Progressive Muscle Relaxation (PMR)

Progressive Muscle Relaxation (PMR)

PEP Topic 
Anxiety
Description 

Progressive muscle relaxation (PMR) is a technique of alternately tensing and relaxing muscles 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 pre-recorded script may be used to guide individuals through the process. PMR has been examined for its effectiveness in patients with cancer for managing anxiety, depression, dyspnea, sleep-wake disturbances, fatigue, and chemotherapy-induced nausea and vomiting. PMR is often combined with the technique of guided imagery.

Likely to Be Effective

Guideline/Expert Opinion

Andersen, B.L., DeRubeis, R.J., Berman, B.S., Gruman, J., Champion, V.L., Massie, M.J., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: An American Society of Clinical Oncology guideline adaptation. Journal of Clinical Oncology, 32, 1605–1619. 

PROFESSIONAL GROUP: American Society of Clinical Oncology

doi: 10.1200/JCO.2013.52.4611
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Purpose & Patient Population:

PURPOSE: To screen, assess, and care for anxiety and depression symptoms at various points across the trajectory of care 
 
TYPES OF PATIENTS ADDRESSED: All adult patients with cancer 

Type of Resource/Evidence-Based Process:

RESOURCE TYPE: Evidence-based guideline  
 
PROCESS OF DEVELOPMENT: Used the ADAPTE methodology using existing guidelines from another organization; included two parts, a methodologic review and a content review; used the Rigour of Development Domain of the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument
 
DATABASES USED: MEDLINE, EMBASE, CINAHL, and Cochrane library (recent to December 2009); clinical practice guideline databases; guideline developer websites; published literature  
 
KEYWORDS: Not mentioned specifically, but included state documents that addressed screening, assessment, or treatment of psychosocial distress in adults with cancer
 
INCLUSION CRITERIA: Clinical practice guidelines, systematic reviews, and other guidance documents
 
EXCLUSION CRITERIA: Not mentioned

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Pediatrics, elder care, palliative care 

Results Provided in the Reference:

The guideline provides an algorithm for the screening and assessment of anxiety, a care map for anxiety in adults with cancer, an algorithm for the screening and assessment of depression, a care map for depression in adults with cancer, the Patient Health Questionnaire (PHQ 9) symptom depression scale and generalized anxiety disorder (GAD) items, and selected measures for depression and anxiety (modified).

Guidelines & Recommendations:

  • Before the implementation of guidelines, referral systems and resources should be identified and available in each institution.
  • The guidelines are designed for healthcare providers, patients, family members, and caregivers to guide in the screening, assessment, and treatment approaches of adult patients with cancer who have anxiety and depression at any stage of the cancer continuum, regardless of cancer type, disease stage, or treatment modality. 
  • All patients with cancer and cancer survivors should be evaluated for the symptoms of anxiety and depression with validated instruments at periodic times during the cancer care. Treatment recommendations are based on the levels of symptoms. Follow-up care and reassessment are important in this setting to monitor for follow-through, compliance with referrals, and pharmacologic management. If compliance is poor, develop a plan. After eight weeks of treatment, if symptoms are not improved or poor compliance is noted, alter the treatment course and add a psychological or pharmacologic intervention. The guidelines recommend that individual psychological interventions be delivered by a licensed mental health professional, which may include cognitive and behavioral strategies, education and relaxation strategies, group psychosocial interventions, and physician-prescribed antidepressants. 

Limitations:

  • A guideline that has been adapted from another country often can't lend itself to different policies or cultural influences.
  • Some of the recommendations were removed from the original guideline because of references to the Edmonton Symptom Assessment Scale screening measure, which is not widely used in the United States.

Nursing Implications:

Nurses play a vital role in the early screening, assessment, and treatment of patients who may have significant symptoms of anxiety and depression. By screening and making appropriate referrals, we can impact the emotional, interpersonal, and financial costs for patients and reduce the economic impact for providers and the healthcare system.

Research Evidence Summaries

Chan, C.W., Richardson, A., & Richardson, J. (2011). Managing symptoms in patients with advanced lung cancer during radiotherapy: Results of a psychoeducational randomized controlled trial. Journal of Pain and Symptom Management, 41, 347–357.

doi: 10.1016/j.jpainsymman.2010.04.024
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Study Purpose:

The objective of the study is to examine the effectiveness of a psychoeducational intervention (PEI) that combines patient education with progressive muscle relaxation (PMR) in the relief of a symptom cluster of anxiety, breathlessness, and fatigue in patients with advanced lung cancer receiving palliative radiotherapy (RT).

