Effects of Laughter Therapy on Respiratory Functions and Geriatric Pain in Elderly Individuals
Phase: NA
Conditions: Elderly, Respiratory Function, Pain
Sponsor: Ankara University

OFFICIAL TITLE: EFFECTS OF LAUGHTER THERAPY ON 
RESPIRATORY FUNCTIONS AND GERIATRIC PAIN IN ELDERLY 
INDIVIDUALS 
 
NCT NUMBER: XXXXXX 
 
DATE: JULY 18, 2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

STUDY PROTOCOL 
 
 
 
Structural and functional changes occur with aging, and bodily functions gradually 
decline. One of the body systems affected by aging is the respiratory system. During the aging 
process, the loss of elasticity in lung tissue, weakening of respiratory muscles, and inefficient 
gas exchange lead to a decrease in respiratory capacity. Consequently, this causes shortness of 
breath, increased risk of infection, and a decrease in quality of life. Changes in body systems 
also cause chronic pain in elderly individuals. Pain-related weakness, functional losses, and the 
use of multiple medications are observed. Complementary treatment approaches can be used to 
reduce the symptoms of age-related problems and promote healthy aging in response to these 
changes caused by aging. This study aims to examine the effect of laughter therapy, a 
complementary treatment method, on respiratory functions and geriatric pain in elderly 
individuals. 
 
The study population consists of individuals aged 60 and over, members of a Retirement 
Club affiliated with the Ankara Metropolitan Municipality, who agree to participate in the study 
and who do not have any visual, auditory, intellectual, or orthopedic disabilities. The sample 
consists of 64 individuals who meet the inclusion criteria. The sample will be randomly selected 
using a true random number selector (https://www.random.org/). Random selections will be 
planned in a sequential manner, with one intervention group and one control group. Selection 
will continue until the sample size is complete. As part of the pre-test, individuals in both the 
intervention and control groups will complete a demographic information form, a Pulmonary 
Function Test, oxygen saturation measurement with a pulse oximeter, respiratory count, and 
the Geriatric Pain Scale. The intervention group will receive 8 sessions of laughter therapy, 
twice a week for 4 weeks. The control group will not receive any intervention. As part of the 
post-test, both the intervention and control groups will receive... Pulmonary function tests, 
oxygen saturation measurement with pulse oximeter, respiratory rate, and the Geriatric Pain 
Scale will be administered. Research data will be collected using the Statistical Package . for 
Social The data will be analyzed using the Sciences (SPSS) 25.0 program. 
 
Laughter therapy is a complementary medicine technique that combines laughter 
without a specific reason with breathing exercises. It is a free, accessible, effective, and 
enjoyable intervention for individuals. Laughter therapy is recognized internationally as a 
nursing intervention in the Classification of Nursing Interventions. Through its breathing 
exercises, laughter therapy increases lung capacity and ensures efficient gas exchange. It is 

believed that laughter therapy, which includes breathing exercises, can also lead to positive 
improvements in respiratory parameters. Laughter therapy is considered an effective 
intervention in improving respiratory function and reducing pain. 
 
This study aimed to evaluate the effects of laughter therapy on respiratory function and geriatric 
pain in elderly individuals. 
H₀ Laughter therapy has no effect on respiratory function in elderly individuals. 
H₀ Laughter therapy has no effect on geriatric pain in elderly individuals. 
Randomization and Blinding 
A Personal Information Form containing inclusion and exclusion criteria will be administered 
to elderly individuals registered at the Dikmen Retirement Home. A sample group will be 
formed from individuals meeting the inclusion criteria using a simple randomization method. 
A list will be created by numbering the questionnaires of individuals meeting the inclusion 
criteria. The minimum and maximum numbers in the list will be randomly selected from a true 
random number generator website (https://www.random.org/). Random selections are planned 
in a sequential manner, with one intervention group and one control group. Selection will 
continue until the sample size is complete. 
Preventing Bias 
To prevent potential biases in the sample, the inclusion and exclusion criteria for participants 
were clearly defined . Researcher and participant blinding will not be used in this study . The 
intervention will be conducted by the researchers, and participants will know which group they 
are in because an intervention will be used. To prevent measurement bias, pre-tests and post-
tests will be administered to participants using the same measurement tools under the same 
conditions. 
and characteristics of the research : The Ankara Dikmen Retirement Home is located in the 
Dikmen Valley and operates as a single-story café. Retired elderly individuals use this café to 
socialize with their peers, drink tea and coffee, and chat. 
Inclusion Criteria: Individuals who are members of the Dikmen Retirees' Club, agree to 
participate in the research, are 60 years of age or older, have no auditory, visual, intellectual, or 

