This systematic review and meta-analysis was conducted with the aim of assessing the efficacy of relaxation techniques for pain relief in patients undergoing abdominal surgery. The electronic search of the PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases was performed for studies in the English language published up to May, 2019. A total of 12 studies were included in the review and 7 in the meta-analysis. In total, 4 relaxation techniques were utilized in the included studies: Jaw relaxation, Benson's relaxation, progressive muscle relaxation (PMR) and systematic relaxation. Of the 12 included, 10 studies demonstrated statistically significant pain relief in the relaxation group as compared to the controls. The data of 422 patients in the relaxation group and 424 patients in the control group were pooled for a meta-analysis, which indicated that patients undergoing abdominal surgery had significantly greater pain relief following relaxation therapy as compared to the controls [random: standardized mean difference (SMD), −1.15; 95% CI, −2.04 to −0.26; P<0.00001). The overall quality of the studies was not high. On the whole, despite trials demonstrating the benefits of relaxation therapy for immediate pain relief in patients post-abdominal surgery, there is lack of high-quality scientific evidence substantiating its routine use. There is a need for more robust randomized control trials (RCTs) utilizing standardized relaxation protocols to provide further evidence on this subject.
The International Association for the Study of Pain, describes pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ (
Abdominal surgery is considered to be one of the most painful surgical procedures (
Pain management has been a subject of intense research with a number of technological advancements striving to achieve optimal pain control. Even with the advent of patient- controlled analgesia, continuous intravenous infusion and the intraspinal application of opioids, pain control remains a major challenge (
Relaxation therapy has been shown to provide pain relief by decreasing anxiety, lowering muscle tension and distracting attention (
This systematic review of the literature was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (
We searched for studies evaluating the effects of relaxation therapy in patients undergoing abdominal surgery. No restrictions were placed on the type of relaxation technique and the type of abdominal surgery. Controlled clinical trials (CCTs) and randomized control trials (RCTs) studying the effects of relaxation therapy on post-operative pain reduction in patients undergoing abdominal surgery were included in this review. The participants of the included studies needed to be >18 years of age, had to have undergone surgery under general anesthesia or spinal anesthesia and must have been hospitalized during the period of the surgery for at least 48 h. Participants were not to have any cognitive impairment and were not to have planned to undergo any neurosurgery. Intervention had to include relaxation therapy with muscle relaxation in the post-operative period. Outcome assessment had to include pain scores measured on any scale, such as the visual analogue scale (VAS) (
We searched the PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases (first 100 results) electronically for articles published up to May, 2019. The key words used in various combinations were: Relaxation therapy [MeSH], relaxation techniques [MeSH], progressive muscle relaxation [Free text], systematic relaxation [Free text], Benson's relaxation [Free text], abdominal surgery [Free text], surgery [MeSH], pain [MeSH], pain relief [MeSH], abdominal pain [MeSH], nursing [MeSH] and nursing care [MeSH]. References of included studies and review articles were analysed for the identification of any additional studies.
Two reviewers examined potentially eligible studies. Following the removal of duplicates, studies were scrutinized by their title and abstracts. Full-texts of selected articles were then scanned for their inclusion in the review. Any differences in opinion were resolved by discussion. The following data were extracted from the included trials: Authors, publication year, sample size, demographic data, relaxation technique, relaxation protocol and outcomes assessed.
The Cochrane Collaboration risk assessment tool for RCTs was used for assessing the risk of bias (
Studies were included in the meta-analysis only if pain scores were reported as the means and standard deviation. The results of the remaining studies were summarized in a narrative form. Outcome data extracted were entered into Review Manager [RevMan, version 5.3; Nordic Cochrane Centre (Cochrane Collaboration), 2014] for quantitative analysis. the data of different relaxation techniques were pooled for a sub-group analysis. Considering the heterogeneity amongst studies, a random-effects model was used to calculate the pooled effect size. The standardized mean difference (SMD) with the 95% confidence interval (CI) was used for combining pain data measured on different scales. Heterogeneity was calculated using the I2 statistic. I2 values of 25–50% represented low, values of 50–75% medium and >75% represented substantial heterogeneity.
The search outcome of the review is presented in
A total of 4 relaxation techniques were utilized in the included studies, namely: The jaw relaxation technique, Benson's relaxation technique, progressive muscle relaxation (PMR) technique and systematic relaxation technique. The description of each technique was as follows: i) The jaw relaxation technique was carried out with patients dropping the lower jaw slightly as though starting a small yawn. The tongue was kept quiet and resting at the bottom of the mouth. The lips were to parted slightly, and the patient was to breath slowly and rhythmically with a 3-rhythm pattern (inhale, exhale and rest). Word formation was not advised and the patient was advised to not think of any words (
The details of the included studies are presented in
Seven of the 12 included studies reported sufficient data for inclusion in the meta-analysis (
A number of additional outcome variables were compared between the relaxation and control groups by the included studies. Systemic measures, such as pulse rate, blood pressure and respiratory rate were analyzed by 3 studies (
While Roykulcharoen and Good (
The risk of bias summary of the included studies is presented in
As shown by our literature review, relaxation therapy has been a subject of substantial research in the area of pain relief after abdominal surgery. Studies have compared 4 different relaxation methods to date. ‘Jaw relaxation’, which involves the relaxation of the mouth and throat, is a specific regional approach developed by Jacobson (
Total body relaxation techniques used by studies in our review included, Benson's relaxation, PMR and systematic relaxation. Only minor differences separate these 3 techniques (
The mechanism of pain relief with relaxation therapy has been explained in relation to the gate control theory of pain. The gate control theory of pain postulates that alteration or modification of pain impulses being transmitted from the peripheral nerve receptors to the brain can result in little or no pain perception (
The actual effect of relaxation therapy on anxiety, stress and systemic variables (pulse, blood pressure and respiratory rate) in abdominal surgery have also been studied. While some studies (
The strength of any meta-analysis to a certain extent depends on the homogeneity and quality of the studies included. A number of factors limit our reviews ability to draw strong conclusions for relaxation therapy. Foremost, there was only one high quality study (
Despite a number of trials demonstrating benefits of relaxation therapy for immediate pain relief in patients undergoing post-abdominal surgery, there is lack of high-quality scientific evidence substantiating its routine use. There is a need for more robust RCTs utilizing standardized relaxation protocols to provide further evidence on this subject. However, in the absence of harmful effects of relaxation therapy and minimal time required for training patients, despite weak evidence, it may still be employed by nurses in the post-operative setting to provide short-term pain relief.
