https://doi.org/10.33698/NRF0195 Bhawna Gupta, Mamta Kumara, Tarandeep Kaur
Abstract : Cancer killed 5,56,400 people in the country in 2010 accounted for 8% total deaths. Chemotherapy is the treatment of choice for cancer patients but it is assisted with many side effects. The present study aimed to assess the effectiveness of progressive muscle relaxation technique on physical symptoms among cancer patients receiving chemotherapy. A modified graphing rating scale was used to assess nausea, common toxicity criteria for assessing vomiting, standardized 0-10 numeric pain rating scale were used to collect the data from a sample of 60 cancer patients receiving chemotherapy admitted in selected hospital of Amritsar, Punjab. 30 patients in experimental group and 30 patients in control group were selected using purposive sampling technique. In the present study Progressive Muscle Relaxation Technique is used as intervention. The results of the study showed that progressive muscle relaxation technique is highly effective in reducing the physical symptoms among cancer patients receiving chemotherapy in experimental group.The results of the study showed highly significant difference in pre-interventional and post- interventional physical symptoms of experimental and control group. Hence, it was concluded that progressive muscle relaxation technique is effective in reducing the physical symptoms due to chemotherapy.
Keywords
Effectiveness, Progressive Muscle Relaxation Technique, Physical Symptoms, Cancer patients, Chemotherapy.
Correspondence at
Ms Bhawna Gupta
Lecturer
Khalsa College of Nursing Amritsar
Introduction
The country’s food bowl is in the throes of cancer. There are 90 cancer patients for every 1 lac population in Punjab, it’s more than the national average of 80 per lac. The Malwa region of the state – known as the cancer belt – has the highest average of 136 cancer patients per 1 lac people. Data over the last five years has shown that, on an average, 18 people die of cancer each day. There are 23,874 cancer patients in the state and 33,318 lives have been lost in cancer- related deaths during last five years. What’s worse is that nearly 24,000 people in the state are confirmed cancer cases and there are three times more 84,453 people who are suspected to be suffering from the deadly disease.2
Smeltzer CS et al (2008) explained the various treatment modalities for cancer includes chemotherapy, radiation therapy, immunotherapy and so on, chemotherapy has been recognized as an essential means of treating cancer by providing palliation. This systemic mode of treatment is particularly important to treat the advanced stage of cancer. It can be used alone, or in combination with radiotherapy or surgery. Patients experiencing cancer receive chemotherapy as a main stray of treatment. Chemotherapy is the use of antineoplastic agents to promote tumour cell death by interfering with cellular functions and division. Although chemotherapy is an important treatment modality it brings various side effects to patients who have cancer. The various side-effects of chemotherapy are nausea & vomiting, pain, stomatitis, diarrhoea, constipation, alopecia, thrombocytopenia, leukopenia.3
Molassiotis A (2000) conducted a pilot study on eight patients on the effect of progressive muscle relaxation technique in the management of the post-chemotherapy nausea and vomiting in Chinese breast cancer patients. Nausea, vomiting was assessed by Morrow nausea vomiting scale. Results indicated that duration and intensity of nausea and vomiting were lower in the experimental group. Despite the small size the study shows progressive muscle relaxation technique as an effective adjuvant method to decrease nausea vomiting in patients on chemotherapeutic .4
Relaxation techniques can help to decrease stimuli contributing to symptoms. Progressive muscle relaxation technique significantly reduces chemotherapy induced nausea and vomiting. Relaxation can be highly beneficial if practiced routinely in one’s everyday life. Techniques involving relaxation are widely used by people to reduce anxiety and cope with stress-related problems. Relaxation therapy is initiated and taught to peoples but is practiced primarily in the clients own environment. There are countless methods used to achieve relaxation, but the procedures that are most commonly practiced in the clinical setting are Jacobsons (1938) Progressive Muscular Relaxation. As progressive muscle relaxation is found effective, safe, non- pharmacological, non- invasive, cost effective method in conditions like anxiety, depression, stress and pain.5
Yoo HJ et al (2005) conducted a study to assess the effectiveness of progressive muscle relaxation training (PMRT) and guided imagery (GI) in reducing the anticipatory nausea and vomiting (ANV) and post-chemotherapy nausea and vomiting (PNV) of patients with breast cancer and to measure their effects on the patients’ quality of life (QoL). Thirty breast cancer patients on chemotherapy were randomized to the PMRT and GI group and 30 to the control group. Before each of six cycles of adjuvant chemotherapy, each patient was administered a self-report Multiple Affect Adjective Checklist (MAACL), and incidents of ANV and PNV for the first three post- chemotherapy days were recorded. All patients were administered the Functional Assessment of Cancer Therapy-Breast (FACT-B) at baseline and after 3 and 6 months. They found that the PMRT and GI group was significantly less anxious, depressive, and hostile than the control group. It was also found that the PMRT and GI group experienced significantly less ANV and PNV and that 6 months after CT, the QoL of the PMRT and GI group was higher than that of the control group. These results indicate that PMRT and GI were associated with both the improvements in ANV, PNV and in the QoL of patients with breast cancer.6
Literature indicates the effectiveness of muscle relaxation therapy on management of symptoms of side effects of chemotherapy. Keeping it in mind the present study was conducted.
