0

GARDEN CITY COLLEGE OF NURSING

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.

NAME OF THE CANDIDATE AND ADDRESS

Mr. M. MANOJ KIRUBAKAR 1ST YEAR M.SC. NURSING GARDEN CITY COLLEGE OF NURSING, VIDYANAGAR, K.R. PURAM, BANGALORE, KARNATAKA. GARDEN CITY COLLEGE OF NURSING, VIDYANAGAR, K.R. PURAM, BANGALORE, KARNATAKA. M.SC. NURSING FIRST YEAR MEDICAL AND SURGICAL NURSING 24TH MAY 2010

2.

NAME OF THE INSTITUTION

3.

4.

COURSE OF THE STUDY AND SUBJECT DATE OF ADMISSION TO THE COURSE TITLE OF THE TOPIC

5.

A STUDY TO EVALUATE THE EFFECTIVENESS OF PROGRESSIVE MUSCLE RELAXATION ON PAIN AMONG THE CANCER PATIENTS IN A SELECTED HOSPITAL, BANGALORE.

6.

BRIEFRESUME OF THE INTENDED WORK:

INTRODUCTION Destiny is not a matter of chance, it is a matter of choice; it is not a thing to be waited for, it is a thing to be achieved. -William Jennings Bryan1.

Believe it or not, cancer has afflicted people for several centuries. It is not a new disease. It is because of the early research that we hold a greater knowledge of cancer today2.

Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems3.

Cancer begins as a single abnormal cell that begins to multiply out of control. Groups of such cells form tumours and invade healthy tissue, often spreading to other parts of the body. Carcinogens are substances that promote the development of cancerous cells. They may come from foods, from the air, or even from within the body. Most carcinogens are neutralized before damage can occur, but sometimes they attack the cells genetic material (DNA) and alter it . Dietary fat, on the other hand, is known to be a promoter that helps the abnormal cells grow quickly.(Cancer project)4. Cancer is second largest non-communicable disease and it has a sizable contribution in the total number of deaths. It is important for the public health professionals to understand the dynamics of cancer incidence for future strategies.5

Pain, which can be caused by the disease itself or by treatments, is common in people with cancer, although not all people with cancer will experience pain. Approximately 30% to 50% of people with cancer experience pain while undergoing treatment, and 70% to 90% of people with advanced cancer experience pain. cancer pain can be managed. With today's knowledge of cancer pain and the availability of pain-relieving therapies, no one should have to suffer from unrelieved pain. Physicians may not be adequately educated about pain control or they may be more focused on control of the disease than on control of pain and other symptoms; patients may be reluctant to report their pain; and both physicians and patients may be reluctant to use morphine and other opioids for pain control because they fear addiction6. Clinical studies also show that relaxation techniques reduce the perception of pain. One clinical study (August 2008) conducted in Bangkok found that among patients undergoing colorectal surgery, those who practiced progressive muscle relaxation technique before, during, and after the operation had less pain and needed fewer pain medications than those who did not7. Progressive muscle relaxation [PMR] is a relaxation technique of stress management developed by American physician Edmund Jacobson in 1934. This progressive muscle relaxation technique is focused on tensing and releasing tensions in the 16 different muscle groups . Empirical proofs also supports the use of progressive muscle relaxation in high level tension responses and mind body techniques such as: irritable bowel syndrome, insomnia, reducing tension headaches, adjunct treatment in cancer and chronic pain management in inflammatory arthritis.(Mc Callie et al., 2006)8. The idea behind progressive muscle relaxation is simply that of isolating one muscle group at a time, then intentionally creating muscle tension for 8-10 seconds, and then allowing the muscle to totally relax so as to release the tensions8.

Progressive muscle relaxation practitioner requirements: There are no licensing or certification requirements for teaching PMR, but many health care professionals have had PMR training as part of their formal education. Health care professionals who teach PMR can include: Psychologists nurses health care professionals trained in hypnosis clinical social workers

Many cancer hospitals and clinics offer programs in relaxation training on Progressive Muscle Relaxation9.

