Keywords warm water foot submerged technique - level of fatigue - quality of sleep - quality of life - patients with cancer
Introduction
The World Health Organization has revealed that cancer is the second leading cause of death globally accounting for nearly 19.3 million new cases and 10 million deaths in 2020.[1 ] Cancer treatment depends on the type of cancer, organ, condition of cells, and its stages. It includes single treatment or combination treatment, such as surgery with radiation and chemotherapy, bone marrow transplantation, and immunotherapy.[2 ] It can cause serious side effects that disrupt the quality of life (QOL) in both physiological and psychological aspects.[3 ]
During and after treatments, the patient may experience fatigue. It is different from normal drowsiness experienced by a healthy person and this will not relieve by rest or sleep.[4 ] Prevalence of fatigue can be during treatment range from 25 to 99% depending on the patient.[5 ] Chemotherapy drugs side effects, the tension of cancer, and sleeping day time during treatment may lead to difficulty in falling asleep.[6 ] Radiation therapy is received by approximately 50% of all cancer patients during their treatment period; 40% of curative treatment is contributed by radiation therapy.[7 ] About 65,000 cancer patients receive chemotherapy in the US outpatient's oncology outpatient department. Chemotherapy patients more prone to getting an infection require hospitalization and even lead to death due to complications.[8 ]
Side effects that arise during cancer treatment improve afterward for many patients but persist for others. Late side effects may arise months or even years later. Both the prevalence and severity of side effects vary from person to person by cancer type, the treatment received, and other factors. The most common side effects of cancer and its treatment are pain, fatigue, emotional changes, and sleep disturbance.[9 ] The overall prevalence of sleep disturbance in cancer patients was 60.7%.[10 ] With the continued development of cancer therapeutic advanced technologies, patient survival duration has been significantly extended. Fatigue is the side effect of treatment for cancer and can have a major negative impact on QOL by altering a person's ability to engage in personal work and social activities.[11 ]
When queried regarding their top three concerns, cancer survivors often list sleep difficulty with fatigue and pain as one of their top three worries. Fatigue, pain, and sleep disturbance are interrelated, exacerbating one another and decreasing the QOL. All symptoms overlap together making it difficult to target specific therapies.[11 ]
There is no single therapy to treat cancer-related fatigue but treatment is given as per causes.[4 ] Understanding fatigue, sleep disturbance aspects are essential for defining interventions to improve the quality of care, prevent damage, and reduce the severity in patients.[9 ]
Despite patient's symptoms being managed through medical treatment, patients use alternative methods to relieve symptoms. Patients are encouraged for nonpharmacological methods that are safe to induce sleep and to reduce fatigue like hot water foot bath, biofeedback, aromatherapy, relaxation techniques, herbal remedies, massage, acupuncture, meditation, and exercise.[12 ] Hot water bath therapy is the one type of hydrotherapy that has impact on overall health and daily living. It is a local moist heat application, simple and easy to carry at home. It will increase blood circulation, promote muscle relaxation, and provide soothing.[6 ] Here it is a need of complementary therapy to reduce the side effects of cancer treatment and boosting relaxation.
Warm water foot submerged technique has its importance and needs to relieve fatigue and improve the quality of sleep and life. The objective of this study was to assess the effectiveness of warm water foot submerged technique on the level of fatigue, quality of sleep, and QOL among patients with cancer.
Materials and Methods
A quasi-experimental pretest and post-test control group research design was adopted to conduct the study in oncology ward of selected hospital of Mangaluru, Karnataka, from November 29, 2022 to June 29, 2023. The research protocol was approved by the Scientific Review Board and Institutional Ethics Committee. Informed consent was obtained from all participants before the study. Formal written permission was obtained from the administrative authorities of the hospital. Subjects were informed about the nature and purpose of the study before the data collection and informed consent was obtained. Sample size was calculated by using G*Power. 95% confidence level and 80% power standard effect size is 0.9. Sixty-eight patients with cancer recruited using a nonprobability purposive sampling technique.