Objectives
To assess the effectiveness of ‘progressive muscle relaxation technique’ on management of physical symptoms of cancer patients receiving chemotherapy.
Methodology
For the present study, an experimental research approach was used. Non- Equivalent pre-test post-test control group design was utilized to achieve the objectives of study. The research setting was Fortis Escorts hospital of Amritsar, Punjab which is a 200 bedded multispecialty hospital. The sample consisted of 60 subjects (30 in experimental group and 30 in control group). Purposive sampling technique was used to select sample from the cancer patients receiving chemotherapy. Prior to the data collection the formal permission was obtained from the Director of Fortis Escorts Hospital, Amritsar (Punjab).
To assess the effectiveness of ‘progressive muscle relaxation technique’ on physical symptoms among patients receiving chemotherapy in selected Hospital of Amritsar, Punjab. To assess the intensity of symptoms of side effects of chemotherapy different scales were used such as Modified Graphic Rating Scale was used to assess intensity of nausea, Modified Common Toxicity Criteria was used to assess intensity of vomiting, and Standardized 0-10 Numeric pain rating scale was used to assess pain intensity. Tools were prepared after an extensive review of literature and after consulting with subject experts. The tool consisted of following parts: Part A: Socio-demographic profile-This part included items for obtaining personal information of the cancer patients like age, gender, monthly income, duration of illness, type of cancer, staging of cancer, cycle of chemotherapy. Part B: Modified graphic rating scale to assess nausea (Cancer Care Nova Scotia):This part consisted of graphic rating scale ranging from 0-10. It was divided into 4 levels 0 (No nausea), 1-3 (mild nausea), 4- 6(moderate nausea) to 10 (Severe nausea).Part C: Modified common toxicity criteria to assess vomiting.(Cancer Care Nova Scotia): This part consisted of grading of common toxicity criteria ranges from 0-4 0 (None) and 4 (Very high). It was divided into 5 levels 0(none), 1(mild), 2(moderate), 3(high), 4(very high).Part D: Standardized 0-10 numeric rating scale for assessing pain:This part consisted of numeric rating scale from 0-10. 0 (No pain) and 10 (Severe pain). It was divided into 4 levels 0(no pain), 1-3(mild pain), 4-6(moderate pain), 7- 10(severe pain).
Data collection was done in the months of December 2013 and January 2014. The sample consisted of 60 subjects (30 in experimental group and 30 in control group). Purposive sampling technique was used to select sample from the patients getting chemotherapy in Escorts Hospital. Prior to the data collection the formal permission was obtained from the Director of Fortis Escorts Hospital, Amritsar (Punjab). Prior to filling the research tool, investigator gave self-introduction to the patients and explained the purpose of gathering information; a good rapport was established with the subjects. They were assured that their responses would be kept confidential and the information would be used only for the research purpose. Written informed consent was taken from the patients. Firstly data from the control group was collected and after that data from experimental group was collected. In control group Pre-inter ventional assessment of Nausea, Vomiting and Pain was done by using rating scales by the researcher. On fourth day the intensity symptoms were reassessed. In experiment group Pre-interventional assessment of Nausea, Vomiting and Pain was done by using rating scales by the researcher. After assessing the symptoms patients were taught to perform progressive muscle relaxation technique before chemotherapy for 3 days for the time-period of 30-35 minutes by the researcher herself. On the 4th day, the post-interventional physical symptoms were assessed.
