ORIGINAL ARTICLE

Effects of relaxation training on sleep quality and fatigue in patients

with breast cancer undergoing adjuvant chemotherapy
Meral Demiralp, Fahriye Oflaz and Seref Komurcu

Aim. The purpose of this study was to investigate the effect of progressive muscle relaxation training on sleep quality and
fatigue in Turkish women with breast cancer undergoing adjuvant chemotherapy.
Background. Sleep problems and fatigue are highly prevalent in patients with breast cancer. Progressive muscle relaxation
training is a promising approach in ameliorating the sleep quality and reducing the fatigue associated with cancer and its
treatment.
Design. A prospective, repeated measures, quasi-experimental design with control group.
Methods. The study sampling consisted of 27 individuals (14 individuals formed the progressive muscle relaxation group, 13
individuals formed the control group) who met the criteria for inclusion in the study. Progressive muscle relaxation training was
given to the progressive muscle relaxation group, but not to the control group. The effect of the progressive muscle relaxation
training was measured at different stages of the treatment. A data collection form, Pittsburgh Sleep Quality Index and Piper
Fatigue Scale were used to collect the data for this study.
Results. The progressive muscle relaxation group experienced a greater increase in improved sleep quality and a greater decrease
in fatigue than the control group.
Conclusions. The findings indicated that progressive muscle relaxation training would improve sleep quality and fatigue in
patients with breast cancer undergoing adjuvant chemotherapy.
Relevance to clinical practice. Progressive muscle relaxation training given by a nurse can improve sleep quality and fatigue in
patients with breast cancer. It is important to start relaxation training just before chemotherapy to decrease the frequency and
severity of sleep problems and symptoms such as fatigue during chemotherapy.

Key words: breast cancer, fatigue, nurse, nursing, relaxation training, sleep quality

Accepted for publication: 10 June 2009

after the initial treatments that may negatively impact on the

Introduction
In Turkey, breast cancers comprise 24Æ96% of all cancer
diseases, and the survival rate has increased over the last
10 years (Health Statistics 2004). Even in cases where breast
cancer treatments are successful, they still have side effects
patient’s quality of life. A successful course of chemotherapy
can produce a variety of unpleasant side effects such as
nausea, vomiting, fatigue, powerlessness, decreased mental
and physical capacity, neurological and emotional problems
and sleep problems in these patients (Vockins 2004, Williams

Authors: Meral Demiralp, PhD, RN, Professor, Psychiatric Nursing Correspondence: Meral Demiralp, Professor, Psychiatric Nursing
Department, Gulhane Military Medical Academy, School of Nursing; Department, Gulhane Military Medical Academy, School of Nursing,
Fahriye Oflaz, PhD, Assistant Professor, The Chief of Psychiatric Etlik 06018, Ankara, Turkey. Telephone: +90 312 304 39 55.
Nursing Department, Gulhane Military Medical Academy, School of E-mail: meral_demiralp@yahoo.com
Nursing; Seref Komurcu, MD, Professor, Medical Oncology
Department, Gulhane Military Medical Academy, Etlik, Ankara,
Turkey

