Progressive Muscle Relaxation (PMR) therapy involves sequential tensing and relaxation of major skeletal muscle groups and aims to reduce feelings of tension, to lower perceived stress, and to induce relaxation. PMR is purported to decrease the arousal of the autonomic and central nervous system and to increase parasympathetic activity.
Two systematic reviews (SRs) published since 2019 are included in this summary. One included 12 randomised controlled trials (RCTs) with 1147 participants and assessed a range of outcomes, the other one investigated PMR for preventing and alleviating chemotherapy-induced nausea and vomiting and included six RCTs with 288 participants. An additional 25 randomised and non-randomized controlled clinical trials (RCTs and CCTs) were also reviewed for this summary.
Anxiety PMR appears to improve anxiety better than usual care and similarly to other interventions for various cancers based on one SR, 5 RCTs, and one non-randomised trial (moderate to high-certainty evidence)
Depression: PMR may improve depression although overall study quality in the SR was low to very low based on one SR, 3 RCTs, one non-randomised trial (low-certainty evidence).
Quality of life: PMR appears to improve quality of life based on one SR, although an RCT in breast cancer did not show improvement (low-certainty evidence).
Mood and related outcomes: A good quality trial in palliative care suggests PMR may improve mood, relation with others and enjoyment of life (low-certainty evidence).
Self-esteem and related outcomes: There is very limited poor-quality evidence that PMR may improve self-esteem (1 SR), self-efficacy (2 RCTs), body image (1 RCT) and coping skills (1 RCT) (very-low certainty evidence).
Stress: A non-randomised trial suggests improvements in stress, but evidence for physiological stress changes is conflicting (low-certainty evidence).
Fatigue/sleep: evidence is inconclusive; one SR found no effect on fatigue while three RCTs suggest improvements in sleep in palliative care, fatigue in breast cancer and sleep and fatigue in head and neck cancer (low-certainty evidence).
Nausea and vomiting: PMR may reduce chemotherapy-induced nausea and vomiting based on two SRs (low to moderate-certainty evidence).
Pain: improvements in pain reported in on one SR (very low to moderate quality evidence). The trial in palliative care also found improvements in pain. Evidence for reducing pain in colorectal cancer surgical patients is conflicting (low-certainty evidence).
PMR is considered to have few adverse effects, although some concern has been raised about the use of relaxation therapy interventions among individuals who have a history of psychiatric disorders.
Citation
Ava Lorenc, CAM Cancer Collaboration. Progressive Muscle Relaxation [online document], Jan 24, 2024.
Document history
Revised and updated in November 2023 and March 2019 by Ava Lorenc. Summary updated in July 2015, December 2013, July 2012 by Helen Cooke. Summary first published in July 2011, authored by Helen Cooke.
Next update due: January 2027
Progressive muscle relaxation (PMR) is a relaxation technique that involves the sequential tensing and releasing of major skeletal muscle groups with the aim of inducing relaxation.
Backround and prevalence
Edmund Jacobson, an American physician, drew on studies in psychology and physiology, to develop his own understanding of the mind-body relationship and its role in health, and a method of stress reduction that he described it in his book Progressive Relaxation, published in 1938.
He stated that the mind and voluntary muscles work together in an integrated way.
Keeping the mind calm allows muscles to relax, and freeing the body of tension reduces sympathetic activity and anxiety. He initially developed PMR to induce relaxation by promoting awareness of tension in skeletal muscles. Bernstein and Borkovec later developed a shortened, modified procedure that is now the most frequently used form of PMR (Jacobson 1938).
A population-based study carried out in the USA of 4 000 cancer survivors who were followed up 10 to 24 months after their diagnosis found that 43 percent used some form of relaxation therapy (Gansler 2005).
