A Comparative study to Evaluate the effectiveness of progressive muscle relaxation techniques versus guided imagery therapy on fatigue and quality of life among patients with head and neck cancer who are undergoing chemotherapy in selected hospital at Erode

Mrs. Kavitha. D¹, Mrs. Kalpana. K², Mrs. Tamilselvi. S³, Mrs. Christy Mekala.V⁴

¹RN, RM, M.Sc., (N), Critical Care Nursing, Bishop’s College of Nursing, Dharapuram.

²Professor, Medical Surgical Nursing, Bishop’s College of Nursing, Dharapuram.

³Professor and Head of the Department, Medical Surgical Nursing, Bishop’s College of Nursing, Dharapuram.

⁴Principal and Head of the Department, Community Health Nursing, Bishop’s College of Nursing, Dharapuram.

*Corresponding Author E-mail: kavi.mraur@gmail.com

ABSTRACT:

The burden of cancer is growing globally and is one of the top leading causes of death. Among all age-groups the adults aged 50-74 carry highest burden of cancer. Among men, head and neck and gastro-intestinal cancers are prominent. The treatment of this cancer can cause side effects like fatigue, and it can leads to poor quality of life of the patients. This study was aim to compare the effectiveness of progressive muscle relaxation techniques versus guided imagery therapy on fatigue and quality of life among patients with head and neck cancer who are undergoing chemotherapy in selected hospital at Erode. Two group pretest post test experimental design was used. The conceptual frame-work was based on modified “Wiedenbach’s Helping Art of Clinical Nursing Theory (1964)”. Non-probability purposive sampling method was used to select the samples. The tool used for this study was Brief Fatigue Inventory Scale for fatigue and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire –C30 (3.0) combined with Head and Neck 35 Scale for quality of life. The collected data were analyzed using descriptive statistics and inferential statistics. The mean post test scores of fatigue in the experimental group-I was 40 (SD ±13.26) and the mean post test scores of fatigue in the experimental group-II was 34 (SD ± 12.1). The independent ‘t’ value for fatigue was 1.93 which was slightly significant at P<0.05 level of significance. The mean post test scores of quality of life in the experimental group-I was 148 (SD±17.43) and the mean post test scores of quality of life in the experimental group-II was 142 (SD ±13.5). The independent ‘t’ test value was 0.420 which was slightly significant at P<0.05 level of significance. There was no significant association between fatigue and quality of life with their selected demographic variables. This study concluded that progressive muscle relaxation techniques and guided imagery was beneficial in reducing fatigue and improving quality of life among patients with head and neck cancer undergoing chemotherapy.

KEYWORDS: Head and Neck cancer, progressive muscle relaxation, guided imagery, fatigue, quality of life.

INTRODUCTION:

In the world 17 people die every minute from cancer⁴. The global cancer burden was estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018. One in 5 men and one in 6 women worldwide develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease. Worldwide, the total number of people who are alive within 5 years of a cancer diagnosis, called the 5-year prevalence, is estimated to be 43.8 million. Breast cancer is also the leading cause of cancer death in women (15.0%), followed by lung cancer (13.8%) and colorectal cancer (9.5%), which are also the third and second most common types of cancer, respectively; cervical cancer ranks fourth for both incidence (6.6%) and mortality (7.5%)⁵. The annual incidence of head and neck cancers worldwide is more than 550,000 cases with around 300,000 deaths each year. Male to female ratio ranges from 2:1 to 4:1. About 90% of all head and neck cancers are squamous cell carcinomas. It is the sixth leading cancer by incidence worldwide⁶. Cancer has become one of the ten leading causes of death in India. Head and neck cancer is third most common malignancy seen in both the sexes across the globe but is the commonest malignancy encountered in Indian males². Head and neck cancers in India accounted for 30% of all cancers in males. In females they constitute 11to 16% of all sites of cancer. Among them, tongue and mouth in males contribute to more than one third of the total cancers except in Dibrugarh where hypopharynx (34.5%) was the major contributor and among females mouth cancer was the leading cause¹. Up to 40% of patients report fatigue at cancer diagnosis, 80%-90% during chemotherapy and/or radiotherapy, in particular 17%-21% during chemotherapy alone and 33%-53% during association of chemotherapy and radiation therapy⁷. Fatigue, decreased functionality, and impaired quality of life are some of the most common adverse outcomes of chemo-radiotherapy. Head and neck cancers affect more than half a million individuals globally and its treatment takes a heavy toll on the patient, often affecting their speech, swallowing, and respiratory functions, and as a result they often develop fatigue, depression, and physical inactivity³. Relaxation and guided imagery therapies were used. Relaxation reduces sympathetic nervous system responsivity reducing stress levels. Regular relaxation shows impressive results for people with cancer, e.g. lower stress levels and better immune system function, decreased pain, fewer side effects of chemotherapy, decreased anxiety, improved mood and less suppression of emotions⁸.