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083 1073
doi: 10.1111/j.1365-2702.2009.03037.x
M Demiralp et al.
& Schreier 2004, Yoo et al. 2005, Fillion et al. 2008).
Broeckel et al. (1998) have reported that patients with breast
cancer have more fatigue problems related to poor sleep
quality than non-cancer patients. Broeckel’s study emphasised
the need for interventions that will improve quality of life in
patients with breast cancer. Non-pharmacologic approaches,
which include relaxation exercises, may provide the greatest
promise in relieving symptoms (Barraclough 1996, Molassi-
otis 2000, Shell & Kirsch 2001, Wright et al. 2002).
Patients with breast cancer need qualified and comprehen-
sive care in relation to their diagnosis and treatment and also
in relation to their physiological, sociological, psychological
well-being. Liu et al. (2008) have indicated that, if specific
interventions targeting a cluster of symptoms are begun
before the initiation of chemotherapy, it is possible that
patients will also experience fewer symptoms during treat-
ment. Also they reported that randomised controlled treat-
ment studies exploring these questions are needed.
It is thought that advanced level nursing practices such as
‘relaxation training’ provide symptom control and that they
improve patients’ quality of life in relation to the side effects
of currently performed chemotherapy protocols. There is no
study that specifically addresses the effect of progressive
muscle relaxation training (PMRT) for patients who have
undergone adjuvant chemotherapy for breast cancer in
Turkey. The present study evaluates whether PMRT
improves sleep quality and reduces fatigue in breast cancer.
Background
Sleep quality in patients with breast cancer
Sleep problems in cancer patients have been reported to be
much higher (23–61%) than in control groups (approximately
15%) and the general population (9–30%). The reported
types of sleep problems were characterised by multiple
awakenings during the night, sleeping fewer hours than
normal, trouble getting back to sleep, trouble falling asleep
(sleep latency) and daytime dysfunction (Simeit et al. 2004).
In recent studies, it has been revealed that patients with
breast cancer experience significant sleep difficulties at
diagnosis, during treatment and following treatment (Nort-
house et al. 1999, Davidson et al. 2002, Ancoli-Israel et al.
2006). Savard et al. (2001) argue that 51% of women treated
for breast cancer reported non-specific sleep difficulties, and
19% met diagnostic criteria for an insomnia syndrome.
Fortner et al. (2002) reported that 61% of patients with
breast cancer had significant sleep problems. Prue et al.
(2006), in their review, suggested that all studies reported an
association between higher fatigue and poorer sleep quality.
1074  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
There are no available data about the sleep quality of patients
with breast cancer who live in Turkey.
Fatigue in patients with breast cancer
Fatigue is one of the most frequent and disturbing complaints
of cancer patients with over 75% of patients undergoing
cytotoxic chemotherapy, radiation therapy or treatment with
biological response modifiers reporting feeling tired and
weak. It has been defined by the National Comprehensive
Cancer Network (NCCN) as ‘a distressing, persistent,
subjective sense of tiredness or exhaustion related to cancer
or cancer treatment that is not proportional to recent activity
and interferes with usual functioning.’ (NCCN 2007) Ancoli-
Israel et al. (2001), in a review of sleep and fatigue in cancer,
suggested that fatigue is caused by multiple factors including
physiological factors such as pain or anaemia, chronobiolog-
ical factors such as sleep circadian rhythms, psychological
factors such as depression or anxiety and socio-cultural
factors. Cancer-related fatigue can have a profound impact
on an individual’s life with significant physical, emotional,
social and economic consequences that may persist for
months or years after completing treatment (Prue et al.
2006).
Fatigue or low energy level is one of the most frequent and
distressing symptoms experienced by women with breast
cancer who receive adjuvant chemotherapy. Dirksen and
Epstein (2008) stress that women with breast cancer have
reported some of the highest rates of fatigue when compared
to other types of cancer, with estimates ranging from an
incidence of 99% during adjuvant chemotherapy to a rate of
38% after treatment completion. It is reported that people
with cancer have excessive fatigue with a twofold increase in
insomnia and particularly susceptible were patients with
breast cancer (Davidson et al. 2002). Despite its prevalence,
there are also no available data about the management of
fatigue in Turkish women with breast cancer.
PMRT for sleep quality and fatigue
Cognitive and behavioural techniques for symptom manage-
ment in cancer patients are safe alternatives. PMRT is one of
these techniques and includes voluntary, systematic and
continuous stretching and relaxing of the muscles until the
whole body becomes relaxed. It was named and developed by
Edmund Jacobsen in 1929, and Herbert Benson made it more
accessible to everyone in 1975 (Lovejoy et al. 2000, Lee et al.
2005).
According to this technique, the patient must sit on a
comfortable seat. Playing soft music and showing enjoyable
Original article
visual signs are also important. The relaxation procedures
need to be explained to the patients before beginning the
exercises. Patients start by breathing in deeply and then
slowly breathing out. Stretching exercises follow. Patients
stretch each muscle group for 10 seconds, and while this is
going on, the nurse makes the patient feel the difference
between stress and relaxation by guiding her with instruc-
tions such as: ‘now feel the heats in your hands’, ‘now feel the
tenseness going down through your shoulders and disappear-
ing’. Patients actuate the muscle groups one by one starting
with their hands and then, in order, shoulders, chest and
other muscles down to the feet (Molassiotis 2000, Moore &
Schmais 2001, Stuart 2001, Kneisl 2004).
Early studies report that relaxation training and imagery
were effective in providing a decrease in the latency of sleep
onset and an increase in the duration of sleep in those patients
suffering from insomnia (Cannici et al. 1983, Stam & Bultz
1986). Nowadays various interventions are used, including
relaxation exercises to decrease fatigue, anxiety and depres-
sion and sleep problems as well as side effects such as nausea
and vomiting related to chemotherapy (Molassiotis 2000,
Shell & Kirsch 2001, Adamsen et al. 2003, Wilson et al.
2006, Rabin et al. 2008). A qualitative and quantitative study
on a group of cancer patients carried out by Wright et al.
(2002) reports that, after autogenic relaxation exercise,
falling asleep becomes easier, fatigue is decreased, and the
patients’ ability to cope emotionally is increased, Another
study shows that breathing and relaxation exercises made a
significant decrease in the fatigue scores of bone marrow-
transplanted patients (Kim & Kim 2005). As shown in the
studies, these interventions may improve multiple symptoms
at the same time (Savard et al. 2005, Kirshbaum 2007). In
Turkey, a randomised trial is still needed to document the
efficacy of an intervention to improve fatigue and sleep
problems in patients with breast cancer.
Aim
The aim of this study is to evaluate the effects of PMRT on
sleep quality and the fatigue level of patients with breast
cancer.
Methods
Research design and participants
This study employed a prospective, repeated measures, quasi-
