Determination of the Effects of Autogenic Relaxation Exercise and Cold Pillow Application on Vasomotor Symptom Control and Quality of Life in Postmenopausal Women
Condition: Vasomotor Symptoms; Quality of Life
Study type: Interventional

Summary: 
      The aim of this study was to determine the effect of autogenic relaxation exercise and cold
      pillows on vasomotor symptom control and quality of life. This randomized controlled study
      was carried out at Kirikkale University Faculty of Medicine Hospital, Department of
      Obstetrics and Gynecology, Gynecology Department between 22.06.2018 and 02.01.2019. The
      sample of the study consisted of 88 people, 44 in the intervention group and 44 in the
      control group. Since there were case losses in the research, the research was completed with
      a total of 69 people, 34 in the intervention group and 35 in the control group. The women in
      the intervention group performed autogenic relaxation exercises and cold pillow application
      for 8 weeks, and the women in the control group received outpatient care in the hospital.
      Research data were collected using Descriptive Characteristics Form, Menopause-Specific
      Quality of Life Scale, Vasomotor Symptom and Practice Follow-up Diary. Data collection tools
      were applied to the women during the first interview, and at the 4th and 8th weeks after the
      women were included in the study. In the analysis of descriptive data; number, percentage,
      mean and standard deviation were used. Independent groups t test was used to determine the
      difference between groups. The relationship between two independent categorical variables was
      analyzed using the chi-square test. Variables between dependent groups were compared in
      repeated measurements with anova test and mixed anova test
    

Detailed description: 
      Aims:The aim of this study was to determine the effect of autogenic relaxation exercise and
      cold pillows on vasomotor symptom control and quality of life.

      Hypothesis:H0-1: In the postmenopausal period, there was no difference in the frequency of
      vasomotor symptoms between the group that received autogenic relaxation exercise and cold
      pillows and the control group.

      H1-1: In the postmenopausal period, there is a time difference in vasomotor symptom frequency
      between the autogenic relaxation exercise and cold pillow group and the control group.

      H0-2: In the postmenopausal period, there was no difference in vasomotor symptom duration
      between the group that was applied autogenic relaxation exercise and cold pillow and the
      control group.

      H1-2: In the postmenopausal period, there is a time difference in vasomotor symptom duration
      between the autogenic relaxation exercise and cold pillow group and the control group.

      H0-3: In the postmenopausal period, there was no difference in vasomotor symptom severity
      between the groups that received autogenic relaxation exercise and cold pillows and the
      control group.

      H1-3: In the postmenopausal period, there is a time difference in vasomotor symptom severity
      between the autogenic relaxation exercise and cold pillow group and the control group.

      H0-4: In the postmenopausal period, there was no difference in quality of life between the
      group that was applied autogenic relaxation exercise and cold pillow and the control group.

      H1-4: In the postmenopausal period, there is a time difference in quality of life between the
      group that received autogenic relaxation exercise and cold pillows and the control group.

      Design: A parelel design randomised controlled study was conducted according to the CONSORT
      2010 guidelines.

      Methods: This study was conducted in Kirikkale University Faculty of Medicine Hospital,
      Department of Obstetrics and Gynecology, Kirikkale, Turkey between 22.6.2018-02.01.2019. The
      sample of the study consisted of women who were in the postmenopausal period, who met the
      inclusion criteria and who volunteered to participate in the study.

      Inclusion criteria in the study: Being in the first 5-year period of postmenopause,
      experiencing vasomotor symptoms at least twice a day, being at least literate, living within
      the borders of the center of Kırıkkale province, not having a disease that mimics vasomotor
      symptoms, not taking hormone therapy other than estrogen in the last 12 months, not using
      antidepressants and anxiolytics in the last 3 months, not using herbal alternative treatment
      within the last 4 weeks, women who do not use other alternative and complementary treatment
      methods, who have a body mass index below 35 and who do not use hormone replacement therapy.

      Sample: A power analysis was utilised to determine the sample size using the G*Power 3.1.7
      program. It was calculated that 61 people should be sampled at a significance level of 0.05
      for a minimum power of 90%. In order for the number of people in both groups to be equal, 31
      interventions were planned to be included in the sample group of 62 people in 31 control
      groups. In similar studies in the literature, loss of sample during follow-up and since it
      was seen that there was a sample loss during the preliminary application of our research, it
      was planned to increase the number of samples by 40% and research groups were formed with 44
      people in both groups. 142 women were evaluated in terms of suitability for the study, 45 of
      the women did not meet the inclusion criteria and 88 women could be included in the study
      because 9 of them did not agree to participate in the study. At different stages of the
      study, 10 women from the intervention group and 9 women from the control group withdrew from
      the study. The research was completed with 34 people in the intervention group and 35 people
      in the control group. After the research was completed, post-hoc power analysis was performed
      using the G*power package program and the power of the study was determined as 91% for a
      sample group consisting of 69 people with a significance level of 0.05 for 34 interventions,
      35 control groups and an impact width of 0.225. Intention To Treat (ITT) analysis was
      performed in the study because there were sample losses.

      Randomisation: Since the sample group was not clear before the study, it was recommended that
      a total of 4 papers, 2 of which were written as "intervention group" and "control group",
      were thrown into an envelope during the randomization process and that women should be
      assigned to the relevant group by selecting a paper from this envelope according to the order
      of participation in the study. The drawn paper was not thrown back into the envelope until
      the group of four was finished. After the papers in the envelope were finished, the process
      of assigning women to the relevant groups continued with the same method. After the women
      pulled the paper from the envelope, they were asked to give it to the researcher without
      opening the paper. After the women were invited to the study, they were taken to a separate
      outpatient clinic room and all procedures (randomly assigned to groups, training, teaching
      autogenic relaxation exercise, etc.) were performed in this room. The women were not told
      which group they belonged to during the study.

