Evaluation of the effect of Benson's relaxation technique on pain and quality of life of haemodialysis patients: A randomized controlled trial
Introduction
End stage renal disease (ESRD) is an irreversible and progressive renal dysfunction (Baraz et al., 2010). The prevalence of ESRD has significantly increased around the world as well as in Iran (Roudbari et al., 2010).
One of the most common problems in ESRD and haemodialysis (HD) patients is chronic pain (Masajtis-Zagajewska et al., 2011) and more than 50% of all ESRD patients suffer from pain (Innis, 2006). In fact, most HD patients suffer from moderate to severe pain and 54% of HD patients show more than one location of pain (Masajtis-Zagajewska et al., 2011).
ESRD patients may suffer from pain in a number of ways that are unique not only to the disease but also to the treatment. Bone pain from renal osteodystrophy, peripheral neuropathy, dialysis-related arthropathy, dialysis disequilibrium syndrome, dialysis headache, and muscle cramping during or after haemodialysis are the common causes of pain in HD patients (Shayamsunder et al., 2005).
The experience of pain is associated with many immediate and long-term negative outcomes (Alhani, 2010). Besides, a significant correlation was found between mortality and both frequency and intensity of pain in the HD patients while they were not on dialysis (Harris et al., 2012). Furthermore, disabling symptoms (Nayak-Rao, 2011), depression, insomnia, severe irritability, anxiousness, and inability to cope with stress were more common among the HD patients with pain compared to those without pain (Davison and Jhangri, 2005). Moreover, the patients with chronic pain may experience high levels of disability, distress, and societal burden (Breivik et al., 2006). Overall, chronic pain affects the quality of life (QOL) of the HD patients (Gomez Alonso, 2010).
Although treatments, such as HD, are able to prolong life expectancy (Chow and Wong, 2010), the patients with ESRD potentially experience an alternation in the level of physical activity, loss of job, and disturbance in the social function (Unruh and Hess, 2007). These will have a negative impact on their life plans, employment status, financial situation, self-esteem, and level of independence (Niu and Li, 2005), affecting the patients’ physical, psychological, and social well-being (Rambod and Rafii, 2010). Besides, HD patients indicated lower physical functioning QOL compared to the general population (Cleary and Drennan, 2005). They also experienced a lower level of total QOL and health/functioning and familial subscales of QOL compared to the transplanted patients (Rambod et al., 2011).
Recently, there has been an increasing interest in the use of complementary interventions, such as relaxation therapy, for the individuals with chronic illnesses (Tsai, 2004) and pain management in the patients with ESRD (Innis, 2006). Relaxation techniques improve self-efficacy (Diezemann, 2011) and relieve psychological distress in the patients with chronic illnesses (Yu et al., 2007).
Not surprisingly, non-pharmacologic treatments, such as relaxation therapy, have resulted in improvement of pain (Kwekkeboom et al., 2010). Relaxation techniques lead to muscular stabilization and serve as distraction from pain (Diezemann, 2011). It has been indicated that 6-week combined progressive relaxation technique and guided imagery intervention improved pain in the subjects with chronic and non-malignant pain (Chen and Francis, 2010). Yoga-based exercise program as a relaxation training also decreased the intensity of pain in HD patients (Yurtkuran et al., 2007). Although some studies have indicated that relaxation therapy is a potentially non-pharmacological intervention on pain relief and a variety of medical conditions (Mohammadi Fakhar et al., 2013, Topcu and Findik, 2012), most of these studies have focused on other relaxation techniques, such as applied relaxation (Gustavsson and von Koch, 2006), relaxation and imagery (Chen and Francis, 2010), and a combination of relaxation techniques and back massage (Buyukyılmaz and Astı, 2013). In addition, these studies have examined other diseases, such as non-malignant pain (Chen and Francis, 2010), long-lasting neck pain (Gustavsson and von Koch, 2006), and total hip or knee arthroplasty (Buyukyılmaz and Astı, 2013).
In addition to the effect of relaxation therapy on pain, this technique has been shown to improve QOL in a variety of conditions, including asthma (Nickel et al., 2006) and osteoarthritis in elderly women (Baird and Sands, 2006). It has also been recommended as an adjunctive therapy for anxiety by providing the patients with self-maintenance coping skills to decrease the anxiety symptoms (Pan et al., 2012). Cheung et al. (2003) have indicated that the use of muscle relaxation significantly improved generic QOL in the intervention group, especially in the domains of physical health, psychological health, social concerns, and environment. Moreover, it has been indicated that older women with osteoarthritis who received guided imagery with relaxation experienced a better health related QOL (HRQOL) compared to the control group (Baird and Sands, 2006). Furthermore, the patients with multiple sclerosis using relaxation training reported more energy and vigor (Sutherland et al., 2005) as well as better QOL (Ghafari et al., 2009) in comparison to the control group. Also, they were less limited in their roles due to physical and emotional problems (Sutherland et al., 2005).
