Best Effect of Progressive Muscle Relaxation (PMR) on Children:

A Systematic Review

Casman

and Nani Nurhaeni

Department of Pediatric Nursing, RS Husada’s School of Health Science, Jakarta, Indonesia

Department of Pediatric Nursing,Universitas Indonesia, Depok, Indonesia

Keywords: Progressive Muscle Relaxation, Children, Systematic Review.

Abstract: Objectives: Progressive Muscle Relaxation (PMR) showed good benefit in adult such as reduction stress,

this systematic review to synthesis evidence on progressive muscle relaxation effect in children and

investigates minimum ages to started the PMR. Methods: A literature search was conducted on ProQuest,

EBSCOhost, ScienceDirect, and SpringerLink. The systematic review consisted of retrieving articles

published between 2008 until 2018, using the keywords “progressive muscle relaxation” and child or

pediatric or adolescent. Results: Overall more than 500 potential articles were screened, of which 10 were

eligible. All of articles showed PMR is significant to reduce stress and anxiety of children, 50% articles

showed the participant’s is school age and adolescent with minimum age is 4 year or older. Conclusions:

progressive muscle relaxation is good technic to reduction stress in children, also increased good mood and

attention of children. In closing, further evidence is needed to delineate the obstacle of doing PMR in

children, by qualitative or quantitative research especially in Indonesia.

1 INTRODUCTION

Stress is a result of discrepancy between individual

reaction to difficulties or limitations and his

capability of managing and overcoming important

situations. Children’s strategies to adapt with stress

depend on their abilities as well as their

accomplishment to use the abilities. The stressor

causes emotion changes on that raise stress (Terzian,

Moore, & Nguyen, 2010). Stress becomes the main

cause of negative behaviour in childhood. The

negative behaviour includes anxiety, depression,

memory and language disorder, and reduction of

academic ability (Evans & Schamberg, 2009).

Children frequently encounter difficulty to adapt

stress., Furthermore, when they feel difficult to

express their stress, they will experience emotion

changes, behaviour, or physical disorder. other

physical disorders include increase of muscle

tension, headache, stomach illness, eating and

sleeping disruption, and lack of energy. The emotion

changes include nervousness, worry, unenthusiastic

feeling, anger, revenge to their peer, shyness or self-

isolated behaviour, powerlessness, and desperation.

The behaviour changes include bad habit of eating

and weight loss/gain in a short time (Terzian et al.,

2010).

Relaxation is one of effective non-

pharmacological techniques to decrease stress

because it influences mental and physical conditions,

depression, mood, anxiety, and self-blaming. Several

studies prove that well-ordered and consistent

relaxation can decrease stress. Therefore, nurses are

expected to be able to provide education of

relaxation benefits for patients because the education

is cheap and easy to practice (Gorji, Davanloo, &

Heidarigorji, 2014).

One of the relaxation techniques is Progressive

Muscle Relaxation (PMR). Jacobson (1976) explains

that relaxation to several muscles can be practiced

by making the muscles maximally strain, and then

loosening it until the muscle is relaxed. Jacobson

finds that systematic strains and slow extrication on

some muscles enable someone to feel different

sensation of muscle strain and relaxation. This

process makes someone experience deep relaxation.

Jacobson suggests that relaxation and contraction are

successively conducted in sixteen muscle groups.

However, generally PMR is practiced by adults.

Casman, . and Nurhaeni, N.

Best Effect of Progressive Muscle Relaxation (PMR) on Children: A Systematic Review.

DOI: 10.5220/0008199200120017

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 12-17

ISBN: 978-989-758-406-0

1.1 Purpose

This systematic review proposes to analyze the

influence of PMR on children’s decrease of stress

and to investigate the right time to start PMR on

children.

2 METHODS

The systematic review will be reported in line with

the guidlines from the Cochrane Handbook of

Systematic Reviews of Interventions (versión 5.1.0)

(Higgins, J. P. T., Green, S., & Collaboration, 2011),

also used the recommendations of the PRISMA

statement (Urrútia, G., & Bonfill, 2010).