Not applicable.
No funding was received.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
WJ conceived and designed the study. LR, JC and YD collected the data and performed the literature search. All authors were involved in the writing of the manuscript. All authors have read and approved the final manuscript.
Not applicable.
Not applicable.
The authors declare that they have no competing interests.
Flowchart of the study.
Forrest plot of relaxation therapy for pain relief. CI, confidence interval.
Risk of bias summary (green circles indicate a low risk of bias, yellow circles indicate an unclear risk of bias and red circles indicate a high risk of bias).
Characteristics of the included studies.
No. of participants | |||||||||
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Author/(Ref.), year | Relaxation technique | Surgery type | R | C | Age group | Sex | Relaxation protocol | Time interval between post-test and relaxation | Study conclusion |
Flaherty and Fitzpatrick ( |
Jaw relaxation | Cholecystectomy, herniorrhaphy, haemorrhoidectomy | 21 | 21 | 18–65 | M: 23 F: 19 | 6–8 h after surgery, relaxation started just before patient ambulation (30 ft), continued during and after ambulation. | Immediately | Significantly less incisional pain, body distress and respiratory rate in relaxation group. No difference in blood pressure and pulse rates. |
Wilson ( |
Systematic relaxation | Cholecystectomy, hysterectomy | 17 | 18 | 42.3 10.7 | NS | Relaxation therapy used by patients as and when desired for post-operative days 1, 2 and 3. | NS | Significantly better hospital recovery in relaxation group |
Data of 3 days averaged and compared. | NS | Significantly less pain in relaxation group. | |||||||
Levin |
Benson's relaxation | Cholecystectomy | 9 | 10 | 21–65 | F: 19 | Relaxation therapy used by patients as and when desired. Data collected evening of surgery and then twice daily for 2 days. | No difference in number of analgesics consumed and length of hospital stay between 2 groups. | |
Good |
Jaw relaxation | Gastro-intestinal, gynaecological, exploratory, urinary | 130 | 120 | 20–70 | NS | On 1st post-operative day, relaxation started 5 min prior to ambulation, continued during and after ambulation for 10 min. One half tested after ambulation other half tested at rest. Order reversed on 2nd day. | 10 min | Significantly less pain and distress in relaxationgroup. Reduced pulse rates and respiratory rates in treatment group. |
Roykulcharoen and Good ( |
Systematic relaxation | Gastrointestinal, gynaecological, exploratory | 51 | 51 | 21–65 | M:18 F: 84 | Post-ambulation on 1st post-operative day, relaxation therapy given for 15 min. | Immediately | Significantly less pain sensation and distress of pain in relaxation group. No change in anxiety levels between the 2 groups and no difference in 6-h opioid intake |
Chandrababu ( |
Progressive muscle relaxation | NS | 20 | 20 | 18–60 | NS | On 1st post-operative day, relaxation therapy performed for 20 min. Repeated twice daily for 3 days. | 5 min | Significantly less pain in relaxation group. No difference in respiration rate, systolic blood pressure and diastolic blood pressure between the 2 groups. |
Topcu and Findik ( |
NS | NS | 60 | 60 | 48.38 NS | NS | On post-operative days 1–4, relaxation therapy performed for 20 min. | Immediately | Significantly less pain in relaxation group. |
Rejeh |
Systematic relaxation | NS | 62 | 62 | 65–92 | M: 32 F: 92 | Relaxation therapy repeated 3 times. Post-test measured after 15 min recovery following ambulation. | 15 min, 1 h and 12 h | Significantly less pain, anxiety and analgesic use in relaxation group. |
Solehati and Rustina ( |
Benson's relaxation | Caesarean | 30 | 30 | NS | F: 60 | Relaxation therapy performed 2 h after the operation, continued twice daily for 4 days. | Immediately | Significant pain reduction seen in both relaxation and control groups |
Devi and Saharia ( |
Progressive muscle relaxation | Appendicectomy, cholecystectomy, hernioplasty, gastrectomy, gastro-jejunostomy | 20 | 20 | 20–40 | M: 20 F: 20 | For 3 post-operative days, relaxation therapy performed for 15 min. | 1h | Significantly less pain in relaxation group |
Devmurari and Nagrale ( |
Progressive muscle relaxation | Caesarean | 17 | 17 | 18–30 | F: 34 | Relaxation therapy performed 10 times per session. One session performed each day from post-operative days 3–7. | After completing 5 days of therapy | Greater pain reduction in relaxation group. No statistical analysis done. |
Ismail and Elgzar ( |
Progressive muscle relaxation | Caesarean | 40 | 40 | 20–35 | F: 80 | Relaxation therapy performed thrice daily for 30 min on post-operative days 0 and 1. | After completing 2 days of therapy | Significantly less pain, improved physical activity and better quality of sleep in relaxation group. |
Studies included in the meta-analysis. R, relaxation group; C, control group; M, male; F, female; NS, not specified.