Complementary Therapies in Medicine 63 (2021) 102784

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Effect of Benson and progressive muscle relaxation techniques on sleep

quality after coronary artery bypass graft: A randomized controlled trial
Hossein Bagheri a, Fatemeh Moradi-Mohammadi b, Ahmad Khosravi c, Maliheh Ameri a,
Mahboobeh Khajeh a, Sally Wai-chi Chan d, Mohammad Abbasinia e, Abbas Mardani f, *, 1
a
School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
b
ICU department, Shahid Beheshti Hospital, Shahid Beheshti Boulevard, Azadegan Square, Qom, Iran
c
School of Public Health, Shahroud University of Medical Sciences, Shahroud, Iran
d
Tung Wah College, Hong Kong
e
Nursing faculty, Qom University of Medical Sciences, Qom, Iran
f
Nursing Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: This study aimed to investigate the effect of Benson relaxation (BR) and progressive muscle relaxation
Benson relaxation (PMR) techniques on the sleep quality of patients undergoing coronary artery bypass graft (CABG) surgery.
Coronary artery bypass graft surgery Method: This study was a three-arm, parallel, randomized controlled trial. 120 patients who underwent CABG
Progressive muscle relaxation
surgery at two academic hospitals in an urban area of Iran were randomly allocated into three groups (40 per
Sleep quality
group): the BR, PMR, and control groups. Patients in the BR and the PMR groups performed relevant exercises
twice a day for four weeks. Sleep quality was measured before and immediately after the intervention using
Pittsburgh Sleep Quality Index.
Results: Within-group comparison in the BR (t = 3.51, p = 0.001) and the PMR (t = 4.58, p < 0.001) group
showed that the overall sleep quality showed a significant improvement after the intervention when compared to
baseline. The between-group comparison showed that both the BR and PMR groups showed significant im­
provements in subjective sleep quality (F = 3.75, p = 0.02), habitual sleep efficiency (F = 4.81, p = 0.01), and
overall sleep quality (F = 5.53, p = 005) when compared to the control group after the intervention. However, no
statistically significant differences were identified among the three study groups in terms of sleep latency, sleep
duration, sleep disturbances, sleeping medication, and daytime dysfunction after the intervention (p > 0.05).
Conclusion: The study showed that a four-week program of both PMR and BR can be effective in the overall
improvement of sleep quality in patients following CABG. Further research is required to replicate the findings of
the present study.

1. Introduction
Coronary artery disease (CAD) is considered the most prevalent
cardiovascular disease and accounts for more than half of all cardio­
vascular diseases.1 CAD is the main cause of mortality in both developed
and developing countries.2 It accounts for approximately 50% of all
deaths in Iran.3 Coronary artery bypass graft (CABG), which is used to
alleviate angina symptoms, is one of the main treatment strategies for
CAD. It is the most common type of cardiac surgery in Iran.1,4
Good sleep quality has substantial benefits for optimal health status
and wellness.5 However, poor sleep quality is common among patients
after CABG. Studies showed these patients experienced high levels of
sleep disruption, insomnia, irregular sleep cycle, and sleep disconti­
nuity.6,7 About 39–69% of patients suffering from sleep disturbances in
the first month after CABG.8 There are many factors that impacted sleep
disturbances after CABG. For instance, physiological angina pectoris,
myocardial infarction, arrhythmias, nocturia, medical agents, pain at
the surgical site and insufficient pain management, poor wound healing,

* Corresponding author.
E-mail addresses: bagheri@shmu.ac.ir (H. Bagheri), f.mohammadi186@yahoo.com (F. Moradi-Mohammadi), a.khosravi@shmu.ac.ir (A. Khosravi),
Amerimalihe@shmu.ac.ir (M. Ameri), khajeh@shmu.ac.ir (M. Khajeh), sallychan@twc.edu.hk (S.W.-c. Chan), abbasyniamohammad@yahoo.com (M. Abbasinia),
mardani.a@iums.ac.ir (A. Mardani).
1
ORCID: https://orcid.org/0000-0003-2861-6037

