Progressive Muscle Relaxation and Guided Imagery

To determine the overall efficacy and magnitude of clinical benefit of psychological interventions in patients with breast cancer, specifically looking at three outcome variables: anxiety, depression, and quality of life (QOL)

Databases searched were MEDLINE (1966–January 2004), EMBASE (1980–2004), Cochrane Controlled Trials Register (1985–February 2004), PsycLit (1973–2004), Biological Abstracts (1990–December 2003), CancerLit (1975–October 2002), CINAHL (1982–December 2003), and Health Star (1975–January 2004).

Search keywords were randomized clinical trial and breast cancer and psychological interventions (cognitive behavioral therapy, group psychotherapy, relaxation, supportive therapy, visual imagery) and psychological adjustment (anxiety, depression, maladjustment, distress, quality of life).

Studies were included in the review if they

• Were a randomized clinical trial (RCT)
• Included at least two arms: an intervention arm and a control arm
• Evaluated the efficacy of a psychological/behavioral intervention
• Were aimed at alleviating psychiatric/psychological morbidity, as defined by anxiety, depression, and/or QOL
• Reported on female patients with a histologically confirmed diagnosis of breast carcinoma of any stage who have undergone surgery.

Trials examining efficacy of interventions designed to assuage surgical distress were excluded.

• A total of 383 citations were identified, with 36 potentially relevant articles identified and screened for retrieval.
• The final meta-analysis included 18 RCTs with usable information by outcome.
• Study quality was evaluated using a framework provided by Cook and Campbell (1979) and a quality assessment scale developed and validated by Jadad and colleagues (1996).

Cook, T.D., & Campbell, D.T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Boston, MA: Houghton Mifflin.

• Fourteen trials assessing anxiety were identified, yielding a sample of 1,278 patients.
• Fourteen trials measuring depression were identified, yielding a sample of 1,324 patients.
• Seven trials measuring QOL were identified, yielding a sample of 623 patients.
• Less than half of the trials included were considered to be of high methodological quality.
• Patients’ ages ranged from 25 to 73 years, and approximately 70% were married or in a committed relationship.
• Studies were conducted in the United States, Canada, England, Italy, Australia, Japan, and China.

Anxiety

• Overall effect size (ES) was -0.40 (95% CI, -0.72 to -0.08) in favor of the treatment condition in comparison to the control.
• Sensitivity analyses exploring the impact of methodological quality on overall ES found a reduction in ES associated with higher quality studies, -0.26 (95% CI, -0.42 to -0.10).
• Trials using patients with high morbidity (metastatic breast cancer) yielded a statistically significant overall ES of -0.40.
• Trials whose treatment extended beyond 20 hours had a statistically significant overall ES of -0.30 in favor of treatment.
• Treatment orientation showed differential impact on overall ES with cognitive behavioral therapy (CBT), yielding an ES of -0.11, as well as ESs of -0.40 for guided imagery and relaxation, -0.43 for supportive-expressive therapy, and 0.02 for educational interventions.

Depression

• Overall ES for depression was -1.01 (95% CI, -1.48 to -0.54) in favor of treatment.
• Trials with higher methodological grade were associated with an overall ES of -0.24 in favor of treatment, while lower quality studies had an overall ES of -1.99.
• Studies in which patients had lower morbidity yielded an overall ES of -0.45, whereas those with patients with more advanced disease yielded an overall ES of -1.20.
• Couples and group therapy reached statistical significance with an ES of -1.02 and -1.35, respectively.
• Treatment orientation showed ESs of -0.85 for CBT, -0.55 for guided imagery, -1.80 for supportive expressive therapy, and -0.45 for educational interventions. With the exception of educational interventions, the other subgroup analyses reached statistical significance.

Quality of Life

• Overall ES was 0.74 (95% CI, 0.12 to -1.37) in favor of the treatment group, but this was not statistically significant. When lower quality studies were removed, statistical significance was achieved, but ES was reduced (0.35, p=0.04).

Overall ES trends among the three outcomes show that more reliable studies were associated with smaller gains. Interventions targeted to patients with clinically important levels of anxiety or depression tended to reap the most benefit, compared to patients who undergo treatment on a prophylactic basis. Group psychotherapy appears to be superior to individual therapy in the treatment of both anxiety and depression. However, a direct impact of group therapy on QOL was not supported in this analysis. CBT interventions appeared to be equally as effective as supportive-experiential therapies. Interventions need not span beyond 20 hours to produce statistically significant ES.

The quality of most studies was not high.

Future trials in psychosocial oncology should incorporate methodological features to enhance internal validity. Evaluation of statistically significant findings on psychometric testing may not reflect clinically significant findings and vice versa. This underscores the need for incorporating qualitative analysis in future studies. There is an absence of studies examining the efficacy of short-term interventions on QOL in advanced breast cancer and should be addressed in future research. Short-term, group interventions may provide the best utilization of scarce resources for the most effect; however, they should be targeted to those patients experiencing clinically important levels of distress. Findings point to the need for higher quality research design and reporting in this field.

To test the effectiveness of progressive muscle relaxation (PMR) and guided imagery as stress-reducing interventions

Patients randomized to usual care had weekly meetings with psychologists. Those randomized to PMR and guided imagery had four supervised sessions and daily self-practice for three weeks. To stimulate imagery, the guided imagery component included auditory, tactile, and olfactory images. The imagery script was accompanied by music. The intervention was tested and measured with biofeedback prior to study use.  Both groups were assessed at baseline and at the end of three weeks. Daily text message reminders were sent to the intervention group to remind them to practice PMR.

