The effect of aromatherapy with orange essential oil on anxiety and pain in patients with fractured limbs admitted to an emergency ward: A randomized clinical trial

Abstract

Aim: Pain and anxiety are unpleasant feelings associated with actual or potential tissue damage. The goal of this study is to determine the effect of aromatherapy with orange oil on the pain and anxiety of patients with limb fractures hospitalized in an emergency ward. Design: Randomized Clinical Trial. Methods: 60 patients in an emergency ward were allocated to one of two groups: an experimental and a control group, using a randomized blocking sampling method. Four drops of orange oil were poured onto a pad, which was attached to his/her collar by a plastic safety pin (posing no risk to patients), so that the distance from the patient’s head was not more than 20 cm. To prevent loss of aroma from the impregnated pad, the fragrance was replaced every hour. Pain was measured every hour for six hours, and the patients’ anxiety rate was measured before and after the intervention. All data were analysed using SPSS 21. Results: Mean age of participants was 37.93 ± 18.19 years. Most fractures were in the scapula area (11 patients – 18.3%). The results indicated a significant difference between the mean of anxiety in the intervention group (p < 0.001) compared to the control group (p = 0.339). Regarding pain, a Friedman test showed significant differences between the mean of pain in the intervention group (p < 0.001) compared to the control group (p = 0.339). Conclusion: Aromatherapy with orange essential oil reduced pain and anxiety in patients with limb fractures. Therefore, the application of aromatherapy with orange essential oil as a complementary therapy is recommended for these patients. Keywords: aromatherapy, anxiety, limb fracture, orange oil, pain, relief.

Full text

Cent Eur J Nurs Midw 2017;8(4):716–721
doi: 10.15452/CEJNM.2017.08.0024
© 2017 Central European Journal of Nursing and Midwifery
716
ORIGINAL PAPER
THE EFFECT OF AROMATHERAPY WITH ORANGE ESSENTIAL OIL ON ANXIETY AND
PAIN IN PATIENTS WITH FRACTURED LIMBS ADMITTED TO AN EMERGENCY WARD:
A RANDOMIZED CLINICAL TRIAL
Davood Hekmatpou1, Yasaman Pourandish2, Pouran Varvani Farahani1, Ramin Parvizrad1
1Department of Nursing, Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences,
Arak, Iran
2Department of Nursing, Traditional and Complementary Medicine Research Center (TCMRC), Arak University of Medical
Sciences, Arak, Iran (student)
Received December 19, 2016; Accepted April 4, 2017. Copyright: This is an open access article distributed under the terms of the Creative
Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/
Abstract
Aim: Pain and anxiety are unpleasant feelings associated with actual or potential tissue damage. The goal of this study is to
determine the effect of aromatherapy with orange oil on the pain and anxiety of patients with limb fractures hospitalized in an
emergency ward. Design: Randomized Clinical Trial. Methods: 60 patients in an emergency ward were allocated to one of two
groups: an experimental and a control group, using a randomized blocking sampling method. Four drops of orange oil were
poured onto a pad, which was attached to his/her collar by a plastic safety pin (posing no risk to patients), so that the distance
from the patient’s head was not more than 20 cm. To prevent loss of aroma from the impregnated pad, the fragrance was
replaced every hour. Pain was measured every hour for six hours, and the patients’ anxiety rate was measured before and after
the intervention. All data were analysed using SPSS 21. Results: Mean age of participants was 37.93 ± 18.19 years. Most
fractures were in the scapula area (11 patients – 18.3%). The results indicated a significant difference between the mean
of anxiety in the intervention group (p = 0.0001) compared to the control group (p = 0.339). Regarding pain, a Friedman test
showed significant differences between the mean of pain in the intervention group (p = 0.0001) compared to the control group
(p = 0.339). Conclusion: Aromatherapy with orange essential oil reduced pain and anxiety in patients with limb fractures.
Therefore, the application of aromatherapy with orange essential oil as a complementary therapy is recommended for these
patients.
Keywords: aromatherapy, anxiety, limb fracture, orange oil, pain, relief.
Introduction
Anxiety is the most prevalent mental disorder in 15–
20% of patients in medical clinics (Ghardashi et al.,
2003). The prevalence of preoperative anxiety in
adults is 11–80% (Agarwal, Ranjan, Dhirag, 2005).
