Effect of Benson relaxation response technique on the quality of life among patients with systemic lupus erythematous: quasi-experimental study

Abstract

Objectives

To investigate the effect of Benson relaxation response technique (BRRT) on the quality of life (QOL) among patients with systemic lupus erythematous (SLE).

Methodology

A quasi-experimental design was used to conveniently recruit 170 patients with SLE. Participants were divided into two groups, the control and the intervention group for which the BRRT intervention was administered. Utilising an online questionnaire, the QOL was assessed among the two groups, before and 2 months after the intervention, using the Arabic version of the short form 36-item health survey.

Results

After 2 months of the intervention, the intervention group exhibited significantly higher levels in both components of QOL; physical (t(143.31)=15.35, p<0.001); and mental component (t(143.58)=12.35, p<0.001). Additionally, for the intervention group, the results revealed a statistically significant increase in the levels of both components from baseline measurement; physical (t(84)=−16.24, p<0.001) and mental component (t(84)=−12.93, p<0.001).

Conclusion

The findings demonstrate a notable positive impact of BRRT on QOL among patients with SLE. Healthcare professionals can potentially improve the overall well-being of patients with SLE and complement traditional treatment by implementing BRRT into their care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Patients with systemic lupus erythematous have poor quality of life in both the physical and mental dimensions.

WHAT THIS STUDY ADDS

• This is a pioneer study that has investigated the effect of Benson relaxation response technique (BRRT) as a mind–body intervention on the quality of life of patients living with systemic lupus erythematous (SLE). The study findings demonstrate a significant improvement in the mental and physical aspects of their quality of life.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• By incorporating BRRT into the management approach for patients with SLE, healthcare professionals can potentially enhance the overall well-being of patients with SLE and can serve as a valuable addition to the conventional treatment.

Background

Systemic lupus erythematous (SLE) is a complex autoimmune disease that affects many systems in the body, causing widespread inflammation. It exhibits a broad spectrum of clinical presentations, including skin rashes, joint pain, renal involvement and neurological manifestations. As one of the most prevalent autoimmune diseases worldwide, SLE is a significant health challenge due to its diverse clinical manifestations and its impact on the quality of life (QOL) of individuals living with the condition.^{1 2} SLE can affect patients’ ability to work, and they might lose their jobs within 5 years of diagnosis.²

The prevalence and incidence of SLE varies across different regions and populations. Globally, the prevalence ranges from 13 to 7714 per 100 000 individuals, while the incidence varies from 1.5 to 11 per 100 000.³ Women and African Americans are more susceptible to develop SLE, with 90% of lupus cases being women. Also, African American women are more susceptible to develop SLE by two to three times more than whites.⁴ In Jordan, there are no published data regarding the prevalence or incidence of SLE, but in-hospital mortality was estimated to be 14% over 15 years among 283 Jordanian patients with SLE, with the main causes of mortality being infection and disease-related complications, mainly pulmonary complications.⁵

SLE poses a significant health challenge, not only due to its diverse clinical manifestations or complications but also because of its unpredictable nature and potential to affect the QOL of individuals living with the condition. Gu and colleagues investigated the level of QOL among 6510 patients with SLE in a systematic review and meta-analysis. They found that the level of physical and mental components of QOL were 46.1 and 50.37 out of 100, respectively, which proved the negative effect of SLE on the QOL.⁶ Beyond the physical challenges it poses, SLE can significantly affect the psychological and emotional well-being of those living with the condition; being patients with SLE reported many concerns about living with this disorder that directly affect their QOL, including pain, fatigue, skin problems, sleeping disorders, concerns when female patients want to become pregnant, concerns with all their social relationships, daily activities, professional life, any comorbid diseases, psychological concerns like sadness, anxiety, depression, fear and feeling guilty, and all of these that could affect their compliance with treatment plans.⁷