experimental design with a control group. Patients were
recruited from the outpatient unit of the Medical Oncology
Department, Gulhane Military Medical Academy, Turkey.
 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
Effects of relaxation training on sleep quality and fatigue
Patients who have been diagnosed with breast cancer and
have planned to be treated with adjuvant chemotherapy come
to this unit. They are given a treatment card and medicines.
They are referred to a nurse and tracked in the treatment.
The study sample criteria for inclusion were as follows:
(1) recently diagnosed breast cancer and having adjuvant
chemotherapy protocol for the first time, (2) being 25–
65 years old, (3) having no recent psychological treatment
(including medication and psychotherapy), (4) having no
metastasis, (5) living in the city where the research was
carried out, (6) being literate in Turkish and (7) being willing
to participate in the study.
Instruments
The Pittsburgh Sleep Quality Index (PSQI), was developed by
Buysse et al. (1989) to evaluate sleep quality in psychiatric
practices and clinical researches. The PSQI, a 19-item tool,
measures the subjective sleep quality during the previous
month. The total score includes seven components: sleep
quality, sleep latency, sleep duration, habitual sleep effi-
ciency, sleep disturbances, sleeping medication use and
daytime dysfunction. Components are weighted equally on
a 0–3 scale, yielding a global score ranging from 0–21.
A global score >5 indicates ‘poor’ sleep. This validity and
reliability of this scale for Turkey was assessed by Ağargün
et al. (1996), and its Cronbach’s alpha reliability was
determined as 0Æ804. The Cronbach’s alpha was considered
that because of the time element, the patients’ misunder-
standings of some questions may have been the cause of this
lower alpha value.
The Piper Fatigue Scale (PFS) was specifically developed to
measure fatigue in cancer patients (Piper et al. 1998). It
consists of 22 items numerically scaled from 0–10 that
measure four subscales of subjective fatigue: behavioural/
severity, affective meaning, sensory and cognitive/mood. The
fatigue mean is obtained by calculating the sum of subscale
score/number of item. Higher scores indicate more fatigue.
A validity and reliability study of the PFS for Turkey was
carried out by Can et al. (2004), and the Cronbach’s alpha
for the entire 22-item scale was 0Æ97. The Cronbach’s alpha
for the PFS scale in our study was 0Æ98.
Ethical consideration
The study was approved by the Medical Research Ethics
Committee of the Gulhane Military Medical Academy,
Ankara, Turkey. The study was explained to the patients,
and permission from participants was sought by informed
consent, while confidentiality and anonymity were assured.
1075
M Demiralp et al.
Participants had the right to withdraw from the study at any
time. The researcher assessed each patient’s eligibility for
enrolment.
Data collection
Data were collected between March 2005–2006. The
sample of the study consisted of 27 newly diagnosed
breast cancer patients who had planned to be cured with
adjuvant chemotherapy. Patients who met these study
criteria were accepted to the research programme and
assigned to one of two groups, either progressive muscle
relaxation (PMR) group (n = 14) or control (n = 13) group
sequentially.
Socio-demographic and clinical characteristics, sleep qual-
ity and fatigue were measured as pretest data by the
researchers. The average time for completing the measure-
ments was 15 minutes. After obtaining an information form
including socio-demographic and clinical characteristics of
patients, ‘PSQI’ and ‘PFS’ were only used to collect data on
the days of measurement.
Data were collected from each group at the following four
times: (1) before the first cycle of chemotherapy and relaxing
training when the patients referred to the outpatient clinic for
the first time (first measurement-baseline), (2) on the seventh
day following the first chemotherapy session (second mea-
surement), (3) on the 43rd day following the first chemo-
therapy session, which was the first day of the third
chemotherapy cycle (third measurement), (4) on the 90th
day following the first chemotherapy session, which was the
sixth day following the fourth chemotherapy cycle (fourth
measurement).
Each participant completed both questionnaires PSQI and
PFS four times as previously planned. These forms were filled
out by the researchers who asked the patients the questions
on the first and third measurements in the hospital. On the
second and fourth measurements, the forms were completed
by the patients at home. After they had completed these
forms, they brought them to the researchers when they came
in the hospital to receive chemotherapy.
Procedure
Following the eligibility assessment and obtaining informed
consent, PMR group patients were invited to a private
practice room for relaxation training. Patients in the PMR
group were given PMRT in addition to their chemotherapy
and routine nursing services at the outpatient unit. Patients
who were in control group had their chemotherapy and
routine nursing services without PMRT.
1076  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
Intervention
The goal of the PMRT was to improve the sleep quality and
to decrease fatigue. Each session of PMRT was approxi-
mately 25–30 minutes long. PMRT sessions were performed
on the first and fifteenth day of each chemotherapy cycle.
Thus, after four chemotherapy cycles, eight PMRT sessions
had been performed in total. During the training, a structured
and standardised CD recording including music and some
directives were used. After the first PMRT session, research-
ers gave a CD to the patients in PMR group and told them
that it is necessary to do the exercises every day at home as
performed earlier. Control group patients completed the
pretests, and the other repeated measurements without
having PMRT or CD.
PMRT sessions were performed in a comfortable armchair
in a private air-conditioned room at the outpatient unit. The
room was well-lit and comfortably warm. For the patients’
comfort during the relaxation exercises, they had been told
to wear comfortable clothes (such as tracksuits).
Data analysis
In our research, for statistical analysis of data, Leven’s
homogeneity test, Kolmogorov–Smirnov test, frequencies,
arithmetical mean, Wilcoxon signed ranks test, Student t-test,
Mann Whitney U test, Kruskal Wallis variance analysis and
variance analysis of repeated measures were used. Values of
p < 0Æ05 were considered significant. The SPSS 15.0 package
(SPSS Inc., Chicago, IL, USA) for Windows was used to
compute the data. When the homogeneity of variances was
not provided, non-parametric tests were used for analysis.
Results
There were no statistically significant differences between the
PMR and the control group in relation to age, marital status,
educational status, body mass index, surgery types, breast
cancer clinical stage or treatment types (p > 0Æ05).
The effects of the relaxation training on sleep quality were
assessed by comparing the patients in PMR and control group
(Table 1). At baseline, PSQI total mean scores were >5 in
both PMR and control groups. The PSQI scores for PMR and
control groups were not statistically different (p > 0Æ05), and
patients in both groups experienced poor sleep quality.
Later measurements showed that mean ‘subjective sleep
quality’ score on the third and fourth measurements; mean
‘sleep latency score’ on the second, third and fourth
measurements; mean sleep duration score on the second,
third and fourth measurements; mean ‘habitual sleep
Original article Effects of relaxation training on sleep quality and fatigue