orthopedic disabilities that would prevent participation, and do not smoke or consume alcohol 
will be included in the study. 
Exclusion Criteria: Being under 60 years of age and having conditions that would prevent the 
application of laughter therapy (having undergone abdominal surgery within the last three 
months, glaucoma, hernia , and epilepsy), and being a smoker or alcohol user. 
Exclusion criteria from the study : Failing to adhere to the research plan, wanting to withdraw 
from the research after becoming involved. 
Data Collection Tools 
Data; Personal Information Form, Pulmonary Function Test, oxygen saturation 
measurement with pulse oximeter , respiratory counting, and Geriatric Pain Scale will be 
used to collect data. 
Personal Information Form 
 
This form will ask individuals specific questions about their gender, age, education 
level, occupation, marital status, income level, chronic disease status, regular medication use, 
smoking habits, alcohol use, whether they have undergone surgery in the last 3 months, pain 
level and intensity, and whether they have a hernia, epilepsy, or glaucoma. 
Pulmonary Function Test 
 
It is used to assess respiratory function. It is performed to determine the degree and 
extent of existing respiratory dysfunction, to make a diagnosis, to measure response to 
treatment, and to evaluate the response to exercise. Respiratory function decreases with age 
(Coşkun, 2015). In this study, the pulmonary function test will be used to evaluate the 
respiratory functions of the elderly group before and after laughter therapy application . 
Spirometry: This is the most commonly used basic pulmonary function test (PFT) for 
evaluating respiratory function . It is based on measuring the changes in airflow or volume 
caused by breathing in and out as a derivative of time. Researcher Nisa Nur Akbal, a nurse at 
Ankara Bilkent City Hospital, has sufficient knowledge and skills in the use of spirometry. The 
test involves measuring airway and lung volumes with a spirometer during a forced expiratory 
maneuver after the patient has taken a deep, full inspiration. The expiration time should be at 

least 6 seconds. If the patient coughs and the test is interrupted, the test should be repeated after 
at least 20 minutes of rest. The test is performed at least 3 times; performing it more than 8 
times is not recommended ( Ulubay et al., 2017). 
General Recommendations 
1. The patient must rest for at least 15 minutes before the test. 
2. Because strenuous breathing exercises can cause dizziness, it is recommended that the test 
be performed in a seated position. 
3. It should be explained that breathing should be done at its maximum capacity. 
4. The patient should be given a detailed explanation of how the test will be performed. The 
mouthpiece should not be covered with the tongue or teeth to prevent air leakage. 
5. After positioning the patient, a nose clip is placed, a mouthpiece is fitted, and with the lips 
closed, rapid and deep inspiration is followed by maximum expiration until the lungs are 
emptied ( Ulubay et al., 2017). 
 
Saturation Measurement with Pulse Oximeter 
         Oxygen saturation indicates the oxygenation rate of the blood. Oxygen, along with 
inhaled air, passes from the lungs into the bloodstream. The oxygen saturation level of the 
blood, transported to tissues and organs via the circulatory system, is vital for organ function. 
In a healthy adult, oxygen saturation should be between 95% and 100%. Oxygen saturation will 
be measured by the researcher using a pulse oximeter of the same brand . It is planned to apply 
to our university's Scientific Research Projects (BAP) for this thesis study. With BAP support, 
a triflo , a spirometry device, and a pulse oximeter will be purchased. 
Geriatric Pain Scale 
         Original scale name: Geriatric Pain MEASURE is a twenty-four-item multidimensional 
scale developed by Ferrell et al. in 2000 ( Ferrell et al., 2000). Translated into Turkish... The 
adapted scale is 5-dimensional, like the original scale. It includes subscales of pain-related 
withdrawal (items 19, 20, 22, 23), pain intensity (items 1, 2, 3, 4, 5, 6), pain from movement 

