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Vancampfort, D., De Hert, M., Knapen, J., Maurissen, K., Raepsaet, J., Deckx, S., & ... Probst, M.

(2011). Effects of progressive muscle relaxation on state anxiety and subjective well-being in
people with
schizophrenia:
a randomized controlled trial. Clinical Rehabilitation, 25(6), 567-575
Evaluative
study
9p. doi:10.1177/0269215510395633
Clinical Rehabilitation

Effects of progressive muscle
relaxation on state anxiety and
subjective well-being in people
with schizophrenia: a randomized
controlled trial

25(6) 567–575
! The Author(s) 2011
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DOI: 10.1177/0269215510395633
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Davy Vancampfort1,2, Marc De Hert1,3, Jan Knapen1,2,
Katrien Maurissen1,2, Julie Raepsaet1, Seppe Deckx1,2,
Sander Remans1 and Michel Probst1,2
Abstract
Objective: To examine the efficacy of a single progressive muscle relaxation session compared with
a control condition on state anxiety, psychological stress, fatigue and subjective well-being in patients with
schizophrenia.
Design: Randomized controlled trial.
Setting: An acute inpatient care unit of an University Psychiatric Centre.
Subjects: Sixty-four out of 88 eligible patients with schizophrenia.
Interventions: Patients were randomly assigned to either a single progressive muscle relaxation session
during 25 minutes or a resting control condition with the opportunity to read for an equal amount of time.
Main outcome measures: Before and after the single interventions the State anxiety inventory and the
Subjective exercise experiences scale were completed. Effect sizes were calculated.
Results: Only within progressive muscle relaxation, participants (n=27) showed decreased state anxiety,
psychological stress and fatigue and increased subjective well-being. Between-group differences in post
scores were found for state anxiety, subjective well-being and psychological stress, but not for fatigue. The
effect size favouring progressive muscle relaxation was 1.26 for subjective well-being and 1.25 and 1.02
for respectively state anxiety and psychological stress.
Conclusions: Progressive muscle relaxation is highly effective in reducing acute feelings of stress and
anxiety in patients with schizophrenia. A reduction in stress and state anxiety is associated with an
increase in subjective well-being.

Keywords
Psychiatric rehabilitation, stress, anxiety, physiotherapy
Received 22 March 2010; accepted 5 December 2010
1

University Psychiatric Centre Catholic University Leuven,
Campus Kortenberg, Kortenberg, Belgium
2
Faculty of Kinesiology and Rehabilitation Sciences, Catholic
University Leuven, Leuven, Belgium
3
Faculty of Medicine, Catholic University Leuven, Leuven,
Belgium

Corresponding author:
Davy Vancampfort, University Psychiatric Centre Catholic
University Leuven, Campus Kortenberg, Leuvensesteenweg
517, B-3070 Kortenberg, Belgium
Email: Davy.Vancampfort@uc-kortenberg.be

