2025 Volume 267 Issue 2 Pages 225-233
This study aimed to evaluate the effects of remote symptom monitoring (RSM) combined with progressive muscle relaxation (PMR) in lung cancer patients undergoing chemotherapy. A total of 134 lung cancer patients were recruited and randomly assigned to either the RSM + PMR group (n = 67) or the control group (n = 67). Assessments were conducted at baseline (T0), after the first chemotherapy cycle (T1), and after the second cycle (T2). Outcomes included pain [Visual Analogue Scale (VAS)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], anxiety and depression [Hospital Anxiety and Depression Scale (HADS)], and health-related quality of life (HRQoL, EORTC QLQ-C30). The RSM + PMR group demonstrated significant improvements compared to the control group in reducing pain, enhancing sleep quality, lower anxiety and depression scores at T1 and T2. In terms of HRQoL, the RSM + PMR group showed significant reductions in fatigue, pain, and nausea/vomiting, along with improvements in physical function, role functioning, and social functioning at T1. These positive effects persisted and even strengthened by T2, with further significant improvements in fatigue, pain, dyspnea, and nausea/vomiting. Additionally, the RSM + PMR group reported better global health status at both T1 and T2. By the end of the study (T2), patient satisfaction with the RSM + PMR intervention was significantly higher than in the control group. The RSM + PMR intervention effectively improved pain, sleep, anxiety, depression, and HRQoL in lung cancer patients during chemotherapy, offering a valuable strategy for symptom management.
More than 1.6 million new cases of lung cancer are detected annually worldwide, making it the leading cause of cancer death in men and the second in women, with the highest mortality rates in North Korea (40.9 per 100,000), China (32.5%), Armenia (32%), Turkey (31%), and Timor-Leste (27.9%) (Rehman et al. 2023). Despite advancements in treatment, chemotherapy remains a cornerstone in lung cancer management. However, chemotherapy often exacerbates a range of debilitating symptoms including pain, fatigue, sleep disturbances, anxiety, and depression (Ulibarri-Ochoa et al. 2023; Lee et al. 2024). These symptoms significantly reduce overall well-being and quality of life. Thus, effective symptom management is critical for improving treatment outcomes and enhancing the quality of life for lung cancer patients.
In recent years, digital health innovations have opened new avenues for enhancing patient care. Remote symptom monitoring (RSM) has emerged as a promising tool (Furlong et al. 2019; Mooney et al. 2024). RSM leverages technology to facilitate continuous, real-time monitoring of patient-reported symptoms. This enables early detection of adverse events and allows healthcare providers to deliver timely, personalized interventions (Mooney et al. 2017; Graetz et al. 2024). By bridging the gap between clinic visits, RSM has the potential to reduce symptom severity, prevent hospitalizations, and ultimately improve patient outcomes (Patt et al. 2023; Salako et al. 2023). The effectiveness of RSM has been demonstrated in the outpatient management of various chronic conditions, including cancer, particularly during chemotherapy, as well as patients with cancer during chemotherapy (Lee et al. 2024; Manz et al. 2024).
Alongside technological advancements, non-pharmacological interventions have gained recognition for their role in alleviating the psychological stress associated with cancer treatment (Ruano et al. 2022; Papadopoulou et al. 2023). Techniques such as cognitive behavioral therapy, problem-solving, yoga, distraction techniques, music intervention, virtual reality, and progressive muscle relaxation (PMR) have been recommended for this purpose (Nguyen et al. 2023; Turan et al. 2024). PMR is a deep relaxation technique that involves systematically tightening and then relaxing various muscle groups in the body (Zhou et al. 2015; Nguyen et al. 2023). It has been shown to be particularly beneficial for cancer patients, helping to reduce both psychological stress and physical discomfort associated with treatment (Redd and Hendler 1984; Sari et al. 2024; Turan et al. 2024). Furthermore, PMR may counteract the muscular atrophy and mitochondrial dysfunction caused by chemotherapy, which can lead to higher treatment toxicity (Rehman et al. 2023).