Table 1 Effects of the relaxation training on the sleep quality and sleep quality scores on different days

Pittsburgh *Comparisons
Sleep Group 1. 2. 3. 4. between
Quality PMR: Measurement Measurement Measurement Measurement measurements
Index n = 14 (baseline) (seventh day) (43rd day) (90th day)
components C: n = 13 X ± ss X ± ss X ± ss X ± ss *F p

Subjective PMR 1Æ28 ± 0Æ61 1Æ14 ± 0Æ66 0Æ42 ± 0Æ51 0Æ92 ± 0Æ61 2Æ915 *0Æ040
sleep quality Control 1Æ30 ± 0Æ63 1Æ30 ± 0Æ63 1Æ38 ± 0Æ76 1Æ53 ± 0Æ51

U; p 89Æ000; 0Æ912 79Æ000; 0Æ513 32Æ000; 0Æ002 46Æ000; 0Æ014
Sleep latency PMR 1Æ21 ± 1Æ05 0Æ92 ± 0Æ73 0Æ64 ± 0Æ84 1Æ07 ± 1Æ07 1Æ439 0Æ238
Control 1Æ76 ± 0Æ83 1Æ53 ± 0Æ66 2Æ00 ± 1Æ00 1Æ92 ± 0Æ75

U; p 61Æ000; 0Æ128 53Æ000; 0Æ043 29Æ500; 0Æ002 47Æ000; 0Æ026
Sleep duration PMR 0Æ85 ± 0Æ74 0Æ21 ± 0Æ57 0Æ07 ± 0Æ26 0Æ07 ± 0Æ26 1Æ506 0Æ220
Control 0Æ84 ± 0Æ89 0Æ53 ± 0Æ77 0Æ53 ± 0Æ77 0Æ76 ± 0Æ92

U; p 69Æ000; 0Æ292 51Æ500; 0Æ050 42Æ500; 0Æ012 32Æ000; 0Æ002
Habitual sleep PMR 0Æ94 ± 0Æ07 0Æ93 ± 0Æ12 0Æ93 ± 0Æ07 0Æ91 ± 0Æ11 1Æ648 0Æ186
efficiency Control 0Æ93 ± 0Æ16 0Æ81 ± 0Æ17 0Æ87 ± 0Æ14 0Æ85 ± 0Æ16

U; p 76Æ500; 0Æ402 39Æ500; 0Æ012 31Æ000; 0Æ003 40Æ000; 0Æ012
Sleep PMR 1Æ50 ± 0Æ51 1Æ42 ± 0Æ51 1Æ28 ± 0Æ46 1Æ14 ± 0Æ53 1Æ088 0Æ360
disturbances Control 1Æ53 ± 0Æ51 1Æ46 ± 0Æ77 1Æ30 ± 0Æ48 1Æ76 ± 0Æ59

range U; p 87Æ500; 0Æ845 89Æ000; 0Æ913 89Æ000; 0Æ902 44Æ000; 0Æ010
Use of sleeping PMR 0Æ07 ± 0Æ27 0Æ00 ± 0Æ00 0Æ00 ± 0Æ00 0Æ00 ± 0Æ00 1Æ007 0Æ408
medication Control 0Æ00 ± 0Æ00 0Æ07 ± 0Æ27 0Æ07 ± 0Æ27 0Æ00 ± 0Æ00

