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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.

Effect of Progressive Muscle Relaxation Technique on Quality of Life


and Fatigue Severity among Systemic Lupus Erythematosus Patients'.
1
Noura Mahmoud Mohamed Elrefaey, 2Mohamed Saied Harfoush, 3Hend
Ibrahim Metwaly Abdelaty
1
Lecturer, Medical Surgical Nursing Department, Faculty of Nursing, Matrouh University,
Egypt
2
Lecturer of Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt
3
Lecturer, Medical Surgical Nursing Department, Faculty of Nursing, Damanhour University
*corresponding author: noramahmoud@mau.edu.eg
Abstract
Background: Systemic Lupus Erythematosus (SLE) is a chronic disease that
distresses multiple organ systems and roots a broad spectrum of clinical and
immunological manifestations. Progressive relaxation exercises showed a great
impact on many suffers in both medical and surgical conditions. Aim: to determine
the effect of progressive muscle relaxation technique on quality of life and fatigue
severity among systemic lupus erythematosus patients. Design: A quasi experimental
research design with a pretest-posttest control group was used. Setting: The study was
conducted at the Kidney Diseases Outpatient Clinic at the Damanhur Medical
National Institute. Subjects: A purposive sample of 80 adult patients diagnosed with
SLE (40 patients for each group). Tools: Three tools were used, Tool (I)
"Demographic data structured interview schedule for patients with Systemic Lupus
Erythematosus". Tool (II):- "Systemic Lupus Erythematosus Quality of Life Interview
questionnaire". (SLEQOLIQ). Tool (III):- Fatigue Severity Scale. Results:
Approximately two thirds of patients were aged from 30 to 40 years, majority were
female, married; secondary educated, manual work and house wife, from rural area
with insufficient income. Majority of patients on a state expense for paying treatment,
with more than three years disease duration, discover the disease through its
manifestations, suffering from CVD, renal failure and anemia as disease
complications. It was found a significant difference between the control and study
group regarding quality of life dimensions, total quality of life, and fatigue level even
after 15 days and 30 days of follow up while there was no significant difference
between both groups before intervention. Conclusion: The application of the
progressive muscle relaxation technique as a complementary therapy for SLE patients
is encouraged where the safety, simplicity, and effectiveness of this technique
enhance the QOL and decrease fatigue of SLE patients.
Key words: Progressive Muscle Relaxation Technique, Quality of Life, Fatigue
Severity, Systemic Lupus Erythematosus.
Introduction: and 40, and women are affected ten
Within the autoimmune disease, times more frequently than men.
Systemic Lupus Erythematosus (SLE) Minority individuals typically have
reflecting immune system poorer disease activity, more severe
dysregulation results in extensive clinical symptoms, and more abrupt
tissue damage and inflammation. illness onset. Hispanic, African
Chronicity of the disease leads to American, and Asian SLE patients
inflammation of the skin, joints, typically have greater haematological,
kidneys, lungs, nervous system, and serosal, neurological, and renal
other body organs. Most often, Lupus symptoms, regardless of age or gender.
often develops between the ages of 20 SLE condition is now incurable.

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

(Middleton et al., 2018; Lam et al., Systemic lupus erythematosus as


2016; Frieri., 2013 ). a chronic illness with its general and
In Egypt, the second most local manifestations affects a patient's
common admitted rheumatologic quality of life (QoL) because it is a
disease in Rheumatology, lifelong disease. According to Youssef.,
Rehabilitation, and Physical Medicine (2021) Quality of life is defined as “an
Department, at Assiut University individual’s perception of their
Hospitals is SLE, with 14.3% (Goma position in life in the context of the
et al., 2016). The mortality rate among culture and value systems in which
adult Egyptian patients with SLE is they live and about their goals,
2.5% and the most commonly involved expectations, standards and concerns”.
organs are kidneys as an important Physical, psychological, social,
cause of death among them (Gheita, et and occupational aspects of the
al., 2011). patient's quality of life can all be
In systemic lupus erythematosus, negatively impacted by the clinical
the body's immune system attacks its manifestations of SLE. Where, SLE
own normal cell tissue with its own affects activities of daily living, job
antibodies. During these attacks, performance, career building, and
periods of remission occur in the social activities that lead to social
disease, and treatment-associated isolation and frustration. Also, it
damage occurs, for example, valvular affects of human relationships,
heart disease, cognitive dysfunction, partnerships, and family life. So
vascular necrosis, osteoporosis, and patients with SLE can have a
muscle tenderness. These early significantly lower quality of life
damages in the long run can cause late compared to others with other chronic
damages including infections, diseases (Saletra & Olesińska., 2018).
atherosclerosis, and malignancies Furthermore, in SLE, disease-
associated with immunosuppressive related fatigue is common. It
treatment (Biscetti et al., 2021; considered multifactorial underlying
Hinkle., 2014). symptoms in a broad range of chronic
The management of SLE patients conditions. According to Hersche et
includes pharmacological therapy and al., (2022) and Chegeni et al., (2018)
lifestyle modifications. SLE fatigue is described as "the difficulty or
pharmacological therapy mainly inability to initiate activity (the
depends on several traditional subjective sense of weakness); reduced
medications such as corticosteroids, capacity to maintain activity (easy
antimalarials, immunosuppressive fatigability); or difficulty with
drugs, non-steroidal anti-inflammatory concentration, memory, and emotional
drugs, and analgesia. However, this stability (mental fatigue)". Complex
protocol of treatment is rapidly pathophysiological and psychological
modified due to the advanced processes are involved, which are yet
treatment of SLE which includes poorly understood.
medications specifically designed to A sort of exercise that involves
interfere with the immunological stetching and relaxation of a large
abnormalities present in SLE. muscle group from the hands to the
Concerning lifestyle modifications for feet is called the Progressive Muscle
SLE, they include enough rest, a Relaxation (PMR) technique.
balanced diet, adequate exercise, Numerous studies have shown that
smoking cessation, and adequate PMR exercises can reduce the negative
sunlight exposure (Basta et al., 2020). effects of stress and anxiety as well as