SLE could be managed with either pharmacological or non-pharmacological interventions. One of the most commonly used relaxation techniques is Benson relaxation response techniques (BRRT) or ‘relaxation response’.⁸ BRRT involves a mind–body approach; where the person practices breathing exercises and focuses on a specific calming word or phrase.⁹ As a non-medicinal intervention, BRRT is cost-effective, safe, and has no reported side effects.^{10 11}

The BRRT is a combination of breathing exercises and meditation that has been shown to have a positive impact on physical and mental health as well as a counter effect on stress and its effects.^{9 12} The effectiveness of BRRT has been studied in patients with various chronic disorders. For instance, Habibollahpour and colleagues reported significant improvement in sleep quality, duration, latency and efficiency among 75 elderly persons complaining of sleep disorders.¹¹ Similarly, Rakhshani and colleagues found that BRRT improved sleep quality in patients with chronic heart disease.¹³ Mirhosseini et al reported a positive effect of BRRT on fatigue severity among patients with multiple sclerosis.¹⁰ Similarly, Jafari and colleagues found that BRRT significantly reduced fatigue levels in patients who underwent hematopoietic stem cell transplant.⁸ Despite the evidence supporting the effectiveness of BRRT in improving several patients’ health and well-being outcomes, no study has examined its impact on theQOL of patients with SLE. Therefore, this study aims to investigate the effectiveness of BRRT on the QOL of patients with SLE.

Research questions

1. After 2 months of performing BRRT, are there significant differences in the physical and mental components of QOL among patients with SLE in the intervention group (IG) compared with those in the control group (CG)?

2. After 2 months of performing BRRT, are there significant differences in the physical and mental components of QOL among patients with SLE in the IG compared with preintervention levels?

Methods

Design

This study investigated the effects of Benson’s exercises on the physical and mental components of QOL among Jordanian patients with SLE using an equivalent controlled group quasi-experimental design. This design lacks randomisation and enables the observation of two groups, one of which is the CG, and the other is the IG (who performed BRRT). although quasi-experimental design lacks randomisation, it is the most reliable design in this study. Measures taken before and after the intervention—which was carried out 2 months later—are evaluated in this design. Using a quasi-design, we can assess the efficacy of an intervention and select two groups to collect data from, both before and after the intervention. This design is strong even though it does not use randomisation because it allows us to compare the intervention and CGs by gathering data at baseline.¹⁴

Sampling

Non-probability, a convenience sample was used in this study. A sample of Jordanian adult patients with SLE who met the inclusion criteria of having an SLE diagnosis, being at least 18 years old and being literate in Arabic was selected conveniently in the first stage. Then those who agreed to continue in the study were assigned either to the IG or CG based on the last participant, if the last one was assigned to IG, the next participant was assigned to CG, and vice versa. The first participant was assigned randomly. Conversely, patients with mental disabilities or those with critical illness who are incapable of cooperating were excluded from the study.

Sample size was determined based on Cohen power primer.¹⁵ Using conventional power of 0.8, medium effect size of 0.25 and level of significance of 0.05, and mean difference, the minimum sample size would be 64 for each group of the study. Additional subjects were recruited for the anticipated attrition rate, resulting in 170 subjects as a total sample.

Settings

The study was conducted in two teaching hospitals; one in Amman, the capital, and the other in Irbid, and they are the largest teaching hospitals in Jordan that provide care for the target population.

Intervention

The BRRT⁹ was introduced to the IG in the following steps: (1) close your eyes while you quietly sit in a comfortable position; (2) try to relax all your muscles. Start at your feet and work your way up to your face; (3) breathe via your nose, pay attention to how you are breathing. Say ‘one’ (or any word you like to say) to yourself in silence as you exhale. Take a deep breath through your nose for 3 s, hold it for another 3 s, and slowly release it through your mouth for 4 s. (4) Continue for 10 min. You can glance at the time by opening your eyes, but do not set an alarm. (5) After you are done, sit quietly for a few minutes, first with your eyes closed and then with them open. Patients were told not to worry about whether or not they were able to relax deeply. As long as the patient practice BRRT, it will be easier with less effort. For 2 months, practice this technique two times a day, 20 min before meals.

