European Journal of Oncology Nursing 26 (2017) 9e18

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Effectiveness of a relaxation intervention (progressive muscle

relaxation and guided imagery techniques) to reduce anxiety and
improve mood of parents of hospitalized children with malignancies:
A randomized controlled trial in Republic of Cyprus and Greece
Theologia Tsitsi a, *, Andreas Charalambous b, Evridiki Papastavrou a,
Vasilios Raftopoulos c
a
Cyprus University of Technology, Nursing Department, Limassol, Cyprus
b
Cyprus University of Technology, Nursing Department, Research Centre for Oncology and Palliative Care, Limassol Cyprus
c
Cyprus University of Technology, Nursing Department, Mediterranean Research Centre for Public Health and Quality of Care, Limassol, Cyprus

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To explore the effect of Progressive Muscle Relaxation (PMR) and Guided Imagery (GI),in
Received 11 September 2015 reducing anxiety levels among parents of children diagnosed with any type of malignancy receiving
Received in revised form active treatment at a Paediatric Oncology Unit in Republic of Cyprus and in Greece.
22 September 2016
Method: A randomized non-blinded control trial was conducted between April 2012 to October 2013, at
Accepted 31 October 2016
two public paediatric hospitals. Fifty four eligible parents of children hospitalized with a malignancy
were randomly assigned to the intervention (PMR and GI) (n ¼ 29) and a control group (n ¼ 25). The
study evaluated the changes in anxiety levels(HAM-A) and mood changes(POMSb).
Results: There was a statistically significant difference in the mean scores of the subjects in the inter-
vention group in HAM-A scale between the T0 (14.67 ± 9.93) and T1 (11.70 ± 8.15) measurements
(p ¼ 0.008) compared to the control group in which a borderline difference (16.00 ± 11.52 vs
13.33 ± 8.38) was found (p ¼ 0.066). The effect size for the intervention group was low to moderate
(0.37). Regarding mood changes, there was a statistically significant difference in tension for parents in
the intervention group between T0 and T1 (11.15 ± 5.39 vs 9.78 ± 4.26), (p ¼ 0.027). Furthermore, the
parents in the intervention group were significantly less sad following the intervention (T1) (2.81 ± 1.07
vs 2.19 ± 1.21), (p ¼ 0.001), and felt significantly less tense (2.93 ± 0.91 vs 2.26 ± 0.90), (p ¼ 0.001) and
anxiety (2.63 ± 1.21 vs 2.19 ± 1.07), (p ¼ 0.031) compared to those in the control group.
Conclusions: These findings provided evidence on the positive effect of the combination of PMR and GI in
reducing anxiety and improving mood states in parents of children with malignancy.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction population of developing countries and 0.5% of developed countries

Malignancy is a relatively rare disease which may appear during
childhood or teen years, and manifests different biological char-
acteristics than malignancy in adults (Pritchard-Jones et al., 2013).
The term Childhood Malignancy (CM) is often used to describe
forms of malignancy that occur before the age of 15 (Siegel et al.,
2011) and represent approximately 2% of all malignancies in the
* Corresponding author.
E-mail address: theologia.tsitsi@cut.ac.cy (T. Tsitsi).
URL: http://www.euro-mediterraneancenter.com, http://www.cut.ac.cy/medyp
(Ferlay et al., 2010). In teenagers (aged 15e19 years old) malignancy
incidence rates range between 90 and 300 new cases per million
among young boys, and between 88 and 270 new cases per million
among young girls (Curado et al., 2007).
CM is a stressful situation influencing the life of all family
members (Cornman, 1993; Clarke-Steffen, 1997; Scott-Findlay and
Chalmers, 2001; Woodgate and Degner, 2003a). CM is a constant
source of stress due to its connection to death and to the fact that it
is perceived as an incurable disease, as a source of intense pain
(Grootenhuis and Last, 1997a; Woodgate and Degner, 2003a).
According to the literature, parents experience feelings of pain,

