A systematic review and meta-analysis of the effects of muscle relaxation training vs. conventional nursing on the depression, anxiety and life quality of patients with breast cancer

Introduction

Among the cancers that threaten the health and lives of women, breast cancer ranks first in the world (1). Indeed, the incidence of breast cancer ranks first in most countries (i.e., in 159 of 185 countries) (1). China has the highest incidence of (17.6%), and mortality rate (15.6%) for, female breast cancer in the world (2). With advancements in diagnosis and treatment, the survival rate of breast cancer patients is increasing year by year, but the 5-year survival rate is still as high as 90% (3). Thus, while the life expectancy of breast cancer patients has been prolonged, patients with breast cancer are prone to anxiety, depression, fatigue, and other psychological problems during treatment, which also affect their quality of life (QoL) (4,5).

QoL has become an important criteria for evaluating the overall treatment of cancer. Depression and anxiety are common complications among breast cancer patients. Study has shown that depression and anxiety negatively affect the treatment, relapse, and all-cause mortality of breast cancer patients (6). Thus, improving patients’ psychological state to increase the cure rate has become a popular area of clinical research (7).

Patients with breast cancer have expressed more and more interest in using complementary and integrative therapies as supportive care to restore their physiological functions and adjust their mental state (8,9). Complementary and comprehensive therapies include a variety of activities, such as relaxation approaches, meditation, deep breathing, guided imaging, and stress management interventions (10). Muscle relaxation training is an economical and convenient intervention method. Progressive relaxation training is the most commonly used relaxation training method at present, which has the characteristics of strong operability, good application effect and easy acceptance. Patients through conscious control of the body muscle repeated contract-relaxation cycle process, to achieve the effect of gradual relaxation of the whole body (11,12). However, there is insufficient evidence to support the use of muscle relaxation training in an oncology setting.

Complementary and integrative therapies are becoming more and more commonly used in medical practice, and muscle relaxation training is one of the most promising integrative breast cancer treatments. However, at present, this therapy has been applied in coronary heart disease, diabetes, hypertension, asthma, myocardial infarction and other acute and chronic diseases, which has been proved to help patients reduce negative emotions and improve their quality of life to a certain extent. But the study concluded that the treatment did not work as well as expected in breast cancer patients

This study conducted a systematic review and meta-analysis based on randomized controlled trials (RCTs) or quasi-RCTs to evaluate the effects of muscle relaxation training on the psychological health and QoL of breast cancer patients. This study sought to provide evidence for choosing active care in clinical practice to produce improvements in the psychological state and QoL of breast cancer patients.

We present the following article in accordance with the PRISMA reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-22-428/rc).

Methods

Inclusion criteria for study selection

Types of studies

Only RCTs or quasi-RCTs were included in the meta-analysis.

Types of objects

Only published RCTs or quasi-RCTs with data comparing relaxation training to regular nursing among patients with breast cancer were considered for inclusion in the meta-analysis. For the study selection, all gray literature was excluded.

Intervention measures

The intervention measures of the experimental group were muscle relaxation training, which is a relaxation training method. It is a method to gradually relax the whole body by consciously controlling the process of muscle contraction and relaxation, including yoga, progressive muscle relaxation training and relaxation training. In contrast, for the control group, the intervention was routine care.

Outcome measures

The outcome measures were as follows: (I) depression; (II) anxiety; and (III) QoL. Depression, anxiety, and QoL were continuous effect measures, and the effect size was the variation from the baseline to the follow-up time.

Study exclusion criteria

Articles were excluded from the meta-analysis if they met any of the following exclusion criteria: (I) was about a non-RCT or non-retrospective research, such as in-vitro experiments, reviews, abstracts, or letters; (II) the study did not include a control group or included an inconsistent control group; (III) was published in a language other than Chinese or English; (IV) the original text of the article could not be obtained; (V) the study included <20 samples; and/or (VI) the data could not be obtained or converted.

