain that made her body ache all over. All four participants were routinely taking medication for pain (e.g., approximately 75% of the time). They were reported by nursing to have “fair” sleep patterns. Two participants had additional diagnoses of depression, another participant was described by nursing as anxious and the final participant was described as irritable.

Data Collection

Pain data were collected by the CTRS implementing the study. Participants were pretested and post-tested on the Faces Scale during each session in the baseline and intervention phases. Prior to and at the conclusion of each session, participants indicated the face that corresponded to their self-assessment of pain, scored as 0 (no pain), 1 (mild), 2 (moderate), and 3 (severe). When a participant described her pain as between two ratings, it was recorded with a .5 interval.

Baseline data was collected twice in the week prior to the onset of the intervention. Following the baseline phase (A1), the four-week treatment condition was initiated. A self-assessment of pain was collected before and after each of the 12 treatment sessions (three times a week for four weeks) during this phase, labeled the first intervention phase (B1. Self-assessment of pain was again collected on two separate occasions during the withdrawal phase (A2). This pattern of data collection was again followed during the second intervention phase (B2) and the second withdrawal phase (A3). In addition, the CTRS recorded her observations of the participants and their comments to her regarding their responses to the treatment.

Intervention Procedures

The CTRS designed and implemented the intervention, based on her training. She had completed a 100-hour certificate program in aromatherapy and was certified in reflexology. Reflexology uses finger pressure on the hands and/or the feet to affect change in other parts of the body (Brownlee & Dattilo, 2002) and may incorporate hand massage techniques. During the intervention phases, each participant received an individualized, fifteen minute hand massage and aromatherapy session three times a week for four weeks in the late afternoon or early evening hours. Each individual’s contact with the CTRS was approximately thirty minutes. The sessions were held in the resident’s own room and the CTRS took time to assure a soothing environment was created (e.g., lights lowered, the door closed to minimize interruptions, materials like massage cream and diffuser within easy reach, resident and CTRS in comfortable sitting positions).

In the conventional healthcare setting, massage can be limited to the hands, head, or back, with the patient sitting in a chair fully clothed (Vickers, Zollman, & Reinish, 2001). This was the massage procedure followed in this study. For the massage, the CTRS used the resident’s own brand of hand cream to avoid allergic reactions. Latex gloves were worn by the CTRS, in accordance with the facility’s universal precautions procedures. After rating their pain levels on the Faces Scale, residents told that they could close their eyes if they wished, reinforcing the principles of participant control and choice in the process. The CTRS then used the verbal cue “relax” and encouraged residents to breathe deeply and steadily. She began the massage by holding each resident’s hand, palm down, in both of her own hands and stroking outward in a circulation motion. The massage then advanced to each resident’s wrist and continued with a deep stroking pattern up to their elbow. The CTRS also used her fingertips to massage each resident’s fingers. Toward the end of the massage intervention, the CTRS gave each resident a two-minute notice prior to ending of the session. At the session’s end, each resident rested without speaking for five minutes, then the CTRS asked how they felt and to again indicate their pain level using the Faces Scale. Preparation and procedures for the intervention are presented in Table 1.

Data Analyses

Analysis of single-subject research relies on graphic displays to allow for visual inspection of data. Changes in magnitude and level of the dependent variable are readily observable when data is graphed. A magnitude change refers to the difference between the average value of the dependent variable in one phase compared to the average value of the dependent variable in the following phase (e.g., mean value during baseline compared to mean value during intervention phase). In contrast, a level change refers to the immediate shift in the value of the dependent variable at the end of one phase compared to the value of the dependent variable at the beginning of the next phase. Level changes examine differences occurring immediately at the start or stopping of an intervention; while magnitude changes examine differences in the average score between two phases. Post-session pain data from the four cases in this study were graphed and examined for changes in magnitude and level of the pain ratings. In addition, statistical analysis comparing the pre-session and post-session pain ratings of the four subjects utilizing an unbalanced randomized block design (unbalanced due to missing data for one participant who chose to not participate in the second intervention phase) were conducted.


Because of the single-subject design employed, results are presented via a brief case study of each participant. Each case includes discussion of the client’s pain rating during baseline, intervention, and withdrawal phases, as well as their qualitative comments regarding the intervention’s effectiveness, provided by participants at the end of their sessions. This presentation is then followed with a statistical analysis of changes in pre- to post-session pain ratings during the two intervention phases.