U; p 84Æ500; 0Æ335 84Æ000; 0Æ299 84Æ000; 0Æ299 91Æ000; 1Æ000
Daytime PMR 0Æ78 ± 0Æ69 0Æ64 ± 0Æ63 0Æ35 ± 0Æ49 0Æ50 ± 0Æ51 1Æ536 0Æ212
dysfunction Control 0Æ61 ± 0Æ65 1Æ07 ± 0Æ86 0Æ84 ± 0Æ80 0Æ53 ± 0Æ51

U; p 79Æ000; 0Æ520 65Æ500; 0Æ173 60Æ000; 0Æ095 87Æ500; 0Æ845
Total score PMR 6Æ16 ± 2Æ28 5Æ29 ± 2Æ03 3Æ72 ± 1Æ96 4Æ63 ± 2Æ38 2Æ091 0Æ108
(scale range Control 7Æ00 ± 1Æ98 6Æ81 ± 2Æ66 7Æ03 ± 2Æ55 7Æ39 ± 2Æ40

0–21) U; p 68Æ500; 0Æ274 61Æ000; 0Æ144 27Æ000; 0Æ002 30Æ500; 0Æ003

PMR, progressive muscle relaxation.

*Two-sided variant analysis on repeated measurements.

Mann Whitney U-test.

efficiency score’ on the second, third and fourth measure-

ments and mean ‘sleep disturbances range score’ on the
fourth measurement were significantly different between two
7·00
groups. The mean ‘total PSQI score’ on the third measure-
ment and fourth measurement were also significantly differ-
PSQI total scores

ent. All these mean ‘PSQI subcomponents’ and mean ‘total 6·00
PSQI scores’ of the PMR group were significantly lower than
control group (p < 0Æ05).
When we compared the mean PSQI ‘subcomponents score’ 5·00

of the patients on different days, we observed statistically Group

significant differences in their mean ‘subjective sleep quality’
4·00 PMR
(Table 1). For the ‘subjective sleep quality subcomponent’,
Control
there was statistically significant difference between third and
fourth measurements. Also in mean ‘total PSQI scores’, the 1 2 3 4
third measurement of PMR group has an important decrease Repeated measurements
(Fig. 1).
Figure 1 Pittsburgh Sleep Quality Index total score profile of pro-
In Table 2, the effects of relaxation training on fatigue gressive muscle relaxation and control groups in repeated measure-
scores in the PMR and control groups were compared. At ments. Repeated measurements: 1, baseline; 2, seventh day; 3, 43rd
baseline measurement, the PFS scores of PMR and control day; 4, 90th day.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083 1077
M Demiralp et al.

Table 2 Effect of relaxation training on the fatigue scores and fatigue scores on different days

*Comparisons
Group 1. 2. 3. 4. between
PMR: Measurement Measurement Measurement Measurement measurements
Fatigue n = 14 (baseline) (seventh day) (43rd day) (90th day)
subscale C: n = 13 X ± ss X ± ss X ± ss X ± ss *F p

Behavioural/ PMR 4Æ00 ± 2Æ20 4Æ50 ± 2Æ90 3Æ24 ± 2Æ37 4Æ57 ± 2Æ89 3Æ226 *0Æ027
severity Control 4Æ17 ± 1Æ66 6Æ09 ± 2Æ79 5Æ21 ± 1Æ85 5Æ67 ± 1Æ77

z; p 0Æ073; 0Æ942 1Æ288; 0Æ198 2Æ331; 0Æ020 1Æ068; 0Æ285
Affective PMR 4Æ57 ± 2Æ16 4Æ53 ± 2Æ24 2Æ89 ± 1Æ57 4Æ37 ± 2Æ12 1Æ103 0Æ353
meaning Control 5Æ12 ± 2Æ67 6Æ35 ± 2Æ41 6Æ60 ± 2Æ15 6Æ20 ± 2Æ25

z; p 0Æ146; 0Æ884 1Æ798; 0Æ072 3Æ474; 0Æ001 1Æ969; 0Æ049
Sensory PMR 3Æ96 ± 2Æ59 3Æ63 ± 2Æ33 2Æ64 ± 2Æ15 4Æ21 ± 2Æ50 5Æ072 *0Æ003
Control 3Æ86 ± 1Æ90 5Æ69 ± 2Æ42 5Æ48 ± 1Æ20 6Æ74 ± 1Æ96

z; p 0Æ024; 0Æ981 1Æ943; 0Æ052 3Æ280; 0Æ001 2Æ517; 0Æ012
Cognitive/mood PMR 3Æ27 ± 2Æ83 2Æ92 ± 2Æ44 2Æ42 ± 1Æ93 3Æ36 ± 2Æ63 3Æ576 *0Æ018
Control 3Æ95 ± 1Æ52 5Æ47 ± 3Æ03 5Æ35 ± 1Æ67 6Æ59 ± 2Æ21

z; p 0Æ753; 0Æ451 2Æ113; 0Æ035 3Æ333; 0Æ001 2Æ964; 0Æ003
Total Fatigue PMR 3Æ95 ± 2Æ22 3Æ89 ± 2Æ27 2Æ79 ± 1Æ93 4Æ12 ± 2Æ44 3Æ798 *0Æ014
Score Control 4Æ27 ± 1Æ57 5Æ90 ± 2Æ45 5Æ65 ± 1Æ41 6Æ29 ± 1Æ65

z; p 0Æ097; 0Æ923 1Æ119; 0Æ263 2Æ389; 0Æ017 2Æ608; 0Æ009

PMR, progressive muscle relaxation.