Despite the well-documented individual benefits of RSM and PMR, there is limited research exploring the potential synergistic effects of combining these interventions for lung cancer patients undergoing chemotherapy. Integrating continuous symptom monitoring with a structured relaxation technique like PMR may provide a more holistic approach to managing both physical and emotional challenges. This study aims to fill this gap by evaluating the combined impact of RSM and PMR on key patient outcomes, including pain, sleep quality, anxiety, depression, and health-related quality of life (HRQoL). We hypothesize that lung cancer patients receiving the combined RSM + PMR intervention will experience greater improvements in symptom management and overall well-being compared to those receiving standard care alone. By investigating the efficacy of this integrated approach, our study seeks to contribute to the development of more effective, patient-centered strategies for enhancing the quality of life in lung cancer patients during chemotherapy.
The study was conducted in accordance with the Declaration of Helsinki and written informed consent was obtained from all participants prior to enrollment. The study was approved by the Ethics Committee of Tongde Hospital of Zhejiang Province.
ParticipantsLung cancer patients were recruited between January 2020 and January 2024. Eligible participants were adult inpatients aged 20 years or older, with histologically or cytologically confirmed lung cancer and a life expectancy of at least 3 months. Inclusion criteria required participants to be capable of using a smartphone, tablet, or computer for symptom reporting. Participants also had to be undergoing initial administration of first-line platinum-based chemotherapy, with at least four courses of cisplatin-based chemotherapy within a 21-day cycle. Exclusion criteria included significant cognitive impairments, uncontrolled hypertension, unstable coronary artery disease, severe osteoarthritis, and bone or central nervous system metastases. A total of 134 eligible participants were randomly assigned to two groups. To ensure allocation concealment, a computer-generated randomization sequence using block randomization with a block size of 4 was employed. A total of 134 sequentially numbered, sealed, opaque envelopes were prepared according to this scheme, with each block containing 2 assignments for the RSM + PMR group and 2 for the control group, ensuring equal group sizes. The control group received routine care, including health assessments, general advice, and nutritional counseling from healthcare providers. The RSM + PMR group received the combined intervention of RSM and PMR in addition to routine care. The flow of participants through enrollment, allocation, follow-up, and analysis is depicted in Fig. 1.
Participant flow diagram.
A: Chemotherapy regimen and assessment schedule. Cisplatin-based chemotherapy administered in a 21-day cycle. Study assessments were conducted at three key time points: baseline (T0, Day 1), end of the first chemotherapy cycle (T1, Day 21), and end of the second cycle (T2, Day 42). B: Participant recruitment and allocation flowchart.
The RSM + PMR intervention for lung cancer patients undergoing chemotherapy was designed to integrate patient engagement, symptom monitoring, and PMR exercises. Symptom monitoring was conducted weekly using the PRO-CTCAE system, focusing on 12 core symptoms, including fatigue, insomnia, pain, and anxiety (Wujcik et al. 2022; Offodile et al. 2023). During in-hospital chemotherapy sessions, nurses assisted patients in entering their symptoms into the RSM system to ensure real-time data collection and immediate intervention. Consent was obtained from patients and families to establish communication through WeChat for ongoing support and feedback. Between chemotherapy sessions (out-of-hospital), patients were encouraged to log their daily symptoms through WeChat or a phone-based feedback system. Physicians reviewed these reports and provided personalized advice based on the patient’s condition. For missed symptom reports, reminders were sent via phone, email, or WeChat. Mild to moderate symptoms were managed with written care guidelines and responses within the group chat, while severe symptoms triggered direct phone consultations with the care team.
PMR was introduced through a 20-minute demonstration conducted by the head nurse, instructing patients on techniques that involved the patient first tenses a muscle group for 5-7 seconds, then relaxes it for 20-30 seconds, repeating this for each muscle group (Table 1) (Nguyen et al. 2023). Patients performed a return demonstration, and corrections were made as necessary. They were instructed to practice PMR exercises daily in the morning, evening, or whenever they experienced fatigue or nausea (Koshy et al. 2024). To support PMR practice, follow-up calls were made every other day during the first week and weekly thereafter, each lasting 10 to 30 minutes. Control group participants received similar weekly video or phone calls to monitor their health and remind them of upcoming chemotherapy sessions, ensuring equal contact across both groups.
The tensing instructions of 16 muscle groups in sequence for the progressive muscle relaxation (PMR) intervention.
