The effect of progressive muscle relaxation (PMR) therapy on the anxiety levels of type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital

Introduction: Diabetes mellitus (DM) is one of the most common chronic metabolic diseases. Diabetic patients suffer from anxiety almost twice as much as the general population. Progressive Muscle Relaxation (PMR) is a systematic technique that can be used to achieve a state of deep relaxation. To determine the effect of PMR therapy on the anxiety levels of type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital. Methods & Materials: A quasi-experimental group design study was conducted at the Internal Medicine Outpatient Clinic at Universitas Sebelas Maret Hospital in April 2022–May 2022. This study used a purposive sampling technique with a total sample of 19 subjects in the intervention group and 19 subjects in the control group. The instrument used to assess anxiety is the Hamilton Anxiety Rating Scale (HARS). The intervention uses PMR videos, which were carried out at least twice per week for a month. Results: The parametric test showed a significant effect of PMR therapy on the anxiety levels of type 2 diabetes mellitus patients (Z = -3.675; p value (Asymp. sig. 2-tailed) = 0.001). Conclusion: There was an effect of PMR on anxiety, and the intervention


INTRODUCTION
Diabetes mellitus (DM) is one of the chronic metabolic diseases characterized by increased blood glucose levels (hyperglycaemia) due to impaired insulin secretion, impaired insulin work, or both. 1 In 2018, there were already 500 million people living with type 2 diabetes mellitus (Delahanty, L., 2007).WHO predicts an increase in the number of people with DM in Indonesia from 8.4 million in 2000 to around 21.3 million in 2030 (Perkeni, P. E. 2015).
People with diabetes have an increased risk of developing a number of serious health problems.One of the risks for diabetic patients is suffering from anxiety and depression, which is almost twice that of the general population (Khaledi, M., 2019).The prevalence of anxiety disorders in diabetic patients is approximately 60% higher than that of the general population. 2 Diabetic patients with anxiety disorders usually lack physical activity and show less desire to take prescribed medications (Izgu, N., Gok Metin, Z., 2020).
Progressive Muscle Relaxation (PMR) is one of the systematic techniques that can be used to achieve a state of deep relaxation.Research aimed at determining the impact of PMR techniques on women who experience anxiety disorders has been conducted before.The results revealed that anxiety statistically decreased significantly among the study group after the intervention (Essa, R. M., 2017).
The Internal Medicine Outpatient Clinic at Universitas Sebelas Maret Hospital is a place for patients to conduct monthly examinations for chronic diseases.The number of patients coming to the clinic every month is close to 10 thousand, with the largest number being from diabetes mellitus patients.PERSADIA (Indonesian Diabetes Association) Surakarta Branch Unit of Universitas Sebelas Maret Hospital reported that the treatment given at Universitas Sebelas Maret Hospital for type 2 diabetes mellitus patients is in the form of pharmacological treatment and regularly given counselling by young doctors with internists' supervision (Prabowo, N. A, et al. 2021).
Seeing the high prevalence of type 2 diabetes mellitus and the impact on psychiatric disorders, the author aimed to know whether there was an effect of nonpsychopharmacological management in the form of PMR therapy on type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital.

METHODS & MATERIALS
A quantitative study with a quasi-experimental group design was conducted at the Internal Medicine Outpatient Clinic of Universitas Sebelas Maret Hospital in April 2022-May 2022.The collection research subjects and research process were carried out by a team that had received previous training.Samples were obtained by purposive sampling.The subjects in this study were 38, divided into 2 groups, namely the intervention group (19) and the control group (19).Subjects were requested to fill out informed consent sheet, personal data sheet, and Hamilton Anxiety Rating Scale (HARS) questionnaire.
Progressive Muscle Relaxation video recordings were given specifically for the intervention group.Subjects in the intervention group performed video-guided PMR at least twice per week for a month.Both groups were assessed for HARS scores at the start of the study and a month later.Descriptive analyses were carried out using the Spearman correlation test and the Wilcoxon test.Statistical analyses were conducted using SPSS 28.0.This study had been declared to have passed the research ethics review from the Health Research Ethics Commission of Dr. Moewardi Hospital with number 427/III/HREC/2022.

RESULT
A total of 38 subjects met the criteria.All research subjects were divided into two groups randomly; the intervention group and the control group.The intervention group (19 subjects) was a group of type 2 diabetes mellitus patients who received standard therapy and PMR, while the control group (19 subjects) only received standard therapy.Subjects in the intervention group were given video recordings of PMR, which must be performed at least twice a week and will be followed up for the next 4 weeks.Both groups were given Hamilton Anxiety Rating Scale (HARS) questionnaires that were filled out at the beginning and end of the study.The data was processed descriptively to see the characteristics of the subjects.