• N = 208  
• AGE RANGE: 40-60 years
• MALES: 50%, FEMALES: 50%
• KEY DISEASE CHARACTERISTICS: Breast and prostate cancer
• OTHER KEY SAMPLE CHARACTERISTICS: 49% had university education; 71% were married

• SITE: Multi-site  
• SETTING TYPE: Home    
• LOCATION: Cyprus

• PHASE OF CARE: Active antitumor treatment

• Single, blind. randomized, controlled trial

• Zung self-rating anxiety scale
• Beck Depression Inventory
• Salivary a-amylase and cortisol levels

The group had a decrease in mean anxiety score whereas the control group had an increase in anxiety at three weeks compared to baseline. The difference between groups of this change was significant (p < 0.001).  The same pattern of change between groups was shown for depression (p < 0.001). Salivary amylase and cortisol levels were directly related to anxiety and depression scores (p < 0.001).

PMR and guided imagery were associated with reduced anxiety and depression among patients with breast and prostate cancer during chemotherapy.

• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: No information was provided regarding patient adherence to daily PMR practice. No information was provided regarding any medications for anxiety or depression or chemotherapy regimens involved. Very limited demographic information is provided. The manner in which the imagery scenarios and music were provided were not described.

Findings here showed that progressive muscle relaxation and guided imagery were effective in reducing anxiety and depression during chemotherapy treatment. These are very low-risk interventions that can be helpful and can be readily incorporated into standard patient care.

To evaluate the immediate and short-term effects of relaxation training with the Yoga in Daily Life program on anxiety in patients with breast cancer

Patients were randomized to standard physiotherapy or standard physiotherapy plus the relaxation program after surgery for breast cancer. Physiotherapy was provided for one week. The experimental group also had one-hour group sessions daily in groups of three for one week. The program involved relaxation breathing exercises, visualization, and body scan, providing progressive muscle relaxation techniques. Those in the experimental group were given audiocassettes with instructions for home practice and were asked to do this daily for another three weeks.

• N = 32  
• AGE: All patients were over 40; further information was not provided.
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer having just undergone initial surgery

• SITE: Single site  
• SETTING TYPE: Multiple settings    
• LOCATION: Slovenia

• PHASE OF CARE: Active antitumor treatment

• Single blind RCT

• State Trait Anxiety Scale
• Patient diary of use of relaxation at home

There was significant reduction in anxiety in the experimental group (p < .01), while mean anxiety level in the control group remained essentially the same. State anxiety levels were significantly lower after physiotherapy and relaxation training in the experimental group compared to controls one hour after physiotherapy (p = .038).

Visualization and progressive muscle relaxation as provided in this program may help reduce anxiety after surgery among patients with breast cancer.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement/methods not well described
• Other limitations/explanation: Single blind only. There is no information about how often patients did the program at home after hospital discharge.

Relaxation therapy including visualization and progressive muscle relaxation as accomplished in this program may be helpful for patients to reduce anxiety. This study has limitations and does not provide strong support for effectiveness; however, these are very low-risk types of interventions that may be helpful to some patients.

The relaxation intervention was a 30-minute, therapist-led group with relaxation and visualization therapy (RVT) consisting of relaxation, guided imagery, progressive muscle relaxation, meditation, and deep breathing. Each group had up to four patients. The intervention was delivered daily for 24 treatments immediately following radiation treatments. Patients self-administered the treatment at home using audiotapes twice per day. Patients received telephone calls to remind them to perform the intervention at home. Measures of psychological, endocrine, and immunologic data were collected at baseline and after the 24-day intervention.

The study reported on a sample of 34 women with breast cancer receiving radiation treatments (intervention group = 20; control group = 14).

A randomized controlled trial design was used.

• Inventory of Stress Symptoms–Lipp for adults (ISSL)
• State-Trait Anxiety Inventory (STAI)
• Beck Anxiety Inventory (BAI)
• Beck Depression Inventory (BDI)

Analyses were controlled for basal anxiety levels (trait anxiety). The psychological scores did not change over time in the control group, but the experimental group showed significantly reduced levels of stress, anxiety, and depression scores following the 24-day RVT treatment (all p < 0.05). Experimental and control groups showed similar stress and depression scores at baseline. Patients in the experimental group were more anxious than patients in the control group at baseline.

While no biologic changes were noted with RVT, there were significant improvements in psychological functioning with RVT.

The study had small sample sizes.

The intervention involved progressive muscle relaxation (PMR) and guided imagery (GI). Patients were visited by a community RN who was trained in the use of relaxation and imaging technique. Tape recorders with cassettes were used to teach PMR and GI, with instructions provided by a clinical psychologist guiding the techniques.

Patients were randomized to one of four treatment groups:

1. PMR training
2. GI training
3. Both PMR and GI training
4. Control group (pre/post-test)

• The study reported on a sample of 56 patients with advanced cancer who were experiencing anxiety and depression.
• All patients were receiving palliative care in their own homes, and all were on pain medication.

• Community nursing setting
• Sydney, Australia

A randomized controlled trial design was used.

• Hospital Anxiety and Depression Scale (HADS): Used to measure anxiety and depression
• Functional Living Index–Cancer Scale: Used to measure quality of life (QOL)

• None of the three treatments produced a significant reduction in anxiety (failed to reach significance [p = 0.057]).
• All three treatments produced a significant reduction in depression.
• All three treatments had improved QOL as measured by the index.

The study had a small sample size.