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J Clinic Care Skill 2024, 5(4): 225-231 |
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Received: 2024/10/1 | Accepted: 2024/11/21 | Published: 2024/11/25
Received: 2024/10/1 | Accepted: 2024/11/21 | Published: 2024/11/25
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Arianpour H, Hosseini M, Afrasiabifar A, Malekzadeh J. Effect of Benson Relaxation and Warm Foot Bath on Sleep Quality in Acute Coronary Syndrome Patients. J Clinic Care Skill 2024; 5 (4) :225-231
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1- Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
2- “Faculty of Nursing” and “Social Determinants of Health Research Center”, Yasuj University of Medical Sciences, Yasuj, Iran
3- Faculty of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
4- Department of Nutrition, Faculty of Health and Nutrition, Yasuj University of Medical Sciences, Yasuj, Iran
2- “Faculty of Nursing” and “Social Determinants of Health Research Center”, Yasuj University of Medical Sciences, Yasuj, Iran
3- Faculty of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran
4- Department of Nutrition, Faculty of Health and Nutrition, Yasuj University of Medical Sciences, Yasuj, Iran
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Introduction
Despite advances in diagnostic and therapeutic methods, cardiovascular diseases remain the leading cause of death and disability worldwide [1, 2]. Acute coronary syndrome is the most common form of heart disease requiring hospitalization. This disease refers to a group of cardiac disorders that occur due to reduced blood flow to the coronary arteries, resulting from atherosclerosis and acute arterial occlusion due to thrombosis and embolism. This syndrome can manifest as sudden cardiac arrest and various arrhythmias following myocardial ischemia [3]. Data provided by the American Heart Association estimated the prevalence of cardiovascular diseases (including coronary artery disease, heart failure, stroke, and high blood pressure) in adults over 20 years of age to be about 49.2% (126.9 million in 2018) [4]. These diseases cause approximately 90,000 deaths in Iran annually [5]. The most important symptom of coronary artery disease is chest pain, which is caused by reduced blood supply to the heart [6]. Factors, such as gender, age, unhealthy diet, obesity, smoking, dyslipidemia, diabetes, and hypertension play a role in the development of coronary artery syndrome [7]. Coronary artery patients suffer from sleep disorders due to physiological inflammatory changes, which enhance the contractile force of the heart, increase the severity of the disease, and lead to hospitalization [8]. Many patients also experience reduced sleep quality due to their stay in the intensive care unit, with approximately 56% of patients being deprived of sleep by the end of the first day. According to studies, patients with coronary artery disease have poor sleep quality during the first three days. This is attributed to factors such as light, noise from the care of other patients, air conditioning, frequent movement of nurses, medication use, the severity of the disease, and early awakenings in the morning. Although patients in such situations require more sleep, hospitalization can significantly disrupt sleep patterns [9].
On the other hand, one of the main and important needs for patient recovery is sleep. In Maslow’s hierarchy of needs, sleep falls within the first category of needs, which is essential for maintaining energy, repairing and growing body tissues, and supporting physical well-being and appearance [10]. Poor sleep disrupts quality of life and physical performance and can negatively affect general health, cognition, psychology, and daily activities, leading to increased blood pressure and heart rate, which in turn raises the risk of heart attack [11]. Sleep also plays a crucial role in cardiovascular function, and sleep disturbances can result in irritability, increased myocardial oxygen demand, tachycardia, and anxiety [8].
Davodi Boroujerdi et al. report that patients with coronary heart disease experience poor sleep quality. There is a relationship between psychological parameters, such as depression and anxiety, and sleep quality, which should be addressed using effective measures [12]. The most common medications for the treatment of insomnia are benzodiazepines [13], which reduce the functioning of the nervous system and may compromise patient safety [14]. Various non-pharmacological treatments for sleep disorders exist [11]. Non-pharmacological treatments, including complementary and alternative medicine [15], can be used alone or in combination with other methods [16]. Today, there is a strong desire to utilize these methods [17]. The advantages of these approaches include cost-effectiveness, non-invasiveness, ease of use, and the absence of chemical side effects [18].
One of the complementary and alternative therapies is relaxation. Relaxation methods include Benson relaxation, progressive muscle relaxation, imagery relaxation, meditation, massage, hypnosis, breathing techniques, yoga, and music therapy. Benson relaxation is favored by experts due to its ease of learning and teaching [19]. The Benson relaxation technique is a desirable method because it can be practiced anywhere, is easy to learn and teach to others without the need for a specialist or special tools, and is practical. Utilizing this method reduces pulse rate, respiration, blood pressure, and cardiac workload [11]. Relaxation and reflexology can ultimately improve the delayed sleep stage by reducing stress and anxiety due to their relaxing properties [20]. Bakavoly et al. found that the Benson relaxation technique and foot reflexology massage improve sleep quality in patients with systolic heart failure [21].