2.1 Criteria of Article Selection

The selected articles were articles employing true-

experimental method or quasi-experimental design

which analyzed the influence of PMR on the

decrease of stress, anxiety, or other positive aspects

such as increasing attention or interest. The selected

articles were articles written in English and

published in the last 10 years, and articles with

children as their population

2.2 Search Strategy

The complete search was conducted in four

databases: ProQuest, EBSCOhost, ScienceDirect,

and SpringerLink. The search was conducted from

October to November 2018, with the keywords

progressive muscle relaxation, child, paediatric, and

adolescent

2.3 Articles Selection

After searching articles in several databases, the first

step of selection was to read titles and abstracts of

the articles. Then, the chosen articles were verified

by two reviewers. The two reviewers discussed to

select the articles by considering inclusive and

exclusive criteria. The complete selection process is

presented in Fig.1.

3 RESULT

The result of the search reveals that 551 articles are

found, and only 23 complete articles are analyzed.

Finally, 10 appropriate articles for the inclusive and

exclusive criteria are selected.

3.1 Article Characteristic

The total respondents of the articles are 870

children. Six articles focus on the effect (time

duration and frequency) of decreasing the level of

stress and anxiety (Chan et al., 2015; Hashim &

Zainol, 2015; Manjushambika, Prasanna,

Vijayaraghavan, & Sushama, 2017; Mason,

Burkhart, & Lazebnik, 2018; Olmedilla-zafra,

Rubio, Ortega, & García-mas, 2017; Srilekha,

Soumendra, & Chattopadhyay, 2013), 3 articles

analyze the effect of PMR on increasing

attention/interest, the ability to answer the questions,

and language retardation (Chan, Sze, Siu, Lau, &

Cheung, 2013; McKenney, Broach, & Mullen, 2018;

Murray, Scott, Connolly, & Wells, 2018),

Meanwhile, 1 remaining article discusses the impact

of PMR on children’s headache (Jong et al., 2018).

Figure 1: Article Selection.

There are 5 articles employ true-experimental

design (Chan, Sze, Siu, Lau, & Cheung, 2013; Jong

et al., 2018; Manjushambika, Prasanna,

Vijayaraghavan, & Sushama, 2017; Murray, Scott,

Connolly, & Wells, 2018; Olmedilla-zafra, Rubio,

Ortega, & García-mas, 2017), 4 articles employs

Records identified through

database searching

(n=551)

Records after duplicate

removed

(

n=537

)

Records screened

(

n=537

)

Full-text articles assessed

for eligibility

(n=23)

Articles selected

ProQuest (n=3)

EBSCOhost (n=2)

ScienceDirect (n=4)

SpringerLink (n=1)

Records

excluded

(title and

abstract)

(n=514)

Full-text

articles

excluded

(with criteria

and bias)

(n=13)

Best Effect of Progressive Muscle Relaxation (PMR) on Children: A Systematic Review

quasi-experimental design (Chan et al., 2015;

Hashim & Zainol, 2015; McKenney, Broach, &

Mullen, 2018; Srilekha, Soumendra, &

Chattopadhyay, 2013), and 1 article employs cohort

method (Mason, Burkhart, & Lazebnik, 2018). The

explanation of selected articles is presented in Table

The analysis of selected articles reveals that the

articles have discussed the procedures of PMR,

duration and sessions to practice PMR are different,

and PMR possibly influences the result. The

explanation of how the duration and frequency

session to practice PMR can influence stress,

anxiety, emotion control, and headech of children,

and in what age that children can practice PMR is

presented as follows:

3.2 Duration and Session of PMR

Children who are intervened PMR for 15-20 minutes

a day show the decrease of stress score from 133 to

116 in the first month, and the result becomes 117

after 3 months, p<0.05

(Manjushambika, Prasanna,

Vijayaraghavan, & Sushama, 2017). PMR of which

the duration is 25 minutes and which is practiced 6

to 12 sessions will effectively decrease anxiety,

depression, and stress. In addition, it increases

attention and interest (Hashim & Zainol, 2015).

