Effectiveness of applying progressive muscle relaxation technique on quality of life of patients with multiple sclerosis

Authors

  • Somayeh Ghafari,

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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  • Fazlolah Ahmadi,

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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  • Masoud Nabavi,

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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  • Kazemnejad Anoshirvan,

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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  • Robabe Memarian,

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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  • Mohamad Rafatbakhsh

    1. Authors:Somayeh Ghafari, MSc, Academic Staff, Department of Nursing, Fasa University of Medical Science, Fasa, Iran; Fazlolah Ahmadi, PhD, Associate Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Masoud Nabavi, MD, Associate Professor, Shahed Medical University, Tehran, Iran; Kazemnejad Anoshirvan, PhD, Full Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Robabe Memarian, PhD, Assistant Professor, Medical Faculty, Tarbiat Modares University, Tehran, Iran; Mohamad Rafatbakhsh, PhD, Assistant Professor, English Department, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
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Somayeh Ghafari, Department of Nursing, Fasa University of Medical Science, Fasa, Iran. Telephone: +987312220995.
E-mail:ghafari_somayeh@yahoo.com

Abstract

Aims and objectives.  To identify the effects of applying Progressive Muscle Relaxation Technique on Quality of Life of patients with multiple Sclerosis.

Background.  In view of the growing caring options in Multiple Sclerosis, improvement of quality of life has become increasingly relevant as a caring intervention. Complementary therapies are widely used by multiple sclerosis patients and Progressive Muscle Relaxation Technique is a form of complementary therapies.

Design.  Quasi-experimental study.

Method.  Multiple Sclerosis patients (= 66) were selected with no probability sampling then assigned to experimental and control groups (33 patients in each group). Means of data collection included: Individual Information Questionnaire, SF-8 Health Survey, Self-reported checklist. PMRT performed for 63 sessions by experimental group during two months but no intervention was done for control group. Statistical analysis was done by SPSS software.

Results.  Student t-test showed that there was no significant difference between two groups in mean scores of health-related quality of life before the study but this test showed a significant difference between two groups, one and two months after intervention (< 0·05). anova test with repeated measurements showed that there is a significant difference in mean score of whole and dimensions of health-related quality of life between two groups in three times (< 0·05).

Conclusions.  Although this study provides modest support for the effectiveness of Progressive Muscle Relaxation Technique on quality of life of multiple sclerosis patients, further research is required to determine better methods to promote quality of life of patients suffer multiple sclerosis and other chronic disease.

Relevance to clinical practice.  Progressive Muscle Relaxation Technique is practically feasible and is associated with increase of life quality of multiple sclerosis patients; so that health professionals need to update their knowledge about complementary therapies.

Introduction

Multiple sclerosis (MS) is a heterogeneous chronic disease of the central nervous system(Ozakbas et al. 2004, Schulz et al. 2004) characterised by different patterns of inflammation, demyelisation and axonal loss, predominantly affecting young adults in their most productive years with a higher incidence in women (Schulz et al. 2004, McCabe 2005). The course of the disease is variable and unpredictable; thus, a person who experiences MS is uncertain about his/her future health and general body functioning (McCabe 2005, J W Janssens et al. 2004, Jopson & Moss-Morris 2003). It is estimated that multiple sclerosis affects over one million people worldwide. In industrialised countries, prevalence rates vary between 15–145 per 100 000 (Miltenburger & Kobelt 2002). Multiple sclerosis represents a significant economic burden both on the patient and society. Taylor et al. (2007) reported the average annual direct and indirect costs per patient were AU$20396 and AU$15085 respectively.The greatest uses of resources were for immunomodulating drugs, consultations, hospitalisation and district nursing (Taylor et al. 2007). It has been reported that the somatic symptoms of the MS affect family life, economic condition and social interaction (Patti et al. 2007). Furthermore, quality of life (QOL) is significantly impaired in patients with multiple sclerosis compared with the general population (Janardhan & Bakshi 2002, Patti et al. 2003, Idiman et al. 2006). Fatigue is the most frequently reported symptom of persons with MS, with surveys reporting prevalence rates of up to 92% (Chwastiak et al. 2005, Pittion-Vouyovitch et al. 2006) and brings about lower quality of life (Janardhan & Bakshi 2002, Pittion-Vouyovitch et al. 2006, Ormel et al. 1997, Mercalbach et al. 2002, Chwastiak et al. 2005).