(items 9, 10, 11, 12), pain from strenuous activities (items 7, 8, 18, 21, 24), and pain from other 
activities (items 13, 14, 15, 16, 17). The scale contains two open-ended questions (items 19 and 
20). These questions are scored between 0 and 10. For the other 22 items, each "Yes" answer 
is summed and multiplied by 2.38. The total score can range from 0 to 100. A score between 0 
and 29 indicates mild pain, a score between 30 and 69 indicates moderate pain, and a score of 
70 or higher indicates severe pain. The total Cronbach's Alpha value of the scale is stated as 
0.85 (Dursun and Bektaş, 2017). 
 
Data Collection: 
The data collection process will be conducted at the Ankara Metropolitan Municipality 
Dikmen Retirement Home after obtaining ethical committee and institutional permission. 
Participants will be included in the study on a voluntary basis after the researcher informs them 
about the research at their respective institutions. Individuals who agree to participate will be 
given an informed consent form by the researcher at the Retirement Home, and their consent 
will be obtained. The data collection tools to be used in the research will be administered face-
to-face to the participants by the researcher at the Retirement Home, at times convenient for the 
participants. At the beginning of the application process, each participant will be informed and 
explained about the principles of voluntarism, ethical processes, the purpose of the research, 
data analysis, record keeping, and participants' rights. Thus, the research will be conducted with 
voluntary participants. 
Pre-Test: Individuals in both the intervention and control groups will be administered a 
Demographic Information Form, a Pulmonary Function Test, oxygen saturation measurement 
with a pulse oximeter , respiratory rate, and the Geriatric Pain Scale. The pre-test phase of the 
study will be completed upon administration of these forms and scales. 
Initiative: Laughter Therapy sessions will be conducted by Nisanur Akbal, a 
researcher with Laughter Therapy Leadership .  Laughter therapy will be administered face-to-
face in a group setting in the garden of the Dikmen Retirement Home after a pre-test for the 
intervention group. A meeting will be held with the elderly individuals one week before the 
start of the laughter therapy sessions to share information about laughter therapy and to explain 
and demonstrate the use of the triflo breathing exercises . Laughter therapy will be applied to 
the intervention group twice a week, for 45 minutes each session, for four weeks and eight 

sessions in total. No intervention will be applied to the control group after the pre-test. After 
the completion of this thesis, laughter therapy may also be applied to individuals in the control 
group on a voluntary basis if they request it. Since the sample group does not receive any routine 
intervention, the participants in the control group also do not receive any routine intervention. 
Final Test: After 8 sessions of laughter therapy, individuals in both the intervention and 
control groups will undergo Pulmonary Function Test, oxygen saturation measurement with 
pulse oximeter , respiratory rate, and Geriatric Pain Scale. 
Laughter Therapy Session Plan: 
         A laughter therapy session lasts approximately 40 minutes and consists of four main 
parts: deep breathing exercises, warm-up exercises, childlike play, and laughter exercises. 
Warm-up exercises prepare the body, and breathing exercises prepare the lungs for laughter. 
Childlike play and laughter exercises may vary depending on the choices of the laughter therapy 
leader (Kataria, 1999). 
Part 1: Deep Breathing Exercises (5-10 Minutes) 
This section focuses on breathing exercises using diaphragmatic breathing. Raise your hands, 
take a deep inspiration, hold your breath for 4-5 seconds, and then exhale by pursing your lips. 
With each inhale, the exhalation time should be longer than the inspiration time. To enhance 
the effectiveness of these breathing exercises, the Triflo breathing exercise device will be used 
in this section. 
Triflo Breathing Exercise Device: Triflo is a breathing exercise device with 3 different levels 
of respiratory resistance. The device has a plastic body, is very easy to use, and is ergonomically 
designed so users can easily carry and operate it. The main purpose of using Triflo is to 
strengthen respiratory muscles, increase respiratory capacity, and reduce fluid accumulation in 
the airways after surgery. In this study, the Triflo breathing exercise device will be used to 
increase the respiratory capacity of elderly individuals. ( The Triflo breathing exercise device 
will be provided to each participant with BAP support. ) (The use will be demonstrated by the 
researcher at an information meeting to be held one week before the start of laughter therapy.) 
Triflo exercise: This exercise works on the principle of moving balls located between channels 
through breathing. Triflo breathing exercise equipment is available in models with single, 
double, triple, and quadruple balls; this exercise will use the triple ball model. Participants will 

