Progressive Muscle Training

Progressive Muscle Training

6.
7. / Brief Resume of the intended work
6.1 Need for the study
. Cancer is a disease that poses a threat to many aspects of life. Caring for clients with cancer is one of the most significant tasks facing health care professionals today. One of the most debilitating complications of cancer is moderate to severe pain, calling for aggressive treatment.
Globally it is estimated that there are 7.6 million new cancer cases, of which 52% occur in developing countries. The estimated new cases of cancer in India per year are nearly 6.5lakhs. Patients with terminal cancer present enormous challenges for healthcare professionals. As the disease progresses, these patients have to contend with worsening of symptoms, deteriorating physical health and adverse psychological and social effects that require ongoing medical and nursing care and support.1
Pain is one of the most feared, and one of the commonest symptoms
associated with cancer2. Pain in cancer may be caused by cancer itself, related to cancer, related to treatment and concurrent disorders3.
Of the numerous causes of pain, the pain associated with the invasion of cancer is especially devastating. It has been estimated, for example, that 30 to 40% of persons in the intermediate stages of cancer and 60 to 80% of those who are in more advanced stages experience pain. Cancer pain is multidimensional, it may be progressive with an increase in intensity. In a study of 100 cancer patients, 39% perceived their pain to be unrelated to the disease or treatment and 83% of cancer patients said tension and nervousness increased the pain they were experiencing. Anxiety and depression have also been shown to exacerbate cancer pain4.
Despite significant advances in medicine andoncology, most physicians still deal with patientssuffering from relentless, incurable illnesses, and decisionsare often made about the treatment of terminally ill patientsbased on judgments about their quality of life(QoL) 5. A study was conducted on Quality of life of cancer patients receiving inpatient and home-based palliative care. Fifty eight patients with terminal cancer (32 inpatients, 26 home based) were selected from major palliative care centers in Australia in 1999. It showed QoL of patients with home based care is significantly higher than hospitalized patients. So the main implication for the role of nurse are the need for early detection and management of both physical and psychological symptoms, particularly pain, fatigue, anxiety and depression, and the need to use strategies that will empower patients to have greater sense of control over their illness and treatment1.
Cancer pain is most commonly treated with opioid medication.Some of the most common side effects of opioid medication are: Constipation, Nausea and vomiting, Sleepiness, Slowed breathing6. Halldorsdottirand Hamrin describe the experience of having cancerby five themes: uncertainty, vulnerability, isolation, discomfort,and redefinition. The study illuminates theexperience of withdrawal, nausea, vomiting, fatigue, pain, afeeling of change, and threat of death. All of this causes the pain treatmentin general consists of pharmacotherapy, radiation, or surgical therapy. Unfortunately, these treatments haveunwanted side effects7.
The relation between physiological and psychological aspects justifies the use of non pharmacological interventions as support measures for controlling nausea and vomiting and decreasing anxiety8. Mental imagery, by altering brain biochemistry, may influence or alter the immune system cells. The sessions of the guided imagery makes change in participant’s perceptions of the stress through cognitive/imagery restructuring. Imagining the overall feeling of health and wellbeing seems to actualize the body becoming whole, healthy, beautiful and powerful9. Guided imagery is a skill that can be taught by nurses and can be learned in both inpatient and outpatient settings. Teaching relaxation skills is consistent with the concept that patient who participate in their care are more autonomous. Once it is learned they can practice themselves. Relaxation training is cost-effective also. For patients, the goal of using imagery is to replace the negative images that provoke fear, hopelessness and anxiety with positive images of healing and well being that contribute to recovery10.
The investigator herself during her clinical experience has come across many cancer patients experiencing negative symptoms of cancer and its treatment. This motivated the investigator to undertake the study to improve the Quality of life among cancer patients. The depth of review and the information available about the new advancing therapies in cancer pain relief, kept the investigator’s motivation and keen interest towards the use of diversional therapy to minimize cancer pain and improve the quality of life.
