Relaxation In Cancer Essay, Research Paper

RELAXATION IN CANCER

Introduction

Cancer is encroaching upon heart disease’s status as the number one killer of Americans. Nearly one million people are diagnosed each year with some type of cancer (Heimlich, 1990) and will undergo chemotherapy, radiotherapy, or a combination as an adjunct to surgery. Many of these patients report experiencing debilitating side effects to these treatments. Not only can the physical effects from the illness and the treatment be quite intense, the emotional and psychological impact of fighting cancer can be equally as stressful. Penfold (1996) states that many patients, families, and/or caregivers may experience a degree of difficulty in accepting the diagnosis of cancer.

As a result, unrealistic expectations about the patient’s functional abilities develop. This situation creates the need for an occupational therapist to address problems relating to their social roles, level of activity, and coping skills.

Approximately one million people report pain, both post operative and secondary to their medical condition (McCormack, 1988). Along with nausea and vomiting, pain and fatigue impact patients’ quality of life and ability to cope with their illness. Alleviation of the severity of the pain and fatigue, therefore, is of primary importance in increasing these patients’ quality of life. It has been suggested that the use of relaxation and imagery techniques are important in reducing pain and fatigue as well as other chemotherapy and radiotherapy-induced side effects in cancer patients (Arakawa, 1997).

Before discussing the relevant literature, we will describe pertinent operational terms. Kulich and Warfield (1985) define relaxation as “a skill building process wherein the patient learns a series of deep breathing, progressive muscle control, and cognitive and imagery techniques” (p. 117). Imagery is described as “purposeful mental thoughts imagined to achieve a desired therapeutic” (Wallace, 1987, p. 81). References to side effects include pain, fatigue, depression, and reactive nausea and vomiting. In addition to reactive nausea and vomiting, some patients may experience anticipatory nausea and vomiting. This differs in that it occurs prior to medical treatment and is triggered by fear and anxiety. Palliative care, which attempts to ameliorate these side effects, is considered a “comprehensive, coordinated, and concentrated relief of both pain and suffering in terminally ill or incurably ill patients” (Pellegrino, 1998, p. 1521). Finally, Downer, et al. (1994, p. 86) define complementary or alternative medicine as “a system of health care which lies for the most part outside the mainstream of conventional medicine.”

In cancer treatment it is not enough to focus solely on the disease itself. The occupational therapist must consider the physical and psychological well being of the patient in the management of the illness. This holistic view is consistent with the basic philosophy of occupational therapy. According to Penfold, the primary drive and focus of the occupational therapist is “to facilitate and enable an individual patient to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy” (1996, p. 75). Patients often experience difficulty in accepting their diagnosis and may develop a helpless attitude, and subsequently, become increasingly dependent on others. The functional areas most often affected are activities of daily living, work, and play (Penfold, 1996) which are the areas central to occupational therapy. According to Romsaas and Rosa (1985), occupational therapists can intervene by addressing issues such as independent living, sensorimotor components, and the availability of assistive devices.

Regardless of a patient’s life expectancy, the occupational therapist’s primary focus is to aid the patient in achieving optimal functional performance in daily living skills with consideration given to his or her physical and psychological health. Self-respect and the dignity of the patient are maintained when the patient helps choose the skills on which to focus. Since individual needs and desires vary among patients, occupational therapists need to be sensitive and supportive in discovering what treatment will benefit each patient the most. Our first working hypothesis seeks to show that occupational therapy intervention is underutilized in cancer treatment. In addition, we hypothesize that through the use of relaxation and/or guided imagery, occupational therapists can assist patients in maximizing independence in mobility, self-care, and leisure activities, thus improving their quality of life.

In exploring the role of occupational therapy in oncology, we have chosen the Model of Human Occupation (MOHO) as our frame of reference. According to Kielhofner and Barrett, the MOHO is composed of two central points. In the first point, the model proposes that human behavior is constantly changing, depending on the environment. It is the conditions in the persons’ environment that can influence such things as how that person performs, what they do, and their level of motivation. The second point of the MOHO states that the organization of human behavior is largely due to occupation. Building on these two key points, the ideas of MOHO emphasize the importance of the persons’ environment and occupations in shaping abilities, self-concepts, and identities (1998).

