Indian J Palliat Care. 2017 Oct-Dec; 23(4): 431–436.

doi: [10.4103/IJPC.IJPC_37_17]
PMCID: PMC5661347
PMID: 29123351

The Effect of Aromatherapy with the Essential Oil of Orange on

Pain and Vital Signs of Patients with Fractured Limbs Admitted
to the Emergency Ward: A Randomized Clinical Trial
Davood Hekmatpou, Yasaman Pourandish, Pouran Varvani Farahani, and Ramin Parvizrad

Author information Copyright and License information Disclaimer

Abstract
Go to:

Background and Objective:

Pain is an emotional and unpleasant experience associated with actual or potential tissue
damage. The literature shows no study on the effect of aromatherapy with the essential oil of
orange on unpleasant feelings of patients with fractured limbs. In this regard, this paper aims at
studying the effect of aromatherapy with the essential oil of orange on patients with fractured
limbs admitted to the emergency ward.

Methods:

Sixty patients admitted to the emergency ward of Vali-e-Asr Hospital were selected by purposive
sampling method and then were divided into two groups of control and experiment by block
method. This study was done in one shift work (morning or afternoon). Four drops of the orange
oil were poured on a pad and were pinned with a plastic pin to the patient's collar, about 20 cm
distant from head. The old pad was replaced by the new one every 1 h. The patients' pain and
vital signs were checked every 1 h for at last 6 h. The data were analyzed by SPSS Version 21.

Results:

Forty (66.7%) patients were male and twenty (33.3%) were female. Their age average was 37.93
± 18.19 years old. The most fractured cases were in the scapular (11 patients [18.3%]).
Friedman test showed that pain in the experiment group (P = 0.0001) decreased significantly
rather than the control group (0.339). However, in vital signs, there could be found that no
significant change between the two groups was seen.

Conclusion:

Aromatherapy with orange oil can relieve pain in patients with fractured limbs but has no effect
on their vital signs. Therefore, aromatherapy with orange oil can be used as a complementary
medicine in these patients.
Keywords: Aromatherapy, emergency ward, limb fracture, orange oil, pain, vital sign

INTRODUCTION
According to the definition by International Association for the Study of Pain, pain is an
unpleasant sensory and emotional experience.[1,2] Pain relief by reducing transferring
painful data to the central nervous system and optimizing analgesia treatment can reduce
mortality and morbidity in patients.[3,4,5] Lack of pain control can activate the
sympathetic nervous system and increase morbidity and mortality in patients. Indeed, the
sympathetic system activities 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).[3,4,5,6]
Another important side effect of stimulation of the sympathetic nervous system is
reducing the gastrointestinal motility delay in stimulation of the digestive system
(ileus).[3,4,5,6,7] Lack of proper pain management in patients consequences impaired
respiratory dysfunction in patients, especially during pain in abdomen and thoracic
regions.[7] Moreover, pain has psychological effects as well and is regarded as the main
reason for fear, anxiety, distress, and disappointment.[8] There are different ways to
control pain including systemic analgesics (narcotics and nonnarcotics) and local
anesthesia techniques; each can be prescribed according to the patient's medical
condition.[9] A safe way that can control the pain with no side effects such as respiratory
problems, pruritus, or hemodynamic dysfunction is ideal.[10]
Fractures and orthopedic surgery cause severe pain in patients and applying narcotic
analgesics is necessary to use narcotic analgesics.[11,12,13,14,15,16] Since the narcotic
analgesics have general side effects such as respiratory problems, sedation, nausea and
vomiting, symptoms of tolerance or withdrawal syndrome in patients, using
nonpharmacological methods as complement rather than alternative interventions are
recommended. In this regard, there are methods in complementary medicine by which
nurses can help patients.[17,18] They need to be prescribed by a physician or, in some
cases, nurses avoid prescribing them, due to fear of side effects or make longer the time
between doses. In this regard, using pharmacological drugs with nonpharmacological
methods can be helpful and more efficient than methods.[19] 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.[20] The aromatic oils are extracted from aromatic plants,
which are anti-inflammatory, antimicrobial, and reduce pain and stress.[20,21,22,23] In
fact, applying aromatherapy is common, and it is the second complementary method
among nurses since its clinical applications.[24] It has been proved that inhalation of the
essential oil of orange can reduce the labor pain.[25] It also can stimulate the central
nervous system, enhance moods, cause sedation and relief. It is an antispasmodic, an anti
inflammatory, an antibloating, a food digestive, and a diuretic, and can lower the blood
pressure. Its active substances are limonene and Flanders Citral (Levomenthol).[26,27]
Massage and aromatherapy with a combination of ginger and orange oils were effective
in relieving knee pain in the 1st week among patients with osteoarthritis.[28] A study has
shown that edible oil of orange can reduce breast pain caused by premenstrual
syndrome.[29]
Considering the importance of pain and proper management of pain in patients and few
researches on the relationship between aromatherapy and pains of fractured bones, this
paper aims at studying the effect of aromatherapy with the essential oil of orange on pain
and vital signs of patients with fractured limbs admitted to the emergency ward.
Go to:

METHODS
This research is a clinical trial registered in the Center of Clinical Trial in Iran under code
IRCT201607124519N6. Samples size was obtained by the following formula.[30]

According to the comparison of means formula and reference 30, the sample size for each
group was estimated as 30. In the emergency ward of Vali-e-Asr Hospital, sixty patients
were selected by the purposive sampling method and were divided into two thirty-patients
groups of experiment and control by blocking method. The collecting data tools were a
demographic questionnaire and self-report pain scale measured by the 10-item visual
analog scale (VAS). The vital signs were checked by the researcher of that shift. This
research was done in one shift work (morning or afternoon). The patients were fractured
limbs admitted to the emergency ward of Vali-e-Asr Hospital in Arak, who must undergo
orthopedic surgery voluntarily participated in this trial (they were matched based on their
age, sex, type of fracture, and the initial pain). As patient entered to the emergency ward,
for intervention, four drops of the essential oil were poured on the pad and were pinned
with a plastic safe pin to the patients' collars with about 20 cm distant from the head and
the pads were replaced with new ones every 1 h. The pain and vital signs in patients were
checked every 1 h for at last 6 h. Since aromatherapy was used as a complementary
medicine, the common standard treatments of pain in the ward have been performed to
test and control groups.

Inclusion criteria
Patients with over 18 years old, no history of chronic pain, vision disorders, respiratory
problems, and with mental and smell health, could participate in this research could
participate this research. The informed consents were obtained from the participants.

Exclusion criteria
Patients with lack of interest in participating or withdrawing while performing the
research and having any allergic symptoms while performing the research were excluded
from the study.

Collecting data tools

The VAS (0–10) was used to evaluate the pain. This scale is graded between 0 and 10; 0
shows no pain and 10 implies the most severe pain. The patients show their pain by
pointing on the right scale. This scale allows the patients to show their pain freely.[31]
This scale is the most widely used pain evaluation tool in the world.[31,32,33,34] In
addition to validity and reliability, this tool is easy to use. Zero, in this scale, shows no
pain, 1–3 shows mild pain, 4–6 moderate, 7–9 severe, and 10 indicates very severe
pain.[32] Many studies out of Iran have proved its validity and reliability.[33] In Iran, the
reliability of this scale was confirmed with correlational coefficient 0.88[34] [Figure 1].