6.1

NEED FOR THE STUDY Cancers in all forms are causing about 12 per cent of deaths throughout the world. In the developed countries cancer is the second leading cause of death accounting for 21% (2.5 million) of all mortality. In the developing countries cancer ranks third as a cause of death and accounts for 9.5% (3.8 million) of all deaths. (NCCP)10. Cancer has become one of the ten leading causes of death in India. It is estimated that there are nearly 1.5-2 million cancer cases at any given point of time. Over 7 lakh new cases of cancer and 3 lakh deaths occur annually due to cancer11. Cancer rates in India are considerably lower than those in more developed countries such as the United Statesdata from population based cancer registries in India show that the most frequently reported cancer sites in males are lung, oesophagus, stomach, and larynx. In females, cancers of the cervix, breast, ovary, and oesophagus are the most commonly encountered. But then, 2005 data shows that India has one of the highest cancer rates in the world!! 12. Cancer is a leading cause of death around the world. WHO estimates that 84 million people will die of cancer between 2005 and 2015 without intervention13. The World Cancer Day is 4th February..Each year on 4 February, WHO supports International Union Against Cancer to promote ways to ease the global burden of cancer. Preventing cancer and raising quality of life for cancer patients are recurring themes13.

This year's theme, Cancer can be prevented too, focuses on simple measures to prevent cancer such as:

no tobacco use a healthy diet and regular exercise limited alcohol use Protection against cancer-causing infections13.

The Origin of the Word "Cancer" came from the father of medicine,
Hippocrates, a Greek physician. Hippocrates used the Greek words, carcinos and carcinoma to describe tumours, thus calling cancer "karkinos." The Greek terms actually were words to describe a crab, which Hippocrates thought a tumour resembled. Although Hippocrates may have named "Cancer," he was certainly not the first to discover the disease. The history of cancer actually begins much earlier2. The number of cancer patients in the world is increasing. According to WHO estimates, globally 10 million new cancer cases are diagnosed each year. It is estimated that by the year 2020, there will be 20 million cancer cases. The majority of the worlds cancer patients present with advanced disease and for such patients the only realistic treatment option is pain management and palliative care14. The experience of pain is multi-dimensional; impacting on the cognitive, emotional, physical, social, spiritual and behavioral components of a person. It affects concentration, the ability to problem solve and make decisions. Pain can cause reduced appetite, insomnia, irritability, low mood, feelings of despair and hopeless, anger, low self esteem, and reduce a persons interest and pleasure in what is usually important to them15.

Cancer patients need pain relief at all stages of their disease; pain occurs in one third of patients receiving anti-cancer treatment.30% of patients receiving active treatment for metastatic disease have significant cancer related pain, and these percentage increases to 60-90% in those advance disease. Unfortunately, 25% of cancer patients die without adequate pain relief in spite of appropriate tools for adequate pain control being available. Pain can be physiologically devastating because it is a constant reminder of the incurable and progressive nature of the disease; therefore, all available measures appropriate to the patient should be explored14. One of the most simple and easily learned techniques for relaxation is Progressive Muscle Relaxation (PMR), a widely-used procedure today. This technique involves slowly tensing and then releasing each muscle group individually, starting with the muscles in the toes and finishing with those in the head16. Progressive muscle relaxation can be learned by nearly anyone and requires only ten to 20 minutes per day to practice. Most practitioners recommend tensing and relaxing the muscle groups one at a time in a specific order, generally beginning with the lower extremities and ending with the face, abdomen, and chest. You can practice this technique seated or lying down, and you should try to practice with comfortable clothing on, and in a quiet place free of all distractions17. So the researcher has decided to conduct a study to evaluate the effectiveness of Progressive Muscle Relaxation on pain among cancer patients.