Preoperative anxiety is caused by worries about
problems after surgery, including pain, changes in
body image or function, increased dependency,
family concerns, or likely changes in lifestyle
(OʼBrien, 2003). Preoperative anxiety prevents
postoperative recovery. Excessive preoperative
anxiety is associated with increased pain after surgery
(Kindler et al., 2000), reduced ability to resist
infections, increased intake of painkillers after
surgery, slow-healing wounds (Granot, Ferber, 2005),
Corresponding author: Davood Hekmatpou, Department of
Nursing, Traditional and Complementary Medicine Research
Center, Arak University of Medical Sciences, Arak, Sardasht Sq.,
City, Iran; e-mail: dr_hekmat@arakmu.ac.ir
negative impacts on patients’ mood (Montgomery,
Bovbjerg, 2004), and prolonged hospitalization
(Frazier et al., 2003). Conversely, it has been found
that reduced anxiety can result in faster recovery,
reduced intake of medication during anesthesia,
increased pain tolerance, and early discharge,
ultimately leading to lower costs and a reduction in
postoperative complications (Mahfoozi, Hasani
Mian, 2000). Lack of pain control can activate the
sympathetic nervous system and increase morbidity
and mortality in patients. Indeed, sympathetic system
activitiy can increase myocardial oxygen
consumption and lead to, in some cases, ischemia,
and even myocardial infarction (by decreasing
oxygen due to coronary artery contraction and
inhibition of local vasodilator mechanisms)
(Desborough, 2000; Kehlet, Holte, 2001). Another
important side effect of stimulation of the
sympathetic nervous system is a delay in the
stimulation of the digestive system (ileus)
(Desborough, 2000; Kehlet, Holte, 2001). Moreover,

Hekmatpou D et al. Cent Eur J Nurs Midw 2017;8(4):716–721
© 2017 Central European Journal of Nursing and Midwifery
717
pain also has psychological effects, and is regarded as
the main reason for fear, anxiety, distress, and
disappointment (Naghibi, 2001).
Fractures cause severe pain in patients, necessitating
the use of narcotic analgesics (Ogunnaike et al.,
2002; Marret et al., 2005). Since narcotic analgesics
have general side effects, such as respiratory
problems, sedation, nausea and vomiting, symptoms
of tolerance, or withdrawal syndrome in patients, the
use of non-pharmacological methods as
a complement, rather than an alternative intervention,
is recommended. In this regard, it a complementary
method which nurses can use to help patients
(Stoelting, Miller, 2007; Ball, Bindler, Cowen, 2010).
Aromatherapy derives its name from the words
“aroma”, meaning fragrance or smell, and “therapy”
meaning treatment. It is a natural way of healing
a personʼs mind, body and soul. Aromatherapy has
established itself as a treatment for an array
of complications and conditions (Ali et al., 2015).
It has been used for millennia to offer comfort and
promote healing. Its nursing roots can be traced to its
use by Florence Nightingale during the Crimean War.
More recent evidence supports aromatherapy for the
relief of pain, nausea, and anxiety in a variety
of patient populations (Boyce, Natschke, 2016).
Aromatherapy is the controlled use of natural
aromatic oils to enhance psychological and physical
well-being, and is used as a part of nursing in many
countries including Switzerland, Germany, England,
Canada, and America (Buckle, 2002). The aromatic
oils are extracted from aromatic plants, which are
anti-inflammatory, antimicrobial, and reduce pain
and stress (Cooke, Ernst 2000; Long, Huntley, Ernst,
2001; Buckle, 2002; Howarth, 2002). In fact,
aromatherapy is the second most common
complementary method used by nurses, and has the
most clinical applications (Marline, Laraine, 2008).
Inhalation of essential oils has given rise to olfactory
aromatherapy, whereby simple inhalation results
in enhanced emotional wellbeing, calmness,
relaxation or rejuvenation of the human body.
The release of stress is associated with pleasurable
scents which unlock scent memories (Ali et al.,
2015). It has been proven that inhalation of orange
essential oil can reduce labor pain (Rashidi Fakari et
al., 2013). Moreover, other studies have shown the
effectiveness of this oil in reducing anxiety (Lehrner
et al., 2000; 2005; Kanani et al., 2012). It also can
stimulate the central nervous system, enhance mood,
cause sedation and relief, and it is antispasmodic,
anti-inflammatory, anti-bloating, digestive and
diuretic, and can lower blood pressure. Its active
substances are limonene, and Flanders Citral
(Levomenthol) (Haji Akhondi, Baligh, 2005; Soltani,
2005).
A recently conducted double-blind, randomized,
controlled clinical trial on aromatherapy has
indicated that citrus oil is effective in relieving the
first stages of labor pain. It is effective in controlling
nausea and vomiting, and has mood elevating
properties (Ali et al., 2015).