Participants with the following characteristics were excluded from the study: (a) having a psychiatric co-morbidity (anxiety disorders and/or depressive disorders. (d) not being able to complete the questionnaires within 5–10 minutes . hallucinations and disorganized speech and behaviour. stress and subjective well-being in a sample group of patients with schizophrenia. anxiety and well-being should therefore be key.2 Positive symptomatology reflects an excess or distortion of normal functions and manifests itself in symptoms such as delusions. Methods Over a 12-month period. Chen et al.2–22. consider both trait anxiety and state anxiety. avolition.7.12 To the authors’ knowledge. substance dependence).3 Increased sensitivity to anxiety and stress is related to worsening of symptoms. It influences one’s cognitive appraisal. Negative symptoms reflect a reduction or loss of normal functions. one must. Trait anxiety is independent of specific situations and measures a person’s general level of anxiety that persists on a regular basis. stress and subjective well-being following the intervention. The single-session format was utilized to facilitate evaluation of acute changes in state anxiety.8 Studies of progressive muscle relaxation as an intervention in treating trait anxiety in people with chronic schizophrenia have been performed since the early 1980s.300. however. an increase in subjective anxiety and stress results in an increase in negative affect and a decrease in positive well-being. (c) not being able to concentrate for 25 minutes duration at a time.1 The Diagnostic Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for schizophrenia include positive and negative symptomatology severe enough to cause social and occupational dysfunction.4. social withdrawal and cognitive impairments. People with schizophrenia experience difficulties in coping with anxiety and stress and possess a relatively limited repertoire of coping strategies. Relaxation techniques including progressive muscle relaxation have been considered as an adjunctive therapy for dealing with stress. respectively. In contrast. the present study is the first to examine the effects of a single session of progressive muscle relaxation on state anxiety. (b) exhibiting musculoskeletal problems that might affect progressive muscle relaxation training. consisting of symptoms such as affective flattening. Previous studies only focused on trait anxiety.10 confirmed that the degree of trait anxiety improvement is significantly higher in a progressive muscle relaxation group receiving Clinical Rehabilitation 25(6) 40 minutes of progressive muscle relaxation for 11 consecutive days than in a placebo control group. which has an impact on how individuals perceive stressful situations.5 In schizophrenia. demonstrated that after 10 sessions of 40 minutes of progressive muscle relaxation (five times a week) participants demonstrated reduced trait anxiety compared with a minimal treatment control.0 per 100 000 person-years.11 It can be defined as the actually experienced emotional status. The lifetime prevalence and incidence are 0. state anxiety is dependent on very specific situations and changes on a regular basis.568 Introduction Schizophrenia is one of the most debilitating psychiatric disorders. Hawkins et al.66% and 10. Acute symptoms were at least partially remitted in all patients.6 Clinical rehabilitation strategies that aim to enhance coping with feelings of stress. apathy. When measuring a person’s level of anxiety. Trait anxiety can be defined as a predisposition to perceive a situation as threatening.9 Recently. anxiety and depression and can provide patients with self-maintenance coping skills to reduce these symptoms. consecutive patients with a DSM-IV2 diagnosis of schizophrenia from an acute inpatient care unit were invited to participate. Individuals with higher trait anxiety (a greater disposition to experience anxiety) show higher levels of state anxiety in different situations than lower trait anxious individuals.

Progressive muscle relaxation was offered once a week and lasted approximately 25 minutes. Control condition Participants in the resting control condition sat quietly in a room for 25 minutes and were told that they could read. All participants gave their informed consent. psycho-education about an active lifestyle (once every two weeks) and group-related movement sessions with psychosocial and cognitive objectives (twice a week). Tensing for about 8 seconds and relaxing for about 30 seconds of each muscle group was practised twice prior to proceeding to a subsequent muscle group. The Subjective Exercise Experiences Scale represents one of the most reliable and valid instruments for assessing subjective well-being in exercise settings. without difficulties and with minimal instructions. The effects of 25 minutes of progressive muscle training were compared with a resting control condition. (e) having received previous progressive muscle relaxation training. Questionnaires State Anxiety Inventory.16 The range of possible total scores is 20–80. After the resting control condition and after completing the questionnaires. During the week of the test condition also psychiatric symptoms were administered. Stress. yoga training (once a week). Progressive muscle relaxation is part of a assessed by the State Anxiety Inventory of Spielberger. In the third week participants were randomly allocated to either the experimental progressive muscle relaxation or the resting control condition. The study procedure was approved by the Scientific and Ethical Committee of the University Psychiatric Centre of the Catholic University of Leuven in accordance with the principles of the Declaration of Helsinki. An independent statistician generated a randomization list using a research randomizer (www. Bernstein and Borkovec14 later shortened this technique to 16 muscle groups and found it to be equally effective. which are scored on a scale from 0 (not at all) to 7 (entirely). Feedback was elicited during these sessions to allow participants to experience and share the changes and sensations of relaxation. Subjective Exercise Experiences Scale. During two weeks participants undertook one weekly habituation session in order to get used to the environment and the protocol. 569 larger clinical physiotherapy programme consisting of aquatic sessions (once a week).13 The original Jacobson method required dozens of sessions where the participant was taught to relax 30 different muscle groups.17 .15 The protocol for the progressive muscle relaxation in this study was administered by a trained physiotherapist. The State Anxiety Inventory has been extensively validated and is the most widely used measure of anxiety in exercise research. walking (twice a week).Vancampfort et al. fitness training (twice a week). beginning with the upper body and proceeding to the lower parts.org). Reading material was provided for participants who did not bring their own material. participants still had the opportunity to take part in another progressive muscle relaxation session. Higher scores on a subscale indicate a higher perception for this factor. subjective well-being and fatigue were measured using the Subjective Exercise Experiences Scale. The same physiotherapist was also here present in the room and only left during completion of the questionnaires. Training consisted of successive tensing and relaxing at least five major muscle groups. Questionnaires were answered 5 minutes before and immediately after the completion of the condition. Higher scores indicate higher levels of anxiety.randomizer. State anxiety was Progressive muscle relaxation Progressive muscle relaxation was originally developed by Edmund Jacobson.17 Each subscale contains four items.