Another common non-medical treatment is the local warming of the extremities. Various methods are proposed in this regard, with warm foot baths being considered in this study due to their systemic stimulation of vasodilation, improvement of vascular endothelial function, enhancement of exercise tolerance, improvement of quality of life, and reduction of preload and afterload [22]. Soaking the feet in warm water stimulates tactile sensations and reduces sympathetic nerve activity. Additionally, warm water foot baths increase peripheral blood flow and ambient temperature without raising core body temperature, accelerate sleep onset, and improve sleep quality. Soaking the feet in warm water appears to be more effective than bathing the entire body. It is commonly recommended for the disabled, retirees, and patients with cardiovascular diseases to accelerate sleep onset and enhance sleep quality [3].
Rahmani et al. evaluated the effects of foot reflexology massage, foot baths, and the combination of both on the sleep quality of patients, reporting that the combined intervention produced a more significant reduction in sleep disorders. However, there was no difference in sleep quality between the two groups receiving foot baths and foot reflexology [3].
No study was found that compared the effects of the Benson relaxation method and foot baths on the sleep quality of patients with acute coronary syndrome. Therefore, considering the impact of sleep disorders in hospitalized patients with coronary artery disease on the cardiovascular system, the side effects of chemical drugs, the affordability, ease, and non-invasiveness of the two therapeutic methods—Benson relaxation and foot baths—and the absence of any studies examining a combined intervention of Benson relaxation and foot baths, the present study aimed to compare the effects of Benson relaxation and foot baths both individually and in combination on the sleep quality of patients with acute coronary syndrome.
Materials & Methods
Research design
The present controlled clinical trial was conducted on patients with acute coronary syndrome hospitalized in the ICU of Shahid Rajaee Hospital in Gachsaran during the winter of 2018 and the spring of 2019.
Considering the assumption that the Benson relaxation intervention method and foot baths would improve sleep quality, and taking into account a confidence interval of 95% (Z1-α/2=1.96), a test power of 90% (Z1-β=1.26), and a standard deviation of the Sleep Quality Scale (ranging from 3.88 to 5.82, with an average of approximately four), the number of samples required to achieve a 5-point improvement in sleep quality was estimated to be approximately 14 individuals in each group, using the following formula [23].
Considering a 10% probability of attSrition, equivalent to 1.4 individuals, approximately two people were added to each group, resulting in a total of 16 individuals in each group. Thus, 64 patients were selected using non-random and convenience sampling methods and were assigned to one of three intervention groups or one control group using a block random allocation method [24].
Inclusion criteria included a diagnosis of acute coronary syndrome by a specialist, absence of anxiety or chronic insomnia, first hospitalization of the patient in the intensive care unit, at least one night of hospitalization, informed consent to participate in the study, absence of other acute or chronic diseases, age between 32 and 65 years, good organ health (hearing and feet), and full consciousness. Exclusion criteria included not being employed in healthcare professions, not having mental or motor disorders, not having dermatitis or any type of ulcer on the feet, absence of diabetic ulcers or a diagnosis of diabetic neuropathy, no history of using relaxation methods or foot baths, and lack of informed consent.
Intervention
The interventions included Benson relaxation, warm foot baths, and a combination of Benson relaxation and warm foot baths. Each of the interventions began on the second day of hospitalization and was performed by the researcher for three days (until the fourth night), with data collected the following morning.
Relaxation group: This group underwent the Benson relaxation intervention. The relaxation method was taught to the patients face-to-face by the researcher and a nurse psychiatrist serving as a consultant. In the Benson relaxation method, after ensuring that the patient had learned the technique during the training session, the patient was provided with an audio file containing the steps for performing the relaxation and was instructed to practice it for 20 minutes while listening to the audio file one hour before going to bed each night. The patient would sit quietly in a completely relaxed position and close his eyes. While his eyes were closed, he would inhale through his nose and exhale slowly through his mouth. As he exhaled, he would repeat a calming word under his breath. He would then begin to relax all the muscles in his body, from the soles of his feet to his head and neck. The patient would try to maintain his calm and transmit this calmness to his thoughts. All patients were asked to practice relaxation [25].
Hot foot bath group: The subjects were instructed to use a foot bath every night for one hour before going to bed. Before starting the foot bath, the ambient temperature was measured using a mercury thermometer to ensure that changes in ambient temperature during the study would not disrupt the timing of water temperature changes and would remain consistent for all samples [26]. The water was then heated to 40 degrees Celsius using an electric kettle, and a mercury thermometer was also used to measure the water temperature. After confirming the water temperature, the patients were asked to sit and place their feet 10 cm above the ankles in a basin containing 40°C water for 30 minutes. During this period, the patients were instructed to refrain from any foot movement, washing, or foot massage [3].
Combined group (warm foot bath and Benson relaxation technique): Patients in the combined group were asked to first take a warm foot bath for 30 minutes, followed by relaxation for 20 minutes according to the specified protocols.