Case of MC

MC was a 60-year old nurse who was admitted to the nursing home after 2 weeks in coma, with a history of low blood pressure, anemia, a ruptured disc, cervical arthritis, osteoporosis, spastic bladder, and chronic pain. MC had had 10 major surgeries. Her major pain complaint was chronic back pain due to arthritis and the ruptured disk. She was reported by nursing to have an irritable mood, be fearful and to have a fair sleeping pattern. She was prescribed Ultram for pain and took it routinely.

As can be seen in Figure 1, her average baseline (A1) pain rating was 1.75 on the Faces scale. With the onset of the first intervention phase (B1), an immediate level change is observed indicating an increase in MC’s perception of pain. This increase is observed throughout the first intervention phase with an average mean pain score of 2.5 during this phase.

Contradictory findings in terms of level and magnitude of change are observed in the pain ratings during the withdrawal phase. MC’s initial pain rating during the withdrawal phase was higher than her last pain rating during the intervention phase suggesting that an increase in pain perception occurred when the intervention was withdrawn. However, MC’s pain rating decline during the following week, despite the absence of the intervention and no level change in pain perception occurred with the onset of second intervention phase.

Visual inspection of the data set as a whole suggest that MC’s level of pain was fairly consistent (i.e., at the moderate to high level) across all phases. Although MC said she still felt pain, she reported feeling relaxed at the end of sessions, especially because she liked the smell of lavender. MC did not complain of pain and actually fell asleep during 11 of the 24 interventions sessions that occurred in both phases. MC reported that the intervention helped her sleeping and she also believed it improved her circulation because her hands felt warm.

Case of TS

TS was a 63-year-old office supervisor who had a right cerebral vascular accident at the age of 54. She had left-side hemiparesis, wore a brace on her left leg, and used a motorized wheelchair for mobility. She also had a history of diabetes and hypertension. She was reported to have moderate chronic pain and depression. Her chronic pain was due to arthritis and left hemiparesis that resulted in sagging and pinching of her left arm and neck muscles. TS also had a chipped tail bone that prevented her from shifting her position. She was prescribed Neurotin for pain and used it routinely.

Her mean pain rating at baseline (A1) was 1 on the Faces scale (Figure 2). As can be seen in Figure 2, TS displayed significant level change in her pain score with the onset of the first intervention phase (B1) reflecting a decline in her pain score. She also had a decline in magnitude during this phase with a mean pain score of .7 during this phase. A level change increase in pain rating is seen during the withdrawal phase (A2), with a subsequent decline in pain rating with the onset of the second intervention phase (B2). Magnitude changes indicative of the intervention’s effectiveness in decreasing pain perceptions for TS are also observed during each intervention phase.

Visual inspection of the data set as a whole suggests that the intervention was effective in reducing pain perceptions for TS. Her pain ratings were slightly lower during the intervention phases as compared to the baseline and withdrawal phases. These findings are consistent with TS’s qualitative comments. TS stated that she felt “great” after the intervention sessions, with a feeling of relaxation lasting the rest of the day and through the night. She also reported sleeping better and longer at night. TS also stated that she felt the intervention was effective in improving her breathing (sinuses were clearer) and her neck pain decreased. Like MC, TS enjoyed the smell of lavender and reported looking forward to each session as they diverted her attention from her pain.

Case of DF

DF was a 63-year old factory worker who had a right cerebral vascular accident one year prior to her admission to the nursing home. She had a history of high blood pressure, depression, anxiety, anemia, and gastritis. Due to her left-side paralysis, DF used a wheelchair for mobility. DF developed carpal tunnel syndrome from using her wheelchair affecting her fingers, wrist, and shoulder. She also was reported to have head and back pain and sinus problems. Her chief pain complaint was the carpal tunnel syndrome. DF was prescribed Celebrex and Neurotin for pain and used it routinely.

As can be seen in Figure 3, DF reported level change declines in her pain score during the first intervention phase (B1) and level change increases in her pain score during both withdrawal phases (A2 and A3). DF also had consistent changes in the magnitude of her pain scores during each phase with notable declines in average pain scores occurring during the first (B1) and second (B2) intervention phases. DF’s pain ratings changed from an average pain rating of 2 during baseline to 1 during the first intervention phase. During the first withdrawal phase, there was no change in the magnitude of DF’s pain rating (it remained at 1); however, further declines in the average pain rating occurred during the second intervention phase (it declined to .7). This decline was followed by a dramatic increase (to 2) in average pain ratings during the second withdrawal phase (A3).