PMR exercises (15 minutes a day or 3 days in a

week, conducted for 9 successive weeks) show

meaningful changes in all of the measurements of

research variables: p<0.001 for anxiety and p<0.005

for attention focus (Srilekha, Soumendra, &

Chattopadhyay, 2013). PMR with 30-minute

duration is effectively applied as a stress

management (Mason, Burkhart, & Lazebnik, 2018).

Practicing PMR once in a week for an hour within 3

months will meaningfully overcome stress

(Olmedilla-zafra, Rubio, Ortega, & García-mas,

2017). Group of PMR experiences stress level

decrease (Z=-2.14, p =0.032) in which PMR is

conducted once in a day for 30 minutes within 5

days (Chan et al., 2015).

The effect of PMR is good not only for anxiety

and stress, but also for other functions in children.

Children who get 12 session of PMR will be able to

increase their short memories (Hashim & Zainol,

2015). Exercises conducted once a week for 1 hour

in each session will effectively decrease children’s

illness with value p < 0.001, r

=0.309 (Olmedilla-

zafra, Rubio, Ortega, & García-mas, 2017). PMR

with 20–minute duration will make autism children

experience increase of emotion control (Chan, Sze,

Siu, Lau, & Cheung, 2013). Practicing PMR once in

a day within 3 months will effectively decrease

duration, frequency, and degree of headeach(Jong et

al., 2018). PMR with 20–minute duration in 3

sessions of each week can increase time to answer

questions or assist mentally disabled children to

become more perceptive. The PMR intervention

group requires 58 seconds while the control group

requires 70 seconds to answer a question (Chan, Sze,

Siu, Lau, & Cheung, 2013). However, PMR with 11-

minute duration does not meaningfully increase

children’s ability from language retardation

(Murray,

Scott, Connolly, & Wells, 2018).

3.3 Children’s Age

The 11 articles indicate that the children are 4-20

years old, in which the youngest is 4 years old(Chan

et al., 2015), and the oldest is 20 years old(Mason,

Burkhart, & Lazebnik, 2018).

4 DISCUSSION

The systematic review shows that there is positive

effects of PMR on children. There are several

variations of duration which has positive meaning to

the PMR training, they are 15 minute-duration of

PMR shows significance for children

(Manjushambika, Prasanna, Vijayaraghavan, &

Sushama, 2017; Srilekha, Soumendra, &

Chattopadhyay, 2013), 20 minutes (Chan, Sze, Siu,

Lau, & Cheung, 2013), 25 minutes (Hashim &

Zainol, 2015), 30 minutes (Chan et al., 2015; Mason,

Burkhart, & Lazebnik, 2018), and 60 minutes

(Olmedilla-zafra, Rubio, Ortega, & García-mas,

2017), but 11 minute-duration does not show

significance for children (Murray, Scott, Connolly,

& Wells, 2018). Longer duration of PMR in one

session will give more positive impacts to children.

Musthaq & Khan (2018) makes guidance of

PMR exercise, that is following the step bellow in

times 20 minutes.

a. To sit on a chair as comfortably as possible.

Keep your body loose, continues to light and

free.

b. Be calm and comfortable.

c. Keep your eye closed.

d. Avoid stray thoughts.

e. Avoid extra movements of the body.

f. During the part of the exercise cycle tense the

muscle tightly and hold for slow count of 5

seconds. (Repeat silently 1001, 1002, 1003,…)

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

g. During the relation part of exercise cycle relaxes

the muscle quickly and completely .let your mind

relax and appreciate how relaxed the muscle is

feeling for 10 seconds.

h. Try to keep all other muscles relaxed as you

exercise specific muscle group.

i. As you exercise from head to toe. Observe

changes like tightness and the development of

light and soothing sensations.

Table 1: Description of The Selected Studies.

(Authors, Year) &

Country

Result

(Jong et al., 2018)

Netherlands

Methode: RCT. Intervention group used mind-body techniques (transcendental meditation or hypnotherapy vs

Control group used progressive muscle relaxation, instrument used RCADS, CSI and PCQ.

Age of Sample: 131 children with 9 -18 years old.