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

acute and chronic pain, nausea, and Aim of the study:


vomiting. They can also improve sleep; The aim of the study was to determine
lessen exhaustion, and lower blood the effect of progressive muscle
pressure, heart rate, and muscular relaxation technique on quality of life
tension. progressive muscle relaxation and fatigue severity among systemic
are easy to do, inexpensive, non- lupus erythematosus patients.
invasive, and have no negative side Hypothesis:
effects. They can be used to enhance H0: Systemic lupus erythematosus
quality of life. Additionally, PMR patients who practice PMR technique
activities improve therapeutic care and have the same quality of life and
foster patient-nurse contact. (El Geziry fatigue as those who do not practice it.
et al., 2018; Chegeni et al., 2018). H1: Systemic lupus erythematosus
İbrahimoğlu and Kanan (2017) patients who practice PMR technique
found that progressive relaxation have the better quality of life than
exercises positively affected the vital those who do not practice it.
signs of open heart surgery patients. H2: Systemic lupus erythematosus
Progressive relaxation techniques were patients who practice PMR technique
successful in lowering the fatigue level have less fatigue than those who do not
in dialysis patients, according to Serin practice it.
et al. (2020). Chegeni et al. (2018)
Operational definition:
and Kömürkara & Cengiz (2022)
Progressive muscle relaxation is
found that patients with chronic
defined operationally as a systemic
obstructive pulmonary disease who
contraction of every muscle group with
also underwent liver transplantation
an inhale and holding of breath for 2–
might significantly lessen their degree
10 seconds (depending on the patient's
of fatigue by performing progressive
tolerance), followed by a deep
relaxation exercises.
relaxation of the same muscle group
Significance of the study: with a slow expiration through pursed
Studies conducted on PMR lips within 4–10 seconds (depending
exercise have shown that it is an on the patient's tolerance).
effective supplementary approach that
positively affects the quality of life and
plays an important role in reducing Materials
fatigue levels in people with chronic Research design:
diseases. However, there was no study A quasi experimental research design
examining its effects on SLE patients. with a pretest-posttest control group
Therefore, this study was conducted to was used.
determine the effect of PMR exercises Setting:
on QoL and fatigue severity among The study was conducted at the
SLE patients, and whether it can be Kidney Diseases Outpatient Clinic
used as a safe and effective method of (two days specific for rheumatology
independent nursing intervention for disorders; Sunday and Wednesday
those patients. So, raising the quality of from 10 a.m to 12 m.d), first floor of
life of those patients is the ultimate the critical medicine building, at the
goal of all health interventions. Within Damanhur Medical National Institute,
this respect, proper management of Damanhur city, El Beheira governorate.
such problems is needed through Subjects:
interdisciplinary team of medical, A purposive sample of 80 adult
psychiatric, and community health patients diagnosed with systemic lupus
nurses. erythematosus who attended to the