Intervention Characteristics/Basic Study Process:

A total of 140 participants were randomized by lucky draw method to either an intervention group or a control group. Participants in the intervention group received a 40-minute educational package consisting of leaflets and discussion on the symptom cluster (breathlessness, anxiety, and fatigue) and self-care management. Coaching of PMR was delivered within one week prior to the beginning of the course of RT and reinforced three weeks after RT commencement. The intervention was delivered by RNs with two years of clinical experience who went through a two-day training session on the materials in the educational package and the practice of PMR. An audiotape in Chinese and educational leaflets were also given, and patients were encouraged to practice PMR daily and as required. Patients in the intervention group were given a telephone reminder at the end of the second week to enhance participation in the week three sessions. Those in the control group only received “usual care,” which was offered to patients in both the intervention and control groups and consisted of a mandatory individual briefing of RT procedures and a five- to seven-minute discussion of side effects focusing on skin care by a therapy radiographer. An optional group talk by an RN and a medical social worker about general care before and/or after the start of RT was also offered. Data were collected by a research assistant (RA) who was blinded to group allocation. Data collection on symptoms was obtained at four time points: prior to intervention (T0), week 3 (T1), week 6 (T2), and week 12 (T3). Patients were also asked to record adherence to the relaxation exercise in a simple health diary (calendar) for 12 consecutive weeks.

Sample Characteristics:

  • The study reported on 140 patients.
  • Patient age was not indicated.
  • The sample was 83% male and 17% female.
  • Patients had stage 3 or 4 lung cancer and were scheduled to receive palliative RT of an average of 4.3 Gy/fraction. Less than half of the patients (46%) had distant metastasis. Chest and mediastinum were the major sites of RT.
  • Patients were eligible for inclusion if they were age 16 or older; had stage 3 or 4 lung cancer and were scheduled to receive palliative RT of an average of 4.3 Gy/fraction; were able to communicate in Chinese; signed informed consent; completed an Abbreviated Mental Test with a score of 8 or above, indicating normal cognitive ability; and had a Karnofsky Performance Status score of 60% or more, indicating self-care capacity.
  • Patients with known psychiatric morbidity and/or involvement in other clinical trials were excluded from the study.
  • The majority of patients (75%–80%) had no history of practicing relaxation exercise or use of other forms of complementary therapies/support services.

Setting:

The study was conducted in a single-site, outpatient setting (RT unit) in Hong Kong, China.

Phase of Care and Clinical Applications:

  • Patients were undergoing the end-of-life phase of care.
  • The study has clinical applicability for end-of-life and palliative care.

Study Design:

A randomized, controlled trial design was used.

Measurement Instruments/Methods:

  • 100 mm visual analog scale (VAS) to measure subjective experience/intensity of breathlessness
  • Piper Fatigue Scale (Chinese translation), revised intensity subscale, to measure intensity of fatigue
  • State-Trait Anxiety Inventory, A-state scale, to measure intensity of anxiety
  • SF-36 Health Survey, functional ability subscale, to measure level of functional ability
  • An intervention activity log was recorded at each assessment session (baseline, week 3, week 6, week 12) by a research assistant to assess patients’ general involvement and problems encountered during implementation of the intervention.
  • A patient-recorded “health diary” was used to report adherence to relaxation exercise for 12 consecutive weeks.
  • Previous experience with psychoeducational interventions was assessed as yes/no.

Results:

At baseline, all patients had a low intensity for breathlessness (mean: 15.81; range: 0–100), but low-to-moderate fatigue (mean: 3.41; range: 0–100) and anxiety (mean: 42.04; range: 20–80) intensity scores, and an overall low-to-moderate functional score (mean: 25.14–66.41; range: 0–100). Patients in the control group, however, were noted to have significantly more advanced-stage lung cancer (p < 0.05) than the intervention group. In the intervention group, 94% of participants completed the intervention in full (based on the intervention log), the majority of whom demonstrated high attention and interest. Participants practiced about four to five sessions of PMR per week, and more than 60% both read the leaflets and listened to the audiotape. At all four time periods (T0–T4), significant and moderate positive intercorrelations among breathlessness, fatigue, and anxiety were observed (p < 0.01), thus suggesting a prominent relational effect of the three symptoms when considered as a cluster. Over time (T0–T2), a significant difference in the pattern of change in “composite” outcome (i.e., breathlessness, anxiety, and fatigue considered as a cluster) between the two study groups was observed (p = 0.003). When considered individually, univariate tests also confirmed a significant difference in pattern of symptom changes over time (T0–T2) for breathlessness (p = 0.002), fatigue (p = 0.011), and anxiety (p = 0.001), as well as functional ability (p = 0.000). Due to high attrition rates from death after T3, long-term effect of PEI at week 12 (T4) was not found to have significant difference in the pattern of change in fatigue (p = 0.034).

