PROFORMAFORTHEREGISTRATIONOFSUBJECT FORDISSERTATION

“ASSESS THE EFFECTIVENESS OF FOOT MASSAGE (REFLEXOLOGY) TO REDUCE PAIN AMONG CANCER PATIENTS WHO ARE UNDERGOING RADIATION THERAPY AT SELECTED HOSPITALS,TUMKUR.”

SUBMITTEDBY;

MS. RAJI M VARGHESE

MEDICAL SURGICAL NURSING

SHRIDEVICOLLEGEOF NURSING SIRA ROAD,LINGAPURA TUMKUR

2013-15

RAJIVGANDHIUNIVERSITYOFHEALTHSCIENCES

BENGALURU,KARNATAKA

PROFORMAFORTHEREGISTRATIONOFSUBJECTFORDISSERTATION

1 / NAME OF CANDIDATE AND ADDRESS / MS. RAJI M VARGHESE
1YEARM.ScNURSING SHRIDEVICOLLEGE OF NURSING,
SIRAROAD,LINGAPURA TUMKUR
2 / NAME OFTHE
INSTITUTION / SHRIDEVICOLLEGE OF
NURSING
3 / COURSESTUDYAND
SUBJECT / IYEARM.SC.NURSING
MEDICAL SURGICALNURSING
4 / DATEOFADMISSION
TO COURSE / 01-06-2013
5 / TITLEOFTHETOPIC / “ASSESS THE EFFECTIVENESS OF FOOT MASSAGE (REFLEXOLOGY) TO REDUCE PAIN AMONG CANCER PATIENTS WHO ARE UNDERGOING RADIATION THERAPY AT SELECTED HOSPITALS, TUMKUR.”

6. BRIEFRESUME OFTHEINTENDEDWORK Introduction

“Pain is inevitable, suffering is optional.”

William Rogers

Cancer known medically as a malignantneoplasm, is a broad group of various diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the body through the lymphatic system or bloodstream. Many things are known to increase the risk of cancer, including tobacco use, dietary factors, certain infections, exposure to radiation, lack of physical activity, obesity, and environmental pollutants. These factors can directly damage genes or combine with existing genetic faults within cells to cause cancerous mutations.

WHO (2008) has predicted that cancer would overtake heart disease as leading killer disease. About 7.6 million people died of cancer in 2008, and about 12.4 million new cases are diagnosed each year. 15 % of newly reported cancers were in developing countries; by 2030 it will rise to 70%. Worldwide almost two thirds of the 7.6 million deaths from cancer occur every year in low and middle income countries. Overall fatality from cancer is estimated to be 75 % in countries of low income, 72% in countries of low middle income, 64% in high middle income and 46% in countries of High income1

While cancer can affect people of all ages, the risk of developing cancer generally increases with age. Risk rates are rising as more people live to an old age and as mass lifestyle changes occur in the developing world. According to Indian cancer statistics, India has one of the highest cancer rates in the world. In India, about a million new cancer cases are diagnosed every year, and that number is projected to triple in the next 20 years.

Seven warning signs of cancer such as Unusual bleeding/discharge, A sore which does not heal, Change in bowel or bladder habits, Lump in breast or other part of the body, Nagging cough, Obvious change in moles, Difficulty in swallowing about cancer created awareness among the people,certain cancer can’t be find in its earlier stage.

General signs and symptoms of cancer include unexplained weight loss, fatigue, and pain and skin changes. Approximately 30% to 50% of people with cancer experience pain while undergoing treatment, and 50% to 70% of people with cancer experience pain at advanced stage. It is reported that more than 12,900 elderly cancer patients reported pain depends on many factors such as the type of cancer, the stage of the disease, and the patient’s tolerance2.

Pain is one of the most common symptoms in patients with cancer: it is certainly the most feared. Pain occurs in two-third of patients with advanced cancer.Pain in cancer may arise from a tumor compressing or infiltrating tissue; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by the body's immune response or hormones released by the tumor. Most acute pain is caused by treatment or diagnostic procedures, though radiotherapy and chemotherapy may produce painful conditions that persist long after treatment has ended. It is reported that the 40% to 50% cancer patients with pain, reported it as moderate to severe and another 25% to 30% described it as very severe3.

