Progressive Muscle Relaxation and Guided Imagery

Progressive Muscle Relaxation and Guided Imagery

PEP Topic 
Chemotherapy-Induced Nausea and Vomiting—Adult
Description 

Progressive muscle relaxation (PMR) is a technique of alternately tensing and relaxing muscle groups in sequence throughout the body. When going through muscle groups, individuals can start with the head and neck and progress to the feet, or vice versa. Similarly, individuals may do one side of the body at a time or both sides at the same time. Listening to a prerecorded script may be used to guide individuals through the process. The addition of guided imagery to PMR involves the use of mental visualization and imagination to enhance relaxation and alter specific experiences. It may include direct suggestion. Individuals may use recorded scripts to guide the creation of mental images. Guided imagery can integrate techniques founded in multiple psychological theories and hypnotherapy. PMR with guided imagery has been examined for effectiveness in patients with cancer for chemotherapy-induced nausea and vomiting, anxiety, fatigue, sleep-wake disturbances, and pain.

Likely to Be Effective

Research Evidence Summaries

Arakawa, S. (1997). Relaxation to reduce nausea, vomiting, and anxiety induced by chemotherapy in Japanese patients. Cancer Nursing, 20, 342-349.

doi: 10.1097/00002820-199710000-00005
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Study Purpose:

To evaluate the use of progressive muscle relaxation training in the management of nausea, vomiting, and anxiety induced by chemotherapy

Intervention Characteristics/Basic Study Process:

The experimental group received training that consisted of tensing and releasing 16 muscle groups and breathing deeply for a total of 25 minutes. Each subject was provided with an audiotape and instructed to practice independently twice daily before meals or two hours afterward. The investigator met with the control group for 15 minutes per day to discuss concerns.

Sample Characteristics:

  • The study consisted of 60 Japanese patients with cancer (30 subjects in the experimental group and 30 subjects in the control group) who were actively receiving chemotherapy.
  • Patients' ages ranged from 21–75 years.
  • Patients did not practice progressive muscle relaxation in their daily lives.

Setting:

This study was conducted at a 415-bed, hospital-based cancer center in Japan.

Study Design:

The study was a randomized pretest, post-test control group design with repeated measures.

Measurement Instruments/Methods:

The Rhodes Index of Nausea and Vomiting-Form 2 (Japanese version) and the Spielberger State-Trait Anxiety Inventory were used. Reliability and validity were described in depth.

Results:

  • Progressive muscle relaxation decreased the total index of nausea and vomiting scores of the experimental group.
  • Index of nausea and vomiting scores for the control group increased to their highest levels 60–72 hours after chemotherapy.

Conclusions:

Progressive muscle relaxation may contribute to a reduction in delayed nausea and vomiting. This study did confirm the usefulness of progressive muscle relaxation in decreasing the incidence of vomiting. Progressive muscle relaxation decreased subjective feelings of anxiety.

Limitations:

  • The number, type, and dosage of chemotherapy and antiemetics were not controlled.
  • Vomiting scores were very low for the experimental and control groups.
  • Only one investigator conducted the study, which introduces potential investigator bias.
  • The study involved only one population (Japanese patients).

Molassiotis, A., Yung, H.P, Yam, B.M.C., Chan, F.Y.S., & Mok, T.S.K. (2002). The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: A randomised controlled trial. Supportive Care in Cancer, 10, 237–246.

doi: 10.1007/s00520-001-0329-9
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Study Purpose:

To assess the effectiveness of progressive muscle relaxation (PMR) and guided imagery training as an adjuvant intervention and accompanying antiemetics (metoclopramide, dexamethasone) in managing acute and delayed nausea and vomiting, anxiety, and depression

Intervention Characteristics/Basic Study Process:

In the experimental group, PMR was initiated for 25 minutes and guided imagery for 5 minutes, each one hour before chemotherapy was administered.

Sample Characteristics:

The study reported on 71 Chinese chemotherapy-naive women with breast cancer who were older than 30 years and were receiving doxorubicin and cyclophosphamide.

Setting:

The study was conducted at a university hospital outpatient treatment center in Hong Kong.

Study Design:

This was a randomized, controlled clinical trial.

Measurement Instruments/Methods:

The Profile of Mood States, State-Trait Anxiety Index, and Morrow Assessment of Nausea and Vomiting were translated into Chinese and back-translated. Measures were piloted on 25 patients prior to use in the study. Demographic data and vital signs measures were used.

Results:

The effects of PMR therapy and guided imagery were more pronounced at the initial stage of treatment when patients did not know what to expect. The effects were reduced on the fourth day and beyond. The study did not show a significant reduction in the intensity of nausea and vomiting after chemotherapy; the baseline nausea and vomiting values showed that the patients in this study began with considerably lower levels of nausea and vomiting than in previous studies. The combination of PMR and guided imagery was beneficial for cognitive distraction and relaxation, components that reduce stress and anxiety. The physiologic benefit to these techniques was discussed. Differences in Chinese and Western cultures related to expression of emotions was noted.

