Impact of Relaxation Training According to Yoga in Daily Life ® System on Self-Esteem After Breast Cancer Surgery

Abstract

Objectives:

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to the Yoga In Daily Life^® system on the self-esteem of patients with breast cancer.

Design:

This is a parallel-groups design.

Settings/location:

Baseline interventions took place at the Institute for Oncology of Ljubljana (Slovenia). At discharge, the experimental group was issued with audiocassette recordings containing the instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

Subjects:

The convenience sample of 32 patients with breast cancer was recruited from an accessible population of hospitalized women. Patients were randomized to the experimental (n=16) and to the control group (n=16).

Interventions:

Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to the Yoga in Daily Life^® system. At discharge, the experimental group was issued with audiocassette recordings containing similar instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

Outcome measures:

Outcome measures were obtained by blinded investigators (physiotherapists) using standardized questionnaires (Rosenberg Self-Esteem Scale) at baseline (after the surgery); at 1 week (1 week postattendance; at discharge); and at 4 weeks (4 weeks postattendance); prior the commencement of radiation.

Results:

Analysis of variance showed that there were statistically significant differences between the experimental and control group in all measuring self-esteem scores over the study period (p<0.0005). At the same time, the control group's scores remained unchanged over the study period (p>0.05).

Conclusions:

The results indicate that relaxation training according to the Yoga in Daily Life system could be a useful clinical physiotherapy intervention for patients who have breast cancer and who are experiencing low self-esteem. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.

Introduction

W omen with breast cancer are profoundly affected by physical problems such as alteration of body image, lymphedema, restriction of range of motion, strength and conditioning, pain, sexual function, and desire.¹

Patients with breast cancer are also affected by numerous psychosocial problems such as the fear of death, loss of control, uncertainty of outcome, and additionally by restriction of circumstances of employment and insurability.¹

The body of literature investigating the psychosocial adjustment in women with breast cancer suggests that this disease represents a singular assault on body image and self-concept and places many patients at high risk for developing psychologic problems.^2
–4

Becoming and living as a patient with breast cancer is a health–illness transition that involves many emotions and physiologic distress that are related to uncertainty and disrupted reality.⁵ Most researchers have agreed that breast cancer and its treatments are psychologically traumatic events for even the most stable women. Breast cancer is experienced as an invasion of the body, or a severe malfunctioning of the body.⁶ In either case, the disease poses a threat to the woman's sense of bodily integrity and her conceptions of body image and sexuality. It is not uncommon for women with breast cancer to report that they feel betrayed by their bodies.⁶

The psychologic impact that results from a diagnosis of cancer has also been the subject of extensive investigation.^4,7

–11 Diagnosis with a life-threatening illness, such as breast cancer, can have a significant impact on one's self and immediately and/or prematurely imposes a perceived disruption in the “life trajectory” of the patient.⁸ The second most difficult period is that after discharge following surgery.^12
–14 As stated by Fawzy et al., “Irrespective of her age or phase in the life cycle, the patient is generally concerned with the fear of death, morbidity associated with treatments, fear of recurrence, fear of becoming dependent or a burden, fear of abandonment, fear of loss of function, and inability ultimately to complete the goals of their assumptive world.”⁸