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above mentioned study setting were Part II: Patient's clinical data: This
selected based on the epidemiology part was used to collect patient's
information statistical program (Epi clinical data regarding patient's past
info V7.0) which wasused to estimate medical health history as: onset of the
the minimum sample size required disease discovery, disease duration,
using the following parameters: length of time since diagnosis,
a) Population size: 150/year appearance of signs and symptoms,
b) Expected frequency: 50% associated medical diseases, previous
c) Acceptable error: 10% hospitalization from complications of
d) Confidence coefficient: 99% SLE, number of previous
e) Minimum sample size: 79 hospitalization, previous operations
Patients who fulfilled the following and exposure to radiation.
criteria were considered eligible to take Furthermore, patient's present health
part in the study: history as: chief complains, current
 Adult patients age range from 20 to prescribed medications, side effects of
60 years. prescribed medications and compliance
 Patient recently diagnosed with with medication regimens. Moreover,
Systemic Lupus Erythematosus family history as: diabetes, high blood
(from 1-3 years). pressure, heart disease, cancer,
 Able to communicate verbally. rheumatoid arthritis and systemic lupus
 Exclude the pregnant women as erythematosus.
pregnancy health related quality of Tool (II):- "Systemic Lupus
life may be overlapping with the Erythematosus Quality of Life
SLE quality of life. Interview Questionnaire".
The selected patients were then split (SLEQOLIQ) : This tool was
into two equal groups (control and developed by Leong et al., (2005) to
study), each with 40 individuals. assess the quality of life of SLE
Tools of the study: patients. Content validity was done and
Three tools were used, based on test-retest reliability was done, the
reviewing the related literature in order coefficient value was 0.83 by Leong et
to collect the necessary information al., (2005). It includes six main
Tool (I) "Demographic data categories namely; physical
structured interview schedule for functioning, social and occupational
patients with Systemic Lupus activities, symptoms, treatment, mood
Erythematosus" and self- image. The categories items
This tool was developed by the assembled into a questionnaire. These
researcher after review of related categories are:-
literature (Gheita et al., 2011; Reis & 1. Physical functioning: Included
Costa, 2010; Sliem et al., 2011). It six items namely: walking
was used to assess demographic outdoors on level ground,
characteristics of patients diagnosed shopping, turning taps on and
with Systemic Lupus Erythematosus. off, going to the supermarket,
It includes two parts; bathing and drying themselves,
Part I: Demographic data: This part and walking continuously for 30
was used to collect patient's personal minutes.
data regarding: age, sex, level of 2. Social and Occupational
education, occupation, marital status, activities: Included nine items
area of residence, income adequacy, namely: work and school
source of income and treatment performance, interference with
payment system if present. the career or education, missing

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

work or school, relationship moderately difficult, 3= not difficult at


with friends and relatives, all (questions 1-6), the second 1= very
taking part in sports, sexual troubled, 2= moderately troubled, 3=
activities, taking part in social not troubled at all (questions 7-27), and
activities, unable to go out in the last 1= very often, 2= moderately
the sun, and earning/making often, 3= not at all (questions 28-40).
less money because of having All items were formulated in the
SLE. same direction, with higher scores
3. SLE symptoms: Include eight indicating higher level of quality of life
items namely: poor memory, and lower scores indicating lower level
loss of appetite, fatigue, poor of quality of life.
concentration, itchy skin, sore ● Accordingly, the maximum total
mouth, sore painful or stinging score for patients’ quality of life
skin, and joint pain and swelling. was equal to 120 (40 questions × 3
4. Treatment: Included four items points= 120) and minimum total
namely: fear of needles, dietary score was equal to 40 (40 questions
restrictions, inconvenience of × 1 points= 40).
daily medication, and  Poor quality of life was
inconvenience of frequent clinic defined as a score between 40
visits. and 66.
5. Mood: Included four items  Fair quality of life was defined
namely: self –consciousness, as a score between 67 and 93.
feeling low or down, depression,  Good quality of life was
and anxiety. defined as a score between 94
6. Self- image: Included nine and 120.
items namely: wishing that Tool (III):- Fatigue Severity Scale
other people did not know that I (Hersche et al., 2022; Chegeni et al.,
have SLE, being made fun of by 2018):
my friends and colleagues, low The Fatigue Severity Scale (FSS) is a
self-esteem, embarrassment method of evaluating the impact of
about my SLE, concern about fatigue. The FSS is a short
the financial burden to my questionnaire that requires the patient
family, concern that medicines to rate their level of fatigue. Nine
do not work, concern about side statements on the FSS questionnaire
effects of medicines, fear of measure the severity of fatigue
receiving bad news from symptoms. Each statement should be
doctors, and consuming more responded to by selecting a numerical
alcohol or tobacco. response between 1 and 7, depending
The total number of this tool was on how well it describes the patient's
40 items. The patient was asked to rate condition over the previous week and
the items as regard to their frequency how much the patient agrees or
of occurrence and importance in the disagrees with it.
past month. • A low value (e.g., 1) indicates strong
disagreement with the statement,
Scoring system: whereas a high value (e.g., 7) indicates
Each participant response for strong agreement.
each item was registered on three- Scoring system:
point different Likert-scale  Score from 9- 36 indicate no
according to the type of statement fatigue
that vary from, 1 = very difficult, 2=