Conclusions:

PEI is effective in the simultaneous relief of breathlessness, fatigue, and anxiety as a symptom cluster. The authors suggest that the total difference in symptom intensity between the intervention and control groups would have otherwise gone unrecognized if each were to be examined separately.

Limitations:

One limitation of the study was the higher attrition rate (due to patient mortality) experienced by the control group (42%) than the intervention group (11%) at T3 and overall attrition (27%) at the end of the 12 weeks. More patients in the control group had more advanced-stage cancer and distant metastasis than in the intervention group, thus indicating a failed randomization process. Also, due to high attrition, the authors advise that findings should be viewed with caution because of missing data. Additionally, information is lacking regarding participants’ perceptions and feelings toward the intervention process and outcomes. Other limitations related to possible confounding population characteristics that could influence symptom management include prior lung cancer treatments (especially if known pulmonary toxins), preexisting interstitial lung disease, tumor locations, and patient ages.

Nursing Implications:

PEI with primarily PMR seems promising as a resource for the relief of low-intensity breathlessness in light of low-to-moderate intensity anxiety and fatigue up to at least six weeks after palliative RT. Long-term effect of PEI on this symptom cluster at 12 weeks is inconclusive. Similarly, more studies are warranted to establish if PEI is effective for higher baseline intensity of breathlessness and/or anxiety and fatigue. Cost-effectiveness of PEI (i.e., cost of material and training of personnel to deliver the intervention) should be weighed against the cost of poor symptom management (i.e., frequency of hospitalization, length of stay, and pharmacologic treatments).

Cheung, Y.L., Molassiotis, A., & Chang, A.M. (2003). The effect of progressive muscle relaxation training on anxiety and quality of life after stoma surgery in colorectal cancer patients. Psycho-Oncology, 12, 254–266.

doi: 10.1002/pon.638
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Study Purpose:

To examine progressive muscle relaxation training (PMRT) in reducing anxiety and improving quality of life in patients with colorectal cancer after stoma surgery

Intervention Characteristics/Basic Study Process:

PMRT was provided for 20 minutes along with deep breathing (10 major muscle groups were used, but not valsalva response). Participants received two teaching sessions and practiced at home for 10 weeks. Measurements were taken during hospitalization and 5 and 10 weeks after surgery and intervention.

Sample Characteristics:

The study reported on a sample of 59 participants.

Setting:

The sample was recruited from the department of surgery of two public hospitals in Hong Kong.

Study Design:

A longitudinal randomized controlled trial design was used.

Measurement Instruments/Methods:

  • State-Trait Anxiety Inventory (Chinese version)
  • Quality of Life Index for Colostomy Patients (Chinese translation)
  • World Health Organization Quality of Life measure–abbreviated (Hong Kong Chinese version)
  • Medical/social/demographic data, including frequency of home practice of PMRT

Results:

R-ANOVA indicated there was a significant difference in state-anxiety over the 10 weeks between the two groups (p < 0.01), with the experimental group reporting a significantly lower state-anxiety level than the control group. Also, scores significantly decreased over time (10 weeks) in both groups (p < 0.001), indicating a 43% decrease.

Limitations:

  • No baseline assessment was performed preoperatively.
  • PMRT is time-consuming and labor intensive.

Hernandez-Reif, M., Ironson, G., Field, T., Hurley, J., Katz, G., Diego, M., . . . Burman, I. (2004). Breast cancer patients have improved immune and neuroendocrine functions following massage therapy. Journal of Psychosomatic Research, 57, 45–52.

doi: 10.1016/S0022-3999(03)00500-2
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Intervention Characteristics/Basic Study Process:

  • The intervention was PMR for 30-minute sessions three times per week for five weeks versus massage therapy for five weeks versus a control group.
  • State-Trait Anxiety Inventory (STAI) was completed before and after the first and last sessions. Longer-term anxiety effect was examined by comparing pre-first day and pre-last day measures on STAI and by the SCL-90R anxiety subscale administered on the first and last days of intervention.  
  • Blood samples were drawn to evaluate immune response (NK cell production, cytotoxicity, and hormone levels).