Figure 1
The Visual Analogue Score, VAS (0-10)

Ethical considerations
This project has been registered under code IR. ARAKMU. REC.1395.111. The personal
characteristics of all subjects of the research have been kept confidential. All participated
voluntarily, and the informed consents were obtained. The subjects could withdraw
whenever they wanted.
Go to:

RESULTS
Sixty patients participated in this research, 30 in the intervention and 30 in the control
group [Diagram 1]. Forty (66.7%) patients were male and 20 (33.3%) were female. Their
age average was 31.93 ± 18.19 years old; the youngest was 18 and the oldest patient was
72 years old. Thirty-seven patients (61.7%) were married and 23 (38.3%) were single.
Eleven patients (18.3%) had diploma, 8 (13.4%) had academic studies, and 41 patients
(68.3%) had lower grades. The subjects in the two groups have the same demographic
information, and there could be found no significant differences.
Diagram 1
Flow Diagram of Enrollment
Fisher's exact test results showed that the distribution of fractures in the two groups has
no significant difference. Although the most common fractures were of the scapula with
11 patients (18.3%) [Table 1].
Table 1
Frequency of limb fractures among two intervention and control groups

The results showed no statistically significant difference in mean pain scores in different
times. However, pain scores in the intervention group have significant differences at
different times (P = 0.0001) and with increasing duration of pain was significantly
reduced [Table 2].
Table 2
The mean of pain among two intervention and control groups

The results showed, at all times, no statistically significant difference in mean of systolic
blood pressure. This means that changes in systolic blood pressure in both groups did not
differ at different times [Table 3].
Table 3
Comparing the mean of systolic blood pressure in two intervention and control groups

The results showed, at all times, no statistically significant difference in mean of diastolic
blood pressure. This means that changes in diastolic blood pressure in both groups did not
differ at different times [Table 4].
Table 4
Comparing the mean of diastolic blood pressure in two intervention and control groups
The results showed that, in all times but 3 h after the intervention, the mean heart rate in
both groups was not statistically significant. This means that changes in pulse in both
groups did not differ at different times [Table 5].
Table 5
Comparing the mean of pulse rate in two intervention and control groups

The results showed, at all times, no statistically significant difference in mean of

temperature. This means that changes in temperature in both groups did not differ at
different times [Table 6].
Table 6
Comparing the mean of temperature in two intervention and control groups

The results showed, at all times, no statistically significant difference in mean of

respiratory rates. This means that changes in respiratory rates in both groups did not differ
at different times [Table 7].
Table 7
Comparing the mean of respiratory rate in two intervention and control groups
Go to:

DISCUSSION
The results showed that the pain averages the control and experiment groups before
intervention were 8.3 and 8.1, respectively, which show severe pain. This result conforms
to the results by the previously done researches that revealed the high severity of
orthopedic pains.[11,12,13,14,15,16] Furthermore, the results of this paper showed that
severity of pain in the two groups of experiment and control was not significantly
different. Fractures in limbs result in severe pains were forced medical team to give
narcotic drugs that make the treatment team to use narcotic
analgesics.[11,12,13,14,15,16]
The results showed that changes in pain severity in the intervention group have
significant statistical differences at different times; over the time, the pain reduced
significantly. These findings indicate the positive effect of the essential oil of orange on
pain relief in the patients with orthopedic fractures, which are in line with the results by
Lehrner on dental procedures.[35] Yip and Tam showed that aromatherapy and massage
with orange oil and ginger can reduce knee arthritis pains,[28] conforming to the results
of this paper. However, Małachowska et al. studied the pain from the Lancet to measure
blood sugar in children with type I diabetes[36,37] and obtained results different from the
results in this paper; this difference may be due to difference in pains in orthopedic
fractures and lancet. Ozgoli et al. showed that the orange oil can relive the pain in breasts
caused by premenstrual syndrome.[29] Rashidi Fakari also showed that the orange oil can
reduce labor pain, which is in line with the results of this paper.[25]
Another main objective of this paper was studying the effect of the orange oil on vital
signs such as pulse rate, respiration, blood pressure, and body temperature in patients with
fractured limbs admitted to the emergency ward. No significant difference was observed
between the vital signs in the two groups at different times. Contrary to our results,
Ja'farzade showed that inhalation of the orange oil decreased the heart rates in the
children who had referred to dentist; this difference may be due to difference in the
natures of dental procedures and fractures. Moreover, the atmosphere in the emergency
ward, for example, crowdedness, long waits for surgery, and fear of the future may reduce
the effect of the orange oil on the patients' vital signs. The limitation of this study was a
lack of enough information about the complementary medicine by the patients, which
could affect the results of effects of inhalation of the orange oil on the patients' vital signs
in the study.
Go to:

CONCLUSION
Aromatherapy with the essential oil of orange as a complementary medicine could relieve
pain in patients with fractured limbs before surgery. It can lead to faster recovery and
discharging of patients as well as reduce the costs of hospitalization. In this context,
aromatherapy with the orange oil in patients with fractured limbs is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.
Go to:

REFERENCES
1. Shang AB, Gan TJ. Optimising postoperative pain management in the ambulatory
patient. Drugs. 2003;63:855–67. [PubMed]
2. Agah M, Dabbagh A, Hashemi M. Evaluation of the effect of intravenous magnesium
on acute postoperative pain in elective orthopedic surgeries of the lower
limb. Pajoohandeh. 2006;11:149–52.
3. Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J
Anaesth. 2001;87:62–72.[PubMed]
4. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. their role in
postoperative outcome. Anesthesiology. 1995;82:1474–506. [PubMed]
5. Kehlet H. Modification of responses to surgery by neural blockade. In: Cousins MJ,
Bridenbaugh PO, editors. Neural Blockade in Clinical Anesthesia and Management of
Pain. 3rd ed. Vol. 11. Philadelphia: Lippincott-Raven Publishers; 1998.
6. Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109–
17. [PubMed]
7. Fratacci MD, Kimball WR, Wain JC, Kacmarek RM, Polaner DM, Zapol WM, et al.
Diaphragmatic shortening after thoracic surgery in humans. effects of mechanical
ventilation and thoracic epidural anesthesia. Anesthesiology. 1993;79:654–65. [PubMed]
8. Naghibi K. Principle of Anesthesia and Critical Care. Isfahan: Mani Publicaton; 2001.
9. Practice guidelines for acute pain management in the perioperative setting. A report by
the american society of anesthesiologists task force on pain management, acute pain
section. Anesthesiology. 1995;82:1071–81. [PubMed]
10. Lim J, Lim G, Sung B, Wang S, Mao J. Intrathecal midazolam regulates spinal
AMPA receptor expression and function after nerve injury in rats. Brain
Res. 2006;1123:80–8. [PMC free article][PubMed]
11. Stein C. The control of pain in peripheral tissue by opioids. N Engl J
Med. 1995;332:1685–90.[PubMed]
12. Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW. Anesthetic
considerations for bariatric surgery. Anesth Analg. 2002;95:1793–805. [PubMed]
13. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of nonsteroidal antiinflammatory
drugs on patient-controlled analgesia morphine side effects: Meta-analysis of randomized
controlled trials. Anesthesiology. 2005;102:1249–60. [PubMed]
14. Nuutinen LS, Laitinen JO, Salomäki TE. A risk-benefit appraisal of injectable
NSAIDs in the management of postoperative pain. Drug Saf. 1993;9:380–93. [PubMed]
15. Meet E. Efficacy of NSAIDs drugs in the management of postoperative
pain. Drugs. 1992;44(Suppl 5):14–29. [PubMed]
16. Kehlet H, Dohl JB. Are perioperative NSAIDs erogenic in the short
time? Drugs. 1992;44:38–41.[PubMed]
17. Ball JW, Bindler RC, Cowen K. Child Health Nursing: Partnering with Children and
Families. 2nd ed. Pilladelphia: Prentice Hall; 2010.
18. Steolting R, Miller R. Basics of Anesthesia. 5th ed. Philadelphia: Churchill
Livingstone Elsvier; 2007. pp. 112–22.
19. Hockenberry Marilyn J, Wilson D. Wong's Essentials of Pediatric Nursing. 8th ed.
Louis, MO: Mosby/Elsevier; 2009. pp. 194–8.
20. Buckle J. Clinical aromatherapy and AIDS. J Assoc Nurses AIDS Care. 2002;13:81–