Instrument

The questionnaire in the current study consists of two parts (a) demographics, including age, gender, education, marital status, employment, total income, height and weight, and smoking status; and SLE diagnosis in months, (b) QOL was measured by using the Arabic version of the short form 36-item health survey (SF-36).¹⁶ It consists of 2 major components, 8 domains and 36 items. The physical component summary (PCS) includes the following domains: physical functioning (10 items), role physical functioning (four items), body pain (two items) and general health (five items). The mental component summary (MCS) includes the following domains: role emotional functioning (three items), vitality (four items), mental health (five items) and social functioning (two items). The score for each domain is transformed resulting in a score ranged from 0 to 100. The cut-off point for each domain and component is 47; higher than 47 means good QOL, and 47 or lower means poor QOL. Higher scores for components and domains indicate better QOL. Cronbach α for domains ranging from 0.71 for general health and vitality to 0.90 for physical function.¹⁶ In the current study, Cronbach α for SF-36 yielded 0.82, which indicates good internal consistency.

Data collection

The principal investigator (PI) approached nurses working in the immunology outpatient clinics in the selected hospitals and explained the purpose and the procedure of the study. After attaining the primary approval from eligible patients, the PI explained the purpose and the procedure of the study, participants’ role in the study, their right to withdraw from it, and the fact that all of their information would be kept private and anonymous. The eligible participants were assigned to either IG or CG randomly. The first patient is assigned randomly to IG or CG, and the next one was assigned based on the last patient, if the last one was assigned to IG, the next patient was assigned to CG, and vice versa. All participants were asked for their phone numbers to send them the online questionnaire and contact them after 2 months to fill out the questionnaire again. The PI, who is an expert in providing BRRT, explained the steps of BRRT for IG, and asked them to demonstrate BRRT to ensure that they understand the steps. They asked to repeat BRRT two times daily (20 min each) for 2 months (not within 2 hours after any meal). Also, a video that explained BRRT in Arabic was sent to them to enable them to return to the video for any inquiry. Also, they were asked to fill out a self-reporting sheet daily, to ensure their adherence to perform BRRT. The PI’s phone number was provided for all participants, especially those in IG, for any information or inquiry. After 2 months, the PI contacted all participants, sent them the online questionnaire link and asked them to fill it out again.

Ethical consideration

Institutional Review Board approval was obtained from XXX University and the two educational hospitals. The online questionnaire contained paragraphs outlining the goal of the study, its advantages, potential risks and the steps involved in data collection, including the intervention. It was assured to participants that there would be no coercion and that participation is entirely voluntary. Participants were free to leave at any time without giving a reason or incurring any fees. The confidentiality of all information has been guaranteed to the participants, and results will be reported in aggregate form. Additionally, raw data were kept in a password-protected folder. Participants’ phone numbers were kept private, separate from other data and available to the PI only. Electronic data will be permanently erased after completing the study and following the dissemination of the findings. Finally, participants in the CG have been contacted to educate them about BRRT after completing data collection for ethical reasons.

Data analysis

Data were cleaned for any outliers (determined by IQR), which was managed using imputation. Data analysis was performed using Statistical Package for Social Science (SPSS) for Windows (V.25).¹⁷ Based on the level of measurement, Descriptive values (Means, SDs and Frequencies) were used to describe the variables of interest. To compare between the intervention and CGs based on demographics, independent t-test and χ² were used, based on the level of measurement. The differences in the levels of PCS and MCS among patients in the IG compared with patients in CG were examined by using independent t-test. Moreover, paired t-test was used to assess if there is a difference between PCS and MCS scores before and after the intervention for the same group (control and IGs).

Results

Description of sample

As presented in table 1, a total of 170 patients diagnosed with SLE participated in this study: with a mean duration since the initial diagnosis of approximately 2 years. Patients were 33 men and 137 women with a mean age of 31.38±7.34. Almost two thirds of the patients reported having a diploma degree and above. Nearly 58% of them were single and more than half of them were unemployed.

Table 1. Characteristics of the participants.