Sample Characteristics:

  • N = 3 groups (PMR [n = 20] versus massage therapy [n = 22] versus control [n = 16])

Study Design:

  • Experimental study

Measurement Instruments/Methods:

  • STAI 
  • SCL

Results:

Immediate effects: Analysis of variance on STAI revealed a significant (p < 0.001) group effect on the first day’s change scores, and subsequent Bonferroni t-tests revealed reduced anxiety scores for the massage and PMR groups when compared to the control group. The longer-term effects (SCL-90R subscale) did not differ significantly among the three groups.

Conclusions:

The study supports the use of massage treatment and relaxation to reduce anxiety, pain, and depression in women with breast cancer. Massage therapy demonstrated an increase in dopamine, serotonin, NK cells, and lymphocytes. 
 

Limitations:

  • Small sample sizes
  • Unclear whether the assignment to the three treatment groups was random, which limits the strength of the study
 

Zhou, K., Li, X., Li, J., Liu, M., Dang, S., Wang, D., & Xin, X. (2014). A clinical randomized controlled trial of music therapy and progressive muscle relaxation training in female breast cancer patients after radical mastectomy: Results on depression, anxiety and length of hospital stay. European Journal of Oncology Nursing, 19, 54–59. 

doi: 10.1016/j.ejon.2014.07.010
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Study Purpose:

To examine effects of music therapy and progressive muscle relaxation (PMR) training on depression and anxiety in Chinese patients with breast cancer 

Intervention Characteristics/Basic Study Process:

Patients randomly were assigned to the intervention group (which received the music and PMR intervention) or a usual care group after a radical mastectomy. To avoid contamination, intervention and control patients were placed in different inpatient areas. Music therapy involved listening to music via headphones connected to an MP3 player for 30 minutes twice per day. This began within 48 hours after surgery. Patients selected their preferred music. PMR training was conducted on the second postoperative day. Training was conducted twice per day for 30 minutes until discharge. Patients were encouraged to do PMR and music listening exercises together. Patients in the control group received the usual postoperative nursing care only. Study measures were obtained the day before surgery and the day before hospital discharge. Data collectors were blinded to group assignment.

Sample Characteristics:

  • N = 170  
  • MEAN AGE = 47.01 years (SD = 9.5 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Most had modified radical mastectomy and 89% had chemotherapy immediately after surgery

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: China

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, controlled, single-blinded trial

Measurement Instruments/Methods:

  • Zung Self-Rating Depression Scale (SDS)
  • State-Trait Anxiety Inventory (STAI)

Results:

Analysis showed that there was a significant reduction in anxiety and depression over time alone (p < .001) as well as by group (p < .001), and there was a significant interaction between group and time (p = .0009). Depression scores declined an average of 7.2 points in the intervention group and 4.6 points in the control group. Anxiety scores declined an average of 16 points in the intervention group and 11 points in the control group. Hospital stay time was significantly lower in the intervention group (p < .001). Hospital stay length was shorter in the intervention group.

Conclusions:

The findings of this study suggest that the combination of PMR and listening to music was helpful in reducing anxiety and depression in women after mastectomies.

Limitations:

  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Findings not generalizable
  • Other limitations/explanation: No information was provided regarding other potential confounders such as postoperative complications, pain levels, etc. that could influence reported outcomes. Data collection was conducted via face-to-face interview, and although it was stated that data collectors were blinded, it is not clear where the data collection took place. If it took place in the hospital, data collectors could deduce group assignment because of the different locations in the hospital. This study was of Chinese women, so applicability to other groups is not known. It is not clear in the report whether all sessions of the intervention were guided by the investigators or done by the patients on their own. It is not clear how, if supervised by investigators, the patient could listen to the PMR training if they also were listening to music via headphones.

Nursing Implications:

Listening to music and using progressive muscle relaxation may have a positive impact on anxiety and depression in patients postoperatively. These are low-risk, low-cost interventions that may be beneficial. The findings of this study showed that those who had the intervention also had shorter hospital stays. There is insufficient evidence to determine the real impact of this intervention on duration of hospitalization; however, these findings suggest that this area deserves further exploration.


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