Patients who are receiving chemotherapy or radiation therapy or adjuvant therapy, aged above 18 years, and having all stages of cancer, all solid tumor cancer were included in the study. Critically ill patients having leg injuries and foot ulcers were excluded from the study. The tool was administered for seven samples to assess the reliability. The reliability coefficient was assessed using the test–retest method. The calculated reliability of the multidimensional fatigue inventory was as follows: general fatigue = 0.8, physical fatigue = 0.84, reduced activity = 0.83, reduced motivation = 0.9, and mental fatigue = 0.7.Groningen sleep quality scale was 0.77 and EORTC QLQ-C-30 was 0.8.
The tools used to collect the information were demographic proforma, clinical proforma multidimensional fatigue inventory, Groningen sleep quality scale, and EORTC QLQ-C30. Demographic proforma included age, gender, marital status, educational status, occupation, monthly family income. Clinical proforma included stage of cancer, duration of illness, comorbid illnesses, treatment received, number of chemotherapy cycles, and number of radiation fraction.
Multidimensional fatigue inventory scores per item run from 1 to 5. A higher score indicates more fatigue. Therefore, the items indicative for fatigue needs to be recoded (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1). This concerns item 2, 5, 9, 10, 13, 14, 16, 17, 18, and 19. For each scale, a total score is calculated by summation of the scores of the individual items.[13 ] Groningen sleep quality scale scores can range from 0 to 14, a higher score indicating a lower subjective quality of sleep. These statements are related to patients feeling about the difficulty in falling asleep, sleep fragmentation duration of sleep, and early morning awakening. The first question does not count toward the total score. One point of answer is “True” for questions 2, 3, 4, 5, 6, 7, 9, 11, 13, 14, 15, while one point of answer is “False” for questions 8, 10, 12 and it is categorized as undisturbed or unrestricted sleep (0–5), disturbed sleep (6–7), and poor sleep (8–14).[14 ]
QLQ-C30 is composed of all of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. Thus, a high score for a functional scale represents a high/healthy level of functioning; a high score for the global health status/QOL represents a high QOL, but a high score for a symptom scale / item represents a high level of symptomatology/problems.[15 ]
Data Collection Procedure
This study was performed in the oncology department of selected hospital Mangaluru. The basin was filled with hot water. The temperature of the water was checked by using lotion thermometer. The temperature of the water was maintained between 39 and 43°C. Then the patient was instructed to immerse the foot till the ankles. Warm water foot submerged technique was given for 15 minutes two times per day for 5 consecutive days in the morning and evening. The temperature of the water was checked every 5 minutes once. Hot water was added when the temperature decreased (<39°C). The patient was instructed to dry the legs after the procedure.
Statistical Analysis
The collected data was coded and transformed into a master data sheet for statistical analysis. Demographic data, clinical proforma multidimensional fatigue inventory, Groningen sleep quality scale, and EORTC QLQ-C-30 scores were analyzed using descriptive statistics such as frequency, percentage, mean, and standard deviation (SD). Paired t -test was used for the comparison of pretest and post-test scores of the level of fatigue and quality of sleep. Wilcoxon signed-rank test was used to compare the QOL pretest and post-test scores within the group.
Results
The most of participants in both the intervention and control groups were in the age group of 51 to 60 years, accounting for 35.5% each. More females were part of both groups, comprising 52.9% in the intervention and 58.8% in the control group. Regarding education, a higher percentage in the control group had primary education, reaching 52.9% compared with 29.4% in the intervention group. In terms of marital status, 70.6% of the intervention group were married, while 47.1% of the control group were widows or widowers. A significant portion of participants in both groups identified as homemakers, with 41.2% in the intervention and 29.4% in the control group. Moreover, the majority in the intervention group and control group consumed a mixed diet 88.3 and 64.7% respectively. The majority of participants in both groups reported a monthly income of Rs less than or equal to 25,000, which accounted for 91.2% in each group.
The majority of the participants 52.9% in intervention and 55.9% in control group were diagnosed with stage II cancer, where the duration of illness is lasted within 1 to 2 months 76.5 and 64.7%, respectively. Majority of the participants have not presented with comorbidities (73.5%, 82.4%), receiving chemotherapy and radiation (58.8%, 70.6%), received 1 to 5 chemotherapy cycle (58.8%, 67.6%). Most of the 41.2% participants in intervention group equally received 1 to 10 and 11 to 20 radiation and 50% of control group were received 1 to 10 radiation ([Table 1 ]).