*Two-sided variant analysis on repeated measurements.

Mann Whitney U-test (discontinuous value is used).

groups were not different (p > 0Æ05). PFS total mean scores
showed that all patients in both of PMR and control groups 6·00
experienced moderate fatigue.
In PFS; mean ‘behavioural/severity fatigue score’ on the
third measurement, mean ‘affective meaning fatigue’ score on
5·00
Pfs total scores

the third and fourth measurements, mean ‘sensory fatigue

score’ on the third and fourth measurements, mean ‘cogni-
tive/mood fatigue score’ on the second, third and fourth
measurements and mean ‘total fatigue score’ subcomponent 4·00

on the third and fourth measurements were significantly

Group
different. All these mean ‘PFS subcomponents’ and mean PMR
‘total PFS scores’ of the PMR group were significantly lower 3·00 Control
than control group (p < 0Æ05) (Table 2).
1 2 3 4
When the mean ‘PFS subcomponents scores’ of the patients Repeated measurements
were compared on different days, there were statistically
significant differences in the mean ‘behavioural/severity Figure 2 Piper Fatigue Scale total score profile of progressive
muscle relaxation and control groups in repeated measurements.
fatigue score’, mean ‘sensory fatigue score’, mean ‘cognitive/
Repeated measurements: 1, baseline; 2, seventh day, 3, 43rd day;
mood fatigue score’ and mean ‘total fatigue score’ (p < 0Æ05).
4, 90th day.
There were statistically significant differences between the
second and third measurements of the behaviour/severity
subcomponent, in the sensory subcomponent between the
third and fourth measurements, in the cognitive/mood
Discussion
subcomponent between the third and fourth measurements
and in the total fatigue scores between third and fourth The goal of this study was to assess the effect of PMRT on
measurements. Also when looking at the total fatigue score sleep quality and fatigue in women with breast cancer
profile, in the third measurement, it can be seen that PMR undergoing adjuvant chemotherapy. These results indicate
group mean scores showed a considerable decrease (Fig. 2). that patients who received such training showed a significantly