6.2

REVIEW OF LITERATURE

Review of literature for the present study is organized under the following headings:

a. Review related to pain among cancer patients.

b. Review related to Progressive Muscle Relaxation. c. Review related to pain and Progressive muscle relaxation

A. Review related to Pain among Cancer patients:

A Study was investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer. An instrument especially designed for judging prevalence studies on their methodological quality was used. Pooled prevalence rates of pain were calculated for four subgroups. Fifty-two studies were used in the meta-analysis. Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%). Conclusion: Despite the clear World Health Organisation recommendations, cancer pain still is a major problem18. A Study sought to increase understanding of cancer-related pain and treatment across Europe. The study conducted in 11 European countries and Israel. The survey screened for patients experiencing pain at least weekly. This study completed a detailed attitudinal questionnaire. Of 5084 adult patients contacted, 56% suffered moderate-to-severe pain at least monthly .Conclusion: Across Europe and Israel, treatment of cancer pain is suboptimal. Pain and pain relief should be considered integral to the diagnosis and treatment of cancer; management guidelines should be revised to improve pain control in patients with cancer19.

A Study was done on Improvement of pain related self management for cancer patients through a trans institutional modular nursing intervention: This protocol of a cluster randomized multicenter trial is aimed to test the SCION-PAIN program, a multi modular structured intervention to improve self management in cancer patients with pain. 240 patients with diagnosed malignancy and pain > 3 days and average pain 3/10 will participate in a cluster randomized Discussion: The study will determine if the acquired self management skills of the patients continue to be used after discharge from hospital. It is hypothesized that patients who receive the multi modular structured intervention will have less patient related barriers and a better self management of cancer pain20. B. Review related to Progressive Muscle Relaxation: A Study was done to identify the effects of applying Progressive Muscle Relaxation Technique on Quality of Life of patients with multiple Sclerosis. The Design is Quasi-experimental study. Multiple Sclerosis patients (n = 66) were selected with no probability sampling then assigned to experimental and control groups (33 patients in each group). Individual Information Questionnaire, SF-8 Health Survey, Self-reported checklist. PMRT performed for 63 sessions by experimental group during two months but no intervention was done for control group. Conclusions. Although this study provides modest support for the effectiveness of PMR Technique on quality of life of multiple sclerosis patients, further research is required to determine better methods to promote quality of life of patients suffer multiple sclerosis and other chronic disease21. A Study was done to Measure the efficacy of music, progressive muscle relaxation, and a combination of both variables on tension reduction. Ss were three sections (N = 76) of an introductory music class. Each section received either sedative music (M), PMR, or both (M + PMR) as treatment. Vasoconstriction, or finger temperature, was used to measure stress level prior to and after the intervention. All three groups evidenced significant increases in finger temperature. There was no significant difference among treatment groups, although the M + PMR group's mean increase was greater than the grand mean, while the M and PMR group's increases were below the grand mean22.

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A Study was conducted on Progressive muscle relaxation. PMR was first identified by Jacobson in 1934 as tensing and releasing of 16 muscle groups. Wolpe adapted it for use with systematic desensitization in 1948 and Bernstein and Borkovec in 1973 studied adjustments to the technique to fit cognitive behavioural stress management. Some of these adjustments are: 7 and 4 muscle groups, relaxation through recall, recall and counting, and counting. Empirical evidence supports the use of PMR in high level tension responses and mind body techniques such as: reducing tension headaches, insomnia, adjunct treatment in cancer, chronic pain management in inflammatory arthritis and irritable bowel syndrome. This article analyzes the development of PMR, reviews current research, and discusses the implications to social work practice23. A Study was undertaken of recent research in which abbreviated progressive muscle relaxation training (APRT) was used as an intervention for psycho physiological and stress-related disorders. The strength of association between APRT and outcome measures was calculated for 29 experiments published after 1980. The average effect size across all experiments was moderate (r =.40).APRT was most strongly associated with improvement in experiments that delivered APRT on an individual basis and provided recipients with training tapes. Moreover, the treatment duration and number of sessions positively influenced the strength of association24.