DISCUSSION
The results of the demographic data of type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital showed that the average age of patients was 50.26±8.177in the intervention group and 51.95±6,196 in the control group.This is in accordance with Mildawati's research (2019), which states that the majority of those suffering from diabetes mellitus are over 40 years old.This is because as a person gets older, it will cause physiological changes that can reduce a person's body functions (Mildawati, 2019).
Based on the number of subjects in both groups, it was found that more women suffered from diabetes mellitus compared to men.The reason is based on the theory that women have the tendency to experience a greater increase in Body Mass Index (BMI) compared to men and are also influenced by the monthly cycle and post-menopause syndrome, which make fat easier to accumulate due to hormones.This is also caused by parity and pregnancy, which are two of the risk factors of diabetes mellitus (Rita, 2018).
The study subjects were mostly high school educated, and a total of 32 patients were private employees or unemployed.The higher the education, the greater the patients' concern for health.But it is undeniable that there are still many highly educated people who ignore health for various reasons, one of which is related to work where there is a high level of busyness causing irregular lifestyles or irregular eating patterns that can cause health problems.Usually, people with busy activities often forget to eat but eat more snacks.Changes in diet and lifestyle will cause fat accumulation, which is a risk factor for diabetes mellitus (Gibney. M. 2019).
Obesity is also one of the risk factors for diabetes mellitus, where, according to literature, high free fat deposits can cause increased cell uptake of free fatty acids and spur fat oxidation, which will ultimately inhibit the use of glucose in muscles. 11As in this study, the subject's BMI was 24.73±2.89 in the intervention group and 25.54±3.62which in the obesity group I.
As many as 23 subjects who experienced anxiety were suffering from type 2 diabetes mellitus for 1-3 years.Pauley (2021) suggests that the duration of a person's illness has an impact on the person's ability to understand his condition and control the situation.One study says that there is a correlation with a negative direction in the relationship between the emergence of psychological disorders and the duration of suffering from DM, which means that the longer you suffer from the illness, the more psychological disorders you will develop (Pauley, D., 2021).
The mean of Hamilton Anxiety Rating Scale (HARS) score of the intervention group before undergoing PMR was 19.84±4.095,and the mean after getting the intervention was 14.84±5.003,with a p-value of 0.001.This showed a significant difference in average anxiety scores between before and after the intervention.The difference between the pre-test and post-test scores of the intervention group and the control group also showed a significant difference, with a p-value of <0.001.The results of this study are in line with the results of research by Pauley et al. (2021), which showed that PMR therapy was effective in reducing www.jurnal.us.ack.id/jksanxiety symptoms in a randomized controlled trial study on 60 clinical study subjects.Another study conducted by Devi et al. (2016) also showed similar results, showing that PMR can reduce anxiety levels in type 2 diabetes mellitus patients (Pauley, D., 2021), (Devi, K. S., 2016).
Muscle tension correlates with physiological activation of the autonomic nervous system through an increased sympathetic and decreased parasympathetic tone or hormonal signs of activation of the HPA axis.A reduction in muscle tension tends to improve emotional regulation (Conrad, A., 2007), (Molavi, P., 2018).
This PMR technique uses the principles of "top-down" and "bottom-up" neuronal processing to achieve relaxation.In "top-down" processing, participants use areas higher up in the nervous system, such as the cerebral cortex and cerebellum, to contract muscles and gradually release tension.In "bottom-up" processing, restraining and releasing bodily tension results in proprioceptive stimulation of peripheral muscles that ascend to the brain through the spinal cord and brainstem (Toussaint, L.,2021).
A study conducted by Dolbier and Rush (2012) examined the effect of acute PMR on cortisol levels assessed before and after PMR sessions.The results of this study showed the effectiveness of PMR in lowering cortisol levels.Cortisol levels have been linked to anxiety disorders in children and adolescents, both cross-sectionally and longitudinally (Dolbier, C. L., 2012), (Adam, E. K.,2014).
Cortisol serves to facilitate the adaptation of the organism to environmental challenges, and cortisol secretion increases in times of stress (Heaney, J. 2020).Prolonged stress leads to relentless hypersecretion of corticotrophin-releasing hormone (CRH); it causes prolonged secretion of cortisol in response to repeated stressors, which can increase or decrease the regulation of the HPA axis (Herman, J. P., 2016).
In the control group, the average Hamilton Anxiety Rating Scale (HARS) score before the study was 16.89±2.942and the average after the study was 16.37±3.022,with a p-value of 0.001.Although significant changes were obtained, when the data was processed using Wilcoxon's analysis, the Z value was -3.675 in the intervention group and -2.5 in the control group, with a p-value (Asymp.Sig.2-tailed) of 0.001, which means that Ho's hypothesis is accepted.
Although both have a p<0.01 value, pre-and post-HARS scores can be distinguished between the intervention group and the control group.In the intervention group, there was a decrease in 17 subjects with an average of 10.94 points and an increase in 2 subjects with an average of 2 points.Meanwhile, in the control group, the HARS score in 11 subjects decreased by an average of 7.09 points, increased in 2 subjects by an average of 6.50 points, with 2 subjects obtaining the same score on the pre-and post-test.

CONCLUSION
This study showed that there was an effect of Progressive Muscle Relaxation on anxiety, and the intervention group experienced more reduction in anxiety levels than the control group in type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital.Progressive Muscle Relaxation therapy can be used as additional therapy to reduce anxiety levels in type 2 diabetes mellitus patients at Universitas Sebelas Maret Hospital.This study has several limitations, including: no follow-up was conducted after the study, so the long-term effects of PMR exercises on anxiety in type 2 diabetes mellitus patients are not known; and it did not pay attention to differences in physical activity, area of residence, dietary patterns, psychosocial factors, and neuropathy complaints in type 2 diabetes mellitus patients.

Table 1 .
Characteristics of the Research Subjects

Table 2 .
The Relationship of PMR Therapy to the Anxiety Levels of Type 2 Diabetes Mellitus Patients

Table 3 .
Differences in Anxiety Levels Between Intervention and Control Groups