F E AT U R E S

The Effect of Progressive Relaxation

Exercises on Pain, Fatigue, and Quality of Life
in Dialysis Patients
■ Emine Kaplan Serin, PhD, RN ■ Nimet Ovayolu, PhD, RN ■ Özlem Ovayolu, PhD, RN

Patients receiving hemodialysis treatment may experience several symptoms at the same time, such as fatigue and
pain. Progressive relaxation exercises (PRE) have been reported to have positive effect on the control of these
symptoms. In this study, a randomized, controlled, and experimental study was conducted to examine the effect of
PRE on pain, fatigue, and quality of life in hemodialysis patients; the study was carried out with 48 intervention and
48 control patients receiving treatment in the hemodialysis units of 2 hospitals. Data were collected by a
questionnaire prepared by the researcher, which included questions about sociodemographic variables and the
disease; Piper Fatigue Scale; Visual Analog Scale that measures pain severity; and SF-36 Quality of Life Scale. The
results of study revealed that mean total fatigue score and mean pain score decreased in the intervention group
after the application of PRE; whereas no change was observed in the control group (P < .05). It was also found that
quality of life physical component mean score and mental component mean score increased in the intervention
group after the application of PRE (P < .05). KEY WORDS: fatigue, hemodialysis, pain, progressive relaxation
exercises, quality of life Holist Nurs Pract 2019;0(0):1–8

INTRODUCTION failure patients3 and especially is lifesaving in

emergencies.1-4 Despite improvements in this
End-stage renal failure is a disease that develops treatment model, patients still face many physical,
depending on primary factors such as diabetes (39%) mental, and social problems. Symptoms such as
and hypertension (28%), has increasing incidence and fatigue, cramping, pain, sleep disturbance, dyspnea,
prevalence due to age, and is characterized by pruritis, depression, nausea, vomiting, and
irreversible renal damage.1,2 According to the constipation all affect the individual’s daily life and
CREDIT study (2012) conducted by the Turkish quality of life (QOL) negatively.4-6 Along with these
Society of Nephrology, the prevalence of chronic renal symptoms, which are frequently experienced by
disease was 15.7% and the end-stage renal failure dialysis patients, there are limitations in social life and
point prevalence requiring renal replacement therapy difficulties in realizing physical activities.4 Among
is 816 per million population. Hemodialysis (HD), the these symptoms, fatigue is reported to be one of the
method of renal replacement therapy, is the most most common complaints that disturb the QOL and
common choice in the treatment of end-stage renal affects 60% to 97% of dialysis patients.4,5 It was also
shown that HD patients experience both acute and
Author Affiliations: School of Health, Munzur University, Tunceli, Turkey chronic pain due to various causes and 50% of them
(Dr Serin); and Faculty of Health Science, Gaziantep University, Gaziantep, experience chronic pain. Patients are known to have
Turkey (Drs N. Ovayolu and Ö. O. Ovayolu).
complaints such as headache, musculoskeletal system
This article is based on part of the first author’s MSc thesis from Gaziantep pain, and back pain.2,3,6-8
University of Turkey.
Patients undergoing HD treatment may experience
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article. many symptoms, such as fatigue and pain. If these
symptoms are not controlled, they may affect all areas
Correspondence: Emine Kaplan Serin, PhD, RN, Department of Nursing,
School of Health Munzur University, Merkez, Aktuluk Mahallesi, Üniversite of the patient’s daily life and QOL negatively.4-6
Yerleşkesi, 62000, Tunceli, Turkey (emine_3354@hotmail.com). Although affecting the lives of patients so much,
DOI: 10.1097/HNP.0000000000000347 fatigue and pain are symptoms that are usually