MATERIAL AND METHODS:

Research Approach:

An evaluative approach was used for this study.

Research design:

Two group pretest post test experimental design was adopted for this study.

Setting of the Study:

The study was conducted in selected hospital at Erode

Population:

The target population selected for the study was patients who were diagnosed with head and neck cancer and undergoing chemotherapy.

Sample:

Patients with head and neck cancer who are undergoing chemotherapy.

Sample Size:

The sample size for the study consists of 60 samples, 30 were in group-I and 30 were in group-II.

Sampling Technique:

Non-probability purposive sampling technique was used to select the samples for the study.

Instrument and Scoring Procedure:

The tool consists of 3 parts.

Part I

It consists of demographic variables such as the age, sex, type of family, education, occupation, religion, family monthly income, area of residence, duration of treatment and any bad habits.

Part II

The Brief Fatigue Inventory was used to assess the severity and impact of cancer-related fatigue.

Part III

European organization for research and treatment of cancer quality of life questionnaire C-30 and its core questionnaire for head and neck cancer c-35 scale was used to assess the quality of life.

Validity:

The validity of the tool was established in consultation with three nursing experts and two oncologists. The standard scales are considered valid.

Reliability:

Internal consistency of the Brief Fatigue Inventory scale was established by testing the split half method by using the cronbach’s alpha formula to be reliable (r=0.82) and Internal consistency of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30(version 3.0) and head and neck 35 scale was established by testing split half method by using cronbach’s alpha formula and found to be reliable (r=0.9).

Protecting the Human Rights:

The research proposal was approved by the dissertation committee prior to the main study. The written permission was obtained from the Managing Director of Erode cancer center at Erode. Written consent was obtained from each sample before starting the data collection and their data were kept confidential.

Data Collection Procedure:

Data collection was done for a period of 6 weeks. On the first day, in experimental group data pertaining to the demographic variables was collected by using structured interview schedule then the pretest was conducted to the participants by using Brief fatigue inventory scale to assess the fatigue and EORTC QLQ-30 (version 3.0), H&N 35 scale used to assess the quality of life. Progressive muscle relaxation exercises were given to the 30 participants, which were carried out as a twice (30 minutes) per day for 7 days. After the completion of 7 days post test was conducted. After completing the experimental group-I, from 21^st day onwards 4-6 samples were collected each day for experimental group-II Guided Imagery therapy was given to the 30 participants, which were carried out as a single session (30 minutes in that 5 minutes breathing exercise and 25 minutes audio) per day for 7 days. On the first day demographic variables was collected by using structured interview schedule then pretest was conducted to the participants by using Brief Fatigue Inventory scale for assessing fatigue. EORTC QLQ-30 and H&N-35 scale for assessing quality of life. After the completion of 7 days post test was conducted using the same scale in experimental group-II.