https://doi.org/10.1016/j.ctim.2021.102784
Received 15 July 2021; Received in revised form 18 October 2021; Accepted 18 October 2021
Available online 20 October 2021
0965-2299/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
H. Bagheri et al.
and psychological factors such as anxiety, stress, and cigarette smoking
can affect the sleep quality of patients after CABG.8–10 Sleep problems
may directly influence patients’ capability to lead a normal life,
contributing to a sedentary lifestyle that leads to impairment of
health-related quality of life and the risk for mental health problems.11,
12
Therefore, improving the sleep quality of patients after CABG can
significantly contribute to post-CABG recovery.
Pharmaceutical methods are currently employed to improve sleep
quality in cardiac patients.13 However, many hypnotics are associated
with side effects such as drug resistance and withdrawal symptoms.14
Thus, there has been increasing use of non-pharmaceutical methods for
improving patients’ sleep quality.15 Among such methods are relaxation
techniques. It has been considered as one of the cost-effective and easy
ways to alleviate sleep disturbances by controlling stress and anxiety
levels, mood disorders, autonomic nervous system function, and body
discomfort.15 Commonly used relaxation methods for sleep problems
include Benson’s relaxation (BR) and progressive muscle relaxation
(PMR), yoga, guided imagery, meditation, and massage therapy.16–18
BR technique, which was identified by Herbert Benson, is one of the
more favorite relaxation methods due to its simple way of learning and
led to full relaxation of all the muscles.19 BR technique is known as one
of the foremost muscular relaxation techniques that works through the
regulation of the hypothalamus and reduction of the sympathetic and
parasympathetic stimuli and is effective on the respiratory function,
pulse rate, and heart workload.20,21 In addition, this relaxation method
encompasses mindfulness techniques that can affect many physical and
psychological symptoms such as pain, stress, anxiety, depression, mood,
and self-esteem.19,21,22 The effectiveness of the BR technique on sleep
problems has been documented in the elderly population,22 hemodial­
ysis patients,23,24 and pregnant women with hypertension.25
PMR is another cognitive and behavioral technique that is suggested
for various symptoms such as anxiety, stress, and sleep disturbance. It
includes voluntary, systematic, and ongoing stretching and relaxing of
the body muscles until they become relaxed.26 The main principle of this
method is based on the objectivity that muscle tension is the physio­
logical reaction of the human body to stimulating thinking.26 In this
relaxation method, the mind and body relief from any tension and
anxiety.27 Previous studies have been shown that applying the PMR
technique could improve sleep quality in patients suffering from
COVID-19,27 burn events,28 patients with pneumonectomy,29 breast
cancer undergoing adjuvant chemotherapy,30 and chronic obstructive
pulmonary disease.31
BR and PMR techniques have been used widely for sleep problems of
patients with different health conditions.22–25,27–31 Considering the high
prevalence of sleep problems in patients undergoing CABG and the lack
of evidence that have examined the effects of BR and PMR techniques on
the sleep disturbance of these patients, the present study aimed to
investigate and compare the effects of these relaxation techniques on
sleep quality of patients following CABG. The hypotheses of the study
were as follows when compared to routine care:
1. The practice of the BR technique for four weeks could improve sleep
quality in patients who have undergone CABG;
2. The practice of the PMR technique for four weeks could improve
sleep quality in patients who have undergone CABG; and
3. The sleep quality of patients undergoing CABG who perform the BR
technique may similar to those who perform the PMR.
2. Method
2.1. Design
A parallel, three-armed, randomized controlled trial design was
applied in the present study. It was conducted on patients who under­
went CABG surgery in the two tertiary hospitals in an urban area of Iran
from April 2017 to January 2018.
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Complementary Therapies in Medicine 63 (2021) 102784
2.2. Participants and sampling
A convenience sample was recruited and randomized into three
groups. Inclusion criteria were: patients undergoing CABG surgery and
waiting for discharging from the hospital (patients usually discharge
from the hospital three to five days after the surgery), no history of
previous cardiac surgery, no history of mental disorders according to
medical records, able to communicate, have poor sleep quality (scores
between 5 and 21 based on the Pittsburgh Sleep Quality Index
(PSQI)32)), and able to provide verbal and written informed consent.
Exclusion criteria were practicing other interventions (such as music
therapy and other relaxation exercises) that influence sleep quality
during the study, unwillingness to continue the study, and hospitaliza­
tion during the study.
The required sample size for this study was estimated at 40 partici­
pants per group using the findings of the similar study33 with 80% power
and 95% confidence interval. The consecutive sampling method was
used in this study. First, patients who were transferred to the cardiac
department from the cardiothoracic surgery intensive care unit were
evaluated for their eligibility. Next, the patients who were eligible to
participate in this study gave informed consent and completed the
baseline assessment. Then, they were randomly allocated to three
groups using randomized block designs: the BR, PMR, and control
groups (Fig. 1). A member of the research team (AK) determined the
random allocation sequence (20 sextuplet blocks) using SPSS syntax. For
the concealment, closed envelopes containing the cards with letters A
(for the BR group), B (for the PMR group), or C (for the control group)
were prepared according to the predetermined allocation sequence.
Patients who had provided informed consent opened an envelope. Based
on the card inside it, he/she was assigned to one of the study groups. In
the present study, only one research team member (AK) who was a data
analyzer was blinded to the group assignments to ensure that all
analytical decisions were unbiased. The CONSORT diagram of the study
is presented in Fig. 1.
2.3. Intervention
Participants enrolled in the intervention groups were individually
invited to a private practice room in the cardiac department for relax­
ation training. Relaxation training was conducted by a research team
member (second) who was an expert in the BR and PMR techniques. The
training session was conducted using face-to-face teaching with the help
of a structured and standardized CD that included music and directives.
Each session lasted for 30–45 min. At the end of the training session, to
ensure that participants doing practices accurately, they were asked to
perform techniques in the presence of the researcher. In the absence of
positive feedback, another session was arranged so that their learning
would reach the desired level. In order to enhance compliance with
relaxation exercises, family caregivers also attended the training session,
and they were also asked to support and encourage the participants to
perform their daily exercises. After the training session and before they
were discharged from the hospital, a CD that included the whole in­
struction of the intended relaxation technique and music was given to
the participants. In addition, participants received the same model of
mp3 players and special earphones (headphones) and they were asked to
carry out the relaxation exercise with the help of the CD twice a day,
once at noon and once before falling asleep (20 min each time) for four
weeks after discharge.
Every week, the researchers telephoned participants and gave
required instructions on exercises, resolved their potential problems
during exercises, and assessed any complications due to the interven­
tion. Moreover, the telephone number of one of the researchers (second
author) was provided for the participants and they were allowed to
contact the researcher if they had any concerns, complications or
questions during the intervention program. To assess participants’
adherence to relaxation exercises, a checklist was given to them and they
H. Bagheri et al. Complementary Therapies in Medicine 63 (2021) 102784