Aim
Considering the importance of the control of anxiety
and pain in patients, and the limited amount
of internal and external research on the relationship
between aromatherapy and pain and preoperative
anxiety of patients with fractured bones, this paper
aimed to study the effect of aromatherapy with
orange essential oil on pain and anxiety of patients
with fractured limbs admitted to an emergency ward.
Methods
Design
The research was a Randomized Clinical Trial
registered with the Center of Clinical Trials in Iran
under the code IRCT201607124519N6.
Sample
Samples size was obtained by the following formula.
After comparison of means formula and reference
(Kanani et al., 2012), the sample size for each group
was set at 30.
In the emergency ward of Vali-e-Asr hospital, Arak,
Iran, 60 patients were selected by purposive
sampling. Subsequently, all the patients were
allocated to one of two groups: an experimental and
a control group, by a randomized blocking sampling
method (n = 30). The research was conducted during
one work shift (morning or afternoon), over a period
of six hours. Emergency ward patients with fractured
limbs requiring orthopedic surgery voluntarily
participated in this study (they were matched based
on their age, sex, type of fracture, and the initial
pain). For intervention, four drops of the essential oil
were poured onto a pad pinned with a plastic safety
pin to patients' collars, about 20 cm from the head.
The pads were replaced with new ones every hour for
the six hours. The pain in patients was checked every
hour for the six hours. Anxiety rates were measured
by the state section of the Spiel Berger questionnaire,
after the first hour (before), and after intervention

Hekmatpou D et al. Cent Eur J Nurs Midw 2017;8(4):716–721
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(after six hours). In addition to the aromatherapy that
was provided as a complementary medicine in the
intervention group, common analgesic treatments
(e.g. Acetaminophen tablets) were administered to
both groups to control pain.
Inclusion criteria: patients over 18 years old, with no
history of chronic pain, problems with vision,
respiratory problems, asthma, allergies, mental
health, and sense of smell could participate in the
research. Informed consent was obtained from the
participants.
Exclusion criteria: lack of interest in participating
in or subsequent withdrawal from the research, and
displaying any allergic symptoms during the course
of the research.
Data collection
Data collection tools: The Visual Analog Scale (VAS
0–10) was used to evaluate pain (Figure 1).
Figure 1 Visual Analog Scale (VAS 0–10)
This scale is graded from 0–10; 0 indicating no pain,
and 10 indicating the most severe pain. Patients
report their level of pain by selecting the appropriate
number on the scale. The scale allows patients to
indicate their pain freely (Lehrner et al., 2000). It is
the most widely used pain evaluation tool in the
world. In addition to validity and reliability, the tool
is easy to use. On this scale, a score of 0 indicates no
pain; 1–3 indicates mild pain; 4–6 indicates moderate
pain; 7–9 indicates severe pain; and 10 indicates very
severe pain (Soltani, 2005). Many studies from Iran
have proved its validity and reliability (Haji Akhondi,
Baligh, 2005). In Iran, the reliability of this scale has
been confirmed with a correlational coefficient
of 0.88 (Wilkinson, Simpson, 2002).
The State-Trait Anxiety Inventory (by Charles D.
Spiel Berger) is an introspective psychological
inventory consisting of 40 self-report items
pertaining to the effects of anxiety. These items are
graded on a four-option Likert scale, by which 1 –
almost never, 2 – sometimes, 3 – often, and 4 –
nearly always. The total score ranges from 40 to 160.
Scores under 40 indicate mild anxiety; 41 to 80
indicate average anxiety; 81–120 indicate higher than
average anxiety; 121–140 indicate severe anxiety;
and 141–160 indicate very severe anxiety. The
validity of this inventory was measured as 0.95
in a study by Kumar, Singh (2007), and Salehi,
Dehghan Nayeri (2011) reported it as 0.94.
Data analysis
To test the differences between main variables
(anxiety and pain) in the two groups before and after
intervention, the Paired t-test, Independent t-tests, the
Mann-Whitney test, and the Friedman test were used.
To test the differences between demographic
variables between the two groups, Fisher’s Exact
Test was used. The SPSS 21 program was used for
statistical evaluation.
Results
60 patients participated in this research, 30 in the
intervention group and 30 in the control group. 40
patients were male (66.7%), and 20 were female
(33.3%). Their age average was 31.93 ± 18.19 years
old; the youngest patient was 18 and the oldest
patient was 72 years old. 37 patients were married
(61.7%) and 23 were single (38.3%). 11 patients
(18.3%) had a diploma, 8 (13.4%) had academic
studies and 41 patients (68.3%) had lower
qualifications. The subjects in the two groups
provided similar demographic information, with no
significant differences.