Research tools and data collection
A demographic questionnaire was used to record information such as age, gender, marital status, and education level. The standard St. Mary’s Hospital Sleep Questionnaire (SMHSQ) was employed to determine the patients’ sleep quality on the first day of hospitalization (before the intervention) and, after the interventions, to assess sleep quality for the second to fourth nights by having the patients complete the questionnaires each morning to evaluate their sleep quality from the previous night (the third, fourth, and fifth days of hospitalization).
The SMHSQ consists of 14 questions that assess the duration and subjective quality of sleep from the previous night. This questionnaire was developed in 1981 by Ellis et al. and includes 14 items; however, they did not specify how the questionnaire was scored [27]. In this study, the questionnaire was scored by the researcher. Based on this scoring system, scores between 9 and 17 indicate poor sleep quality, scores between 18 and 33 indicate moderate sleep quality, and scores between 34 and 48 indicate good sleep quality. Lower scores reflect fewer sleep problems, while higher scores indicate more sleep problems. In this questionnaire, qualitative questions were scored based on a Likert scale, and quantitative questions were scored based on time. The reliability and validity of the questionnaire in Iran were confirmed by Moeini et al. [23] and Abolhasani [28], who used this questionnaire in their studies. Abolhasani confirmed the reliability of the questionnaire using a Cronbach’s alpha of 91% and a reliability coefficient of 99%.
Outcome
The outcome was sleep quality in patients with acute coronary syndrome
Data analysis
The Shapiro-Wilk test was used to determine the normality of the data. The collected data were analyzed using SPSS software and the median test, due to the non-normal distribution of the outcome variable. A significance level of less than 0.05 was considered significant.
Findings
A total of 64 patients with acute coronary syndrome were assessed, including 21 with unstable angina (32.8%), 21 with ST-elevation myocardial infarction (STEMI) (32.8%), and 22 with non-ST-elevation myocardial infarction (NSTEMI) (34.37%). Additionally, there were 24 male patients (62.5%) and 40 female patients (37.5%). The overall mean age of the patients was 54.54±8.16 years, while the mean ages of the patients in the Benson, foot bath, combination, and control groups were 51.25±10.7, 55.3±7.6, 56.38±5.9, and 54±7.4 years, respectively (p=0.32). All patients remained in the study until its conclusion. No significant differences were observed between the groups regarding demographic characteristics, such as age, gender, and employment (Table 1).
Table 1. Frequency of demographic information of the groups
There was no statistically significant difference between the median sleep quality of the patients in the four groups before the intervention and on the second night of hospitalization. However, on the third and fourth nights of hospitalization, there was a statistically significant difference in the median sleep quality. Pairwise comparisons showed that on the third night of hospitalization, this difference was only related to the control and relaxation groups (p=.015), but on the fourth night of hospitalization, the observed statistical difference was related to each of the intervention groups including warm bath (P=0.004), relaxation (P=0.001), and combination (P=0.00), compared to the control group (Tables 2 and 3).
Table 2. Between-group comparison of the overall sleep quality of patients in the four groups according to measurement times
Table 3. Pairwise comparison of overall sleep quality of patients in the four study groups
Discussion
The present study aimed to compare the effects of Benson relaxation and foot baths, both individually and in combination, on the sleep quality of patients with acute coronary syndrome. Coronary artery disease is the most common cause of death among cardiovascular diseases in the United States and European countries. In Iran, despite advancements in the use of modern treatment methods, the mortality rate associated with this disease is also increasing [29]. This condition is the most prevalent form of heart disease that necessitates hospitalization. Studies have shown that patients with acute coronary syndrome experience poor sleep quality during the first three days of hospitalization in cardiac care units [9]. Therefore, selecting the best method to improve sleep quality during this period is considered a nursing priority. Given the absence of studies examining the combined intervention of warm water baths and relaxation on sleep in patients with acute coronary syndrome, the present study was conducted to compare the combined effects of Benson relaxation and foot baths on sleep quality in these patients.
After three days of hot water baths, relaxation, and a combination of these two interventions, sleep quality in hospitalized patients with acute coronary syndrome improved. Based on the scores from the SMHQ, most of the research samples showed a decrease in many of the items assessed on the first night of hospitalization, indicating a decline in sleep quality among patients. Neyse et al. [30], in a study on the effect of earplugs on sleep quality in patients with acute coronary syndrome, reported that the rate of sleep problems in these patients was 68.3%. Additionally, in the study by Zeraati et al. [31], which aimed to evaluate sleep quality and the use of hypnotic drugs in adults hospitalized in the internal ward of Ekbatan Hospital in Hamadan, 74% of patients were found to have poor sleep quality. In the Benson relaxation group, the peak effect on sleep quality was observed on the third night of hospitalization. Bakavoly et al. concluded in their study on heart failure patients at Torbat Heydariyeh Hospital that sedation for 20 minutes and reflexology for 30 minutes, three days a week, can improve the sleep quality of these patients, which is consistent with the results of the present study [11]. The Benson relaxation technique creates a balance between the anterior and posterior hypothalamus, reduces sympathetic nervous system activity, releases catecholamines, alleviates muscle spasms, and, through slower breathing patterns during relaxation, has a beneficial effect on resting heart rate and respiratory sinus arrhythmia [25]. Moradi Mohammadi et al. argue that Benson relaxation is significantly effective in improving subjective sleep quality, reducing sleep onset delay, enhancing beneficial sleep, mitigating sleep disturbances, and overall sleep quality [19]. In line with our results, Sirati et al. showed that the Benson relaxation technique significantly improves sleep quality [32]. Akbarzadeh et al. also argue that Benson relaxation leads to a significant improvement in sleep quality in chronic heart patients [33], which is consistent with the results of the present study.