Cancer pain can be eliminated or well controlled in 80 to 90 percent of cases by the use of drugs (such as morphine) and other interventions, but nearly one in two patients receives less-than-optimal care. Treatment guidelines for the use of drugs in the management of cancer pain have been published by the World Health Organization and other organizations. Healthcare professionals have an ethical obligation to ensure that, whenever possible, the patient or patient's guardian is well-informed about the risks and benefits associated with their pain management options. Adequate pain management may sometimes slightly shorten a dying patient's life.

There are many ways to relieve pain, from drugs to surgery. Treatment may vary from individual to individual, depending on the type and severity of pain, risk factors involved with using a particular treatment, and personal preference. Opioids, a common treatment for pain, can lead to dependence, addiction and tolerance. Pain is often under treated. Some of the most common treatments are analgesic therapy,WHO three-step analgesic ladder that is If pain occurs, there should be prompt oral administration of drugs in the following order: non-opioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used4.

All cancer patients are using conventional medical treatment offered by modern oncology to fight cancer. At the same time more and more patients are using complementary and alternative medicine (CAM) alone or in combination with the traditional treatment in order to improve the quality of life and relieve secondary symptoms.

Foot massage is a complimentary therapy that has great potential use by the nurses in a multidisciplinary pain management programme. Because nurses are the only person who provide care to the patients round o clock. Foot massage is the process of gentle but firm manipulation to feet to stimulate specific reflex points of the body. This is based on the reflexes running along the body which terminate in the feet and that the body’s organs and systems are reflected onto the surface of the skin. Massage acts like an analgesic and inhibits those pain signals from being transmitted to the brain. It is also thought that massage helps the body to release endorphins. Foot massage can be given at anytime, anywhere, there is no time limit, and it won’t produce any side effects. Foot massage is an effective pain relieving therapy for the patient with cancer pain, recommended the use of foot massage as a complementary therapy and as a relatively simple nursing intervention for patients experiencing pain or nausea related to the cancer experience5.

6.1NEEDFORTHESTUDY

Cancer is a global problem and has a major impact on life, requiring chemotherapy and radiation therapy as an important treatment measure. Many cancer patients seek medical help at terminal stage. The cancer related pain is still one of the critical problems of modern oncology. In India, about a million new cancer cases are diagnosed every year, and that number is projected to triple in the next 20 years. Nearly two-thirds of allcancerpatients will receiveradiation therapyduring their illness6.

Radiation therapy use of ionizing radiation, generally as part of cancer treatment to control or kill malignantcells. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor (for example, early stages of breast cancer). Radiation therapy is synergistic with chemotherapy, and has been used before, during, and after chemotherapy in susceptible cancers.

Radiation therapy involves the use of ionizing radiation in an attempt to either cure or improve the symptoms of cancer. Ionizing radiation works by damaging the DNA of exposed tissue leading to cellular death. To spare normal tissues (such as skin or organs which radiation must pass through in order to treat the tumor), shaped radiation beams are aimed from several angles of exposure to intersect at the tumor, providing a much larger absorbed dose there than in the surrounding healthy tissue. It is used in about half of all cases and the radiation can be from either internal sources in the form of brachytherapy or external sources. Radiation is typically used in addition to surgery and or chemotherapy but for certain types of cancer such as early head and neck cancer may be used alone. For painful bone metastasis it has been found to be effective in about 70% of people.The amount of radiation used in radiation therapy is measured in gray (Gy), and varies depending on the type and stage of cancer being treated. The following are the statistics of radiation therapy in Radiology department at Rajiv Gandhi Government General Hospital, Chennai.

YEAR / NEW CASES / OLD CASES / RADIATION THERAPY RECEIVED
2008 / 986 / 4532 / 14340
2009 / 1093 / 6540 / 16782
2010 / 1494 / 7379 / 17170
2011 / 1946 / 9189 / 28049
2012 / 2013 / 10856 / 28889

Side effects from radiation are usually limited to the area of the patient's body that is under treatment. The main side effects reported are fatigue and skin irritation. Acute side effects are Nausea and vomiting, damage to the epithelial surfaces, pain, Mouth, throat and stomach sores Intestinal discomfort Swelling and Infertility. Late side effects are Fibrosis, epilation, dryness, lymphedema, Heart disease, and Radiation proctitis7.