Variable	Total sample (N=170)n (%)/M±SD	Intervention (N=85)n (%)/M±SD	Control(N=85)n (%)/M±SD	t/X2	P
Gender				0.04	0.188
Male	33 (19.4)	17 (20.0)	16 (18.8)
Female	137 (80.6)	68 (80.0)	69 (81.2)
Marital status				0.90	0.156
Single	99 (58.2)	51 (60.0)	48 (56.5)
Married	61 (35.9)	28 (32.9)	33 (38.8)
Divorced/widowed	10 (5.9)	6 (7.1)	4 (4.7)
Education				4.17	0.173
Primary	16 (9.4)	7 (8.2)	9 (10.6)
Secondary	45 (26.5)	24 28.2)	21 (24.7)
Diploma	52 (30.6)	23 27.1)	29 (34.1)
Bachelors	52 (30.6)	30 (35.3)	22 (25.9)
Postgraduate	5 (2.9)	1 (1.2)	4 (4.7)
Employment				0.65	0.158
Unemployed	54 (31.8)	29 (34.1)	25 (29.4)
Cannot work	37 (21.8)	19 (22.4)	25 (29.4)
Full time	39 (22.9)	18 (21.2)	21 (24.7)
Part time	40 (23.5)	19 (22.4)	21 (24.7)
Smoking				0.85	0.174
Yes	92 (54.1)	49 (57.6)	43 (50.6)
No	78 (45.9)	36 (42.4)	42 (49.4)
Duration since diagnosis (months)	23.69±10.27	23.22±9.50	24.15±11.03	−0.59	0.183
Income (JD)	507.79±73.31	505.47±69.58	510.12±77.19	−0.41	0.193
Weight (Kg)	65.51±6.64	65.04±5.90	65.99±7.31	−0.94	0.114
Height (cm)	156.90±5.62	156.47±6.10	157.33±3.76	−1.00	0.118
Age (years)	31.38±7.34	30.32±7.27	32.44±7.31	−1.90	0.135

Patients in this study were distributed equally into two groups (ie, the IG and the CG). The characteristics of the patients were described as an overall and then for each group separately. Table 1 shows a comparison between the IG and the CG depending on patients’ characteristics using independent t-test or χ² where appropriate. The table shows that there were no significant differences between the two groups based on the patients’ characteristics; and both groups are comparable in terms of the sociodemographic characteristics.

The effect of BRT on the QOL of patients diagnosed with SLE

The main focus of the study was to examine the effect of BRT on the outcome variables, which were the levels of PCS and MCS, representing the QOL. Accordingly, four steps were done and results are presented in tables2 3.

Table 2. Independent samples t-tests between intervention and control groups at baseline and follow-up measurements.

Outcome variable	Group	M±SD	t	P value
Baseline measurement
PCS	BensonControl	43.87±16.8942.54±17.14	0.51	0.141
MCS	BensonControl	43.20±16.7343.21±16.13	−0.002	0.162
Follow-up measurement
PCS	BensonControl	76.92±11.0243.00±17.15	15.35	<0.001
MCS	BensonControl	69.06±10.3843.40±16.10	12.35	<0.001

MCS, mental component summaryPCS, physical component summary

Table 3. Paired samples t-tests between baseline and follow-up measurements for the intervention and the control group.

Outcome variable	BaselineM±SD	Follow-upM±SD	t	P value
Intervention group
PCS	43.87±16.89	76.92±11.02	−16.24	<0.001
MCS	43.20±16.73	69.06±10.38	−12.93	<0.001
Control group
PCS	42.54±17.14	43.00±17.15	−1.27	0.136
MCS	43.21±16.13	43.40±16.10	−1.36	0.123

MCS, mental component summaryNS, not significant; PCS, physical component summary

Step 1: independent samples t-test was used to compare the levels of the outcome variables (ie, levels of PCS and MCS) between the two groups at baseline prior to initiation of the intervention. The results showed that there were no significant differences in levels of PCS and MCS between the two groups at baseline, table 2. This concludes that both groups reported similar levels of PCS and MCS before applying the BRRT.