C. Review related to pain and Progressive Muscle Relaxation: A study compared the effectiveness of guided imagery and progressive muscle relaxation in reducing pain and distress. Thirty adult oncologic patients in a large military hospital listened to two taped transcripts in random order; one used guided imagery and the other progressive muscle relaxation. Patients rated their pain and distress on a 10 cm analog scale before and after listening to each tape. The results indicated that both strategies were equally effective in reducing pain and distress in this small sample. The majority of patients expressed a preference for the PMR technique. Nurses are encouraged to use these strategies in helping oncologic patients reduce pain and distress25.

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A Study was conducted on the effects of progressive muscle relaxation training on nociceptive flexion reflex threshold in healthy young adults. This randomized controlled study utilized the nociceptive flexion reflex (NFR) to evaluate nociceptive responding among 55 college-age men and women (mean age = 19.4 1.2 years). Participants completed laboratory assessments of NFR threshold and questionnaires evaluating pain and stress. Participants were then randomly assigned to either a 25-min PMR condition or a no-treatment control condition. Results indicated a significant time by condition interaction for NFR, with participants in the PMR condition experiencing a significant increase in NFR threshold while participants in the no-treatment condition experienced no change in NFR. Ratings of pain did not change during the study, but PMR participants reported decreased stress following the PMR intervention. This is the first study with a randomized no-treatment control group demonstrating the effect of a brief PMR protocol on descending inhibition of nociception26.

A Study was done to examine the variation in pain outcomes achieved with progressive muscle relaxation (PMR) and analgesic imagery interventions among hospitalized patients with cancer pain, and assessed the influence of four individual difference variables (cognitive ability, outcome expectancy, previous experience, and concurrent symptoms) on pain relief achieved with each intervention. A crossover design was used in which 40 hospitalized cancer patients received two trials of PMR, two trials of analgesic imagery, and two trials of a control condition. In comparing means between treatment and control conditions, both PMR and analgesic imagery produced greater improvements in pain intensity, pain-related distress, and perceived control over pain than the control condition. Investigators should continue efforts to identify factors that moderate the effects of cognitive-behavioural pain coping strategies so that clinicians can identify the most beneficial treatments for individual patients27.

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6.3

PROBLEM STATEMENT: A study to evaluate the effectiveness of progressive muscle relaxation on pain among the cancer patients in a selected hospital, Bangalore.

6.4

OBJECTIVES OF THE STUDY:

1. To assess the level of pain among cancer patients. 2. To evaluate the effectiveness of Progressive Muscle Relaxation technique on pain among cancer patients. 3. To associate the level of pain among the cancer patients with the selected demographic variables (age, sex, marital status, type of cancer).

6.5

OPERATIONAL DEFINITIONS

Effectiveness: It refers to the outcome of progressive muscle relaxation technique on pain as determined by differences between pre and post pain scale score.

Progressive Muscle Relaxation technique: It refers to the use of tensing and releasing the muscles, one body part at a time, to bring about a feeling of physical relaxation.

Pain: Refers to the verbal responses of cancer patients in the rating scale ranging from mild pain to severe pain. Pain will be measured in terms of pain scores.

Cancer patients: It refers to the patients who diagnosed as cancer by the physician and got admitted to the selected hospital is known as cancer patients.

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6.6

HYPOTHESIS: H1- There will be significant reduction on pain among the cancer patients after administration of progressive muscle relaxation technique. H2- There will be significant association between the level of pain among cancer patients and selected demographic variables.

6.7

RESEARCH VARIABLES UNDER STUDY:

INDEPENDENT VARIABLE: In this study the independent variable is Progressive Muscle Relaxation Technique.

DEPENDENT VARIABLE: In this study the dependent variable is Pain among the cancer patients.