http://dx.doi.org/10.1016/j.ejon.2016.10.007
1462-3889/© 2016 Elsevier Ltd. All rights reserved.
10 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
anxiety, depression, guilt, anger and weakness (Pai et al., 2007;
Vrijmoet-Wiersma et al., 2008; Norberg and Boman, 2008; Po €der
et al., 2008). These feelings are believed to be mainly experienced
at a great extent right after their child's diagnosis with malignancy,
and they partially subside in a year and reach pre-diagnosis levels
(Dolgin et al., 2007; Patino-Fernandez et al., 2008; Po € der et al.,
2008). Longitudinal studies showed that stress levels during the
diagnosis of malignancy decrease through time and reach normal
levels five years post-diagnosis (Visser et al., 2003; Vrijmoet-
Wiersma et al., 2009). The vulnerability of parents to handle
these intense emotional situations affects their psychological
health status seriously (Peek and Mazurek 2010).
The ability of parents to manage their psychological state during
their child's treatment is vital not only for their comfort but also,
because it may have an impact on their child's well-being (Vance
et al., 2001) and long-term psychological adjustment. There is
research evidence to support that long-lasting psychological ten-
sion in parents is related to adjustment difficulties by children
diagnosed with malignancy and their siblings at an emotional and
social level (Noojin et al., 1999; Robinson et al., 2007).
According to Lazarus and Folkman (1984), stress may be a result
of the differentiation between the person and his/her environment.
When the sense of threat is not balanced by a sense of support and
the ability to deal with a difficult situation, stress is a usual psy-
chological reaction. As a negative feeling, stress generates in turn
more negative feelings (e.g. anxiety and depression) that are
consequently barriers for the psychological health of children and
parents. Thus, an early relaxation intervention, aiming at reducing
parental stress levels, is crucial in order to support the parents
during this challenging period (Kazak et al., 2007). The benefits of
such an intervention can be dual fold, since not only parents can
feel better after their active effort to fight against the disease but,
they can also help their children face and survive the hardships.
PMR technique has been used since the early 1920's. It is used to
manage stress, to decrease tension and anxiety, to interrupt
obsessive negative thoughts and to enhance the coping ability
(Snyder, 1992; Parle et al., 1996; Walker et al., 1999). PMR involves
physiological effects opposite to those effects caused by psycho-
logical stress. In particular, it decreases the Sympathetic Nervous
System activity while increasing the Parasympathetic Nervous
System activity: a consciously directed way which first tenses a
group of muscles and then, consciously releases the tension in that
muscle group. Therefore, PMR decreases heart rate, blood pressure,
oxygen consumption and sweat gland activity, it changes the pat-
terns of brain waves, and finally, it decreases motor-physical ac-
tivity (Benson et al., 1977; Davidson et al., 1979).
According to Jacobson (1938), “once the body achieves a state of
neuromuscular homeostasis, the mind will follow suit”. Through GI
(Guided Imagery), the mind is directed to intentionally invoke
images in order to bring positive change. The imagination is used to
conjure places, objects or events that are not externally present,
aiming at the influence of psychological and physiological states
(Achterberg et al., 1985; Post-White, 2002; Richardson, 1994). GI is
a commonly used intervention and many health benefits have been
reported.
Serra et al. (2012) evaluated the impact of GI on patients who
received radiotherapy for breast cancer. They noticed reduced
breathing and heart rate, as well as reduced SBP and DBP. Pawlow
and Jones (2002) aimed to study if practicing relaxation techniques,
in two different occasions, could lead to reduction of subjective and
objective stress indicators, in 46 participants. They found that a
relaxation exercise of short duration caused significantly lower
heart rate, stress, self-reported stress and cortisol levels than the
control group, along with increased levels of self-reported
relaxation.
A literature review (Tsitsi et al., 2014) that aimed to review
Randomized Controlled Trials (RCTs) by assessing the effectiveness
of complementary and alternative medical interventions (CAM) for
reducing anxiety in parents of children with malignancy, revealed a
limited number of RCTs in the literature and unfortunately, the
majority of these trials were pilot studies. Thus, they failed to
provide any sufficient information to assess the effectiveness of
CAM interventions. A variety of stress reduction techniques were
reported. Overall, 5/9 of the studies reported the use of massage
therapy (Field et al., 2001; Phipps et al., 2005, 2010; Post-White
et al., 2008; Mehling et al., 2012). In two out of the five studies
which used massage therapy on children as an intervention, mas-
sage was combined with relaxation/imagery in the first (Phipps
et al., 2010) and in the second (Mehling et al., 2012), parents
delivered acupressure to their children. Two other studies used
breathing techniques/guided imagery, another one used relaxation
training (Kazak et al., 1996; Streisand et al., 2000) and the last one
(Ndao et al., 2010) used inhalation aromatherapy. Moreover, seven
out of the nine studies found no significant changes in parents'
anxiety levels and only two pilot studies reported significant
changes in parents' anxiety and depressed mood levels. Specifically,
Field et al. (2001), and Post-White et al. (2009), assessed the effects
on anxiety and depressed mood in parents of children with leu-
kemia, while teaching parents to give massage therapy to their
children or while parents received massage. Their results suggested
that the parents' anxiety and depressed mood decreased after
massaging their child (Field et al., 2001) or while receiving massage
(Post-White et al., 2009).
The current study explored the effectiveness of the combination
of PMR and GI, in reducing anxiety levels among parents of children
diagnosed with any type of malignancy receiving active treatment
at paediatric oncology units in two paediatric hospitals.
1.1. Research questions
The study was designed to provide answers to the following
research questions:
1. How effective is the combination of PMR and GI in reducing
anxiety in parents of children with malignancy compared to
usual care as a control arm?
2. How effective is the combination of PMR and GI in improving
the mood state of parents of children with malignancy
compared to usual care as a control arm?
3. What is the effect of the combination of PMR and GI on the
following vital signs as a proxy measure of anxiety: diastolic/
systolic blood pressure, heart rate and skin temperature, in the
intervention group compared to the provision of usual care in
the control group?
2. Sample and methods
2.1. Study design and participants
This randomized non-blinded control trial was conducted be-
tween April 2012 to October 2013, at two public hospitals in Re-
public of Cyprus and Greece. Parents of children hospitalized with a
malignancy were randomly assigned either to the intervention or
the control group (‘standard psychological support’ provided from
their own physician, the nurses and the psychologist of the
department). Inclusion criteria were as follows: willingness to
participate, having a child 0e18 years old with childhood malig-
nancy, having a child with childhood malignancy being hospital-
ized for at least 3 weeks, able to speak and write Greek fluently, no
previous experience of Complementary and Alternative-CAM
 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
techniques. Parents who had received drug therapy for anxiety or
had used another CAM technique during the study have been
excluded from the study, as well as parents whose children were
receiving palliative care.
2.2. Sample size
The sample calculation was based on the average annual new
cases (n ¼ 50) of children with malignancy in Republic of Cyprus.
According to the power analysis, a sample size of 50 individuals was
equally divided between the two groups, given also an anticipated
dropout rate of 5%. Given that no other similar study has been
previously published (using these tools) in this target group in or-
der to use the effect size to calculate the sample size needed and
given that in Republic of Cyprus every year only 50 children are
diagnosed with malignancy we have calculated the power by
considering these 50 persons (25 in control group and 25 in
intervention group). From the analysis we concluded that in order
to obtain 80% power the effect size should be 0.8 the standard