Progressive muscle relaxation technique is a technique for reducing anxiety by alternating tensing and relaxing the muscles. As per Jacobson muscle tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscle tension. Progressive Muscle Relaxation is a physical and mental component. The physical component involves the tensing and relaxing of muscle groups over the legs, abdomen, chest, arm, and face. With the eyes closed and in a sequential pattern, a tension in a given muscle group is purposefully done for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group.5 The researcher firstly learnt the progressive muscle relaxation technique and got herself certified by Neuro-psychatrist to practice it on the patients.
The data was analyzed descriptively (frequency distribution); then they were subject to Wilcoxcon-signed rank test & for association Chi-square was used and level of 0.05 were used for statically significance.
Results
Table 1 reveals the socio demographic profile of the study subjects. According to age, it was revealed that majority (90%) of cancer patients were in age group of ≥ 48 years in experimental group followed by (10%) were in age group of 38-47 years and in control group majority (70%) were in the age group of ≥ 48 years followed by (30%) were in age group of 38-47 years. As per gender, in experimental group, more than half (56.7%) of patients were male and 43.3% were females and control group more than half (53.3%) of cancer patients were females and 46.7% males.
In context of Monthly Income (in rupees), in experimental group two-third (63.3%) of subjects were having income ≥ Rs.10,001-15,000 followed by (11%) having monthly income Rs.5,001-10,000 and in control group majority (83.3%) were having monthly income Rs.10,001-15,000 followed by (13.3%) having monthly income Rs.5,001-10,000 and (3.3%) having monthly income ≥ Rs.15,001. As per age, gender and income both groups were homogenous as per chi square test (p>0.05)
Table-1: Socio demographic profile of subjects
| Demographic Variables | Experimental group | Control group | df | z2 | |
| (n=30) | (n=30) | ||||
| N(%) | N(%) | ||||
| Age(in years) | |||||
| · 38-47 | 3(10.0) | 9(30.0) | 1 | 3.750NS | |
| · S48 | 27(90.0) | 21(70.0) | |||
| Gender | |||||
| · Male | 17(56.7) | 14(46.7) | 1 | 0.671NS | |
| · Female | 13(43.3) | 16(53.3) | |||
|
Monthly income (in rupees) |
|||||
| 5001-10,000 | 11(36.7) | 4(13.3) | 2 | 5.085NS | |
| 10,001-15,000 | 19(63.3) | 25(83.3) | |||
| S15,001 | – | 1(3.3) | |||
According to disease profile of subjects in experimental group 43.3% were having reproductive organ cancer followed by 30% having cancer of respiratory system organ and 26.7% having cancer of gastro- intestinal system. In control group half (53%) of subjects were having reproductive organ cancer followed by 26.7% having cancer of respiratory system organ and 20% having cancer of gastro-intestinal system. As per Duration of illness nearly half (46.7%) of subjects in experimental group were having 3-5 years of sickness followed by 36.7% having ≤ 2 years and 16.7% having 6-8 years of illness. In control group nearly half (46.7%) of subjects having 3-5 years of illness followed by 30% were having > 8 years and 23.3% ≤ 2 years of illness (Table-2).
According to Staging of cancer, in experimental group nearly half (46.7%) of subjects were having cancer of stage 2 followed by 30% in stage 1 and 23.3% in stage 3. In control group half (53.3%) subjects were having cancer of stage 2 followed by 26.7% in stage 1 and 20% in stage 3. As per Cycle of chemotherapy, 60% of subjects in experimental group had taken 4-5 cycle followed by 26.7% having 6-7 and 13.3% were having 2-3 cycle of chemotherapy and in control group half (53.3%) of subjects had taken 4-5 cycle followed by 30% having 6-7 and 16.7% having 2-3 cycle of chemotherapy. The above description showed that the sample in experimental and control group were homogenous in characteristics as per chi- square test ( p> 0.05).