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

 Score from 37- 46 indicate mild findings of the jury’s comments and
fatigue the pilot study, the tool was reviewed.
 Score from 47- 55 indicate According to statistical analysis, some
moderate fatigue questions were clarified, others were
 Score from 56- 63 indicate added and few were omitted.
severe fatigue Data collection: The data collection
Method: was initiated covering a period of 6
Approval: months (from February 2022 to July
An official letter was obtained 2022).
from the Faculty of Nursing; For the study group:
Damanhur University, then it was The researchers interviewed each
directed to the director of the patient in the study group individually
outpatient clinic after explanation of for around 45 minutes. The researchers
the aim of the study, in order to carry introduced themselves to the patient
out the research. and clarified the purpose of the study
Tool development: and then written consent was attained
Demographic data structured for participation in the study.
interview schedule for patients with Throughout this interview tool 1 was
Systemic Lupus Erythematosus (Tool I) used to collect demographic data from
to collect data about the demographic, the patient.
as well as patient's clinical data was The patient was instructed to sit down
developed by the researcher. Systemic in a comfortable position, close his
Lupus Erythematosus Quality of Life eyes, and maintain them closed (if
Interview Questionnaire (SLEQOLIQ) possible) until the treatment was
(Tool II) was translated into Arabic complete. The patient was asked to re-
language by the researcher after review demonstrate each phase of the PMR
of relevant literature. Tool III was procedure after the researchers had
adopted and translated into Arabic. previously demonstrated it, as the
Testing of content validity: The following steps:
content validity of the tools was  The patient was encouraged to take
submitted to jury members of five deep breaths and inhale deeply
experts in the Medical-Surgical through the nose. As the patient
Nursing and community health nursing filled his or her body with air, the
field , to assure the content validity, abdomen rose. Next, slowly
completeness, and clarity of items, exhale through your lips, bringing
appropriateness of translations, and your navel in towards your spine
applicability on the Egyptian society. as you do so. Breathe deeply for
Reliability testing: was done using the 3-5 cycles (or as long as the
test-retest method within three weeks patient can handle it).
intervals on 8 patients by Alpha  The patient was told to contract and
Cronbach'sfor the tool 2, and 3 were relax their muscles by the
α= 0.905, α= 0.855. researchers. Starting with your
Pilot study: Pilot study was carried feet, tighten your toes and push
out on 8 SLE patients at the previously your heels down. For a few
mentioned study setting to ascertain breaths, squeeze firmly, then let
the clarity and applicability of the go. Then, flex your feet inward
study tools and to identify obstacles with your toes pointing up
that may be faced during data towards your head. Hold for 10
collection. They are not included in seconds, then slowly release as
the actual study subjects. Based on the you count to 10.

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 Keep tensing and releasing each daily in the morning and evening
muscle group. Counting to ten for one month
while slowly releasing the  The patients was followed by
contractions in your thigh telephone calling for assuring
muscles as you work your way up compliance and outpatients
to your right leg. Repeat for the follow up after 2 and 4 weeks
left leg, buttocks (tighten by  Tool II and III were completed at
pulling buttocks together, holding the second week and one month
for 10 seconds, and then slowly post intervention.
releasing while counting to 10), For the control group:
abdomen (tighten by inhaling  The control group's patients were
deeply, holding for 10 seconds, left for routine care. Each patient
and then gradually releasing underwent a 15-minute individual
while counting to 10), chest interview with the researchers, who
(tighten by clenching fist, holding utilized tools 1, 2, and 3 to obtain
for 10 seconds, and then information from them. The patient
gradually releasing while was then interviewed by
counting to 10), hands (tighten researchers two weeks and one
fist), and right arm (tighten bicep), month later to conduct a post-test
for the muscles in the neck and using tools 2 and 3.
shoulders (raise shoulders up to  Each patient in both groups
touch ears, holding for 10 seconds, underwent a private, one-on-one
and then slowly releasing while interview to receive written
counting for 10), mouth (open informed consent to participate in
mouth wide enough to stretch the the study and to receive an
hinges of the jaw, holding for 10 explanation of its aim. Patients
seconds, and then slowly were reminded of their ability to
releasing while counting for 10), refuse study participation, and they
and finally for the forehead (raise were guaranteed of the
eyebrows as high as possible, confidentiality and anonymity of
holding for 10 seconds, and then their responses. Additionally, it
slowly releasing while counting was guaranteed that they could
for 10). withdrawal from the study at any
 The patient exhales deeply as the time.
procedure comes to a close, Statistical Analysis:
remarking how much calmer and  After data collection was
more at ease they felt. completed, it was feed to SPSS to
 According to the patient's needs, be analyzed. Data was coded and
the researchers conducted re categorized, number, percentage,
demonstration. The researchers mean and stander deviation were
also corrected the patient's used to describe the basic data.
incorrect use of the procedure. The used tests were:
The patient was invited to 1 - Chi-square test for categorical
demonstrate the PMR technique variables to compare between
again after the explanation was different groups
finished until he or she had 2 - Monte Carlo correction for chi-
mastered it. square when more than 20% of the
 The patients then instructed to do cells have expected count less than
PMR technique for two sessions 5.