deviation. This means that 85% of the persons in one group are
expected to obtain a mean value below the mean value of the other
Fig. 1. The progress through the phase of parallel randomized trial of two groups (that is, enrolment, intervention allocation, follow-up and data analysis)
11
group.
2.3. Randomization and blinding
In the current study, 54 parents met the inclusion criteria and
they entered the study consecutively (Fig. 1). Twenty nine parents
were randomly allocated to the intervention group. In addition to
the usual care provided by nurses and psychologists in the inter-
vention group, parents received PMR and GI sessions. Twenty five
parents were randomized to the control group and received only
the standard psychological support. Parents in the control group
were given the opportunity to undertake these techniques if they
wished upon the completion of the study. Randomization was
performed by using a computer-generated sequence, concealed in
sequentially numbered, sealed, opaque envelopes, (by an inde-
pendent person) and kept by the research assistant.
The parents and the research assistant were not possible to be
blinded, because blindness is often more difficult to apply in trials
relating to evaluation of non-pharmacological treatments (Boutron
et al., 2004). Both participants and research assistant took part in
the relaxation intervention, and thus, they knew what treatment
12 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
they had received. Additionally, there was a contact between par-
ents and research assistant (for clinical examination, blood pres-
sure, pulse and skin temperature).
2.4. Design/description of the intervention
The intervention entailed a combination of supervised PMR and
GI sessions. Supervised sessions were carried out by an experienced
research assistant. The interventions were delivered with the aid of
a digital media player (CD). A PMR and GI script were developed
specifically for this research: 1) the PMR included the tensing of 11
specific muscle groups followed by releasing the tension, resulting
in an overall feeling of relaxation, while providing knowledge of
bodily sensations combined with some relaxation breathing exer-
cises 2) the GI script involved the envisioning of a comfortable and
restful place on the beach. Through the generation of different
mental images the capacities of visualization and imagination were
used. The scenario was dressed with music which camouflaged
alpha wave pulses that bring the mind to a relaxed but, at the same
time, conscious state (Da Silva, 1991).
Based on the research protocol, the parents participated in
individualized supervised sessions once a week, for 25 min, in a
private room at the hospital. The intervention appointment was
mutually scheduled between the researcher and the parents.
Additionally to the supervised sessions, each participant applied
the relaxation techniques at least once a day. Each participant's
number of unsupervised sessions (self-reported) was recorded
during the intervention under supervision.Sessions lasted for 3
weeks while the cd was given to parents to continue applying the
relaxation techniques at the hospital or at home.
3. Research tools
3.1. Tools for assessing anxiety
To assess the levels of anxiety before and after the intervention
three physiological measurements and three self-administered
questionnaires were used. Specifically, physiological assessments
were performed 5 min prior to each intervention, immediately after
it, and 5 min later. The questionnaires were given at baseline
(before the first intervention) and at the end of the three-week
intervention period. For the control group a baseline assessment
with the questionnaires was done after the randomization and at
the end of the three-week period. Based on the results of similar
studies (Payne, 2000), blood pressure, heart rate and skin tem-
perature are important indicators of relaxation. Therefore, blood
pressure, heart rate and mean skin temperature, were selected as
indicators of the participants' status of anxiety or relaxation.
Measurements of physiological indices of blood pressure, heart rate
and skin temperature were taken 5 min before the intervention and
immediately after, as well as 5 min later. The results were recorded
following a special data protocol. Specifically, blood pressure and
pulse were measured by an electronic sphygmomanometer
(Dinamap monitor). The evaluation of stress levels was done by
measuring parents' skin temperature using the Biodot skin ther-
mometer, which accurately measures the participant's skin tem-
perature reflecting the levels of stress experienced by the
individual (Schultz and Schultz, 2002). The Biodot thermometer is
flexible, has a quick reaction time, is easy to interpret and is a cheap
stress assessment tool (Schultz and Schultz, 2002). It can be easily
placed on the participant's skin between the base of the index
finger and thumb. Although the position of the skin thermometer is
highly visible, it is not likely to be removed or disturbed by the
bending of fingers.
3.2. Self-administered questionnaires
A. An anonymous and self-completed questionnaire was
designed and it included: individual and family characteristics:
child's gender, child's, mother's and father's age, ethnicity, family
type, total number of children in the family and the parents' level of
education.
B. Sources of participant's support: health professionals, family,
friends and parents of children with malignancy, neighbours, priest
and others.
C. The date of diagnosis of the child, the elapsed time since the
date of diagnosis (in months), type and stage of cancer, and the type
of treatment administered. This form was completed by the
researcher after the participant's informed consent to participate in
the research.
D. Hamilton's Anxiety Scale (HAM-A) (Hamilton, 1959): This
scale allows the evaluation of the overall level of anxiety and as-
sesses also the intensity of individual's symptoms of anxiety
(Hamilton, 1959). It consists of 13 symptom-oriented questions and
measures of psychic anxiety (mental agitation and psychological
distress) and somatic anxiety (physical complaints related to anx-
iety), which, if added together, provide an indication that corre-
sponds to the overall anxiety level. Each item is scored on a scale of
0 (not present) to 4 (severe), with a total score range of 0e56: <17
indicates mild severity, 18e24 mild to moderate severity and
25e30 moderate to severe. A “global” question was added by the
interviewer: “How capable do you feel that you are able to trou-
bleshoot problems that you have?” A 10-point scale from 0 (none)
to 10 (perfect) was used to indicate their answer. The question was
used as a criterion validity indicator of the scale. The HAM-A was
translated and culturally adapted in the Greek language with a very
good Cronbach's a (0.864) and easy to apply (Karanikola et al.,
2009).
E. Profile of Mood States Brief scale (POMS Brief): The POMS Brief
questionnaire (McNair et al., 1981) is a widely used tool whose psy-
chometric properties are well documented (McNair et al., 1981;
Dolgin et al., 2007). It was adapted for Greek patients by Zervas
(1993). It consists of 30-items of positive and negative aspects of six
mood states during the previous week. Each item is rated on a 5-point
scale ranging from 1 (not at all) to 5 (extremely). The scale consists of
six subscales: Tension/Anxiety, Depression/Dejection, Anger/Hostil-
ity, Vigour/Activity, Fatigue/Inertia and Confusion/Bewilderment.
The individual grading subscales are combined to produce an overall
score of mood disorders (TMD), with the following factors:
Intensity þ Depression þ Anger þ Fatigue þ Confusion -
Energy þ 100. The higher rating reflects the increased mood disor-
ders (negative effect).Initially, a general type question was added by
the researcher: “How do you rate your mood during the past week
including today's day?”. The participants had to use a 10-point scale
from 0 (bad) to 10 (perfect). The question was used to assess the
criterion validity of the scale.
3.3. Ethical considerations
The protocol of the study was approved by the Cyprus Bioethics
Committee (ЕЕВΚ/ЕP/2011/21), the Ministry of Health
(YY5.34.01.7.6Е) and the Commissioner for the Protection of Per-
sonal Data (3.28.24). Participation in the study was voluntary and
anonymous. The researcher provided an explanation of the pur-
poses of the research, the expected duration of the participant's
participation as well as a description of the procedures to be fol-
lowed, and a statement that participation was voluntary, with no
penalty or loss of benefits to which the subject was otherwise
entitled upon refusal of participation, and that the subject could
discontinue participation at any time without penalty or loss of
 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18 13