Alleged indications
In relaxed subjects, alterations in sympathetic nervous system activity, including decrease in pulse rate, blood pressure, and musculoskeletal tone, and altered neuroendocrine function have been observed. It has been suggested that deep somatic restfulness reduces anxiety and physical arousal (Payne 2010) and that muscular relaxation may directly inhibit anxiety and the muscular activity that generally precedes nausea and vomiting. It has been proposed that learning relaxation techniques can help people feel more in control of side effects and therefore less anxious (Payne 2010).
Some researchers have suggested that PMR may serve as a distraction for patients who undergo chemotherapy, (Arakawa 1997) whereas others propose that distraction is only part of the effectiveness of such interventions. (Kwekkeboom 2008).
Mechanisms of action
PMR is a technique based on a theory that a psychobiological state called neuromuscular hypertension is the basis for a variety of negative emotional states and psychosomatic diseases and that the body’s muscle tension develops from anxiety-provoking thoughts and events (Lee 2012). The cognitive and physiological pathways involved in negative emotional states are complex and the extent to which learning to relax muscles is an efficient way to overcome self-reported tension in anxiety disorders is presently unclear.
Although the exact mechanism of action is unclear, muscle relaxation techniques are reportedly effective in decreasing muscle tension in the body (Conrad 2007).
Application and dosage
PMR may be taught by health care professionals, including clinical psychologists and nurses, as well as hypnotherapists, yoga instructors, and other complementary practitioners. Training may be conducted in groups or one-on-one, during one or a series of sessions, or via a CD/audiotape as a self-help technique. There is some evidence that PMR for cancer patients is only successful if delivered by a professionally trained person (Burish 1992).
Training may be offered before, during, or after medical treatment or procedures. PMR sessions commonly last for 20 to 30 minutes (Pelekasis 2017), but are not standardized and may therefore vary in duration, frequency and the number of involved muscle groups, and may also include deep breathing techniques.
Supportive/palliative care
Two systematic reviews (SRs) published since 2019 are included. The first is by Tan et al (2022) on the effect of PMR on a range of outcomes in cancer patients. It included 12 randomised controlled trials (RCTs) with 1147 patients and the review is well conducted and reported. The meta-analysis found significant effects for PMR alleviating multiple outcomes (reported below in the relevant sections), although the overall quality of evidence was moderate to very low.
The second SR (Tian 2020) investigated PMR for preventing and alleviating chemotherapy-induced nausea and vomiting (reported below). An earlier SR of 5 RCTs (Pelekasis 2017) was not included here due to poor quality of both the review and the included studies. An additional 25 randomized and non-randomized controlled clincial trials (RCTs and CCTs) were reviewed for this summary. Only trials published since the reviews, or on a different topic, were included, and only trials of PMR alone (many trials test PMR combined with another intervention such as guided imagery).
The trials are described in table 1. Although there is promising evidence for anxiety, evidence for all other outcomes is insufficient due poor quality and methodological limitations of published studies.
Mental health and quality of life
Anxiety
Meta-analysis by Tan 2022 in all cancers found that PMR significantly alleviated anxiety [6 RCTs, standardized mean difference (SMD) =- 1.32, 95% CI (-1.88, -0.75), p<0.001]. Three RCTs reported improvements similar to other interventions for anxiety in mixed cancers (Holland 1991, n=147), gynaecological cancer (Goerling 2014, n=45) and those undergoing radiotherapy (although this study has severe limitations) (Jaya 2020, n=50); two RCTs reported improvements better than usual care for head and neck cancer (Loh 2022, n=60) and colorectal cancer (Ozhanli 2022, n=82). A non-randomized trial in prostate cancer with matched pair comparisons reported improvements in anxiety (Isa 2013b).
Depression
The SR by Tan et al (2022) reported that included RCTs showed significant benefits for PMR for depression (2 RCTs), but meta-analysis was not possible and the overall quality of evidence was moderate to very low. Three other RCTs reported improvements similar to other interventions for depression in mixed cancers (Holland 1991, n=147) and those undergoing radiotherapy (although this study has severe limitations) (Jaya 2020, n=50) and better than usual care for head and neck cancer (Loh 2022, n=60). A non-randomized trial in prostate cancer with matched pair comparisons reported no improvement in depression (Isa 2013b, n=138).