Step 2: independent samples t-tests were used to compare the levels of the outcome variables (ie, levels of PCS and MCS) between the two groups after 2 months of the last sessions of the BRT (follow-up measurement). The results showed that IG had significantly higher levels of PCS (76.92±11.02) than the CG (43.00±17.15); t (143.31)=15.35, p<0.001. The magnitude of the difference in the mean=0.58 indicating a large effect size. Moreover, results indicated that the IG had significantly higher levels of MCS (69.06±10.38) compared with the CG (43.40±16.10); t (143.58)=12.35, p<0.001. The magnitude of the difference in the mean=0.48 indicating a large effect size, table 2.

Step 3: paired samples t-test was used to compare the levels of the outcome variables (ie, levels of PCS and MCS) for the IG between the baseline and the follow-up measurement. The results showed that there was statistical significant increase in the levels of PCS from baseline measurement (43.87±16.89) to follow-up measure (76.92±11.02); t(84)=−16.24, p<0.001. The magnitude of the difference in the mean=0.75 indicating a large effect size. Moreover, results showed that there was statistically significant increase in the levels of MCS from baseline measurement (43.20±16.73) to follow-up measure (69.06±10.38); t (84)=−12.93, p<0.001. The magnitude of the difference in the mean=0.63 indicating a large effect size, table 3.

Step 4: paired samples t-tests were used to compare the levels of the outcome variables (ie, levels of PCS and MCS) for the CG between the baseline and the follow-up measurement. The results showed that there were no significant changes in the levels of PCS and MCS at the follow-up measure, table 3.

To conclude, results showed a statistical increase in the levels of PCS and MCS after BRT in the IG but not in the CG. This suggests an effect of the BRRT in improving the levels of QOL for patients with SLE as measured by PCS and MCS.

Discussion

This study aimed to investigate the effectiveness of BRRT on the QOL among patients with SLE. The results of the current study showed poor QOL among patients with SLE. Patients’ scores were lower than those found in Gu and colleagues’ systematic review of 36 articles covering 6510 patients with SLE. The results showed that the pooled mean scores of PCS and MCS were 46.1 and 50.37, respectively, indicating poor QOL.⁶ Furthermore, Mizukami and colleagues investigated the level of QOL among 134 patients with SLE using SF-36. They found that PCS and MCS were 62.3 and 65.3, respectively, indicating better QOL compared with the current study.¹⁸ An Egyptian study also showed poor QOL among 164 patients with SLE.¹⁹ Additionally, An Iranian study, using the Lupus Erythematosus Quality of Life Questionnaire, revealed low QOL (65.5±22.4, range=0–100) for 140 patients with SLE.²⁰

There are many interventions and educational programmes, either physically or psychologically directed, aimed to improve physical and mental health as well as the total QOL. A systematic review of five randomised controlled trials (RCTs) and nine qualitative studies evaluated the impact of exercise interventions on the QOL of patients with SLE. The findings indicated an improvement in the physical functioning component of QOL.²¹ Additionally, psychoeducational programmes seemed to enhance QOL.^{22 23} Similarly, psychological interventions had a positive effect on QOL. Results from a systematic review of six RCTs involving 394 patients with SLE suggested that psychological intervention improved QOL but did not show significant improvement in disease activity, pain and fatigue.²⁴

BRRT affects both physical and mental health by combining breathing exercises with relaxation techniques. Once the patients master the technique, they would not need to practice in healthcare settings; they can perform BRRT alone. Although no studies have investigated the impact of BRRT among patients with SLE, several research studies have examined its impact on different QOL domains and overall QOL in diverse patient populations and illness states. For instance, an Iranian RCT study assessed the effect of BRRT on the quality of sleep among 75 elderly individuals. The IG showed significant improvement in subjective sleep quality, latency, duration and efficiency as well as daytime dysfunction.¹¹ Another Iranian RCT study among patients on haemodialysis found significant improvements in daytime functioning, medication use and sleep quality and disturbances.²⁵

