INDONESIAN JOURNAL OF NURSING PRACTICES 124 INDONESIAN JOURNAL OF NURSING PRACTICES Mar’atun Ulaa1, Wiwin Lismidiati2, Elsi Dwi Hapsari2 1 School of Nursing STIKes Muhammadiyah Palembang 2 School of Nursing Faculty of Medicine, Universitas Gadjah Mada Email: maratunulaa@gmail.com Differences Use of Yoga and Self Tapping Towards Long Pain of Primary Dysmenorrhea on Adolescent Info Artikel Masuk Revisi Diterima DOI Number : : 15 September 2017 : 15 November 2017 : 30 November 2017 : 10.18196/ijnp.1370 Abstract Background: Dys menorrhea i s a common compl ai nt i n young women, characteri zed by pai n. Dys menorrhea pai n has a s i gni fi cant i mpact on women's l i ves , s uch as l i mitati ons i n dai l y acti vi ti es . Pri mary dys menorrhea can be treated us i ng yoga and s el f-tappi ng. Objective: unders tandi ng di fferences on us e of Compl ementary and Al ternati ve Medi ci ne (CAM), s uch as yoga and s el f-tappi ng towards changi ng l ong pai n of pri mary dys menorrheal . Method: Study was conducted by quas i experi ment wi th nonequi val ent pretes t-pos ttes t control group des i gn. Study was conducted on November 2016 unti l February 2017 i n SMK “A” Pedan Kl aten and SMK “B” Kl aten. Sampl e of s tudy amounted 88 res pondent di vi ded on 47 res pondents on experi mental group and 41 res pondent as control group. The experi mental group was gi ven a yoga i nterventi on; control group was gi ven s el f-tappi ng. Meas uri ng tool us ed Numeri cal Rati ng Scal e (NRS). Data anal ys i s us ed t-tes t for i ndependent s ampl e, Mann-Whi tney tes t and Wi l coxon. Result: Stati s ti cal l y yoga and s el f-tappi ng were equal l y effecti ve i n reduci ng the l ong pai n of pri mary dys menorrheal wi th p val ues of 0.000 and 0.012 res pecti vel y. Cl i ni cally yoga i s more effecti ve i n reduci ng the l ong pai n of pri mary dys menorrhea wi th mean 1,49 compared wi th s el f-tappi ng 0,46. Conclusion: Yoga become more effecti ve i nterventi on on reducti on l ong pai n of pri mary dys menorrhea compared to s el f-tappi ng. Keywords: pri mary dys menorrhea, yoga, s el f-tappi ng, l ong pai n, adol es cent. mailto:maratunulaa@gmail.com VOL. 1 NO. 3 DESEMBER 2017 125 Introduction Dysmenorrhea is a common complaint and often occurs on girls adolescent and women in reproductive age with marked cramps in lower abdominal area during menstruation. Primary dysmenorrhea occurred without pathological conditions in female reproductive organs. The heaviest duration of pain usually occurred on 48 to 72 hours in a single menstrual cycle 1, 2, 3. Pain period have a significant impact o n women's lives. The highest prevalence of primary dysmenorrhea occurred on girls adolescent, ranging from 20% - 90%, sixty percent occurred on adolescents aged 12-17 years old and peaks at the age of 20-24 years. Based on research conducted by Rodrigues (2011), 62.8 % of respondents experience menstrual pain and 65.7% experience limitations in daily activities due to dysmenorrheal 4. Prevalence of limitations in daily activities was influenced by the intensity and duration of pain. A similar study was conducted in Canberra and Western Australia showed an estimated prevalence of adolescents absent from school due to menstrual symptoms of 80% -94% 1, 3, 5, 6, 7. The prevalence of primary dysmenorrhea in Indonesia is estimated to be 55% in women of reproductive age 8. Based on Mardiyah et al’s research (2015) who study on adolescents in Madrasah Aliyah Negeri (MAN) 1 Semarang result, it was found that 65.2% of respondents experiencing dysmenorrhea 9. Wijayanti (2008) conducted research on the students SMA Muhammadiyah 1 Yogyakarta 63.6% of the students had primary dysmenorrhea 10. Management of primary dysmenorrhe a can be done by pharmacological and nonpharmacological approaches. Nonpharmacological approaches have been used with some degree of success. Based on data from the 2007 National Health Interview Survey (NHIS), forty percent of adults use complementary therapies such as acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy and yoga 11, 12, 13. Yoga is a mind-body practice derived from ancient Indian philosophy, consisting of physical posture (asana), breathing exercises (pranayama), and meditation (dhyana), which integrate the balance of body and mind in harmony 14. In addition, therapy that can be used to overcome the pain is self-tapping. Self-tapping is a tapping touch is a thorough maintenance technique using a rhythmic touch. Gentle massage helps to reduce the tension in the body and mind and increase feelings of prosperity and positive thoughts 15. Based on preliminary study was conducted in SMK “A” Pedan Klaten, girls have experienced dysmenorrhea pain during menstruation on 1-3 days of 200 students (59%). Sixty point five percent feel annoyed at the time of learning and 56% cannot learn effectively. Based