Visual inspection of DF’s data set as a whole suggests that the aromatherapy and massage intervention was effective in decreasing her perceptions of pain. Qualitative comments support this conclusion. DF reported that she felt more relaxed and had less pain after interventions. She noted that during the intervention sessions her mind wandered-a sign to her that she was not focused on her pain. She also fell asleep in two of the sessions. She also stated that she felt her breathing and sleep improved. She believed that the intervention was more effective in relieving her pain than other interventions she had received in physical therapy (i.e., hot compresses). Like the other participants, DF reported enjoying the smell of lavender.

Case of AT

AT was a 90-year old retired nurse’s aide with a history of diabetes, hypertension, cervical cancer, and neuropathy. She experienced chronic pain in her legs, knees, and hands due to arthritis, and more recently in her eyes due to glaucoma. She was reported to have a depressed mood and described her body as aching all over-“nothing helps.” She routinely took Neurotin and Tylenol for pain.

AT only participated in the research up until the beginning of the second phase of the intervention. At this point, AT declined to participate any further due to the fact that she had recently received a diagnosis of glaucoma and did not “feel up to it.” Despite AT’s decline, her data from the baseline through the first withdrawal phase, suggested that the intervention was effective in reducing AT’s perceptions of pain (Figure 4). A significant change in level is observed in the transition from baseline (A1) to the first phase of the intervention (B), with an associated decline in magnitude in each phase (i.e., from 1.5 in baseline to 1.0 in the first intervention phase).

AT stated that following intervention sessions, she felt good, relaxed, and sleepy. She stated her pain had either decreased or disappeared. She found the sessions to be helpful in distracting her attention from the pain and improving her breathing.

Summary of Cases

Three of the 4 participants (TS, DF, and AT) showed an immediate response at the initiation of the first intervention phase as indicated by level changes in between these phases (Figures 2-4). These same participants also had magnitude declines during the intervention phases suggesting that aromatherapy and massage was an effective pain management intervention for these participants. Table 2 contains the mean scores for each participant during each phase of the study.

The only participant for whom the intervention did not appear effective was MC. Interestingly, unlike TS, DF, and AT, she was not hypertensive; rather, she had a history of low blood pressure. She was also unlike the other participants in that her major pain complaint centered on back pain. The other participants may have had back pain, but they also reported hand, arm, neck, and shoulder pain. These differences may partly explain the differences in MC’s response to the intervention.

Summative evaluation of the qualitative data also supports the effectiveness of the intervention. Regardless of how participants numerically rated their pain after each session, they all reported feeling more relaxed and sleeping better following the interventions. They described their sleep as deeper, more sound, less restless, and longer. Their reports of sleep patterns were verified by nursing staff. Three of the participants said their pain was relieved or decreased, 3 said their mind was diverted from the pain, and 3 said they liked the aroma.

Statistical Analysis of the Pre-Post Session Pain Scores

While the graphic analysis of the data provided some support for the effectiveness of this TR intervention, statistical analysis of the pre-post session pain scores would provide further support. A 2 (time) by 2 (intervention phase) unbalanced randomized block design was computed using the average pain rating scores from the 83 intervention sessions that were conducted with the 4 subjects. Diagnostic checks of the underlying assumptions associated with this statistical analysis included an examination of the variance distribution of the scores (i.e., homescedaciticty) and the normality of the residuals. No significant violations of the underlying assumptions for this analysis were found.

A significant main effect for time, F (1, 10.1) = 8.68, p .57. Likewise, no statistically significant interaction effects were found, F(1, 10.1) = 0.11, p > .74. These findings indicated that clients reported statistically significant declines in pain ratings from pre- to post-session, regardless of intervention phase. It can therefore be concluded that the aromatherapy and hand massage intervention was effective in reducing participant’s perceptions of pain following a treatment session.


The purpose of the study was to investigate the use of aromatherapy and hand massage as therapeutic recreation interventions for pain management. Limitations of the study in measuring pain are noted. One limitation may have been the use of the modified Faces Scale. The four-point scale did not produce much variation in the ratings. Most ratings were 1 (mild) or 2 (moderate) and with a rating of 3 (severe) given only four times. Use of other scales in future studies may be warranted. Another limitation was the number of times pain levels were measured during the baseline and withdrawal phases. In future research, more than two baseline ratings should be taken so that a more stable measure of pain prior to treatment is obtained.

Another limitation of the study is the fact that all participants were receiving pain medications prior to, during, and subsequent to the interventions. While the study’s single subject design would control for the effects of medication as each participant serves as their own control, the researchers did not assess if changes in the patterns of types of pain medications used occurred throughout the study. Future research should more carefully control for this variable.