Conclusions:

PMR therapy with guided imagery was found to be superior to standard antiemetic treatment alone in managing acute and delayed chemotherapy-induced nausea and vomiting.

Limitations:

  • Pharmacologic agents prescribed were metoclopramide and dexamethasone for doxorubicin and cyclophosphamide treatment; 5-HT3 was not given despite publication in 2002.
  • Only one population (Chinese) was included.

Systematic Review/Meta-Analysis

Luebbert, K., Dahme, B., & Hasenbring, M. (2001). The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: A meta-analytical review. Psycho-Oncology, 10, 490-502.

doi: 10.1002/pon.537
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Search Strategy:

Databases searched were MEDLINE, PsycINFO, PSYNDEX, and CANCERLIT (1980-Dec., 1995).

Search keywords were relaxation techniques, progressive muscle relaxation (PMR), autogenic training, hypnosis, imagination, and guided imagery in combination with neoplasms, cancer treatment, chemotherapy, radiotherapy, drug therapy, and bone marrow transplantation.

Literature Evaluated:

A total of 280 abstracts were found, 58 studies were relevant, and 15 met the inclusion criteria for meta-analysis. Moderator variables included intensity, schedule, and focus of intervention.

Sample Characteristics:

A total of 742 primarily female subjects with variable malignancies receiving highly emetogenic chemotherapy and trained in progressive muscle relaxation (PMR) were part of this review.

Results:

Consistent positive results in meta-analysis studies showed clinically significant reductions in nausea and other symptoms. Relaxation during the courses of treatment made the experience less stressful, reducing side effects. Studies supported the implementation of relaxation training into clinical routines as standard adjunctive treatment.

Miller, M., & Kearney, N. (2004). Chemotherapy-related nausea and vomiting—Past reflections, present practice and future management. European Journal of Cancer Care, 13(1), 71-81.

doi: 10.1111/j.1365-2354.2004.00446.x
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Search Strategy:

  • Databases searched were MEDLINE and CINAHL (1990-2002).
  • Search keywords were nausea, vomiting, chemotherapy and neoplasm, assessment, management, complementary therapies, pharmacological, and nonpharmacological.
  • Studies were included in the review if they included primary research, literature reviews, opinion articles, and information leaflets/booklets.
  • Studies were excluded if they involved anticipatory nausea and vomiting associated with chemotherapy, because the authors felt that symptoms with a psychological basis should be addressed in a separate paper.

Literature Evaluated:

  • Nonpharmacologic management interventions were reviewed with the intention that they do not replace standard antiemetic therapies but, rather, are adjuncts to improve quality of life (QOL).
  • Intervention articles were reviewed for progressive muscle relaxation, guided imagery, self-hypnosis, acupressure/acupuncture, transcutaneous electrical nerve stimulation, biofeedback, cognitive distraction, and music therapy.

Conclusions:

Support for the use of nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV) was weak.

Limitations:

Many studies were flawed because of small sample sizes and confounding variables (e.g., stage of disease, various chemotherapy regimens, culture, patient compliance).

Nursing Implications:

Preliminary available evidence suggests positive benefits through nonpharmacologic techniques; however, larger randomized trials are needed to demonstrate the exact benefits, including economic.

Redd, W.H., Montgomery, G.H., & DuHamel, K.N. (2001). Behavioral intervention for cancer treatment side effects. Journal of the National Cancer Institute, 93, 810-823.

doi: 10.1093/jnci/93.11.810
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Search Strategy:

  • Databases searched were National Library of Medicine PubMed database, which includes MEDLINE, PreMedline, and other related databases (1979-January, 2000).
  • Search keywords were cancer and behavior, intervention, nausea, vomit, depression, anxiety, fatigue, neuro, cognitive, menopause, sex, and post-traumatic stress disorder.
  • Studies were included if they were randomized controlled studies, within-subject studies, or case reports.

Literature Evaluated:

  • The review consisted of 54 studies that met the criteria.
  • Three symptom clusters were evaluated. The review included published reports for nausea and vomiting, anxiety/stress, and pain.
  • For the nausea and vomiting review, studies must have addressed
    • Cancer-related treatment side effect with behavioral intervention
    • Cancer-treatment intervention effects.

Results:

  • The following treatments were evaluated: relaxation, hypnosis, cognitive/attentional distraction, desensitization, and rehearsal modeling.
  • Four studies for relaxation and hypnosis showed effectiveness of behavioral intervention for control of anticipatory nausea and vomiting (no anticipatory vomiting occurred).
  • Results from the individual analyses were confirmed in 12 of 13 randomized-controlled trials that compared behavioral interventions with no treatment/attention control conditions.
  • The impact of behavioral intervention on postchemotherapy side effects was less established, with four studies reporting that the behavioral intervention reduced the intensity of the postchemotherapy side effects but did not prevent their occurrence.

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