Physical changes associated with acute and chronic effects of treatment, disruptions in the ability to fulfill one's roles within family and society, and psychologic and spiritual aspects of coping with a life-threatening illness can lead to changes in attitudes, perspective, meaning, outlook, and interpersonal interactions.^15,16 Researchers have used a variety of terms to describe changes in the self that occur following breast cancer diagnosis and treatment, including identity reconstruction,¹⁷ reformulation of the self,¹⁸ reconstructing the self,^15,19 and self-transcendence.²⁰ Although these terms have been developed from separate descriptive studies among individuals with cancer, they describe a common phenomenon: the notion that the self is changed or transformed by the cancer experience. The contributions of “improvement of self-esteem” data in breast cancer clinical research are multifold. “Improvement of self-esteem” data can enhance understanding of the impacts of cancer complementary treatment, either as a basis for providing appropriate supportive complementary care to individuals or as a stimulus for choosing the best complementary relaxation treatments in order to reduce negative sequel. Certainly, the nature of breast cancer and the limitations of conventional treatment combine to produce a population of vulnerable individuals with breast cancer whose emotional and psychologic needs go largely unmet by mainstream medicine. As women with breast cancer continue to live longer with their chronic illness, the desire for better self-esteem translates into increasing interest in complementary therapies as adjuncts to conventional modes of care. Relaxation as a stress management technique is widely used as an adjunct to traditional medical cancer therapies. However, the effectiveness and efficacy of relaxation therapies must be demonstrated to justify their use. The holistic management of loss of self-esteem by a variety of complementary interventions is becoming part of multidisciplinary practice and has a sound if untested rationale. The terms complementary therapies are vague headings encompassing a wide variety of activities (imaging and visualization, relaxation techniques, yoga, meditation, progressive muscle relaxation, deep breathing, visualization, guided imagery, stress management interventions); thus it is important to describe as fully as possible the kind of therapy that is being evaluated.

These complementary treatments are another area of neglect in the field of breast cancer research. Many resources are poured into the scientific search for the elusive cure, but little support is offered for exploring ways of improving “self-esteem” of patients with breast cancer. Loss of self-esteem in patients with breast cancer is underdiagnosed by primary care physicians, and even misdiagnosed in some cases. Relaxation techniques are very effective complementary treatment interventions and ones in which physiotherapists can play an important part.²¹ As Jones and Barker,²² Trew,²³ and Sapsford et al.²⁴ already outlined in detail, relaxation techniques have many physical and psychologic effects, and physiotherapists are well qualified to evaluate these. Physiotherapists have an historic involvement in exercise and rehabilitation, and should therefore be primarily involved in the move to mental health promotion and prevention via relaxation in the breast caner populations. Complementary cancer care supports the physical, emotional, and spiritual needs of the patient with cancer and plays a vital part in improving self-esteem and self-acceptance. Although a number of investigators have advocated the use of relaxation techniques for patients with cancer, there are few well-controlled studies.^{18,25

–30}

The basic premise of this study is to include relaxation training according to the Yoga in Daily Life^® (YIDL^®) system as an integral part of rehabilitation program in physiotherapy. The overall aim of this pilot study is to examine the effects on self-esteem in patients with breast cancer, and to determine whether relaxation training, conducted by a physiotherapist-researcher as an integral part of his activities leads to patients with breast cancer in the experimental group experienced a higher self-esteem than patients in the control group during hospitalization and 3 weeks after discharge (before radiation/chemotherapy).

It was hypothesized that patients receiving relaxation training according to YIDL would evidence significantly higher self-esteem level than patients assigned to control group.

Methods

Participants

The independent coordinator was asked to screen 32 women being treated at the Institute for Oncology of Ljubljana; these women had a primary diagnosis of breast cancer using the eligibility criteria (Table 1). For each patient identified by the coordinator, permission was gained to contact her and ask her willingness to participate in this study. They were told that the study was being carried out to evaluate relaxation training during hospitalization (after the surgery) and its impact on psychologic parameters.

Table 1.

Inclusion and Exclusion of Study Population

Inclusion criteria	Exclusion criteria
Initial diagnosis: breast cancer	Known and documented psychiatric disorders
Stage I and II breast cancer	Active substance abuse (a history of dependence on alcohol or drugs, taking psychotropic drugs)
Postoperative hospitalization: 1 week	Stage III and IV breast cancer
40 years of age or older	Patients with seriously impaired hearing
Surgical options: breast conserving surgery or radical modified mastectomy	Patients with seriously reduced cognitive capacity
Patients who were willing to accept the randomization to any group	Patients who did not understand the information given about the study and/or who could not be expected to have the ability to follow the instructions in a relaxation training
Multimodal therapy (surgery, radiotherapy, chemotherapy)	Patients who have received psychotherapy^a

Psychotherapy's effects might be confounded with those of the relaxation intervention.