In the warm foot bath group, sleep quality improved significantly from the fourth night of hospitalization compared to the control group. A study by Talebi Ghadicolaei et al. in the Mazandaran Cardiac Intensive Care Unit showed that although warm baths do not improve sleep quality in all patients, the number of patients with severe sleep disorders decreases [34]. The discrepancy between the results of the previous study and the present study may be attributed to differences in various environmental factors, including types of environmental stress. Several factors, such as the environment, illness, pain, medication, nursing care, noise, light, and circadian changes, which can vary across different hospitals, may have differing effects on sleep [34]. In line with the present study, Rahmani et al. demonstrated that foot baths can improve sleep disturbances in patients with acute coronary syndrome and have a synergistic effect when used in conjunction with foot reflexology [3]. In each of the intervention groups and the combination group, the greatest effect was observed on the fourth night of hospitalization. Therefore, all three interventions are more effective over time, leading to better outcomes. Patients hospitalized in intensive care units endure high stress due to the severity of their illness; stress and anxiety can stimulate sympathetic activity and increase vasoconstriction, which in turn reduces heat transfer from the body’s core to the environment. Warm foot baths also stimulate nitric oxide synthesis, dilate blood vessels, reduce vascular resistance, and subsequently increase blood flow and heat transfer to the environment. This results in an increased proximal-distal gradient, ultimately improving sleep quality [34]. The effectiveness of foot reflexology massage in improving sleep quality in hemodialysis patients has been demonstrated in Qazvin City within the intervention group over time, which aligns with the present study regarding the enhanced effects of interventions over time [35].
Although the Benson relaxation intervention significantly improved sleep quality on the third night, its combination with a foot bath did not yield significant results. This may be attributed to subjective differences in responses to the questionnaire items and the need for more time to acclimate to both techniques—the warm foot bath and Benson relaxation—which can itself lead to fatigue. Similarly, on the fourth night, sleep quality improved significantly in the combined intervention group, as observed with Benson's relaxation. However, several other factors, such as pain, ventilators, environmental factors and noise, medications, and the severity of the disease, have influenced the results of this study and can disrupt sleep quality in the hospital setting.
This study has several limitations, including a small sample size, a short intervention duration, a lack of control over sleep-disrupting factors in the hospital, potential errors in using the self-report questionnaire, the impact of individuals’ mental and emotional conditions at the time of completing the questionnaires, and the extended duration of the intervention in the combined Benson relaxation and foot bath intervention group.
Based on the findings, all three methods—Benson relaxation, warm foot baths, and the combination of both interventions—were effective in improving the sleep quality of patients with acute coronary syndrome. Therefore, considering the duration of the two interventions, Benson relaxation and warm foot baths, and the lack of significant differences in the effects of the combined intervention compared to each of these interventions alone, as well as the better cost-effectiveness, either of the individual methods—warm foot baths or Benson relaxation—can be recommended, depending on feasibility, to enhance the sleep quality of patients. Given the high prevalence of sleep problems in patients with acute coronary syndrome, it is advisable for nurses to teach these interventions to patients. Additionally, it is recommended to conduct a study on the same topic with a larger sample size, a longer intervention period, and follow-up using a different questionnaire to assess sleep quality.
Conclusion
Benson relaxation techniques, warm foot baths, and their combination equally improve sleep quality in patients with acute coronary syndrome.
Acknowledgments: The authors would like to thank all the professors and colleagues at the Hazrat Zainab (PBUH) School of Nursing and Midwifery, Shahid Rajaee Hospital in Gachsaran, and everyone who assisted us in this study. This article is based on Hoda Arianpour’s master’s thesis from Yasuj University of Medical Sciences. We are grateful for the support of the Vice Chancellor for Research at Yasuj University of Medical Sciences. The research was registered with the Iranian Registry of Clinical Trials (IRCT20190126042497N1).