38

Fig. 1. The process of the study according to the CONSORT flow diagram (2010).

were asked to mark their daily performance of exercises. Participants’ the entire body. Meanwhile, he/she take deep breaths inhaling via the
checklists were received at the end of the intervention. nose and exhaling through the mouth and focuses on the emotions
The BR technique is as follows: experienced during muscle contractions and relaxations.27,28
First, the patient sits in a comfortable position in a quiet room with Participants in the control group only received routine nursing care
dim light, slowly closes the eyes, slowly relaxes muscles beginning from including giving recommendations for sleep health.
the feet to the face, remains relaxed, breathes through the nose, and is
aware of breathing. The patient exhales gently through the mouth while,
2.4. Data collection
based on the respective belief system, repeating a word or expression
silently. The patient breathes normally and at ease and tries to keep his
After obtaining ethics approval, the researchers contacted the study
muscles relaxed. Then, the patient opens their eyes but does not stand up
cardiac departments and then applied face-to-face interviews with pa­
for a few minutes. The patient does not worry about whether a deep level
tients to provide study information and assess their eligibility criteria.
of relaxation has been achieved but rather lets relaxation occur at its
Eligible patients provided written informed consent if they were inter­
own pace. When distracting thoughts intervene, the patient tries to
ested in participating in the study. Data were collected at baseline and
ignore them and be indifferent to them.21,22
immediately after the intervention at the 4th week.
The PMR technique is as follows:
First, the patient sits or lies on the back in a comfortable position in a
2.4.1. Demographic characteristics form
quiet room with dim light. Next, tighten and relax the muscle groups in
Data regarding the participants’ socio-demographic characteristics
order from the lower to the upper parts or vice versa. Accordingly, the
such as age, gender, education level, monthly household income, and
patient tenses the muscles tightly and maintains for 5 s and then quickly
occupation status were obtained through face-to-face interviews at
and completely relax them for 10 s until all the feeling of relaxation in
baseline.