The sample was made up of a consecutive series of patients who had been treated by either modified radical mastectomy or breast-conserving surgery (lumpectomy, quadrantectomy, segmental mastectomy) for early breast cancer stages I and II A, B that are classified using the recognized TNM system (Table 2), which identifies the tumor size (T), lymph node involvement (N), and presence of secondary tumors or metastases (M) as defined by Box²⁴ and Curling.³¹ Initially, 40 women fulfilled the study criteria but 8 refused to participate. Reasons given were too fatigued (n=2), too distressed (n=5), unknown reason (n=1). Informed consent was given by the remaining 32, who were then randomly assigned to either an experimental or control condition.

Table 2.

TNM System

TNM classification	Clinical stage	Description
T1, N0, M0	I	Tumor ≤2 cm, confined to the breast, no lymph node or metastatic involvement
T0-2, N0-1, M0	IIA	No primary tumor to tumor ≤5 cm, no or only ipsilateral moveable axillary lymph node involvement, no metastases
T2-3, N0-1, M0	IIB	Tumor >2 cm, no or only ipsilateral moveable axillary lymph node involvement, no metastases

TNM, tumor size (T), lymph node involvement (N), and presence of secondary tumors or metastases (M).

Thirty-two (32) patients were randomized (stratified randomization) to the standard physiotherapy (control group, n=16) and to a standard physiotherapy plus relaxation training according to the YIDL system (experimental group, n=16) before the surgery. It was also decided not to include a placebo group for ethical reasons.

The Latin Square randomization method was used in the study. Stratifying factors were as follows: type of surgery, severity and stage of breast cancer, and sociodemographic characteristics (age, marital status, employment status, and education). Baseline values between experimental and control group regarding stratifying factors were successfully equalized (Table 3).

Table 3.

Descriptive Statistics for Sociodemographic and Clinical Variables by Experimental and Control Group

		Group	f	%	df	p
Marital status	Married or cohabiting	EG	11	68.8	3	0.713
		CG	13	81.3
	Separated or divorced	EG	1	6.3
		CG	1	6.3
	Widowed	EG	3	18.8
		CG	2	12.5
	Single, never married	EG	1	6.3
		CG	0	0
Employment status	Employed	EG	13	81.3	2	0.317
		CG	11	68.8
	Retired	EG	1	6.3
		CG	4	25
	Housewife	EG	2	12.5
		CG	1	6.3
Educational status	High school	EG	8	50	1	1.000
		CG	8	50
	College	EG	8	50
		CG	8	50
Type of breast cancer surgery	Breast-conserving surgery	EG	6	37.5	1	0.642
		CG	6	37.5
	Modified radical mastectomy	EG	10	62.5
		CG	10	62.5

EG, experimental group; CG, control group.

From Table 3 it can be seen that regarding sociodemographic and clinical variables, there were no statistically important differences between experimental and control group. The age differences between both groups were also not statistically significant (t(30)=− 0.136; p=0.893).

Approval from the ethics committees of University of East London and Republic Slovenia had been obtained before the initiation of the study.

Written informed consents were obtained from all patients. An explanation of the study was given to each patient, together with assurance of confidentiality. A randomization list was prepared by the independent statistician using the random permuted blocks.^32,33 This technique has ensured that equal numbers of patients within each stratum were randomized to each intervention (restricted stratified randomization). Although patient blinding was impossible, the other physiotherapists and health professionals providing standard care had no knowledge of group assignment (single blinding).

