INTRODUCTION:

Cancer is the name given to a collection of related diseases. In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues. Cancer can start almost anywhere in the human body, which is made up of trillions of cells. Normally, human cells grow and divide to form new cells as the body needs them. When cells grow old or become damaged, they die, and new cells take their place¹. Cancer is among the leading causes of death worldwide. In 2012, there were 14 million new cases and 8.2 million cancer-related deaths worldwide. In 2015, an estimated 1,658,370 new cases of cancer will be diagnosed in the United States and 589,430 people will die from the disease³.

NEED FOR THE STUDY:

Patients with cancer suffer from a multitude of symptoms that adversely affect their quality of life. Pain is one of the most dreaded symptoms in cancer; regrettably, it is often under-treated. Even with the greater availability of pain medications, it continues to be moderate to severe in more than 50% of cancer patients. Guidelines for managing cancer pain, although widely published, have not been universally applied, and as a result, there are considerable gaps in the treatment of pain⁴. Fatigue is one of the most common and debilitating symptoms experienced by patients with cancer. Cancer-related fatigue (CRF) is characterized by feelings of tiredness, weakness, and lack of energy, and is distinct from the “normal” drowsiness experienced by healthy individuals in that it is not relieved by rest or sleep. It occurs both as a consequence of the cancer itself and as a side effect of cancer in 40% of patients at diagnosis⁵. As the incidence and prevalence of cancer pain and fatigue is relatively high, the focus on reducing pain and fatigue needs to be more. Many studies have examined a range of management methodologies for pain only, a few have examined pain and fatigue together. So the investigator felt that there is a need to assess the effect of a non- pharmacological intervention such as progressive muscle relaxation on reducing the symptoms of pain and fatigue among patients with cancer.

PROBLEM STATEMENT:

A Study to assess the effect of Progressive Muscle Relaxation on pain and fatigue among patients with cancer admitted in a selected cancer institute, Kottayam.

OBJECTIVES:

· Assess the effect of Progressive Muscle Relaxation (PMR) on pain among patients with cancer.

· Assess the effect of Progressive Muscle Relaxation on fatigue among patients with cancer

· Assess the correlation between pain and fatigue among patients with cancer.

OPERATIONAL DEFINITIONS:

Effect:

Effect in this study refers to the extent to which PMR helps in reducing pain and fatigue of cancer patients as measured by Numeric pain rating scale and Modified cancer fatigue scale respectively.

Progressive muscle relaxation:

In this study PMR refers to a 13 minutes session of periodic relaxation of the muscles from the fore head to feet one by one as per the instructions given by the researcher using a prerecorded audio CD administered twice a day for 4 consecutive days.

Pain:

Pain is an unpleasant sensory and emotional experience perceived by cancer patients which may be either due to cancer, its complications or complications of treatment as measured on Numerical Pain Rating scale (NPRS).

Fatigue:

Fatigue refers to a persistent feeling of weakness or tiredness among cancer patients which interferes with their usual functioning as measured using the Modified Cancer Fatigue Scale.

Cancer Patients:

In this study cancer patient refers to those patients who are admitted in Caritas Cancer institute, diagnosed to have cancer and with symptoms of pain and fatigue.

Hypothesis:

All the hypotheses are tested at 0.05 level of significance.

H₁: There is a significant difference between mean pretest score and post test scores of pain among patients with cancer in the experimental group after PMR.

H₂: There is a significant difference between the posttest scores of pain between experimental group and control group

H₃: There is a significant difference between mean pretest and post test scores of fatigue among patients with cancer after PMR

H₄: There is a significant difference between the post test scores of fatigue among experimental and control group.

H₅: There is correlation between pain and fatigue among cancer patients.

Assumptions:

· Patients with cancer have pain and fatigue.

· Progressive Muscle Relaxation technique which is a non-pharmacological measure helps in reducing pain and fatigue.

LIMITATIONS:

· The study was done on small group of samples in selected hospitals so generalization cannot be done.

· Lack of motivation among samples to attend the therapy regularly as they were chronic patients, so the researcher had to spend considerable time in organizing PMR regularly.