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H. Bagheri et al. Complementary Therapies in Medicine 63 (2021) 102784

2.4.2. Pittsburgh Sleep Quality Index Table 1

The Pittsburgh Sleep Quality Index (PSQI) is a standard question­ Demographic characteristics of study groups.
naire developed by Buysse et al. to evaluate sleep quality.32 The PSQI Variables Study groups, n (%) p-
contains a 19-item that determines the subjective sleep quality during value
the last month. It has seven subscales encompassing sleep quality, sleep BR PMR Control
(n = 40) (n = 40) (n = 40)
latency, sleep duration, habitual sleep efficiency, sleep disturbances,
sleeping medication use, and daytime dysfunction. The weight of the Age Mean (SD) 61.9 (5.3) 62.1 (6.3) 63.1 (7.6) 0.66a
subscales is evenly weighted on a scale from 0 (no difficulty) to 3 (severe Gender Female 11 (27.5) 15 (37.5) 18 (45) 0.26b
Male 29 (72.5) 25 (62.5) 22 (55)
difficulty), giving a global score of 0–21. A total PSQI score of ≥ 5 in­ Marital Single 3 (7.5) 9 (22.5) 11 (27.5) 0.06b
dicates poor sleep quality.32,34 The Cronbach’s alpha coefficient and status
test-retest reliability of the original version PSQI were 0.83 and 0.85, Married 37 (92.5) 31 (77.5) 29 (72.5)
respectively.32 Cronbach’s alpha coefficient for the Farsi version of PSQI Educational illiterate 8 (20) 16 (40) 21 (52.5) 0.02c
level
in 133 healthy people and 125 people with psychiatric disorders was
Less than 25 (62.5) 21 (52.5) 17 (42.5)
reported 0.77.35 high school
This questionnaire was completed by the participants before the diploma
intervention at the hospital and after the intervention at their place of High 7 (17.5) 3 (7.5) 2 (5)
residence by face-to-face interview. school
diploma
and higher
2.5. Ethical considerations Occupation Housewife 7 (17.5) 15 (37.5) 18 (45) 0.09b
Employed 24 (60) 16 (40) 16 (40)
Ethical approval was obtained from the Ethics Committee of Shah­ Retired 9 (22.5) 9 (22.5) 6 (15)
roud University of Medical Sciences under the code IR.SHMU. BR: Benson relaxation; PMR: progressive muscle relaxation
REC.1396.163. In addition, the protocol of the study was registered in a
One-way ANOVA
the Iranian Registry of Clinical Trials (IRCT) under the code b
Chi-squared test
c
IRCT201703123064N6. Before the study, all potential participants were Fisher’s exact test
provided information about the study aim and procedure, the confi­
dentiality of the data, and the right to withdraw from the study at any PMR (52.5%) had less than high school diploma education, and the
time. In addition, they were assured that participation or non- majority of participants in the control group (52.5%) were illiterate.
participation of them in the study would not influence their received
care. Finally, written informed consent was obtained from the willing
participants for participation in the study. 3.2. Sleep quality