Table -2 : Disease profile of subjects
| Variables related to disease | Experimental group (n=30) | Control group (n=30) | df | z2 |
| TYPE OF CANCER
· Respiratory · Gastro-intestinal · Reproductive |
9(30.0) 8(26.7) 13(43.3) |
8(26.7) 6(20.0) 16(53.3) |
2, |
0.655NS |
| Duration of illness (in years)
· £2 · 3-5 · 6-8 |
11(36.7) 14(46.7) 5(16.7) |
7(23.3) 14(46.7) 9(30.0) |
2, |
2.032NS |
| Staging of cancer
· Stage 1 · Stage 2 · Stage 3 |
9(30.0) 14(46.7) 7(23.3) |
8(26.7) 16(53.3) 6(20.0) |
2, |
0.269NS |
| Cycle of chemotherapy
· 2-3 cycle · 4-5 cycle · 6-7 cycle |
4(13.3) 18(60.0) 8(26.7) |
5(16.7) 16(53.3) 9(30.0) |
2, |
0.288NS |
Table 3 depicts the impact of ‘Progressive muscle relaxation technique’ on the intensity of symptoms of cancer patients receiving chemotherapy. In pre- intervention, majority (93.3%) had severe nausea followed by (6.7%) moderate nausea and in post-intervention approx two- third (60%) had mild nausea followed by (40%) had moderate nausea. The x2 value between pre-intervention and post- intervention was 4.932 which was found statistically highly significant in experimental group (p<0.001). In control group during pre-intervention assessment, majority (76.7%) had severe nausea followed by 23.3% moderate nausea and in post-intervention majority (73.3%) had mild nausea followed by 26.7% had moderate nausea. The x2 value between pre- intervention and post-intervention was 1.0 which was found statistically not significant in control group (p >0.05).
Intensity of vomiting in experimental group during pre-intervention assessment, majority (86.7%) had moderate intensity of vomiting followed by 13.3% mild intensity of vomiting and in post-intervention majority (70%) had none followed by 26.7% had mild intensity of vomiting and 3.3% had moderate intensity of vomiting. The x2 value between pre-intervention and post- intervention was 4.862 which was found statistically highly significant (p<0.001). In control group during pre-intervention assessment, majority (83.3%) had moderate intensity of vomiting followed by 10% had mild intensity of vomiting followed by 6.7% had high intensity of vomiting and in post-intervention majority (80%) had moderate intensity of vomiting followed by 13.3% had mild intensity of vomiting and 6.7% had high intensity of vomiting. The x2 value between pre-intervention and post-intervention was 1.0 which was found statistically non-significant in control group at p<0.05.
The intensity of pain in experimental group during pre-intervention assessment revealed that all the subjects (100%) experienced severe pain and in post- intervention majority (63.3%) had mild pain followed by 36.7% had moderate pain. The x2 value between pre-intervention and post- intervention was 4.964 which was found statistically highly significant (p<0.001)(as per chi square test). In control group during pre-intervention assessment majority (93.3%) had severe pain followed by 6.7% had moderate intensity of pain. The x2 value between pre-intervention and post- intervention was 0 which was found statistically non-significant in control group at p>0.05(as per chi square test).