Review of Literature:

The International Association for the Study of Pain (IASP), reported that, pain occurs in as many as 50% of patients with cancer undergoing treatment for their disease, and more than 70% of patients experience pain towards the end of life. At least 40% of patients with cancer reported more than one pain site. Of those cancer patients reporting pain, 42% report inadequate analgesia. In addition, as much as one third of patients with cancer report severe pain affecting their quality of life (QoL). There are different etiologies of pain in patients with cancer. Cancer pain can result from direct tumor involvement and also it is associated with cancer therapy and sources of this pain can range from initial diagnostic procedures to standard therapeutic modalities⁵.

A cross-sectional, questionnaire-based survey was conducted among one thousand three hundred seven outpatients with cancer attending the three units over a 30-day period by a questionnaire and the fatigue sub-scale of the Functional Assessment of Cancer Therapy -Fatigue (FACT-F) questionnaire. Fatigue was reported to affect 58% of patients ‘somewhat or very much’. The comparable figures for pain and nausea/vomiting were 22% and 18%, respectively. Fatigue had never been reported to the hospital doctor by 52% (281 of 538) of patients with this symptom. Only 75 patients (14%) had received treatment or advice about the management of their fatigue. Fatigue was reported to be not well-managed by 33% (180 of 538) of patients with this symptom. The comparable figures for pain and nausea/vomiting were 9% (46 of 538) and 7% (37 of 538), respectively. The median FACT-F score was 18 (range 0–52). The study concluded that Fatigue has been identified as an important problem by patients with cancer. It affects more patients for more of the time than any other symptom and is regarded by patients as being more important than either pain or nausea/vomiting⁶.

A meta-analysis examined the effectiveness of relaxation training among patients undergoing acute non-surgical cancer treatment including chemotherapy, radiotherapy, bone marrow transplant and hyperthermia. In 14 of 15 studies reviewed, PMR, guided imagery and other modalities were lumped together and evaluated for their effects on symptom control. The review concluded that clinically significant reductions in nausea, pain, anxiety, depression, hostility and physical arousal (blood pressure and pulse) were achieved following relaxation training⁷.

Research Design:

The research design used is two group pretest posttest design.

Setting of the study:

The study was conducted in general cancer wards (CCI-III, CCI-IV) of Caritas Cancer Institute of Caritas Hospital.

Population:

The study population comprised of all cancer patients (non surgical) admitted in the wards of Caritas Cancer Institute.

Sample size:

The sample size for the present study was 30 subjects in experimental group and 30 in control group.

Sampling Technique:

The sampling technique selected for the present study was purposive sampling technique and samples were allotted to the experimental and control group by random assignment.

Criteria for sample selection:

Inclusion criteria:

1. Cancer patients admitted in cancer wards between ages of 18-70 years.

2. Cancer patients who experience pain and fatigue

3. Patients who are able to understand Malayalam or English

Exclusion criteria:

1. Patients who are not willing to participate in the study.

2. Patients who underwent recent surgery

3. Terminally ill patients/patients admitted in pain and palliative wards

4. Patients with neuromuscular weakness.

Tool:

Tool 1: Socio demographic and clinical proforma

Tool 2: Numerical pain rating scale

Tool 3: Modified cancer fatigue scale

Tool 4: Progressive Muscle Relaxation training using audio CD

Tool 1:

Socio demographic data was collected using a Structured Interview Schedule by interview technique. The interview schedule included socio demographic and clinical information of the client such as age, gender, education, site of cancer, stage of cancer, duration of illness, type of treatment, and days of hospitalization. This section was developed after reviewing literature and based on expert opinion.

Tool 2:

Degree of pain was assessed by self-reported technique by using numeric pain rating scale. This is a horizontal 10 cm line with no pain (score of 0) at one end and worst pain possible (score of 10) at other end. The pain scores were graded as 0=no pain,1-3 mild pain-6 moderate pain,7-10 severe pain. Samples were asked to mark on the line to indicate intensity of pain they experienced.

Tool 3:

The scale consists of 15items and three sub scales - physical, affective and cognitive. Each item was rated ona likert scale from 1 (not at all) to 5 (very much). Patients were instructed to mark the number that describes the current state of fatigue. This tool was used with slight modifications, was validated by experts and translated to Malayalam.

Scoring

The scores obtained in every factor was added together to get the total score.