2.6. Data analysis 3.2.1. Within group comparison

The data were analyzed applying SPSS software version 25. Chi-
square, Fisher’s exact, and one-way ANOVA tests were used to assess
the homogeneity of the participants’ demographic characteristics in the
three study groups. Paired sample t-test was used to compare before and
after the intervention sleep quality within study groups. In addition,
analysis of covariance (ANCOVA) test was applied to compare the sleep
quality between the study groups before and after the intervention.
Moreover, the rate of adherence to the intervention program in the BR
and the PMR group was assessed using the independent t-test. Besides,
p < 0.05 was regarded as statistically significant.
3. Results
Out of 166 patients who were reviewed for inclusion criteria, 38
patients had not met the study inclusion criteria, and 8 patients declined
to participate in the study. Thus, 120 patients were randomly allocated
to the BR (n = 40), PMR (n = 40), and control (n = 40) groups. During
the follow-up, none of the participants were excluded from the study.
Therefore, data gathered from all participants entered the final analysis
(Fig. 1).
3.1. Demographic characteristics and homogeneity comparisons between
the groups
The mean (SD) age of participants was 61.9 (5.3) years old in the BR
group, 62.1 (6.3) years old in the PMR group, and 63.1 (7.6) years old in
the control group. 72.5% of participants in the BR group, 62.5% in the
PMR group, and 55% in the control group were male. The demographic
characteristics of participants were presented in Table 1. There was no
significant difference among the participants in the study groups in
terms of demographic characteristics except in educational level
(p = 0.02). More than half of the participants in the BR (62.5%) and the
Results of within-group comparison were presented in Table 2. In the
BR group, there was a statically significant improvement in the majority
of the PSQI subscales: subjective sleep quality (t = 2.33, p = 0.02), sleep
latency (t = 2.91, p = 0.006), sleep duration (t = 2.76, p = 0.009), sleep
disturbances (t = 5.70, p < 0.001), daytime dysfunction (t = 3.25,
p = 0.002), and overall sleep quality (t = 3.51, p = 0.001) between
baseline and after the intervention.
In the PMR group, a statically significant improvement was observed
in 4 of the PSQI subscales: subjective sleep quality (t = 3.16, p = 0.003),
sleep latency (t = 2.10, p = 0.04), sleep disturbances (t = 4.22,
p < 0.001), daytime dysfunction (t = 4.85, p < 0.001), and overall sleep
quality (t = 4.58, p < 0.001) after the intervention compared to
baseline.
In the control group, compared to baseline, a statically significant
improvement was observed in 3 PSQI subscales: subjective sleep quality
(t = 2.43, p = 0.02), sleep disturbances (t = 3.98, p < 0.001), and day­
time dysfunction (t = 4.09, p < 0.001) after the intervention. However,
the participants used significantly more sleeping medication when
compared to baseline (t = − 3.34, p = 0.002).
3.2.2. Between groups comparison
As shown in Table 2, according to ANCOVA results after adjusting for
educational levels, there were no statistically significant differences
between the subscales of sleep quality and overall sleep quality among
the study groups before the intervention (p > 0.05) except in the
sleeping medication use (F = 4.20, p = 0.01). Fisher’s least significant
test (LSD) following ANCOVA revealed that sleeping medication use was
lower in the BR group than PMR (mean difference, MD = − 0.52,
p = 0.008) and control (MD = − 0.40, p = 0.04) groups.
After the intervention, a statistically significant difference was found
in terms of subjective sleep quality (F = 3.75, p = 0.02), habitual sleep
efficiency (F = 4.81, p = 0.01), and overall sleep quality (F = 5.53,
p = 005) among the three study groups. According to the LSD, the BR

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H. Bagheri et al. Complementary Therapies in Medicine 63 (2021) 102784

Table 2
Comparison of sleep quality in study groups.
Variable Time Study groups F-value p-valuea

BR Mean (SD) PMR Mean (SD) Control Mean (SD)

Subjective sleep quality Before intervention 1.55 (0.74) 1.50 (0.67) 1.75 (0.77) 1.33 0.28
After intervention 1.20 (0.56) 1.15 (0.48) 1.47 (0.59) 3.75 0.02
t-value 2.33 3.16 2.43
p-valueb 0.02 0.003 0.02
Sleep latency Before intervention 1.65 (0.97) 1.65 (1.07) 1.80 (0.99) 0.25 0.77
After intervention 1.15 (0.92) 1.30 (0.91) 1.65 (1.02) 2.65 0.06
t-value 2.91 2.10 0.92
p-valueb 0.006 0.04 0.36
Sleep duration Before intervention 1.85 (0.83) 1.65 (1.05) 1.85 (1.09) 0.51 0.60
After intervention 1.37 (1.14) 1.35 (1.16) 1.82 (1.21) 2.91 0.07
t-value 2.76 1.45 0.15
p-valueb 0.009 0.15 0.87
Habitual sleep efficiency Before intervention 1.20 (1.09) 1.27 (1.26) 1.42 (1.19) 0.17 0.84
After intervention 0.95 (1.10) 0.90 (1.25) 1.60 (1.23) 4.81 0.01
t-value 1.00 1.42 -0.81
p-valueb 0.32 0.16 0.42
Sleep disturbances Before intervention 1.57 (0.50) 1.55 (0.59) 1.72 (0.55) 0.85 0.43
After intervention 1.07 (0.41) 1.12 (0.40) 1.27 (0.45) 2.35 0.09
t-value 5.70 4.22 3.98
p-valueb < 0.001 < 0.001 < 0.001
Sleeping medication Before intervention 0 0.52 (1.10) 0.40 (1.00) 4.20 0.01
After intervention 0 0.72 (1.17) 1.05 (1.35) 1.36 0.25
t-value 0 -1.21 -3.34
p-valueb > 0.999 0.23 0.002
Daytime dysfunction Before intervention 1.60 (0.63) 1.77 (0.65) 1.70 (0.56) 0.88 0.41
After intervention 1.15 (0.76) 1.07 (0.65) 1.12 (0.75) 0.17 0.83
t-value 3.25 4.85 4.09
p-valueb 0.002 < 0.001 < 0.001
Overall sleep quality Before intervention 9.45 (3.28) 9.90 (4.11) 10.65 (3.64) 0.93 0.39
After intervention 7.37 (3.43) 7.62 (3.66) 9.87 (4.16) 5.35 0.005
t-value 3.51 4.58 1.44
p-valueb 0.001 < 0.001 0.15