benefits, to which the subject was otherwise entitled. All the par-
ticipants provided a signed informed consent form.
3.4. Statistical analysis
Data was analyzed using the IBM-SPSS software package
(version 22; SPSS, Inc., Chicago, Illinois). Means and standard de-
viations were calculated for each variable. Chi-square test was used
for categorical data. Analysis of covariance (ANCOVA) was used to
assess differences between groups, by using the pre-intervention
score as covariant, group as the independent variable, and post-
intervention score as the dependent variable. The statistical anal-
ysis was conducted at a 95% confidence level. A p < 0.05 was
considered to indicate statistical significance in all analyses.
4. Results
4.1. Demographics and clinical characteristics
The two groups were generally well-matched at baseline for key
demographic variables (Table 1). Between April 2012 and October
2013, 62 parents were assessed for their eligibility and 54 parents
successfully completed all the assessments in the study. The
intervention group consisted of 29 participants and the control
group of 25 participants. Eleven of the participants came from
Greece. The mean age of the mothers in the control groups was
40.92 ± 5.90 years of age, while that of the fathers was 43.92 ± 6.42
years. In the intervention group the mean age of the parents was
respectively 39.79 ± 5.93 and 37.72 ± 6.94. The majority of the
children suffered from acute lymphoblastic leukemia and lym-
phoma (Table 2). The median time since diagnosis was 4 weeks
(range, 4e20 weeks). Most of the children were in the chemo-
therapy induction stage and there were receiving chemotherapy
(Table 2). There was no statistically significant difference (p ¼ 0.12)
in the average age of children between the intervention
(8.11 ± 4.94) and control group (10.20 ± 4.81), as well as in the
distribution of the percentages of each type of malignancy of
children in the control and the intervention group (p ¼ 0.298) and
the distribution of the stage of malignancy among children in the
control and the intervention group (p ¼ 0.267). No significant
Table 1
Demographics and clinical characteristics.
Control group Intervention group
differences between groups were shown by the Kolmogorov-
Smirnov test in any variables at baseline.
The HAM-A scale had a very good Cronbach's a ¼ 0.926. In order
to explore potential differences between T0 (baseline) and T1
measurements in the intervention and control group several t-tests
were performed. The t-test did not show a statistically significant
difference in the overall anxiety mean scores in the HAM-A scale
between the intervention and control group in the T0 (baseline)
measurement (p ¼ 0.673) and in the T1 measurement (p ¼ 0.501)
respectively. On the contrary, there was a statistically significant
difference in the mean scores of the participants in the intervention
group in HAM-A scale between the T0 (14.67 ± 9.93) and T1
(11.70 ± 8.15) measurements (p ¼ 0.008) compared to the control
group in which a borderline difference (16.00 ± 11.52 vs
13.33 ± 8.38) was found (p ¼ 0.066). The effect size for the inter-
vention group was low to moderate (0.37).
Table 3 summarizes the mean cumulative scores for each
symptom in the intervention and control group. In the intervention
group there was a statistically significant reduction T0 compared to
T0 (2.04 ± 0.98 vs 1.70 ± 0.95), in anxious mood (p ¼ 0.036), in
tension (2.00 ± 1.07 vs 1.48 ± 0.93) (p ¼ 0.006), in intellectual
symptoms (difficulty in concentration, poor memory) (1.48 ± 1.12
vs 1.00 ± 0.87), (p ¼ 0.001), in the respiratory (0.89 ± 1.05 vs
0.48 ± 0.64), (p ¼ 0.031) and gastrointestinal symptoms
(0.93 ± 0 .95 vs 0.59 ± 0.69), (p ¼ 0.036). Additionally, the effect size
was significant in tension (0.52), in the cognitive reactions (0.48)
and in the respiratory symptoms (0.47). In the control group there
was a statistically significant reduction T0 compared to T1, in
depressed mood (1.52 ± 1.28 vs 1.14 ± 1.23), (p ¼ 0.017), in the
general somatic symptoms (sensory) (1.10 ± 1.41 vs 0.62 ± 1.02),
(p ¼ 0.047) and in respiratory symptoms (0.90 ± 1.17 vs 0.33 ± 0.57),
(p ¼ 0.030). In addition, the effect size was average for the
depressed mood (0.30) and for the general somatic symptoms
(sensory) (0.39), but significant for the respiratory symptoms
(0.62).
In order to assess the effect of covariates (the total pretest score
of each factor in the HAM-A scale), ANCOVA was performed for the
total score of each factor in the T1 intervention measurement, with
the group to which the parent belonged to (intervention or control)
as a covariate in the total score in the test. The group interaction
and the score in the general somatic symptoms and the cardio-
vascular symptoms were marginally statistically significant F
(1.44) ¼ 3.55, p ¼ 0.066 and F (1.44) ¼ 3.60, p ¼ 0.064 respectively.
4.2. Mood (POMS brief)
p-value