Literature screening methods

In this study, 2 of the authors independently searched the following databases: PubMed, EMbase, Web of Science, The Cochrane Library, CNKI, WanFang Data, CBM, and VIP to retrieve articles on RCTs examining the effects of muscle relaxation training on the psychological health and QoL of breast cancer patients. The systematic searches were carried out from the establishment of the databases to August 31st, 2021. Additionally, the reference lists of any review articles were also reviewed to supplement the relevant literature. The search strategy combined theme words and free words. Among them, the PubMed search theme terms included breast Neoplasms [Mesh] and Muscle Relaxation [Mesh], and the Chinese search terms included breast neoplasms, mammary carcinoma, breast cancer, breast tumor, muscle relaxation, etc.

Study selection and data extraction

Next, the 2 authors independently screened the literature, extracted the data, and cross-checked the data. Any disagreement between the reviewers was resolved by discussion or consulting a third party. When selecting the literature, the reviewers first read the title and abstract, and then excluded any irrelevant articles. Next, they read the full text of the remaining articles to determine inclusion/exclusion. If necessary, the reviewers contacted the corresponding authors via email or telephone for detailed information that had not yet been confirmed but was crucial for this research.

The following information was extracted: (I) basic information about the included article, including the title, the first author’s name, date of publication, country, and region; (II) the baseline characteristics of the research objects, including the sample size, age, education status, marriage, and clinical stage; (III) the intervention and control measures, including the muscle relaxation training methods, period, frequency, and duration; (IV) the included standard outcome measures and related results; and (V) the relevant information on the bias-risk evaluations.

Risk of bias assessment

Risk of bias assessments were conducted by the 2 reviewers independently, and the results were cross-checked. If any inconsistences arose in the process, a third reviewer was consulted to resolve the disagreement. The risk of bias assessment was conducted by applying the tools for risk of bias assessment recommended by the Cochrane Handbook for Systematic Reviews of Interventions (13), which include the 7 items were designed from the following 6 aspects: (I) selection bias (e.g., random-sequence generation, and allocation-result concealment); (II) implementation bias (e.g., the patient-blinding method); (III) measurement bias (e.g., the result evaluator blinding method); (IV) loss to follow-up bias (e.g., incomplete data); (V) reporting bias (e.g., selective-result reporting); and (VI) other possible biases. Each item was classified as “high risk”, “low risk”, or “unclear” for the bias-risk assessment results.

Outcome measures

The outcome measures of this meta-analysis were as follows: (I) the level of depression as assessed by the Self-Rating Depression Scale (SDS) compiled by Zung (14); (II) the level of anxiety as assessed by the Self-Rating Scale (SAS) compiled by Zung (14); (III) QoL as evaluated by the Functional Assessment of Cancer Therapy developed by the Center on Outcomes Research and Evaluation (15); and (IV) the QoL Measurement Scale for Breast Cancer Patients (FACT-B), which is a specific scale composed of FACT-G and breast cancer-specific modules for breast cancer patients.

Statistical analysis

Stata 15.0 software was used for the statistical analysis. In this meta-analysis, the level of depression, the level of anxiety, and the QoL were continuous effect indicators, and the dimensions of each study were unified. Thus, the combined effect size was determined by the weighted mean difference (WMD), which is expressed with the 95% confidence interval; that is, WMD (95% CI). The Q test and I² test were used to determine the extent of heterogeneity. When I²<50% or P<0.1, the fixed-effects model was used to combine the outcome measures; and when I²≥50% or P<0.1, indicating statistical heterogeneity among the results, we analyzed the source of heterogeneity and excluded the influence of any obvious clinical heterogeneity, and then used the random-effects model.

When I²≥50%, clinical heterogeneity was analyzed by a subgroup analysis or sensitivity analysis. The publication bias of the included studies was displayed in a funnel chart, and the Begg’s test and Egger’s test were used to analyze the funnel chart. In this study, for the Begg’s test and Egger’s test, a P value <0.05 indicated a statistically significant difference.

Results

Article selection process and results

In total, 572 studies were retrieved, and after review, 13 RCT or quasi-RCT trials, comprising a total of 1,355 patients, were finally included in the meta-analysis (11,16-27). The article screening process and results are shown in Figure 1.

Figure 1 Article selection process and results.

The basic characteristics of the included studies and the results of the risk assessment of bias

The included studies were published from 2005 to 2021, and comprised a total of 1,355 patients (679 in the experimental group and 676 in the control group) (17,21,25). Of the articles, 3 were quasi-RCTs. A random sequence was generated in the order of admission time (17). One study was an open-label trial. The basic characteristics of the included articles are set out in Table 1.