Study assessments were conducted at three key time points: baseline (T0, Day 1), end of the first chemotherapy cycle (T1, Day 21), and end of the second cycle (T2, Day 42). There were no dropouts, and all participants were included in the final analysis. Pain was measured using a visual analogue scale (VAS-pain) on a 100-mm line from “no pain” to “worst discomfort” (Murat-Ringot et al. 2020). Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), which provides a global score ranging from 0 to 21, with scores > 5 indicating “problem sleep” (Helles et al. 2024). Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale (HADS), consisting of 14 items with scores ranging from 0-21, where higher scores indicate more severe symptoms (Anjum et al. 2023). The 30-item EORTC QLQ-C30 (version 3) includes five functioning scales (physical, emotional, role, cognitive, social), three symptom scales (fatigue, nausea/vomiting, pain), six single-item symptoms (dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties), and a global health status/quality of life scale (Mansfield et al. 2020). Items are scored from 1 to 4 (or 1 to 7 for global health status) and transformed to a 0-100 scale. Higher scores indicate greater symptom burden, better function, or improved quality of life. At T2, patient satisfaction with the RSM intervention plus PMR or routine care was assessed using a 5-point scale (strongly disagree to strongly agree: 1-5) (Mody et al. 2021).
Statistical analysisThe statistical analysis was performed using GraphPad Prism version 8.0, with a significance threshold set at P < 0.05. Fisher’s exact test or Chi-square tests were used for categorical variables to compare group differences. The Shapiro-Wilk test was employed to assess the normality of continuous variables. For normally distributed data, results are presented as mean ± standard deviation (SD) and were compared using the unpaired t-test. Non-normally distributed data are presented as median (interquartile range, IQR) and were analyzed using the Mann-Whitney test. To evaluate the effects of the intervention over time, a two-way analysis of variance (ANOVA) followed by Sidak’s multiple comparisons test was conducted.
As demonstrated in Table 2, the baseline characteristics of the study population showed that the age was similar between the control group (69.19 ± 9.00 years) and the RSM + PMR group (69.10 ± 10.07 years) with nearly identical distribution of sex. ECOG performance status indicated that 44.8% of the control group had a status of 0 compared to 53.7% in the RSM + PMR group ( P = 0.388). Tumor histology revealed that squamous cell carcinoma was slightly more prevalent in the control group (68.7%) compared to the RSM + PMR group (62.7%). Disease stages were distributed similarly between the two groups, with stage IIIA being the most common. Most participants underwent lobectomy or sleeve lobectomy, with 76.1% in the control group and 80.6% in the RSM + PMR group. Mediastinal lymph node dissection was performed in 92.5% of the control group and 88.1% of the RSM + PMR group. Tobacco use history and chemotherapy treatment types were also comparable between the groups. There were no statistically significant differences in these baseline characteristics, indicating that the two groups were well-matched (allP > 0.05).
Comparison of baseline characteristics between control and RSM + PMR groups.
The baseline median scores for VAS and PSQI scores were similar between the control group and the RSM + PMR group, with no significant differences (all P > 0.05). By the end of the first chemotherapy cycle (T1, Day 21), the RSM + PMR group demonstrated a significantly greater reduction in pain compared to the control group (median VAS: 53.00 vs. 67.00, P < 0.001) and improved sleep quality (median PSQI: 8.00 vs. 11.00, P < 0.001). These differences were further accentuated at the end of the second cycle (T2, Day 42), where the intervention group’s median VAS and PSQI scores reached 44.00 and 6.00, respectively, compared to 62.00 and 9.00 in the control group (both P < 0.001, Fig. 2A,B). These results indicate that the RSM + PMR intervention was significantly more effective than standard care in reducing both pain and improving sleep quality during chemotherapy.
Effects of remote symptom monitoring (RSM) plus progressive muscle relaxation (PMR) intervention in lung cancer patients during chemotherapy.
A: Comparison of Visual Analogue Scale (VAS) for pain, B: Pittsburgh Sleep Quality Index (PSQI), C: Hospital Anxiety and Depression Scale-Anxiety (HADS-A), and D: Hospital Anxiety and Depression Scale-Depression (HADS-D) scores at baseline (T0), end of the first chemotherapy cycle (T1, Day 21), and end of the second cycle (T2, Day 42). *Indicates a statistically significant difference compared to the control group (P < 0.05).