be in a seated position, with the breathing exercise equipment in an upright position. After 
exhaling normally, the lips are tightly placed over the mouthpiece to prevent air from remaining. 
A quick inhale is taken, fast enough to lift the first ball. After exhaling, a short pause is taken, 
and a normal inhale is taken. Gradually, the second and third balls are also attempted to be 
lifted. 
Section 2: Warm-up Exercises (10 Minutes) 
Holding hands parallel to each other, with palms and fingers touching, aims to stimulate 
acupuncture points. To increase energy levels, a rhythmic 1-2 and 1-2-3 clapping is necessary. 
Once the group's movements are synchronized, the rhythmic sounds of Ho-Ho and Ha-Ha-Ha 
are added to these clapping movements. 
Chapter 3 Childish Games (10 Minutes) 
This section aims to elicit laughter through childlike games. After each game, the words "Very 
good," "Very good" are repeated accompanied by applause, and group motivation is increased 
by raising hands in a 'Y' shape and shouting "Hey." This section ends after 10 minutes, 
depending on the group's energy level. 
Chapter 4: Laughter Exercises (10 Minutes) 
This section includes laughter exercises such as greetings, strawberry milk, conductor, hot soup, 
lion, aloha , appreciation, laughter lotion, elevator, cream cake, and popping balloon. The aim 
of these exercises is to induce laughter without reason and to encourage the group to laugh. At 
the end of the section, relaxation is achieved with deep breathing exercises for approximately 
three minutes, and the laughter therapy session concludes. 
Data Analysis 
Research data from the Statistical Package for Social The data will be analyzed using the 
SPSS 25.0 program. Numbers and percentages will be used to present the descriptive 
characteristics of individuals . The Kolmogorov -Smirnov test will be performed to determine 
the normality of the data distribution . For variables with two groups, the independent samples 
t-test will be used. For variables with at least three or more groups, the Mann Whitney U test ( 
a non-parametric test) and the Kruskal -Wallis H test ( a one-way analysis of variance ) were 
considered. In cases where the variances are not homogeneously distributed in one-way analysis 

of variance, the Welch test ( a robust test in one-way analysis) was considered. Heteroscedastic 
ANOVA will be used (Harrison et al., 2021; Jan and Shieh , 2013; Yılmaz and Özdemı̇r , 2016). 
In the analysis of differences and changes between two measurements over time in groups, the 
paired samples t-test will be used for groups that meet the assumption of normal distribution. 
samples t-test), Wilcoxon signed-rank test ( Wilcoxon) for groups that do not meet the 
assumption of normal distribution signed It is foreseen that the rank test will be used. Also, in 
the analysis of differences and changes between three or more measurements over time in 
groups, one-way analysis of variance (RANOVA) for repeated measures in groups that meet 
the assumption of normal distribution will be used . measures For groups that do not meet the 
assumption of normal distribution , the Friedman test will be used. For comparisons between 
intervention and control groups, the independent t-test and mixed-design analysis of variance 
will be used. The statistical significance level in this study will be accepted as p < 0.05 . 
Limitations of the Study: 
This study is limited to individuals in the retirees' local community who agreed to participate. 
The results of this study can only be generalized to the individuals included in the study. The 
limitation of this study is that its results are limited to the 8-week period in which the study was 
conducted.