Quality of life
Meta-analysis by Tan et al (2022) for PMR in all cancers found that PMR significantly improved quality of life (QoL) [SMD = 1.65, 95% CI (0.53, 2.76), p = 0.004]. The non-randomized trial in prostate cancer reported improvements in health-related quality of life (Isa 2013a, n=138), although an RCT in women with breast cancer found that PMR did not improve quality of life compared to usual care (Gok Metin 2019, n=63).
Mood, wellbeing,distress
Three trials explored mood, wellbeing and distress. A good quality large RCT (n=148) in cancer patients receiving palliative care found PMR significantly improved mood, relations with others, and enjoyment of life compared to control (Anshasi 2023). A non-randomized trial in prostate cancer with matched pair comparisons reported improvements in mental wellbeing (but not physical wellbeing), (Isa 2013a, n=138). An RCT of patients with lung cancer (n=84) found significantly reduced level of distress compared to control (Kirca 2021), however the sample size may not have been powered and they had high loss to follow-up.
Self-esteem and related outcomes
One SR and four RCTs explored self-esteem, self-efficacy, body image and coping skills. Tan et al (2022) reported that included RCTs also showed significant benefits for PMR for self-esteem (2RCTs), but meta-analysis was not possible and the overall quality of evidence was moderate to very low. Two RCTs in various cancers (Noruzizamenjani 2019, n=80) and in lung cancer (Kirca 2021,n=84) found that PMR compared to standard care may increase self-efficacy, although Kirca (2021) had a high dropout rate.
An RCT in women with breast or gynaecological cancer found that PMR improved body image similar to hypnosis (Barton 2019, n=87), but there was no non-treatment control. An RCT in women with breast cancer found that PMR improved some aspects of coping skills compared to usual care (Gok Metin 2019, n=63).
Stress
A non-randomized trial in prostate cancer with matched pair comparisons reported improvements in stress (Isa 2013b, n=138). Four trials measured physiological stress parameters: one RCT of oncological patients undergoing a stressful diagnostic medical intervention found PMR had an effect similar to medical treatment and better than standard care on brain glucose metabolism (Pifarre 2015, n=84); another RCT in gynaecological cancer found a single session of PMR compared to a psycho-oncological session reduced physiological stress parameters (Goerling 2014, n=45).
In colorectal cancer patients evidence for the impact on cortisol of PMR compared to usual care is conflicting – an RCT found no significant difference (Ozhanli 2022, n=82), but a non-randomised trial found some positive effects (Kim 2016, n=46).
Fatigue/sleep
The meta-analysis by Tan et al (2022) found no significant effect of PMR reducing fatigue [SMD=-1.00, 95% CI (-2.27, 0.27), P=0.120].
However, three good quality RCTs found that PMR improved sleep for cancer patients receiving palliative care (Anshasi 2023, n=148), fatigue for breast cancer patients (Gok Metin 2019, n=63) and sleep and fatigue for patients with head and neck cancer (Loh 2022, n=60). Two other controlled clinical trials reported an improvement in sleep quality and insomnia, but these trials have methodological limitations – one had no non-treatment control group (Simeit 2004, n=229), and the other had a small sample size (Cannici 1983, n=30).
Two other trials showed no effect on fatigue for children with cancer (Sulistyawati 2021, n=30), and patients undergoing radiotherapy (Jaya 2020, n=50), but both have severe methodological limitations. Although there is some evidence of improved sleep and fatigue, it is not possible to draw clear conclusions about the benefits of PMR for these symptoms.