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3 - Student t-test for normally of the study and control groups,


distributed quantitative variables to respectively, had insufficient
compare between two studied income. No statistical significance
groups. differences were found between the
4- Mean and Standard Deviation study and control group in relation to
for categorical variables to demographic characteristics.
compare between different groups Table II: shows that for both the study
Ethical Considerations: and control groups, the treatment
1. Approval of ethical research payment system was 82.5% and 90.0%,
committee was obtained. respectively. Regarding disease
2. Witness/ written informed consent duration, the majority of patients
was obtained from patients (97.5% and 92.5%, respectively) had
participating in the study after disease duration longer than 3 years in
explanation of the aim of the both the study and control groups. On
study. the other hand, of the total patients
3. Privacy was ascertained. reporting having complications, 40.0%
4. The anonymity and confidentiality and 30.2% of both groups complained
of the collected data for each of cardiovascular conditions, and
patient were assured. 33.7% of the study group and 27.0% of
5. Each patient had the right to the control had renal failure and more
withdraw at any time in the study than one fifth (21.7 and 28.6%
without any drawbacks. respectively) of study and control
group had Anemia. Finally, more than
Results: two thirds of patients (72.5% and
Table (1) shows that roughly 82.5%) in both the study and control
two-thirds of the study and control groups had previous hospitalizations
groups (60.0% and 67.5%) were for complications. No statistically
between the ages of 30 and 40 years. significant differences were found
As regards sex, most of the study between the two groups in relation to
subjects (95.0% and 92.5%) in the their demographic and clinical data,
study and control groups respectively which indicated proper matching
were female. In relation to marital between the study and control groups
status, less than half (47.5% and 40.0%) in these variables.
of the participants in the study and Figure I: indicates that all (100.0%) of
control groups, respectively, were the patients in the study and control
married. Regarding level of education, groups had symptoms such as
it was found that 52.5% and 50.0% of headache, difficulty concentrating, a
the participants in both the study and red malar rash on the face over the
control groups, respectively, had cheeks, a nasal bridge, painful, swollen
completed secondary or technical joints, joint movement
education. Concerning occupation, it limitation, sensitivity to the sun, and
was found that 40.0% and 35.0% of the external fatigue. On the other hand,
work in both the study and control less than one fifth (12.5%) of patients
groups, respectively, was manual work. in the control group had unusual hair
Regarding place of residence, it was loss, compared to more than half
found that more than half (65.0% and (57.5%) of patients with unusual hair
55.0%) of the participants in both the loss in the experimental group.
study and control groups, respectively, Table III: It was noticed that more
were from rural areas. In terms of than half (55.0% and 57.5.5%) of the
income sufficiency, 95.0% and 90.0% study and control groups had a fair

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

quality of life, and there was no statistically significant (PMC = 0.000).


statistically significant difference The same difference in the control
between both groups, where p = 0.786. group was not statistically significant
After 15 days of practicing the (PMC = 0.332), and the difference
progressive muscle relaxation between the two groups before the
technique, 87.5% of the study group progressive muscle relaxation
had a fair quality of life, while 52.5% technique intervention was not
of the control group had a fair quality significant (0.06). The difference
of life. There was a statistically between the two groups after the 15
significant difference (P = 0.020*) days of intervention was statistically
between both groups. After 30 days of significant (0.019*). On the other hand,
practicing the progressive muscle the difference between the two groups
relaxation technique intervention, after the 30 days of intervention was
55.0% of the study group had a good statistically significant (P = 0.000*).
quality of life compared to only 10.0% Table V: It was observed that there
of the control group. There was a was no statistically significant
statistically significant difference difference between the study and
between both the study and control control groups in all dimensions of
groups in the 30 days where P = quality of life before the intervention
0.000*. of the progressive muscle relaxation
Table IV was observed that 7.5% of technique. While there was a
the study group had mild fatigue before statistically significant difference
the progressive muscle relaxation between the study and control groups
technique intervention, while 40.0% of after 15 days of progressive muscle
them had mild fatigue in the 15 days relaxation technique in physical
after the progressive muscle relaxation functioning and social and
technique intervention, and 55.0% of occupational activities (p = 0.000 and p
them had mild fatigue after 30 days of = 0.002, respectively), no statistically
the progressive muscle relaxation significant difference was observed
technique intervention. This compares between SLE symptoms, treatment,
to the control group (5.0%, 7.5%, and mood, and self-image (p = 0.555, 0.328,
7.5%), who had mild fatigue prior to 0.273, and 0.242, respectively).
intervention, after 15 days, and after 30 Moreover, there was a statistically
days of progressive muscle relaxation significant difference in all dimensions
technique intervention, respectively. of quality of life after 30 days of
The differences between the study progressive muscle relaxation
group before and after 15 days and technique intervention (0.000*, 0.000*,
after 30 days of progressive muscle 0.018*, 0.001*, 0.000*, and 0.000*,
relaxation technique intervention are respectively).

