Original Article| Volume 23, ISSUE 3, P353-358, June 2022

A New Approach on the pain management of intramuscular injection: A Triple-Blind Randomized Clinical Trial

Published:March 10, 2021DOI:



      Pain management is an important part of care provided by nurses.


      The present study aimed to investigate the effect of an innovative method named the skin traction, pressure, and rapid muscle release (TPR) on reducing IM injection pain compared with the Z-track injection method


      This triple-blind clinical trial investigated 63 patients who required Methocarbamol injection.


      Two, 5-cc methocarbamol injections were given to each patient by the two techniques in two of his/her muscles. In the TPR technique, after applying skin traction and imposing deep pressure on the muscle, the needle was inserted at a 90° angle near the skin and the muscle was released rapidly towards the needle. Hence, the needle was embedded in the muscle. However, muscle release was not applied in the Z-track method. The visual analog scale (VAS) was used to measure pain intensity. For data analysis, T-independent and χ2 tests were used.


      The findings showed that the mean pain score in TPR and Z-track methods was 1.68 ± 1.20 and 3.76 ± 1.42, respectively. The difference was statistically significant.


      The results of this study showed that the innovative method (TPR) can be used as a substitute for the Z-track method to reduce IM injection pain.


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        • Astuti I.T.
        • Wijayanti K.
        • Nuraini L.
        • Khasanah N.N.
        • Susanto H.
        Effects of cold compress on the heguous point of meridian large intestine on pain before giving immunization in infants.
        Jurnal Ners. 2019; 14: 358-361
        • Aydin E.
        • Avşar G.
        Examining the effect of “Shotblocker” in relieving pain associated with intramuscular injection.
        Complementary Therapies in Medicine. 2019; 47102192
        • Barnhill B.J.
        • Holbert M.D.
        • Jackson N.M.
        • Erickson R.S.
        Using pressure to decrease the pain of intramuscular injections.
        Journal of Pain and Symptom Management. 1996; 12: 52-58
        • Begum R.
        Validity and reliability of visual analogue scale (vas) for pain measurement.
        Journal of Medical Case Reports and Reviews. 2019; 2
        • Chung J.W.
        • Ng W.M.
        • Wong T.K.
        An experimental study on the use of manual pressure to reduce pain in intramuscular injections.
        Journal of Clinical Nursing. 2002; 11: 457-461
        • Davoudi A.
        • Rismanchian M.
        • Akhavan A.
        • Nosouhian S.
        • Bajoghli F.
        • Haghighat A.
        • Arbabzadeh F.
        • Samimi P.
        • Fiez A.
        • Shadmehr E.
        A brief review on the efficacy of different possible and nonpharmacological techniques in eliminating discomfort of local anesthesia injection during dental procedures.
        Anesthesia,Essays and Researches. 2016; 10: 13-16
        • Derya E.-Y.
        • Ukke K.
        • Taner Y.
        • Izzet A.Y.
        Applying manual pressure before benzathine penicillin injection for rheumatic fever prophylaxis reduces pain in children.
        Pain Management Nursing. 2015; 16: 328-335
        • Hylton A.
        Nurses' knowledge and attitudes regarding pain (Thesis, Master of Nursing).
        University of Otago, Dunedin, New Zealand2019
        • Jukić M.
        • Puljak L.
        Legal and ethical aspects of pain management.
        Acta Medica Academica. 2018; 47: 18-26
        • Kara D.
        • Yapucu Güneş Ü.
        The effect on pain of three different methods of intramuscular injection: A randomized controlled trial.
        International Journal of Nursing Practice. 2016; 22: 152-159
        • Karaman D.
        Using ventrogluteal site in intramuscular injections is a priority or an alternative?.
        International Journal of Caring Sciences. 2015; 8: 507
        • Karasu Y.
        • Cömert D.K.
        • Karadağ B.
        • Ergün Y.
        Lidocaine for pain control during intrauterine device insertion.
        Journal of Obstetrics and Gynaecology Research. 2017; 43: 1061-1066
        • Knezevic N.N.
        Pain as a fifth vital sign: Do we regret?.
        in: 9th Annual Spring Scientific Symposium in Anesthesiology and Intensive Care, Niš, Serbia2019 (2019 April 12-14)
        • Madeira G.
        • Mocumbi A.O.
        • Mayosi B.M.
        Advice to health professionals: Use of lignocaine as a diluent to reduce the pain associated with the administration of benzathine penicillin G.
        South African Medical Journal. 2016; 106 (-742): 742
        • McNamara B.
        • Russo J.
        • Chaiken S.
        • Jacobson J.
        • Kerns J.
        A qualitative study of digoxin injection before dilation and evacuation.
        Contraception. 2018; 97: 515-519
        • Mohammady M.
        • Janani L.
        • Sari A.A.
        Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity.
        Cochrane Database of Systematic Reviews. 2017; 11CD008077
        • Öztürk D.
        • Baykara Z.G.
        • Karadag A.
        • Eyikara E.
        The effect of the application of manual pressure before the administration of intramuscular injections on students' perceptions of postinjection pain: a semi-experimental study.
        Journal of Clinical Nursing. 2017; 26: 1632-1638
        • Potter P.
        • Perry A.
        • Stockert P.
        Fundamentals of Nursing-E-Book.
        9th ed. Elsevier Health Sciences, New York2016
        • Sah S.R.
        • Maskey S.
        Knowledge of intramuscular injection among the nurses of a teaching hospital.
        Journal of Chitwan Medical College. 2020; 10: 40-43
        • Salari M.
        • Estaji Z.
        • Akrami R.
        • Rad M.
        Comparison of skin traction, pressure, and rapid muscle release with conventional method on intramuscular injection pain: A randomized clinical trial.
        Journal of Education and Health Promotion. 2018; 7: 172
        • Şanlialp Zeyrek A.
        • Takmak Ş.
        • Kurban N.K.
        • Arslan S.
        Systematic review and meta-analysis: Physical-procedural interventions used to reduce pain during intramuscular injections in adults.
        Journal of Advanced Nursing. 2019; 75: 3346-3361
        • Sisson H.
        Aspirating during the intramuscular injection procedure: a systematic literature review.
        Jurnal of Clinical Nursing. 2015; 24: 2368-2375
        • Siu W.
        • Goubert L.
        Reducing the burden of pain from vaccination.
        Clinical Journal of Pain. 2015; 31: S132-S133
        • Torki B.
        • Firouzjaei I.T.
        • Taghadosi M.
        Comparing the effect of EMLA cream and lavender oil on severity of pain caused by enoxaparin injection in cardiac patients.
        Journal of Mazandaran University of Medical Sciences. 2020; 30: 1-10
        • Yilmaz D.
        • Khorshid L.
        • Dedeoglu Y.
        The effect of the Z-track technique on pain and drug leakage in intramuscular injections.
        Clinical Nurse Specialist. 2016; 30: E7-E12
        • Yilmaz D.K.
        • Dikmen Y.
        • Kokturk F.
        • Dedeoglu Y.
        The effect of air-lock technique on pain at the site of intramuscular injection.
        Saudi Medical Journal. 2016; 37: 304-308