Nausea and vomiting
The SR without meta-analysis investigated PMR for preventing and alleviating chemotherapy-induced nausea and vomiting (Tian 2020). They included six RCTs of 288 patients, three of which were low quality, three moderate. All included RCTs suggested a positive effect, especially on the incidence, frequency, and degree of delayed nausea and vomiting. However, the review did not conduct a meta-analysis and did not justify this, and the process of study selection is unclear.
In the other systematic review (Tan 2022) three included RCTs showed significant reduction in the frequency of nausea and vomiting for PMR compared to control, but meta-analysis was not possible and the overall quality of evidence was moderate to very low. One RCT not included in Tan et al reported improvements in nausea and vomiting (Cotanch 1987). A trial in children with cancer (n=30) found no difference of PMR compared to usual care but results are unclear and it has severe methodological limitations (Sulistyawati 2021).
Pain
The SR by Tan et al (2022) found that PMR showed significant effects of alleviating pain [SMD=- 1.02, 95% CI (- 1.93, - 0.11), P=0.030], however the overall quality of evidence was moderate to very low.
Nine trials (seven RCTs, one pilot and one non-randomised trial) investigated the benefits for cancer pain and other symptoms.
A good quality large RCT (n=148) for cancer patients receiving palliative care found PMR significantly decreased pain intensity and pain interference with general activity compared to control (Anshasi 2023).
Two good quality trials were with colorectal cancer surgery patients. One (n=60) found no effect of PMR compared to standard care on pain and other symptoms (Haase 2005). However, this may be because the PMR was audiotape-only, as the second study (n=82; face to face PMR) found lower postoperative pain and anxiety levels and a lower rate of using opioid analgesic compared to usual care (Ozhanli 2022). Loh (2022) found PMR as an audio-recording did lower pain in patients with head and neck cancer (n=60).
The final three studies have methodological limitations. The first (various cancers, all receiving radiotherapy, n=100) compared PMR to standard care and showed improvements in both cancer pain and fatigue, but lacks reporting of randomisation and has limited quality (validity) outcome measures (Pathak 2013). There is insufficient evidence from the pilot crossover study of various cancers with regards to the efficacy of PMR compared to analgesic imagery or standard care for cancer pain (Kwekkebook 2008, n=40)
The non-randomised trial in breast cancer compared PMR to standard care and showed reductions in severity of pain and other symptoms but has major methodological limitations (Kurt 2018, n=49). A trial in children with cancer (n=30) found no difference of PMR compared to usual care but results are unclear and it has severe methodological limitations (Sulistyawati 2021). A final study of gynaecological patients had so many limitations, including not comparing groups, we cannot draw conclusions (Dikmen 2019).
Other symptoms
Four trials investigated PMR for other symptoms.
An RCT investigated PMR compared to medication and placebo for patients with breast cancer (Shirzadi, n=82). They found significant reduction in hot flushes between the PMR and placebo groups but not compared to medication, but the sample size was not powered and did not reach its target.
A good quality ‘quasi-experimental’ trial investigated PMR compared to usual care for women with breast cancer (n=96) (Vuttanon 2019) and found a significant reduction in some symptoms ‘clusters’.
An RCT of patients with lung cancer (n=84) found significantly reduced symptom scores (frequency, severity and level of distress) compared to control (Kirca 2021), however the sample size may not have been powered and they had high loss to follow-up.
An RCT of women with breast or gynaecological cancer (n=87) found that PMR had similar effects to hypnosis on a range of measures of sexual health (Barton 2019) but the sample was small and the study reporting limited.
Adverse events
PMR is considered to have few or no known adverse effects. (Payne 2010; Pelekasis 2017). Some of the trials included here reported no adverse events (Gok Metin 2019; Barton 2019; Dikmen 2019), but many studies did not report on safety.
Contraindications
Some concerns have been raised about the use of PMR among individuals who have a history of psychiatric disorders, (Isa 2013b) but adverse effects are not well documented.
Interactions
No known interactions.
Warnings
See contraindications.
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