Progressive Muscle Relaxation (PMR)

Progressive Muscle Relaxation (PMR)

PEP Topic 
Chemotherapy-Induced Nausea and Vomiting
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 prerecorded script may be used to guide individuals through the process. PMR has been examined for effectiveness in patients with cancer for anxiety, depression, dyspnea, sleep-wake disturbances, fatigue, and chemotherapy-induced nausea and vomiting. PMR often is combined with the technique of guided imagery.

Effectiveness Not Established

Research Evidence Summaries

Borjeson, S., Hursti, T.J., Tishelman, C., Peterson, C., & Steineck, G. (2002). Treatment of nausea and emesis during cancer chemotherapy: Discrepancies between antiemetic effect and well-being. Journal of Pain and Symptom Management, 24, 345–358.

doi: 10.1016/S0885-3924(02)00543-2
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Study Purpose:

To evaluate the relationship between antiemetic effect and well being over four different antiemetic treatment strategies

Sample Characteristics:

  • The study consisted of a total of 162 chemotherapy-naive patients with ovarian cancer.
  • All patients received similar combination chemotherapy, including cisplatin (50 mg/m2).

Setting:

This study was conducted in the greater Stockholm, Sweden, area, with two gynecologic oncology wards.

Study Design:

Patients were randomly admitted to one of the two hospital wards for the study. Study II was a randomized, double-blind trial on the same hospital wards.

Measurement Instruments/Methods:

  • Patients completed self-assessment questionnaires the day after and two weeks after chemotherapy.
  • Presence, frequency, and intensity (on a 0–100 visual analog scale [VAS]) of nausea and vomiting was recorded. 
  • Duration of acute nausea, including time of onset and number of hours until relieved, were recorded.
  • Delayed nausea, including the number of days with any symptoms, was recorded for two weeks after chemotherapy.
  • Questionnaires were administered regarding well-being before, during, and after chemotherapy.
  • A 0–100 VAS was used to measure aspects of quality of life and well-being.

Results:

  • Relief from delayed symptoms was highest in the group that received high-dose metoclopramide (2.5 mg/kg x 2), dexamethasone (20 mg x 1), lorazepam (1 mg x 2), and biperiden (1-2 mg x 3) followed by low-dose metoclopramide (20 mg x 3) orally for three days after chemotherapy.
  • Nausea intensity was lowest in the group that received ondansetron (8 mg x 3) and dexamethasone (20 mg x 1) IV during the chemotherapy day and ondansetron orally (8 mg x 3) for five days after chemotherapy.
  • Duration of acute nausea was shortest in the high-dose metoclopramide group. The high-dose metoclopramide and the ondansetron and dexamethasone groups reported better well-being.
  • Duration of acute nausea was the only variable that was significantly related to well-being in both samples.
  • Relaxation training was offered to 20 patients in the ondansetron and placebo group and 18 patients in the ondansetron and dexamethasone group; no differences were found in the studied variables.

Limitations:

  • Some patients received a benzodiazepine, but no comparison regarding effect can be made.
  • All patients had ovarian cancer, were in the same department, and were treated with similar chemotherapy.

Campos de Carvalho, E., Martins, F.T., & dos Santos C.B. (2007). A pilot study of a relaxation technique for management of nausea and vomiting in patients receiving cancer chemotherapy. Cancer Nursing, 30(2), 163-167.

doi: 10.1097/01.NCC.0000265007.87311.d0
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Study Purpose:

To determine the effect of progressive muscle relaxation (PMR) on chemotherapy-induced nausea and vomiting (CINV)

Intervention Characteristics/Basic Study Process:

Patients receiving chemotherapy underwent an intervention consisting of 25-minute sessions of PMR (tensing-releasing) and control of respiration in an environment characterized by little artificial illumination and adequate music, without interruptions. Before and after the interventions, specific physiologic and self-report variables were measured. A registered nurse, who was trained in measuring physiologic alterations and muscle reactions, collected the data. Patients were asked to consider the presence of nausea one hour before and one hour after the intervention.

Sample Characteristics:

The study consisted of 30 patients who were over 18 years of age, had been diagnosed with hematologic cancers, were receiving chemotherapy, were experiencing nausea and vomiting at the time of data collection, and were hospitalized. Participants were capable of maintaining a logical conversation and had not received antiemetics five hours before undergoing the relaxation intervention. Patients were excluded from the study if they had evolving multiple myeloma or suspected bone fractures.

Setting:

The study was conducted at a large hospital in Brazil.

Study Design:

This was a pre-and post-test pilot study.

Measurement Instruments/Methods:

  • Physiologic indicators of nausea (e.g., vital signs, perspiration, pupil dilatation, salivation, skin color) were recorded.
  • Muscle reactions (e.g., forearm, leg, forehead, eye tension) were recorded.
  • Huskisson’s visual analog scale (VAS) (adapted version) for nausea and vomiting intensity levels was used.

Results:

PMR was associated with decreased physiologic conditions and muscle reactions, as well as a statistically significant reduction in the intensity of nausea and vomiting levels.

Conclusions:

PMR techniques may be an effective intervention to reduce nausea in patients receiving chemotherapy.

Limitations:

  • No control group was included.
  • The population was heterogeneous.
  • The types of chemotherapeutic and antiemetic agents were not controlled.
  • Patients were undergoing various chemotherapy cycles.
  • RN training is required.

Nursing Implications:

PMR is a low-cost technique that can be easily taught to patients for use as an intervention for the management of CINV.

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.


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