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

Table (I): Distribution of the Studied Patients according to their


Demographic Characteristics.
Group type Test
Total
Study Control of significant
Items (n=80)
(n=40) (n=40) X2
No % No % No %
Age (in years)
 20˂30 12 30.0 8 20.0 20 25.0 X2=1.088
 30˂40 24 60.0 27 67.50 51 63.75 P= 0.581
 40≤50 4 10.0 5 12.50 9 11.25
Sex
 Male 2 5.0 3 7.5 5 6.25 X2=0.213
 Female 38 95.0 37 92.5 75 93.75 P=0.649
Marital status
 Single 12 30.0 15 37.5 27 33.75 X2=1.876
 Married 19 47.5 16 40.0 35 43.75 P=0.598
 Divorced 1 2.5 3 7.5 4 5.0
 Widowed 8 20.0 6 15.0 14 17.5
Level of education
 Illiterate 3 7.5 2 5.0 5 6.25 X2=3.616
 Read & write 2 5.0 0 0.0 2 2.5 P=0.616
 Primary school education 2 5.0 1 2.5 3 3.75
 Prep school education 2 5.0 4 10.0 6 7.5
 Secondary/technical education 21 52.5 20 50.0 41 51.5
 University education 10 25.0 13 32.5 23 28.75
Occupation
 Manual work 16 40.0 14 35.0 30 37.5 X2=1.451
 Housewife 11 27.5 16 40.0 27 33.75 P=0.484
 Not work 13 32.5 10 25.0 23 28.75
Place of residence
 Urban 14 35.0 18 45.0 32 40.0 X2=0.833
 Rural 26 65.0 22 55.0 48 60.0 P=0.494
Income sufficiency
 Insufficient 38 95.0 36 90.0 74 92.5 X2= 0.721
 Sufficient 2 5.0 4 10.0 6 7.5 P=0.675

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Original Article Egyptian Journal of Health Care, 2022 EJHC Vol 13. No.3

Table (II): Distribution of the Studied Patients according to their Clinical


Data:
Group type Test
Total
Study Control of significant
Items (n=80)
(n=40) (n=40) X2
No % No % No %
Treatment payment system
 Patients expense 7 17.5 4 10.0 11 13.75 X2= 0.949
 State expense 33 82.5 36 90.0 69 86.25 P= 0.518
Disease duration
 Less than 3 years 1 20.5 3 7.5 4 5.0 X2= 1.053
 More than 3 years 39 97.5 37 92.5 76 95.0 P= 0.615
Disease diagnosed
 By sign and symptoms 40 100.0 40 100.0 80 100.0 ….
Complication#
N=60 N=63 N=123
 Renal failure 20 33.3 17 27.0 37 30.1
 Stroke 1 1.7 3 4.8 4 3.3
13 21.7 18 28.6 28 22.8 X2=2.848
 Anemia
24 40.0 19 30.2 43 35.0 P=0.583
 Cardiovascular disease
 Pneumonia 8 13.3 6 9.2 14 11.4
Pervious hospitalization from complication
 Yes 29 72.5 33 82.5 62 77.5 X= 1.147
 No 11 27.5 7 17.5 18 22.5 P= 0.284
# Responses are NOT mutually exclusive.
Figure (1): Distribution of Systemic Lupus Erythematous Patients according to
the Presence of Signs and Symptoms:

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# the center of the figure represents zero percent


Table (III): Effect of Progressive Muscle Relaxation Technique on the Study and Control Groups' Quality of Life:
Study group (n=40) Control group (n=40) X2 (P)
Before After 15 days After 30 days Before After 15 days After 30 days Before
Item intervention X2 (P) after X2 (P) after
No. % No. % No. % No. % No. % No. % 15 day 30 day
intervention intervention
Levels of quality of life
 Poor quality of life 17 42.5 3 7.5 2 5.0 15 37.5 15 37.5 16 40.0
0.480 11.277 23.790
 Fair quality of life 22 55.0 35 87.5 16 40.0 23 57.5 21 52.5 20 50.0
(0.786) (0.020*) (0.000*)
 Good quality of life 1 2.5 2 5.0 22 55.0 2 5.0 4 10.0 4 10.0
X2 (P) X = 83.36 P= 0.000
2
X = 3.100 P= 0.541
2