Literature Review

As the number of cancer survivors continues to increase, occupational therapy intervention may become a more common aspect of treatment in an effort to help patients improve their quality of life and functional abilities. Problems frequently associated with cancer include fatigue, a decrease or loss of the ability to perform self-care activities and activities of daily living, pain, and decreased mobility (Romsaas and Rosa, 1985). Integral to our study is the assumption that the psychological distress and physical discomfort of the side effects have a negative impact upon a person’s quality of life. In addition, the assumption is made that the chronic pain often associated with cancer can interfere with the therapy process if the patient becomes uncooperative in order to avoid exacerbating pain.

It is further assumed that occupational therapists can help improve quality of life by using noninvasive modalities to trigger natural physiological mechanisms that can reduce the patient’s pain perception (McCormack, 1988). Kulich and Warfield (1985) and Sims (1987) state the theoretical bases of relaxation and imagery are that deep muscle relaxation and anxiety produce diametrically opposed physiological states and cannot coexist. Some techniques for achieving relaxation include progressive tension and release of muscle groups, deep breathing, guided imagery, and auditory distraction (Bayuk, 1985).

While chemotherapy and radiotherapy are important treatment modalities, they often cause serious side effects such as nausea and vomiting. Chronic nausea and vomiting can lead to nutritional deficits, dehydration, and disruption of functional status. As a result, the patient may experience a decrease in quality of life. Currently, the nausea and vomiting are controlled with the use of pharmacological antiemetics that may produce negative side effects of their own. When a form of alternative medicine such as relaxation and imagery are implemented, the need for antiemetics may be reduced resulting in fewer side effects and decreased medical cost (Arakawa, 1997).

Psychological factors such as anxiety must also be considered when searching for more effective management of side effects. Arakawa points out that anxiety plays an influential role in the occurrence of anticipatory and post-treatment nausea and vomiting. Taking into account the close relationship between these physiological and psychological factors, relaxation techniques could be considered as one of the more desirable interventions for the control of nausea, vomiting, and anxiety induced by chemotherapy (Arakawa, 1997).

According to Wallace (1997), experts in pain management have highly recommended the use of relaxation and guided imagery to reduce the occurrence of side effects, which in turn helps to improve a patient’s attitude toward his or her future cancer treatments. This argument was substantiated by Arakawa (1997) who found that the use of relaxation techniques were more effective than routine nursing care in reducing nausea and vomiting. Although relaxation and imagery “do not work magic”, they do serve as an effective adjunct to medication and other comfort measures (Bayuk, 1985, p. 149).

Despite this supporting evidence, relaxation therapy and guided imagery are seldom employed in helping improve the patient’s status.

The most frequently experienced symptom of cancer treatment is fatigue. Contributors to fatigue can include such psychosocial factors as depression, anxiety, stress, and sleep disturbances, as well as environmental factors such as temperature and noise (Yarbro, 1996). According to Hickok, Morrow, McDonald, and Bellg (1996, p. 370):

Fatigue induced by treatment for cancer adversely affects patients’ quality of

life. Not only is it discouraging and debilitating, but it also affects leisure

activities, family relationships, work needs, social activities, and self-care

needs, as well as the ability of patients to participate in the treatment

regimen.

Fatigue may also adversely affect patients’ “fighting spirit” or will to live.

If activity and rest are not appropriately balanced while battling cancer, fatigue “may significantly impair the patient’s quality of life during all phases of the cancer experience” (Yarbro, 1996, p. 35). To prevent this from occurring, the patient should establish realistic goals for fatigue management. It may benefit the patient to alter their daily schedule and prioritize activities so that they may be performed when energy levels are highest. In addition, education about the treatment of side effects, exercise programs, coping skills, and self care restoration have been suggested to reduce or ameliorate fatigue (Hickok, et al., 1996). Occupational therapy intervention can assist the patient with energy conservation and work simplification techniques. Living with cancer is not an easy task, but organization of priorities can make life less fatiguing and perhaps even more productive.