Main Result: Headache frequency, the primary outcome, was significantly reduced in all groups (from 18.9

days to 12.5 and 10.5 at respectively 3 and 9 months; p <0.001), pain medication was significantly reduced in

all children at 3 months (p = 0.003) and 9 months (p = 0.032), but no significant differences were observed

between the three groups.

Author Conclusion: non-pharmacological techniques effectively reduce the number of primary headache in

children

(Mason, Burkhart, &

Lazebnik, 2018)

USA

Methode: Cohort. Intervention group participants received training in diaphragmatic breathing, progressive

muscle relaxation (30 minutes), and use of no-cost/low-cost exercise options.

Age of Sample: 86 adolescents with 11-20 years old.

Main Result: There was not a significant difference between the intervention group and the control group on

key study variables (generalized anxiety, depression, perceived stress, pre-inter- vention subjective units of

distress score, and pre-intervention coherence rates), SUDS scores was a significant ( p < 0.001), and HRV was

a significant (p = 0.003).

Author Conclusion: Integrated care model in a primary care setting is feasible and effective at improving

stress management.

(Chan et al., 2015)

Hong Kong

Methode: Exploratory trial using a pre-teste post-test control group design. PMR given to intervention group

for 30 minutes.

Age of Sample: 65 patients who diagnosis of cancer and still chemotherapy, aged 4-11 years. Main Result:

Group PMR had significantly lower levels of child anxiety (Z=-2.14, p =0.032) than education group, No

statistical differences in body weight, the occurrence of nausea and vomiting, the intake of antiemetics, and

anxiety level (p > 0.05) between the two intervention groups.

Author Conclusion: The intervention process and higher levels of perceived usefulness of intervention were

given by patients in the relaxation group compared to those in the education group.

(Manjushambika,

Prasanna,

Vijayaraghavan, &

Sushama, 2017)

India

Methode: RCT. Jacobson’s Progressive Muscle relaxation (JPMR) took about 15-20 minutes daily.

Age of Sample: 145 students, range of ages 11-17 year.

Main Result: JPMR was statistically significant (Mc Nemer Chi-square =16.06; p<0.001).We conclude that

JPMR was effective in reducing the stress significantly.

Author Conclusion: JPMR is effective in reducing educational stress among adolescents.

(Hashim & Zainol,

2015)

Malaysia

Methode: Quasi experiment used 25 min pre-recorded PMR compact disc (CD), DST for measured short-term

memory, DVT for measured attention, and DASS21 to measure depression, anxiety, and stress levels.

Age of Sample: 132 primary school students, 24% 10 years old, and 76% 11 years old.

Main Result: A significant difference among the groups in mean changes in short-term memory (F = 3.89, df =

2, and p < 0.05), 12 session PMR>6 session PMR or no Intervention group, and no significant differences were

observed among the groups in anxiety (p > 0.05), depression (p > 0.05), stress (p > 0.05), or sustained attention

(p > 0.05)

Author Conclusion: This particular finding may provide general support for the use of at least 12 sessions of

PMR training, to reduce stress level, increase attention and strength short-term memory.

(Chan, Sze, Siu,

Lau, & Cheung,

2013)

Hong Kong

Methode: RCT. Intervention group used Chinese mind-body intervention (Nei Yang Gong)

Control group used PMR (20 minutes)

Age of Sample: 48 students (autism child), range of ages 6-17 year.

Main Result: The results showed that there were significant and marginally significant Time (Pre vs Post) by

Group (Control vs Experimental) interaction effects on the two indices of the TOLDX, i.e., the frequency of

rule violation, F(1,34)=6.02, p=0.02, and the initial time, F(1,34)=3.25, p=0.08.

Author Conclusion: Nei Yang Gong and PMR had a positive effect in enhancing the self-control of children

with autism spectrum disorders, but elevated brain activity was not observed in the children practicing PMR.

Best Effect of Progressive Muscle Relaxation (PMR) on Children: A Systematic Review

Table 1: Description of The Selected Studies (cont.).