Ethical Permissions: This study was approved under the ethical approval code IR.YUMS.REC.1397.133 and was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the patients. Confidentiality of information, anonymity, and privacy of the patients were upheld. Patients had the right to withdraw from the study at any time if they wished. No physical or financial harm was inflicted upon the patients.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Arianpour H (first author), Introduction Writer/Methodologist/Main Researcher/ (30%); Hosseini M (second author), Introduction Writer/Assistant Researcher/Discussion Writer/Statistical Analyst (30%); Afrasiabifar A (third author), Assistant Researcher/Discussion Writer/Statistical Analyst (20%); Malekzadeh JM (fourth author) Introduction Writer/Assistant Researcher/Discussion Writer (20%)
Funding/Support: The present study was funded by the Yasuj University of Medical Sciences, Iran.
Despite advances in diagnostic and therapeutic methods, cardiovascular diseases remain the leading cause of death and disability worldwide [1, 2]. Acute coronary syndrome is the most common form of heart disease requiring hospitalization. This disease refers to a group of cardiac disorders that occur due to reduced blood flow to the coronary arteries, resulting from atherosclerosis and acute arterial occlusion due to thrombosis and embolism. This syndrome can manifest as sudden cardiac arrest and various arrhythmias following myocardial ischemia [3]. Data provided by the American Heart Association estimated the prevalence of cardiovascular diseases (including coronary artery disease, heart failure, stroke, and high blood pressure) in adults over 20 years of age to be about 49.2% (126.9 million in 2018) [4]. These diseases cause approximately 90,000 deaths in Iran annually [5]. The most important symptom of coronary artery disease is chest pain, which is caused by reduced blood supply to the heart [6]. Factors, such as gender, age, unhealthy diet, obesity, smoking, dyslipidemia, diabetes, and hypertension play a role in the development of coronary artery syndrome [7]. Coronary artery patients suffer from sleep disorders due to physiological inflammatory changes, which enhance the contractile force of the heart, increase the severity of the disease, and lead to hospitalization [8]. Many patients also experience reduced sleep quality due to their stay in the intensive care unit, with approximately 56% of patients being deprived of sleep by the end of the first day. According to studies, patients with coronary artery disease have poor sleep quality during the first three days. This is attributed to factors such as light, noise from the care of other patients, air conditioning, frequent movement of nurses, medication use, the severity of the disease, and early awakenings in the morning. Although patients in such situations require more sleep, hospitalization can significantly disrupt sleep patterns [9].
On the other hand, one of the main and important needs for patient recovery is sleep. In Maslow’s hierarchy of needs, sleep falls within the first category of needs, which is essential for maintaining energy, repairing and growing body tissues, and supporting physical well-being and appearance [10]. Poor sleep disrupts quality of life and physical performance and can negatively affect general health, cognition, psychology, and daily activities, leading to increased blood pressure and heart rate, which in turn raises the risk of heart attack [11]. Sleep also plays a crucial role in cardiovascular function, and sleep disturbances can result in irritability, increased myocardial oxygen demand, tachycardia, and anxiety [8].
Davodi Boroujerdi et al. report that patients with coronary heart disease experience poor sleep quality. There is a relationship between psychological parameters, such as depression and anxiety, and sleep quality, which should be addressed using effective measures [12]. The most common medications for the treatment of insomnia are benzodiazepines [13], which reduce the functioning of the nervous system and may compromise patient safety [14]. Various non-pharmacological treatments for sleep disorders exist [11]. Non-pharmacological treatments, including complementary and alternative medicine [15], can be used alone or in combination with other methods [16]. Today, there is a strong desire to utilize these methods [17]. The advantages of these approaches include cost-effectiveness, non-invasiveness, ease of use, and the absence of chemical side effects [18].
One of the complementary and alternative therapies is relaxation. Relaxation methods include Benson relaxation, progressive muscle relaxation, imagery relaxation, meditation, massage, hypnosis, breathing techniques, yoga, and music therapy. Benson relaxation is favored by experts due to its ease of learning and teaching [19]. The Benson relaxation technique is a desirable method because it can be practiced anywhere, is easy to learn and teach to others without the need for a specialist or special tools, and is practical. Utilizing this method reduces pulse rate, respiration, blood pressure, and cardiac workload [11]. Relaxation and reflexology can ultimately improve the delayed sleep stage by reducing stress and anxiety due to their relaxing properties [20]. Bakavoly et al. found that the Benson relaxation technique and foot reflexology massage improve sleep quality in patients with systolic heart failure [21].
Another common non-medical treatment is the local warming of the extremities. Various methods are proposed in this regard, with warm foot baths being considered in this study due to their systemic stimulation of vasodilation, improvement of vascular endothelial function, enhancement of exercise tolerance, improvement of quality of life, and reduction of preload and afterload [22]. Soaking the feet in warm water stimulates tactile sensations and reduces sympathetic nerve activity. Additionally, warm water foot baths increase peripheral blood flow and ambient temperature without raising core body temperature, accelerate sleep onset, and improve sleep quality. Soaking the feet in warm water appears to be more effective than bathing the entire body. It is commonly recommended for the disabled, retirees, and patients with cardiovascular diseases to accelerate sleep onset and enhance sleep quality [3].