M±sd M;±sd A statistically significant difference was observed in depression-

N (%) N (%) dejection (8.63 ± 5.20 vs 7.37 ± 5.06) (p ¼ 0.071) and in tension
(11.15 ± 5.39 vs 9.78 ± 4.26) (p ¼ 0.027) in T0 and T1 intervention
Education
measurements in the intervention group and a statistically signif-
Primary-Secondary 11 (44%) 13 (44.8%) 0.188
icant difference was observed in fatigue (10.71 ± 4.58 vs
College-University 12 (48%) 8 (27.5%)
MSc 2 (8%) 7 (24.3%) 8.71 ± 3.32) (p ¼ 0.014) in the control group. Additionally, the effect
Not stated 0 (0%) 1 (3.4%) size for depression (0.24), fatigue (0.22) and tension (0.28) in the
Nationality intervention group was relatively small and fatigue (0.50) in the
Greek-Cypriot 18 (72%) 24 (82.8%) 0.343 control group was significant (Table 4).
Greek 7 (28%) 5 (17.2%)
Marital status
For a further exploration of the differences in both measure-
Married 25 (86.2%) 24 (96%) 0.420 ments of the six mood factors of the POMS brief questionnaire, each
Separated/divorced 3 (10.3%) 1 (4%) item of the subscales was analyzed separately. Thus, parents in the
Widow 1 (3.4%) 0 (0%) intervention group reported significantly less sadness (p ¼ 0.001),
District of residence
less weariness (p ¼ 0.026), less forgetfulness (p ¼ 0.050), less
Nicosia 9 (50%) 7 (29.2%) 0.333
Limassol 6 (33.3%) 7 (29.2%) tension (p ¼ 0.001) and less anxiety (p ¼ 0.031) at the post-
Famagusta 0 (0%) 1 (4.2%) intervention measurements. Parents in the control group signifi-
Larnaka 0 (0%) 4 (16.7%) cantly reported that they were less exhausted (p ¼ 0.018), forgetful
Paphos 3 (16.7%) 4 (16.7%) (p ¼ 0.010) and felt less reduction in fatigue (p ¼ 0.002) at the post-
Not stated 0 (0%) 1 (4.2%)
intervention measurements.
14 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18

Table 2
Type of childhood malignancy/ treatment stage of malignancy: Frequencies and percentages.

Type of malignancy N % Treatment Stage of malignancy N %

Acute Lymphoblastic Leukemia 23 43,4 Induction 44 81,5

Acute myeloblastic leukemia 4 7,5 Consolidation (also called intensification) 3 5,6
Lymphoma 14 26,4 Maintenance 5 9,3
Nephroblastoma 1 1,9 Treatment for recurrent disease 2 3,7
Sarcoma 5 9,4 Total 54 100,0
Brain tumor 2 3,8 Missing values 1
Ectodermal tumour 1 1,9 Total 55
Other 3 5,7
Total 53 100,0
Missing values 1
Total 54

Table 3
Pre and post-intervention measurements of mean scores of the intensity of individual symptoms of anxiety on HAM-A scale in the intervention and control groups

Anxiety symptoms T0 T1 Size effect Cohen's p- Το Τ1 Size effect Cohen's p-

d value d value

(intervention group) (control group)

Anxious mood 2.04 ± 0.98 1.70 ± 0.95 0.35 0.036* 1.86 ±0 .96 1.95 ± 1.16 0.08 0.680
Tension 2.00 ± 1.07 1.48 ± 0.93 0.52 0.006* 2.00 ± 1.14 1.76 ± 0.99 0.22 0.234
Fears 0.48 ± 0.93 0.41 ± 0.57 0.09 0.626 0.33 ±0 .65 0.29 ± 0.46 0.07 0.576
Insomnia 1.33 ± 1.27 1.04 ± 0.94 0.26 0.058 1.29 ± 1.05 1.19 ± 1.16 0.09 0.576
Intellectual symptoms (difficulty in concentration, poor 1.48 ± 1.12 1.00 ± 0.87 0.48 0.001* 1.19 ± 1.07 1.29 ± 1.14 0.09 0.605
memory)
Depressed Mood 1.44 ± 1.08 1.26 ± 1.16 0.16 0.247 1.52 ± 1.28 1.14 ± 1.23 0.30 0.017*
General somatic symptoms (muscular) 1.22 ± 1.05 1.16 ± 1.09 0.05 0.449 1.57 ± 1.43 1.14 ± 1.19 0.32 0.186
General somatic symptoms (sensory) 0.93 ± 1.07 0.74 ± 1.05 0.18 0.202 1.10 ± 1.41 0.62 ± 1.02 0.39 0.047*
Cardiovascular symptoms 0.59 ± 0.84 0.59 ± 0.93 0 1.000 1.14 ± 1.49 0.81 ± 1.16 0.24 0.090
Respiratory symptoms 0.89 ± 1.05 0.48 ± 0.64 0.47 0.031* 0.90 ± 1.17 0.33 ± 0.57 0.62 0.030*
Gastrointestinal symptoms 0.93 ± 0.95 0.59 ± 0.69 0.41 0.036* 1.19 ± 1.28 1.00 ± 0.94 0.17 0.407
Genito-urinary system 0.59 ± 0.84 0.67 ± 0.73 0.10 0.490 0.95 ± 1.16 0.95 ± 0.92 0 1.000
Autonomic symptoms 0.70 ± 1.17 0.63 ± 1.00 0.06 0.537 0.95 ± 1.07 0.86 ± 1.15 0.08 0.428

*Statistically significant.

Table 4
Pre and post-intervention measurements of mean scores of the six mood factors of POMS brief questionnaire in the intervention and control group

POMS Item Το Τ1 Size effect Cohen's d p-value Το Τ1 Size effect Cohen's d p-value

(intervention group) (control group)

Depression-Dejection 8.63 ± 5.20 7.37 ± 5.06 0.24 0.071 7.62 ± 6.51 7.33 ± 4.78 0.05 0.739
Fatigue-Inertia 11.37 ± 5.84 10.11 ± 5.54 0.22 0.127 10.71 ± 4.58 8.71 ± 3.32 0.50 0.014*
Confusion-Bewilderment 9.33 ± 4.44 8.74 ± 2.98 0.15 0.263 8.43 ± 3.76 8.10 ± 4.02 0.08 0.624
Anger-Hostility 7.48 ± 5.22 6.89 ± 4.48 0.12 0.350 6.71 ± 5.83 6.81 ± 5.28 0.01 0.925
Vigor-Activity 7.81 ± 3.86 8.00 ± 4.22 0.04 0.692 7.95 ± 5.13 9.05 ± 3.42 0.25 0.311
Tension-Anxiety 11.15 ± 5.39 9.78 ± 4.26 0.28 0.027* 9.90 ± 5.16 10.10 ± 4.03 0.04 0.876

*Statistically significant.