Measures and procedures

Outcome measures were obtained at the Institute for Oncology of Ljubljana at three time points:

1. At baseline (after the surgery)

2. At 1 week (1 week postattendance; at discharge)

3. At 4 weeks (4 weeks postattendance; prior to the commencement of radiation)

Outcome measures were obtained by blinded investigators (physiotherapists) using standardized questionnaires. Single blinding was used in order to maintain the ignorance of assessors about which group the patients had been assigned to (blinding) and to eliminate assessors' effects by excluding personal interaction with patients (they receive standardized letters, scales, tape-recorded instructions, and self-completion questionnaires). The oncologists, nurses, physiotherapists, and other health professionals were also blinded to the patients' Rosenberg Self-Esteem Scale (RSE)³⁴ scores but they were aware that the assessment of self-esteem was being made.

The RSE is a 10-item measure of global self-esteem.³⁴ Patients rate each item on a scale ranging from strongly agree (1) to strongly disagree (4). Appropriate items were reverse scored, and all responses were totaled to obtain total scores ranging from 10 to 40. The higher score indicates higher self-esteem.

The study length of 1 month was chosen to allow for time to show a clinical effect, to minimize the potential for compounding medical complications, and to reduce the likelihood that reactive and/or situational distress would have spontaneously resolved. The inclusion of a nontreatment arm was viewed as desirable to control for placebo effect and change over time, and was therefore included. It is recognizable that blinding is often not feasible, particularly in evaluating psychologic treatments, but it is not advisable for the person (author–researcher) who delivers the relaxation to administer the assessment as well.²⁶ Baseline measurements were made after the randomization in order to serve as a check on the effectiveness of randomization in equalizing both groups.

Relaxation training according to the YIDL system³⁵ was chosen as a complementary treatment option (mind–body intervention) in order to plan such a program that promotes coping and adjustment to breast cancer treatment and helps to improve quality of life.

After discharge, the control group received adjuvant systemic chemotherapy (based on the tumor's size, spread to lymph nodes, and/or prognostic features) and external radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy (MRM) (given in the fifth week after the surgery). None of the patients in the control group was given neoadjuvant chemotherapy prior to surgery.

The experimental-relaxation group received surgery and attended 1-week standard physiotherapy program plus 1-hour group relaxation session per day. The detailed description of the procedure for the interventions is given in the Table 4. The subjects were naive with respect to experience with relaxation training according to the YIDL system, though most had heard of this approach. After hospitalization, they received adjuvant systemic chemotherapy (based on the tumor's size, spread to lymph nodes and/or prognostic features) and external radiation therapy to the lymph nodes near the breast and to the chest wall after a MRM (given in the fifth week after the surgery). None of the patients in experimental group was given neoadjuvant chemotherapy prior to surgery.

Table 4.

The Procedure for the Interventions

Intervention level	Activities	Duration (min)
Initial relaxation	Normal breathing, concentration on the whole body	5
Abdominal breathing	Slightly deeper than normal breathing for coordination of breath and abdomen movement, concentration on the abdomen	5
Full yoga breathing	Full use of lung capacity breathing, for coping with fears, concentration on one's entire trunk	5
Formulation of intention statement (Sankalpa)	Setting goals for the future in order to cope with uncertainty and fears, mental concentration	5
Body scan	Focusing on sensory awareness of a series of individual muscle groups	15
Reaffirming of intention statement (Sankalpa)	Mental concentration	5
End of relaxation	Concentration on the whole body	5

The physiotherapists provided a standard physiotherapy program for patients with breast cancer with appropriate exercise prescription and assisted in the education of the control and experimental group in order to facilitate the following:

• Recovery of shoulder range of movement and physical function of the operated arm

• Awareness of lymphedema, its prevention and early detection

• Minimization of the effect of the development of secondary complications on their ultimate physical recovery.

Results

The data were analyzed using Statistical Package for Social Sciences (SPSS) program v16.0. The α was set at α=0.05.

The χ² test or Fisher exact test was used in order to compare differences in the distribution of sociodemographic and clinical details for categorical variables and t test for continuous variables. One-sample Kolmogorov-Smirnov test was used in order to test for normality.

The Mann–Whitney U-test for the RSE showed that there were no statistically significant differences (Mann–Whitney U, p>0.05) in baseline self-esteem scores between patients with breast cancer who underwent MRM and breast-conserving surgery (BCS).

