Progressive Muscle Relaxation | Cam-Cancer

Progressive Muscle Relaxation

Abstract and key points
  • Progressive muscle relaxation (PMR) is a technique that involves the sequential tensing and relaxation of major skeletal muscle groups with the aim of inducing relaxation
  • There is insufficient evidence for the effectiveness of PMR for cancer patients suffering from pain, anxiety, depression, sleep disorders and chemotherapy-induced nausea
  • PMR is generally considered to be safe

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.

Systematic reviews/controlled trials suggest that PMR may reduce chemotherapy-related side effects (one review), reduce anxiety and depression (two trials), reduce physiological stress parameters (three trials), improve self-efficacy (one trial), reduce duration of nausea and vomiting (two trials) and improve cancer pain (four trials). Evidence for sleep is inconclusive. The evidence for all outcomes is insufficient due to the limited number of trials per outcome, poor quality and methodological limitations of published studies.

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.

Document history

Last revised and updated in March 2019 by Ava Lorenc.
Last revised and updated in July 2015 by Helen Cooke.
Summary last updated in December 2013 by Helen Cooke.
Summary fully revised and updated in July 2012 by Helen Cooke.
Summary first published in July 2011, authored by Helen Cooke.

Citation

Ava Lorenc, Helen Cooke, CAM-Cancer Consortium. Progressive Muscle Relaxation [online document]. 22nd March, 2019.

What is it?

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.

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 person27.

Training may be offered before, during, or after medical treatment or procedures. PMR sessions commonly last for 20 to 30 minutes6, 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.

History and provider

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 PMR1.

Claims of efficacy/mechanism of action/alleged indications

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 events15. 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 body26.

Alterations in sympathetic nervous system activity, including decrease in pulse rate, blood pressure, and musculoskeletal tone, and altered neuroendocrine function, have been observed in relaxed subjects. It has been suggested that deep somatic restfulness reduces anxiety and physical arousal2 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 anxious2.

Some researchers have suggested that PMR may serve as a distraction for patients who undergo chemotherapy3, whereas others propose that distraction is only part of the effectiveness of such interventions4.

Prevalence of use

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 therapy5.

Legal issues

Although many institutions and individuals offer PMR training, what they teach is not standardized, and no credentialing process is available for PMR instructors.

Costs and expenditures

PMR can be administered or taught relatively easily and is therefore in most cases a relatively inexpensive therapy.

Does it work?

Supportive/palliative care

Three systematic reviews including one meta-analysis and eighteen additional papers (reporting seventeen controlled clinical trials) 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.

These systematic reviews/controlled trials suggest that PMR may reduce chemotherapy-related side effects (one review), reduce anxiety and depression (two trials), reduce physiological stress parameters (three trials), improve self-efficacy (one trial), reduce duration of nausea and vomiting (two trials) and improve cancer pain (four trials). Evidence for sleep is inconclusive.

The evidence for all outcomes is insufficient due to the limited number of trials per outcome, poor quality and methodological limitations of published studies.

Quality of life/various outcomes

A systematic review examined the effectiveness of PMR for patients undergoing chemotherapy6.  It included 5 studies (four randomised controlled trials; one matched controls) which were all very low quality (only scoring 0 or 1 on the Jadad scale). The review did not synthesise the results but presented them narratively. The review suggests that PMR might reduce discomfort, anxiety and side effects caused by chemotherapy, except for vomiting, but the poor quality of studies does not allow any reliable conclusions6.

Ten controlled clinical trials used outcomes of mental health, wellbeing or quality of life. Two randomized clinical trials (one good quality, one moderate) in mixed cancers (n=147)11 and colorectal cancer (n=59)12 reported improvements compared to usual care and similar to medical intervention for anxiety and depression. A non-randomized trial in prostate cancer (published as two papers) with matched pair comparisons reported improvements in mental wellbeing (but not physical wellbeing), health-related quality of life (n=138)13 and anxiety and stress (but not depression) (n=138)14. One pilot study in gynaecological cancer compared PMR to music therapy and showed significant improvements in physical and psychological wellbeing in both interventions (n=40)15. A randomised controlled trial of colorectal cancer patients post-surgery showed no effect of PMR compared to standard care on short-term quality of life (however this may be because the PMR was audiotape-only) (n=60)16.  Three trials measured physiological stress parameters: one randomised controlled trial 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 (n=84)17; another randomised clinical trial in gynaecological cancer found a single session of PMR compared to a psycho-oncological session reduced physiological stress parameters (n=45)18; and a non-randomised trial in colorectal surgery patients of PMR compared to standard care found some positive effects on cortisol (n=46)19. Finally, a randomised controlled trial in various cancers found that PMR compared to standard care may increase self-efficacy (n=80)20. All trials have, however, methodological limitations. The findings on anxiety and depression and self-efficacy are probably the most reliable.

