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 thatimproves the quality of life of patients (adults and children) and their families who arefacing problems associated with life‐threatening illness, through the prevention andrelief of suffering by means of early identification and impeccable assessment andtreatment of pain and other problems, physical, psychosocial, and spiritual". Emphasizingthe 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 alleviatingpain and other distressing symptoms. Palliative care is implemented for individuals withlife‐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, rheumatoidarthritis, and drug‐resistant . According to the European Association for Palliative Care(EAPC), approximately 4.4 million people (including 14,000 children) in the WHO EuropeanRegion require palliative care each year. Patients diagnosed with cancer constitute thevast majority of those in need of palliative care, accounting for 34.01%. Indeed, thefoundations of palliative care in our country began with interventions aimed at relievingpain and alleviating other symptoms of cancer patients by algology specialists andoncologists. Along with increased life expectancy and improving living conditions, anincrease in cancer diseases is observed. According to global cancer statistics, withapproximately 20 million new cancer cases and 9.7 million cancer deaths worldwide in2022, it has become a major health problem both globally and for our country. Cancerpatients require palliative care especially during the final stages of theirlives/terminal period.In palliative care, individuals experience numerous disease‐related symptoms such aspain, fatigue, pruritus, cough, constipation, nausea, vomiting, dysphagia, dehydration,anorexia, delirium, and dyspnea. Advanced‐stage cancer patients constitute a largeproportion of patients receiving palliative care, and dyspnea is observed inapproximately 10‐70% of cancer patients. It is known that the prevalence of dyspnea risesup to 90% in patients with lung cancer. Dyspnea and shortness of breath are defined byESMO as "a qualitatively distinct and subjective experience of breathing discomfort thatvaries in intensity". The experienced dyspnea causes anxiety, fear, fatigue, and adecrease in the quality of life in individuals. Fatigue is another frequently observedsymptom in palliative care conditions. Fatigue is defined by patients using variousconcepts such as "weakness, exhaustion, tiredness, insomnia, and lack of strength."Cancer‐related fatigue is a distressing symptom commonly seen in cancer patients thatadversely affects activities of daily living and health‐related quality of life. Fatigueoccurs 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, theydetermined 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 anotherstudy 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 toperform daily activities, functional capacity, and performance status. Self‐care, asdefined by Orem, is the form of care that an individual performs independently bydisplaying controlled, purposeful, and effective behaviors along with maintaining theirhealth and well‐being. Dyspnea and fatigue can affect self‐care behaviors such asbathing, dressing, toileting, mobility, elimination, and nutrition by causing functionallimitations in patients . The purpose of palliative care is to eliminate or alleviatethese symptoms that may be observed in patients as early as possible. Thus, by performinga more effective symptom management, physical and psychological relief of patients willbe achieved, thereby enhancing their self‐care behaviors and quality of life .Many pharmacological and non‐pharmacological treatment methods are applied for thesymptoms observed in palliative care patients. One of the non‐pharmacological methodsapplied is breathing exercises. Breathing exercises for dyspnea management includepursed‐lip breathing and diaphragmatic breathing. Pursed‐lip breathing involves patientsinhaling deeply through the nose and exhaling this breath over 4‐6 seconds by pursingtheir lips. Pursed‐lip breathing leads to an increase in tidal volume and arterial oxygenlevels, 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. Duringexhalation, the diaphragm is pushed upward by the abdominal muscles, and the utilizationof diaphragm muscles is increased, thereby enhancing the ventilation level of the lungs.Studies have shown that performing pursed‐lip and diaphragmatic breathing either alone orin combination are effective methods in relieving dyspnea‐related distress in patients.Another non‐pharmacological application for symptoms is relaxation exercises. ProgressiveMuscle Relaxation (PMR) covers the conscious contraction and relaxation of major musclegroups throughout the entire body. Each muscle or muscle group is tensed for 5‐7 secondsand then relaxed for 20‐30 seconds. One of the most important steps in the application ofPMR is the correct breathing exercise. Relaxation exercises are applied simultaneouslywith deep breathing exercises, requiring the patient to breathe correctly, deeply, andeffectively during the tensing‐relaxing phase of the muscle groups. With the patientbreathing effectively, correctly, and deeply throughout the exercise, the oxygen neededby using the whole of the lungs is taken into the body, and the relaxation of the patientis achieved through the relaxation of the muscles. Studies have revealed that relaxationtechniques reduce heart rate, respiratory rate, and dyspnea, thereby being effective onfatigue by increasing functional performance. In studies conducted on cancer patients, ithas also been determined that progressive muscle relaxation exercises are effective onweakness, loss of energy, fatigue, and dyspnea. Patients and their relatives in thepalliative care process face many physical, psychosocial, and spiritual problems anddifficulties. During this period, multiple symptoms observed in cancer patientsnegatively affect patients' physical and social functions, treatment course, and survivaltimes. Therefore, preventing the occurrence of symptoms or controlling existing symptomsin 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 symptomsobserved in cancer patients receiving palliative care were found. The aim of our study isto examine the effects of progressive muscle relaxation and deep breathing exercises tobe applied to cancer patients receiving palliative care on dyspnea, fatigue, andself‐care behaviors.This randomized controlled study aims to evaluate the effects of Progressive MuscleRelaxation (PMR) and Deep Breathing Exercises on dyspnea, fatigue, and self‐carebehaviors among cancer patients receiving palliative care. Patients meeting the inclusioncriteria will be informed about the study's purpose, content, and method. Standardpalliative 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 followingthree groups for a duration of 6 weeks:Intervention Group 1 (PMR Group): In the initial interview, patients will receive visualtraining regarding Progressive Muscle Relaxation (PMR) exercises. They will be providedwith 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 detailedtraining on deep breathing exercises. They will be requested to perform these breathingexercises twice a day for 6 weeks.Control Group: Patients assigned to this group will receive standard routine clinicalcare and follow‐up without any additional experimental relaxation or breathingintervention.For hospitalized patients in both intervention groups, the exercises will be directlyadministered and supervised by the researcher. Following patient discharge, thecontinuity and monitoring of the exercise protocols will be managed via phone‐callfollow‐ups.Data Collection and Timeline:Data collection and instrument administration will be performed uniformly for all threegroups at three specific timelines: Baseline (Pre‐intervention), Week 3, and Week 6. Thefollowing measurement tools and scales will be utilized:Patient Demographics and Characteristics FormCommon Terminology Criteria for Adverse Events (CTCAE) Dyspnea ClassificationECOG Performance Status ScaleCancer Dyspnea Scale (CDS)Hirai Cancer Fatigue ScaleKATZ Index of Independence in Activities of Daily Living (ADL)Glasgow Coma Scale (GCS)