Table 1: Comparison of mean score, standard deviation, mean difference and paired ‘t’ value of pretest and post test level of fatigue among patients with head and neck cancer who are undergoing chemotherapy in experimental group-I. n₁ =30

Sl. No	Variable	Mean	Standard deviation	Mean difference	Paired ‘t’ value	Table value	Inference
1.	Pretest	66	10.8	26	13.90	2.05	Significant
2.	Post test	40	13.26

df=29 p<0.05

Table 2: Comparison of mean score, standard deviation, mean difference and paired ‘t’ value of pretest and post test level of quality of life among patients with head and neck cancer who are undergoing chemotherapy in experimental group-I. n₁=30

Sl. No	Variable	Mean	Standard deviation	Mean difference	Paired ‘t’ value	Table value	Inference
1.	Pretest	196	52.25	48	21.70	2.05	Significant
2.	Post test	148	17.43

df=29 p<0.05

Table 3: Comparison of mean score, standard deviation, mean difference and paired ‘t’ value of pretest and post test level of fatigue among patients with head and neck cancer who are undergoing chemotherapy in experimental group-II. n₂ =30

Sl. No	Variable	Mean	Standard deviation	Mean difference	Paired ‘t’ value	Table value	Inference
1.	Pretest	68	6.34	34	16.01	2.05	Significant
2.	Post test	34	12.1

df=29 p<0.05

Table 4: Comparison of mean score, standard deviation, mean difference and paired ‘t’ value of pretest and post test level of quality of life among patients with head and neck cancer who are undergoing chemotherapy in experimental group-II. n₂ =30

Sl. No	Variable	Mean	Standard deviation	Mean difference	Paired ‘t’ value	Table value	Inference
1.	Pretest	206	7.15	64	23.5	2.05	Significant
2.	Post test	142	13.5

df=29 p<0.05

Table 5: Effectiveness between the progressive muscle relaxation techniques and guided imagery therapy on mean scores, standard deviation, mean difference, and independent ‘t’ value of post test level of fatigue among patients with head and neck cancer who are undergoing chemotherapy in group-I and group-II. n₁ =30, n₂=30

Sl. No	Group	Mean	Standard deviation	Mean difference	Independent ‘t’ value	Table value	Inference
1.	Experimental group-I	40	13.26	6	1.93	8.07	Slightly
2.	Experimental group-II	34	12.1				significant

df= 58 p<0.05

Table 6: Effectiveness between the progressive muscle relaxation techniques and guided imagery therapy on mean scores, standard deviation, mean difference, and independent ‘t’ value of post test level of quality of life among patients with head and neck cancer who are undergoing chemotherapy in group-I and group-II. n₁ =30, n₂=30

Sl. No	Group	Mean	Standard deviation	Mean difference	Independent ‘t’ value	Table value	Inference
1.	Experimental group-I	148	17.43	6	0.420	8.07	Slightly
2.	Experimental group-II	142	13.5				significant

df= 58 p<0.05

Table 5: showed that the mean post test score of fatigue in experimental group-I was 40(SD±13.26) and the mean post test scores of fatigue in experimental group-II was 34(SD±12.1). The mean difference was 6. The independent ‘t’ test value was 1.93 which was slightly significant at P<0.05 level. It showed that the progressive muscle relaxation techniques and guided imagery both was effective in reducing fatigue among patients with head and neck cancer who are undergoing chemotherapy.

Table 11: showed that the mean post test score of quality of life in experimental group-I was 148 (SD±17.43) and the mean post test score of quality of life in experimental group-II was 142 (SD±13.5). The mean difference was 6. The independent ‘t’ test value was 0.420 which was slightly significant at P<0.05 level. It showed that both PMRT and guided imagery therapy was effective in improving the quality of life among patients with head and neck cancer who are undergoing chemotherapy.

There was no significant association between fatigue with their selected demographic variables in experimental group-I. There was no significant association between quality of life with their selected demographic variables in experimental group-I. There was no significant association between fatigue with their selected demographic variables in experimental group-II except for type of family (χ²=10.83). There was no significant association between quality of life with their selected demographic variables in experimental group-II except for occupation (χ²=15.8) and religion (χ²=13.92).