Rahmani et al. evaluated the effects of foot reflexology massage, foot baths, and the combination of both on the sleep quality of patients, reporting that the combined intervention produced a more significant reduction in sleep disorders. However, there was no difference in sleep quality between the two groups receiving foot baths and foot reflexology [3].
No study was found that compared the effects of the Benson relaxation method and foot baths on the sleep quality of patients with acute coronary syndrome. Therefore, considering the impact of sleep disorders in hospitalized patients with coronary artery disease on the cardiovascular system, the side effects of chemical drugs, the affordability, ease, and non-invasiveness of the two therapeutic methods—Benson relaxation and foot baths—and the absence of any studies examining a combined intervention of Benson relaxation and foot baths, the present study aimed to compare the effects of Benson relaxation and foot baths both individually and in combination on the sleep quality of patients with acute coronary syndrome.
Materials & Methods
Research design
The present controlled clinical trial was conducted on patients with acute coronary syndrome hospitalized in the ICU of Shahid Rajaee Hospital in Gachsaran during the winter of 2018 and the spring of 2019.
Considering the assumption that the Benson relaxation intervention method and foot baths would improve sleep quality, and taking into account a confidence interval of 95% (Z1-α/2=1.96), a test power of 90% (Z1-β=1.26), and a standard deviation of the Sleep Quality Scale (ranging from 3.88 to 5.82, with an average of approximately four), the number of samples required to achieve a 5-point improvement in sleep quality was estimated to be approximately 14 individuals in each group, using the following formula [23].
Considering a 10% probability of attSrition, equivalent to 1.4 individuals, approximately two people were added to each group, resulting in a total of 16 individuals in each group. Thus, 64 patients were selected using non-random and convenience sampling methods and were assigned to one of three intervention groups or one control group using a block random allocation method [24].
Inclusion criteria included a diagnosis of acute coronary syndrome by a specialist, absence of anxiety or chronic insomnia, first hospitalization of the patient in the intensive care unit, at least one night of hospitalization, informed consent to participate in the study, absence of other acute or chronic diseases, age between 32 and 65 years, good organ health (hearing and feet), and full consciousness. Exclusion criteria included not being employed in healthcare professions, not having mental or motor disorders, not having dermatitis or any type of ulcer on the feet, absence of diabetic ulcers or a diagnosis of diabetic neuropathy, no history of using relaxation methods or foot baths, and lack of informed consent.
Intervention
The interventions included Benson relaxation, warm foot baths, and a combination of Benson relaxation and warm foot baths. Each of the interventions began on the second day of hospitalization and was performed by the researcher for three days (until the fourth night), with data collected the following morning.
Relaxation group: This group underwent the Benson relaxation intervention. The relaxation method was taught to the patients face-to-face by the researcher and a nurse psychiatrist serving as a consultant. In the Benson relaxation method, after ensuring that the patient had learned the technique during the training session, the patient was provided with an audio file containing the steps for performing the relaxation and was instructed to practice it for 20 minutes while listening to the audio file one hour before going to bed each night. The patient would sit quietly in a completely relaxed position and close his eyes. While his eyes were closed, he would inhale through his nose and exhale slowly through his mouth. As he exhaled, he would repeat a calming word under his breath. He would then begin to relax all the muscles in his body, from the soles of his feet to his head and neck. The patient would try to maintain his calm and transmit this calmness to his thoughts. All patients were asked to practice relaxation [25].
Hot foot bath group: The subjects were instructed to use a foot bath every night for one hour before going to bed. Before starting the foot bath, the ambient temperature was measured using a mercury thermometer to ensure that changes in ambient temperature during the study would not disrupt the timing of water temperature changes and would remain consistent for all samples [26]. The water was then heated to 40 degrees Celsius using an electric kettle, and a mercury thermometer was also used to measure the water temperature. After confirming the water temperature, the patients were asked to sit and place their feet 10 cm above the ankles in a basin containing 40°C water for 30 minutes. During this period, the patients were instructed to refrain from any foot movement, washing, or foot massage [3].
Combined group (warm foot bath and Benson relaxation technique): Patients in the combined group were asked to first take a warm foot bath for 30 minutes, followed by relaxation for 20 minutes according to the specified protocols.
Research tools and data collection
A demographic questionnaire was used to record information such as age, gender, marital status, and education level. The standard St. Mary’s Hospital Sleep Questionnaire (SMHSQ) was employed to determine the patients’ sleep quality on the first day of hospitalization (before the intervention) and, after the interventions, to assess sleep quality for the second to fourth nights by having the patients complete the questionnaires each morning to evaluate their sleep quality from the previous night (the third, fourth, and fifth days of hospitalization).