4.3. Physiological indicators of anxiety in the intervention group
Measurements of the physiological indicators of anxiety were
taken on T0 and T1 in every week intervention. Specifically, T1
measurements were made immediately after the relaxation inter-
vention and 5 min later.
1. Systolic blood pressure
The effect of the intervention in accordance with the index
Wilks' Lambda is statistically significant (p ¼ 0.030) during the 3
measurements (the time that the measurements were made). More
specifically, the size of the effect is large (Partial ETA
Squared ¼ 0.262). There was a significant reduction of the systolic
pressure in the intervention group at baseline and in the two post-
intervention measurements.
2. Diastolic blood pressure
The post hoc test using the Bonferroni correction did not show a
statistically significant difference in the 3 measurements, although
a progressive reduction was observed. In addition, the effect of the
intervention in accordance with the index Wilks' Lambda is not
statistically significant (p ¼ 0.112) in the intervention group at the
baseline and in the two post-intervention measurements.
3. Heart rate
The post hoc test using the Bonferroni correction showed a
statistically significant difference in the 3 measurements (p ¼ 0.002
and p ¼ 0.003 respectively). In addition, the effect of the inter-
vention in accordance with the index Wilks' Lambda is statistically
significant (p ¼ 0.003) in the intervention group at the baseline and
in the two post-intervention measurements (in the time that the
measurements were made). The size effect is large (Partial ETA
Squared ¼ 0.401).
4. Skin temperature
The post hoc test using the Bonferroni correction showed a
statistically significant difference in the 3 measurements
(p < 0.001). In addition, the effect of the intervention in accordance
 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
with the index Wilks' Lambda is statistically significant (p < 0.001)
in intervention group at baseline and two post-intervention mea-
surements (within the time measurements were made). The size of
the effect is very large (Partial ETA Squared ¼ 0.755).
4.4. Perceived benefits of the intervention for the parents
All the parents reported that the intervention made them feel
“very much better” (37.5%), ‘much better’ (20.83%), ‘better’ (20.83%)
and ‘somewhat better’(20.83%). Seventy-five percent of the parents
have reported that ‘they think they will use this relaxation technique
when they encounter a problem in the future’. Eighty-three percent
of parents reported that ‘they would recommend this technique to
others facing the same or similar problem like them’. Those who
answered that they would definitely suggest this technique to others
were the ones who felt much better after the intervention. The same
applies for those who considered using relaxation techniques when
they face a similar problem in the future.
5. Discussion
To the best of our knowledge, this is the first RCT to explore the
effectiveness of PMR and GI techniques in parents of children
diagnosed with any type of malignancy and receiving active
treatment at paediatric oncology units. The effect of the interven-
tion on anxiety symptoms and mood states was explored by
employing a combination of psychometric tools (HAM-A, POMs
Brief) and physiological measures (B/P, pulse and skin
temperature).
In the current study, the combination of PMR and GI techniques,
a non-invasive nursing intervention, reduced the anxiety symp-
toms and improved the mood states of the parents. The analyses
provided evidence that the intervention managed to reduce severe
anxiety symptoms. Participants in the experimental group experi-
enced significantly greater reduction of anxiety symptoms and
improved mood states compared to participants in the control
group. This is affirmed by literature (Kazak et al., 1996; Hoekstra-
Weebers et al., 1998): a number of parents of children with can-
cer, either in control group or in intervention group, effectively
managed the stressful situation of their child's malignancy.
A wide acceptance of the intervention was an important part of
this study, since parents experienced a completely new stressful
situation, which was overwhelming and burdensome. As part of
their child's treatment they found themselves facing complicated
treatment protocols, and unpleasant and stressful chemotherapy
complications. More precisely, 80% of the participants stated that
they felt ‘better’ to ‘much better’ after the intervention and 75% said
that they intended to use the specific relaxation techniques in the
future, when they deal with a problem. Additionally, 80% of those
asked answered that they would recommend these techniques to
others facing the same or similar problems. It is worth noting that
the parents who would recommend the techniques to others were
those who felt much better after the intervention. The same applied
for those thinking of using the techniques in the future for a similar
problem. Our findings are consistent with these of other studies,
which support that interventions in parents of children diagnosed
with malignancy during the first stages of diagnosis and treatment
was accepted by the parents (Surviving Cancer Competently
Intervention Program for Newly Diagnosed (SCCIP-ND) (Kazak
et al., 2005; Stehl et al., 2009) and the ‘‘Connections to Coping’’
intervention: a manualized, multimodel stress management and
coping enhancement intervention (Marsland et al., 2013).
During the intervention, the children were able to engage
constructively with an educator in the hospital units, which was an
additional reason why parents could participate in the study
15
unobstructed. This facilitated the parents' participation in the study
since they were not worried about the security and healthcare of
their children. As a result, they were more relaxed and devoted to
the intervention, seeing this as a chance to ‘take an emotional
break’. The specific intervention can be exercised at the hospital in
such a way which soothes and relaxes the parents during their
child's hospitalization. The possibility of practicing such an inter-
vention to parents for their stress reduction is also supported by
earlier studies (Post-White et al., 2009; Marsland et al., 2013).
Concerning the impact of the intervention on the reduction of
stress symptoms, there was a statistically significant difference in
the mean score of stress symptoms in the intervention group on
HAM-A scale between pre- and post-measures compared to the
control group. For the intervention group, there was a statistically
significant decrease of anxious mood, tension, breathing and
gastrointestinal symptoms. Additionally, the extent of the impact
was important for tension, cognitive and breathing symptoms.
Although the parental anxiety symptoms declined over time, the
interaction between group and parental rate on HAM-A scale dur-
ing pre-intervention measures was not statistically significant,
indicating that there was an impact of the intervention on anxiety
reduction. A larger sample could probably show a larger impact,
which would be manifested by ANCOVA testing.
Another interesting finding of this study is that during post-
intervention measures in the intervention group, parents stated
significantly less tension and anxiety. This is consistent with the
findings of another study, that of Scheufele (2000). In a sample of
57 volunteer men who were exposed to stress situations (scenario)
and then to one of two types of relaxation, music therapy or PMR,
PMR had a significant impact on reducing the tension and anxiety
and improving the sense of relaxation of the participants
(Scheufele, 2000).
A difference in parental mood was observed in the intervention
group on POMS subscales. These parents reported being less sad,
less weary, forgetful and less anxious, compared to those in the
control group. In the control group, a significant reduction of fa-
tigue was observed. This may be explained by the fact that during
the assessments the parents had some free time, relaxing away
from their difficult routine. Similar findings can be seen in the study
of Post-White et al. (2009), with parents stating less tension and
stress after 15 min of relaxing massage. Nevertheless, parents in the
control group reported a significant reduction of fatigue, which was
marginally statistically significant. These positive changes which
occurred from the specific study to the intervention group, agree
with other studies which have used the same questionnaire in
relation to the mood of healthy adults (Parkinson et al., 1996;
Thayer, 1996). Moreover, Berger et al. (1988) discovered that both
exercise and relaxation can be linked to a short-term reduction of
tension, depression and anger on some POMS subscales.
However, Pollock et al. (1995) spotted some differentiations in
the way parents complete a questionnaire for their anxiety. They
noticed that a significant sub-group of parents reported severe
symptoms of anxiety, in contrast with low levels of self-reported
anxiety in similar questionnaires. This contradiction was clearer
between parents of healthy children and parents of children diag-
nosed with malignancy. Parents of children diagnosed with ma-
lignancy possibly hide or underreport their levels of self-reported
anxiety. This can be a result of parents' effort to stay strong and be
protective, or it can be blamed on their adjustment to stressful
situations. However, the objective anxiety measures reveal that
many of these parents are psychologically influenced by stress. The
present study suggests that parents can more easily identify and
report anxiety symptoms (tachycardia, headaches or nausea) than
self-reported anxiety. Using only parents' self-reports could lead to
an incorrect classification of an important sub-group of parents.
16 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
These psychometric and physiological assessments (diastolic/sys-
tolic blood pressure, heart rate and skin temperature) were used to
explore the intervention's effectiveness.
This combination is also supported by literature (Kibler and
Foreman, 1983; Pollock et al., 1995) given that, according to the
physiological base of the intervention's effectiveness, anxiety levels
reduction could be a result of the sympathetic nervous system's
relaxation, through the activation of the parasympathetic. This
leads to the reduction of heart rate, blood pressure, breathing rate,
oxygen in the lungs and muscle tension, and also, to the creation of
feelings of tranquility and control (Payne, 2000), indirectly
reducing anxiety, too.
The data analysis showed that there was a reduction in DBP
which was not statistically significant. On the contrary, there was a
powerful and statistically significant reduction in SBP, heart rate
and body temperature right after the intervention, which provides
evidence on the immediate impact of this technique on vital signs.
Relaxing during the intervention immediately influences the
function of the body so; it reduces blood pressure, heart rate and
increases body temperature. These findings support the theory of
Benson et al. (1974), that practicing relaxation techniques activates
the human body's reaction, which leads to relaxing. Specifically,
this relaxation response (RR) results in a decreased sympathetic
nervous system responsivity, counteracts the activity of NE/
epinephrine or cortisol, and opposes the stress response. Relaxa-
tion is associated with instantly occurring physiological changes
that include decreased oxygen consumption or carbon dioxide
elimination (i.e, reduced metabolism), lowered heart rate, arterial
blood pressure, and respiratory rate (Benson, 1975). Herbert Ben-
son, who first described and pioneered the initial research studies
involved in the RR, identified it as the physiological counterpart of
the stress or fight-or-flight response (Benson et al., 1974; Benson,
1975).
Concerning vital signs indicators in studies of the last 60 years,
heart rate has been used as a reliable and independent indicator
(King, 1980), and its popularity as a physical measure lasts until
today (Hall and Whitehouse, 1998, Norton et al., 1997, Pawlow and
Jones, 2002). The reduction of blood pressure is one of the most
stable changes which are observed during the relaxation reactions.
A body of literature has supported this finding both in healthy and
hypertensive populations (Sudsuang et al., 1991, Schneider et al.,
2005, Dusek et al., 2008). In Patel et al. (2012), the SBP was
significantly reduced in the intervention group after 3 months of
progressive muscle relaxation to a hypertensive sample (137, 87 vs.
142, 93 mmHg), whereas the DBP had no statistically significant
change. A similar reduction of SBP, but none of DBP, was also re-
ported by Goldstein et al. (1984).
Experimental studies showed that increased levels of SBP relate
to situations which demand continuous adjustment and link to a
long-term stimulation of the hypothalamus (emergency situa-
tions), which is further attached to an increased activity of the
sympathetic nervous system (SNS) (Benson et al., 1974). If a per-
son's experiences cause an increase of the SBP, practicing relaxation
techniques can lead to a reduced activity of the sympathetic ner-
vous system which, in turn, can further reduce systolic blood
pressure. The findings of this study provided evidence that the
systematic use of PMR and GI can reduce the activity of the SNS and
further on, it can reduce SBP. Reducing anxiety levels by practicing
relaxation techniques could function as a long-term strategic
confrontation with the disease. Therefore, blood pressure could be
reduced through the reduction of the SNS's activity (McGrady et al.,
1981; Patel et al., 1981). As a matter of fact, earlier studies using
PMR and other types of relaxation had a similar impact on heart
rate (Wallace, 1970, Wallace and Benson, 1972) and blood pressure
(Detay et al., 1969, Benson et al., 1975).
In conclusion, the intervention has a positive and immediate
impact on the human organism which is expressed through sub-
jective and objective indicators. The intervention leads to an
objective reduction of the rates of the 3 vital signs and an
improvement in mood and mainly parental anxiety.
6. Limitations of the study
This study needs to be read in light of the following limitations,
the first of which concerns the small sample size. The sample size is
a highlighted issue in the literature of childhood oncology (Drotar,
2002). The complexity of the disease and its prognosis, the treat-
ment protocols, and so on, are indications of possible difficulties
encompassed in a larger sample recruitment process. This high-
lights the need for longitudinal studies and multicentre trials. The
multi-center studies are suggested as a means of collecting large
population samples to draw conclusions about the effect size of
therapeutic interventions. The 'Hawthorne' effect could affect the
results of this RCT study. Given that the participants knew about
their participation in the present research, they may have behaved
in a certain way. This effect could be a threat for the external val-
idity of the study, thereby affecting the generalizability of the
findings to other populations or environments. The use of objective
measures aimed to address this limitation. The restrictions arising
from the particularities of the participants, as well as time con-
straints, did not allow for a longitudinal study in order to assess the
long-term effect of the intervention on the participants' anxiety
and this is an aspect that needs to be considered in future research
in this population and context.
7. Recommendations
This is one of the first studies in literature which shows the
benefits of relaxation for the reduction of anxiety symptoms and
the improvement of mood in parents of children diagnosed with
malignancy. The present study supports the acceptability, effec-
tiveness and impact of relaxation techniques (PMR and GI) con-
cerning the reduction of parental anxiety. Since the results in this
study show improvement on both subjective and objective mea-
sures, it is suggested that it is offered to parents of hospitalized
children diagnosed with malignancies as a daily nursing practice, or
that parents themselves are educated to practice it on their own,
considering that it is a non-invasive, inexpensive and non-time
consuming process.
Since the results of this study show improvement on both
subjective and objective measures, it is highly recommended to be
offered to the parents of hospitalized children diagnosed with
malignancies as a daily nursing intervention, or to train the parents
in order to practice it on their own, considering that it is a non-
invasive, inexpensive and non-time consuming process.
Parents play an extremely important role regarding the out-
comes of their children's health. Thus, it is crucial that they feel
strong, in order to support their child and all other members of the
family, psychologically and physically, during this hard period.
Parental strength is per se a confrontation with the problem.
Conflict of interest
None declared.
Acknowledgments
We would like to thank all the individuals who participated in
this study.
 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18 17