Sleep/insomnia

Two controlled clinical trials assessing the effects on sleep reported an improvement in sleep quality and insomnia, but these trials have methodological limitations – one had no non-treatment control group (n=229)9, and the other had a small sample size (n=30)10. It is not possible to draw clear conclusions about the benefits of PMR for these symptoms.

Nausea and vomiting

Two randomised controlled trials reported improvements in nausea and vomiting21-22.  The higher quality trial was in breast cancer and had a powered sample size, little missing data, and details of randomisation (n=71). They compared practitioner-delivered PMR to standard care and found a shorter duration of nausea and vomiting and less mood disturbance, but no difference in frequency or intensity21.  

Pain

Four trials (two randomised controlled trials, one pilot and one non-randomised trial) investigated the benefits for cancer pain and other symptoms. One good quality trial (n=60) for colorectal cancer surgery patients found no effect of PMR compared to standard care on pain and other symptoms (however this may be because the PMR was audiotape-only)23, the other (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 measures24. 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 (n=40)4. 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 (n=49)25.

PMR in combination with other treatments

Two further systematic reviews did not analyse the effect of PMR separately and it is therefore not possible to draw conclusions about the effect of PMR alone. One systematic review examined the effect of PMR plus guided imagery on cancer patients receiving chemotherapy7. Nearly all the 7 included studies were for breast cancer only.  Although the review concluded that PMR plus guided imagery is effective at reducing the impact of nausea and vomiting and improving patients’ mental state, the trials were of poor quality, scoring between 0 and 3 on the 5-point Jadad scale. A meta-analysis examined the effectiveness of relaxation training among patients undergoing acute non-surgical cancer treatment including chemotherapy, radiotherapy, bone marrow transplant and hyperthermia8. In 14 of 15 studies reviewed, PMR, guided imagery and other modalities were lumped together and evaluated for their effects on symptom control. The review concluded that clinically significant reductions in nausea, pain, anxiety, depression, hostility and physical arousal (blood pressure and pulse) were achieved following relaxation training. No quality assessment of the included studies was reported.

Is it safe?

Adverse events

PMR is considered to have few or no known adverse effects2,6. No adverse events were reported in the studies analysed for this summary, although 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 disorders14, but adverse effects are not well documented.

Interactions

No known interactions.

Warnings

See contraindications.

