Annals of Tropical Medicine and Public Health
Home About us Ahead Of Print Instructions Submission Subscribe Advertise Contact e-Alerts Editorial Board Login 
Users Online:3632
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size
 


 
Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 11  |  Issue : 1  |  Page : 8-12
Studying the effect of progressive muscle relaxation technique on fatigue in hemodialysis patients – Kermanshah- Iran


1 Lecturer of Nursing, Nursing Department, Faculty Member of Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Lecturer of Nursing of Operation Room, Operation Room Department, Faculty Member of Paramedical School, Kermanshah University of Medical Science, Kermanshah, Iran
3 Assistant Professor of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Science, Kermanshah, Iran
4 Assistant Professor of Biostatistic, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran

Click here for correspondence address and email

Date of Web Publication10-Dec-2019
 

   Abstract 


Background: Renal chronic disease is a major challenge to public health all around the world. Despite the development of sundry renal replacement therapies, the patients usually complaint about disabling symptoms and low quality of life. In fact, fatigue is one of the most annoying and disabling symptoms in dialysis patients. Therefore, the present study is an attempt to determine the effect of progressive muscle relaxation technique on fatigue in hemodialysis patients. Methods: A clinical trial study to measure the effect of progressive muscle relaxation technique on fatigue in 65 hemodialysis patients in Imam Reza Hospital (Kermanshah) was carried out in 2011. The participants were grouped in experiment and control groups. The brief fatigue inventory was used for data gathering, and the data were analyzed in SPSS-16. Results: There was no significant difference between the mean changes of fatigue before and after progressive muscle relaxation in control and experiment groups (P ≥ 0.05). However, the difference between scores of fatigue before and after the intervention in the experiment group was significant (P ≤ 0.05). Conclusion: Although progressive muscle relaxation improved fatigue in the patients in the experiment group, the difference between the control and experiment groups was not significant. Failure to control some of the effective factors might be the reason for the result.

Keywords: Fatigue, hemodialysis patients, Kermanshah, progressive muscle relaxation

How to cite this article:
Hadadian F, Jalalvandi F, Karimi S, Abdi A, Salari N, Ghobadi A. Studying the effect of progressive muscle relaxation technique on fatigue in hemodialysis patients – Kermanshah- Iran. Ann Trop Med Public Health 2018;11:8-12

How to cite this URL:
Hadadian F, Jalalvandi F, Karimi S, Abdi A, Salari N, Ghobadi A. Studying the effect of progressive muscle relaxation technique on fatigue in hemodialysis patients – Kermanshah- Iran. Ann Trop Med Public Health [serial online] 2018 [cited 2020 Feb 29];11:8-12. Available from: http://www.atmph.org/text.asp?2018/11/1/8/272533



   Introduction Top


Healthy kidney and urinary ducts are essential for a healthy life.[1] Renal chronic disease is a health problem all around the world.[2] The end-stage renal disease (ESRD) leads to death if renal replacement therapy is not possible.[1],[3],[4] Hemodialysis is the most common dialysis method.[1] The patients usually demonstrate symptoms of fatigue and degraded quality of life.[5] That is, fatigue is reported by many hemodialysis patients as one of the most prevailing stressor.[6] Fatigue intervenes with one's ability to fulfill their role in life.[7] There is no consensus on the definition of fatigue and researchers tend to approach to it as a multi-aspect phenomenon Jhamb et al. (2008) reported that prevalence of fatigue varies from 60 to 90% in chronic hemodialysis patients.[8] Lee (2007) showed that 82% of hemodialysis patients complain about fatigue.[9] Tsay and Chen (2003) highlighted that fatigue in ESRD under hemodialysis treatment was 5.98 out of 10 according to Piper Fatigue Scale, which is a relatively intense fatigue.

Fatigue is a serious problem and nurses can play an effective role in improving quality of life of the patient.[7] Medicines and their side-effects, nutrition problems, physiological changes (abnormal urea and hemoglobin level in particular), hemodialysis problems (low sodium content of dialysis solution, and rapid ultrafiltration) and psychological problems such as depression, and sleep disorder are effective on the fatigue experienced by ESRD patients.[10] In addition, the researchers[11],[12] reported that fatigue in hemodialysis patients is featured with high stress. A qualitative study by Lee et al. showed that hemodialysis patients usually experienced physical, emotional, and cognitive fatigue.[9]