6.8

ASSUMPTION Level of pain varies from individual to individual Progressive muscle relaxation Technique helps to impove pain control among the cancer patients. Progressive muscle relaxation technique improves the comfort of the cancer patients. Progressive Muscle Relaxation Technique will improve nursing care and quality.

6.9

DELIMITATION The study will be delimited to cancer patients in a selected hospital. The sample is limited to only 30 subjects. The study period is limited to 4weeks only.

6.10

PROJECTED OUTCOME The study will reduce the pain among cancer patients.

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7.

MATERIALS AND METHODS:

7.1

SOURCE OF DATA: Cancer patients of selected hospital.

7.1.1

RESEARCH DESIGN: The design adopted for the study will de quasi experimental design.(one group pre test-post test design)
E=O1 X O2

E= Experimental group

O1= Pre test

O2= Post test

X = Intervention( Progressive Muscle Relaxation Technique)

7.1.2

SETTING: The study will be conducted among cancer patients in a selected hospital, Bangalore.

7.1.3

POPULATION: The study population comprises of cancer patients in a selected hospital.

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SAMPLING PROCEDURE

8.1

SAMPLE The cancer patients who will be present in the selected hospital within the period of study and who fulfil the sampling criteria.

8.1.1

SAMPLE SIZE. The sample size of this study will be 30 cancer patients in a selected hospital, Bangalore.

8.1.2

SAMPLING TECHNIQUE. The technique that is adopted for this study will be purposive sampling.

8.1.3

INCLUSION CRITERIA
1. Subject who diagnosed as cancer. 2. Both genders will be included. 3. Those who cooperate during the study. 4. Having analgesics therapy prescribed by physician.

5. No history of opioid dependent.

8.1.4

EXCLUSION CRITERIA: 1. Cancer patient who are not willing to participate in the study. 2. Administrated analgesics within 2 hours before starting the
intervention.

3. The patient who got the complication.

8.2

INSTRUMENT INTENDED TO BE USED

Section A. A tool to assess the demographic information of the sample. Section B. A tool to assess the effectiveness of Progressive Muscle Relaxation technique on pain by Numerical rating scale.

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8.2.1

METHOD OF DATA COLLECTION: The permission for conducting the study in the in the selected hospital will be obtained from the ethical committee of that hospital. Data collection procedure is explained to all the 30 participants. Each participant will be provided with privacy and comfort. The purpose of the study will be explained to them. The patient will be informed that their identity will not be revealed and their responses will be used only for the research purpose. The informed consent will be obtained from the patient to do Progressive Muscle Relaxation Technique on them. The researcher will be using rating scale to assess stress by structured interview for 30 patients. On the 1st day of Progressive Muscle Relaxation Technique session the investigator briefly explained the topics of 15 days session and will be instructing the patients to attend morning as well as evening session for half an hour respectively. The post test will be administered for all the 30 patients.

8.2.2

METHOD OF DATA ANALYSIS AND PRESENTATION:

It will be analysed through descriptive and inferential statistical analysis. Statistical analysis such as standard deviation, percentage and paired test will be used to determine the effectiveness of Progressive Muscle Relaxation Technique. Chisquare analysis will be done to associate the level of pain and demographic variable.

8.3

DOES

THE

STUDY

REQUIRE

ANY

INVESTIGATION

OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.

Yes. The study requires implementation of Progressive Muscle Relaxation Technique to be conducted among cancer patients in selected hospital, Bangalore.

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8.4

HAS

ETHICAL

CLEARENCE

BEEN

OBTAINED

FROM

YOUR

INSTITUTION IN CASE OF 8.3? Ethical clearance is obtained from the research committee of Garden City College of Nursing. Permission will be obtained from the committee of the Hospital, Bangalore. Consent form will be obtained from the cancer patients who are willing to participate in the study.

