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

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
 

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