Another disturbing symptom that cancer patients experience is chronic pain (Bernabei, 1998). Those patients for whom pain is a manifestation of their disease find the severity is influenced by several factors such as the individual’s mood, emotions, and perceptions (Morgan, Lindley, and Berry, 1994). Pain also induces psychological effects such as “loss of hope, fear of worsening or progressing disease, rejection of treatment programs, loss of enjoyment of family or societal roles, disruption of productive work, and in some patients, thoughts of suicide” (Zimmerman, Story, Gaston-Johansson, and Rowles, 1996, p. 44). Regardless of the severity, the pain consumes a significant portion of the patient’s energy which could be used for other more constructive purposes such as activities of daily living, work, and play (McCormack, 1988).

Occupational therapists can contribute to pain management by employing relaxation and imagery therapies that have been found to be highly effective. Relaxation techniques “appear to alter pain transmission in the body by decreasing oxygen consumption, lowering respiratory and heart rates, lowering blood pressure, and increasing electroencephalographic slow brain waves” (National Institute of Health, 1996). This is further substantiated by previous studies which have shown that “both relaxation and imagery and cognitive-behavioral training reduce pain” (Syrjala, Donaldson, Davis, Kippes, and Carr, 1995, p. 196). Michael and Tannock’s analysis of the effects of pain indicated that quality of a patient’s life and the length of survival depended, in part, on the intensity of pain (1998). As a part of treatment, an occupational therapist may be called upon to help restore the patients’ self-esteem and confidence. According to Penfold (1996), “recreating a sense of worth may ease the pain threshold” (p.79). When pain is managed, the psychological state of a patient improves and his or her self-confidence increases, thus allowing the individual the courage to face cancer head on (McCormack, 1988).

Quality of life has historically been relegated to the back burner in regard to aggressive cancer therapy. However, several studies have demonstrated a strong correlation between patient assessed quality of life and survival. Michael and Tannock said, “there is evidence that quality of life has a role in determining prognosis; in fact, quality of life is often a better indicator of prognosis than factors relating to the disease or its treatment” (1998, p. 1728). Clinically, some patients may experience “more difficulty coping with chemotherapy than the disease itself” (Mastenbroek and McGovern, 1991, p. 138). With survivorship increasing due to medical advances, the question of how a patient perceives the quality of his or her days becomes an important aspect of cancer patient care.

Quality of life is a subjective concept best defined by patients in relation to their own lives, but generally encompasses elements of social and familial interactions as well as leisure and daily activities (Montazeri, Milroy, Gillis, & McEwen, 1990). The patient’s perception of quality of life may be adversely impacted by the distress caused by a cancer diagnosis, the physical effects of the disease, and the medical treatments. These aspects of treatment can be “highly distressing and limiting of quality of life” (Andrydowski, Curran, & Lightner, 1998, p. 3). Occupational therapy intervention must take the patient’s individual needs and goals into consideration in order to assist in uncovering his or her own personal coping skills (Gage, 1992). In addition, Pizzi (1984) stated that therapeutic intervention should be governed by the occupational needs of the individual. Through the use of relaxation and imagery therapy, patients may be able to lower anxiety and stress to tolerable levels and allow them to focus on regaining quality of life.

Researchers have found “strong evidence for the use of relaxation techniques in alleviating pain associated with cancer” (NIH, 1996) and (Syrjala, et al., 1995). Some form of alternative or complementary therapy, such as relaxation or guided imagery, may be used in conjunction with traditional cancer treatments such as chemotherapy or radiation. Some patients receiving relaxation training were considered to be coping better with a significantly lower level of nausea and vomiting (Bindemann, Soukop, and Kaye, 1991). Other studies have reported that “both relaxation and imagery reduce pain” and patient’s practicing these techniques report “significantly less pain” than those who are not ( Syrjala, et al., 1995, p. 196).