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2 HOLISTIC NURSING PRACTICE • 00 2019

overlooked and neglected because of their subjective

quality. However, the control of these symptoms
requires a multidisciplinary approach. Nurses who are
members of this team may apply different methods to
control pain and fatigue.4,5,9,10 Progressive relaxation,
a complementary therapy, has been reported to have a
positive effect on the management of these
symptoms.11-23 Progressive muscle relaxation was
developed by Jacobson in 1920s and it is an exercise
that consists of systematic muscle straining and
relaxation of large groups of muscles.24
As nursing adopts the concept of care centered on
the patient, it aims to improve QOL dimensions such
as physical, social, and psychological well-being.
Therefore, nursing care concentrates on behaviors that
affect QOL positively, such as relaxation and
exercise.5,7-9 Quality of life is affected when there is a
deviation in people’s health. At this point, the role and
purpose of nursing is to improve the QOL. When
nurses fulfill these responsibilities, they play an active
role in controlling the symptoms that significantly
affect QOL, such as fatigue and pain factors. Thus, FIGURE. The flow diagram of the process.
this study was conducted to evaluate the effect of
progressive relaxation exercises (PRE) on fatigue, 5. to have no difficulties communication and no
pain, and QOL of HD patients. In addition, the study mental disorders as confirmed by hospital
aims to guide future studies by making appropriate psychologists,
suggestions according to the obtained results. 6. to agree to participate in the research, and
7. to practice relaxation exercises.
MATERIALS AND METHODS In the power analysis, it was determined that the
The overall flow diagram of the method is depicted in effect size was 0.7, the bias level was 0.05, and the
the Figure. representative power was 0.92.
Measurement and instrument
Setting and sample
The data were collected by the researchers through
The study was conducted as randomized, controlled,
face-to-face interviews with the patients. In the data
and experimental to examine the effect of PRE
collection, the form including sociodemographic
administered to patients receiving HD treatment on
variables and questions related to the disease prepared
pain, fatigue, and QOL. Patients receiving HD
by the researchers, the Piper Fatigue Scale to assess
treatment in dialysis units of the Adiyaman State
fatigue, Visual Analog Scale to measure pain, and the
Hospital and the Gaziantep Avukat Cengiz Gökçek
SF-36 Quality of Life Scale to assess QOL were used.
State Hospital were included in the study. The sample
Questionnaire form: The form has 3 parts consisting
group from the population consisted of a total of 96
of sociodemographic characteristics of the individual,
patients: 48 from control group and 48 from
descriptive information about the disease, and
intervention group.
questions related to patients receiving HD treatment.
The inclusion criteria of the study are as follow:
Visual Analog Scale: Visual Analog Scale is used to
1. to continue treatment in the dialysis unit as chronic, measure perceived pain. The severity of pain is
2. to receive HD treatment for longer than 6 months, marked on a 10-cm (100 mm) ruler where
3. to be at least 18 years of age, painlessness is at one end and the most severe pain at
4. to be at least literate (being able to read and write the other end. It was reported that in the assessment of
basic Turkish text to understand the questionnaires), the severity of pain, the sensitivity is high.8,17,19,25

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 Effect of Progressive Relaxation Exercises 3