Fatigue is a complicated concept and due to its complicacy, its treatment entails a multi-aspect approach. Among the medicine interventions to improve fatigue, erythropoietin stimulation factor, growth hormone, vitamin C and B, intravenous levocarnitine, and psychometric factors such as methylphenidate are notable. As to nonmedicine interventions, healthy nutrition, sleep hygiene, stress control, depression treatments are to name but a few. Other techniques such as exercising, Yoga, energy saving strategies, acupressure, acupuncture, and relaxation have been examined in limited clinical trial studies, and promising results have been reported. However, to prove positive effect of these interventions on dialysis patients, in particular, further clinical trial study is needed.[13],[14],[15] In fact, health-care personnel usually take fatigue as a part of ESRD process and for improvement of which no measure can be taken.[7]

Progressive muscle relaxation technique is a supplementary treatment introduced by Edmond Jacobson in 1938. The technique is an intervention that, along with positive and lasting effect, as a supplementary treatment, is effective on dealing with headache, stress, chemotherapy side-effects, and the like.[16] The technique is considered as one of the best supplementary treatments, which is also favorable given the ease of implementation, low expense, no need for special equipment, and that it can be performed by the patients.[17],[18] There are several studies on using progressive muscle relaxation technique including Mohammadi ) who examined the effect of the technique on attenuating anxiety in heart attack patients.[19] In addition, Eckes Peck compared the effect of touch therapy and progressive muscle relaxation on soothing pain and stress in osteoarthritis (a chronic disease) patients.[20]

Despite high rate of fatigue and its negative effect on quality of life of ESRD patients, few interventions have been carried out and examined on dealing with the disabling symptoms.[21] Fatigue in chronic patients is a serious challenge and worry for the patients and the health personnel including nurses. This problem is more serious in hemodialysis patients and needs to be treated in an efficient manner.[2] Therefore, the present study is aimed for evaluating the effectiveness of progressive muscle relaxation technique on fatigue in hemodialysis patients.


   Methods Top


A clinical trial randomized study was carried out. The participants were selected through purposeful sampling, and the participants were randomly grouped in control and experiment groups. The study population was comprised of all above 15 years old patients under hemodialysis treatment who referred to hemodialysis ward of Imam Reza Hospital of Kermanshah-Iran. With confidence level of 99% and power of test of 90%, sample group size was obtained 20 for each group. Taking into account the probability that some of the participants might leave the study during the study, fifty participants for each group were selected. The study purposes were explained to the candidate participants, and those who expressed willingness to cooperate were asked to sign a letter of consent. Afterward, the participants were randomly grouped in control and experiment groups. Inclusion criteria were receiving hemodialysis treatment for at least 6 months, willingness to participate in the study, age at least 15 years, complete awareness of the situation, hearing and speaking ability as needed to learn the technique, and no psychological disease. The exclusion criteria were lack of willingness to learn relaxation technique, failure to attend the training course, hospitalization for whatever reason, and encountering physical or mental problems during the study. A CD containing the first and second steps was placed on the test group. Each relaxation step lasts about 15 minutes. A relaxation technique for 2 consecutive sessions ( first session of in-person training and a second session with questions from the patient and answering the questions he was asked to do in the practice technique) to the patient. After being assured of the person's learning, he was asked to do 2 relaxation sessions a day, according to the program set at home, so that one should be aware of the frequency of relaxation before bedtime. The entire test group performed relaxation exercises for 30 days at home according to the schedule. During this period, the researcher also regularly monitored the process of doing work by attending a dialysis session and telephone follow up of patients at home. Also, the researcher's telephone number was provided to patients to resolve the patient's ambiguity. Finally, only those who completed at least 70% of the program completed the final evaluation, and the rest were excluded from the study. In the control group, no intervention was performed and only before and after the intervention were evaluated using the data collection tool. After the end of the intervention period, all the samples were retested and the pre- and post-test scores were obtained. After intervention, the two groups were analyzedquestionnaire before and after the intervention. Data gathering tools included demographic information questionnaire and brief fatigue inventory. The latter is a checklist with 10 questions so that the first question asks if the respondents had felt fatigue over the last week. Other questions asks about level of fatigue felt by the respondent at the time, normal and highest level of fatigue over the past 24 h, and the effects of fatigue on their general activity, mood, ability to walk, communicate with others, and enjoying the life. The questions are designed based on an 11-point scale (0–10) so that “zero” is the best possible condition and 10 is the worst. Eventually, total fatigue level of the patient is calculated as the total score of the questions 2–10 (nine questions) divided by nine. The obtained score is interpreted as zero denoting no fatigue, 0.1–3.9 denoting trivial fatigue, 4–6.9 as average fatigue, 7–9.9 as severe fatigue, and 10 as very severe fatigue. Several studies in Iran and other countries have supported the reliability of the checklist (r > 90%). To analyze the collected data, descriptive statistics (concentration and distribution indices such as mean and standard deviation and frequency distribution table and diagrams) and inferential statistics (paired-sample t-test to compare mean score of quantitative trait) were used. It is noticeable that normal distribution of the data was ensured using Kolmogorov–Smirnov (KS) test and P < 0.05 was assumed as a significant level for all the tests.