Baseline HADS-A and HADS-D scores were comparable between groups (all P > 0.05). At T1, the RSM + PMR group exhibited significantly lower anxiety (median HADS-A: 7.0 vs. 9.0) and depression (median HADS-D: 7.0 vs. 8.0) scores compared to the control group (P < 0.001 for both). At T2, further improvements were observed, with the intervention group’s scores declining to 5.0 for both anxiety and depression, while the control group’s scores remained at 8.0 (both P < 0.001, Fig. 2C,D). These findings suggest that the RSM + PMR intervention was significantly more effective than standard care in reducing anxiety and depression during chemotherapy.
RSM plus PMR intervention significantly improved quality of life in lung cancer patients during chemotherapyTable 3 summarized the HRQoL outcomes measured by the EORTC QLQ-C30 scale. At T1, the RSM + PMR group experienced significant reductions in fatigue (P = 0.001), pain (P = 0.045), and nausea/vomiting (P = 0.037). Physical functioning (P = 0.008), role functioning (P = 0.034), and social functioning (P = 0.043) also showed significant improvements at T1. These positive trends continued through the second chemotherapy cycle, with further significant reductions in fatigue (P < 0.001), pain (P = 0.030), dyspnea (P = 0.003), and nausea/vomiting (P = 0.019) at T2. The RSM + PMR group also exhibited significant improvements in insomnia (P = 0.045), physical functioning (P < 0.001), role functioning (P = 0.004), social functioning (P = 0.043), emotional functioning (P < 0.001), and cognitive functioning (P = 0.006). Additionally, the global health status in the RSM + PMR group was significantly better than the control group at both T1 (P = 0.042) and T2 (P < 0.001). At T2, patient satisfaction with the RSM + PMR intervention was also higher than in the control group (P = 0.021, Fig. 3).
RSM plus PMR intervention significantly improved quality of life in lung cancer patients during chemotherapy.
Comparison of patient satisfaction between Control group and RSM + PMR Group.
Patient satisfaction levels were assessed using a 5-point scale (strongly disagree to strongly agree: 1-5) and compared between the control group and the RSM + PMR group at the end of the second chemotherapy cycle. The data are presented as median (interquartile range, IQR).
This study demonstrates that the combined intervention of RSM and PMR significantly improves symptom management and overall quality of life in lung cancer patients undergoing chemotherapy. Patients who received the RSM + PMR intervention experienced substantial reductions in pain, anxiety, and depression, along with notable improvements in sleep quality and HRQoL, compared to those who received standard care alone. These results highlight the potential of integrated, patient-centered care models in oncology, particularly in managing the complex challenges faced by cancer patients during chemotherapy.
The significant reduction in pain and improvement in sleep quality observed in the RSM + PMR group can be attributed to several factors. PMR induces a deep relaxation response that reduces muscle tension and stress-related symptoms, thereby alleviating pain and enhancing sleep quality. For instance, Turan et al. (2024) demonstrated that PMR effectively reduces dyspnea and pain severity in lung cancer patients. Additionally, Tian et al. (2020) found that PMR is particularly effective in preventing and alleviating chemotherapy-induced nausea and vomiting, symptoms that can exacerbate pain and disrupt sleep. Other studies, such as those by Koshy et al. (2024) and Sari et al. (2024), further support the role of PMR in mitigating various chemotherapy-related adverse effects and improving sleep quality.
The integration of RSM into this intervention likely amplified these benefits by enabling continuous, real-time monitoring of symptoms. This continuous monitoring facilitated early intervention and allowed for tailored care, which may have prevented symptom escalation. Manz et al. (2024) reported that higher symptom burden and reduced activity levels were strong predictors of hospitalization or death in advanced cancer patients. In addition, Lee et al. (2012) observed that both Monochord sounds and PMR reduced anxiety and enhanced relaxation, while Dikmen and Terzioglu (2019) reported that reflexology combined with PMR decreased pain and fatigue. These studies collectively highlight the importance of continuous monitoring and timely interventions in optimizing patient outcomes. Furthermore, the findings of Mody et al. (2021) supported the use of electronic patient-reported outcomes monitoring as an effective tool in managing severe symptoms and improving patient well-being.
