Progressive Muscle Relaxation (PMR)

Progressive Muscle Relaxation (PMR)

PEP Topic 
Sleep-Wake Disturbances

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 is often combined with the technique of guided imagery.

Effectiveness Not Established

Research Evidence Summaries

Cannici, J., Malcolm, R., & Peek, L. A. (1983). Treatment of insomnia in cancer patients using muscle relaxation training. Journal of Behavioral Therapy and Experimental Psychiatry, 14, 251–256.


Intervention Characteristics/Basic Study Process:

The intervention consisted of individual muscle relaxation training over three sessions plus instructions for home practice twice daily. Patients were either in the relaxation (n = 15) or usual care (n = 15) group. The outcome was sleep.

Sample Characteristics:

  • The sample was comprised of 30 patients (11 men, 19 women).
  • Mean age was 56 years (range 21–80).
  • Patients had various cancers.


  • Quiet office in the hospital, patient’s home, or patient’s hospital room
  • Southeastern United States

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment and long-term follow-up phases of care.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

Daily diary and questionnaire pertaining to sleep behavior the previous night, for a total of nine nights


Sleep-onset latency was reduced in the relaxation group compared with the usual care group; differences in sleep latency were maintained at the three-month follow-up. No differences were found in other sleep variables.


  • Sleep was measured by self-reports.
  • Training is needed in delivering muscle relaxation.

Nursing Implications:

No cost issues existed.

Demiralp, M., Oflaz, F., & Komurcu, S. (2010). Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. Journal of Clinical Nursing, 19, 1073–1083.

doi: 10.1111/j.1365-2702.2009.03037.x

Study Purpose:

To investigate the effect of progressive muscle relaxation (PMR) training on sleep quality and fatigue in Turkish women with breast cancer undergoing adjuvant chemotherapy.

Intervention Characteristics/Basic Study Process:

Following the eligibility assessment and obtaining informed consent, patients in the PMR group were invited to a private practice room for relaxation training. Patients in the PMR group were given PMR therapy in addition to chemotherapy and routine nursing services at the outpatient unit. Patients in the control group had chemotherapy and routine nursing services without PMR therapy. PMR therapy was performed in 25- to 30-minute sessions on the first and fifteenth days of each chemotherapy cycle. Patients in the intervention group were given a CD and encouraged to do exercises every day at home.

Sample Characteristics:

  • The sample was comprised of 27 women (PMR group, n = 14; control group, n = 13).  
  • Age ranged from 25 to 65 years.
  • To participate, patients had to be recently diagnosed with breast cancer, be undergoing adjuvant chemotherapy for the first time, and have no metastases or recent psychological treatments. 
  • All patients were living in the city where the research was performed and were literate in Turkish.


The study was conducted in the outpatient unit of the medical oncology department of the Gulhane Military Medical Academy in Turkey.  

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment (chemotherapy) phase of care.

Study Design:

The study used a prospective, repeated-measures, quasiexperimental design with a control group.

Measurement Instruments/Methods:

  • Sociodemographic and clinical characteristics
  • Pittsburgh Sleep Quality Index (PSQI)
  • Piper Fatigue Scale (PFS)


The PMR group experienced a greater increase in improved sleep quality and a greater decrease in fatigue than the control group. Mean sleep efficiency, sleep distrubances, and total PSQI scores were significantly lower in the control group (p < 0.05). Total fatigue scores were significantly better in the experimental group compared to the control group (p = 0.014).


The findings suggested that PMR training may improve sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy.


  • The study had a small sample size.
  • The article included no discussion or measurement of adherence to home PMR; therefore, the intervention dose is unknown.
  • There was no discussion of therapist experience or education.
  • Information was lacking about therapist training or strategies to maintain intervention fidelity.
  • The study had no random assignment or attentional control.

Nursing Implications:

PMR training given by a nurse may improve sleep quality and fatigue in patients with breast cancer. It is important to start relaxation training just before chemotherapy to decrease the frequency and severity of sleep problems and symptoms, such as fatigue during chemotherapy.

Systematic Review/Meta-Analysis

Kwekkeboom, K. L., Cherwin, C. H., Lee, J. W., & Wanta, B. (2010). Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. Journal of Pain and Symptom Management, 39, 126–138.

doi: 10.1016/j.jpainsymman.2009.05.022


To identify and synthesize the evidence for mind-body interventions for which the evidence suggests benefit for at least two of the three cluster symptoms of pain, fatigue, and sleep disturbance.

Search Strategy:

Databases searched were CINAHL, MEDLINE, and PsycINFO through March 2009.