   Results Top


The study was carried out with 65 participants (27 in experiment and 38 in control group). Women constituted 56.9% (n = 37) of the participants and 81.5% were married. Average age of the participants was 52.66 ± 2.007; and 47.7 were homemaker, and 27.7% were unemployed. As to literacy, the majority of the participants did not have high school diploma (73.8%). The reason for kidney failure in most of the cases (41.5%) was high blood pressure; in addition, 95.5% of the participants would undergo three dialysis operations per week and each operation would take (3 h and 56 min) and most of them were in kidney transplant list. The control and experiment groups had no significant difference as to demographical specifications although the two group were significantly different as to dialysis operation time based on Mann–Whitney test (P < 0.001).

To test the hypothesis “mean total fatigue of the two groups is identical before and after the intervention,” independent t-test was used. The results showed that mean scores of the control and experiment groups before the intervention was 4.89 and 4.56 respectively and given that P = 0.98, mean score of the two group before the intervention was not significantly different. In addition, with mean score of fatigue of the control and experiment groups after the intervention equal with 3.98 and 5.46, respectively, and P = 0.008, the two groups were significantly different as to mean score of fatigue after the intervention. Moreover, there was significant difference between the two groups as to total fatigue score before and after the intervention [Table 1].
Table 1: Mean and standard deviation of the scores of the two groups before and after the intervention

Click here to view


Normal distribution of the data before (P = 0.921) and after (P = 0.91) was supported for the control group based on KS test. Therefore, to test the hypothesis “mean scores of the control group before and after the intervention is significantly different,” paired-sample t-test was used. As the results showed, total fatigue scores of the control group before and after the intervention were 4.89 and 3.97 respectively and with P = 0.027, mean total fatigue scores of the control group before and after the intervention were significantly different [Table 1].

In addition, paired-sample t-test showed that total mean scores of fatigue in the experiment group before and after the intervention were 4.56 and 5.38 respectively and with P = 0.179, one may conclude that there was no significant difference between total mean score of the experiment group before and after the intervention [Table 1]. As to the dependent variable (fatigue), independent t-test showed that, after the intervention, there was no significant difference between experiment and control groups with regard to fatigue felt at the time, highest and average fatigue level over that past 24 h, the effects of fatigue on activities, ability to walk, communication with other, and total fatigue over the last 24 h (P ≥ 0.05). Independent t-test results showed that there was a significant difference between the control and experiment groups after the intervention with regard effect of fatigue on mood and ability to enjoy the life over the past 24 h (<0.05). This indicates that progressive muscle relaxation program was effective on curtailing fatigue in hemodialysis patients [Table 2].
Table 2: Mean and standard deviation of the scores with regard to the aspects of fatigue in the groups before and after the intervention

Click here to view



   Discussion Top


Fatigue is a disabling symptom and side-effect that is observed in many hemodialysis patients.[22] It has a variety of effect in physical, emotional, and cognitive functions of the patients.[23] Jablonski[24] reported fatigue level in patients under hemodialysis treatment equal with 77%. Our results showed that the majority of the patients were women and average age of the patients was 52.29. Authors have argued that situational factors including age have direct effect on fatigue experienced by the patients under hemodialysis so that the older the patient, the higher the experienced fatigue. In addition, complaint about fatigue is more common in patients older than 50.[25] Our results showed that 73.8% of the participants did not have high school diploma; it is notable that educated individuals are more successful in implementing fatigue soothing strategies.[26] Moreover, 75.4% of the respondents were not employed; this is consistent with the results of similar works that express employment rate in hemodialysis patients is very low. Without a job and forced to stay at home, hemodialysis patients lose their social supports and role, which intensifies the fatigue they feel.[27],[28] This brings extra costs to the patient, family of the patient, and the society.