The results of the risk of bias assessment are shown in Table 2, Figure 2, and Figure 3. In the studies included in the meta-analysis, the risk of sequence generation and allocation of the 11 articles was low (21,25). The 2 studies that generated random sequences in the order of odd and even numbers and admission time had a high risk of bias. In general, the risks of implementation bias and detection bias were low. All the studies were feasible, and the outcome of the scheme was consistent with the results of the study.

Figure 2 Summary of risk of bias.

Figure 3 Chart of risk of bias.

Results of the meta-analysis

Depression degree

Of the included studies, 6 (21,23-27) (comprising a total of 949 patients) reported on the effects of muscle relaxation training on the level of depression of patients. A random-effects model was adopted (I²=84.6%, P=0.000), and the combined results showed that the difference between the 2 groups was statistically significant (–9.31, 95% CI: –11.96, –6.65). Thus, muscle relaxation training for the adjuvant treatment of breast cancer patients was significantly better than conventional care in terms of reducing depression (see Figure 4A).

Figure 4 Analysis of depression. WMD, weight mean difference; s.e. of: WMD, standard error of weighted mean difference.

A subgroup analysis was carried out according to the study types, and the results showed that the heterogeneity mainly originated from 2 quasi-RCTs, and there was a large heterogeneity between the quasi-RCTs and RCTs.

For the outcome measure of depression, we used a funnel chart to demonstrate the publication bias, and the Egger’s test and Begg’s test to analyze the funnel chart. The results of the tests (P>0.05) indicated that the possibility of publication bias was small. Additionally, the sensitivity analysis results showed that the effect size after excluding each study did not change significantly (see Figure 4B,4C).

Anxiety

Of the included studies, 6 (21,23-27) (comprising a total of 949 patients) reported on the effects of muscle relaxation training on the anxiety of patients. A fixed-effects model was adopted (I²=5.6%, P=0.381), and the combined results showed that the difference between the 2 groups was statistically significant (WMD =–8.96, 95% CI: –10.06, –7.86). Thus, muscle relaxation training adjuvant therapy for breast cancer patients was significantly better than conventional nursing in terms of reducing anxiety (see Figure 5A).

Figure 5 Analysis of anxiety. WMD, weight mean difference; s.e. of: WMD, standard error of weighted mean difference.

For the outcome measure of anxiety, we used a funnel chart to display the publication bias, and the Egger’s test and Begg’s test to analyze the funnel chart. The results of the tests (P>0.05) indicated that the possibility of publication bias was low. Additionally, the sensitivity analysis results showed that the effect size after excluding each study did not change significantly (see Figure 5B,5C).

QoL

Of the included studies, 8 (18,20,21,23-27) (comprising a total of 1,039 patients) reported on the effects of muscle relaxation training on patients’ QoL. A random-effects model was adopted (I²=97.2%, P=0.000), and the combined results showed that the difference between the 2 groups was statistically significant (WMD =13.13, 95% CI: 7.24, 19.02). Thus, muscle relaxation training treatment was significantly better than conventional care in improving the QoL of breast cancer patients (see Figure 6A).

Figure 6 Analysis of QoL. QoL, quality of life. WMD, weight mean difference; s.e. of: WMD, standard error of weighted mean difference.

A subgroup analysis was carried out according to the study type, and the results showed that the heterogeneity mainly originated from 2 quasi-RCTs, and there was a large heterogeneity between the quasi-RCTs and RCTs.

For the outcome measure of QoL, we used a funnel chart to display the publication bias, and used the Egger’s test and Begg’s test to analyze the funnel chart. The results of the tests (P>0.05) indicated that the possibility of publication bias was low. Additionally, a sensitivity analysis was carried out by excluding individual studies one by one. The results showed that this study (25) had a great impact on the results, which may be related to the high risk of random allocation of odd and even numbers. However, after excluding the above study, the combined analysis results showed no fundamental changes, indicating that the results of the meta-analysis were relatively stable (see Figure 6B,6C).

Discussion

We conducted a meta-analysis of RCTs and quasi-RCTs to examine the effects of muscle relaxation training on the mental health and QoL of breast cancer patients compared to conventional care. In total, 13 RCTs and quasi-RCTs, were included in the meta-analysis. The results showed that compared to conventional care, muscle relaxation training significantly reduced the level of depression and level of anxiety of breast cancer patients, and improved their QoL.