6.2Review of the literature
A longitudinal, prospective, two-group, randomized, controlled clinical trial was conducted to test the effects of Guided Imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia in mid-Atlantic region. Forty eight participants randomized to Guided Imagery plus usual hcare intervention group received a set of 3 audio taped guided imagery strips and were instructed to use at least one tape daily for 6 weeks and report weekly frequency of use (dosage). Participants assigned to usual care alone group submitted weekly report forms on usual care. All participants completed the Short-Form Mc Gill Pain Questionnaire (SF-MPQ), Arthritis Self Efficacy Scale (ASES), and Fibromyalgia Impact Questionnaire (FIQ), at baseline, 6, and 10 weeks. FIQ scores decreased over time in the GI group compared to the Usual Care group (P = 0.03), ratings of self-efficacy for managing pain (P=0.03) and other symptoms of FM also increased significantly over time ( p = <0.01) in the GI group compared to the Usual Care group11.
A study was conducted on 230 patients to determine whether GI in the perioperative period could improve the outcome of colorectal surgery patients. Group I received standard perioperative care, and Group II listened to a GI tape 3 days preoperatively, a music only tape during induction, surgery and postoperatively in recovery room, a GI tape during each of the first six post operative days. All patients rated their levels of pain and anxiety daily, on a linear analogue scale of 0 to 100. Total narcotic consumption, time to first bowel movement, length of stay, and number of patients with complication were also recorded. Result showed significant reduction in postoperative anxiety (p<0.001), pain (p<0.001) and narcotic requirements (p<0.001). Time to first bowel movement was significantly less the imagery group (p<0.001) than in control group. The number of patients experiencing post operative complications did not differ in two groups12.
A study was conducted in Sydney, Australia to determine the effect of relaxation and imagery for anxiety, depression and quality of life in patients with advanced cancer. Study was a randomized pre-test post-test control group clinical trail. By randomization 56 people with advanced cancer who were experiencing anxiety and depression were assigned to one of the four treatment conditions:
  1. Progressive muscle training.
  2. Guided imagery training.
  3. Both these.
  4. Control group.
Scales used were HAD scale and the functional living index Lancer scale. Results showed there was significant positive changes for depression ( p= 0.01 ) and QOL ( p< 0.01 ) for the entire group expect the control group13.
An experimental, randomized controlled trial was designedto examine theeffectiveness of the Progressive Muscle Relaxation Training (PMRT) and GI in reducing chemotherapy side effects in patients with breast cancer and in improving their Quality of life. Thirty chemotherapy patients with breast cancer were randomized to Progressive Muscle Relaxation Technique (PMRT) and GI group and 30 to the control group. Before each of six cycle of adjuvant chemotherapy, each patient was administered a self-report Multiple Affect Adjective Checklist (MAACL), and incidents of Anticipatory Nausea and Vomiting (ANV) and Postchemotherapy Nausea and Vomiting (PNV) for the first three postchemotherapy days were recorded. All patients were administered the Functional Assessment of Cancer Therapy-Breast (FACT-B) at baseline and after 3 and 6 months. Results showed the PMRT and GI group was significantly less anxious, depressive, and hostile than thecontrol group. 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 (p0.05, p0.01, p0.01)14.
6.3 Statement of the problem:-
“Effectiveness of Guided Imagery (GI) on intensity of pain and quality of life among patients with cancer in a selected hospital at Mangalore”
6.4 Objectives of the study
  1. To determine the intensity of pain before and after the administration of guided imagery as measured by visual analogue scale (VAS).
  2. To determine the quality of life (QOL) of cancer patients before and after the administration of guided imagery as measured by multidimensional quality of life index FACT- G
  3. To find out the relationship between intensity of pain and quality of life of cancer patients.
  4. To determine the association between pre intervention intensity of pain scores and selected demographic variables.
  5. To determine the association between pre intervention QoL scores and selected demographic variables.
6.5 Operational definitions
1. Effectiveness: - In this study, effectiveness refers to the extent to which
practicing guided imagery (GI) has achieved the results as expressed in
terms of reduction in intensity of pain scores in patients with cancer and
improved their quality of life in the post intervention period.