The SMHSQ consists of 14 questions that assess the duration and subjective quality of sleep from the previous night. This questionnaire was developed in 1981 by Ellis et al. and includes 14 items; however, they did not specify how the questionnaire was scored [27]. In this study, the questionnaire was scored by the researcher. Based on this scoring system, scores between 9 and 17 indicate poor sleep quality, scores between 18 and 33 indicate moderate sleep quality, and scores between 34 and 48 indicate good sleep quality. Lower scores reflect fewer sleep problems, while higher scores indicate more sleep problems. In this questionnaire, qualitative questions were scored based on a Likert scale, and quantitative questions were scored based on time. The reliability and validity of the questionnaire in Iran were confirmed by Moeini et al. [23] and Abolhasani [28], who used this questionnaire in their studies. Abolhasani confirmed the reliability of the questionnaire using a Cronbach’s alpha of 91% and a reliability coefficient of 99%.
Outcome
The outcome was sleep quality in patients with acute coronary syndrome
Data analysis
The Shapiro-Wilk test was used to determine the normality of the data. The collected data were analyzed using SPSS software and the median test, due to the non-normal distribution of the outcome variable. A significance level of less than 0.05 was considered significant.
Findings
A total of 64 patients with acute coronary syndrome were assessed, including 21 with unstable angina (32.8%), 21 with ST-elevation myocardial infarction (STEMI) (32.8%), and 22 with non-ST-elevation myocardial infarction (NSTEMI) (34.37%). Additionally, there were 24 male patients (62.5%) and 40 female patients (37.5%). The overall mean age of the patients was 54.54±8.16 years, while the mean ages of the patients in the Benson, foot bath, combination, and control groups were 51.25±10.7, 55.3±7.6, 56.38±5.9, and 54±7.4 years, respectively (p=0.32). All patients remained in the study until its conclusion. No significant differences were observed between the groups regarding demographic characteristics, such as age, gender, and employment (Table 1).
Table 1. Frequency of demographic information of the groups
There was no statistically significant difference between the median sleep quality of the patients in the four groups before the intervention and on the second night of hospitalization. However, on the third and fourth nights of hospitalization, there was a statistically significant difference in the median sleep quality. Pairwise comparisons showed that on the third night of hospitalization, this difference was only related to the control and relaxation groups (p=.015), but on the fourth night of hospitalization, the observed statistical difference was related to each of the intervention groups including warm bath (P=0.004), relaxation (P=0.001), and combination (P=0.00), compared to the control group (Tables 2 and 3).
Table 2. Between-group comparison of the overall sleep quality of patients in the four groups according to measurement times
Table 3. Pairwise comparison of overall sleep quality of patients in the four study groups
Discussion
The present study aimed to compare the effects of Benson relaxation and foot baths, both individually and in combination, on the sleep quality of patients with acute coronary syndrome. Coronary artery disease is the most common cause of death among cardiovascular diseases in the United States and European countries. In Iran, despite advancements in the use of modern treatment methods, the mortality rate associated with this disease is also increasing [29]. This condition is the most prevalent form of heart disease that necessitates hospitalization. Studies have shown that patients with acute coronary syndrome experience poor sleep quality during the first three days of hospitalization in cardiac care units [9]. Therefore, selecting the best method to improve sleep quality during this period is considered a nursing priority. Given the absence of studies examining the combined intervention of warm water baths and relaxation on sleep in patients with acute coronary syndrome, the present study was conducted to compare the combined effects of Benson relaxation and foot baths on sleep quality in these patients.
After three days of hot water baths, relaxation, and a combination of these two interventions, sleep quality in hospitalized patients with acute coronary syndrome improved. Based on the scores from the SMHQ, most of the research samples showed a decrease in many of the items assessed on the first night of hospitalization, indicating a decline in sleep quality among patients. Neyse et al. [30], in a study on the effect of earplugs on sleep quality in patients with acute coronary syndrome, reported that the rate of sleep problems in these patients was 68.3%. Additionally, in the study by Zeraati et al. [31], which aimed to evaluate sleep quality and the use of hypnotic drugs in adults hospitalized in the internal ward of Ekbatan Hospital in Hamadan, 74% of patients were found to have poor sleep quality. In the Benson relaxation group, the peak effect on sleep quality was observed on the third night of hospitalization. Bakavoly et al. concluded in their study on heart failure patients at Torbat Heydariyeh Hospital that sedation for 20 minutes and reflexology for 30 minutes, three days a week, can improve the sleep quality of these patients, which is consistent with the results of the present study [11]. The Benson relaxation technique creates a balance between the anterior and posterior hypothalamus, reduces sympathetic nervous system activity, releases catecholamines, alleviates muscle spasms, and, through slower breathing patterns during relaxation, has a beneficial effect on resting heart rate and respiratory sinus arrhythmia [25]. Moradi Mohammadi et al. argue that Benson relaxation is significantly effective in improving subjective sleep quality, reducing sleep onset delay, enhancing beneficial sleep, mitigating sleep disturbances, and overall sleep quality [19]. In line with our results, Sirati et al. showed that the Benson relaxation technique significantly improves sleep quality [32]. Akbarzadeh et al. also argue that Benson relaxation leads to a significant improvement in sleep quality in chronic heart patients [33], which is consistent with the results of the present study.