Fisherʼs exact test results showed that there was no
significant difference in the distribution of fractures
in the two groups, although the most common
fractures were of the scapula, in 11 patients (18.3%)
(Table 1).
Table1 Frequency of limb fractures in intervention
and control groups
p-
value
total
Control
n (%)
Intervention
n (%)
Limb
fracture
0.808
1
1 (100.0)
0 (0.0)
foot finger
4
2 (66.7)
2 (66.7)
hand
finger
1
0 (0.00)
1 (100.0)
dorsal of
the foot
3
1 (33.3)
2 (66.7)
knee
5 (71.4)
3 (42.9)
forearm
6
2 (66.7)
4 (57.1)
leg
6
4 (66.7)
2 (33.3)
thigh
11
6 (54.5)
15 (45.5)
shoulder
2
1 (50.0)
1 (50.0)
sole of the
foot
2
2 (100.0)
0 (0.0)
palm of
the hand
9
4 (66.7)
5 (71.4)
ankle
7
4 (57.1)
3 (42.9)
wrist
60
30 (50.0)
30 (50.0)
total

Hekmatpou D et al. Cent Eur J Nurs Midw 2017;8(4):716–721
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The results revealed no significant statistical
difference between the two groups based on the
frequency of deferent levels of state anxiety before
intervention (Table 2).
Table 2 Frequency of different levels of state anxiety
in the two groups before intervention
Time
Control
n (%)
Intervention
n (%)
Total
p-
value
mild
5 (62.5)
3 (37.5)
8
0.775
average
9 (50.0)
9 (50.0)
18
higher than
average
4 (40.0)
6 (60.0)
10
severe
8 (44.4)
10 (55.6)
18
very severe
4 (66.7)
2 (33.3)
6
However, after intervention, the results revealed
a significant statistical difference between the two
groups based on the frequency of deferent levels
of state anxiety (p = 0.0001) (Table 3).
Table 3 Frequency of different levels of state anxiety
in the two groups after intervention
Time
Control
n (%)
Intervention
n (%)
Total
p-
value
mild
0 (0.0)
10 (100.0)
10
0.0001
average
5 (29.4)
12 (70.6)
17
higher than
average
6 (66.7)
3 (33.3)
9
severe
7 (87.5)
1 (12.5)
8
very severe
8 (80.0)
2 (20.0)
10
The results indicated that after intervention the mean
of state anxiety in the intervention group decreased
significantly (p = 0.0001). Thus, after intervention
a significant statistical difference between the two
groups (p = 0.0001) could be seen (Table 4).
Table 4 The mean and Standard deviation of State
Anxiety in the two groups, before and after
intervention
State
Anxiety
Before
intervention
mean ± SD
After
intervention
mean ± SD
Paired
t-test
p-
value
intervention
56.96 ± 12.03
39.80 ± 14.22
0.0001
control
56.63 ± 14.04
59.43 ± 14.72
0.004
independent
t-tests (p-
value)
0.922
0.0001
SD – standard deviation
The results showed no significant statistical
difference in mean pain scores at different times.
However, pain scores in the intervention group
indicated significant differences at different times (p
= 0.0001), with pain falling significantly over time
(Table 5).