All participants expressed satisfaction with the techniques and the effects of relaxation, including improved sleep and the diversion of their thoughts from the pain. This supports other studies that reported the effects of massage on improving sleep and promoting a sense of well-being (Brownlee & Dattilo, 2002; Healthcare Review, 2001; Smith et al., 2002).

In some respects these four participants were atypical of the current nursing home population. Three of the four participants were in their early sixties. The average age of the residents of this facility was 86 years. However, they had the multiple health problems typical of elderly nursing home residents and pain in nursing homes affects residents of all ages. Another difference was that while an estimated 85% of the residents of the facility had some evidence of dementia, these participants did not. Future research with older residents and those with dementia is recommended. When working with adults with dementia it is important to observe and document nonverbal indicators, such as behavior changes, facial expressions, and body language (Acello, 2000). In the present study, nonverbal indicators presented powerful evidence of pain relief (i.e., falling asleep, more relaxed posture), and could be an interesting area for future research.

An unexpected outcome of this study that also warrants further research was the effect of the intervention on improving sleep patterns. Falling asleep in a nursing home during the day may be attributed to overmedication or boredom. However, this day-time sleeping pattern was not typical for the study’s participants. Rather, their high and consistent activity level would suggest they were not bored or constrained in their activities due to overmedication. MC was a member of the resident’s council; she and TS were also active as volunteers in the nursing home, and AT spent much of her time socializing in the nursing home café, so it is interesting to note that these participants often fell asleep during the intervention, a behavior that was atypical for them.

Additional research could be done on the use of relaxation techniques in therapeutic recreation with diverse groups. Other populations of all ages and in all settings have been shown to benefit from relaxation techniques in the areas of pain management and anxiety reduction (Brownlee & Dattilo, 2002). Combining aromatherapy and hand massage with music, guided imagery, and/or relaxation breathing techniques, established methods of TR practice, are other areas of potential study. An important consideration to explore would be delivering the intervention in groups. Practically speaking, one-to-one intervention is labor-intensive. Could participants themselves, and/or their family members, be trained in basic techniques and a group be held under staff supervision? Another consideration is length of sessions. Although short sessions do provide some benefits, longer and more frequent sessions may produce more intense and more lasting outcomes (Smith et al., 2002).

Successful delivery of programs such as massage and aromatherapy depend on support from upper management and the unit level in their willingness to try out new ideas (Australian Nursing Federation, 2003). It is the manager’s role to establish an organizational culture that recognizes the importance of pain management (Darr, 2001). The JCAHO pain management standards also require a pain audit, which is an assessment of pain management methods and tools. A range of pain management approaches should be offered. Multidisciplinary collaboration and communication are essential if complementary and alternative techniques are to play a more significant role in symptom control and pain management (Scrace, 2003). The successful use of relaxation techniques by the CTRS in this study lends support to the inclusion of therapeutic recreation as part of a comprehensive pain management program.

TR can offer participants a choice of relaxation techniques that are carefully planned to increase their level of comfort and sense of control over their pain. The significant declines in pain ratings from before to after the sessions that were found in this preliminary study support aromatherapy and hand massage as contributors to feelings of well-being. Outcomes of relaxation, improved sleep, reduced anxiety, and mental distraction are not only quantifiable, but are also subjective indicators of quality of life. The comments of the participants indicated they experienced the benefits of the intervention into the following day and were eager to resume the treatment long after the study ended.

Hand massage has physical and emotional benefits, allowing a participant to experience physical contact in an atmosphere of respect and dignity. “Aromatherapy allows the patient and carer to ‘be’ with one another and perhaps is one of the ‘kindest’ therapies we can offer” (Buckle, 1999, p. 50). Respect, dignity, and kindness are values of therapeutic recreation evident in our goal of providing holistic approaches that are accessible to all. An important finding of this study may be to remind us to focus on the quality of the TR experience, the joy and meaning that comes from participation, as well as the quantitive outcomes we document after the activity is over.


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Robin Kunstler, Re.D., CTRS, Fred Greenblatt, M.S., MPA, CTRS, and Nereida Moreno, CTRS

Robin Kunstler is Professor and Recreation Education Program Director, Department of Health Services at Lehman College of the City University of New York. Fred Greenblatt is Director of Therapeutic Recreation and Nereida Moreno is a Therapeutic Recreation Specialist at the Jewish Home and Hospital in the Bronx, NY.

This project was funded by the National Therapeutic Recreation Society Research Support funds and the Lehman College Shuster Fellowship Award Committee. The authors gratefully acknowledge their support, without which this project would not have been possible.

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