Table 1
Distribution of participants according to clinical proforma
n = 34 + 34
Sl. no.
Clinical proforma
Intervention group
Control group
f(%)
f(%)
1
Stage of cancer
a) Stage1
02(5.9)
02(5.9)
b) Stage II
18(52.9)
19(55.9)
c) Stage III
08(26.5)
11(32.4)
d) Stage IV
04(11.8)
02(5.9)
2
Duration of illness
a) 1–2 months
26(76.5)
22(64.7)
b) 3–4months
06(17.6)
06(17.6)
c) 5–6 months
02(5.9)
06(17.6)
3
Comorbid illnesses
a) Diabetes mellitus
04(11.8)
02(5.9)
b) Hypertension
05(14.7)
04(11.8)
c) Cardiovascular disease
–
–
d) No illness
25(73.5)
28(82.4)
4
Treatment received
a) Chemotherapy
-
01(2.9)
b) Radiation therapy
14(41.2)
09(26.5)
c) Both
20(58.8)
24(70.6)
5
Number of chemotherapy cycles
a) No chemotherapy
12(35.3)
08(23.5)
b) 1–5
22(64.7)
23(67.6)
c) 6–10
–
03(8.8)
6
Number of radiation fraction
a) 1–10
14(41.2)
17(50)
b) 11–20
14(41.2)
08(23.5)
c) 21–30
06(17.6)
09(26.5)
The data represented is the frequency with percentage.
Paired t -test showed significant difference in level of fatigue in intervention group (p < 0.05) after the warm water footbath technique and no significance difference in control group (p > 0.05; [Fig. 1 ]). The significant difference was found in quality of sleep in intervention group (p < 0.001); thus, it states that warm water foot submerged technique improves sleep quality (p < 0.001; [Fig. 2 ]).
Fig. 1 Comparison of pretest and post-test level of fatigue scores in intervention and control group. *Significant (p < 0.05), ***very highly significant (p < 0.001). SD, standard deviation.
Fig. 2 Comparison of pretest and post-test scores of quality of sleep in intervention and control group. ***Very highly significant (p < 0.001). SD, standard deviation.
The overall QOL mean pretest score in intervention and control group were 79.92 ± 12.049 and 77.49 ± 10.91, respectively. The mean pretest scores of global health were 63.38 ± 11.01 and 66.17 ± 12.80, respectively. The mean pretest score in functional scales were categorized in subscale such as physical functioning (76.08 ± 19.22, 73.72 ± 25.58) the role functioning (81.86 ± 18.52, 80.88 ± 23.97), emotional functioning (81.86 ± 20.36, 77.94 ± 19.01), cognitive functioning (97.06 ± 7.64, 85.78 ± 15.96), and social functioning (85.29 ± 24.54, 86.27 ± 21.11). The mean pretest scores of symptoms scales in intervention and control group were categorized in different items such as fatigue (54.25 ± 25.48, 52.61 ± 24.96), nausea and vomiting (3.92 ± 11.65, 13.23 ± 22.76), pain (23.04 ± 24.96, 28.43 ± 23.40), dyspnea (6.68 ± 17.94, 6.86 ± 13.68), insomnia (58.82 ± 32.88, 53.92 ± 30.72), appetite loss (17.65 ± 18.78,24, 51 ± 32.11), constipation (1.96 ± 7.967, 84 ± 21.82), and diarrhea (16.67 ± 28.72, 9.80 ± 22.51). The financial difficulties mean pretest scores in intervention and control group were 11.76 ± 25.80 and 15.69 ± 24.94, respectively ([Table 2 ]).
