Relaxation Therapy

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.

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.

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.

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

Relaxation

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.

Meditation

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.

Music

• 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.

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.

To measure the efficacy of relaxation training for hospitalized patients with advanced cancer.

Patients were randomized to receive an immediate or delayed intervention, on day 3 or day 6 of a nine-day study period. The intervention was a one-hour training session delivered by a specially trained registered nurse (RN) in deep breathing and somatic tension release, as well as instruction on maintaining a state of somatic relaxation. Patients were given a CD of the audio training to repeat at night after the training.

• The sample was comprised of 18 patients (33% male, 66% female).
• Mean age was 61 years (standard deviation [SD] = 15 years) in the intervention group and 66 (SD = 12 years) in the delayed intervention group.
• Patients were hospitalized with advanced metastatic cancer, with a life expectancy of less than six months, a diagnosed sleep disorder, and fairly well-controlled pain and dyspnea.
• Multiple cancer diagnoses were included.
• Patients were hospitalized for at least five days.
• Patients had a Mini-Mental State Examination (MMSE) score of 20 or greater.
• Patients spoke French.

• Single site
• Inpatient
• Switzerland

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

This was a pilot, randomized, controlled trial.

• Numerical Rating Scale of 1 to 10
• Sleep diary
• Hospital Anxiety and Depression Scale (HADS)

Only 11 patients were able to complete the treatment phase of the study. Both groups improved (not statistically) between the day of inclusion and day 2 of therapy. No improvement occurred between days 2 and 5, which was when the intervention occurred for half of the patients. No change occurred in the use of benzodiazepines during the nine-day study.

The study did not show that a simple relaxation therapy intervention improved satisfaction with sleep in patients with advanced cancer hospitalized on a palliative care unit.

Assessment and management of sleep disturbances should be integrated into patient care early in the disease process.  Further work is needed to identify and test interventions that can be used to improve sleep in patients with advanced cancer. Further work is also needed to determine whether relaxation therapies have an effect on sleep satisfaction.

• The study had a small sample size.  
• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Unintended interventions or applicable interventions not described would have influenced the results.
• Measurements/methods were not well described.
• Measurement validity/reliability was questionable.

It is critical to assess and manage sleep disturbances in patients with cancer early in the disease process. Ongoing evaluation and research is required into effective interventions to promote sleep in patients with cancer; specifically, further work is needed to look at relaxation therapies and determine if they are effective and a means of improving patient satisfaction with sleep.