The first study of HRQOL on MS was published in 1990 and the first comparative study appeared two years later. At least 90 studies have now measured QOL in patients with MS (Mitchell et al. 2005). Consensus about the definition of QOL has yet to be reached, but most researchers believe it is multidimensional (Indredavik et al. 1998, WHOQOL Group 1998) comprising three broad ‘domains’: physical, mental and social. QOL has recently been defined by the World Health Organization Quality of Life (WHOQOL) group as ‘individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns (Ormel et al. 2005, Whitmarch 2003). No definitive treatment yet exists to halt the almost inevitable decline in function and increasing of disability over the years in sufferers. Management mainly aims at controlling the various symptoms which arise in the course of the condition. Conventional therapies, for example immunomodulating drugs and steroid therapy which have been used with some success in treating the MS symptoms are not effective in everyone, or cause unacceptable side-effects, such as fatigue or emotional lability. Therefore, there are no generally accepted treatments (Hernandez-Reif et al. 1998). Although some of these drugs help relieve symptoms, they don’t reverse the disease progression and often have adverse side-effects (e.g. increased spasticity, nausea, depression, myelgia, fever, headache). These consequences and decreased physical and social functioning contribute to lifestyle problems and decrease MS patients QOL (Huntley & Ernst 2000). Here, a knowledge of complementary therapies can be beneficial to MS patients. Complementary and alternative therapies are extensively used by people with MS (Fawsett et al. 1994, Hernandez-Reif et al. 1998). One study reported that two-thirds of the MS respondents used alternative therapies because traditional therapies did not relieves them (Hayes & Cox 2000). In recent years, there has been an increased approval of the use of complementary therapies in the health care system. Moreover the use of non-pharmacological interventions to complement modern technological medicine is proving popular among nurses in clinical practice. Progressive Muscle Relaxation Technique (PMRT) is a type of complementary therapy which has been in use since its introduction in 1938 by Edmond Jacobson (Conrad & Roth 2006). This Technique is one of the most simple and easily learned techniques for relaxation with a positive effect on automatic balance (Nichel et al. 2005) that has always been concerned with the integration of the best beneficial conventional therapies for the patients (Hernandez-Reif et al. 1998). PMRT originated from the theory that a psychobiological state called neuromuscular hypertension is the basis for a variety of negative emotional states and psychosomatic disease (Nichel et al. 2005). Multiple sclerosis can result in impaired muscle function leading to weakness, fatigue, spasm and decreased ambulatory ability and QOL (NG et al. 2004). Briefly speaking, in PMR patients lie or sit in comfortable chairs and then the therapist instructs them to contract and release different muscle groups. Patients practice tensing a muscle group until they feel the slight contraction and then practice to release it. The patients learn to practice contraction in various parts in a certain order. The large muscle groups are involved first, since the felt from them is the most conspicuous. When patients relax a given part, they simultaneously relax all parts that have previously received practice. Classical PMRT was time - consuming. Jacobson (Nichel et al. 2005) initially suggested 30–60 min sessions a week for up to more than a year. Brokovec and Krogh (Nichel et al. 2005) reported that PMRT frequently exceeds over 50 sessions and the length of each session is 20–30 min (Nichel et al. 2005). There is no research concerning the effects of PMRT on QOL of the patients with MS. This study has been conducted to investigate and determine the effect of PMRT on QOL of the patients with multiple sclerosis.

