Original article

A retrospective audit exploring the use of relaxation as an

intervention in oncology and palliative care
J. MILLER, bsc (hons), msc & senior occupational therapist, Occupational Therapy Department, The Royal
Marsden Hospital, Sutton, Surrey, & C. HOPKINSON, bhsc(ot), team leader, Occupational Therapy Department,
Thames Hospicecare, Windsor, Berkshire, UK

MILLER J. & HOPKINSON C. (2008) European Journal of Cancer Care 17, 488–491
A retrospective audit exploring the use of relaxation as an intervention in oncology and palliative care

The benefits of relaxation in cancer care have been well documented within the literature, with the majority
of research being undertaken by nursing professionals. However, evidence of the effectiveness of relaxation
interventions by occupational therapists is lacking. Occupational therapists are in an ideal situation to provide
information and practical relaxation sessions. Athough in numerical terms, the outcome of relaxation inter-
ventions is small, functional outcome related to quality of life and independence in activities of daily living is
immeasurable. This article reports the findings of a retrospective audit exploring relaxation-specific referrals
to occupational therapy, and identifies effectiveness of a variety of different techniques currently employed
within this specific programme. Patients with a primary diagnosis of breast cancer were the most frequently
seen, and this prevalence is reflected in current national statistics. Similarly, those between 50 and 59 years of
age comprised the largest group. Guided visualization was the most commonly used technique, although there
appeared to be very little change in perceived tension between all the techniques. Further study of the impact
relaxation has on occupational performance would be worthwhile.

Keywords: occupational therapy, oncology, palliative care, relaxation, symptom management, audit.

IN TR O D U C T I O N Relaxation management promotes a client-centred and

Recently published statistics report that one in three
people are diagnosed with cancer during their lifetime
(ONS 2005). Within the field of oncology and palliative
care, there is an increasing prevalence of the use of non-
pharmacological interventions as an adjunct to conven-
tional treatments such as radiotherapy, chemotherapy and
pharmacological treatments (Shen et al. 2002). Relaxation
is now viewed as a core component of such interventions,
and comprises an essential element of specific rehabilita-
tion programmes run at the Royal Marsden Hospital,
Europe’s largest cancer centre.
Correspondence address: Jenny Miller, Senior Occupational Therapist,
Occupational Therapy Department, The Royal Marsden Hospital, Sutton,
Surrey SM2 5PT, UK (e-mail: jenny.miller@rmh.nhs.uk).
Accepted 25 October 2007
DOI: 10.1111/j.1365-2354.2007.00899.x
European Journal of Cancer Care, 2008, 17, 488–491
educational approach that facilitates the individual’s rec-
ognition of potential stressors and equips them with the
skills required to manage such stressors (Ewer-Smith &
Patterson 2002). While the majority of published literature
refers primarily to nurse-led relaxation programmes, this
definition brings relaxation in line with occupational
therapy philosophy, and, therefore, makes it an appropri-
ate intervention for the profession. It is imperative to
appreciate that side effects and symptoms of both disease
and treatment can seriously impact on occupational func-
tion, and a multiprofessional approach is consequently
necessary to identify and address these barriers, thereby
enabling optimal occupational performance.
A review of the literature demonstrated that relaxation
has been found to be effective in managing both distress-
ing side effects of cancer treatment (Leubbert et al. 2001)
and common symptoms associated with the advanced
stages (Hanratty & Higginson 1994). The positive effects