1078  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
Original article
greater improvement in their sleep quality and a significant
reduction in perceived fatigue.
Liu et al. (2008) in their prospective study emphasised that
too many cancer patients with depression and fatigue have
received inadequate treatment for their symptoms. This
resulted in a call for prospective studies on the definition,
occurrence, assessment and treatment of these symptoms, as
well as for theoretically driven research to support the
concept of cancer symptom clusters. Our study is the first
research in response to this call to have been conducted in
Turkey.
At baseline measurement (first measurement), PMR and
control groups’ scores of sleep quality were >5, indicating
that they had experienced poor sleep during the last month
before the chemotherapy. Ancoli-Israel et al. (2006), in their
review study, reported that sleep disturbance and fatigue were
reported by cancer patients before the initiation of chemo-
therapy. However, they hypothesised that those women who
began treatment with a higher symptom cluster index would
also suffer from more symptoms during treatment than those
women who began treatment with fewer symptoms. Berger
et al. (2007) also reported sleep maintenance problems and
mild fatigue experienced by women with breast cancer even
before receiving chemotherapy. Liu et al. (2008) indicated
that specific interventions for these pretreatment symptoms
may improve the frequency and severity of these same
symptoms during chemotherapy. In the light of these articles,
our baseline values are important as they show the presence of
poor sleep quality before chemotherapy in patients with
breast cancer living in Turkey. We believe it is, therefore,
important to start relaxation training just before chemother-
apy to decrease the frequency and severity of sleep problems
and symptoms such as fatigue during the chemotherapy.
In this study, the second measurement day is the day on
which the active phase of chemotherapy begins. On the
second measurement day, it can be seen that sleep latency and
subjective sleep quality of the PMR group had better mean
scores than control group. Therefore, it has been determined
that the occurrence of falling asleep during the day in PMR
group was decreased, and the sleeping time in bed was
increased. Kuo et al. (2006) show the poor sleep quality and
daytime sleepiness in patients with breast cancer during the
active phase of chemotherapy. In another study, Liu et al.
(2008) also report that patients with breast cancer have poor
sleep quality during the active phase of chemotherapy. A
descriptive study on patients with breast cancer by Roscoe
et al. (2002) has shown disturbances in the circadian rhythm
scores of patients with breast cancer 7–10 days after the first
chemotherapy. They also report that disruption of circadian
rhythm is significantly correlated with increased symptoms
 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
Effects of relaxation training on sleep quality and fatigue
of fatigue. Our control group results are consistent with the
results of this study. Our control group patients had poor
sleep quality on the second measurement day during the
active phase of chemotherapy. The sleep latency and
subjective sleep quality scores of our PMR group patients
were significantly better than the control group. It is
surprising that sleep scores improved as little as seven days
after starting relaxation exercises. Moore and Schmais (2001)
have suggested that personal differences and the willingness
and concentration of the subject are important in the
relaxation experience. In this study on newly diagnosed
patients with breast cancer receiving adjuvant chemotherapy
in Turkey, our patients participated with a high degree of
motivation. The relaxation exercises were seen by our PMR
group patients as a special and meaningful approach different
from routine nursing care and were accepted willingly. We
believe this influenced our second measurement results.
The third measurement sleep quality scores indicated that,
in contrast to the control group, the PMR group subjects
believed that their sleep quality had been better, that they had
fallen asleep more quickly and stayed asleep longer and that
their sleep quality had generally been better during the last
month. The third measurement day had special significance in
our study (Fig. 1). Total sleep quality score of the third
measurement day revealed that the PMR group had better
sleep quality. The reason for the improved sleep quality in the
PMR group in our study may have been the cumulative effect
of regular daily relaxation exercises. Simeit et al. (2004) have
separated patients with diagnoses of various types of cancer
into three groups: (1) muscle relaxation training group, (2)
autogenic training group and (3) control group. They found
that muscle relaxation and autogenic training influenced
sleep (sleep latency and sleep durations) and fatigue scores
after four weeks. Davidson et al. (2001) found a decrease in
the number of times patients awoke during the night and an
increase in sleep efficiency and in total sleep time on the
eighth week in their non-pharmacological group therapy
(including relaxation exercises) study on cancer survivors. In
our study, the duration between starting relaxation exercises
and the third measurement day was six weeks, and we can
see that PMRT enabled an improvement in sleep quality in
these six weeks. We also found a significant improvement in
sleep efficiency, in contrast to the findings of Simeit et al.
(2004) but similar to those of Davidson et al. (2001). We feel
that the improvement in sleep efficiency in addition to sleep
duration is important in assessing sleep quality in our patients
with breast cancer. Our patients did not use any medication
that could influence sleep quality during any measurement.
There was no change in the ‘daytime dysfunction’ component
throughout the study.
1079
M Demiralp et al.
The fourth measurement sleep quality values showed a
mild increase compared to the third measurement values
regarding subjective sleep quality, sleep latency, sleep dura-
tion and sleep efficiency. However, the PMR group total sleep
quality score was still <5, indicating good sleep quality. By
contrast, the control group had poor-sleep quality. The
relaxation exercises schedule we planned had the patients
performing their last training exercise on the 78th day
following chemotherapy with no exercises until the 90th day
measurement. We believe the 90th day measurement changes
in sleep quality values of the PMR group were because of the
discontinuation of relaxation exercises. However, our PMR
group still had the best sleep quality on the fourth measure-
ment. There was also a significant improvement in the ‘sleep
disturbance range’ (a component of sleep quality in the PMR
group) on the fourth measurement. Our result for this
component is similar to those reported by Simeit et al.
(2004) and need to be investigated in future studies. Our
results indicate that PMRT improves the poor sleep quality
present before and during chemotherapy in patients with
breast cancer.
The perceived fatigue baseline values and first measure-
ment of the PMR and control groups in our study showed a
moderate degree of perceived fatigue in our cases. We found
that most intervention-type studies for symptom control had
accepted fatigue as a side effect of chemotherapy and started
after chemotherapy and other treatments had been completed
(Savard et al. 2005, Epstein & Dirksen 2007, Dirksen &
Epstein 2008, Fillion et al. 2008, Rabin et al. 2008). How-