Methods

This research is quasi–experimental. It has been performed in Iran National MS Society during June and October 2006. Patients aged 20–45 suffering from MS (definitive multiple sclerosis according to the diagnosis of an experienced neurologist and specific diagnostic tests). These individuals were the members of MS Association, under treatment with no changes in medicine during the study. Their expanded disability status scale (EDSS) was <5·5 (EDSS was rated by an experienced neurologist). They were able to read and understand the questionnaires. Patients whose diagnoses were not clearly verified were excluded from our research. Also excluded the patients who were suffering from an acute relapse, other acute or chronic physical disorders, severe cognitive deficits, hearing loss, vocal disorder, having sign(s) of any psychiatric disease or they had history of doing Previous Relaxation Techniques or special sport activities in last six months. Pockok method and Gigi Statistical table was used to specify the number of samples in clinical trial (Pocock 1990). Sample size (α = 0·01, β = 0·05) was estimated to be 30 patients for each group. Regarding the probable decrease of subjects (for any reason) the number of subjects in each group was increased to 35, but by the end of research, four patients were excluded from the study, so our study was conducted with 66 patients. No probability sampling was carried out according to the inclusion criteria; however the participants were divided randomly in two experimental and control groups. After taking formal consent from patients in the experimental group and making sure about their willingness to participate in the study, they were divided into three groups, two with nine patients and one with eight patients. Training in the progressive muscle relaxation technique was planned for 16 days for all groups. In the first day the patients were familiarised with the concept of relaxation technique, the role and importance of performing relaxation technique and, following it, the aim and duration of the study, how to contact and cooperate with the investigator, the way and the time they should complete the questionnaires. Finally the way and the time they should complete the checklist following the progressive muscle relaxation. Then the preplanned instructional booklets (containing all the above mentioned information as well as the progressive muscle relaxation training and the way to follow it) and the instructional PMRT CD was given to the patients. Three days were allocated to training and performing this technique (for each group). A training program, in seven processes planned and performed in this regard, was as follows:

  • To familiarise the patients with muscles and muscle groups;
  • To train in the process of performing progressive muscle relaxation technique, using explanation and practical presentation;
  • To answer the patients, questions about the technique;
  • Performance of the technique by assistant researcher using instructional CD;
  • Performance of the technique by patients along with the assistant researcher;
  • To state differences in physical and mental feelings of subjects after performing the technique;
  • To perform the technique under the supervision of the assistant researcher by subjects.

Here, the patient was asked to perform PMRT by using instructional CD at home for eight weeks, each day in one session (total 60 sessions). The patients recorded the performance of PMRT in the checklist during the next 30 days and returned it to the researcher after 30 days and received the new checklist for another 30 days. The researcher supervised the PMRT process and also checked the checklists completed by the patients. The researcher would call the patient 2–3 times per week during the study to see if they were following or not following the technique and to find out about problems and solutions to them. It should be noted that no intervention was made for the control group except to ask them to complete the checklists and questionnaires. Means of data collection included:

1 Individual Information Questionnaire: Individual Information Questionnaire included demographic information (age, sex, Body Mass Index (BMI), marital status, education, number of children, occupational status, income, health insurance) and disease information (disease duration, the number of relapses and hospitalisations in the last year and the most crucial and the first symptom of disease, other diseases, type medicines used and type of MS).

2 Self-reported checklist: The self-reported checklist was used for the experimental group to record daily performance of progressive muscle relaxation and also for the control group to record performance of any exercise or relaxation techniques over eight weeks.