on the above description, researchers are interested to know the difference between the use of yoga an d self-tapping on changes in the long pai n of primary dysmenorrhea. This is supported by the absence of a study comparing yoga and self-tapping interventions to address long pain of primary dysmenorrhea. INDONESIAN JOURNAL OF NURSING PRACTICES 126 Methods Study was conducted by quasi experiment with nonequivalent pretest- posttest control group design, by dividing the respondents into experimental groups (SMK “A” Pedan Klaten) and control groups (SMK “B” Klaten). In the experimental group given yoga intervention and control group given self-tapping intervention. Pain measured by Numerical Rating Scale (NRS) with validity value r>0,86 and reliability based on value of test-rete st r=0,96 and r=0,95. This research was conducted on 22 November 2016 until 27 February 2017, with total population of 641 students aged 14-18 years, with criteria inclusion have got menstruation, experiencing primary dysmenorrhea, menstrual cycle regularly in the last 2 months, coming from the Javanese tribe and willing to be a respondent. While the criteria for the exclusion are consuming drugs or drink pain relievers, consuming alcohol , body time index <18.5, experiencing anxiety with score ≥ 55 and performing at least 2 Times of the week (including yoga, classical ballet, and athletics). The number of samples in this study was calculated using the formula Lemeshow, et al (1997), the results obtained sample of 45 people, to anticipate the drop out rate, a 10% of the total sample was added. The samples in this study were 50 people i n each group (experimental and contro l ) . A total sample of 100 people taken using simple random sampling technique by way of drawing. Fifty respondents in the experimental gro u p who participated in the study, only 47 respondents completed the study according to the study protocol, 3 respondents drop out. While in the control group of 50 respondents who participated in the study, only 41 respondents completed the study according to the study protocol, 9 respondents drop out. This research was conducted after obtaining the approval or feasibility of ethical research from the Ethics Commission in Faculty of Medicine, Gadjah Mada University with referen ce number: KE/FK/1261/EC/2016 November 21, 2016. The researcher was assisted by two research assistants, who had previously done a perception equation on how to disseminate and guided the screening questionnaire, State Trait Anxiety Inventory Form Y (STAI-Y), Numerical Rating Scale (NRS). The researcher also uses 1 person facilitator and 6 facilitator assistants, research facilitator is yoga instructor from Yoga First Klaten certified studio, licensed yoga alliance and has experience of yoga teaching for more than 5 years. The yoga facilitator was assisted by three facilitators from the First Yoga studio Klaten. They were certified and have at least 2 years of yoga experience. As for self-tapping is taught by a research assistant who has been trained to teach self tappping movements. The self-tapping facilitato r will be assisted by 3 assistants who have previously performed apperception related to the procedure and research implementation. Implementation of data collection begins with screening using questionnaires and measurements of height and weight to all prospective respondents who previously had been given explanation of the research. Prospective respondents who fulfilled inclusion and exclusion criteria were VOL. 1 NO. 3 DESEMBER 2017 127 taken 100 people (each school 50 people). Further explaining the research process and informing consent, and distributing NRS instruments (pretest) and explaining how to fill it. The collection of pretest data was d o n e by asking respondents to fill in NRS instruments every day during menstruation. The first pain intensity measurements were performed for up to 10 hours after the first day's menstruation, for subsequent measurements taken at the same time as the first day of measurement. NRS instrument filling is monitored by researchers and research assistants either directly or through social media such as WhatsApp group (WA group), BlackBerry Messenger group (BBM group) or Short Message Service (SMS ) . After menstruation is complete respondents are asked to collect back NRS instruments that have been filled to researchers or research assistant. Subsequently given health education, the respondents were divided into tw o groups (experimental group and control group). Experimental group was taught yoga and control group taught self - tapping. The facilitator explains the general guidelines of yoga practice or self tapping, followed by demonstration of yoga or self-tapping procedures assisted by assistant facilitators followed by all responde nts. After the demonstration the respondents were