Chan, C.W., Lam, L.W., Li, C.K., Cheung, J.S., Cheng, K.K., Chik, K.W., . . . Tang, W.P. (2015). Feasibility of psychoeducational interventions in managing chemotherapy-associated nausea and vomiting (CANV) in pediatric oncology patients. European Journal of Oncology Nursing, 19, 182–190. 

To determine the feasibility of using a combination of relaxation techniques and patient education (multidimensional psychoeducational intervention package) to alleviate (chemotherapy-induced nausea and vomiting (CINV) while estimating the effect size and assessing the research design feasibility and stability of the Morrow Assessment of Nausea and Emesis (MANE) and the Chinese version of the State-Trait Anxiety Inventory (STAI) in children

Two intervention groups and two matching control groups were followed for 60 days. Patients randomly were assigned to the relaxation (progressive muscle relaxation [PMR] and guided imagery [GI]) or the education group. Patients in the relaxation group received six sessions of daily PMR and GI training (days 0–5, 30 minutes per session) and daily self-practice for two months with a PMR and GI audiotape. Patients in the education group received two 30-minute sessions of patient and parent education on days 1 and 2 (risk assessment, antiemetic use, and meal planning). The usual care also was given to participating patients, which included antiemetic ondansetron intravenously as needed and diet advice (i.e., avoid spicy and greasy food, eat easily swallowed and digested food).

• N = 40 (10 relaxation, 10 education, and two control groups of 10 each)
• MEAN AGE = 8.6 years (range = 4–11 years)
• MALES (%): Not stated, FEMALES (%): Not stated 
• KEY DISEASE CHARACTERISTICS: Receiving chemotherapy; chemotherapy-naïve; able to understand Chinese; no brain metastasis; and no advanced-stage cancer

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Hong Kong

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

Exploratory pre- and post-test control group pilot study

• Eight instruments were used.
• The occurrence of nausea and vomiting (primary) was assessed using the Morrow Assessment of Nausea and Emesis (MANE).
• The use of antiemetics was obtained from medical records.
• Child and parent anxiety was assessed using the Chinese version of the State-Trait Anxiety Inventory (STAI).
• Physiologic indices such as caloric intake (food diary), changes in body weight (measured daily before breakfast), performance status (0-100 Play Performance Scale), satisfaction with care (child and parent self-reported four-point Likert scale), pulse, and blood pressure (for group 1 only) were measured.
• Group 1 self-rated the usefulness of the intervention (child and parent), activity log, and daily PMR and GI practice.

Because of the small sample size, the findings were not confirmatory. A significant reduction in vomiting as a possible result of the relaxation exercise was reported on day 3 (the day most patients in the study experienced CINV and a lowered performance status and satisfaction with care). From days 2–7, fewer patients in both intervention groups vomited compared with the control groups. Anticipatory nausea and vomiting was experienced by 40% of patients prior to chemotherapy. The study was feasible, but it took 18 months to recruit 20 patients. Patients and parents prefered relaxation to the education intervention. MANE and STAI scales were easy to understand in Chinese, and there were no difficulties with completion.

Relaxation and education could reduce vomiting. Anticipatory nausea and vomiting also may be alleviated with relaxation techniques. The early intake of antiemetics controlled and decreased patients' experience of CINV.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias(sample characteristics)
• Key sample group differences that could influence results
• Findings not generalizable
• Other limitations/explanation: The patients' anxiety levels were not stratified. Historical controls were used. Chemotherapy was of low emetogenicity. Two intervention groups were used to compare the effects of relaxation alone and education alone without a four-group factorial design. The study depended on patients' self-practice of PMR and adherence was not discussed.

Relaxation and patient education (major components of a combined psychoeducational interventions) are potential helpful for CINV and are accepted techniques. However, preventive measures provided before the commencement of chemotherapy are more helpful. Patients preferred relaxation for anxiety reduction over education.