3 SF-8 Health Survey: The SF-8 Health Survey is an eight-item short form designed to provide a HRQOL (health-related quality of life) profile (Ware et al. 2001). It is the most recent version of the (Short Form) health surveys, which are the most widely used patient-based health surveys in the world (J W Janssens et al. 2004). Several of the SF scales, specially the SF-36, based on 36 questions and the SF-12, based on 12 questions, have been used extensively in outcomes research, case- control and cross- sectional studies and clinical trials to monitor health outcomes and to assess HRQOL in a variety of studies (Camacho et al. 2002, Lefante et al. 2005). The SF-8 four-week recall was used in this evaluation. All three SF surveys can be summarised into an eight-scale profile that can be compared across the surveys. They also can be scored to report an overall measure of physical and mental functioning that is comparable across the surveys (Ware et al. 2001). Use of the scale to assess programmatic success is common, measuring physical and mental health both before and after the implementation of a program, with higher scores indicating better self-reported HRQOL. Test-retest reliability of the SF-8 survey has previously been investigated and proven to be strong, indicating that the survey is sensitive to change and can, therefore, be use to assess change in HRQOL over time (Ware et al. 2001). Although designed for use in large surveys of general populations, the SF-8 questionnaire has proven useful in outcomes research applications. The questionnaire has the practical advantage of being brief (only eight questions, rather than 12 or 36), while yielding scores that are directly comparable to the eight scores produced by the standard SF-36 and SF-12 (Lefante et al. 2005). The choice of using the SF-8 for the evaluation in this population came after an unsuccessful pilot test of the MS-54QOL and SF-36 which showed that the patients were not completing the survey, often requiring substantial assistance. To calculate these comparable scores, the SF-8 survey first measures the following eight ordinal items: general health (SF8GH), physical functioning (SF8PF), physical role (SF8RP), bodily pain (SF8BP), vitality (SF8VT), social functioning (SF8SF), mental health (SF8MH), emotional roles (SF8RE). Scale means based on the same standard metrics as the SF-36 are assigned to each ordinal response, creating a continuous outcome for each of the eight items. Regression coefficient weights are assigned to each item to produce a physical component score (PCS-8) and a mental component score (MCS-8) for each patient (Ware et al. 2001). This scale measures two dimensions of QOL (i.e physical and psychological) and included eight questions, each question has 0–100 score range, indicating the lowest and highest level of QOL respectively. Contextual and formal validity of the SF-8 was confirmed by the professors of Medical Sciences. The test-retest reliability conducted over two weeks was 0·89. Cronbach alpha reliabilities for the physical and mental subscales ranged between 0·90–0·87 respectively for the present study. The SF-8 questionnaire was used three times (at the beginning of the study, four weeks after the intervention and at the end of eight week course) by control and experimental groups.

The researcher assured the patients that their information will be kept private and studies on them will be reported anonymously and, finally, the results will be presented generally, not individually. Data were analyzed using SPSS version 11.5 (SPSS Inc. Chicago, IL, USA).

Results

In this research 66 subjects participated. Demographic and clinical characteristics of the study samples are shown in (Tables 1 and 2 respectively). No significant differences in age, sex, BMI, marital status, education, occupation, income, disease duration, the number of relapses and hospitalisations in the last year, type of medicine, type of MS and EDSS were observed between patients of control and experimental groups and the two groups were matched regarding the variables before the intervention (Table 3). Measurement by SF-8 showed that life quality level in both dimensions and as totally was poor in control and experimental groups compared with the general population before the study (Table 4). The results of self-reported checklists showed that 92% of patients in experimental group had done progressive muscle relaxation exercise at home regularly. Independent t-test showed that there is no significant difference between two groups before the study, according to the PCS-8, MCS-8 and total scores of life quality (> 0·05). However, four weeks after intervention, this difference between control and experimental groups was significant in PCS-8, MCS-8 and total scores of quality of life (< 0·0001, < 0·0001, < 0·004 respectively). Independent t-test showed significant difference between control and experimental groups in PCS-8, MCS-8 and total scores of quality of life eight weeks later (< 0·0001). Life quality level has been increased both in PCS-8 and MCS-8 scores of quality of life in experimental group (Table 4). Repeated measures of Analysis of Variance (anova) showed that there is a significant difference between total, PCS-8 and MCS-8 mean scores of quality of life between experimental and control groups four and eight weeks after intervention (< 0·05) (Table 4, Figs 1–3). The results of this research showed that there is no significant correlation between quality of life and sex, marital status, educations status, income, duration of disease, kinds of drugs used (> 0·05). But there is a significant correlation between quality of life and age (< 0·05), so that age correlates with a lower quality of life. There is also a significant correlation between life quality level and disease duration (< 0·05). In this research, correlation showed that there is an indirect significant correlation between PCS-8, MCS-8 and EDSS (r = −0·52, r = −0·42, < 0·05 respectively). The increase of EDSS score leads to a decrease in the quality of life score which is more noticeable in the physical dimension. In other words, severity of disease affects more the physical dimension of quality of life rather than the mental dimension.