(Authors, Year) &

Country

Result

(Olmedilla-zafra,

Rubio, Ortega, &

García-mas, 2017)

Spain

Methode: RCT. Included the following modules:

1. Linking thoughts and emotions;

2. PMR breathing, imagery, passive and differential muscle relaxation;

3. Self- instructional and attention-focus training; and

4. Stress inoculation training.

Age of Sample: 74 male soccer players from, range of ages 17-19 year.

Main Result: There were no significant differences between the two groups regarding the average number of

injuries before the treatment, t(61)=-0.460, p =0.647. The differences between the groupswere significant in the

post-treatment phase (p=0.005, r

=0.077), showing that the average number of injurieswas larger in the non-

treatment group.

Author Conclusion: A program aimed at controlling the stress response can reduce the incidence of sports

injuries in young athletes.

(Murray, Scott,

Connolly, & Wells,

2018) England

Methode: RCT. Intervention used Attention Training Technique (ATT) and PMR (min. 11 minutes).

Age of Sample: 101 children (learning or behavioural difficulty) with 5.55 -6.82 years old.

Main Result: (Time: Pre vs Post) x 3 (Condition: ATT vs PMR vs no-intervention) revealed a significant

effect of time, F(1, 98)=32.79, p < .0005and no significant effect of condition, F(2, 98)=1.23, p=0.30.

Author Conclusion: ATT showed an improvement in delay of gratification that was significantly greater than

shown in the PMR or no-intervention group.

(Srilekha,

Soumendra, &

Chattopadhyay,

2013)

India & Bangladesh

Methode: Quasy experiment with pre post test. PMR given to intervention group for 15 minutes per day, 3

days per week for 9 consecutive weeks.

Age of Sample: 80 boys, age range of 9-12 year.

Main Result: PMR training showed significant changes on all of the variables measures in the desired

direction (p<0.001) for anxiety and (p<0.005) for attention.

Author Conclusion: Abbreviated version of PMR exercise training could be effective enough in modulating

heightened emotionality, reduction of dispositional anxiety and improvement in attentive performances.

(McKenney, Broach

& Mullen, 2018)

USA

Methode: Quasy experiment. Intervention used Multisensory training (MST) vs PMR 20 minutes.

Age of Sample: 8 students (behavior disorder), range of ages 7-14 year.

Main Result: Overall mean time on task score for all participants aſter MST was 72 seconds, compared to 58

seconds aſter the PRT sessions, and 70 seconds aſter the control sessions.

Author Conclusion: The mean time on task score for MST was slightly higher when compared to scores

obtained from the PRT and control sessions.

j. Relax by taking three deep breaths inhaling

through nose and exhaling through mouth after

each step.

k. Now make your body completely loose,

continuous feeling light and free

Children at least 4 years old possibly practice PMR.

The category of childhood is under 19 years old or

younger. This statement is in line with national law

in each country. In the age of 10-19 years old,

people will be categorized as adolescent(WHO,

2013). Four-year-old children eagerly have their first

valley of development process, because they can see

the world in a bigger perspective. Children start to

ask about the world and are interested in many

things, and thus, they feel anxious and even stressed

for facing unfamiliar world(Department of Health

Western Australia, 2018). It can be a stressor for

children because of unsupportive environment.

5 CONCLUSIONS

The systematic review reveals that PMR possibly

assists children to maximize positive influence of

relaxation to control stress and anxiety. PMR is

considered meaningful if it is practiced in at least

once a day for 15 minutes in each session of

training. Based on the result of analysis, PMR can

be practiced since the children are 4 years old.

Recommendation for researcher, effect PMR in

Children should be developed by researcher in

Indonesia.

ACKNOWLEDGEMENTS

The authors would like to thank Universitas

Indonesia and Perpusatakaan Nasional Indonesia for

facilitating the database search for conducting this

review. Our special thanks also to Dessie Wanda,

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

Ph.D and yeni Rustina, Ph. D., Universitas

Indonesia, for improving the writing style of this

manuscript in the EBP class.

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Best Effect of Progressive Muscle Relaxation (PMR) on Children: A Systematic Review