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.

Reports of patients who participated in PMR training following cancer treatment indicate that they experienced reduced state anxiety, pain, and symptoms of depression, as well as improvements in sleep parameters and overall quality of life.

The evidence is however insufficient due to the limited number of trials per outcome 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 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

Helen Cooke, CAM-Cancer Consortium. Progressive Muscle Relaxation [online document]. July 7, 2015.

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.

Training may be offered before, during, or after medical treatment or procedures. PMR sessions commonly last for 20 to 30 minutes, 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 indication(s)

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 body21.

 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.

Cost(s) and expenditures

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

Does it work?

One meta-analysis and fifteen subsequently published controlled clinical trials were reviewed for this summary. The trials are described in table 1. There is, due to the low number (per outcome) of published studies and methodological weaknesses, insufficient evidence for the effectiveness of PMR for cancer patients suffering from pain, anxiety, depression, sleep disorders and chemotherapy-induced nausea. It is, due to the challenges of applying blinding, difficult to test the efficacy of PMR.

Meta-analysis

A meta-analysis examined the effectiveness of relaxation training among patients undergoing acute non-surgical cancer treatment including chemotherapy, radiotherapy, bone marrow transplant and hyperthermia6. 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. However, because PMR was not analyzed separately, its effects on those outcomes were impossible to determine.

Controlled clinical trials

Three controlled clinical trials assessing the effects on sleep reported an improvement in sleep quality and insomnia but these trials have methodological limitations including small sample sizes, lack of non-treatment control group, lack of information on randomization procedure7-9. It is not possible to draw clear conclusions about the benefits of PMR for these symptoms.

Two randomized clinical trials investigating the effects on anxiety and depression reported improvements in both, anxiety and depression10-11. Two further non-randomized trials with matched pair comparisons reported improvements in mental wellbeing (but not physical wellbeing) and health-related quality of life14 and anxiety and stress (no reported improvement in depressions scores)15. A randomised clinical trial suggested a single session of PMR reduced physiological stress parameters18. A further randomised trial reported  significantly lower anxiety levels and cancer-related symptoms19 and a non-randomised trial indicated an improvement in anxiety and general comfort20. All trials have, however, methodological limitations.

Although patients who participated in the two controlled3,12 and one uncontrolled13 trial reported an improvement in nausea and vomiting, all trials were small in numbers and have methodological limitations.

One randomised controlled trial investigating the benefits for cancer pain and fatigue showed improvements in both cancer pain and fatigue. The lack of report of a randomisation process and the quality (validity) of the outcome measures used limit the overall conclusion of this trial16. There is insufficient evidence from one pilot study with regards to the efficacy of PMR for cancer pain4.

One pilot study comparing a type of music therapy with PMR showed significant improvements in physical and psychological wellbeing in both interventions17.

Is it safe?

Adverse events

PMR is considered to have few or no known adverse effects2. No adverse events were reported in the studies analysed for this summary.

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. 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.
  7. Simeit R, Deck, R and Conta-Marx, B. Sleep management training for cancer patients with insomnia. Supportive care in Cancer. 2004; (3): 176-83.
  8. 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.
  9. Demiralp MF, Oflaz, et al. Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. Journal of Clinical Nursing. 2010; 19(7-8): 1073-83.
  10. 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.
  11. Cheung YL, Molassiotis A, Chang AM, 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.
  12. Cotanch PH, Strum S. Progressive muscle relaxation as antiemetic therapy for cancer patients. Oncology Nursing Forum. 1987; 14(1):33-7.
  13. Campos de CE, Martins FT, dos Santos CB. A pilot study of a relaxation technique for management of nausea and vomiting in patients receiving cancer chemotherapy. Cancer Nursing. 2007; 30(2):163-167.
  14. 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.
  15. Isa MR, Moy FM, Abdul 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.
  16. 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.
  17. 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.
  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. Song QH, Xu RM, Zhang QH, Ma M, Zhao XP. Relaxation training during chemotherapy for breast cancer improves mental health and lessens adverse events. Int J Clin Exp Med. 2013;6(10):979-84.
  20. Yilmaz SG, Arslan S. Effects of progressive relaxation exercises on anxiety and comfort of Turkish breast cancer patients receiving chemotherapy. Asian Pac J Cancer Prev. 2015;16(1):217-20.
  21. Conrad A, Roth WT. Muscle relaxation therapy for anxiety disorders: It works but how? Journal of Anxiety Disorders. 2007; 21: 243-264.

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