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:

To examine the effectiveness of a psychoeducational intervention (PEI) on the symptom cluster of anxiety, breathlessness, and fatigue compared with usual care

Intervention Characteristics/Basic Study Process:

A 40-minute educational intervention consisted of preparatory information; discussion of symptom experience; exploration of means of, and goals associated with, symptoms; advice on self-care strategies; and training and practice in progressive muscle relaxation. The educational package consisted of an audiotape and leaflets as well as discussion on the selected symptoms and their self-care management.

Sample Characteristics:

  • The study reported on a sample of 140 patients.
  • No data on patient age were provided, but inclusion criteria stipulated that participants be age 16 or older.
  • The sample was 83% male and 17% female.
  • Patients were diagnosed with stage 3 or 4 lung cancer and were scheduled to receive palliative radiation therapy.
  • Mean duration of cancer illness was 4.4 months.
  • Chest and mediastinum were the major sites of radiation therapy.
  • Of the sample, 87% were married and 54% were retired.

Setting:

  • Single site
  • Hong Kong

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A pre/post-test randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Visual analog scale to measure intensity of breathlessness
  • Piper Fatigue Scale: 23-item intensity subscale (Chinese version)
  • State-Trait Anxiety Inventory: 20-item A-state scale (Chinese version)
  • Short Form-34 Health Survey functional ability subscale (Chinese version)

Results:

Univariate tests on anxiety showed a significant difference (p = 0.001) in the pattern of change over the course of time, with a very small effect size (partial eta² = 0.051).

Conclusions:

Findings suggest that interventions such as those tested in the current study, including progressive muscle relaxation, education, and counseling, have significant effects on patterns of symptom change over time.

Limitations:

  • Between-group differences were not analyzed or reported.
  • The study yielded very small effect sizes.
  • The study had no attentional control.
  • The control group had more advanced stage of cancer (p < 0.05) compared to the intervention group and therefore had much higher attrition rates (42% versus 11%).
  • Results reported gave information about pattern changes over time, but data provided did not give clear information regarding the direction of change associated with the intervention.

Nursing Implications:

Progressive muscle relaxation and education may be helpful in managing anxiety, fatigue, and breathlessness in patients with cancer, but effects may be small.

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.

Goerling, U., Jaeger, C., Walz, A., Stickel, A., Mangler, M., & van der Meer, E. (2014). The efficacy of short-term psycho-oncological interventions for women with gynaecological cancer: A randomized study. Oncology, 87, 114–124. 

doi: 10.1159/000362818
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Study Purpose:

To study the effects of two different interventions on anxiety and depression postoperatively

Intervention Characteristics/Basic Study Process:

The interventions that were studied included a single educational session and a single session of progressive muscle relaxation delivered between the third and sixth postoperative day to women who had surgery for gynecologic cancers. Women randomly were assigned to intervention groups. Study measures were obtained preoperatively prior to hospital discharge.

Sample Characteristics:

  • N = 35  
  • MEAN AGE = 49.4 years (range = 23–79 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Varied tumor types (ovarian and cervical were most common); most had grade-2 disease

Setting:

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

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, noncontrolled trial

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Perceived-stress questionnaire
  • NeXus 1 (device for measuring physiological measures, respiratory rate, heart rate, skin conductance, etc.)

Results:

Anxiety scores declined significantly in both groups (p < .005), and depression declined significantly in those receiving the educational intervention (p < .001). There were no differences between groups in self-reported stress, and there were no significant changes in physiologic measures.

Conclusions:

The findings of this study demonstrate that the interventions tested here may have some benefit; however, the strength of the results is low due to study limitations

Limitations:

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10%  
  • Other limitations/explanation: It could be expected that anxiety levels would decline between preoperative and postoperative states without any intervention. The types of surgery were not described. It could be expected that outcomes at discharge could vary according to the type of surgical procedure performed and expected prognosis. Almost one fourth of participants dropped out of the study.

Nursing Implications:

This study does not provide strong evidence in support of educational and muscle relaxation interventions for the reduction of anxiety or depression.

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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