One of the plausible and attractive relaxation techniques which is easy to learn is Benson's relaxation technique. Since most of the HD patients need vascular access, such as arteriovenous fistula and arteriovenous graft for HD procedure, performing some exercises and relaxation techniques might be difficult for them. However, Benson's relaxation technique can be better tolerated by these patients. Nonetheless, a limited number of studies have specifically evaluated Benson's relaxation technique in HD patients (Elali et al., 2012). Benson (1975) presented the relaxation technique and denoted that it could bring about relaxation response by reducing the autonomic nervous system's activity (Benson, 1975). This technique has been reported to decrease anxiety level (Galvin et al., 2006), cognitive and somatic anxiety (Kolt et al., 2002), mood disturbance (Rabin et al., 2009), and body discomfort (Leon-Pizarro et al., 2007). It also improves attention, declarative memory performance (Galvin et al., 2006), and self-confidence (Kolt et al., 2002). It was indicated that Benson's relaxation technique improved the patients’ well-being in a chronic condition, such as rheumatoid arthritis (Bagheri-Nesami et al., 2006). This implies that this technique might affect the individuals’ life and QOL. However, no studies have been conducted on the effect of Benson’s relaxation technique on the intensity of pain and QOL of the ESRD patients on HD. Thus, the present study aims to examine the effectiveness of Benson's relaxation technique in relieving the intensity of pain and improving the QOL in HD patients. The following hypotheses were posed in this study: (1) after eight weeks, the HD patients receiving Benson's relaxation technique show greater relief of pain compared to those receiving routine care. (2) The QOL and subscales of QOL in the HD patients receiving Benson's relaxation technique in addition to the routine care will be better compared to those receiving the routine care alone after 8 weeks.
Section snippets
Design
The present study was a randomized, controlled trial examining the effects of Benson's relaxation technique on the intensity of pain and QOL in HD patients.
Study settings
The study was performed at two HD units in Namazi and Shahid Faghihi hospitals affiliated to Shiraz University of Medical Sciences, Shiraz (one of the big cities of Iran).
Samples
The target population consisted of 260 HD patients listed in the two above-mentioned HD units. The patients referring to these HD units of Shiraz University of Medical
Socio-demographic characteristics
Overall, 81 HD patients completed the study. The mean age of the subjects was 49.89 years (SD = 12.47) ranging from 20 to 82 years old. In addition, most of the HD patients were male (61.6%) and married (79.14%). Besides, an elementary level of education was reported by 47.7% of the participants. The mean length of dialysis was 42.10 months (SD = 38.48). The socio-demographic and clinical characteristics of the subjects in each group are presented in Table 1. The results revealed no significant
Discussion
The results of the study showed that Benson's relaxation technique relieved the intensity of pain in the HD patients over time. Moreover, the relaxation group showed greater improvement in the total QOL and health-functioning, socioeconomic, and family subscales of QOL compared to the control group.
In our study, HD patients receiving Benson's relaxation technique reported greater relief of pain compared to the control group. In another study conducted on long-lasting neck pain patients also,
Conclusion
The results of this study showed that Benson's relaxation technique significantly relieved the intensity of pain and improved the QOL and health-functioning, socioeconomic, and family subscales of QOL in the HD patients. The study provided an evidence-based intervention for healthcare providers attempting to relieve the pain and promote the QOL in the HD patients.
Conflicts of interest
There were no conflicts of interest.
Ethical approval
The study was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (88-4666).
Funding
This study was a research project financially supported by Shiraz University of Medical Sciences, Shiraz, Iran (88-4666).
Acknowledgments
The clinical trial was registered in IRCT and allocated a unique code as IRCT2013061613690N1. Special thanks go to Shiraz University of Medical Sciences as well as the healthcare providers from haemodialysis units for their assistance. The authors also wish to acknowledge all the 86 study participants for contributing their time and effort to this study. The authors also would like to thank Research Improvement Center of Shiraz University of Medical Sciences and Ms. A. Keivanshekouh for
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