An interesting finding in our study was the significant reduction in anxiety and depression in the RSM + PMR group. PMR, as part of broader stress management programs, has been shown to reduce psychological distress. For instance, Seliniotaki et al. (2021) found that an 8-week stress management program, including PMR, significantly improved emotional and cognitive functioning in women with breast cancer. The reduction in anxiety and depression in our study could be attributed to the calming effects of PMR, which helps mitigate the psychological distress associated with cancer and its treatment. Additionally, the RSM component likely provided patients with a sense of being closely monitored and supported, contributing to reduced anxiety and a greater sense of security during the stressful period of chemotherapy.
Moreover, improvements in HRQoL—particularly in physical, role, and social functioning—can be partly explained by the combined effects of PMR and RSM. The physical relaxation induced by PMR likely alleviated discomfort and fatigue, while regular RSM monitoring helped patients remain engaged with their care. This dual approach may have positively influenced patients’ roles and social interactions. These findings are consistent with Charalambous et al. (2016), who demonstrated that a combination of guided imagery and PMR significantly improved HRQoL in cancer patients by effectively managing a cluster of symptoms, including pain, fatigue, and depression. The study by Maguire et al. (2008) also supports our findings, as nurses involved in their trial perceived remote monitoring systems as valuable tools for managing chemotherapy-related toxicity, enabling early intervention and effective symptom management. Overall, the feedback loop established by RSM appears to enhance the effectiveness of the intervention by ensuring timely adjustments to the care plan.
However, several factors could influence the outcomes observed in this study. The psychological benefit of feeling continuously monitored may have contributed to the reduction in anxiety and overall well-being. Basch et al. (2007) noted high patient satisfaction with electronic symptom monitoring systems, even though engagement between visits was limited without reminders. Furthermore, the structured RSM approach combined with the active participation required for PMR may have increased patients’ sense of involvement in their own care. This enhanced involvement could partly explain the improvements in both emotional and physical health.
Despite the positive findings, there are several limitations to our study. First, outcomes were evaluated at three time points—baseline (T0), end of the first chemotherapy cycle (T1, Day 21), and end of the second cycle (T2, Day 42)—resulting in a total follow-up period of only 42 days. This relatively short duration may not adequately capture the long-term effects of the RSM + PMR intervention on chronic symptom management and overall quality of life, especially considering that many chemotherapy-related symptoms and adverse effects can persist or evolve beyond two cycles. Consequently, it remains uncertain whether the improvements observed in the short term would be sustained over an extended period. Additionally, the study was conducted at a single institution, which may limit the generalizability of our findings to other clinical settings or patient populations, as local practice patterns and patient demographics could influence the outcomes. Furthermore, although both groups received regular telephone or video follow-ups, the intervention group was given additional PMR training and personalized feedback. This extra attention may have inadvertently led participants to modify their behavior simply because they were being observed—a phenomenon known as the Hawthorne effect (Berkhout et al. 2022). Such an effect could artificially enhance the observed benefits, thereby confounding the true impact of the RSM + PMR intervention. Finally, the reliance on self-reported adherence to PMR exercises may introduce bias, as patients might overestimate their compliance due to recall or social desirability bias. To address these limitations, future research should incorporate longer follow-up periods to assess the durability of the intervention’s effects, utilize a multi-center design to improve the generalizability of the results, and implement objective adherence measures—such as digital logs or wearable monitoring devices—to more accurately capture patient compliance and reduce potential bias.
In conclusion, the combination of RSM and PMR offers a promising strategy for improving symptom management and quality of life in lung cancer patients undergoing chemotherapy. This integrated approach addresses both the physical and emotional challenges faced by patients, providing a comprehensive method for managing the adverse effects of chemotherapy. Our findings suggest that incorporating such interventions into routine oncology care could significantly enhance patient well-being and lead to better clinical outcomes.
Yong Jiang and Jing-Ping Yang conceived the study design. Qin Liu contributed to data collection and analysis. Jing-Ping Yang supervised the project. All authors contributed to manuscript writing, review, and approval of the final version.
The authors declare no conflict of interest.