      Data collection and outcome measures:The research data were collected using the 'Identifying
      Features Form', 'Menopause Specific Quality of Life Scale' and 'Vasomotor Symptom and
      Application Follow-up Diary'.

      Introductory features form: In line with the literature were created by researchers with
      expert opinions. The form includes a total of 28 questions about sociodemographic
      characteristics, general health status, medical obstetric history and menopausal history.

      Menopause-specific quality of life scale: It was developed by Hilditch et al. (1996) to
      determine the quality of life of women related to menopause and its validity and reliability
      in Turkish were made by Kharbouch and Şahin (2005). In the Menopause Specific Quality of Life
      Scale, which consists of 29 items and 4 sub-dimensions, each sub-area score is ranked from 0
      to 6. A score of "0" indicates that there is no problem with that issue, a score of "1"
      indicates that the problem is experienced but not at all, and a score of 2-6 indicates the
      severity and increasing degrees of the existing problem. The total scale score is not
      calculated in the Menopause Specific Quality of Life Scale. Scoring is done according to
      scale sub-dimensions.

      Vasomotor symptom and application follow-up diary: It was created by the researchers to
      record vasomotor symptoms and relaxation exercise and cold pillow application applied in the
      research by taking expert opinions in line with the literature.

      Pilot test: In order to evaluate the intelligibility and usability of the data collection
      forms, the autogenic relaxation exercise and cold pillow application training booklet and the
      autogenic relaxation exercise CD to be used in the research, a pre-application was made on 3
      women from the intervention and control groups who met the inclusion criteria of the study.
      Women with pre-treatment were not included in the study sample.

      Intervention group: After the women to be included in the intervention group were determined,
      individual interviews were held with the women in the room where the orogenic relaxation
      exercise would be performed. A quiet and dim room has been prepared for relaxation exercise.
      In the first interview, the introductory characteristics form was filled and the Menopause
      Specific Quality of Life Scale was completed. In addition, women were given training in line
      with the training booklet about the menopause period, autogenic relaxation exercise and cold
      pillow. After the training, autogenic relaxation exercise was taught accompanied by the
      autogenic relaxation exercise CD. The woman was informed about performing autogenic
      relaxation exercises 3 times a day and using a cold pillow when she experienced vasomotor
      symptoms. The autogenic relaxation exercise and cold pad application follow-up chart, which
      was prepared for the purpose of recording the applications, was given. The women were
      evaluated by being invited to the hospital at 4 and 8 weeks, and they filled out the
      Menopause Specific Quality of Life Scale during the follow-ups. The intervention was
      implemented for 8 weeks.

      Control group:After the women to be included in the control group were determined, individual
      interviews were conducted with the women in a separate room for orogenic relaxation. In the
      first interview, the introductory characteristics form was filled and the Menopause Specific
      Quality of Life Scale was completed. The women were evaluated by being invited to the
      hospital at 4 and 8 weeks, and they filled out the Menopause Specific Quality of Life Scale
      during the follow-ups. The women were followed for 8 weeks. No other intervention was applied
      to the women other than the standard care they received at the hospital. The women were
      called every week and their vasomotor symptoms were questioned.

      Ethical Approval: Institutional and ethical committee permissions were obtained before
      starting the study (Approval number: 13/01). In addition, written consent was obtained from
      the scale owner of the scale to be used in the study and the participants who will
      participate in the study. After the implementation of the study, the women in the control
      group were given autogenic relaxation exercise and cold pillow application training and
      training materials.

      Statistical Analysis:Blinding was done during the evaluation of the data. Intervention and
      control groups were coded as 1 and 2. The analysis of the data coded in terms of groups was
      made by the statistician. After the statistical analysis, the coding for the intervention and
      control groups was explained. Statistical bias was checked with this blanking technique.

      The research data were transferred to the IBM Statistical Package for Social Sciences (SPSS)
      26 program and analyzed. In the study, frequency distributions were used in the evaluation of
      categorical variables, and descriptive statistics (X̄±SD) were used for numerical variables.
      The scale sub-dimension scores of the Menopause Specific Quality of Life Scale, which was
      used as a measurement tool in the research, were obtained by taking the sum of the related
      items. The mixed-pattern anova test was used to test changes or differences in repeated
      measures of within-group (in-group effect), between-group (time) effect, and co-effect
      (group*time effect) repeated measures in intervention and control groups. The margin of error
      for statistical analysis results was accepted as 5%. In the evaluation of the effect size,
      the partial η2 value was used (small effect size=0.01, medium effect size=0.06 and large
      effect size=0.14). The negative (-) value in front of the effect sizes indicates that the
      initiatives have a negative effect; a positive (+) value indicates that interventions have a
      positive effect (230).

      Intention To Treat (ITT) analysis was performed because there were sample losses in the
      study. The results of the analyzes (ITT) and Per Protocol (PP) were similar.
    

Intervention name(s): cold pad pillow; autogenic training
Intervention type(s): Device; Behavioral
Intervention description(s): cold pad pillow application when women have vasomotor symptoms for 8 weeks; Autogenic relaxation for three times a day for eight weeks
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A randomised controlled trial
Masking: Single (Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: vasomotor symptoms, quality of life