With advancements in diagnosis and treatment, the life span of breast cancer patients has been prolonged, but studies have shown that nearly 50% of breast cancer patients suffer from psychological distress during diagnosis and treatment or recovery, which seriously affect their QoL (5,28). Thus, more attention needs to be paid to patients’ QoL during and after cancer treatment. It is necessary to explore an effective way to intervene in patients’ psychological health and quality of life to improve their QoL. Thus, we used depression, anxiety, and QoL as the outcome measures in this meta-analysis to examine the effect of conventional nursing and muscle relaxation training on patients’ mental health and QoL.

The latest meta-analysis published by Ramírez-Vélez et al. (29) confirmed that exercise moderately improved the QoL of breast cancer patients, and also slightly improved different aspects, such as anxiety, body shape and appearance, depression, overall QoL, and emotional function. It also pointed out the limitations of related meta-analysis research, including the lack of evidence for some important outcome measures, and the limitation of the method of RCT. The meta-analysis of Yi et al. (30) showed that yoga may help to reduce fatigue, depression and anxiety, improve sleep disorders, and improve the QoL of breast cancer patients receiving short-term chemotherapy. However, due to the inconsistent control group in the study, it is not yet clear whether yoga has a significant advantage over other treatments. Notably, our research was based on RCTs and quasi-RCTs, and we found that muscle relaxation training significantly improved the level of depression and the level of anxiety of patients and improved their QoL compared to conventional care, and thus improved patients’ management of bad emotions and their QoL.

However, this study still had some limitations. First, while we conducted a comprehensive search of mainstream databases, there are still a few RCTs that could have been included in this meta-analysis. Second, the collection of characteristic factors was limited, and the history of abortion, history of contraception, history of benign breast diseases, and other clinical factors and basic demographic characteristics were not examined.

In summary, this study has important clinical significance. It emphasizes the importance of a more systematic screening of breast cancer patients’ anxiety, depression, and QoL. It also emphasizes the necessity of using muscle relaxation training in breast cancer care to improve patients’ mental health and QoL. Our findings can be used by oncologists, cancer nurses, and physical therapists, and provide a reference for future cancer rehabilitation management.

Conclusions

Based on the limited evidence, compared to conventional care, muscle relaxation training significantly reduces the level of depression and level of anxiety of breast cancer patients and improves their QoL. This meta-analysis was limited by the number and the quality of the included studies. The above conclusions need to be verified by larger-scale and multi-center investigations, using more accurate and high-quality studies.

