Progressive Muscle Relaxation and Guided Imagery

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.

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.

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.

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.

• 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.

• 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.

Support for the use of nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV) was weak.

Many studies were flawed because of small sample sizes and confounding variables (e.g., stage of disease, various chemotherapy regimens, culture, patient compliance).

Preliminary available evidence suggests positive benefits through nonpharmacologic techniques; however, larger randomized trials are needed to demonstrate the exact benefits, including economic.

• Databases searched were National Library of Medicine PubMed database, which includes MEDLINE, PreMedline, and other related databases (1979-January, 2000).
• Search keywords were cancer and behavior, intervention, nausea, vomit, depression, anxiety, fatigue, neuro, cognitive, menopause, sex, and post-traumatic stress disorder.
• Studies were included if they were randomized controlled studies, within-subject studies, or case reports.

• The review consisted of 54 studies that met the criteria.
• Three symptom clusters were evaluated. The review included published reports for nausea and vomiting, anxiety/stress, and pain.
• For the nausea and vomiting review, studies must have addressed
  • Cancer-related treatment side effect with behavioral intervention
  • Cancer-treatment intervention effects.

• The following treatments were evaluated: relaxation, hypnosis, cognitive/attentional distraction, desensitization, and rehearsal modeling.
• Four studies for relaxation and hypnosis showed effectiveness of behavioral intervention for control of anticipatory nausea and vomiting (no anticipatory vomiting occurred).
• Results from the individual analyses were confirmed in 12 of 13 randomized-controlled trials that compared behavioral interventions with no treatment/attention control conditions.
• The impact of behavioral intervention on postchemotherapy side effects was less established, with four studies reporting that the behavioral intervention reduced the intensity of the postchemotherapy side effects but did not prevent their occurrence.

To evaluate the use of progressive muscle relaxation training in the management of nausea, vomiting, and anxiety induced by chemotherapy

The experimental group received training that consisted of tensing and releasing 16 muscle groups and breathing deeply for a total of 25 minutes. Each subject was provided with an audiotape and instructed to practice independently twice daily before meals or two hours afterward. The investigator met with the control group for 15 minutes per day to discuss concerns.

• The study consisted of 60 Japanese patients with cancer (30 subjects in the experimental group and 30 subjects in the control group) who were actively receiving chemotherapy.
• Patients' ages ranged from 21–75 years.
• Patients did not practice progressive muscle relaxation in their daily lives.

This study was conducted at a 415-bed, hospital-based cancer center in Japan.

The study was a randomized pretest, post-test control group design with repeated measures.

The Rhodes Index of Nausea and Vomiting-Form 2 (Japanese version) and the Spielberger State-Trait Anxiety Inventory were used. Reliability and validity were described in depth.

• Progressive muscle relaxation decreased the total index of nausea and vomiting scores of the experimental group.
• Index of nausea and vomiting scores for the control group increased to their highest levels 60–72 hours after chemotherapy.

Progressive muscle relaxation may contribute to a reduction in delayed nausea and vomiting. This study did confirm the usefulness of progressive muscle relaxation in decreasing the incidence of vomiting. Progressive muscle relaxation decreased subjective feelings of anxiety.

• The number, type, and dosage of chemotherapy and antiemetics were not controlled.
• Vomiting scores were very low for the experimental and control groups.
• Only one investigator conducted the study, which introduces potential investigator bias.
• The study involved only one population (Japanese patients).

To assess the effectiveness of progressive muscle relaxation (PMR) and guided imagery training as an adjuvant intervention and accompanying antiemetics (metoclopramide, dexamethasone) in managing acute and delayed nausea and vomiting, anxiety, and depression

In the experimental group, PMR was initiated for 25 minutes and guided imagery for 5 minutes, each one hour before chemotherapy was administered.

The study reported on 71 Chinese chemotherapy-naive women with breast cancer who were older than 30 years and were receiving doxorubicin and cyclophosphamide.

The study was conducted at a university hospital outpatient treatment center in Hong Kong.

This was a randomized, controlled clinical trial.

The Profile of Mood States, State-Trait Anxiety Index, and Morrow Assessment of Nausea and Vomiting were translated into Chinese and back-translated. Measures were piloted on 25 patients prior to use in the study. Demographic data and vital signs measures were used.

The effects of PMR therapy and guided imagery were more pronounced at the initial stage of treatment when patients did not know what to expect. The effects were reduced on the fourth day and beyond. The study did not show a significant reduction in the intensity of nausea and vomiting after chemotherapy; the baseline nausea and vomiting values showed that the patients in this study began with considerably lower levels of nausea and vomiting than in previous studies. The combination of PMR and guided imagery was beneficial for cognitive distraction and relaxation, components that reduce stress and anxiety. The physiologic benefit to these techniques was discussed. Differences in Chinese and Western cultures related to expression of emotions was noted.

PMR therapy with guided imagery was found to be superior to standard antiemetic treatment alone in managing acute and delayed chemotherapy-induced nausea and vomiting.

• Pharmacologic agents prescribed were metoclopramide and dexamethasone for doxorubicin and cyclophosphamide treatment; 5-HT₃ was not given despite publication in 2002.
• Only one population (Chinese) was included.