© 2008 The Authors

Journal compilation © 2008 Blackwell Publishing Ltd

the techniques can have on the psychological experience
of living with cancer includes enhancing patients experi-
ence of depression (Sloman 2002), management of anxiety
and stress reduction (Decker et al. 1992), and subse-
quently improving overall quality of life (Cheung et al.
2003).
The efficacy of relaxation in promoting comfort as a
means of managing side effects of disease and pharmaco-
logical and surgical interventions is also evident within
the literature. Examples of the side effects that have been
found to positively respond to relaxation are: disease-
related and treatment-related pain (Syrjala et al. 1995),
nausea and vomiting (Carty 1997), anxiety and stress
(Leubbert et al. 2001), and breathlessness (Cooper 1997).
Brief description of programme and techniques
As a general rule, of those patients referred to the occupa-
tional therapy service for relaxation, four sessions of relax-
ation are offered, with an end point ideally being indicated
by a decrease in tension or other related symptom, and an
improvement in occupational performance. However, the
tertiary status of the Trust means that patients potentially
live too far away to consider returning for a complete
relaxation programme, and so inpatients commonly
receive one relaxation session. Patients are also com-
monly provided with a compact disc (CD) on which the
practised technique is available, as well as written infor-
mation outlining the safe and most effective use of the CD
provided, for example ‘do not use when driving’. Due to
potential contra-indicators, it is vital that CDs are only
issued as an accompaniment to a session with the profes-
sional, so that the risks can be minimized and the benefits
optimized by using the most appropriate technique for
each individual patient. The techniques shown in Table 1
are implemented within the Royal Marsden’s relaxation
programme in the form of written scripts, which are ver-
balized by the therapist.
Aims of the audit
The aims of this audit were to identify the nature of
referrals to the relaxation programme, explore the variety
of relaxation techniques implemented and evaluate its
general effectiveness.
M ET H O D
The study took the format of a retrospective clinical audit
using anonymous data gained during the referred patient’s
period of treatment. The sample consisted of patients
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd
Use of relaxation as intervention in cancer care
Table 1. Brief description of techniques used
Technique Brief description
Induction script Gentle introduction to the principles
of relaxation which encourages
awareness of breathing patterns and
muscular tension.
Progressive muscular Involves tensing and then relaxing
relaxation each muscle group consecutively.
Passive neuromuscular Focuses on the use of suggestion to
relaxation tense and relax the muscles
without involving any active
movement.
Autosuggestion Using the themes of heaviness and
warmth, this systematic technique
uses short statements such as ‘my
left arm is heavy’ to educate the
mind and body to respond
positively to simple, verbal
commands.
Guided visualization The participant is guided to use their
imagination to visualise themselves
in a safe and pleasant environment.
Unguided visualization Unstructured form of visualization,
whereby the participant chooses
their own scene to visualise.
referred to the service between January 2002 and Decem-
ber 2005. Both men and women patients were included in
the study, and data was collected from both the Trust’s
sites. Ethical approval was sought from the Clinical Audit
Committee, and subsequently granted. Although all
patients are provided with an information booklet when
they initially register at the hospital which implies that
hospital data may be used for audit purposes, upon reflec-
tion the authors felt that there should be a more formal
way of gaining informed consent from relaxation partici-
pants. This has led to the revision of the paperwork to
include information about why patients are being asked
specific questions, what the data may be used for, and
then giving them the opportunity to consent to use of
their data or opt out.
Using a Microsoft Excel spreadsheet specifically de-
signed for the purpose, data was collected in two stages.
The first involved obtaining and entering patient details
into the spreadsheet, which is gender, age group, referral
source, diagnosis and date of last session. The second stage
incorporated tracking the sessions until discharge through
inputting data related to the session number, technique
used, initial- and post-tension score, and change in per-
ceived tension.
Tension was recorded before and after each relaxation
session using an adapted Visual Analogue Scale (VAS)
(Huskisson 1974) where ‘pain’ was substituted with
‘tension’ and thus scored from one to 10, with one per-
taining to no tension and 10 – excessive or worst tension.
489
MILLER & HOPKINSON