Repeated-measures analysis of variance (ANOVA) was used to analyze the within-subject changes over time (changes of quantitative data from pretest to 1 week postoperation and 4 weeks postoperation) as well as between-subject differences related to other independent factors in the model. For post-hoc testing, a Bonferroni correction was applied.

Repeated-measures ANOVA, Tests of Between-Subjects Effects, showed that in general the type of surgery itself did not have statistically important impact on the values of outcome measures on RSE scores (F(1.28)=1.512, p=0.229), nor was the interaction between treatment (experimental/control group) and type of surgery statistically important (F(1.28)=1.512, p=0.229). On the other hand, the treatment itself in general had a statistically important impact on outcome measures on RSE (F(1.28)=40.495, p<0.0005).

When testing the within-subject effects, there was a statistically significant change over time in RSE scores in each of the control and experimental groups (F(1.28)=75.227, p<0.0005). Post-hoc testing showed that there was no statistically significant difference in mean score of RSE (p=0.898) between experimental (21.31±1.35) and control (21.25±1.39) groups at baseline. Statistically significant differences (p<0.0005) of means were noted at 1-week postattendance measurement for the experimental (23.75±1.06) group. The groups had statistically significant differences of mean scores (21.25±1.73) at 1 week postattendance (p<0.0005). There was statistically significant (p<0.0005) increased self-esteem demonstrated by improvements in the RSE scores for the experimental group at 4 weeks postattendance (27.25±1.73) (Table 5).

Table 5.

Changes Within Groups Over Time on Outcome Measures' Values on Rosenberg Self-Esteem Scale Over the Study Period

			Study period
			1		2		3
		N	M	SD	M	SD	M	SD
EG	BCS	6	20.67	1.35	23.17 (p=0.0067)	0.75	26.33 (p=6.73·10⁻⁵)	1.37
	MRM	10	21.70	1.059	24.10 (p=9.94·10⁻⁵)	1.10	27.80 (p=2.2·10⁻⁸)	1.75
	Together	16	21.31	1.35	23.75 (p=3.57·10⁻⁶)	1.06	27.25 (p=7.27·10⁻¹²)	1.73
CG	BCS	6	21.67	1.03	21.5(p=0.8174)	1.38	19.83 (p=0.0236)	1.33
	MRM	10	21.00	1.56	21.1(p=0.9013)	1.97	20.90(p=0.9029)	2.02
	Together	16	21.25	1.39	21.25(p=1.0000)	1.73	20.50(p=0.2011)	1.83

Statistically significant results are bolded.

N, number; M, mean; SD, standard deviation; EG, experimental group; CG, control group; 1, at baseline; 2, at 1 week postattendance; 3, at 4-week postattendance; BCS, breast-conserving surgery; MRM, modified radical mastectomy.

From the information above, it can be seen that self-esteem among participants in the relaxation training group increased significantly during the study period. These results together with the Tests of Between-Subjects Effects indicate that relaxation training according to the YIDL system had a significant impact on increasing self-esteem as measured with RSE among participants in the experimental group over the study period.

Discussion

Since this is the first study of yogic relaxation training according to the YIDL system, it is premature to form strong conclusions regarding the effects of relaxation according to the YIDL system. A need exists for additional, well-designed studies on this topic before a recommendation can be made regarding the efficacy of yogic relaxation as a nonpharmacologic therapy for maintaining or increasing psychologic well-being in patients with breast cancer.

Coming to terms with breast cancer and its effect on body image, femininity and self-esteem are major issues confronting women who have lost a breast to cancer. Furthermore, messages from the media, cosmetic industry and health care profession perpetuate the “beauty myth” affecting the self-esteem of patients with breast cancer.³⁶ The importance of outcomes such as higher self-esteem that extend beyond traditional measures, such as mortality and survival, should gain increased attention in cancer care in future.

