Concerted Action for Complementary and Alternative Medicine Assessment in the Cancer Field (CAM-Cancer) www.cam-cancer.

org

Project initiated under the European Commission 5th Framework Program "Quality of Life", now hosted by the National Information Center for
Complementary and Alternative Medicine in Tromsø, Norway.

Scientific Co-ordinator Barbara Wider contact@cam-cancer.org.

Written by Helen Cooke and the CAM-Cancer Consortium.

Updated July 7, 2015
Progressive Muscle
Relaxation

Abstract and key points

Progressive Muscle Relaxation (PMR)
therapy involves sequential tensing and Progressive muscle relaxation (PMR) is a technique
relaxation of major skeletal muscle that involves the sequential tensing and relaxation of
groups and aims to reduce feelings of major skeletal muscle groups with the aim of
tension, to lower perceived stress, and to inducing relaxation.
induce relaxation. PMR is purported to There is insufficient evidence for the effectiveness
decrease the arousal of the autonomic of PMR for cancer patients suffering from pain,
and central nervous system and to anxiety, depression, sleep disorders and
increase parasympathetic activity. chemotherapy-induced nausea.
PMR is generally considered to be safe.
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.

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

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
1/6
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 events.15 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.21

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 anxious.2

Some researchers have suggested that PMR may serve as a distraction for patients who undergo
chemotherapy,3 whereas others propose that distraction is only part of the effectiveness of such
interventions.4

Prevalence of use

A population-based study carried out in the USA of 4 000 cancer survivors who were followed up 10 to 24

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
2/6
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 (see also table 1)

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

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
3/6
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.

Table 1: Controlled clinical trials of PMR

Table 1: Controlled clinical trials of PMR

Citation
Helen Cooke, CAM-Cancer Consortium. Progressive Muscle Relaxation [online document].

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
4/6
http://www.cam-cancer.org/CAM-Summaries/Mind-body-interventions/Progressive-Muscle-Relaxation. July
7, 2015.

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.

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.

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
5/6
 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.

Legal notice
The present documentation has been compiled by the CAM-CANCER Project with all due care and expert knowledge.
However, the CAM-CANCER Project provides no assurance, guarantee or promise with regard to the correctness,
accuracy, up-to-date status or completeness of the information it contains. This information is designed for health
professionals. Readers are strongly advised to discuss the information with their physician. Accordingly, the
CAM-CANCER Project shall not be liable for damage or loss caused because anyone relies on the information.

Please visit the CAM-Cancer website for more information about the project:

www.cam-cancer.org

Published with Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License
www.cam-cancer.org
6/6