As to physical and mental aspects of fatigue, the results showed no significant difference between the control and experiment groups. One reason for this finding could be the significance of fatigue of the patients in control and experiment group before the intervention. However, the patients in the experiment group after the intervention reported increase in fatigue in some aspects; which indicates no effectiveness of progressive muscle relaxation on fatigue of the patients. Wu et al. carried out a study to survey the effects of Yoga on fatigue in hemodialysis patients and found that practicing Yoga was effective in reducing fatigue in hemodialysis patients.[29] The results of another study showed that progressive muscle relaxation technique (once a day for 6 weeks) attenuated fatigue and improved quality of sleep of MS patients.[25]

Hadian-Jazi et al. examined the effect of jogging on fatigue felt by hemodialysis patients and showed that supplementary treatments such as doing exercise was effective on cutting fatigue of the subjects.[30] Hadadian et al. reported that acupuncture with electrical stimulation decreased fatigue in hemodialysis patients.[23] In addition, Basiri Moghadam et al. (2014) used progressive muscle relaxation technique as a supplementary treatment method. Their results, consistent with ours, showed effectiveness of the technique on reducing fatigue in hemodialysis patient.[31]

With regard to limitations of the study, carrying out progressive muscle relaxation technique at home by the patient is notable. That is, the author was not able to ensure that the practices were carried out as needed by participants. Thereby, the results should be generalized with cautious.

In short, given the ease and simplicity of progressive muscle relaxation technique as a supplementary treatment for hemodialysis patients and that the technique was found to be no effective on soothing fatigue experienced by the respondents, it is recommended other research to verify this results would be done. Moreover, the effects of the technique on other symptoms developed by chronic liver failure diseases and other chronic diseases can be examined by future studies.


   Conclusion Top


In this study, progressive muscle relaxation has no remarkable positive effect on the fatigue of hemodialysis patients, in other words, practicing the technique was not effective on reducing fatigue to a normal level. This might be due to failure to control other effective factors.

Acknowledgment

This study plan was financially supported by Research and Technology Department, Kermanshah Medical Science University. The authors express their gratitude toward all hemodialysis patients, the personnel of hemodialysis ward and the students who helped us to carry out the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Smeltzer SC, Bare B. Brunner and Suddarths Textbook of Medical Surgical Nursing. 11th ed. Philadelphia: Lippincott Co.: 2008. p. 1326-34.  Back to cited text no. 1
    
2.
Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G, et al. Clinical practice guidelines for chronic kidney disease in adults: Part I. Definition, disease stages, evaluation, treatment, and risk factors. Am Fam Physician 2004;70:869-76.  Back to cited text no. 2
    
3.
Hogan DB. Did Osler suffer from “paranoia antitherapeuticum baltimorensis”? A comparative content analysis of the principles and practice of medicine and Harrison's principles of internal medicine, 11th edition. CMAJ 1999;161:842-5.  Back to cited text no. 3
    
4.
McDougall GJ. Research review: The effect of acupressure with massage on fatigue and depression in patients with end-stage renal disease. Geriatr Nurs 2005;26:164-5.  Back to cited text no. 4
    
5.
Horigan AE. “Fatigue in hemodialysis patients: A review of current knowledge.” Journal of Pain and Symptom Management 2012;44: 715-24.  Back to cited text no. 5
    
6.
Williams AG, Crane PB, Kring D. Fatigue in African American women on hemodialysis. Nephrol Nurs J 2007;34:610-7, 644.  Back to cited text no. 6
    
7.
McCann K, Boore JR. Fatigue in persons with renal failure who require maintenance haemodialysis. J Adv Nurs 2000;32:1132-42.  Back to cited text no. 7
    
8.
Jhamb M, Weisbord SD, Steel JL, Unruh M. Fatigue in patients receiving maintenance dialysis: A review of definitions, measures, and contributing factors. Am J Kidney Dis 2008;52:353-65.  Back to cited text no. 8
    
9.
Lee BO, Lin CC, Chaboyer W, Chiang CL, Hung CC. The fatigue experience of haemodialysis patients in Taiwan. J Clin Nurs 2007;16:407-13.  Back to cited text no. 9
    
10.
Bonner A, Wellard S, Caltabiano M. Levels of fatigue in people with ESRD living in far North Queensland. J Clin Nurs 2008;17:90-8.  Back to cited text no. 10
    
11.
Logan SM, Pelletier-Hibbert M, Hodgins M. Stressors and coping of in-hospital haemodialysis patients aged 65 years and over. J Adv Nurs 2006;56:382-91.  Back to cited text no. 11
    
12.
Hui DS, Wong TY, Li TS, Ko FW, Choy DK, Szeto CC, et al. Prevalence of sleep disturbances in Chinese patients with end stage renal failure on maintenance hemodialysis. Med Sci Monit 2002;8:CR331-6.  Back to cited text no. 12
    
13.
Haddadian F, Fayyazi S, Ghorbani A, Fallah H, Latifi M. Cutaneous electrical stimulation of acupuncture points on fatigue in hemodialysis patients. J Kermanshah Univ Med Sci 2012;15:165-72.  Back to cited text no. 13
    