In the warm foot bath group, sleep quality improved significantly from the fourth night of hospitalization compared to the control group. A study by Talebi Ghadicolaei et al. in the Mazandaran Cardiac Intensive Care Unit showed that although warm baths do not improve sleep quality in all patients, the number of patients with severe sleep disorders decreases [34]. The discrepancy between the results of the previous study and the present study may be attributed to differences in various environmental factors, including types of environmental stress. Several factors, such as the environment, illness, pain, medication, nursing care, noise, light, and circadian changes, which can vary across different hospitals, may have differing effects on sleep [34]. In line with the present study, Rahmani et al. demonstrated that foot baths can improve sleep disturbances in patients with acute coronary syndrome and have a synergistic effect when used in conjunction with foot reflexology [3]. In each of the intervention groups and the combination group, the greatest effect was observed on the fourth night of hospitalization. Therefore, all three interventions are more effective over time, leading to better outcomes. Patients hospitalized in intensive care units endure high stress due to the severity of their illness; stress and anxiety can stimulate sympathetic activity and increase vasoconstriction, which in turn reduces heat transfer from the body’s core to the environment. Warm foot baths also stimulate nitric oxide synthesis, dilate blood vessels, reduce vascular resistance, and subsequently increase blood flow and heat transfer to the environment. This results in an increased proximal-distal gradient, ultimately improving sleep quality [34]. The effectiveness of foot reflexology massage in improving sleep quality in hemodialysis patients has been demonstrated in Qazvin City within the intervention group over time, which aligns with the present study regarding the enhanced effects of interventions over time [35].
Although the Benson relaxation intervention significantly improved sleep quality on the third night, its combination with a foot bath did not yield significant results. This may be attributed to subjective differences in responses to the questionnaire items and the need for more time to acclimate to both techniques—the warm foot bath and Benson relaxation—which can itself lead to fatigue. Similarly, on the fourth night, sleep quality improved significantly in the combined intervention group, as observed with Benson's relaxation. However, several other factors, such as pain, ventilators, environmental factors and noise, medications, and the severity of the disease, have influenced the results of this study and can disrupt sleep quality in the hospital setting.
This study has several limitations, including a small sample size, a short intervention duration, a lack of control over sleep-disrupting factors in the hospital, potential errors in using the self-report questionnaire, the impact of individuals’ mental and emotional conditions at the time of completing the questionnaires, and the extended duration of the intervention in the combined Benson relaxation and foot bath intervention group.
Based on the findings, all three methods—Benson relaxation, warm foot baths, and the combination of both interventions—were effective in improving the sleep quality of patients with acute coronary syndrome. Therefore, considering the duration of the two interventions, Benson relaxation and warm foot baths, and the lack of significant differences in the effects of the combined intervention compared to each of these interventions alone, as well as the better cost-effectiveness, either of the individual methods—warm foot baths or Benson relaxation—can be recommended, depending on feasibility, to enhance the sleep quality of patients. Given the high prevalence of sleep problems in patients with acute coronary syndrome, it is advisable for nurses to teach these interventions to patients. Additionally, it is recommended to conduct a study on the same topic with a larger sample size, a longer intervention period, and follow-up using a different questionnaire to assess sleep quality.
Conclusion
Benson relaxation techniques, warm foot baths, and their combination equally improve sleep quality in patients with acute coronary syndrome.
Acknowledgments: The authors would like to thank all the professors and colleagues at the Hazrat Zainab (PBUH) School of Nursing and Midwifery, Shahid Rajaee Hospital in Gachsaran, and everyone who assisted us in this study. This article is based on Hoda Arianpour’s master’s thesis from Yasuj University of Medical Sciences. We are grateful for the support of the Vice Chancellor for Research at Yasuj University of Medical Sciences. The research was registered with the Iranian Registry of Clinical Trials (IRCT20190126042497N1).
Ethical Permissions: This study was approved under the ethical approval code IR.YUMS.REC.1397.133 and was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the patients. Confidentiality of information, anonymity, and privacy of the patients were upheld. Patients had the right to withdraw from the study at any time if they wished. No physical or financial harm was inflicted upon the patients.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Arianpour H (first author), Introduction Writer/Methodologist/Main Researcher/ (30%); Hosseini M (second author), Introduction Writer/Assistant Researcher/Discussion Writer/Statistical Analyst (30%); Afrasiabifar A (third author), Assistant Researcher/Discussion Writer/Statistical Analyst (20%); Malekzadeh JM (fourth author) Introduction Writer/Assistant Researcher/Discussion Writer (20%)
Funding/Support: The present study was funded by the Yasuj University of Medical Sciences, Iran.
Keywords:
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