divided into 4 smaller groups (consisting of 12-13 people), each group was guided by the facilitator's assistant until the respondent was able to intervene properly using the teach-back technique (re demonstration) and evaluated using the observation sheet in the form check list. Furthermore, researchers will distribute NRS (posttest) instruments, monitorin g sheets and health education evaluatio n questionnaires after intervention. Respondents were asked to complete NRS instruments and monitoring sheets daily as long as the respondent had menstruation. Measuring the intensity of pain, blood pressure and heart pu l s e on the first day was performed maximum of 10 hours after the respondent intervened (yoga intervention was done for 30 minutes each session while self-tapping was done for 20 minutes each session). For the next measurement is done at the same time with the first day measurement time. Researchers and research assistants monitor the implementation of NRS instrument intervention and completeness as well as monitoring sheets directly or indirectly through social media, as described previously. After the menstruation is complete th e respondent is asked to reassemble the NRS (posttest) instrument and the completed monitoring sheet completely. Data analysis was performed using t-test for independen t sample, Mann-Whitney and Wilcoxon test. Results After analyzing data can be presented characteristics and homogeneity of respondents by age, age of menarche, Body Mass Index (BMI), long periods and anxiety in Table 1: INDONESIAN JOURNAL OF NURSING PRACTICES 128 Table 1. Characteristics of research and homogeneity of experimental and control group in SMK “A” Pedan Klaten and SMK “B” Klaten 2017. Characteri s ti cs Group p Experi ment (n=50) Control (n=50) Mean ± SD Mean ± SD Age of res pondents (years ) 15,14±0,49 15,20±0,53 0,50 Age of Menarche (years ) 12,70±0,76 12,54±0,71 0,49 Body Mas s Index (BMI) (kg / m2) 20,50±3,13 20,16±2,69 0,73 Long Mens truati on (day) 5,90±1,11 6,28±1,13 0,69 Anxi ety STAI-Y1 Anxi ety STAI-Y2 44,28±7,60 44,24±6,01 43,82±6,24 42,78±7,08 0,24 0,20 *P val ue was obtai ned bas ed on t-tes t for i ndependent s ampl e Table 1 shows the respondents in this study homogeneous with the overall p value greater than 0,05 based on the homogeneity test result using t-test f o r independent sample. Homogeneity test on long pain between experimental group and control group, as shown in table 2: Table 2. Description of homogeneity of data on long pain prior to intervention of experimental and control group in SMK “A” Pedan Klaten and SMK “B” Klaten 2017. Vari abl e Experi ment Control P* n Medi an (mi n-max) Mean ± SD n Medi an (mi n-max) Mean ± SD Pai n Intens i ty 50 3,00 (1-8) 3,54±1,681 50 3,00 (1-7) 3,32±1,301 0,574 * P val ues were obtai ned bas ed on the Mann-Whi tney tes t Based on homogeneity test results in table 2 above shows that the characteristics of long pain before the intervention between the experimental and control groups is homogeneous, with a value of p≥0.05. The change of long pain before and after intervention in experiment and control group, as shown in table 3 below: Table 3. An illustration of the long pain of experimental and control group before and after intervention in SMK “A” Pedan Klaten and SMK “B” Klaten 2017. Group Pretest Posttest Mean Di fference P* n Medi an (mi n-max) Mean ± SD n Medi an (mi n-max) Mean ± SD Experi ment Control 47 41 3,00 (1-8) 3,00 (1-6) 3,53±1,718 3,12±1,166 47 41 2,00 (0-6) 3,00 (0-5) 2,04±1,574 2,66±1,109 1,49 0,46 0,000 0,120 * P values are obtained based on the Wilcoxon test In Table 3 above shows that statisticall y there was a significant decrease in l o n g pain before and after intervention o n l y in the experimental groups, whereas the control group did not have significant decrease in long pain. Clinically, the mean difference of decrease in long pain before and after VOL. 1 NO. 3 DESEMBER 2017 129 intervention of the experimental gro u p was higher than control group. Discussion Characteristic of respondent included age, age of menarche, body mass index (BMI), menstrual period and anxiety of respondents. According to Potter and Perry (2006) several factors that potentially affected pain such as age. Average age of respondents on treatment group was 15,4 years old an d 15,2 years old on control group16. According to Banikarim et al (2015) prevalence of primary dysmenorrhea i n girls adolescent ranged from 60-93%17. Primary dysmenorrhea is common in women less than 25 years old18, 19. Another risk factor for dysmenorrhea i s age of menarche. This is the age at which a woman receives the first menstruation that occurs in the age range 10-16 years or at puberty before entering the reproductive period8. The mean age of menarche in this study was more than 12 years. According to Kolhe (2016), age of menarche affects primary