Table 1.   Demographic characteristics of the patients (control and experimental)
CharacteristicControl n (%)Experimental n (%)
  1. SD, standard deviation; BMI, body mass index.

Mean age ± SD (range)31·12 ± 7·2131·93 ± 7·71
Sex
 Male7 (21·2)13 (39·4)
 Female26 (78·8)20 (60·6)
BMI
 14–2215 (45·5)12 (36·4)
 22·01–3016 (48·5)20 (60·6)
 30·01–382 (6·1)1 (3)
Marital status
 Single10 (33·3)12 (36·4)
 Married23 (69·7)21 (63·6)
Education
 Under diploma5 (15·2)3 (9·1)
 Diploma13 (39·4)63·6 (21)
 University15 (45·5)9 (27·3)
Income
 Insufficient6 (18·2)13 (39·4)
 Poor sufficient17 (51·5)15 (45·5)
 Complete sufficient10 (30·3)5 (15·2)
Health insurance
 Yes30 (90·9)29 (87·8)
 No3 (9·1)4 (12·12)
Table 2.   Clinical characteristic of the patient (control and experimental)
CharacteristicControl n (%)Experimental n (%)
  1. SD, standard deviation; RR, relapsing–remmiting; SP, secondary progressive; DMD, disease modified drugs; EDSS, expanded disability status scale.

Current disease course
 RR30 (90·9)30 (90·9)
 SP3 (9·1)3 (9·1)
Mean disease duration: (years)
 1–625 (75·8)18 (54·5)
 7–138 (24·2)12 (36·4)
 14–2003 (9·1)
Type of medicine
 None5 (15·2)6 (18·2)
 DMD9 (27·3)10 (30·3)
 Symptomatic1 (3)1 (3)
 Mixed18 (54·5)16 (48·5)
Mean EDSS score
 0–1·517 (51·5)16 (48·5)
 2–3·513 (39·4)13 (39·4)
 4–5·53 (9·1)4 (12·1)
Relapsing during last year
 None12 (36·4)14 (42·4)
 1 time16 (48·5)13 939·4)
 2 times2 (6·1)2 (6·1)
 >2 times3 (9·1)4 (12·1)
Hospitalisations during last year
 None26 (78·8)24 (72·7)
 1 time5 (15·2)7 (21·2)
 >1 time2 (6·1)2 (6·1)
Table 3.   Matching of HRQOL, PCS-8 and MCS-8, demographic and clinical characteristic measures between control and experimental groups before the study
Quantitative variablesdftp*Qualitative variablesdfχ2p
  1. BMI, body mass index; EDSS, expanded disability status scale; PCS-8, physical component score; MCS-8, mental component score; HRQOL, health related quality of life.

  2. *p-value refers to level of significant difference in quantitative variables measures of independent samples t-test between control and experimental groups before the study.

  3. p-value refers to level of significant difference in qualitative variables measures of chi-square test between control and experimental groups before the study.