References
  1. Jacobson, E. Progressive Relaxation. Chicago, University of Chicago Press, 1938
  2. Payne, R and Donaghy, M. 2010. Fourth Edition. Payne’s Handbook of Relaxation Techniques: a practical guide for the health care professional. London: Churchill Livingstone, Elsevier.
  3. Arakawa S. Relaxation to reduce nausea, vomiting, and anxiety induced by chemotherapy in Japanese patients. Cancer Nursing. 1997; 20(5):342-914.
  4. Kwekkeboom K, Wanta B, Bompus M. Individual difference variables and effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. Journal of Pain and Symptom Management. 2008; 36(6): 604-615
  5. Gansler T, Kaw C, Crammer C, Smith T. A population-based study of prevalence of complementary methods use by cancer survivors: a report from the American Cancer Society's studies of cancer survivors. Cancer.2008; 113(5):1048-57.
  6. Pelekasis P, Matsouka I, Koumarianou A. Progressive muscle relaxation as a supportive intervention for cancer patients undergoing chemotherapy: A systematic review. Palliat Support Care 2017; 15(4): 465-473.
  7. Kapogiannis AS, Tsoli S, Chrousos G. Investigating the Effects of the Progressive Muscle Relaxation-Guided Imagery Combination on Patients with Cancer Receiving Chemotherapy Treatment: A Systematic Review of Randomized Controlled Trials. Explore (NY) 2018; 14(2): 137-143.
  8. Luebbert K, Dahme B, Hasenbring M. The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: a meta-analytical review. Psycho-Oncology. 2001; 10(6):490-502.
  9. Simeit R, Deck, R and Conta-Marx, B. Sleep management training for cancer patients with insomnia. Supportive care in Cancer. 2004; (3): 176-83.
  10. Cannici J, Malcolm R, Peek LA. Treatment of insomnia in cancer patients using muscle relaxation training. Journal of Behavior Therapy and Experimental Psychiatry. 1983; 14:251– 256
  11. Holland JC, Morrow GR, Schmale A, Derogatis L, Stefanek M, Berenson S, et al. A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms. Journal of Clinical Oncology. 1991; 9(6):1004-11.
  12. Cheung YL, Molassiotis A, Chang AM, The effect of progressive muscle relaxation training on anxiety and quality of life after stoma surgery in colorectal cancer patients. Psycho-Oncology. 2003; 12(3):254-66.
  13. Isa MR, Moy FM, Razack AH, Zainuddin ZM, Zainal NZ. Impact of applied progressive deep muscle relaxation training on the health related quality of life among prostate cancer patients--a quasi experimental trial. Preventive medicine. 2013; 57 Suppl:S37-40.
  14. Isa MR, Moy FM, Razack AH, Zainuddin ZM, Zainal NZ. Impact of applied progressive deep muscle relaxation training on the level of depression, anxiety and stress among prostate cancer patients: a quasi-experimental study. Asian Pacific journal of cancer prevention : APJCP. 2013;14(4):2237-42.
  15. Lee EJ, Bhattacharya J, Sohn C, Verres R. Monochord sounds and progressive muscle relaxation reduce anxiety and improve relaxation during chemotherapy: a pilot EEG study. Complementary therapies in medicine. 2012;20(6):409-16.
  16. Koplin, G., V. Muller, G. Heise, J. Pratschke, W. Schwenk and O. Haase. Effects of psychological interventions and patients' affect on short-term quality of life in patients undergoing colorectal surgery. Cancer Med 2016; 5(7): 1502-1509.
  17. Pifarré P, Simó M, Gispert JD, Plaza P, Fernández A, Pujol J. Diazepam and Jacobson's progressive relaxation show similar attenuating short-term effects on stress-related brain glucose consumption. European psychiatry 2015; 30(2): 187‐192.
  18. Goerling U, Jaeger C, Walz A, Stickel A, Mangler M, van der Meer E. The efficacy of short-term psycho-oncological interventions for women with gynaecological cancer: a randomized study. Oncology. 2014; 87(2):114-24. 
  19. Kim KJ, Na YK, Hong HS. Effects of Progressive Muscle Relaxation Therapy in Colorectal Cancer Patients. 2016; West J Nurs Res 38(8): 959-973.
  20. Noruzizamenjani M, Masmouei B, Harorani M, Ghafarzadegan R, Davodabady F, Zahedi S, et al. The effect of progressive muscle relaxation on cancer patients’ self-efficacy. Complementary Therapies in Clinical Practice 2019; 34: 70-75.
  21. Molassiotis, A, Yung HP, Yam BM, Chan FY, Mok T. The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a randomised controlled trial. Supportive Care in Cancer 2002; 10(3): 237-246.
  22. Cotanch PH and Strum S. Progressive muscle relaxation as antiemetic therapy for cancer patients. Oncology Nursing Forum. 1987; 14(1):33-7.
  23. Haase O, Schwenk W, Hermann C, Muller JM. Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Dis Colon Rectum 2005; 48(10): 1955-1963.
  24. Pathak P, Mahal R, Kohli A, Nimbran V. Progressive Muscle Relaxation: An Adjuvant Therapy for Reducing Pain and Fatigue Among Hospitalized Cancer Patients Receiving Radiotherapy. Int J Adv Nurs Stud. 2013;2:58-65.
  25. Kurt B, Kapucu S. The effect of relaxation exercises on symptom severity in patients with breast cancer undergoing adjuvant chemotherapy: an open label non-randomized controlled clinical trial. European journal of integrative medicine 2018; 22: 54‐61.
  26. Conrad A, Roth WT. Muscle relaxation therapy for anxiety disorders: It works but how? Journal of Anxiety Disorders. 2007; 21: 243-264.
  27. Burish TG, Tope DM. Psychological techniques for controlling the adverse side effects of cancer chemotherapy: Findings from a decade of research. Journal of Pain and Symptom Management 1992; 7(5): 287-301.

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