Search keywords were guided imagery, hypnosis, relaxation, biofeedback, cognitive behavioral therapy, coping skills training, meditation, virtual reality, music AND cancer AND fatigue, sleep disturbance, sleep difficulty, insomnia, and pain.

Studies were included in the review if they

  • Were limited to research
  • Included adults aged 18 years and older
  • Included mind-body activities that involved primarily mental activity that could be performed by almost all patients
  • Included pain, fatigue, or sleep among study dependent variables.

Studies were excluded if they

  • Involved the use of yoga
  • Involved patients in whom a diagnosis of cancer was not yet established
  • Had a sample that included people without cancer.

Literature Evaluated:

A total of 47 studies were identified. In four of those, all testing virtual reality, only the symptom of fatigue was measured, so these were eliminated.

Sample Characteristics:

The final sample included 43 studies. Study sample sizes and total patients involved across studies were not reported.



Six studies examined relaxation interventions in hospitalized patients, outpatients with chronic pain, and women with early-stage breast cancer.

  • Significantly greater pain relief was obtained with progressive muscle relaxation compared to massage, usual treatment, mood manipulation, distraction, and controls.
  • One study found no difference in pain between a daily relaxation exercise and distraction.
  • Training in muscle relaxation did not improve fatigue in one study compared to provision of information.
  • In one study, muscle relaxation improved sleep compared to usual treatment controls.

Imagery and Hypnosis

Six studies examined imagery and hypnosis.

  • In four studies, imagery was used in hospitalized patients with cancer pain, and beneficial effects were reported.
  • One study found no differences in pain or fatigue between patients with an imagery intervention and those receiving standard care.
  • Four studies used imagery in comparison to cognitive-behavioral therapy (CBT) and combined imagery with relaxation. Of those, one study reported no significant effect, two reported significant pain reduction, and one reported significant reduction in fatigue and sleep disturbance.

Cognitive Behavioral Therapy (CBT)/Coping Skills Training (CST)

Twenty-one studies tested CBT/CST.

  • In three studies, fatigue was the primary focus. Significantly more improvement in fatigue was reported with a six- to 12-week CBT/CST intervention compared to usual treatment and controls.
  • Three studies evaluated CST effects on the combination of pain and fatigue. In all of these, a one-session CST intervention resulted in no difference in symptoms compared to controls.
  • Seven studies evaluated the effects of CBT/CST on fatigue and sleep disturbance. One study reported a decreased incidence of fatigue and sleep disturbance using an audio recording for coping skills training prior to chemotherapy. Two studies reported improvement in sleep with a four- to eight-week CBT intervention, but only one of these also reported improvement in fatigue. One study reported improvement in sleep and fatigue with a five-session CBT intervention, two other studies showed improvement in sleep but no change in fatigue, and one study reported no improvement in either of these two symptoms.
  • Four studies reported effects of CBT/CST on all three symptoms concurrently. One showed improvement in fatigue and sleep but no impact on pain. One study reported less sleep disturbance but no difference in pain or fatigue. One reported lower ratings of worst pain immediately after the CBT program and greater reduction in pain and fatigue six months after the intervention compared to controls. One study found no differences in any of the three symptoms with a CST intervention.


Four studies were included.

  • Three of these studies used mindfulness-based interventions. One study reported significant improvements in both fatigue and sleep among outpatients who participated in an eight-week intervention.


  • Four studies looked at the effect of music on pain. Two studies found significant improvements in a pre-/posttest design using 30 minutes of preferred music among hospitalized patients. Two other studies found no difference in pain with listening to music compared to control groups.
  • Two studies tested a music intervention on fatigue. One found a significant effect, and one found no difference in fatigue between intervention and control groups.


Findings of this review were equivocal.


  • Although the authors stated a criterion for inclusion of examination of at least two of the three symptoms of interest, the review appeared to include studies in which only one of these symptoms was reported.
  • Few investigators used multisymptom interventions and evaluations.
  • Measures of symptom clusters were not been well identified.
  • Some instruments were stated to potentially be more sensitive; however, the scales and individual items that were most useful to measure this symptom cluster were not determined.
  • Timing, dosage, and frequency of interventions varied among studies, making it difficult to draw systematic conclusions. Most music interventions were very brief.
  • This review did not provide study details, such as clear sample descriptions, sample sizes, or actual statistical results, and no effect sizes were calculated, although some studies used the same outcome measures.

Nursing Implications:

Although the findings did not clearly demonstrate the effects of these interventions across studies, the authors concluded that these interventions hold promise. Although such interventions carry minimal risk to patients, some interventions would require substantial time and resource commitment to provide.