Acknowledgments

We would like to thank the researchers and study participants for their contributions.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-22-428/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-22-428/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work, including ensuring that any questions related to the accuracy or integrity of any part of the work have been appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71:209-49. [Crossref] [PubMed]
2. Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016;66:115-32. [Crossref] [PubMed]
3. Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet 2018;391:1023-75. [Crossref] [PubMed]
4. Li J, Zhang F, Wang W, et al. Prevalence and risk factors of anxiety and depression among patients with breast cancer: a protocol for systematic review and meta-analysis. BMJ Open 2021;11:e041588. [Crossref] [PubMed]
5. Burgess C, Cornelius V, Love S, et al. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ 2005;330:702. [Crossref] [PubMed]
6. Wang X, Wang N, Zhong L, et al. Prognostic value of depression and anxiety on breast cancer recurrence and mortality: a systematic review and meta-analysis of 282,203 patients. Mol Psychiatry 2020;25:3186-97. [Crossref] [PubMed]
7. Pei W. Patient CPOTGfC. Chinese Psychosocial Oncology Therapy Guidelines for Cancer Patient. Chinese Journal of Experimental Prescriptions 2021:1.
8. Lemanne D, Maizes V. Advising Women Undergoing Treatment for Breast Cancer: A Narrative Review. J Altern Complement Med 2018;24:902-9. [Crossref] [PubMed]
9. Chin CY, Chen YH, Wu SC, et al. Complementary and Alternative Medicine Use in Breast Cancer Patients at a Medical Center in Taiwan: A Cross-Sectional Study. Integr Cancer Ther 2020;19:1534735420983910. [Crossref] [PubMed]
10. Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin 2017;67:194-232. [Crossref] [PubMed]
11. Demiralp M, Oflaz F, Komurcu S. Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. J Clin Nurs 2010;19:1073-83. [Crossref] [PubMed]
12. Sinha MK, Barman A, Goyal M, et al. Progressive Muscle Relaxation and Guided Imagery in Breast Cancer: A Systematic Review and Meta-analysis of Randomised Controlled Trials. Indian J Palliat Care 2021;27:336-44. [Crossref] [PubMed]
13. Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev 2019;10:ED000142. [Crossref] [PubMed]
14. Zung WW. A SELF-RATING DEPRESSION SCALE. Arch Gen Psychiatry 1965;12:63-70. [Crossref] [PubMed]
15. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 1993;11:570-9. [Crossref] [PubMed]
16. Kovačič T, Kovačič M. Impact of relaxation training according to Yoga In Daily Life® system on self-esteem after breast cancer surgery. J Altern Complement Med 2011;17:1157-64. [Crossref] [PubMed]
17. Kurt B, Kapucu S. The effect of relaxation exercises on symptom severity in patients with breast cancer undergoing adjuvant chemotherapy: an open label non-randomized controlled clinical trial. Eur J Integr Med 2018;22:54-61. [Crossref]
18. Pruthi S, Stan DL, Jenkins SM, et al. A Randomized Controlled Pilot Study Assessing Feasibility and Impact of Yoga Practice on Quality of Life, Mood, and Perceived Stress in Women With Newly Diagnosed Breast Cancer. Glob Adv Health Med 2012;1:30-5. [Crossref] [PubMed]
19. Vuttanon N, Finnegan L, Lojanapiwat B, et al. Effect of progressive muscle relaxation on symptom clusters in breast cancer patients receiving chemotherapy: A quasi-experimental controlled trial. Complement Ther Clin Pract 2019;37:27-31. [Crossref] [PubMed]
20. Yoo HJ, Ahn SH, Kim SB, et al. Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Support Care Cancer 2005;13:826-33. [Crossref] [PubMed]
21. Chen M, Guo MX. The effects of progressive muscle relaxation training on the mental state and quality of life of breast cancer patients in perioperative period. Modern Nurse 2021;28: [Crossref]
22. Liu Y. Application effects of progressive muscle relaxation training in postoperative rehabilitation nursing of breast cancer patients. Contemporary Medicine Forum 2020;14:14-15.
23. Hou N, Wang H, Wang Y. Effects of progressive muscle relaxation training on anxiety, depression and quality of life of breast cancer patients in the perioperative period. Journal of Modern Nursing 2017;23:489-93.
24. Wei J, Liu B, Zuo L, et al. Exploration of the effects of progressive muscle relaxation training on depression, anxiety and quality of life of breast cancer patients in the perioperative period. Chinese Journal of Clinical Laboratory Science 2016;3:147-9.
25. Xi X, Bai X. Effects of progressive muscle relaxation training on anxiety, depression and quality of life in breast cancer patients in perioperative period. Clinical Research and Practice 2019;4:175-7.
26. Yuan L, Zhang F, Yao W, et al. Effects of muscle relaxation training on the quality of life of breast cancer patients in the perioperative period. Journal of Nurses Training 2017;32:296-9.
27. Song C. Evaluation of the Application Effects of Relaxation Training of Patients with Breast Cancer. Psychology Journal 2019;14:3-6.
28. Prates ACL, Freitas-Junior R, Prates MFO, et al. Influence of Body Image in Women Undergoing Treatment for Breast Cancer. Rev Bras Ginecol Obstet 2017;39:175-83. [Crossref] [PubMed]
29. Ramírez-Vélez R, Zambom-Ferraresi F, García-Hermoso A, et al. Evidence-Based Exercise Recommendations to Improve Mental Wellbeing in Women with Breast Cancer During Active Treatment: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021;13. [Crossref] [PubMed]
30. Yi LJ, Tian X, Jin YF, et al. Effects of yoga on health-related quality, physical health and psychological health in women with breast cancer receiving chemotherapy: a systematic review and meta-analysis. Ann Palliat Med 2021;10:1961-75. [Crossref] [PubMed]