BRRT has been shown to affect various symptoms, such as pain,^{26 27} fatigue,^{8 10 26 28 29} anorexia³⁰ and anxiety,^{31 32} which improves QoL among patients with various disorders. An RCT in Iran found that 19 patients who underwent stem cell transplants in the IG experienced significantly lower levels of fatigue than 18 patients in the CG.⁸ Another clinical trial study conducted in Iran evaluated the impact of BRRT on patients with multiple sclerosis (MS) in terms of fatigue. The findings revealed that IG (30 patients) had significantly less fatigue than CG (30 patients).¹⁰ Also, Alzaghmouri and colleagues reported significant reduction in physical, cognitive and psychosocial fatigue among 95 Jordanian patients with MS.²⁸

The impact of BRRT on anxiety and haemodynamic vitals—such as blood pressure, pulse pressure, heart rate and respiratory rate—was investigated in an Iranian RCT involving 144 patients prepared for heart surgery, cardiac catheterisation and other procedures. The outcomes showed a significant decrease in anxiety and all haemodynamic vitals among the IG (72 patients).³¹ Additionally, Kaplan Serin and colleagues investigated the effect of BRRT on fatigue, pain and QOL among 96 patients on haemodialysis and found a significant reduction in pain and fatigue levels as well as a significant improvement in PCS and MCS scores of QOL in IG.²⁶ Furthermore, BRRT demonstrated its impact on appetite and sleep quality,^{30 33} anxiety and QOL in patients with cancer.³³ BRRT also proved its effect on anxiety and QOL among patients with Thalassemia Major; as Ghaljeh and colleagues found in a semiexperimental clinical trial study of 140 Iranian patients.³⁴ Finally, it was found that BRRT had a significant impact on QOL among 96 elderly individuals living in nursing homes.³⁵

Limitations

The present study has a few limitations that need to be acknowledged. First, the quasi-experimental design lacks full randomisation. Using RCT design can generate more rigorous results. Second, the use of convenient sampling may introduce a potential bias as it may not fully represent the broader population of patients with SLE and compromising generalisability to wider populations. Third, this is a two-setting study, which may limit the applicability of the findings to other contexts. Additionally, although the focus of the study was on the QOL of those patients, including factors such as lupus activity, severity and medications could add more weight to the results. Moreover, high disease activity, treatment methods/medications and cognitive difficulties may have affected the ability of the patients to participate. Furthermore, the follow-up period in this study was limited to only 2 months, which may not capture long-term effects or changes that could emerge over an extended period. Consequently, the sustainability of the BRRT intervention may not be fully assessed within this timeframe. These limitations emphasise the importance of considering these factors when interpreting and utilising the findings of the current study or undertaking future research.

Implications

The study highlights the positive impact of BRRT on the QOL for individuals with SLE. Healthcare professionals can incorporate BRRT into the comprehensive management of patients with SLE to improve their overall well-being. This approach recognises the multifaceted nature of SLE and aims to address the diverse needs of patients through a combination of interventions. By integrating BRRT into the treatment regimen, healthcare providers can address not only the physical symptoms but also the psychological and social aspects of the disease. This empowers patients to actively participate in their care and fosters a sense of control over their health outcomes.

Further research is needed to explore the long-term effects and efficacy of BRRT as an adjunctive therapy for SLE management. It is recommended to conduct RCT at regional and international levels. Also, it is advised to conduct longitudinal studies with larger sample sizes to validate the findings and assess the sustainability of the positive impact on the QOL observed in this study. Additionally, comparative studies comparing BRRT with other relaxation techniques or interventions for SLE management can provide insights into the relative effectiveness and suitability of the BRRT compared with other approaches.

Conclusion

The current study highlights the significant positive impact of the BRRT on the QOL of patients diagnosed with SLE. Integrating BRRT into the management approach for patients with SLE has the potential to enhance their QOL and augment their overall well-being. BRRT shows promise as a complementary intervention that can significantly improve the QOL and overall outcomes for individuals with SLE.

Data availability statement

Data are available upon reasonable request.