Table 2(a): Impact of ‘Progressive muscle relaxation technique’ on the intensity of symptoms of cancer patients receiving chemotherapy
N=30
| Intensity of symptoms | Experimental group | x2
P |
Control group | x2
P |
||
| Pre intervention n(%) | Post intervention n(%) | Pre intervention n(%) | Post intervention n(%) | |||
| Intensity of | ||||||
| Nausea | ||||||
| Mild | – | 18(60.0) | 4.932 | – | – | 1.0 |
| Moderate | 2(6.7) | 12(40.0) | <0.001 | 7(23.3) | 8(26.7) | >0.05 |
| Severe | 28(93.3) | – | 23(76.7) | 22(73.3) | ||
| Intensity of | ||||||
| vomiting | ||||||
| None | – | 21(70.0) | 4.862 | – | – | 1.0 |
| Mild | 4(13.3) | 8(26.7) | <0.001 | 3(10.0) | 4(13.3) | >0.05 |
| Moderate | 26(86.7) | 1(3.3) | 25(83.3) | 24(80.0) | ||
| High | – | – | 2(6.7) | 2(6.7) | ||
| Intensity of | ||||||
| Pain | ||||||
| Mild | – | 19(63.3) | 4.964 | – | – | 0 |
| Moderate | – | 11(36.7) | <0.001 | 2(6.7) | 2(6.7) | >0.05 |
| Severe | 30(100.0) | – | 28(93.3) | 28(93.3) | ||
Chi square/ Fisher’s exact test
Discussion
Cancer are emerging as major public health problems in India. Based on the cancer registry data it is estimated that there will be about 800,000 new cancers cases in India every year. At any given point there is
likely to be 3 times this load that about 240,000 cases. Cancer can be treated by surgery, chemotherapy, radiation therapy, hormonal therapy, and targeted therapy (including immunotherapy such as monoclonal antibody therapy).7 The choice of therapy depends upon the location and grade of the tumour and the stage of the disease, as well as the general state of the patient. Chemotherapy is most commonly used treatment modality for cancer patients. The cancer patients experience many side effects of chemotherapy which can be reduced by simple measures of relaxation techniques if practiced by patients. The present study was to assess the effectiveness of progressive muscle relaxation technique on physical symptoms among patients receiving chemotherapy in selected hospital, Amritsar, Punjab.
The results revealed that progressive muscle relaxation technique was effective in reducing the intensity of nausea, vomiting and pain. This is very simple technique and can be easily taught to patients.
Carvahlo CD (2007)conducted a similar study in cancer patients receiving chemotherapy at saopaoul, Brazil. For nausea and vomiting, the wilcoxon test indicated that changes were statically significant (Z= 4.729, p=0, and Z= 4.739, p=0 respectively). The results showed a reduction in the intensity of nausea and vomiting after progressive muscle relaxation, suggesting that relaxation can contribute to the control of nausea and vomiting in these patients. Participants in this study generally gave positive comments on the progressive muscle relaxation technique. 8 It was concluded that progressive muscle relaxation technique is effective in reducing the physical symptoms due to chemotherapy. So, it is important to teach the patients about the progressive muscle relaxation technique so that the side effects of chemotherapy can be minimised and patient feels relaxed and comfortable. Hence it is recommended that this can be incorporated in day to day practice by the nurses taking care of patients on chemotherapy. Similar study can be undertaken on a large sample for making more valid generalization. Time series study can be conducted to evaluate long term effect of progressive muscle relaxation technique in relieving the physical symptoms due to chemotherapy.
References
- The Hindu .Cancer Killed 56 lacs in India in 2010. Cancer facts and figures. 2012 March. Available from: http//www. W.H.O. int. Accessed in 2012.
- Shimona At 90 cancer patients for every 1 lakh population in Punjab, it’s more than recorded cancer incidence of 107.4 per lakh as against the national average of 80 per lac. Times of India (Newspaper online). 2013 jan 29.
- Smeltzer CS, Bare GB, Hinkle LJ, Cheever Brunner and Suddarth’s. Text book of medical surgical nursing. 10thed. New Delhi (India): Lippincott company. 2008; p. 383
- Molassitosis A, Yung HP, Yam BM, Chan FY, Mok A pilot study of the use of progressive muscle relaxation training in the management of post- chemotherapy nausea and vomiting. European Journal of Cancer Care (England).2000 Dec; (4): 230-234.
- Redd Jacobson Behavioural intervention in comprehensive cancer care. Hand book of health psychology. Lawrence Erlbaum Associates. 2000.
- Yoo HJ, Ahn SH, Kim SB, Kim WK, Han Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer. 2005;13(10):826–833.[PubMed]
- Varghese Cancer prevention and control in India. 50 Years of Cancer Control in India. [accessed on
1 2 . 1 2 . 1 5 ] a v a i l a b l e a t http://rcfcare.org/admin/articles/doc/pg56to67.pdf
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