ANOVA showed that there was a statistically significant difference in self-esteem between the experimental and control group over the study period (F(1.28)=40.495, p<0.0005). The most striking finding (post-hoc comparisons) was that patients in the experimental group who were receiving relaxation training reported a statistically significant trend (p<0.0005) toward higher self-esteem as measured with the RSE, but the control group scores remained practically the same over the study period (p>0.05). RSE has been used extensively in previous cancer research and has excellent psychometric properties.^18,37

Most of the psychologic morbidity and loss of self-esteem associated with breast cancer has been blamed on the radical nature of mastectomy.³⁸ Little or no attention had been paid to the psychologic burden of the disease itself or to the multiple problems that can be associated with additional systemic therapies.³⁸ No statistically significant difference in baseline measurements of self-esteem scores between patients with breast cancer who underwent MRM and BCS between treatment groups was found in present study. The incidence of loss of self-esteem was high in both groups. These findings question the assumption that mutilating surgery per se is predominantly responsible for psychologic morbidity; there is clearly the possibility that breast cancer itself is the cause of the morbidity and loss of self-esteem and that patients use the mode of breast cancer treatment as a focus for their unease. The “treatment is to blame” explanation for the loss of self-esteem of the breast cancer should perhaps finally be put to rest. Unfortunately, breast-conservation therapy does not categorically eliminate all the low self-esteem associated with breast cancer.

The degree of loss of self-esteem among the patients treated by BCS was a disappointing finding, but one that cannot be ignored. These women clearly need just as much psychologic support as patients who undergo MRM as already argued by Fallowfield et al.,³⁹ Stefanek,⁴⁰ and many others.

The concept of “self-esteem” was used in this study to refer to feelings of satisfaction a patient with breast cancer has about herself and to the attitude a patient has toward herself. Actually, present findings further support the construct of self-esteem as theoretically defined, since one would not expect self-esteem to be completely stable, but rather to be subject to fluctuations. It was clearly shown that self-esteem was not stable for patients with breast cancer. The physical self is definitely threatened during breast cancer experience, and one's sense of self in relationship to the physical body is reflected in one's sense of self-esteem.

Many of our patients reported that their ability to use the relaxation technique was followed by observed improvements in self-esteem and finally allowed them to feel that they had some control over their disease and lives during the postoperative period. Previous research has also shown that patients with breast cancer who have a sense of control over events and actively take part in rehabilitation and cancer treatment (CT) adjust better than those with a helpless outlook.^41,42 The realization that one can exercise some control over the loss of self-esteem is important because it may help to improve self-esteem. Patients with breast cancer who have increased self-esteem, perceptions of control, and enhanced self-efficacy over the psychologic distress therefore appear to influence their psychologic well-being, as already reported in previous studies.⁴³ It was already argued by Royak-Schaler⁴¹ and Andersen⁴³ that women who believe they have personal control over their mental health are more likely to take an active role during breast cancer surgery, breast cancer treatment, and early recovery period. Relaxation also involved active patient participation and thus encouraged patients to feel that they had been the effective causal agents in improving of self-esteem. Thus, the effects produced by the relaxation procedures extended well beyond those attained by standard medical care and standard physiotherapy alone. An important psychologic consequence of the relaxation training according to the YIDL system is that the level of self-esteem of the breast cancer patients was likely to be increased as a result of much improved control of stress reactions, as already noted by Heptinstall.²¹ Already Hare⁴⁴ argued that physiotherapists could play an important part in increasing a patient's self-esteem, particularly in relation to a patient's perception of her own body. Furthermore, active involvement in one's health, reduced psychologic distress, and improved quality of life in the postoperative period would result. An extended lifespan has been observed in previous studies of complementary interventions (including relaxation techniques) in patients with breast cancer that have encouraged active coping and stress management skills through relaxation training.^8,25,41 The findings from these methodologically sound studies yield a statistically significant survival advantage that has stimulated a few follow-up studies,²⁵ but they have prompted no large-scale research effort, and no establishment-based call for widespread implementation of relaxation interventions in oncology units and cancer treatment centers.²⁵