14.
Tayyebi A, Savari S, Nehrir B, Rahimi A, Eynollahi B. The effect of Vitamin B12 supplemention on fatigue in hemodialysis patients. IJCCN 2013;6:39-48.  Back to cited text no. 14
    
15.
Biniyaz V, Tayebi A, Sadeghi Shermeh M, Ebadi A, Neamati E. The effect of supplementation with intravenous Vitamin C on fatigue of hemodialysis patients. IJCCN 2013;6:145-54.  Back to cited text no. 15
    
16.
Conrad A, Roth WT. Muscle relaxation therapy for anxiety disorders: It works but how? J Anxiety Disord 2007;21:243-64.  Back to cited text no. 16
    
17.
Hernandez-Reif M, Field T, Field T, Theakston H. Multiple sclerosis patients benefits from massage therapy. J Bodywork Mov Ther 1998;2:168-74.  Back to cited text no. 17
    
18.
Hayes J, Cox C. Immediate effects of a five-minute foot massage on patients in critical care. Intensive Crit Care Nurs 1999;15:77-82.  Back to cited text no. 18
    
19.
Mohammadi F. Effect of Progressive Muscle Relaxation Technique on Anxiety in Myocardial Infarction Patients. Thesis of M.S in Nursing Tarbeat Modarres; 2004.  Back to cited text no. 19
    
20.
Eckes Peck SD. The effectiveness of therapeutic touch for decreasing pain in elders with degenerative arthritis. J Holist Nurs 1997;15:176-98.  Back to cited text no. 20
    
21.
Tsay SL, Cho YC, Chen ML. Acupressure and transcutaneous electrical acupoint stimulation in improving fatigue, sleep quality and depression in hemodialysis patients. Am J Chin Med 2004;32:407-16.  Back to cited text no. 21
    
22.
Sajadi A, Farmahini Farahani B, Esmaeilpoor Zanjani S, Durmanesh B, Zare M. Effective factors on fatigue in patients with chronic renal failure undergoing hemodialysis. Intensive Iran J Crit Care Nurs 2010;3:33-8.  Back to cited text no. 22
    
23.
Hadadian F, Ghorbani A, Falah H, Latifi SM. The effect of trancscutaneus electrical acupoint stimulation (TEAS) on fatigue reduction in hemodialysis patients. J Kermanshah Univ Med Sci 2011;15:165-72.  Back to cited text no. 23
    
24.
Jablonski A. The multidimensional characteristics of symptoms reported by patients on hemodialysis. Nephrol Nurs J 2007;34:29-37.  Back to cited text no. 24
    
25.
Dayapoǧlu N, Tan M. Evaluation of the effect of progressive relaxation exercises on fatigue and sleep quality in patients with multiple sclerosis. J Altern Complement Med 2012;18:983-7.  Back to cited text no. 25
    
26.
Beto J. Improving first-year mortality in patients on dialysis: A focus on nutrition and exercise. Nephrol Nurs J 2010;37:61-5, 98.  Back to cited text no. 26
    
27.
Jhamb M, Pike F, Ramer S, Argyropoulos C, Steel J, Dew MA, et al. Impact of fatigue on outcomes in the hemodialysis (HEMO) study. Am J Nephrol 2011;33:515-23.  Back to cited text no. 27
    
28.
Najafi S, Pashandi SH, Mahmoudi H, Ebadi A, Ghaneie M. The relationship of fatigue with spirometry parameters in veterans with respiratory disorders. Iran J War Public Health 2010;8:29-35.  Back to cited text no. 28
    
29.
Wu CY, Han HM, Huang MC, Chen YM, Yu WP, Weng LC, et al. Effect of qigong training on fatigue in haemodialysis patients: A non-randomized controlled trial. Complement Ther Med 2014;22:244-50.  Back to cited text no. 29
    
30.
Hadian-Jazi Z, Aliasgharpour M. Evaluating the effect of designed exercise program on mean of activity tolerance in hemodialysis patients. J Shahrekord Univ Med Sci 2012;14:83-91.  Back to cited text no. 30
    
31.
Basiri Moghadam M, Madadkar Dehkordi SH, Mohammadpour A, Vaezi AA. Effect of progressive muscle relaxation technique on fatigue in patients undergoing hemodialysis. Prev Care Nurs Midwifery J 2013-2014:3:24-32.  Back to cited text no. 31
    

Top
Correspondence Address:
Akram Ghobadi
Faculty Member of Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_450_17

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *


    Abstract
   Introduction
   Methods
   Results
   Discussion
   Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed203    
    Printed2    
    Emailed0    
    PDF Downloaded2    
    Comments [Add]    

Recommend this journal