Factor 1 = (items 1 + 2 + 3 + 6 + 9 + 12 + 15) − 7 P. (Physical subscale)

Factor 2 = 20 − (items 5 + 8 + 11 + 14) P. (Affective subscale)

Factor 3 = (items 4 + 7 + 10 + 13) − 4 P. (Cognitive subscale)

Adding the factors together gives P. (Total scale score). A score between 1-20 is described was mild, 21-40 as moderate and 41-60 as severe fatigue. Subtractions adjust for 0 as a state of no fatigue.

Tool 4:

Progressive Muscle Relaxation training

The investigator taught the technique of Progressive Muscle Relaxation to the samples in the experimental group. The investigator underwent one month certified training on Progressive Muscle Relaxation technique. An audio CD was made with instructions that the subjects should follow during PMR. The duration of audio CD was 13 minutes and it had instructions with light background music. The subjects were instructed to listen to this audio CD using head phones while they performed Progressive Muscle Relaxation. The audio CD was also validated by experts. The complete session of Progressive Muscle Relaxation lasted for 13-14 minutes.

RESULTS:

· There was a statistically significant reduction in pain and fatigue among patients with cancer by the Progressive Muscle Relaxation.

· Progressive Muscle Relaxation is effective in reducing pain (t=6.2, p=and lt;.01) and fatigue (t=9.2, p= and lt; .01) among patients with cancer.

· There is a non zero positive correlation (r=.531, p=and lt;.01) between pain and fatigue among the samples included in the study.

CONCLUSION:

The present study aimed to find out the effect of Progressive Muscle Relaxation on pain and fatigue among patients with cancer in Caritas Cancer Institute. The findings of the study show that there was a statistically significant reduction in pain (p=and lt; .05) and fatigue (p=and lt; .05) among patients with cancer by the Progressive Muscle Relaxation and there is a non zero positive correlation (r=.531) between pain and fatigue among the samples included in the study. Hence Progressive Muscle Relaxation is effective in reducing pain and fatigue among patients with cancer.

NURSING IMPLICATIONS:

The study findings have implications for nursing education, nursing service, nursing administration and nursing research.

Nursing practice:

· Nurses have an important role in creating a body of knowledge and use it in to practice.

· Nurses can practice progressive muscle relaxation while caring for patients with pain and fatigue in all clinical setting.

Nursing research:

Nursing research is an essential aspect of nursing as it uplift the profession and have an important role in creating the body of knowledge and using it to improve practice. As PMR is a no expensive and non pharmacological intervention in reducing distressing symptoms of cancer patients, further researches can be done in large samples and in different settings thus widening the body of knowledge.

Nursing administration:

· Nursing administrators can implement the findings of the study by utilizing PMR in cancer patients.

· Nurse administrators can organize continuing nursing education programs regarding the muscle relaxation technique and motivate the staff to participate in the training so that they can teach patients progressive muscle relaxation in the clinical setting.

RECOMMENDATIONS:

· A time series study can be conducted to identify the long term effects of PMR.

· A Comparative study can be done to compare the effect between PMR and other mind and body techniques.

· This study may be replicated in a large sample.

· A similar study can be done with focus on fatigue assessment, its causes and management in patients with cancer.

REFERENCES:

1. National cancer Institute at the National Institutes of Health (Internet). Report. Available from: www.cancer research.org. New York; 2015.

2. Lewis L, Dirksen R, Obrien P, Bucher L and Obrien P. Medical Surgical Nursing: Assessment and management of clinical problems. Elsevier; 2011.p.258-259.

3. The Burden of Cancer worldwide (Internet) Available from www.new cancer.gov

4. Cancer care for the whole patient meeting psychological health needs; National Academy of sciences. 2008.

5. McMillan SC, Tittle M, Hagan S. Management of pain related symptoms in hospitalized veterans with cancer. Cancer Nursing. 200;23(5). p.327-336.

6. Armida P, Millar D. Cancer pain. Cleaveland Clinical Journal of Medicine. 2013 Sept.

7. Cancer pain; Relief is possible.Mayo foundation for Medical Education and Research.

Received on 26.09.2020 Modified on 21.10.2020

Int. J. of Advances in Nur. Management. 2021; 9(2):184-187.

DOI: 10.5958/2454-2652.2021.00041.X