2. Guided imagery: - It is the purposeful use of imagination to achieve
relaxation or direct attention away from undesirable sensation15.
In this study therapist makes the patient to relax in a comfortable position and environment and guides the patient through sequence of pleasant situations with the use of audio cassette for 15 minutes, twice a day for seven days.
  1. Cancer patients: - Patients admitted to the hospital with the diagnosis of any cancer and having pain intensity of more than 2 on visual analog scale with the age group of 20-70 years.
  2. Intensity of pain: - It refers to mild to severe intensity of pain sensation, as experienced by the patients with cancer it can be due to cancer or its treatment modalities and subjectively measured by visual analogue scale (VAS) of 1-10 points.
Severe pain intensity: - It refers to the arbitrary scores of 7-10 on the
VAS.
Moderate pain intensity: - It refers to the arbitrary scores of 4-7 on the
VAS.
Mild pain intensity: - It refers to the arbitrary scores of 2-4 on the VAS.
  1. Quality of life: - It is a pragmatic day to day functional representation of patient’s physical, psychological, and social response to a disease and its treatment5.
In this study it refers to the day to day functional representation of
physical, social, emotional and functional response of patients with cancer to
cancer and its treatment which is measured by FACT-G scale.
6.6 Assumptions
  1. Patients with cancer experience certain amount of pain.
  2. Pain has some effect on Quality of Life.
  3. Quality of Life is a subjective concept
6.7 Delimitation
The study will be delimited to patients with cancer pain in selected hospital at Mangalore.
6.8Hypothesis (projected outcome)
All hypotheses will be tested at 0.05 level of significance.
H1: The mean post intervention pain intensity score of cancer patients will be a significantly lower than that of their pre intervention pain intensity score as measured by visual analogue scale.
H2: The mean post intervention quality of life score will be significantly higher than the mean pre intervention quality of life score.
H3: There will be a significant relationship between the intensity of pain and quality of life of patients with cancer.
H4: There will be a significant association between pain intensity and selected demographic variables like age, sex, socioeconomic status (income), occupational status, activity level, duration of illness.
H5: There will be significant association between quality of life and selected demographic variables like age, sex, socioeconomic status (income), occupational status, activity level, duration of illness.
Material and Methods
7.1 Source of data
Patients who are diagnosed with cancer and having pain, in the selected hospitals at Mangalore.
7.1.1.Research design
Quasi experimental
7.1.2 Setting
The study will be conducted in FatherMullerMedicalCollegeHospital at Mangalore, where nearly 100-150 patients with cancer of different site get admitted every month for different modalities of treatment.
7.1.3 Population
Patients with the diagnosis of cancer and having pain admitted in selected hospital at Mangalore with the age group of 20-70 years.
7.2 Methods of data collection
7.2.1Sampling procedure
Purposive sampling technique.
7.2.2Sample Size
30 cancer patients
7.2.3Inclusion Criteria
  1. Patients admitted to hospital who are suffering with pain due to cancer or its treatment modalities.
  2. Patients with age group of 20-70 years
  3. Patients having pain intensity of >2 on visual analogue scale (VAS), on the first day.
  4. Patients who are willing to under go guided imagery therapy
  5. Subjects who are mentally sound
  6. Patients who are able to follow verbal instruction and can read and write in English, Kannada, and Malayalam.
7.2.4Exclusion Criteria
  1. Patients who have visual and hearing impairments
  2. Patients who are critically ill
7.2.5Instruments intended to be used
  1. Visual Analogue Scale (VAS)
  2. Quality of life scale : – Multidimensional QOL index FACT-G
7.2.6Data collection method
Permission will be obtained from the concerned authority and informed consent will be taken from the subjects. Pre intervention intensity of pain and QOL of cancer patients will be measured using pain scale and QOL scale. This will be followed by administration of guided imagery with audio cassette for 15 minutes duration, twice a day for seven days. Intensity of pain will be measured every day before and after administration of Guided Imagery and post intervention QOL will be measured after 7 days.