For differences in gender distribution the Fisher exact test was used. All Cronbach’s alpha values exceeded the commonly used criterion of 0. feelings of guilt. excitement) symptoms. depression. The scores for each factor range from 4 to 28.00 (95% CI ¼ 1. 64 met the inclusion criteria.570 Clinical Rehabilitation 25(6) Psychosis evaluation tool for common use by caregivers The significance level was set at 0. The psychosis evaluation tool for common use by caregivers18 was used by an independent and well-trained nurse to evaluate schizophrenia symptoms. positive well-being and fatigue on the Subjective Exercise Experiences Scale. Reasons for exclusion are presented in Figure 1. fatigue and increased subjective well-being could be observed. somatic concerns). 0.49).63) for state anxiety. The established criteria of the effect size. hostility.25 (95% CI ¼ 1. passive/apathetic withdrawal. Both groups differed significantly from each other for all the post measures.43) for . resulting in an overall score ranging from 20 to 140. body mass index and symptomatology.92 and 0. psychological stress. One of these 26 reports contained incomplete data and was excluded from the final analysis. Participants in the progressive muscle relaxation and control condition were similar at baseline related to age. lack of cooperation. Out of 88 patients with schizophrenia. More details on drop-out data are given in Figure 1. which indicates acceptable internal consistency of the measurements.83 to 0.58 to 0. Symptoms are grouped in five factors: positive (hallucinations. The descriptive characteristics of the patients who completed the intervention study are shown in Table 1. and 0.78.19 Results Statistical analysis To assess the differences in baseline characteristics between the progressive muscle relaxation group and control condition groups an unpaired Student’s t-test was used. MANOVA showed a significant time by group interaction for the State Anxiety Inventory and Subjective Exercise Experiences Scale (Wilks  ¼ 0. cognitive (poor attention. The internal consistency assessed by Cronbach’s alpha coefficients in the present study was 0. A 2  2 (condition  time) MANOVA with post-hoc Scheffe´ was conducted using Statistica 9 to test the significance of the within pre–post and between-groups post scores differences. P < 0. Scheffe´ post-hoc analysis revealed that within the progressive muscle relaxation group significant decreased state anxiety. There were no significant pre–post changes within the control group. unusual thought content.05 (twotailed). depressive (anxiety. conceptual disorganization) and excitatory (poor impulse control. blunted affect.20 Relationships between changes in measurement variables were assessed using Pearson product moment correlations.79) and large (>80).70. 27 (84%) completed the session and filled out the questionnaires correctly. Effect sizes for progressive muscle relaxation were 1. In the control group. grandiosity).50–0. Effect size for a given variable was calculated as the difference after treatment between the treatment and control condition divided by the pooled standard deviation. disorientation.001). negative (poor rapport. motor retardation). The results for all outcomes are presented in Table 2.90 for the State Anxiety Inventory. 26 patients (81%) filled out the questionnaires. It evaluates 20 symptom items on a 7-point scale. 1. delusions.44.20–0. Validation results suggest that the psychosis evaluation tool for common use by caregivers can be successfully used for the evaluation of symptoms in schizophrenia. gender.70 for respectively the subscales psychological stress. difficulties with abstract thinking. which reflects the effect of a treatment are small (0. medium (0. From the 32 patients who where allocated to the progressive muscle relaxation.