dysmenorrhea, this opinion is in line with Perry et al (2014) Which states that severe dysmenorrhea is always associated with early menarche 18, 19. Women who have menarche less than 12 years have a risk to experience pain during menstruation 20, 21. Body Mass Index (BMI) is a measure that compares the weight (in kilograms) with the square of the height (in meters). Body Mass Index between th e experimental group and control group in this study was homogeneous (p = 0.73), with mean ≥18.5. According to Osayande et al (2014) a low Body Mass Index is a risk factor for dysmenorrhea21. According to Perry et al (2014) The average duration of menstrual blood discharge is 5 days, with a range of 3-6 days19. The mean duration of menstruation between the experimental and control groups in th i s study was 5.9 and 6.28 days. According to ACOG (2015), most women experience menstruation for 2-7 days. In this study, the instant anxiety score (state anxiety) as measured by STA I Y- 1 instrument between the experimental group and the homogeneous control group, as well as the trait anxiety measured using the STAIY-2 instrumen t having a homogeneous score. Respondents in this study did not experience the momentary anxiety an d basic anxiety. Anxiety has a reciprocal relationship with pain perception. When anxiety increases then the perception of pain will increase, in other hand if the perception of pain increases then anxiety will increase. People who have stable emotions will more easily tolerate pain than people who have unstable emotions. Base d o n the results of research Dhayita (2011) there is a significant relationship between emotional stability before menstruation with the emergence of dysmenorrhea. Wijayanti (2008) Examined the relationship of stress with the incidence of primary dysmenorrhea, the results statistically there is a significant relationship between stress with the incidence of primary dysmenorrhea in adolescents10. According to Kolhe (2016) psychosocial factors play a role in the perception and severity of pain. 1. Differences long pain of primary dysmenorrhea before and after yoga. The results of this study were statistically significant differences in the long pain of primary dysmenorrhea INDONESIAN JOURNAL OF NURSING PRACTICES 130 before and after yoga (table 3). The results of this study confirm previous research conducted by Rakhshaee (2011). There was a significant difference in intensity and duration of pain before and after intervention in the yoga group 24. Siahaan (2011) also conducted a study that aims to determine the influence of yoga on dysmenorrhea level, the result is influence of yoga on dysmenorrhea25. Based on research Rani et al (2011) yoga nidra can also reduce the intensity of pain, gastrointestinal symptoms. 2. Differences long pain of primary dysmenorrhea before and after sel f tapping. In this study the control group was given self tapping intervention, the result statistically not significant difference of long pain before and afte r self tapping (table 3). This study are statistically inconsistent with research conducted by Akbar (2015), the result there is a significant difference of pain intensity primary dysmenorrhea before and after self tapping27. 3. Differences long pain of primary dysmenorrhea experimental group who performed yoga with a contro l group that performed self tapping. The results of this study statistically showed decrease in long pain before and after intervention only in yoga intervention. The mean difference of decrease in long pain before and after yoga intervention in the experimental group were higher than the control group (Table 3). So the conclusions of interpretation of long pain in the experimental group were statistically and clinically compatible, whereas in the control group were statistically an d clinically incompatible. The results of this study confirm previous research conducted by Sakuma et al (2012), the results were statistically significant differences in pain intensity before and after intervention between yoga groups compared with the control group. While the clinical average decrease in intensity of menstrual pain group gi v e n by intervention home-based simple yoga is higher than the control group14. Manurung (2015) also conducted a study on the effectiveness of yoga on dysmenorrhea pain in adolescents, the results were statistically significant differences in pain intensity before an d after intervention in the experimental group taught yoga compared to the untreated control group28. Conclusion Yoga become more effective intervention on reduction long pain of primary dysmenorrhea compared to self tapping. Acknowledgements The authors thank to Dr. Heny Suseani Pangastuti, S.Kp, M.Kes and Widyawati , S.Kp, M.Kes.,PhD, who has provided much input in this research. 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