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LIST OF REFERENCES: 1. Heart quotes [internet] 2010 [cited 2010nov 28]; Available from: http://www.heartquotes.net/Choice.html. 2. Lisa fayed.Cancer History - The History of Cancer. Cancer[internet] 2009[updated july 8\; cited 2010 nov 26]. Available from:

http://cancer.about.com/od/historyofcancer/a/cancerhistor_2.html. 3. cancer [internet] 2010 [updated 2010 dec 5; cited 2010 nov 27] : Available from: http://www.medicinenet.com/cancer/article.htm 4. Nomad Blogger. Three short definition of cancer[internet] 2008 oct 26 [cited 2010 nov 27] Available from: http://rajapayloadz.com/2008/10/26/threeshort-definition-about-cancer/ 5. P Marimuthu Projection of cancer incidence in five cities and cancer mortality in India . 2008 [cited 2010 nov 28] ; (1) 4-7. Available From: http://www.indianjcancer.com/article.asp?issn=0019509X;year=2008;volume=45;issue=1;spage=4;epage=7;aulast=Marimuthu 6. understanding cancer pain [internet] 2001 [updated 2002 july 26; cited 2010 nov 27] Available from: http://www.cancerpain.org/understanding/whatis.html. 7. Slomon.R(2008).Relaxation and the relief of cancer pain. Nursing Clinics Of North America,30(4),697-709. 8. Progressive muscle relaxation [internet] 2010 [updated 2010 feb 28; cited 2010 nov 28]. Available from: http://gain-muscle.org/progressive-musclerelaxation/ 9. Progressive Muscle Relaxation [internet] 2008 aug 5[cited 2010 nov 28]; Available from: http://www.breastcancer.org/treatment/comp_med/types/muscle_relax.jsp. 10. Ministry Of Family Health and welfare. National Cancer control programme [internet] 2010 [cited 2010 nov 28]; Available from: http://www.mohfw.nic.in/kk/95/i9/95i90e01.htm. 11. Health programs [internet] 2010 [updated 2010 dec 5 cited 2010 nov 26 ]. Available from: http://www.aarogya.com/component/content/140-healthprograms/2722-national-cancer-control-programme-nccp.html?start=1/04

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12. Nita. India has one of the highest rates in the world [internet] 2007 apr 26 [cited 2010 nov 27]. Available from: http://nitawriter.wordpress.com/2007/26/india-has-one-of-the-highestcancer-rates-in-the-world/ 13. World health organisation. World cancer day [internet] 2010 [cited 2010 nov 28 ]; Available from: http://www.who.int/mediacentre/events/annual/world_cancer_day/en/ 14. Seema Mishra, Sushma Bhatnagar, Amit kumar Singhal. Recent trends in cancer pain management [internet] 2010 [cited 2010 nov 26] 25(4): 22-29: Available from: http://medind.nic.in/ias/t04/i4/iast04i4p22.pdf 15. The role of therapies in managing cancer-related pain [internet] 2010 [cited 2010 nov 29]: Available from: http://www.onlinecancereducationforum.com/OCEF/The role of therapies in managing cancer-related pain.pdf 16. Medical centre. Relaxation techniques [internet] 2010 [cited 2010 nov 27]: Available from: http://www.umm.edu/altmed/articles/relaxation-techniques000359.htm 17. Melissa Stoppler, M.D.,William C. Shiel, Jr, MD, FACP, FACR. Progressive Muscle Relaxationfor stress and insomnia [internet] 2010[updated dec 5; cited 2010 nov 27]: Available from:http://www.medicinenet.com/script/main/art.asp?articlekey=47281 18. Ann oncol.Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of oncology [internet] 2010[cited 2010 nov 25]:18(9); 1437-1449.Available from: http://annonc.oxfordjournals.org/content/18/9/1437.abstract/doi: 10.1093/annonc/mdm056 19. H. Breivik, N. Cherny, B. Collett, F. de Conno, M. Filbet, A. J. Foubert et.al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes: Annals of oncology [internet]: 2010[cited 2010 nov 25]:20(8): 1420-1433.Available from: http://annonc.oxfordjournals.org/content/20/8/1420.abstract