X2= Chi Square test t= t test * Significant p at ≤0.05


Table (IV): Effect of Progressive Muscle Relaxation Technique on the Study and Control Groups' Fatigue Severity :
Study group (n=40) Control group (n=40) X2 (P)
Before After 15 days After 30 days Before After 15 days After 30 days X2 (P) after X2 (P) after
Item Before
15 day 30 day
No. % No. % No. % No. % No. % No. % intervention
intervention intervention
Fatigue Severity
 No fatigue 0 0.0 0 0.0 3 7.5 0 0.0 0 0.0 0 0.0
 Mild fatigue 3 7.5 16 40.0 22 55.0 2 5.0 3 7.5 3 7.5
25 62.5 20 50.0 12 30.0 21 52.5 19 47.0 18 45.0 11.414 8.556 35.151
 Moderate fatigue
12 30.0 4 10.0 3 7.5 17 42.5 18 45.0 19 47.5 (0.06) (0.019*) (0.000*)
 Sever fatigue
MC (P) P = 0.000
MC P = 0.332
MC

X = Chi-Square test PMC = Monte Carlo test *Significant at P ≤ 0.05


2

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Table V: Effect of Progressive Muscle Relaxation Technique on the Study and Control Groups' Different Domains of Quality of Life:
Dimensions of quality of Before intervention After 15 day of intervention After 30 days of intervention
life Study Control Study Control Study Control
group group group group group group
8.35±1.732 8.025±1.073 14.10±1.316 8.61±0.877 15.95±1.218 8.92±0.720
 Physical functioning
t= 0.479 P= 0.368 t=68.102 P=0.000 t=31.476 P=0.000
 Social and 12.65±2.190 12.50±2.57 19.80±3.24 17.28±3.59 19.85±4.16 17.00±2.56
Occupational activities t=0.581 P=0.780 t=3.26 P=0.002 t=3.695 P=0.000
15.325±3.95 14.10±2.01 15.82±3.40 15.30±4.450 17.40±3.24 15.30±4.45
 SLE Symptoms
t=1.74 P=0.086 t=0.593 P=0.555 t=2.413 P=0.018
6.40±1.19 6.40±1.10 8.205±1.56 7.65±1.83 9.32±2.15 7.80±1.84
 Treatment
t=0.000 P=1.00 t=0.985 P=0.328 t=3.404 P=0.001
8.45±1.35 7.97±1.95 8.92±1.92 8.350±2.66 10.750±1.192 8.85±1.67
 Mood
t=1.262 P=0.211 t=1.106 P=0.273 t=5.84 P=0.000
8.45±1.35 7.97±1.95 17.67±3.51 16.70±3.87 24.27±2.38 17.50±3.4
 Self- image
t=0.398 P=0.692 t=1.79 P=0.242 t=10.30 P=0.000
t= T test *Significant at P ≤ 0.05

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Discussion: results as half of the patients were


Systemic lupus married, females, two-thirds of them
erythematosus (SLE) is a chronic were diagnosed between ages 31 and
disease that affects multiple organ 44, and few male patients were
systems and causes a broad spectrum involved in the study because SLE is a
of clinical and immunological female-predominant disease. In
manifestations (Olesińska & Saletra, addition, Boedecker et al (2020) who
2018). These manifestations not only confirmed that nearly 90% of patients
influence patients' general health, but with systemic lupus erythematosus are
also have serious impact on household females.
responsibilities, parenting roles, The majority of patients were on a
activities of daily living over time, state expense for paying treatment
especially regarding family, social or because the disease medication cost is
recreational events, work performance, highly expensive. Patients, had the
scholastic achievement and quality of disease for more than three years
life. (Aranow, Diamond & Mackay, duration, discover the disease through
2019). Furthermore, SLE patients face its manifestations, suffering from CVD,
many challenges from the disease itself; renal failure, and anemia as disease
multiple types of medications are complications. In the context of the
prescribed to control the disease current study findings, (Aringer et al.,
activity besides its harmful side effects. 2019) found that Long-term use of
In addition; the negative physical and drugs and the inflammatory potential
psychological impact of SLE is of the disease itself cause a host of
exacerbated by the disease's comorbidities such as cardiovascular
unpredictable course. All of these disease, end-stage renal failure, or
factors set a responsibility on the nurse osteoporosis. Also, (Fanouriakis et al.,
to relieve the patient discomfort and 2019) findings have shown that
increase their QOL with a non- cardiovascular disease is the main risk
pharmacological way (Youssef (2021). factor for increased death and organ
Among classical therapy options damage among SLE patients.
or non-pharmacological modalities is In addition, the majority of studied
the progressive muscle relaxation patients were previously hospitalized,
technique. It is considered the most all of them suffering from fatigue, sun
applicable maneuver as it's easy to sensitivity, malar rash, painful swollen
learned and performed. Moreover, joints, headache and difficult
PMR is inexpensive, available, self- concentration. This result was in the
induced by the patients with no side same line with Leuchten et al (2018)
effects. It also gathering the benefits of who reported that (89.4%, 86.7%,
deep breathing exercises and relaxation 79.4%, 76.1%, 66.1%, 33.0%
exercises as Yoga with the welfares of respectively) suffering for fatigue, joint
muscle activity (Elsayed Rady et al., pain, photosensitivity, myalgia, skin
2020). and renal involvement. While, these
The results of the present study results contradict Cojocaru, et al
revealed that approximately two thirds (2011) who found in their study that
of patients were aged from 30 to 40 SLE symptoms vary from one patient
years of age, majority were female, to another either mild, moderate, or
married secondary educated, manual severe. It may come and go, depending
work and house wife, from rural area on which body part is affected.
with insufficient income. This was This was harmonious with
congruent with Brailovski et al, (2019) study results that Youssef (2021)