BR: Benson relaxation; PMR: progressive muscle relaxation

a
ANCOVA was adjusted for educational levels
b
Paired samples t-test

group (MD = − 0.27, p = 0.02) and the PMR group (MD = − 0.32,
p = 0.01) had better subjective sleep quality as compared with the
control group. In the same way, in the habitual sleep efficiency subscale,
BR (MD = − 0.65, p = 0.01) and the PMR (MD = − 0.70, p = 0.01)
groups had better status compared to the control group. Finally, the BR
group (MD = − 2.5, p = 0.004) and the PMR group (MD = − 2.25,
p = 0.009) had better overall sleep quality as compared with the control
group. However, there were no statistically significant differences
among the three study groups in terms of sleep latency, sleep duration,
sleep disturbances, sleeping medication, and daytime dysfunction after
the intervention (p > 0.05).
3.3. Adherence to the intervention program
The rate of adherence to the intervention program in the BR and the
PMR group was reported at 88.66% (4.96) and 90.13% (5.03), respec­
tively. There were no statistically significant differences between the BR
and the PMR group in terms of adherence to the intervention program
(p = 0.19). Furthermore, participants in the intervention groups did not
report any complications or dissatisfaction related to BR and PMR ex­
ercises during the study period.
4. Discussion
The present study was conducted to investigate and compare the
effects of BR and PMR techniques on sleep quality in patients following
CABG. The findings from the current study suggested that applying BR
and PMR techniques can result in improvement of the overall sleep
quality among patients following CABG. The researchers did not find
any published study evaluating the effect of BR or PMR techniques on
sleep quality in patients undergoing CABG.
In the present study, the subjective sleep quality, sleep latency, sleep
duration, sleep disturbances, sleep dysfunction, and overall sleep quality
in the BR group improved significantly after four weeks of intervention.
Consistent with our findings, Rambod et al.’s23 study was conducted to
evaluate the effect of the BR technique on sleep quality of hemodialysis
patients using a randomized controlled trial design for eight weeks and
findings showed that patients’ sleep disturbance, sleep latency, subjec­
tive sleep quality, daytime dysfunction, the use of sleep medication, and
overall sleep quality improved after the intervention. A longer inter­
vention program by the above study could be justified some of the
inconsistent results such as daytime dysfunction in our findings. In
addition, consistent with our findings, the results of another study
demonstrated that applying the BR technique for four weeks could
improve sleep quality among community-dwelling older adults in terms
of subjective sleep quality, sleep latency, sleep duration, sleep suffi­
ciency, daytime dysfunction, and overall sleep quality.22 A recent study
by Harorani et al.36 reported that the sleep quality of cancer patients
undergoing chemotherapy significantly improved with administration
of the BR technique twice a day over 5 consecutive days. Moreover,
applying this technique led to improve sleep quality of parents who had
children with leukemia under chemotherapy.37
In this study, the PMR technique improved the subjective sleep
quality, sleep latency, sleep disturbances, daytime dysfunction, habitual
sleep efficiency, and overall sleep quality in patients following CABG.
Our findings are consistent with the results of a study that evaluated the
effect of PMR training on the quality of sleep in breast cancer patients
who underwent adjuvant chemotherapy.30 In this study, the subjective
sleep quality, sleep latency, sleep duration, habitual sleep efficiency,
sleep disturbances, and overall sleep quality of breast cancer patients in