In this preliminary audit, the term tension was chosen as
a global, non-medical term to describe a range of symp-
toms, including pain, breathlessness, anxiety and feelings
of helplessness It is assumed that increased tension will
decrease or impair occupational performance.
R ES U L T S A N D D I S C US S I ON
During the 3-year period, relaxation referrals were
recorded for n = 327 patients, 22% (n = 72) of whom were
men and 78% (n = 255) were women. These referrals were
obtained from a number of sources within the multipro-
fessional team, and also included self-referrals as a result
of being informed of the service by a team member. The
referrals were related to both outpatients (n = 222) and
inpatients (n = 105), and a primary diagnosis of breast
cancer accounted for the highest percentage of referrals
(39%, n = 128), which is also reflected in UK cancer
research statistics, with 31% of women cancer diagnoses
being breast cancer (Tobias & Eaton 2001). Patients aged
between 50 and 59 years constituted the greatest number
of referrals (32%, n = 105), with the next most prevalent
group being those aged between 40 and 49 years (24%,
n = 79).
Of the 327 patients referred to the service, 186 partici-
pated in intervention. Reasons for non-involvement in the
relaxation programme following initial referral were
varied, however, the majority of those patients (47%,
n = 66) did not reply to an appointment letter. Other
reasons included patients declining intervention (16%,
n = 23), death prior to appointment (5%, n = 7) or too ill
too attend (5%, n = 7). Only 15% of patients declined
intervention and just a further 2% failed to attend their
appointment.
Technique selection is very much based on the thera-
pist’s clinical reasoning and of the eight techniques:
guided visualization was used in 120 of the 472 sessions,
closely followed by 106 sessions of progressive muscular
relaxation. In terms of comparison of the average changes
in tension scores, there was very little difference between
each technique (Table 1). The age group that experienced
the largest average change in tension (pretension minus
post-tension scores) were those within the 30–39 years
range (3.33). Although the other ages groups, with excep-
tion of those within the 70–79 years range, experienced
similar changes in perceived tension (Table 1).
Attendance declined considerably with 186 people
attending the first session and only 62 of those attending
a fourth, providing evidence for offering a finite number of
sessions. However, change in tension scores did gradually
increase as the sessions progressed (from 2.92 in session
490
one to 3.46 in session four) possibly being due to the
patients experiencing an increased awareness of their
tension and therefore providing a more accurate score. In
addition, patients are encouraged to practise the tech-
niques at home and so they may respond to the session in
a more effective manner.
Although the average changes in tension scores appear
small, the implications of even a seemingly minimal
reduction in tension have an immeasurable effect on the
quality of life, and this is often obtained in the form of the
patients’ comments. Furthermore, it is important not to
forget that patients may be using the techniques within
their own environments and achieving a greater decrease
in tension, compared with when they attend the hospital
and combine their relaxation session with other poten-
tially stressful appointments.
Limitation
The use of a VAS as an outcome measure is limited in
terms of capturing the subjective experience and benefits
of relaxation, and scores may be distorted if the patients
perceive a pressure on them to prove to the therapist that
the programme is effective. Also, it may be deemed inap-
propriate to pursue a score if the patient is upset or emo-
tional at the conclusion of the session, and so scores for
every patient seen by occupational therapy may not have
been recorded.
While therapists are encouraged to record each referral
and outcomes for each session, it is possible that time
constraints meant that not all the information was
recorded for every patient, which may have influenced
sample size. Also, as the majority of referrals were
received from the multiprofessional team, new staff
members may not have been aware of the service and
therefore less referrals may have been made.
Despite demonstrating in this audit that patients expe-
rienced a decrease in tension following the application of
relaxation, increase or decrease in tension has a limited
end point. From an occupational therapy perspective,
ideally, the outcome measure should be an improvement
or decline in occupational performance. The authors
would recommend pursuing this form of outcome
measure in further studies of the effectiveness of relax-
ation programmes.
Personal reflections
Implementation and analysis of this audit has provided
the occupational therapy department with the opportu-
nity to evaluate the relaxation service and consequently
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd

make some necessary changes to the paperwork and
general format. It was identified that each therapist was
carrying out the programme in a different way, so alter-
ations have now been made to incorporate a core pro-
gramme, an aspect which will aim to enhance the service
already provided.
C O N C L U SI O N
First, this audit offers a brief overview of the type of
programme offered at the Royal Marsden, incorporating
techniques used and methods for recording data. The data
demonstrates that relaxation can be useful adjunctively in
reducing the tension experienced by patients in the oncol-
ogy and palliative care setting, and is a beneficial inter-
vention that occupational therapists can utilize to
enhance the quality of life of their patients. Further study
of the benefits of relaxation on occupational performance
and level of function would be valuable, incorporating the
use of an outcome measure such as the Canadian Occu-
pational Performance Measure (Law et al. 1998) and estab-
lishing a qualitative piece of research.
A C K N O W L E D G E M E NT S
The authors would like to thank Daniel Lowrie for his
assistance in collating the data, Jill Cooper for proof-
reading and the other occupational therapy team members
of the Royal Marsden Hospital.
The authors declare that they have no conflict of inter-
est, financial or otherwise, related to this journal article.
REF E R E N C E S
Carty J.L. (1997) Relaxation to reduce nausea, vomiting, and
anxiety chemotherapy in Japanese patients. Cancer Nursing 20,
342–349.
© 2008 The Authors
Journal compilation © 2008 Blackwell Publishing Ltd
Use of relaxation as intervention in cancer care
Cheung Y.L., Molassiotis A. & Chang A.M. (2003) The effect of
progressive muscle relaxation training on anxiety and quality
of life after stoma surgery in colorectal cancer patients. Psy-
chooncology 12, 254–266.
Cooper J. (1997) Occupational therapy in specific symptom
control and dysfunction. In: Occupational Therapy in Oncol-
ogy and Palliative Care (ed. Cooper J.), pp. 59–86. Whurr Pub-
lishers, London, UK.
Decker T.W., Cline-Elsen J. & Gallagher M. (1992) Relaxation
therapy as an adjunct in radiation oncology. Psychooncology
12, 254–266.
Ewer-Smith C. & Patterson S. (2002) The use of an occupational
therapy programme within a palliative care setting. European
Journal of Palliative Care 9, 30–33.
Hanratty J. & Higginson I. (1994) Palliative Care in Terminal
Illness. EPL Publications, Northampton, UK.
Huskisson E.C. (1974) Measurement of pain. Lancet 9, 1127–
1131.
Law M., Baptiste S., Carswell A., McColl M.A., Polatajko H. &
Pollock N. (1998) Canadian Occupational Performance
Measure, 2nd edn. Rev. CAOT Publications ACE, Ottawa, ON,
Canada.
Leubbert K., Dahme B. & Hasenbring M. (2001) The effectiveness
of training in reducing treatment-related symptoms and
improving emotional adjustment in acute non-surgical cancer
treatment, a meta-analysis. Psychooncology 10, 490–502.
Office for National Statistics (2005) Cancer, 1 in 3 Develop
Cancer in Their Lives. Office for National Statistics [online]
Available at: http://www.statistics.gov.uk/CCI/nugget.
asp?ID=920&Pos=2&ColRank=1&Rank=294 (Accessed 26
April 2006).
Shen J., Andersen R., Albert P.S., Wenger N., Glaspy J., Cole M. &
Shekelle P. (2002) Use of complementary/alternative therapies
by women with advanced-stage breast cancer. BMC Comple-
mentary and Alternative Medicine 2, 1–7.
Sloman R. (2002) Relaxation and imagery for anxiety and depres-
sion control in community patients with advanced cancer.
Cancer Nursing 25, 432–435.
Syrjala K., Donaldson G., Davis M., Kippes M. & Carr J. (1995)
Relaxation and imagery and cognitive-behavioural training
reduce pain during cancer treatment, a controlled clinical trial.
Pain 63, 489–498.
Tobias J. & Eaton K. (2001) Living with Cancer. Bloomsbury,
London, UK.
491