not able to concentrate for 25 minutes (n=1).09) for fatigue.02 to 0.21. other appointment (n = 1). musculoskeletal problems (n = 4). not motivated to fill in the questionnaires (n = 1). This corresponds with earlier observed associations in schizophrenia between subjective appraisals of anxiety.26 (95% CI ¼ 0.46 (1. psychological stress and subjective well-being in patients with schizophrenia. Table 3 indicates that in the progressive muscle relaxation group a reduction in state anxiety was significantly correlated with a psychological stress reduction and an increase in subjective well-being. transfer to other hospital (n= 2) Analysed (n = 25) Excluded from analysis (n= 1) Reason: incomplete data Figure 1. stress . previous experience with progressive muscle relaxation (n= 13).Vancampfort et al. psychological stress. Flowchart of the eligible patients. Allocated to progressive muscle relaxation (n= 32) Received progressive muscle relaxation (n= 27) Did not receive allocated intervention (n = 5) Reasons: refused to participate (n = 1). The findings concur with previous progressive muscle relaxation studies investigating trait anxiety reductions in schizophrenia9. +1. other appointment (n= 2).10 and are consistent with prior reports in other populations.84) for subjective well-being and 0. not motivated to continue the session (n= 1) Analysed (n= 27) Excluded from analysis (n = 0) Allocated to the control condition (n = 32) Received control condition (n = 26) Did not receive allocated intervention (n = 6) Reasons: refused to participate (n = 2). Discussion This is the first study with a randomized controlled group design demonstrating significant effects of a single session of progressive muscle relaxation on state anxiety.65 to 1. 571 Assessed for eligibility (n = 88) Excluded (n = 24) Reasons: psychiatric comorbidity (n = 6). transfer to other hospital (n = 1).22 Results furthermore indicated that reduced ratings of state anxiety are associated with decreased psychological stress and increased subjective well-being.

41 0. The use of alcohol.76  5.b 45.86 7.23–25 Although numerous motivations exist to use these substances. State Anxiety Inventory.36  5.52  4.90  4.24  11.99 2. This study demonstrates that relaxation techniques may .98  4.59 12. Table 2.57a.92  3.64 0. Sheffe´ test (P set at 0.44 11.48  3.22  10. The ability to deal with state anxiety.59  5. State anxiety.60 10.77 54.68  10.52  5.75 24.08  0.67 %) 9 (33.78  4.65 9. psychological stress and negative affect during progressive muscle relaxation may of relevance for several other mental health benefits. PECC.85 0.74  10.40  11.22  13.11  5.b 7. it has been suggested that the mentioned unhealthy behaviours may partly be attempts to alleviate or to cope with unpleasant affective states and feelings of state anxiety.25 12.97 6.58  3.6 The present study provides support for the utility of behavioural interventions such as progressive muscle relaxation in reducing state anxiety and increasing subjective well-being in patients with schizophrenia.84 0.15  0.74a. stress.12 P-value 0.49 Values expressed as mean  standard deviation.12a.85  4.52  4.26–28 The limited benefit of such efforts supports the need to provide other more healthy methods to regulate the variability of subjective well-being.05 16.33 %) 35.44  8.16  5.37  3. Psychosis Evaluation tool for Common use by Caregivers.30 11.97 12.56  4. SAI.48 0.57 10. MANOVA with repeated measures. Subjective Exercise Experiences Scale.64 Values expressed as mean  standard deviation or as otherwise indicated.51 2.64a. well-being and fatigue scores before and after progressive muscle relation and control condition State anxiety (SAI) Stress (SEES) Well-being (SEES) Fatigue (SEES) Progressive muscle relaxation (n ¼ 27) Control condition (n ¼ 25) Pre Post Pre Post 45. Baseline characteristics of the participants who received progressive muscle relaxation or a control condition Gender Male (%) Female (%) Age Body mass index Number of antipsychotics PECC total score Positive symptoms Negative symptoms Depressive symptoms Excitement Cognitive symptoms Progressive muscle relaxation (n ¼ 27) Control condition (n ¼ 25) 18 (66.44 15.28 24.70  5.92  4.68  5.94 11.71 0. b Post progressive muscle relaxation versus post control condition.00%) 35.29  2. SEES.05).b 21.44 11.16  5. nicotine or illegal drugs is a common practice among individuals with schizophrenia.92 45.77 13 (52.50 15.96  12.37 33.b 8.84 54.33  4. a Pre versus post progressive muscle relaxation.572 Clinical Rehabilitation 25(6) Table 1.71 13. and concurrent mood (an increase in negative and a decrease in positive affect).00%) 12 (48.80 12.64  4.40 0.31 11.91 0.99 12.57 0.

