The Effect of Progressive Muscle Relaxation and Deep Breathing Exercises Applied to Palliative Care Cancer Patients on Dyspnea, Fatigue, and Self-Care Behaviors

Palliative care is defined by the World Health Organization (WHO) as "an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual". Emphasizing the needs of patients and their families rather than the treatment of the disease itself, the primary goals of palliative care include reducing the disease burden and alleviating pain and other distressing symptoms. Palliative care is implemented for individuals with life-threatening chronic conditions such as cancer, cardiovascular diseases, HIV/AIDS, Alzheimer's and other dementias, liver cirrhosis, chronic obstructive pulmonary diseases (COPD), diabetes, kidney failure, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, and drug-resistant . According to the European Association for Palliative Care (EAPC), approximately 4.4 million people (including 14,000 children) in the WHO European Region require palliative care each year. Patients diagnosed with cancer constitute the vast majority of those in need of palliative care, accounting for 34.01%. Indeed, the foundations of palliative care in our country began with interventions aimed at relieving pain and alleviating other symptoms of cancer patients by algology specialists and oncologists. Along with increased life expectancy and improving living conditions, an increase in cancer diseases is observed. According to global cancer statistics, with approximately 20 million new cancer cases and 9.7 million cancer deaths worldwide in 2022, it has become a major health problem both globally and for our country. Cancer patients require palliative care especially during the final stages of their lives/terminal period.

In palliative care, individuals experience numerous disease-related symptoms such as pain, fatigue, pruritus, cough, constipation, nausea, vomiting, dysphagia, dehydration, anorexia, delirium, and dyspnea. Advanced-stage cancer patients constitute a large proportion of patients receiving palliative care, and dyspnea is observed in approximately 10-70% of cancer patients. It is known that the prevalence of dyspnea rises up to 90% in patients with lung cancer. Dyspnea and shortness of breath are defined by ESMO as "a qualitatively distinct and subjective experience of breathing discomfort that varies in intensity". The experienced dyspnea causes anxiety, fear, fatigue, and a decrease in the quality of life in individuals. Fatigue is another frequently observed symptom in palliative care conditions. Fatigue is defined by patients using various concepts such as "weakness, exhaustion, tiredness, insomnia, and lack of strength." Cancer-related fatigue is a distressing symptom commonly seen in cancer patients that adversely affects activities of daily living and health-related quality of life. Fatigue occurs at a rate of 60-90% in cancer patients receiving palliative care.

In a study conducted by Uysal et al. (2015) on patients receiving palliative care, they determined that the most common symptoms observed were anxiety (92%), pain (90%), nausea (66%), constipation (61%), and shortness of breath (59%) (Uysal et al., 2015). In another study evaluating 142 cancer patients with palliative care needs, the presence of fatigue (87.3%), dyspnea (76.1%), and sleep problems (67.6%) were found to be the most prevalent, respectively.

Dyspnea burden and fatigue negatively affect the patient's self-care, their capacity to perform daily activities, functional capacity, and performance status. Self-care, as defined by Orem, is the form of care that an individual performs independently by displaying controlled, purposeful, and effective behaviors along with maintaining their health and well-being. Dyspnea and fatigue can affect self-care behaviors such as bathing, dressing, toileting, mobility, elimination, and nutrition by causing functional limitations in patients . The purpose of palliative care is to eliminate or alleviate these symptoms that may be observed in patients as early as possible. Thus, by performing a more effective symptom management, physical and psychological relief of patients will be achieved, thereby enhancing their self-care behaviors and quality of life .