References biofeedback-assisted relaxation on blood pressure and selected biochemical

parameters in patients with essential hypertension. Biofeedback Self Regul. 6,
343e354.
Achterberg, J., Kenner, C., Lawlis, G., 1985. Severe burn injury: a comparison of
McNair, D.M., Lorr, M., Droppleman, L.F., 1981. POMS™ Profile of Mood States.
relaxation, imagery, and biofeedback for pain management. J. Ment. Imag. 12
McNair, D.M., Lon, M., & Droppleman, L.E. (1971, 1981, 1992) Profile of Mood States.
(1), 71e88.
San Diego: Education and Industrial Testing Service.
Benson, H., 1975. The Relaxation Response, vol. 22. William Morrow, New York.
Mehling, W.E., Lown, E.A., Dvorak, C.C., Cowan, M.J., Horn, B.N., Dunn, E.A., et al.,
Benson, H., Beary, J.F., Carol, M.P., 1977. The relaxation response. Psychiatry 37,
2012. Hematopoietic cell transplant and use of massage for improved symptom
37e46.
management: results from a pilot randomized control trial. Evidence-based
Benson, H., Klemchuk, H.P., et al., 1974. The usefulness of the relaxation response in
Complementary Altern. Med. 2012, 1e9.
the therapy of headache. Headache 14 (1), 49e52.
Ndao, D.H., Ladas, E.J., Cheng, B., Sands, S.A., Snyder, K.T., Garvin Jr., J.H., et al., 2010.
Benson, H., Alexander, S., Feldrnan, C.L., 1975. Decreased premature ventricular
Inhalation aromatherapy in children and adolescents undergoing stem cell
contractions through the use of relaxation response in patient with stable
infusion: results of a placebo-controlled double-blind trial. Psycho-Oncology 21,
ischemic heart disease. Lancet 2, 380e382, 6.
247e254.
Berger, B.G., Friedman, E., Eaton, M., 1988. Comparison of jogging, the relaxation
Noojin, A.B., Causey, D.L., Gros, B.J., Bertolone, S., Carter, B.D., 1999. The influence of
response, and group interaction for stress reduction. J. sport & Exerc. Psychol.
maternal stress resistance and family relationships on depression in children
10, 431e447.
with Cancer. J. Psychosoc. Oncol. 17 (2).
Boutron, I., Tubach, F., Giraudeau, B., Ravaud, P., 2004. Blinding was judged more
Norberg, A.L., Boman, K.K., 2008. Parent distress in childhood cancer: a comparative
difficult to achieve and maintain in non-pharmacological than pharmacological
evaluation of posttraumatic stress symptoms, depression and anxiety. Acta
trials. J. Clin. Epidemiol. 57, 543e550.
Oncol. 47 (2), 267e274.
Clarke-Steffen, L., 1997. Reconstructing reality: family strategies for managing
Norton, M., Holm, J., McSherry, W., Clinton, W., 1997. Behavioral assessment of
childhood cancer. J. Pediatr. Nurs. 12 (5), 278e287.
relaxation. J. Behav. Ther. Exp. Psychiatry 28, 129e137.
Cornman, B.J., 1993. Childhood cancer: differential effects on the family members.
Pai, A.L.H., Greenley, R.N., Lewandowski, A., Drotar, D., Youngstrom, E.,
Oncol. Nurs. Forum 20 (10), 1559e1566.
Peterson, C.C., 2007. A meta-analytic review of the influence of pediatric cancer
Curado, M.P., Edwards, B., Shin, H.R., et al. (Eds.), 2007. Cancer incidence in Five
on parent and family functioning. J. Fam. Psychol. 21 (3), 407e415.
Continents, vol. IX. IARC Sci Publ No. 160. IARC, Lyon.
Parkinson, B., Totterdell, P., Briner, R.B., Reynolds, S., 1996. Changing Moods: the
Da Silva, E.L., 1991. Neural mechanisms underlying brain waves: from neural
Psychology of Mood and Mood Regulation. Longman, New York.
membranes to networks. Electroencephalogr. Clin. Neurophysiol. 29, 81e93.
Parle, M., Jones, B., Maguire, P., 1996. Maladaptive coping and affective disorders
Davidson, Dennis M., Winchester, Mark A., Taylor, Barr C., Alderman, Edwin A.,
among cancer patients. Psychol. Med. 26 (4), 735e744.
Ingels Jr., Neil B., 1979. Effects of relaxation therapy on cardiac performance and
Patel, C., Marmot, M.G., Terry, D.J., 1981. Controlled trial of biofeedback-aided
sympathetic activity in patients with organic heart disease. Am. Psychosom.
behavioural methods in reducing mild hypertension. Br. Med. J. 282,
Med. 31 (4).
2005e2008.
Detay, K., Deshmukh, S., Dalvi, C., Venikar, S., 1969. Shavasan: ayogis exercise in the
Patel, H.M., Kathrotia, R.G., Pathak, N.R., Thakkar, H.A., 2012. Effect of relaxation
management of hypertension. Angiology 20, 325e333.
technique on blood pressure in essential hypertension. NJIRM 3 (4), 10e14.
Dolgin, M., Phipps, S., Fairclough, D., Sahler, O.J., Askins, M., Noll, R., Katz, E.R., 2007.
Patino-Fernandez, A.M., Pai, A.L., Alderfer, M., Hwang, W.T., Reilly, A., Kazak, A.E.,
Trajectories of adjustment in mothers of children with newly diagnosed cancer:
2008. Acute stress in parents of children newly diagnosed with cancer. Pediatr.
a natural history investigation. J. Pediatr. Psychol. 32, 771e782.
Blood Cancer 50, 289e292.
Drotar, D., 2002. Enhancing reviews of psychological treatments with pediatric
Pawlow, L.A., Jones, G.E., 2002. The impact of abbreviated progressive muscle
populations: thoughts on next steps. J. Pediatr. Psychol. 27 (2), 167e176.
relaxation on salivary cortisol. Biol. Psychol. 60, 1e16.
Dusek, J.A., Hibberd, P.L., Buczynski, B., et al., 2008. Stress management versus
Payne, R., 2000. Relaxation Techniques: a Practical Handbook for the Health Care
lifestyle modification on systolic hypertension and medication elimination: a
Professional. Churchill Livingstone, London.
randomized trial. J. Altern. Complement. Med. 14 (2), 129e138.
Peek, G., Mazurek, B., 2010. Coping interventions for parents of children newly
Ferlay, J., Parkin, D.M., Steliarova-Foucher, E., 2010. Estimates of cancer incidence
diagnosed with Cancer: an evidence review with implications for clinical
and mortality in Europe in 2008. Eur. J. Cancer 46, 765e781.
practice and future research. Pediatr. Nurs. 36 (6), 306e313.
Field, T., Cullen, C., Diego, M., Hermandez-Reif, M., Sprinz, P., Beebe, K., et al., 2001.
Phipps, S., Dunavant, M., Gray, E., Rai, S.N., 2005. Massage therapy in children un-
Leukemia immune change following massage therapy. J. Bodyw. Mov. Ther. 5
dergoing hematopoietic stem cell transplantation: results of a pilot trial.
(4), 271e274.
J. Cancer Integr. Med. 3 (2).
Goldstein, I.B., Shapiro, D., Thananopavaran, C., 1984. Home relaxation techniques
Phipps, S., Barrera, M., Vannatta, K., Xiong, X., Doyle, J.J., Alderfer, M.A., 2010.
for essential hypertension. Psychosom. Med. 46 (5), 398e414.
Complementary therapies for children undergoing stem cell transplantation.
Grootenhuis, M.A., Last, B.F., 1997. Adjustment and coping by parents of children
Rep. a multisite trial Cancer 15 (116), 3924e3933.
with cancer: a review of the literature Support Care. Cancer 5, 466e484.
€der, U., Ljungman, G., Essen, L.v, 2008. Posttraumatic stress disorder among
Po
Hall, B., Whitehouse, A., 1998. The effects of imagery manipulated appraisal on
parents of children on cancer treatment: a longitudinal study. Psycho-Oncology
intensity and direction of competitive anxiety. Sport Psychol. 12, 40e51.
17 (5), 430e437.
Hamilton, M., 1959. The assessment of anxiety states by rating. Br. J. Med. Psychol.
Pollock, R.A., Rosenbaum, J.F., Marrs, A., Miller, B.S., Biederman, J., 1995. Anxiety
32, 50e55.
disorders of childhood: implications for adult psychopathology. Psychiatric Clin.