Piper Fatigue Scale was developed by Barbara F. theoretical and practical face-to-face training about the
Piper et al in 1987 to evaluate the multifaceted exercises was given to the intervention group by the
measurement model of fatigue. It consists of 22 items researcher at the hospitals. The average duration of
each evaluated on 0- to 10-point Visual Analog Scale, training for each patient varied from 30 to 40 minutes.
and the subjective perception related to fatigue of the The trainings were held according to the direction of
patient is evaluated with 4 subscales. These subscales the “Handbook” prepared for relaxation exercises for
are subscale of behavior/violence that assesses the dialysis patients. The PRE handbook was developed
effect and severity of fatigue in daily life activities; by the researchers from literature on PRE and from
subscale of affection that includes emotional meaning expert opinions. The handbook contains titles such as
attributed to fatigue; emotional subscale reflecting the pain, fatigue and relaxation, benefits of relaxation,
mental, physical, and emotional symptoms of fatigue; techniques of relaxation, conditions required to be
and cognitive/psychological subscale that reflects the successful in relaxation exercises, PRE, and QOL.28,29
level of affecting cognitive functions and mental state A CD with instructions for the relaxation exercises
of fatigue. In addition, in the scale, there are 5 other was prepared by the Turkish Psychological
items that are not used in fatigue score calculation but Association. The CD included relaxing background
are recommended to be included in the scale because music as well as breathing and progressive relaxation
of their importance in evaluating data related to exercises. Patients listened to the CD in a quiet
fatigue. Subscale scores are obtained by dividing the environment. The PRE was then conducted by the
scores of all the items in that subscale by the number researcher. After the training, the CD and the prepared
of items. The total fatigue score is obtained by handbook were given to the patients. At least twice a
dividing the addition of item scores by the total week, the researcher applied the exercises to the
number of items.22,26,27 patients in the intervention group. The patients were
SF-36 Quality of Life Scale it is an individual also informed about the need to listen to the
evaluation scale developed by Ware in 1987. It commands on the CD and practice the exercises for at
consists of 8 subscales including physical function, least once a day for 6 weeks at home. The patients
role limitation due to physical problems, social shared these at-home exercises with researchers as
function, role limitation due to emotional problems, verbal (talking, writing, etc) or visual (photographs,
mental health, fitness/fatigue, pain, and understanding video, etc). After 6 weeks, the pain, fatigue, and QOL
of general health. By calculating the scores obtained scales were again administered to all patients in the
from the subscales, 2 main scale scores are obtained; control and intervention groups.
physical and mental scales. SF-36 was scored as the
health-related QOL increases with the increase of each Statistical analysis
health field score. Each subscale score ranges from 0
to 100. The physical and mental scale scores are also In the statistical evaluation of the data, descriptive
between 0 and 100. Zero indicates the worst and 100 statistics such as percentage, mean, and standard
indicates the best health condition. The SF-36 Quality deviation were used to assess the patients’
of Life Scale, whose validity and reliability tests were demographic profile. Distribution of the patients
conducted by Pinar in 1995, has been used in many according to sociodemographic information was
studies of chronic disease including kidney assessed by independent-samples t test and χ 2 test.
disease.18,23 Comparisons of total fatigue, QOL scores of
individuals in the intervention and control groups for
Intervention before and after PRE were quantified by independent-
samples t test. Paired-samples t test was used to
One of the researchers was trained to conduct PRE by compare pretest and posttest for the intervention
a physiotherapist and a psychologist. All PRE sessions groups. Distribution of correlations of fatigue, pain,
were conducted by the trained researcher. and QOL scores of the groups for before and after
After the patients were assigned to the control and PRE was analyzed by bivariate correlations.
intervention groups by random sampling method, all
data collection tools were applied. The intervention Ethical consideration
group was trained in PRE and the application of these
exercises, while the control group continued to receive The necessary permissions were received by the
routine treatment. In intervention stage, first, the researchers to conduct the study. Informed consent

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4 HOLISTIC NURSING PRACTICE • 00 2019