Age64−0·4450·65Sex12·5830·18
BMI64−0·1060·91Marital10·2730·79
Duration of illness64−1·8610·67Education23·8820·14
EDSS64−0·1240·90occupation76·6020·47
PCS-8 score640·160·87Income24·3710·12
MCS-8 score64−0·0520·95Drug30·2610·96
Total score of HRQOL640·0650·94MS type10·0000·66
    Relapsing during last year30·6070·89
    Hospitalisations during last year20·4130·81
Table 4.   Effects of the eight-week PMRT training on PCS-8, MCS-8 and total score of health related quality of life in experimental (= 33) and control (= 33) patients (pre, mid, post intervention)
HRQOLTimeGroupnIndependent t-testRepeated measurement
Mean (SD)p*Within subjectsBetween groups
CaseExperimental
  1. HRQOL, health related quality of life; PCS-8, physical component score, MCS-8, mental component score.

  2. *p-values refer to level of significance of the independent samples t-test between groups time (pre, mid, post of intervention).

  3. p-values refer to level of significance of the time × group interaction of repeated measures analysis of variance (anova) with time (pre, mid, post of intervention) as the within –subjects factor.

  4. p-values refer to level of significance of the time × group interaction of repeated measures analysis of variance (anova) with time (pre, mid, post of intervention) between groups (training vs. control).

PCS-8 scoreBeforeControl3329·64 (13·10)0·87Wilks’ LambdaWilks’ LambdaF = 8·25
Experimental3329·16 (11·30)
1 month laterControl3327·14 (13·29)0·004F = 25·31
= 0·0001
F = 5·40
= 0·01
= 0·006
Experimental3335·61 (9·13)
2 month laterControl3326·95 (12·76)0·0001
Experimental3342·07 (8·29)
MCS-8 scoreBeforeControl3328·45 (11·70)0·95Wilks’ LambdaWilks’ LambdaF = 12·005
Experimental3328·54 (9·96)
1 month laterControl3325·79 (11·70)0·0001F = 69·58
= 0·0001
F = 5·13
= 0·01
= 0·001
Experimental3335·52 (8·12)
2 month laterControl3325·79 (11·24)0·0001
Experimental3340·74 (7·61)
Total scoreBeforeControl3358·04 (23·05)0·94Wilks’ LambdaWilks’ LambdaF = 11·74
Experimental3357·70 (19·07)
1 month laterControl3352·93 (23·73)0·0001F = 56·56
= 0·0001
F = 9·08
= 0·01
= 0·001
Experimental3371·13 (14·55)
2 month laterControl3352·55 (22·22)0·0001
Experimental3382·81 (12·81)
Figure 1.

 Effects of PMRT on PCS-8 in experimental (= 33) and control (= 33).

Figure 2.

 Effects of PMRT on MCS-8 in experimental (= 33) and control.

Figure 3.

 Effects of PMRT on Total score of SF-8 in experimental (= 33) and control (= 33) groups.