Table 2
Distribution of QOL pretest scores
n = 34 + 34
QOL
Intervention group
Control group
Pretest
Pretest
Mean ± SD
Mean ± SD
Overall QOL
79.92 ± 12.049
77.49 ± 10.91
Global health status/QOL
Global health status/QOL (revised)
63.38 ± 11.01
66.17 ± 12.80
Functional scales
Physical functioning (revised)
76.08 ± 19.22
73.72 ± 25.58
Role functioning (revised)
81.86 ± 18.52
80.88 ± 23.97
Emotional functioning
81.86 ± 20.36
77.94 ± 19.01
Cognitive functioning
97.06 ± 7.64
85.78 ± 15.96
Social functioning
85.29 ± 24.54
86.27 ± 21.11
Symptom scales/items
Fatigue
54.25 ± 25.48
52.61 ± 24.96
Nausea and vomiting
3.92 ± 11.65
13.23 ± 22.76
Pain
23.04 ± 24.96
28.43 ± 23.40
Dyspnea
6.68 ± 17.94
6.86 ± 13.68
Insomnia
58.82 ± 32.88
53.92 ± 30.72
Appetite loss
17.65 ± 18.78
24.51 ± 32.11
Constipation
1.96 ± 7.96
7.84 ± 21.82
Diarrhea
16.67 ± 28.72
9.80 ± 22.51
Financial difficulties
11.76 ± 25.80
15.69 ± 24.94
Abbreviations: QOL, quality of life; SD, standard deviation.
Each subscale score: 0–100
Wilcoxon signed-rank test has shown significant difference in the QOL that includes global health status (p < 0.001), physical functioning (p < 0.001), emotional functioning (p = 0.03), fatigue (p < 0.001), insomnia (p < 0.001), and overall QOL score (p < 0.001) in intervention group. Hence, it improves QOL. In the control group, nausea and vomiting (p = 0.01) showed significant difference but there was no significant difference in overall QOL score (p = 0.20; [Table 3 ]).
Table 3
Comparison of pretest and post-test QOL scores in the intervention and control group
n = 34 + 34
QOL
Groups
Pretest
Post-test
Z value
p -Value
Median
IQR
Median
IQR
Overall quality score
Intervention
82.35
14.17
87.1
15.36
5.08
<0.001[a ]
Control
78.20
14.48
79.20
13.86
1.26
0.200
Global health status/QOL
Global health status/QOL (revised)
Intervention
66.66
18.75
70.83
10.42
−4.30
<0.001[a ]
Control
66.66
16.67
66.66
16.67
−0.45
0.651
Functional scales
Physical functioning (revised)
Intervention
83.33
26.67
93.33
20
−4.66
<0.001[a ]
Control
80
46.66
80
40
−0.83
0.401
Role functioning (revised)
Intervention
83.33
33.34
91.66
33.33
−1.78
0.075
Control
91.66
33.33
91.66
25
−0.10
0.916
Emotional functioning
Intervention
87.5
27.09
91.66
33.34
−2.08
0.03[b ]
Control
83.33
5
75
25
−1.34
0.180
Cognitive functioning
Intervention
100
0
100
0
−0.44
0.655
Control
83.3
33.33
83.3
16.67
−0.33
0.739
Social functioning
Intervention
100
33.34
100
16.67
−1.63
0.102
Control
100
20.83
100
20.83
−0.37
0.705
Symptom scales / items
Fatigue
Intervention
55.55
44.44
22.22
33.33
−4.83
<0.001[a ]
Control
44.44
36.11
55.5
44.44
−1.81
0.07
Nausea and vomiting
Intervention
0
0
0
0
−1.63
0.102
Control
0
16.67
0
4.17
−2.57
0.01[b ]
Pain
Intervention
16.66
33.33
16.66
33.33
−1.89
0.058
Control
25
16.67
16.66
16.66
−0.47
0.655
Dyspnea
Intervention
0
0
0
0
−1.0
0.31
Control
0
0
0
0
−1.63
0.102
Insomnia
Intervention
66.66
66.66
33.33
33.33
−4.59
<0.001[a ]
Control
50
33.33
66.66
33.33
−0.83
0.405
Appetite loss
Intervention
16.66
33.33
0
33.33
−1.73
0.083
Control
0
41.66
0
33.33
−0.81
0.417
Constipation
Intervention
0
0
0
0
−1.41
0.157
Control
0
0
0
0
−0.70
0.48
Diarrhea
Intervention
0
33.33
0
33.33
−1.26
0.206
Control
0
0
0
0
−1.13
0.257
Financial difficulties
Intervention
0
0
0
0
0
1
Control
0
33.33
0
33.33
0
1
Abbreviations: IQR, interquartile range; QOL, quality of life.