Hoekstra-Weebers, J.E., Heuvel, F., Jaspers, J.P., Kamps, W.A., Klip, E.C., 1998. Brief
N. Am. 18, 745e766.
report: an intervention program for parents of pediatric cancer patients: a
Post-White, J., 2002. Clinical indication for use of imagery in oncology practice. In:
randomized controlled trial. J. Pediatr. Psychol. 23 (3), 207e214.
Edwards, D.M. (Ed.), Voice Massage, Scripts for Guided Imagery. Oncology
Jacobson, E., 1938. Progressive Relaxation Univ. Chicago Press, Chicago, Ill.
Nursing Society, Pittsburgh, PA.
Karanikola, M.N.K., Stathopoulou, H., Kalafati, M., Terzi, A.M., Bouzika, M.,
Post-White, J., Fitzgerald, M., Savik, K., Hooke, M.C., Hannahan, A.B., Sencer, S.F.,
Papathanassoglou, E.D.E., 2009. Rating anxiety symptoms in intensive care
2008. Massage therapy for children with Cancer. J. Paediatr. Oncol. Nurs. 26
nursing staff in Greece. Nosileftiki 48 (4), 447e457.
(JanuaryeFebruary (1)), 16e28.
Kazak, A.E., Penati, B., Boyer, B.A., Himelstein, B., Brophy, P., Waibel, M.K., et al., 1996.
Post-White, J., Fitzgerald, M., Savik, K., Hooke, M.C., Hannahan, A.B., Sencer, S.F.,
A randomized controlled prospective outcome study of a psychological and
2009. Massage therapy for ChildrenWith Cancer. J. Paediatr. Oncol. Nurs. 26
pharmacological intervention protocol for procedural distress in paediatric
(JanuaryeFebruary (1)), 16e28.
leukemia. J. Paediatr. Psychol. 21 (5), 615e631.
Pritchard-Jones, K., Rob, P., Gregory, H.R., Lars, H., Peter, D., Gabriele, C.,
Kazak, A.E., Boeving, C.A., Alderfer, M.A., Hwang, W.T., Reilly, A., 2005. Posttraumatic
Marianne, C.N., Steliarova-Foucher, E., 2013. Sustaining innovation and
stress symptoms during treatment in parents of children with cancer. J. Clin.
improvement in the treatment of childhood cancer: lessons from high-income
Oncol. 23 (30), 7405e7410.
countries. Lancet Oncol. 14 (3), e95ee103. March 2013.
Kazak, A.E., Rourke, M.T., Alderfer, M.A., Pai, A., Reilly, A.F., Meadows, A.T., 2007.
Richardson, A., 1994. Individual Differences in Imaging: Their Measurement, Origins
Evidence-based assessment, intervention and psychosocial care in pediatric
and Consequences. Baywood, Amityville, NY.
oncology: a blueprint for comprehensive services across treatment. J. Pediatr.
Robinson, K.E., Gerhardt, C.A., Vannatta, K., Noll, R.B., 2007. Parent and family fac-
Psychol. 32 (9), 1099e1110.
tors associated with child adjustment to pediatric cancer. J. Pediatr. Psychol. 32
Kibler, V.E., Foreman, R.J., 1983. Effects of progressive muscle relaxation training on
(4), 400e410.
trait anxiety. Psychol. Rep. 53, 128e130.
Scheufele, P.M., 2000. Effects of progressive relaxation and classical music on
King, N.J., 1980. Abbreviated progressive relaxation. Prog. Behav. Modification 3,
measurements of attention, relaxation, and stress responses. J. Behav. Med. 23
147e182.
(2), 207e228.
Lazarus, R.S., Folkman, S., 1984. Coping and Adaptation. In: Gentry, W.D. (Ed.), The
Schneider, R.H., Alexander, C.N., Staggers, F., et al., 2005. A randomized controlled
Handbook of Behavioral Medicine. Guilford, New York, pp. 282e325.
trial of stress reduction in African Americans treated for hypertension for over
Marsland, A.L., Long, K.A., Howe, C., Thompson, A.L., Tersak, J., Ewing, L.J., 2013.
one year. Am. J. Hypertens. 18 (1), 88e98.
A pilot trial of a stress management intervention for primary caregivers of
Schultz, M., Schultz, J., 2002. The Biofeedback Stress Test. Development in Business
children newly diagnosed with cancer: preliminary evidence that perceived
Simulation and Experiential Learning, vol. 29.
social support moderates the psychosocial benefit of intervention. J. Paediatr.
Scott-Findlay, S., Chalmers, K., 2001. Rural families' perspectives on having a child
Psychol. 38 (4), 449e461.
with cancer. J. Pediatric Oncol. Nurs. 18 (5), 205e216.
McGrady, A.V., Yonker, R., Tan, S.Y., Fine, T.H., Woerner, M., 1981. The effect of
Serra, D., Parris, C.R., Carper, E., et al., 2012. Outcomes of Guided Imagery in Patients
18 T. Tsitsi et al. / European Journal of Oncology Nursing 26 (2017) 9e18
Receiving Radiation Therapy for Breast cancer. Clin. J. Oncol. Nurs 16 (6),
617e623.
Siegel, R., Ward, E., Brawley, O., Jemal, A., 2011. Cancer statistics (2011) the impact of
eliminating socioeconomic and racial disparities on premature Cancer deaths.
CA Cancer J. Clin. 61, 212e236.
Snyder, M., 1992. Progressive Relaxation. In: Snyder, M. (Ed.), Independent Nursing
Interventions, second ed. Delmar Publishers Inc., New York, pp. 47e62.
Stehl, M.L., Kazak, A.E., Alderfer, M.A., Rodriguez, A., Hwang, W.T., Pai, A.L., Reilly, A.,
2009. Conducting a randomized clinical trial of an psychological intervention
for parents/caregivers of children with cancer shortly after diagnosis. J. Pediatr.
Psychol. 34, 803e816.
Streisand, R., Rodrique, J., Houck, C., Graham-Pole, J., Berlant, N., 2000. Brief report:
parents of children undergoing bone marrow transplantation: documenting
stress and piloting a psychological intervention program. J. Pediatr. Psychol. 25,
331e337.
Sudsuang, R., Chentanez, V., Velu-van, K., 1991. Effect of Buddhist meditation on
serum cortisol and total protein levels, blood pressure, pulse rate, lung volume
and reaction time. Physiol. Behav. 50, 543e548.
Thayer, R.E., 1996. The Origin of Everyday Moods: Managing Energy, Tension and
Stress. Oxford University Press, New York.
Tsitsi, T., Raftopoulos, V., Papastavrou, E., Charalambous, A., 2014. Complementary
and alternative medical interventions for the management of anxiety in parents
of children who are hospitalized and suffer from a malignancy: a systematic
review of RCTs. Eur. J. Integr. Med. 6 (1), 112e124. February 2014.
Vance, Y.H., Morse, R.C., Jenney, M.E., Eiser, C., 2001. Issues in measuring quality of
life in childhood cancer: measures, proxies, and parental mental health. J. Child
Psychol. Psychiatry Allied Discip. 42 (5), 661e667.
Visser, O., Siesling, S., Van Dijk, J.A.A.M., 2003. Incidence of cancer in the
Netherlands (1999/2000). Association of Comprehensive Cancer Centres,
Utrecht.
Vrijmoet-Wiersma, C.M.J., van Klink, J.M.M., Kolk, A.M., Koopman, H.M., Ball, L.M.,
Egeler, R.M., 2008. Assessment of parental psychological stress in pediatric
Cancer. A Rev. J. Pediatr. Psychol. 33 (7), 694e706.
Vrijmoet-Wiersma, C.M.J., Egeler, M.R., Koopman, H.M., Norberg, A.L.,
Grootenhuis, M.A., 2009. Parental stress before, during and after pediatric stem
cell transplantation: a review article. Support. Care Cancer 17, 1435e1443.
Walker, L.G., Walker, M.B., Ogston, K., et al., 1999. Psychological, clinical and path-
ological effects of relaxation training and guided imagery during primary
chemotherapy. Br. J. Cancer 80, 262e268.
Wallace, R.K., 1970. Physiological effects of transcendental meditation. Science 167,
1751e1754, 21.
Wallace, R.K., Benson, H., 1972. The physiology of meditation. Sci. Am. 226 (2),
85e92.
Woodgate, R.L., Degner, L.F., 2003. A substantive theory of keeping the spirit alive:
the spirit within children with Cancer and their families pediatric oncology
nurses, 20 (3), 103e119.
Zervas, C., 1993. Psychology of Physical Education and Sport. University notes,
University of Athens.