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conducted to compare the effect of These results was in the same


strengthening exercises on depression, line with the study finding as the study
fatigue and quality of life in both SLE group patients showing a great
and sedentary subjects. It found that improvement in the physical and mood
SLE has reduced exercise capacity due domains of quality of life. As well as,
to fatigue, depression and drugs (Rovsing et al., 2021) reported that
associated with several complications the progressive muscle relaxation
arising from disease progression. This technique enhance decreasing muscle
leads to lower fitness levels, reduced tension, lowering anxiety level by
exercise capacity, reduced muscle distracting attention, reducing fatigue
strength, greater disability, decreased levels, improving sleep quality,
quality of life and increased social physical fitness, mood, and QOL.
dependence when compared to As the study results showed a
sedentary controls. positive impact of PMR on mood and
Concerning the impact of self-imaging dimensions. The reasons
progressive muscle relaxation for this consistency in results can be
technique, it was found a significant attributed to the fact that progressive
difference between the study and muscle relaxation increases the self ‑
control group regarding quality of life
esteem of patients with chronic
dimensions, total quality of life, and
diseases and enhances the patients’
fatigue level even after 15 days and 30
internal control power and increases
days of follow up while there was no
their cognitive abilities (Aarabi et al.,
significant difference between both
2018). Furthermore, Akbari et al
groups before intervention. This may
(2022) refined that complementary
be owed to that patients in the both
therapies, such as progressive muscle
groups are quietly similar in their
relaxation techniques, have many
demographic and disease
physical and psychological effects and
characteristics.
promote the self-care, emotion, and
It is known that patients with
spirituality, resulting in the promotion
SLE have an autonomic dysfunction,
especially decreased parasympathetic of self‑esteem in chronic patients.
function mainly the vagus nerve that Moreover, progressive muscle
controls visceral functions. relaxation, are thought to affect the
(Liboriussen et al., 2022). Vagus pituitary ‑ adrenal axis of the
nerve stimulation can be performed
hypothalamus, preventing
through physiological methods such as
overproduction of cortisol and
deep breathing, which is an essential
improving mood, resulting in a
part of progressive muscle relaxation
relaxing response. It acts as a
technique, yoga, or meditation. As
neuroendocrine mediator in neural
deep breathing make the vagus nerve
circuits, which are responsible for
stimulated through the baroreflex.
regulating mood and emotion
When blood pressure increases, the
(Masmouei et al., 2019).
arterial baroreceptors are activated
The finding of the present study
which in turn activates of the vagus
also supported by Izgu et al., (2020)
nerve, that direct the vagus nerve
who examine the effects of progressive
signals to the sinoatrial node in the
muscle relaxation and mindfulness
heart, resulting in decreased heart rate
meditation on the severity of diabetic
(Bonaz et al., 2016; Yap et al., 2020;
peripheral neuropathic pain (DPNP),
Rovsing et al., 2021).
fatigue, and quality of life in patients
with type 2 diabetes. They found that
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both progressive muscle relaxation and well as enable patients to gain


mindfulness meditation had a positive beneficial effects on SLE patients'
impact on providing pain relief and quality of life and fatigue. Future
fatigue in patients with DPNP. In studies with a larger sample size and
addition, Ebrahem & Masry (2017) long-term follow-up are warranted to
found a positive impact of relaxation support the findings of this study.
therapy on depression, anxiety, stress
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