Statistical test used: Wilcoxon signed-rank test.
a Very highly significant (p < 0.001).
b Significant (p < 0.05).
Discussion
The cancer patient during their treatment may experience fatigue, pain, sleep disturbance that are interrelated, exacerbating one another and decreasing the QOL.[11 ] Warm water foot submerged technique helps to reduce the side effects of cancer treatment and boosting relaxation. The baseline characteristics obtained from these studies are majority of participants in the intervention, control groups (35.5% each) belong to the age group of 51 to 60 years, and majorities were female (52.9%, 58.8%). Majority of the participants in intervention (52.9%) and control group (55.9%) were diagnosed with stage II cancer, and had not presented with comorbidities (73.5%, 82.4%). The study done by D'Souza et al revealed that most of the participants, 47%, in the intervention and, 40%, in the control group were in the age group of 51 to 60 years. Majority of participants, 60%, in the intervention and, 66.66%, in the control group were female. In the intervention group, all participants (100%) and in the control group, majority of the participants (93%) were diagnosed with stage II cancer. In both, the intervention (53%) and control group (40%) majority did not have any comorbid illness.[16 ]
This study depicted the mean scores of general fatigue (13.2,13.64), physical fatigue (11.91,13.35), reduced fatigue (11.91,11.85) mental fatigue (9.41,9.47), and reduced motivation (9.71, 10.18). The study conducted by Bindusha revealed that, both the intervention and control group had severe fatigue during pretest (63.33% 60%).[17 ] It proved that patient will experience fatigue during cancer treatment period.[4 ]
This study identified that sleep quality of study participants was poor in both the intervention and control group. The study done by Lanjewar et al revealed that most of participants had poor sleep due to the side effect of treatment.[18 ]
This study revealed that in the intervention group the mean ± SD of general fatigue was 13.21 ± 3.16 and 10.44 ± 2.46 during pretest and post-test, respectively. There was a significant difference found at the level of p -value less than 0.05. The study conducted by Chauhan and George revealed there was a significant decrease in fatigue level, mean ± S.D. of pretest and post-test of mean ± S.D. value was 53.63 ± 7.978 and 43.27 ± 7.682 respectively at p < 0.05 level.[19 ]
This study revealed that in the intervention group the mean ± SD of quality of sleep in pretest was 6.38 ± 2.42 and in post-test it was 5.09 ± 2.19 that was highly significant to maintain the sleep quality (p < 0.001). The study conducted by Suneesh et al revealed that warm water foot bath helps in reducing insomnia and improving sleep onset time (p < 0.001).[20 ]
Warm water foot submerged technique has showed significant difference in the global health status (p < 0.001), physical functioning (p < 0.001), emotional functioning (p = 0.03), fatigue (p < 0.001), insomnia (p < 0.001), and overall QOL score (p < 0.001) in the intervention group. A study was conducted by Prakash et al to assess the effectiveness of yoga on QOL of breast cancer patients undergoing chemotherapy. The study results found that yoga practice effective in global health status, physical function, role function, emotional function, and reducing the symptoms of fatigue, insomnia, loss of appetite, and constipation during the period of chemotherapy p- value less than 0.05 level.[21 ]
Warm water foot submerged technique has its importance and needs to relieve fatigue and improve the quality of sleep and QOL.
Limitation
The small sample size and short duration of time limit the generalization of this study. This study results were confined to a single hospital. Confounding variables have to be evaluated. Comparative study can be conducted using other complementary therapy.
Conclusion
This study showed that the warm water foot submerged technique is effective in reducing the fatigue and improving the quality of sleep and QOL among patients with cancer. Thus, this study was found to be effective. The nurse can encourage the caregivers to use warm footbath therapy as a complementary therapy for patients to improve quality of care.