99. [PubMed]
21. Long L, Huntley A, Ernst E. Which complementary and alternative therapies benefit
which conditions? A survey of the opinions of 223 professional
organizations. Complement Ther Med. 2001;9:178–85.[PubMed]
22. Cooke B, Ernst E. Aromatherapy: A systematic review. Br J Gen Pract. 2000;50:493–
6.[PMC free article] [PubMed]
23. Howarth AL. Will aromatherapy be a useful treatment strategy for people with
multiple sclerosis who experience pain? Complement Ther Nurs Midwifery. 2002;8:138–
41. [PubMed]
24. Marline S, Laraine K. Foundation of aromatherapy. Lippincotts. 2008;22:3–9.
25. Rashidi Fakari F, Tabatabaee Chehr M, Rashidi Fakari F, Mortazavi H, Kamali H,
Tayebi V. The effects of aromatherapy on painof labor in nulliparous women. J North
Khorasan Univ Med Sci. 2013;5:363.
26. Soltani A. Encyclopedia of Traditional Medicine Herbal. 2nd ed. Tehran: Arjmand;
2005.
27. Haji Akhondi A, Baligh N. Guidline of Herbal Medicine. Tehran: Islamic Azad
University; 2005.
28. Yip YB, Tam AC. An experimental study on the effectiveness of massage with
aromatic ginger and orange essential oil for moderate-to-severe knee pain among the
elderly in Hong Kong. Complement Ther Med. 2008;16:131–8. [PubMed]
29. Ozgoli G, Esmaeili S, Nasiri N. The effect oral of orange peel on the severity of
symptoms of premenstrual syndrome, double-blind, placebo-controlled clinical trial. J
Reprod Fertil. 2011;12:123–9.
30. Kanani M, Mazloum SR, Emami A, Mokhber N. The effect of aromatherapy with
orange essential oils on anxiety in patients undergoing hemodialysis. Q J Sabzevar Univ
Med Sci. 2012;19:249–57.
31. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog
scale for pain (VAS pain), numeric rating scale for pain (NRS pain), mcGill pain
questionnaire (MPQ), short-form mcGill pain questionnaire (SF-MPQ), chronic pain
grade scale (CPGS), short form-36 bodily pain scale (SF-36 BPS), and measure of
intermittent and constant osteoarthritis pain (ICOAP) Arthritis Care Res
(Hoboken) 2011;63(Suppl 11):S240–52. [PubMed]
32. Mendelson G, Selwood TS. Measurement of chronic pain: A correlation study of
verbal and nonverbal scales. J Behav Assess. 1981;3:63–9.
33. Vickers ER, Cousins MJ, Woodhouse A. Pain description and severity of chronic
orofacial pain conditions. Aust Dent J. 1998;43:403–9. [PubMed]
34. Rezvani Amin M, Siratinayer M, Ebadi A, Moradian T. Correlation between visual
analogue scale and short form of McGill questionnaire in patients with chronic low back
pain. Qom Univ Medl Sci J. 2012;6:31–4.
35. Lehrner J, Eckersberger C, Walla P, Pötsch G, Deecke L. Ambient odor of orange in a
dental office reduces anxiety and improves mood in female patients. Physiol
Behav. 2000;71:83–6. [PubMed]
36. Małachowska B, Fendler W, Pomykała A, Suwała S, Młynarski W. Essential oils
reduce autonomous response to pain sensation during self-monitoring of blood glucose
among children with diabetes. J Pediatr Endocrinol Metab. 2016;29:47–53. [PubMed]
37. Jafarzadeh M, Arman S, Pour FF. Effect of aromatherapy with orange essential oil on
salivary cortisol and pulse rate in children during dental treatment: A randomized
controlled clinical trial. Adv Biomed Res. 2013;2:10. [PMC free article] [PubMed]

Articles from Indian Journal of Palliative Care are provided here courtesy of Wolters Kluwer --
Medknow Publications