was obtained from the patients who were treated in positive linear relationship between PC and MC
HD units of the Gaziantep Avukat Cengiz Gökçek subscales in the QOL, and this correlation was
State Hospital and the Adiyaman State Hospital. The statistically significant (P < .01). These data show that
written permission from the institutions and MC score decreases as PC score decreases. There was
permission from the Ethics Committee of Gaziantep a positive linear relationship between total fatigue and
University Faculty of Medicine (2011/127) were pain after PRE, which was statistically significant
obtained. (P < .01). These data show that fatigue and pain
scores increase together. Fatigue and pain after PRE
RESULTS were correlated with QOL negatively and this
correlation was statistically significant (P < .01).
The mean age of the control group was 49.8 ± 14.1 These data show that QOL increases as fatigue and
years, the mean age of the intervention group was pain scores decrease.
39.1 ± 15.3 years, and 29.2% of the 2 groups were
55 years of age and older. When the DISCUSSION
sociodemographic characteristics of the experimental
and control groups included in the study were In studies examining the effects of different
examined, there was no significant difference between complementary methods such as PRE, acupressure,
the groups (P > .05) (Table 1). and massage on fatigue, it was documented that these
As a result of the study, it was determined in the methods were reducing fatigue scores.22,23,26,30 In our
intervention group that the average total fatigue score study, it was also found that PRE reduced the fatigue
of 4.3 ± 1.5 before PRE decreased to 2.6 ± 1.6 and experienced by patients. The decrease in fatigue
average pain score of 3.0 ± 1.9 before PRE decreased subscale and total scale scores in the intervention
to 1.1 ± 1.7, while there was no such change in the group after PRE and the absence of this change in the
control group. The intervention and control groups control group indicate that PRE reduces fatigue
were found to be statistically significant (P < .05) in severity (P < .01). Amini et al22 reported in their
terms of fatigue subscale and total scale, and it was study with HD patients that PRE reduced fatigue. In
determined that the PRE decreased the fatigue and the study conducted by Kosmadakis et al,14 it was
pain intensity that patients experienced. In the determined that the patients who applied exercise
intervention group, it was determined that QOL achieved significant improvement in symptoms
Physical Component (PC) average score of 49.06 ± compared with those who did not exercise. In the
21.45 before PRE increased to 66.97 ± 21.32 after study conducted by Storer et al, exercise was found to
PRE, and Mental Component (MC) average score of reduce fatigue by increasing physical performance in
49.55 ± 20.42 before PRE increased to 65.49 ± 19.42 HD patients.13,14 In different studies, it has been
after PRE (P < .05) (Table 2). Quality of life scores in shown that PRE reduces fatigue in parallel with our
the intervention and control groups were statistically findings.23,27,28
significant (P < .05) and it was determined that PRE Mood disorders (depression), years of illness,
was increasing QOL. duration of HD treatment and frequency, fatigue,
As shown in Table 3, it was determined that before insomnia, anxiety, loss of work, and sadness may
PRE, there was a positive linear correlation between decrease the pain threshold in HD patients.4-7
total fatigue and pain and this correlation was Hemodialysis patients experience all these symptoms,
statistically significant (P < .01). These data show that the severity of pain experienced with age increases,
as the total fatigue score increases, the pain score also and their QOL is adversely affected.2,4-7 In our study,
increases. Quality of life and total fatigue were the pain score decreased in the post-PRE intervention
correlated negatively, and this correlation was found to group, while there was no such change in the control
be statistically significant (P < .01). These data show group. This result suggests that PRE reduces pain
that the QOL score decreases as the total fatigue score severity. Reducing the pain, which is an important
increases. It was determined that there was a negative problem for HD patients, can increase the QOL by
correlation between QOL and pain before PRE and relaxing patients. Progressive relaxation exercises has
this correlation was statistically significant (P < .01). been found to reduce pain and fatigue and improve
These data show that the QOL score decreases as the QOL in many studies using PRE parallel to our
pain score increases. It was found that there was a study.11-24,25,27,28 For this reason, it is advisable to

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 Effect of Progressive Relaxation Exercises 5

TABLE 1. Distribution of Individuals Included in the Study by Sociodemographic Information

Control (n = 48) Intervention (n = 48)
Characteristics n (%) n (%) P

Sex
Female 21 (43.8) 12 (25.0) .053
Male 27 (56.2) 36 (75.0)
Marital status
Married 36 (75.0) 31 (64.6) .266
Single 12 (25.0) 17 (35.4)
Employment status
Yes 2 (4.2) 3 (6.2) .646
No 46 (95.8) 45 (93.8)
Economic condition
Bad 33 (68.8) 25 (52.1)
Average 13 (27.1) 22 (45.8) .153
Good 2 (4.2) 1 (2.1)
Caregiver
Partner 28 (58.3) 28 (58.3)
Children 10 (20.8) 4 (8.3) 6.479
Parents 4 (8.3) 13 (27.1)
Other 6 (12.5) 3 (6.2)
Diagnosis time past
1-5 y 18 (37.5) 16 (33.3)
6-10 y 20 (41.7) 17 (35.4) .506
≥11 y 10 (20.8) 15 (31.2)
Diagnosis causing dialysis
Chronic glomerulonephritis 9 (18.8) 9 (18.8)
Pyelonephritis 6 (12.5) 7 (14.6)
Diabetes mellitus 13 (27.1) 6 (12.5) .223
Hypertensive kidney disease 15 (31.2) 14 (29.2)
Other 5 (10.4) 12 (25.0)
Other diseases
Diabetes mellitus 13 (36.1) 6 (24.0)
Hypertension 16 (44.4) 13 (52.0) .781
Other 7 (19.4) 6 (24)
Training related to the disease
Yes 29 (60.4) 32 (66.7)
No 19 (39.6) 16 (33.3) .525
HD treatment duration
1-5 y 30 (62.5) 27 (56.2)
6-10 y 14 (29.2) 15 (31.2) .744
≥11 y 4 (8.3) 6 (12.5)
HD frequency
3 sessions per week 43 (89.6) 47 (97.9) .092
2 sessions per week 5 (10.4) 1 (2.1)
BMI
Weak 6 (12.5) 6 (12. 5)
Normal 23 (47.9) 29 (60.4) .578
Overweight 15 (31.2) 11 (22.9)
Obese 4 (8.3) 2 (4.2)
BMI average 23.8 ± 5.2 22.5 ± 3.7 .159
Duration of feeling fatigue
Months 5 (10.4) 9 (18.8)
Years 43 (89.6) 39 (81.2) .386
(continues)