7.2.7Data analysis plan
Descriptive and inferential statistics will be used to analyze. Findings will be presented in the form of tables and figures.
  1. Demographic variables are analyzed by frequency and percentage
  2. Score of VAS analyzed by frequency and percentage
  3. Relationship between intensity of pain and QoL analyzed by Karl Pearson’s correlation coefficient method
  4. Chi-square test will be used to analyze the association between intensity of pain, QoL and selected demographic variables
  5. Effectiveness of Guided Imagery will be analyzed using ‘t’ test
7.3 Does the study require any investigations or interventions to be conducted on patients/other humans/animals? If so please describe briefly
Yes, the investigator will administer Guided Imagery.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes, Ethical clearance has been obtained.
List of Reference:
  1. Peters L, Sellick K. Quality of life of cancer patients receiving inpatient and home-based palliative care. Journal of Advanced Nursing 2006; 53(5): 524-33.
  2. Pain Relief Foundation,
  3. Cancer Pain Relief and Palliative Care, Report of the WHO Expert Committee on Cancer Pain Relief and Supportive Care, 1989.
  4. Ferrel-Torry A T, Glick O J. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nursing 1993; 16(2): 93-101.
  5. Waldron D, O’Boyle C A, Kearney M, Moriarty M, and Carney D. Quality-of-Life Measurement in Advanced Cancer: Assessing the Individual. J Clin Oncol 1999; 17(11): 3603-3611.
  6. Pain Management Treatment at M. D. Andersonain,the University of Texas, 2007.
  7. Billhult A, Dahlberg K, A Meaningful Relief from SufferingExperiences of massage in cancer care. Cancer Nursing. 2001; 24(3): 180-84
  8. Carvalho E C D, Martins F T M, Santos C B D. A Pilot Study of a Relaxation Technique for Management of Nausea and Vomiting in Patients Receiving Cancer Chemotherapy. Cancer Nursing. 2007; 30(2): 163-67.
  9. Brigham DD, Toal PO. The use of imagery in a multimodal psychoneuro immunology program for cancer and other chronic diseases In: Kunzendorf, ed. Proceedings of 11th and 12th Annual conference of American Association for study of mental Imagery; 1989 June 15-18, Washington, DC. 1990 June 14-17, Lowell, Boston; 1990. 147-274.
  10. Dossey BM. Awakening the inner healer. American journal of nursing 1995: 41-6.
  11. Victoria M, Ann GT, Cheryl B. Effects of Guided Imagery on Outcomes of Pain, Functional Status, and Self-Efficacy in Persons Diagnosed with Fibromyalgia. The Journal of Alternative and Complementary Medicine 2006; 12(1): 23-30
  12. Tusek DL, Church J M, Stron S A, Grass JA. “Guided imagery. A significant advance in the care of patients undergoing elective colorectal surgery. Dis colon rectum 1997; Feb. 40(2): 172-78.
  13. Sloman, R. Relaxation and Imagery for Anxiety and Depression Control in Community Patients with Advanced Cancer. Cancer Nursing; 2002; 25(6): 432-435
  14. Hee J. Yoo, Se H. Ahn, Sung B. Kim, Woo K. Kim, Oh S. Han. Efficacy of progressive muscle relaxationtraining and guided imagery in reducingchemotherapy side effects in patientswith breast cancer and in improvingtheir quality of life.Support Care Cancer 2005 13: 826–833
  15. Boyd MA, Nihart MA. Psychiatric nursing contemporary practice. 1st ed. Philadelphia: Lippincott; 1998.

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