Historically, relaxation and guided imagery have been shown to give the patient more hope (Downer, et al., 1994) and to shift the patient from being “passive participants in their treatment to becoming responsible, active partners in their rehabilitation” (NIH, 1996). The scope of occupational therapy in oncology centers around the therapists’ training in physical and mental health fields. With this base of training, they are better trained to address physical limitations as well as emotional needs. Considering that the occupational therapy knowledge base is founded on the study and management of purposeful occupations in persons’ life, this background better enables them to provide alternative therapies.

Methods

According to Crepeau and Deitz (1998), the goal of qualitative research is ” to explore the meaning and interpretation of experience” (p.842). With this definition as a basis, we believe that a qualitative approach would be most effective in evaluating our hypothesis because this type of research focuses on words, thoughts, and insights, rather than numbers. In addition, we believe that there is not one singly defined reason for the use of alternative therapies by occupational therapists as a part of cancer treatment. Therefore, we plan to use a qualitative approach in an effort to uncover the diverse perspectives and preferences of occupational therapists practicing in oncology.

Upon reviewing the available literature on occupational therapy practice in oncology, we discovered that there are a limited number of studies and resources pertaining to this topic. Further, with the number of cancer cases on the rise, we believe that some members of this population will seek occupational therapy intervention to improve their quality of life. Due to the variation of each individual’s response to treatment, we believe that we cannot state one exact method of treatment that is most effective. Therefore, we have chosen to conduct our research using a survey, consisting of closed and open ended questions, to collect the ideas and opinions of occupational therapists in regard to the use and the effectiveness of relaxation and guided imagery therapies.

Research Objectives

The primary objective of our research is to determine the range of treatment strategies used by used by occupational therapists in the treatment of cancer patients. In particular, we hope to determine why occupational therapists feel they are better qualified to guide and assist cancer patients in relaxation and imagery therapies.

The Sample

In conducting our research, we plan to use a random sample of occupational therapists practicing in Tennessee. A sample of n=75 will be drawn from members of the Tennessee Occupational Therapy Association. Randomization provides a greater likelihood that our sample will be representative of the population of occupational therapists in Tennessee.

In surveying our sample, we will include close and open-ended questions that will garner information from all occupational therapists regarding their attitudes and involvement in the treatment of cancer patients. The members of the sample will receive a questionnaire via mail including a return envelope to encourage response. Approximately two weeks after the initial survey is sent, a follow-up letter and duplicate questionnaire will be mailed to all members of the random sample.

The Measures

In developing our questionnaire, we will have experienced occupational therapists critique the content. Questionnaires received within six weeks of initial mailing will serve as our sample. In organizing our qualitative data, we will look for themes evident in attitudes among therapists. In doing so, we will examine such variables as practice settings, age, experience, and gender.

According to Maxwell (1996), “the main threat to valid interpretation is imposing one’s own framework or meaning, rather than understanding the perspective of the people studied and the meanings they attach to their words and actions” (p. 89-90). We will reduce the chance of this threat in two ways. First, the questionnaire will contain open-ended questions to allow for expression of individual opinions. Second, four researchers will interpret the information gathered.

The Hypotheses

In evaluating the available literature, we found limited references to the use of occupational therapists in the treatment of cancer in the United States. Therefore, we hypothesize that occupational therapists are underutilized in cancer treatment. In addition, we further hypothesize that through the use of relaxation and guided imagery a patient can maximize his or her quality of life.

Data Analysis

In order to categorize our data, we will utilize a coding strategy. The goal of coding, according to Maxwell (1996), is to break the data into smaller pieces and “rearrange it into categories that facilitate the comparison of data within and between these categories and that aid in the development of theoretical concepts” (p. 78). We plan to use this strategy for better understanding by breaking the data into main themes and analyzing particular interactions.

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