RESULTS AND DISCUSSION:

Regarding age, in experimental group-I, 2(7%) belongs to the age group of 35-40 years, 2(7%) belongs to the age group of 41-45 years, 8(27%) belongs to the age group of 46-50 years, 4(13%) belongs to the age group of 51-55 years, 14(46%) belongs to the age group of 56 years and above. In experimental group-II, 1(3.5%) belongs to the age group of 35-40 years, 2(7%) belongs to the age group of 41-45 years, 7(23%) belongs to the age group of 46 -50 years, 3(9.5%) belongs to the age group of 51-55 years, 17(57%) belongs to the age group of 56 years and above. With regards to sex, in experimental group-I, 24(80%) were males and 6(20%) were females. In experimental group-II, 21(70%) were males and 9(30%) were females. Regarding the educational status in experimental group-I, the majority of the patients 13(43%) had illiterate, 12(40%) were primary education, 5(17%) had high school education. In experimental group-II, majority of the patients 11(37%) were primary education, 8(27%) were high school education, 7(23%) had illiterate, 4(13%) had higher secondary education. Regarding the type of family in experimental group-I, 20(66.5%) were from nuclear family and 10(33.5%) were from joint family. In experimental group-II, 20(66.5%) were from nuclear family and 10(33.5%) were from joint family. Regarding occupation in experimental group-I, majority 11(37%) were coolie, 10(33.5%) were self employed, 6(20%) were private employee and 3(9.5%) were unemployed. In experimental group-II majority 9(30%) were self-employed, 8(27%) were unemployed, 7(23%) were coolie and 6(20%) were private employee. Regarding religion in experimental group-I, majority 28(93%) belonged to Hindu religion, 2(7%) belonged to Muslim religion. In experimental group-II, majority 28(93%) belongs to Hindu religion, 1(3.5%) were Muslim and 1(3.5%) were Christian religion. With regard to family monthly income, in experimental group-I, majority 23(77%) were in between Rs. 5000- Rs. 10000, 6(20%) were in between Rs. 10001-Rs.15000, and 1(3.5%) were between Rs. 15001- Rs. 20000. In experimental group-II, the majority 15(50%) were in between Rs. 5000 –Rs. 10000, 9(30%) were in between Rs. 10001 – Rs. 15000, 5(16.5%) were in between Rs. 15001 – Rs. 20000, and 1(3.5%) was above Rs. 20001. With regard to area of residence, in experimental group-I, majority 22(73%) were in rural area and 8(27%) were in urban area. In experimental group-II, majority 23(77%) were in rural area, and 7(23)% were in urban area. With regard to duration of treatment, in experimental group-I, majority 18(60%) were getting treatment for a period of 0- 12 months 11(36.5%) were getting treatment for a period of 13-24 months, and 1(3.5%) were getting a treatment for a period of 37-48 months. In experimental group-II, majority 25(83.5%) were getting treatment for a period of 0-12 months, and 5(16.5%) were getting treatment for a period of 13-24 months. With regards to bad habits, in experimental group-I, majority of the patients 15(50%) had smoking, 10(33.5%) had betel nut chewing, 3(9.5%) had alcoholism and 2(7%) had no bad habits. In experimental group-II, majority of the patients 10(33.5%) had smoking, 8(27%) had betel nut chewing, 7(23%) had alcoholism and 5(16.5%) had no bad habits.

CONCLUSION:

The present study was conducted that compare the effectiveness of progressive muscle relaxation and guided imagery therapy on fatigue and quality of life among patients with head and neck cancer who are undergoing chemotherapy in Erode Cancer Centre at Erode. The independent ‘t’ test value for fatigue was 1.93 which was slightly significant at P<0.05 level. The independent ‘t’ test value for quality of life was 0.42 which was slightly significant at P<0.05 level. The results of the study showed that progressive muscle relaxation techniques and guided imagery therapy was effective in reducing fatigue and improving the quality of life among patients with head and neck cancer who are undergoing chemotherapy.

IMPLICATIONS:

The findings of the study have certain improvement implication for Nursing service, nursing education, nursing administration, nursing research.

