When a Symptom Intervention Works, Why Not Use It?


When oncology nurses move proactively to learn more about and use proven effective “green-lighted” interventions like exercise and muscle relaxation in their daily practice, it can go a long way in helping patients and their caregivers manage symptoms associated with a cancer diagnosis like fatigue and anxiety.

Jennifer A. Wenzel, PhD, RN, CCM, FAAN

Sandra Mitchell, CRNP, PhD, AOCN

Sandra Mitchell, CRNP,


When oncology nurses move proactively to learn more about and use proven effective “green-lighted” interventions like exercise and muscle relaxation in their daily practice, it can go a long way in helping patients and their caregivers manage symptoms associated with a cancer diagnosis like fatigue and anxiety.

“We need to flip the mindset, and ‘go green,’” stressed Janelle Tipton, MSN, RN, AOCN, who moderated a panel focused on optimizing use of evidence-based symptom management interventions at the 2016 Oncology Nursing Society (ONS) 41st Annual Congress in San Antonio.

“Many of our patients experience clusters of problems, so we can absolutely help them by developing and learning more about these interventions that have solid clinical evidence behind them.” said Tipton, who manages the infusion center at the University of Toledo Medical Center. These approaches are strong enough to be rated “Recommended for Practice” or “Likely to Be Effective” by the ONS Putting Evidence into Practice (PEP) initiative, now in its 10th year.

Using Progressive Muscle Relaxation to Relieve Anxiety

A poll of the audience found that many were not familiar with progressive muscle relaxation (PMR), one of the practices that experts have deemed likely to be effective to help patients with cancer avert or cope with anxiety.

PMR dates as far back as 1929, noted Diane G. Cope, PhD, ARNP-BC, AOCNP, a nurse practitioner with Florida Cancer Specialists in Fort Myers, who has been involved in the development of the PEP anxiety and depression section for several years. She explained that PMR is a learned technique whereby one muscle group, often beginning with the feet, is tensed for approximately 30-60 seconds, while relaxing all the other muscle groups in the body. A darkened room can be used, but it’s not essential, as long as there are no distractions.

Initially, PMR is done twice a day and involves 16 muscle groups. That seems like a time-consuming process, Cope acknowledged, but after the first week, “You can at any point in time just focus on one muscle group.”

A nurse could say to a patient, for example, “You seem anxious. Why don’t we try this with one muscle group while we’re doing this IV infusion?” Approaching it “one encounter, one shift at a time,” makes sense Cope said, and assessing patients and caregivers for anxiety at each visit is important. She said that she finds that encouraging patients to keep a diary or journal of their feelings and other symptoms can be very helpful.

Nurses can use PMR to relieve their own anxiety, Cope added, but it requires a commitment from institutions and managers; one idea might be to begin a nursing meeting with PMR, Cope suggested.

PMR can be self-learned or professionally trained and deployed on the inpatient, outpatient, or home setting; it is low cost, and helps both patients and their caregivers. Cope said that she “got hooked” on the technique through viewing how the technique works on YouTube, but there are also informative apps; professional training from a psychologist, mental health counselor, or therapist is another option. Some universities also offer courses on PMR for nurses.

Importantly, PMR can be used anytime along the cancer trajectory.

“Think of all the areas where we have anxiety,” said Cope. “Anxiety waxes and wanes for our patients. There’s so much anxiety when they’re diagnosed: ‘What is that PET scan going to show? What is that biopsy going to show?’” Providing them with a treatment plan or regimen may give them some relief, she continued, but then there’s the worry over the first therapy: “How is it going to feel, how is going to affect my quality of life, will I still be independent?”

“Every single study has shown that there has been a decrease in anxiety using progressive muscle relaxation.”

Prescribing Exercise and Physical Activity

A widely and rapidly expanding body of literature confirms the benefits of exercise for patients with cancer, not only in managing fatigue and improving quality of life, noted Sandra Mitchell, CRNP, PhD, AOCN, a Research Scientist in the Outcomes Research Branch, Division of Cancer Control and Population Sciences, at the National Cancer Institute. The research now suggests that exercise improves prognosis and survival, with studies showing an association between a low level of physical activity and recurrence.

Symptoms shown to be relieved through exercise include fatigue, sleep-wake disturbances, lymphedema, anxiety, and depression, and physical activity can also attenuate or reduce late and long-term effects of cancer treatment.

Yet despite these benefits, studies show that less than 40% of patients are meeting the American Cancer Society’s recommended levels for physical activity.

To help more patients increase their physical activity, Mitchell suggested that exercise prescriptions need to be specific and individualized to reflect the patient’s cardiorespiratory fitness, muscle strength, and comorbidities. The physical activity must be progressively increased in intensity and duration, and the programs must also allow for appropriate rest and recovery between sessions.

To begin, nurses need to assess the patient’s current level of physical activity and health status and disease stage, and then establish goals. Mitchell said that she uses the acronym FIT as a frame for the prescription:

  • How frequently should they do that activity?
  • At what intensity?
  • For what time, and what type of activity should that be, e.g., walking, swimming, yoga?

The prescription should also include a plan to incorporate behavior change.

“For most of us, even if we look at our own lives, it’s very difficult to keep an exercise program,” Mitchell noted. “We want to look at principles of behavior change so that people will not only begin an exercise program, but maintain it.” Supervised exercise programs really help with adherence, she added, and formal programs may be especially appropriate for special populations who may be more vulnerable to adverse events from exercise.

Referrals to community exercise programs, rehabilitation professionals, and personal training can be very important, said Mitchell, along with the use of mobile health tools.

Practitioners may want to consider waiting until after the first cycle of chemotherapy before recommending an exercise program, if a patient has not been regularly active; slow walks several times a day are typically well-tolerated and can be a good way to remain active. Patients should be exercising with a partner, a caregiver, or exercise professional for safety reasons.

“If patients are immunocompromised, there may be several types of exercises that may be off-limits, swimming, for example,” Mitchell continued. “And it’s important to advise patients of what symptoms should lead them to stop exercising and see a member of their healthcare team.”

For any exercise prescription to be followed, motivation remains pivotal, and Mitchell has high hopes that expanding technologies like pedometers, accelerometers, wearable sensors, and smartphone apps that capture progress and send motivational messages and reminders will make a difference.

It’s really important that patients understand the benefits of exercise, said Mitchell: “Cancer diagnosis and completion of treatment are two ‘highly teachable’ moments,” and the oncology team should educate patients, “to ensure they understand their opportunity for risk reduction.”

More information and resources on these and several other interventions rated by the PEP can be found on the ONS website.

“We really need to dig deeper into the interventions,” said Cope, “and not always just focus on a symptom—we need to move beyond this and apply them.”

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