Table 5 The mean of pain in the intervention and control groups
Time
Control (Mean of pain)
mean (SD)
Intervention (Mean of pain)
mean (SD)
Mann-Whitney test
p-value
start treatment
8.10 ± 2.15
8.30 ± 2.08
0.729
1 hour later
8.33 ± 1.93
7.46 ± 2.28
0.101
2 hours later
8.53 ± 1.80
6.40 ± 2.45
0.0001
3 hours later
8.33 ± 1.72
6.10 ± 2.46
0.0001
4 hours later
8.36 ± 1.69
5.66 ± 2.46
0.0001
Friedman test (p-value)
0.339
0.0001
SD – standard deviation
Discussion
The anxiety averages in patients of the control and
experimental groups before intervention were 56.63
and 56.96, respectively, indicating relatively high
anxiety. Since the patients in this study were due to
have operations, the results of this study confirm the
results of previous studies. The literature shows that
preoperative anxiety is caused by worries about
problems after surgery, including pain, changes
in body image or function, increased dependency,
family concerns, or likely changes in lifestyle
(OʼBrien, 2003). Preoperative anxiety may prevent
postoperative recovery. Excessive preoperative
anxiety is associated with increased pain after surgery
(Kindler et al., 2000), reduced ability to resist
infection, increased intake of painkillers after
surgery, slow-healing wounds (Granot, Ferber, 2005),
negative impacts on patient mood (Montgomery,
Bovbjerg, 2004), and prolonged hospitalization
(Frazier et al., 2003). Whereas it has been found that
reduced anxiety can result in faster recovery, reduced

Hekmatpou D et al. Cent Eur J Nurs Midw 2017;8(4):716–721
© 2017 Central European Journal of Nursing and Midwifery
720
intake of medication during anesthesia, greater pain
tolerance, and earlier discharge, ultimately leading to
lower costs, and fewer postoperative complications
(Mahfoozi, Hasani Mian, 2000). The results of the
present study showed that aromatherapy with orange
oil could reduce anxiety in the experimental group;
the frequency distributions of different levels
of anxiety were significantly different in the two
groups after intervention. These results are in line
with thosein a study by Goes et al. (2012). They
studied the effects of aromatherapy using tea oil and
orange oil on reducing anxiety, concluding that
orange oil is more effective than tea oil in reducing
anxiety. Lehrner et al. (2000) studied the effects
of aromatherapy with orange oil on pain and anxiety
in patients referred to a dentist, and showed that
aromatherapy using orange oil reduced anxiety,
confirming the results of this study. Kanani et al.
(2012) conducted research on dialysis patients,
demonstrating that aromatherapy with orange oil can
reduce anxiety in these patients. This result is also
in line with the results of our study. Jafarzadeh,
Arman, Pour (2013) studied the effects
of aromatherapy with orange oil on anxiety
in children who had been referred to a dentist, and
found that orange oil can reduce anxiety in children,
further confirming the results of the current study.
The mean of pain for the control and experimental
groups before intervention was 8.3 and 8.1,
respectively, indicating severe pain. This result
confirms the results of previous research, revealing
the high severity of orthopedic pain (Marret et al.,
2005). Changes in pain severity in the intervention
group demonstrate statistically significant differences
at different times; over time, pain reduced
significantly in the intervention group. These findings
indicate the positive effect of orange oil on pain relief
in patients with orthopedic fractures, which is in line
with the results of a study by Lehrner on dental
procedures (Lehrner et al., 2005). Yip, Tam (2008)
showed that aromatherapy and massage with orange
oil and ginger can reduce arthritic knee pain,
conforming to the results of this paper. However,
Małachowska et al. (2016) studied the pain produced
when a lancet was used to measure blood sugar in
children with type I diabetes, obtaining different
results to those in this paper. This difference may be
due to the different nature of the respective pains.
Ozgoli, Esmaeili, Nasiri (2011) showed that orange
oil can relieve breast pain caused by premenstrual
syndrome. Rashidi Fakari et al. (2013) also showed
that orange oil can reduce labor pain, which is in line
with the results of this paper. Thus, as this and other
studies have indicated, aromatherapy can be a safe,
effective, inexpensive addition to a holistic patient-
centered approach to pain management (Boyce,
Natschke, 2016).
Limitation of study
The limitation of this study was the lack
of information about additional complementary
medications taken by the patients which might have
influenced the results regarding the effect of the
inhalation of orange oil on the patientsʼ anxiety and
pain.
Conclusion
Aromatherapy with orange essential oil reduced pain
and anxiety in patients with limb fractures. It can lead
to faster recovery and discharge of patients, as well
as reduced hospitalization costs. Therefore the
application of aromatherapy with orange essential oil
as a complementary therapy in such patients is
recommended.
Ethical aspects and conflict of interest
The study was carried out in accordance with the
Helsinki Declaration. This project was registered
under code IR.ARAKMU.REC.1395.111 by the
Ethics Committee of Arak University of Medical
Sciences. The personal characteristics of all subjects
of the research have been kept confidential. All
participated voluntarily, and informed consent was
obtained. The subjects were free to withdraw from
the study at any time. The authors declare no conflict
of interest.
Acknowledgment
We would like to thank the Traditional and
Complementary Medicine Research Center
(TCMRC) in Arak University of Medical Sciences,
the personnel in the emergency ward of Vali-e-Asr
Hospital in Arak and all the patients who participated
in this project.
Author contribution
Concept and design (DH, YP), data collection (YP,
RP, PVF), analysis and interpretation of data (DH),
the drafting of the manuscript (YP, PVF), a critical
revision of the manuscript (DH, RP), the final
completion of the article (DH, YP).
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