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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

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Date of Web Publication10-Dec-2019


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 May 29];11:8-12. Available from:

   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

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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

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   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.


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


Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Akram Ghobadi
Faculty Member of Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_450_17

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