Discussion

The current proliferation of quality-of-life (QOL) research in neurology is due to many factors in medical practice. These include technological advances with their ever-increasing costs, consumerism in the marketplace with competition to gain more health care dollars and the demonstration of wide institutional varieties in the practice of medicine unaccompanied by obvious or discernible differences in patient outcomes (Bernstein & Walters 1998, Gerszten 1998). The life quality level is usually low in patients with multiple sclerosis. In general, QOL was clearly impaired in the patients with MS. The overall and domains of SF-8 scores were significantly lower than those of the control group (Ormel et al. 1997). The results of a previous study supported the use of the SF-8 survey for health research studies (Lefante et al. 2005). In the present study, quality of life in MS patients had decreased according to SF-8 measurement. Studies in Canada, Norway, Spain and the USA proved that many MS patients have notable decrements in QOL. This is because the effect of disability in daily living is greater in MS than in other chronic diseases (Mitchell et al. 2005). The results of this study revealed that, compared with the control group, patients with multiple sclerosis in the experimental group who exercise the progressive muscle relaxation over eight weeks, experienced higher quality of life in physical and mental dimensions. In other words, this technique has been effective in improving the level of quality of life in MS patients in this research. These results are consistent with those obtained by Stuifbergen et al. (2006) who investigated the effect of exercise on functional limitations and quality of life of MS patients. Also it is proved that complementary treatment programs like exercise have positive effects on life quality level among these patients (Stuifbergen et al. 2006). The results of Mathiowets et al.'s study (2001) about the efficacy of an energy conservation course for patients with multiple sclerosis showed that complementary therapies have good effects on the life quality level of these patients (Mathiowetz et al. 2001). On the other hand, studies showed that a 5–20 minute session of progressive muscle relaxation, is as effective as a one-hour sleep for preserving energy in an individual (Jeferson 1998). Petajan et al.’s study (1996) verified the impact of aerobic training on fitness and quality of life in multiple sclerosis. This study was performed on 46 patients in two groups of experimental and control for 15 weeks and showed that sport as a complementary treatment leads to improvement of physical symptoms in MS patients (Petajan 1996). The lack of significant difference regarding quality of life scores between two groups before the study indicated that the two groups were matched with respect to quality of life. Minor decline in quality of life of the control group can be attributed in progressive and chronic nature of M.S disease. It may be due to the effects of the disease symptoms such as fatigue and depression on the quality of life of patients, causing slight decrease in quality of life of patients in the control group over eight weeks. The studies of Janardhan and Bakshi (2002) and Pitiun Viovich also confirm that MS patients life quality level may decrease gradually (Janardhan & Bakshi 2002). Of course, this process varies in different patients. Fatigue and depression are two very common symptoms in these patients that affect their life quality level adversely. The results of this research showed that there was a significant difference in total quality of life and its physical and mental dimensions between experimental and control groups by three times. Oken et al. (2004) investigated the effect of yoga and exercise on MS patients and claimed that yoga and exercise as complementary therapies bring about significant differences in quality of life scores between experimental and control group by three times. Three measurements proved that above mentioned exercises lead to the enhancement of quality of life of patients in two groups (Oken et al. 2004). The results of this research indicated that there is no significant relationship between quality of life and sex, marital status, educations status, income, duration of disease, type of drugs used, Idiman et al. (2006) did not find any significant correlation between above mentioned variables and quality of life of MS patients. However, the results of the research asserted that age affects the quality of life whereas Idiman et al. (2006) found no significant correlation between quality of life of MS patients and their age. It appears that the chronic nature of MS and also pathophysiological changes with ageing lead to the lowering of patients, quality of life. In the present study, a significant negative correlation was found between physical and mental health dimensions of SF-8 and EDSS. These findings are consistent with those of Ozakbas (Ozakbas et al. 2004). Mitchell reported that quality of life in MS sufferers correlates with severity of impairment and disability such as EDSS. However, this correlation is surprisingly weak, varying from 2–29% depending on the interplay of multiple additional influences (Mitchell et al. 2005). The increase of EDSS scores correlates with the decline of life quality level which is more noticeable in the physical dimension of quality of life (Ozakbas et al. 2004).

The research limitations include: individual differences and psychological state of participants in response to the intervention and their effects, the effect of environmental factors and individuals’ cultures on their understanding about the impact of relaxation technique on improving the quality of life, the influence of learning and lack of mental concentration on progressive muscle relaxation and also the disabling nature of the disease.

Conclusion and relevance to clinical practice

Progressive muscle relaxation technique is one of the complementary treatments that is a non-invasive and low cost approach in managing symptoms and enhancing the quality of life of MS patients in which they can easily be trained by medical personnel including nurses. Regarding the environmental, economic and human time limitations and also the nature of multiple sclerosis and psychological state of patients, we can claim that the results of the present study are significant. We suggest further study of this technique and also to investigate its effects on other MS symptoms and also in other chronic diseases.

Acknowledgement

This study was supported by a grant from a Tarbiat Modares University (TMU). Additional support for data collection was provided by Iran National MS Association. We sincerely appreciate all patients who cooperated us in doing this research.

Contributions

Study design: GhS, AF, NM, MR; data collection and analysis: KA, GhS, AF and manuscript preparation: Ghs, AF, KA, RM.

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