State Anxiety Inventory. It also needs to be demonstrated if the beneficial effects of progressive muscle relaxation can be translated into behavioural outcomes. A third limitation was the lack of repeated measures after the progressive muscle relaxation session.Vancampfort et al. Even though these were habituation sessions.00 Further studies need to replicate the present findings in a larger sample and with more repeated measures. SAI. Fifth. offer such an easy to learn healthy alternative for subjective stress and state anxiety regulation. for example through increasing rates of abstinence from alcohol.47* 0. Fourth. the current study did not examine potential physiological and/or psychological mechanisms that are responsible for the reduced state anxiety. Secondly. 573 Table 3. psychological distress and improved subjective well-being. distraction)31 that could be responsible for the reduced state anxiety and psychological stress and improved subjective well-being. The sample size was rather small and collected in a single hospital which may affect the generalizability of the findings. Despite state anxiety reductions lasting for 2–4 hours after cessation of the exercise. *P < 0. increased selfefficacy. it is not known whether the session of progressive muscle relaxation may have exerted its effects Recommendations and implications for clinical practice As progressive muscle relaxation has produced very encouraging results in this study.58* 1. Pearson product moment correlation matrix of the significant pre–post difference effect sizes for State Anxiety Inventory and Subjective Exercise Experiences Scale in the progressive muscle relaxation group State anxiety (SAI) Stress (SEES) Well-being (SEES) merely as a diversion or as welcomed evidence to patients that their psychosocial needs were being acknowledged. Furthermore.00 / 0. SEES. increased norepinephrine. future studies should examine whether implementing self-managed relaxation techniques increases rates of abstinence from substance abuse and whether any effects of progressive muscle relaxation on abstinence rates are mediated by reductions in psychological stress and state anxiety and increases in subjective well-being during or following these activities. Subjective Exercise Experiences Scale. Lastly.51* 1. State anxiety (SAI) Stress (SEES) Well-being (SEES) Recommendations and implications for future research 1. The present study indicates that progressive muscle relaxation could already be started in an acute inpatient care unit.32 . the amount of time spent with a patient may have been therapeutic in nature.05 (two-tailed).29 only the response immediately after the completion of the session was assessed.g. The present results should be viewed in the light of several methodological limitations. nicotine or illegal drugs. state anxiety and well-being responses only were measured with self-report questionnaires. This echoes previous findings suggesting that searching for a method of self-management is a powerful factor in the early stages of treatment.g. it can be argued that the two habituation sessions given before the intervention are actually part of the intervention and their effects on the outcomes of the study need to be considered. Specifically. We also did not include parameters such as illness duration or educational level in order to increase the external validity.00 / / 0. it is suggested that progressive muscle relaxation should be offered as routine care to patients with schizophrenia experiencing state anxiety and psychological stress. increased parasympathetic activity)30 and/or psychological mechanisms (e. serotonin and beta-endorphins. future research needs to examine potential physiological (e. No power analysis was completed prior to the start of data collection.

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