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20. Patrick Jahn, Maria Kitzmantel, Petra Renz, Ene Kukk, Oliver Kuss, Anette Thoke-Colberg et.al.Improvement of pain related self management for oncologic patients through a trans institutional modular nursing intervention: protocol of a cluster randomized multicenter trial: study protocol [internet]: 2010 [cited 2010 nov 28]: 11:29.Available from: http://www.trialsjournal.com/content/11/1/29/doi:10.1186/1745-6215-11-29 21. Somayeh Ghafari, Fazlolah Ahmadi, Masoud Nabavi, Kazemnejad Anoshirvan, Robabe Memarian, Mohamad Rafatbakhsh. Effectiveness of applying progressive muscle relaxation technique on quality of life of patients with multiple sclerosis.Clinical Nursing [internet] 2009 aug [cited 2010 nov 28]: 18(15):2171-2179.Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.13652702.2009.02787.x/abstract 22. Virginia E. Kibler,Mark S. Rider. Effects of progressive muscle relaxation and music on stress as measured by finger temperature response. Clinical psychology [internet] 2006 feb [cited 2010 nov 24]:39(2): 213-215. Available from: http://onlinelibrary.wiley.com/doi/10.1002/10974679%28198303%2939:2%3C213::AID-JCLP2270390211%3E3.0.CO;22/abstract 23. Martha S. McCallie, Claire M. Blum , Charlaine J. Hood . Progressive muscle relaxation. Human behaviour in social environment. [internet] 2006 july 3 [cited 2010 nov 27]: 13(3):51-66. Available from: http://www.informaworld.com/smpp/content~db=all~content=a903372146~f rm=abslink/DOI: 10.1300/J137v13n03_04 24. Charles R. Carlson , Rick H. Hoyle. Efficacy of Abbreviated Progressive Muscle Relaxation Training: A Quantitative Review of Behavioral Medicine Research[internet] 2002 sep 19 [cited 2010 nov 28] . Available from : http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WY646T4DY1-32 & user

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25. Shirley Graffam , Arthur Johnson. A comparison of two relaxation strategies for the relief of pain and its distress. Pain and symptom management [internet] 2010 may 14 [cited 2010 nov 25]: 2(4);229-231.Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8R5031TRT-9 26. Charles F. Emeryabc, Christopher R. Franced, Jennifer Harrisa, Greg Normana, Courtney VanArsdalena .Effects of progressive muscle relaxation training on nociceptive flexion reflex threshold in healthy young adults: A randomized trial.pain [internet] 2008 aug [cited 2010 nov 22]:138(2):375-379. Available from: http://www.painjournalonline.com/article/S0304-3959(08)00024 9/abstract/doi:10.1016/j.pain.2008.01.015. 27. Kristine L. Kwekkeboom, Britt Wanta, Molly Bumpus.Individual Difference Variables and the Effects of Progressive Muscle Relaxation and Analgesic Imagery Interventions on Cancer Pain.pain and symptom management [internet] 2008 dec [cited 2010 nov 28]: 36(6):604-615. Available from: http://www.jpsmjournal.com/article/S0885-3924%2808%29002224/abstract/doi:10.1016/j.jpainsymman.2007.12.011

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10.

SIGNATURE OF THE CANDIDATE

11.

REMARK OF THE GUIDE

12.

NAME AND DESIGNATION OF THE GUIDE

PROF. SENTHIL KAVITHA M.SC.(N) (PhD) MEDICAL SURGICAL NURSING GARDEN CITY COLLEGE BANGALORE

12.1

SIGNATURE

12.2

CO-GUIDE

SIGNATURE 12.3

12.4

HEAD OF THE DEPARTMENT

PROF. SENTHIL. KAVITHA M.SC (N) (PhD) MEDICAL SURGICAL NURSING

12.5

SIGNATURE

13.

REMARKS OF THE PRINCIPAL

13.1.

SIGNATURE