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6 HOLISTIC NURSING PRACTICE • 00 2019

TABLE 1. Distribution of Individuals Included in the Study by Sociodemographic Information (Continued)

Control (n = 48) Intervention (n = 48)
Characteristics n (%) n (%) P

Condition that causes fatigue

Dialysis 37 (77.1) 28 (58.3)
Disease 11 (22.9) 20 (41.7) .080
Methods for reducing fatigue
Sleep 33 (68.8) 26 (54.2)
Rest 13 (27.1) 16 (33.3) .208
Distraction 2 (4.2) 6 (12.5)

Abbreviations: BMI, body mass index; HD, hemodialysis.

apply complementary methods, such as PRE, correctly patients face with problems such as limitations on
to the patient with the pain. their social and physical activities, which negatively
The practice of increasing QOL is important to affect their QOL in many ways. One of these adverse
ensure that patients with chronic renal failure continue conditions is the treatment of dialysis. The fact that
their lives at the highest possible level.31,32 These dialysis is a time-consuming procedure, the need to

TABLE 2. Comparison of Total Fatigue, Pain, and Quality of Life Scores of Individuals in the Intervention and
Control Groups for Before and After PRE
Significance Test
Intervention, X̄ ± SD Control, X̄ ± SD t P

Before PRE
Total fatigue score 4.3 ± 1.5 5.1 ± 1.3 − 2.53 .013
Pain 3.0 ± 1.9 3.0 ± 1.9 0.052 .959
Physical component 49.0 ± 21.4 41.1 ± 20.6 1.848 .068
Mental component 49.5 ± 20.4 42.9 ± 17.7 1.698 .093
After PRE
Total fatigue score 2.6 ± 1.6 6.0 ± 1.4 − 11.108 .000
Pain 1.1 ± 1.7 3.5 ± 1.7 − 6.530 .000
Physical component 66.9 ± 21.3 37.7 ± 19.9 7.404 .000
Mental component 65.4 ± 19.4 37.7 ± 17.2 6.928 .000

Abbreviation: PRE, progressive relaxation exercises.

TABLE 3. Distribution of Correlations of Fatigue, Pain, and Quality of Life Scores of Groups for Before and
After Application
Before PRE Application After PRE Application
r/p Pain PC MC Pain PC MC

Total fatigue
Intervention 0.543 − 0.782 − 0.821 0.574 − 0.782 − 0.786
0.000 0.000 0.000 0.000 0.000 0.000
Control 0.444 − 0.829 − 0.853 0.360 − 0.675 − 0.683
0.002 0.000 0.000 0.012 0.000 0.000
Pain
Intervention ... − 0.574 − 0.454 ... − 0.608 − 0.524
0.000 0.001 0.000 0.000
Control ... − 0.633 − 0.529 ... − 0.576 − 0.434
0.000 0.000 0.000 0.002

Abbreviations: MC, Mental Component; PC, Physical Component; PRE, progressive relaxation exercises.

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 Effect of Progressive Relaxation Exercises 7

come to the hospital, the dependence on health care 1. to facilitate patients coping with the symptoms,
personnel and the machine, and the complications 2. to reduce the severity of fatigue and pain,
affecting daily life can cause job loss for patients and 3. to improve the QOL of HD patients, and
related changes in their lifestyles. This adversely 4. to conduct related studies with a longer period and
affects the QOL of the person.11 It was determined larger sample group in a suitable environment
that the post-PRE intervention and control groups had where the patients can comfortably apply relaxation
statistically significant PC and MC point scores, PC exercises in the dialysis units.
and MC scores of the intervention group increased
after the PRE, and there was no such change in the
control group. In the study conducted by Kuzeyli and REFERENCES
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