Many pharmacological and non-pharmacological treatment methods are applied for the symptoms observed in palliative care patients. One of the non-pharmacological methods applied is breathing exercises. Breathing exercises for dyspnea management include pursed-lip breathing and diaphragmatic breathing. Pursed-lip breathing involves patients inhaling deeply through the nose and exhaling this breath over 4-6 seconds by pursing their lips. Pursed-lip breathing leads to an increase in tidal volume and arterial oxygen levels, a decrease in respiratory rate, and a decrease in arterial carbon dioxide levels. Diaphragmatic breathing involves the patient expanding their abdomen while inhaling, flattening the diaphragm muscle, and then exhaling by pursing their lips. During exhalation, the diaphragm is pushed upward by the abdominal muscles, and the utilization of diaphragm muscles is increased, thereby enhancing the ventilation level of the lungs. Studies have shown that performing pursed-lip and diaphragmatic breathing either alone or in combination are effective methods in relieving dyspnea-related distress in patients. Another non-pharmacological application for symptoms is relaxation exercises. Progressive Muscle Relaxation (PMR) covers the conscious contraction and relaxation of major muscle groups throughout the entire body. Each muscle or muscle group is tensed for 5-7 seconds and then relaxed for 20-30 seconds. One of the most important steps in the application of PMR is the correct breathing exercise. Relaxation exercises are applied simultaneously with deep breathing exercises, requiring the patient to breathe correctly, deeply, and effectively during the tensing-relaxing phase of the muscle groups. With the patient breathing effectively, correctly, and deeply throughout the exercise, the oxygen needed by using the whole of the lungs is taken into the body, and the relaxation of the patient is achieved through the relaxation of the muscles. Studies have revealed that relaxation techniques reduce heart rate, respiratory rate, and dyspnea, thereby being effective on fatigue by increasing functional performance. In studies conducted on cancer patients, it has also been determined that progressive muscle relaxation exercises are effective on weakness, loss of energy, fatigue, and dyspnea. Patients and their relatives in the palliative care process face many physical, psychosocial, and spiritual problems and difficulties. During this period, multiple symptoms observed in cancer patients negatively affect patients' physical and social functions, treatment course, and survival times. Therefore, preventing the occurrence of symptoms or controlling existing symptoms in palliative care patients is of great importance for patients and their relatives.

As a result of the literature review, no studies targeting dyspnea and fatigue symptoms observed in cancer patients receiving palliative care were found. The aim of our study is to examine the effects of progressive muscle relaxation and deep breathing exercises to be applied to cancer patients receiving palliative care on dyspnea, fatigue, and self-care behaviors.

This randomized controlled study aims to evaluate the effects of Progressive Muscle Relaxation (PMR) and Deep Breathing Exercises on dyspnea, fatigue, and self-care behaviors among cancer patients receiving palliative care. Patients meeting the inclusion criteria will be informed about the study's purpose, content, and method. Standard palliative care will be continued for all patients across all groups.

Study Arms and Interventions:

Following the randomization process, patients will be assigned to one of the following three groups for a duration of 6 weeks:

Intervention Group 1 (PMR Group): In the initial interview, patients will receive visual training regarding Progressive Muscle Relaxation (PMR) exercises. They will be provided with and instructed on how to use an MP3 player to practice these exercises at home. These patients will be asked to perform PMR exercises once a day for 6 weeks.

Intervention Group 2 (Deep Breathing Group): Patients in this group will receive detailed training on deep breathing exercises. They will be requested to perform these breathing exercises twice a day for 6 weeks.

Control Group: Patients assigned to this group will receive standard routine clinical care and follow-up without any additional experimental relaxation or breathing intervention.

For hospitalized patients in both intervention groups, the exercises will be directly administered and supervised by the researcher. Following patient discharge, the continuity and monitoring of the exercise protocols will be managed via phone-call follow-ups.

Data Collection and Timeline:

Data collection and instrument administration will be performed uniformly for all three groups at three specific timelines: Baseline (Pre-intervention), Week 3, and Week 6. The following measurement tools and scales will be utilized:

Patient Demographics and Characteristics Form

Common Terminology Criteria for Adverse Events (CTCAE) Dyspnea Classification

ECOG Performance Status Scale

Cancer Dyspnea Scale (CDS)

Hirai Cancer Fatigue Scale

KATZ Index of Independence in Activities of Daily Living (ADL)

Glasgow Coma Scale (GCS)