5
H. Bagheri et al.
the intervention group improved significantly compared to the control
group.30 In addition, the results of a recent study demonstrated using the
PMR technique for 30 min per day for five days improve sleep quality in
patients with COVID-19.27 Furthermore, Chegeni et al.’s31 study eval­
uated the effect of 8 weeks of PMR program on the sleep quality of pa­
tients who were suffered from chronic obstructive pulmonary disease
and the results supported the efficacy of this intervention.
A possible explanation for improving overall sleep quality and some
of its subscales in this study might be due to the effect of the applied
relaxation techniques on decreasing anxiety and stress,36,38–42 pain,43
and fatigue29,31 among the patients undergoing CABG, as these people
experience different levels of mentioned symptoms due to the surgery
that can result in poor sleep quality.8 Also, relaxation can decrease
anxiety and pain by improving self-esteem and self-control.44 In addi­
tion, some chemical changes associated with relaxation exercises in the
blood such as decreased levels of adrenal hormones45 may improve sleep
quality. Furthermore, relaxation techniques help the management of
stress, decrease psychological stress, improve subjective well-being, and
help the ignore the deviant thoughts,39,40,46 and consequently may
improve the sleep quality.
4.1. Implication for clinical practice
Our study has some important implications for clinical practice. The
findings highlight the importance of BR and PMR techniques targeting
sleep quality following CABG in this population. Therefore, healthcare
providers can incorporate BR and PMR techniques in the care plan of
patients undergoing CABG to improve their sleep quality. However,
more studies are required to replicate our study findings. Studying the
effect of BR and PMR techniques on the quality of sleep in CABG patients
for more than four weeks and investigating the changes and trends of
sleep quality during the different time points in the study period is also
suggested. Moreover, qualitative studies are recommended to discover
the challenges of the utilization of these interventions in clinical practice
from point of view of health care providers and CABG patients.
4.2. Limitations
There were some limitations in the present study that require
consideration when the findings are interpreted. Firstly, the trial was
conducted in two healthcare centers in an urban area of Iran, which
limited the generalization of the findings to all patients undergoing
CABG. Secondly, in the present study, the measuring of the effect of BR
and PMR techniques on sleep quality was limited only to two points,
before the intervention and after the intervention in the 4th week.
Thirdly, both BR and PMR techniques were taught by the same
researcher, which might have been associated with the bias of one of the
relaxation techniques. Fourthly, the psychological state of the partici­
pants such as anxiety and depression as well as pain which might have
affected the quality of sleep had not been evaluated in this study. Lastly,
in this study, we measured only subjective sleep quality, not objective
sleep quality.
5. Conclusion
In this study, BR and PMR techniques were evaluated in the patients
undergoing CABG. Although the results of this study showed that
applying BR and PMR techniques have a significant effect on improving
overall sleep quality in the patients following CABG, further studies are
needed before these techniques incorporate into the care plan of patients
undergoing CABG.
Funding
This study was funded by Shahroud University of Medical Sciences,
Shahroud, Iran under the grant number of 9630.
6
Complementary Therapies in Medicine 63 (2021) 102784
CRediT authorship contribution statement
Hossein Bagheri: Conceptualization, Methodology, Validation, Re­
sources, Writing – original draft, Writing – review & editing, Supervi­
sion, Project administration, Funding acquisition. Fatemeh Moradi-
Mohammadi: Conceptualization, Methodology, Investigation, Data
curation, Writing – original draft. Ahmad Khosravi: Validation, Formal
analysis, Data curation. Maliheh Ameri: Conceptualization, Method­
ology. Mahboobeh Khajeh: Conceptualization, Methodology. Abbas
Mardani: Formal analysis, Data curation, Writing – original draft,
Writing – review & editing, Visualization. Mohammad Abbasinia:
Investigation, Methodology, Sally Wai-chi Chan: Writing – original
draft, Writing – review & editing.
Declaration of Competing Interest
The authors declare that there is no conflict of interest.
Acknowledgements
The authors would like to thank all the participants in this study and
Shahroud University of Medical Sciences for financial support.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.ctim.2021.102784.
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