ever, our results indicate that fatigue, as with sleep quality
problems, starts as soon as diagnosis of breast cancer is made
(before chemotherapy is started). In contrast to other studies,
the results of our study have shown the importance of starting
symptom management before chemotherapy. We believe that
the surgical treatment undergone by our patients as recently
as two to three weeks ago, the emotional stress because of the
diagnosis of breast cancer and the poor sleep quality may
have caused the baseline fatigue in our patients. Defining
patient symptoms after diagnosis but before chemotherapy
for future studies will make important contributions to
symptom management during breast cancer treatment.
Ancoli-Israel et al. (2006), Berger et al. (2007) and Liu et al.
(2008) have also reported fatigue, sleep problems and
depressive symptoms in patients before chemotherapy.
When we analysed the second measurement perceived
fatigue results of our study, we found a significant change
only for the cognitive/mood subcomponent between the
PMR and control groups. The PMR group felt better than
the control group with no effect on cognitive functions on
this measurement day when chemotherapy side effects were
1080  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
present. The first intergroup difference for fatigue percep-
tion was in the second measurement cognitive/mood
subcomponent but, looking at the total fatigue scores, it
may be said that our patients still perceived fatigue on the
second measurement day. Our control group patients
perceived a moderate degree of fatigue on the second
measurement day, when chemotherapy side effects were
present, similar to the literature (Berger & Higginbotham
2000, Molassiotis et al. 2002, Roscoe et al. 2002, Kuo et al.
2006).
The highest second measurement mean scores in our study
for perceived fatigue were for affective meaning and the
lowest for the cognitive/mood subcomponent. Can et al.
(2004) have also found that the highest mean scores were for
sensory/affective meaning in their study on patients with
breast cancer receiving adjuvant chemotherapy in Turkey.
Some other studies have reported that the biggest increase in
patients with breast cancer receiving chemotherapy was in
the cognitive/mood subcomponent (Berger 1998, Broeckel
et al. 1998, Woo et al. 1998). Our results are similar to the
study by Can et al. (2004). We believe the emotional needs of
our patients and the ways they live with the disease are
influenced by cultural factors that may also increase the
emotional impact of fatigue.
We found an improvement in all components of perceived
fatigue in the PMR group compared to the control group in
the third measurement results of our study. The PMR group
was better able to perform daily routine activities and felt
more rested and better compared to the control group and
suffered no adverse effect on their cognitive functions.
Davidson et al. (2001) report a significant improvement in
fatigue and sleep scores at the end of eight weeks in their
non-pharmacological treatment group including relaxation
exercises in their study on cancer survivors. Adamsen et al.
(2004) have reported an improvement in fatigue symptoms in
six weeks in cancer patients with the multidimensional
exercise programme they developed. Kim and Kim (2005)
found a significant decrease in perceived fatigue subcompo-
nents with six weeks of relaxation exercises in their study on
patients who had received bone marrow transplants. Our
results are similar to this study.
The third measurement results are significantly different
from the other measurement days. We found a significant
decrease in the levels of perceived fatigue in the PMR group
on the third measurement day compared to the other
measurement days (Fig. 2). Our PMR group patients per-
formed their daily relaxation exercises regularly in the
six weeks until the third measurement day, and the cumula-
tive effect led to a marked improvement in the total fatigue
score. The improvement in perceived fatigue was parallel to
Original article
the improvement in sleep quality. Recent studies also show
that a similar approach to symptom management in cancer
patients improves multiple symptoms (Wilson et al. 2006,
Kirshbaum 2007, Dirksen & Epstein 2008, Fillion et al.
2008, Liu et al. 2008, Rabin et al. 2008).
The fourth measurement PMR mean group scores were
slightly increased, although there was still a significant
difference in perceived fatigue between the groups. The
PMR group showed a moderate degree of fatigue on the
fourth measurement day. The relaxation exercises schedule
we planned had the patients performing their last training
exercise on the 78th day following chemotherapy. They did
not continue the exercises until the fourth measurement day
(90th day). This change in the levels of perceived fatigue is
thought to be because of the discontinuation of relaxation
exercises. Broeckel et al. (1998) have reported that patients
with breast cancer have a high risk of fatigue, after
chemotherapy is completed. The increase in the fatigue
scores of the PMR group who had not been undergoing any
intervention on the fourth measurement day shows that our
patients were at risk for fatigue, supporting Broeckel et al.’s
notion. Our results indicate that PMRT leads to an improve-
ment in the perceived fatigue that is present before and
continues throughout the chemotherapy in patients with
breast cancer.
Limitations
Our findings are limited because of the small sample size of
our study. The PSQI’s lower Cronbach’s alpha in our research
should be taken into account in future research. The
researchers will need to ascertain whether the meanings of
questions are understood by the patients participating in the
survey before the questions are answered by the patients at
home.
Relevance to clinical practice
This study has several important clinical implications. It
emphasises the importance of screening more systematically
for sleep problems or fatigue among patients with newly
diagnosed breast cancer, a problem that has largely been
neglected in oncologic practice. The study also highlights the
importance of PMRT specifically targeting sleep quality and
fatigue on a more routine basis in this population. It is
important to start relaxation training just before chemother-
apy to decrease the frequency and severity of sleep problems
and symptoms such as fatigue during chemotherapy. Glob-
ally, as the number of patients with breast cancer and
survivors in the population continues to grow, it is imperative
 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 1073–1083
Effects of relaxation training on sleep quality and fatigue
that nurses continue testing interventions that may positively
affect quality of life and the commonly experienced
symptoms of fatigue and sleep problems. It is also important
to test these interventions to improve the evidence-based
nursing implications.
Patients with breast cancer live through many experiences
in the period after diagnosis but before chemotherapy. We
believe that the defining of these experiences will make
important contributions to symptom management during
breast cancer treatment for future studies.
Acknowledgements
This study was not supported by any grant. We thank all of
the women who took part in the study, Professor Bonnie
Nesbitt PhD, ANP-BC for reviewing the language, Mr Yavuz
Sanisoglu for his statistical support and Professor Sevgi
Hatipoglu PhD, RN for her support and guidance throughout
the project.
Contributions
Study design: MD, FO, SK; data collection and analysis: MD
and manuscript preparation: MD, FO, SK.
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