Moreover, the present study suggests that many patients are able to successfully induce relaxation after several researcher–physiotherapist-directed sessions, thereby increasing the likelihood of the continued protective effects of relaxation and its overall cost effectiveness. Thus, once patients learn to relax, professionally prepared audiotaped instructions may be useful in maintaining the beneficial effects of improving a patient's self-esteem. Taken together, these findings suggest that the early introduction of relaxation training may have several clinical advantages in improving self-esteem of breast cancer treatment. The recognition of breast cancer as a chronic illness with a substantial loss of patients' self-esteem has contributed to increasing attention to quality-of-life issues and an increasing appreciation for the role of psychosocial/complementary interventions as both clinically effective and cost-effective. The prevalence of loss of self-esteem in women with breast cancer is substantial, yet none of the future patients at the Institute of Oncology Ljubljana will be referred for active relaxation training, despite the demonstrated-rapid response to such an intervention. Due to the lack of training among nonspecialized clinicians, nurses, and physiotherapists in detecting the loss of self-esteem of patients with breast cancer, there is a need for easily handled “diagnostic methods” such as the RSE scale. Results in the present study suggest that more emphasis is needed on addressing the loss of self-esteem in all patients with breast cancer. Without attention to these psychosocial issues in breast cancer, the potential of clinical science to improve self-esteem and therefore promote mental health and quality of life may go unrealized. Ways of identifying loss of self-esteem clearly need further research. It should be suggested that physiotherapists could routinely undertake patients' self-esteem assessment in the same way that they undertake physical/functional assessment or could apply questionnaires with good validity and reliability. Physiotherapists who specialize in treating breast cancer should be available for all patients undergoing treatment for breast cancer in order to monitor the loss of self-esteem of women after the breast cancer surgery. This might help to identify the loss of self-esteem much earlier or even to reduce it with relaxation techniques, as demonstrated in present study. Physiotherapists should guard the rights and interests of patients with breast cancer by increasing attention to their mental health issues. Physiotherapists are also expected to change the prevalent norms of professional behavior toward a more holistic and emphatic way of treating patients. Although present results have clear theoretical and methodological implications, this pilot study demonstrated only short-term effectiveness of relaxation training for Slovenian patients with breast cancer, especially in improving self-esteem. Clearly, the long-term health implication from relaxation training according to YIDL on the clinical oncological status of patients in the present study is not known and was not the object of the study. Therefore, it remains a challenge for future research.

Conclusions

This investigation will add to the accumulating body of research that empirically documents the effects of relaxation interventions as health-promotion strategies on the mental health of hospitalized oncology patients. Although this pilot study using a clinical trial design is too small to address the scientific hypotheses of interest, it provides researchers important data as well as the necessary experience to carry out a large-scale clinical trial capable of examining the potential role of this specific relaxation training on psychologic well-being, mental and physical health, and quality of life.

This article presents short-term effects of relaxation training according to the YIDL system on the self-esteem of patients with breast cancer.

While the present results are provocative, caution in their interpretation is warranted for several reasons. First, while statistically significant differences between the experimental and control groups were evident on a number of measures of psychosocial status, the clinical significance of these differences is difficult to gauge. Although present results have clear theoretical and methodological implications, this pilot study demonstrated only short-term effectiveness of relaxation training for Slovenian patients with breast cancer in improving self-esteem, which was demonstrated by a rapid increase in RSE scores. This investigation will add to the accumulating body of research that empirically documents the effects of relaxation interventions as health-promotion strategies on self-esteem improvement of patients with breast cancer.

Clearly, the long-term health implication from relaxation training according to YIDL on the clinical oncological status of patients and the effect of other sociodemographic variables on self-esteem in the present study were not known and were not the object of the study. Therefore, with a larger sample, they remain a challenge for future research.

Footnotes

Acknowledgments

The authors would like to thank Dr. Ivan Verdenik and Miha Zagoričnik for the statistical help and for sharing the intellectual territory.

Disclosure Statement

No competing financial interests exist.

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