Nursing Service:

· The nurse must conduct in-service education about the non-pharmacological measures used in treating patients with head and neck cancer who are undergoing chemotherapy.

· Nurse as the change agent, can introduce the various measures for the reduction of fatigue and improving quality of life among patients with head and neck cancer who are undergoing chemotherapy are admitted in the ward.

· Nursing service department can arrange health education program in OPD for teaching the patient on progressive muscle relaxation techniques and guided imagery therapy.

Nursing Education:

· The nurse educator can orient the students with alternative therapies in reducing the level of fatigue and improving the quality of life among patients with cancer who are undergoing chemotherapy.

· Nurse educator should motivate the students to do mini projects on techniques to promote quality of life among patients with head and neck cancer who are undergoing chemotherapy.

· Nurse educator should conduct workshops/ seminars to update the knowledge of students to promote practicing alternative therapies among patients with cancer.

· The nurse educator can include the progressive muscle relaxation techniques and guided imagery therapy in the curriculum, which can be adopted by the students and the nursing personnel.

Nursing Administration:

· Nurse administrator can organize continuing education program regarding promoting optimal well-being of patients living with head and neck cancer who are undergoing chemotherapy.

· Nurse administrator can organize conferences and seminar and also enhance the knowledge and practice of alternative therapies among patients with head and neck cancer who are undergoing chemotherapy in reducing the level of fatigue and improving the quality of life.

· Nurse administrator can prepare and distribute information booklet about progressive muscle relaxation techniques and guided imagery therapy to patients with head and neck cancer who are undergoing chemotherapy.

· Nurse administrator should conduct in-service education to disseminate the research findings through continuous nursing education to all nurses and student nurses.

· Pamphlets, leaflets about progressive muscle relaxation techniques and guided imagery therapy can be made available to nursing staff in the cancer ward and to the nurse educators in nursing educational institution.

Nursing Research

· The study findings can be a baseline for further future studies to build upon for improving the body of knowledge in nursing.

· The study findings can be effectively utilized by the emerging researchers to conduct further studies.

· The health benefits of progressive muscle relaxation techniques and guided imagery therapy can be studied by various nursing researcher.

RECOMMENDATIONS:

Based on the findings the following recommendation are stated

· Similar study can be conducted with randomization.

· Similar study can be replicated on a large sample to generalize the findings.

· Similar study can be conducted with alternative therapies like yoga, music therapy, and meditation to reduce the level of fatigue and improve the quality of life.

· A study can be conducted by a combination of progressive muscle relaxation techniques and guided imagery therapy to reduce the side-effects of chemotherapy.

· Similar study can be replicated with subjects form different settings.

LIMITATIONS:

It was time consuming for the researcher to clarify the doubts of the samples about progressive muscle relaxation techniques and guided imagery therapy before implementation.

REFERENCES:

1. Kulkarni.R.M., ‘Head and cancer burden in India’ International Journal of Head and Neck Surgery. (2013); 4(1), PgNo.29-35.

2. Mishra.A.et al., ‘Head and neck cancer: global burden and regional trends in India’ Asian Pacific Journal of Cancer Prevention. (2014);15(2), PgNo.537-550.

3. Samuel.R.S.et al. ‘Effectiveness of exercise based rehabilitation on functional capacity and quality of life in head and neck cancer patients receiving chemo-radiotherapy’ Journal of Supportive Care in Cancer. (2019); 27. Pg No.3913-3920.

4. http://www.who/9789240001299-eng.pdf

5. https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21492

6. https://www.who.int/selection_medicines/committees/expert/20/applications/HeadNeck.pdf

7. https://www.annalsofoncology.org/article/S0923-7534(20)36077-4/pdf

8. https://docs.bvsalud.org/biblioref/2017/04/833107/48208-191972-1-pb.pdf

Received on 26.11.2020 Modified on 13.12.2020

Int. J. of Advances in Nur. Management. 2021; 9(1):72-77.

DOI: 10.5958/2454-2652.2021.00019.6