Cancer pain often leads to debilitation, diminished quality of life, and depression. Effective pain control is best achieved through a combination of both pharmaceutical and non-pharmaceutical therapies. Pharmaceutical management has been the primary means of providing relief from pain. Analgesics have maximum effective dose; increasing the dose cannot increase pain relief, but may increase side effects. Tolerance also may occur when larger doses of medicines are needed to provide the same amount of pain relief as the previous smaller dose. Although pharmaceutical medications continue to serve as a major contributor to pain management, non-pharmaceutical techniques are increasingly used to provide pain relief.

Reflexology has been used for centuries. It is thought to have originated in the ancient Egypt. It is not a medical approach in the usual sense of the word but rather a holistic approach that is complementary to more traditional conventional medicine. Foot massage is the manipulation of the soft tissue of whole body areas to bring about generalised improvements in health, such as relief of muscular aches and pains. or specific physical benefits, such as relaxation or improved sleep,

It is a touch therapy which works by applying pressure and massage to certain areas on feet and hands (it is more common to treat feet than hands). The reflexologists believe that 'reflex areas' in the feet related to individual parts of body. And thus by applying pressure to certain reflex areas, certain bodily functions or corresponding organs can be stimulated. It is one of the most popular types of complementary therapies in the UK among cancer patients. As it is a complementary therapy it should not be used as an alternative to conventional medicine but rather as an additional therapy to conventional treatment. Foot massage can reduces the intake of pain relieving medications among the cancer patients8.

The human body is divided into different zones represented by a point in the foot or hand. Feet and hands have nerve endings. Reflexology works by stimulating these nerve endings which results in promoting relaxation, improving circulation, stimulating vital organs in the body and encouraging the body's natural healing processes. Unlike conventional medicine, reflexology works on the underlying problems within the body through the body's nervous system.

Reflexology aims to help muscles relax and encourage the body to use its own resources more effectively. As a result, reflexology is believed to help with a wide variety of conditions which including:

  • pain
  • stress and anxiety
  • depressed mood

Reflexology will not lead serious health problems. If it is used regularly it will enhance other treatments by keeping the circulation stimulated and the lymph system active. Individual also experience feelings of vitality and well-being after reflexology treatment which encourages the healing process throughout the body.

6.2REVIEW OFLITERATURE

Thereviewofliteratureis definedasbroad,comprehensivein-depth, systematic andcriticalreviewofscholarly publications, unpublished scholarly printmaterials,audiovisualmaterialsandpersonalcommunications.

SECTION A: REVIEWS RELATED TO CANCER PAIN AND TREATMENT

American Cancer Institute(March2012) “This report demonstrates the value of cancer registry data in identifying the links among physical inactivity, obesity, and cancer,” said CDC Director Thomas R. Frieden, M.D. “It also provides an update of how we are progressing in the fight against cancer by identifying populations with unhealthy behaviors and high cancer rates that can benefit from targeted, lifesaving strategies, and interventions to improve lifestyle behaviors and support healthy environments.”

Wang HL, Kroenke K (2011) Assessed the cross-sectional association between cancer-related pain and disability is well established, their longitudinal relationship has been less studied. Disability over 12 months in patients with cancer-related pain is predicted by changes in pain severity over time. Results suggest that effective pain management may reduce subsequent disability among cancer survivors9.

PubMed (2011) A trial of Sativex for cancer related pain. There are different ways to treat cancer pain, including strong painkillers called opioids. In this trial, they are looking at a drug called Sativex. The main active ingredients of Sativex are tetrahydrocannabinol (THC) and cannabidiol (CBD). Both of these molecules come from the cannabis (marijuana) plant. But sometimes, even opioids and other drugs cannot completely control the pain. Researchers are looking for ways to help people in this situation10.

Constantini.M, et.al., (2009) reported a mortality follow-back survey to determine the prevalence, distress, management and relief of pain during last 3 months of cancer patients life of a representative sample of dying cancer patients. Care givers were interviewed, after the patient’s death, about pain experienced by the patients. According to care givers, 82.3% (95% to 79.9% to 84.4%) patients experienced pain and 61.0% (95% CI 57.9% -64.0%) very stressing pain, the younger population experienced a higher prevalence of pain in respect to their patients(P<0.01)11.

Tsai Sc (2009) studied the incidence and factors related to Emergency Department visits by cancer patients with pain complaints during a year period. Medical charts by stratified random sampling included 1179 ED visits by 1026 cancer patients were actively reviewed. Pain was the most common reason for emergency department visits by cancer patients12.

Sheeba.C. (2007) reported selected acute symptoms experienced by cancer patients and the feasibility of a structured training programme on symptom management of 30 cancer patients receiving palliative home care in and around Vellore using purposive sampling. Pain measured using numerical pain rating scale and it showed that majority of the terminally ill cancer patients experienced pain(80%)13.

Deimling GT, Bowman KF and Wagner LJ (2007) observed the fatigue and pain reported by survivors of breast, prostate, and colorectal cancer selected by random sampling in case Western Reserve University, USA. Importance of cancer and age-related factors as correlates of pain and fatigue as well as the relationship between pain and fatigue and functional difficulty. The results were examined of multivariate analysis indicated that the pain, energy level, and weakness reported by older adult cancer survivors are more strongly related to age-related factors than they are to cancer-related factors14.

Edrington, et al., (2007) reported a study to examine of pain in these cancer patients. Pub med, psych info and Google scholar searches were conducted years 1996 to 2005 for all research in English. The literature search and review science lists from the studies identified the 24 studies that were used in the review. Most of the descriptive co- relational studies evaluated the physiologic and sensory dimensions of the experience reported moderate to severe pain and that pain interfered with their normal rate and mood. P<.001)15.

Winnie Dawson, MA (2007) observed Pain is one of the most common and most feared symptoms in patients with cancer. Toward the end of life up to 80% of patients with cancer may experience severe pain. Documents in this section focus on pain control and associated symptom management via pharmacotherapy’s, nonpharmacologic strategies, and/or complementary approaches during cancer care16.

Robb KA, Williams JE(2006) A large proportion of patients may develop chronic pain following cancer treatments such as surgery, radiotherapy, or chemotherapy. These patients can experience significant levels of physical and psychological morbidity. A combination of physical and psychological techniques were adapted from previous work in chronic benign pain and implemented by two therapists. Interventions included education, relaxation, exercise training, and goal setting. There was a significant trend toward improvement in many variables, including anxiety and depression (P < .01), fitness (walking: P < .05), and coping with pain (P < .01)17.

Kalyani.V.C.(2006) conducted an experimental study to assess the effectiveness of music therapy on pain, anxiety and selected factors in 30 cancer patients using purposive sampling technique in Apollo hospitals Chennai by giving 2 sessions of 30 minutes music therapy for 5 consecutive days. The instruments used were demographic and clinical variables Performa, spiel burger’s state anxiety sub scale, 0-10 point pain intensity scale and assessment tool on physiologic variables. The pain of cancer patients was high before in comparison with scores after the music therapy 18.

SECTION B: REVIEWS RELATED TO PAIN ASSESSMENT

Willianmson A, Hoggart B Birmingham, UK (2006) conducted a study on a review of three commonly used pain rating scales, the visual analogue scale, the verbal rating scale and the Numerical rating scale. All three pain-rating scales are valid, reliable and appropriate for use in clinical practice, although the visual Analogue scale has more practical difficulties then the verbal Rating Scale (or) the Numerical Rating scale. Numerical Rating Scale has good sensitivity and generates data that can be statistically analyzed for audit purpose19.

Kane RL, Bershadsky B, Rockwood T et.al. USA (2005), conducted a study on Visual Analog scale pain reporting was standardized. Whereas pain is frequently measured using a visual Analog scale that can examine charge over short time interval in the same subject, such ratings are not useful in analyzing differences across subjects. Results on individual variations in pain rating were found to be independent of respondent age and gender, but were correlated with experience of the event (or) behavior and with self-reported health status. A new scoring method that takes into account these correlations is proposed. It concluded that it is possible to standardize VAS pain ratings to compare pain between different populations20.