Journal of Advanced Nursing, 1998, 27, 466–475

Relaxation techniques for acute pain

management: a systematic review
Kate Seers BSc(Hons) PhD RGN
Senior Research Fellow, Royal College of Nursing Institute, Radcliffe Infirmary

and Dawn Carroll BA(Hons) SRN ONC

Senior Research Nurse, Pain Research Unit & Nuffield Department of Anaesthetics,
University of Oxford, The Churchill, Oxford, England

Accepted for publication 25 February 1997

SEERS K. & CARROLL D. (1998) Journal of Advanced Nursing 27, 466–475

Relaxation techniques for acute pain management: a systematic review
This review aims to document the effectiveness of relaxation techniques, when
used alone for the management of acute pain, after surgery and during
procedures. A systematic review of randomized controlled trials (RCTs) was
undertaken. Seven studies involving 362 patients were eligible for this review.
One hundred and fifty patients received active relaxation as the sole
intervention. Reports were sought by searching MEDLINE, psycLIT, CINAHL,
and the Oxford Pain Relief Database. The outcome measures used were pain and
psychological factors. A meta-analysis was not possible, due to lack of primary
data. Three of the seven studies demonstrated significantly less pain sensation
and or pain distress in those who had relaxation. Four studies did not detect any
difference. There was some weak evidence to support the use of relaxation in
acute pain. However, this was not conclusive and many of both the positive and
the negative studies suffered from methodological inadequacies. Well designed
and executed randomized controlled trials are needed before the clinical use of
relaxation in acute pain management can be firmly underpinned by good
quality research evidence. Until this evidence is available we recommend that
the clinical use of relaxation in acute pain settings is carefully evaluated and
not used as the main treatment for the management of acute pain.

Keywords: pain, postoperative, acute, relaxation, systematic review,

non-pharmacological, surgical pain

has thus been suggested. Relaxation has become increasingly

BACKGROUND
Relaxation has been described as a ‘state of relative freedom
from both anxiety and skeletal muscle tension’ (McCaffery
& Beebe 1989 p. 188), and as bringing ‘the mind of the partici-
pant to a state of balance and peace’ (Ryman 1995 p. 141).
Some sort of action on both physical and cognitive processes
Correspondence: Kate Seers, Royal College of Nursing Institute, Radcliffe
Infirmary, Woodstock Road, Oxford OX2 6HE, England.
popular as a pain relieving intervention. It has been sug-
gested that relaxation works by breaking the vicious circle
of pain, tension and thus more pain (Linton 1982a). Many
books describe relaxation techniques for health professionals
(for example Payne 1995), and for nurses in particular
(Rankin-Box 1995, McCaffery & Beebe 1989).
It would seem important to determine the effectiveness
of relaxation if these techniques are to be used more
widely. Linton (1982b) reviewed non-drug interventions

466 © 1998 Blackwell Science Ltd


for chronic pains other than headache and concluded
relaxation seemed to be generally effective. However, he
cautioned that the studies were of poor quality, were lack-
ing in appropriate and adequate controls, outcomes and/or
follow-ups. This comment, whilst addressing the chronic
pain literature, would suggest that at least in some of the
research, the potential for bias exists.
If the practitioner wants to know whether relaxation is
effective in reducing pain (and other outcomes), then only a
well designed and conducted randomized controlled trial
can start to provide an answer in which practitioners can
have some degree of confidence (Schultz et al. 1995). Other
research designs may well provide valuable knowledge in
other areas, but cannot be used to address a question about
effectiveness. Non-randomized studies have for nearly 20
years been shown to yield larger estimates of treatment
effects than studies using random allocation (Chalmers et al.
1977). The size of the over-estimation of odds ratios when
randomization is inadequately concealed can be as much as
40% (Schultz et al. 1995). These findings underpin the
inclusion criteria chosen in systematic reviews.
Whilst some authors have suggested that relaxation is
effective for postoperative pain ( Jessup & Gallegos 1994
p. 1330), this assertion is not based on randomized con-
trolled trials with pain as an outcome. Similarly, although
the Agency for Health Care Policy and Research (Acute
Pain Management Guideline Panel 1992 p. 23) guidelines
for acute pain management suggest relaxation strategies
have shown ‘some degree of effectiveness’, this recommen-
dation is not based exclusively on evidence from ran-
domized controlled trials. Johnstone & Vogele (1993) also
concluded that relaxation had a beneficial effect on pain
and other outcomes after surgery. A recent review of the
effects of relaxation and music on postoperative pain
included randomized controlled trials and non-
randomized studies in the conclusions (Good 1996). It
would thus seem that a review of randomized controlled
trials that have been conducted to assess the specific
effects of relaxation on pain and other psychological out-
comes would be useful for practitioners trying to justify
the use of relaxation with patients in acute pain. Chalmers
& Altman (1995), the NHS Centre for Reviews and
Dissemination (1996) and L’Abbe et al. (1987) provide
guidance for those undertaking this type of review.
METHODS
Published randomized controlled trials (RCTs) of relax-
ation for acute pain were sought. A number of different
methods were used to identify eligible reports. These
included searching of the following electronic databases
using both Knowledge Finder Version 3.25 and MacSPIRS
Version 2.32 as the search platforms. MEDLINE (Index
dates 1966–3/1996), psycLIT (Index dates 1974–3/1996),
Cumulative Index of Nursing and Allied Health Literature
© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475
Relaxation techniques
(CINAHL (Index dates 1982–3/1996) and the Oxford Pain
Relief Database (1950–1994) ( Jadad et al. 1996a). The
Oxford Pain Database is a computerized reference database
containing the reference citations of over 13 000 ran-
domized controlled trials for pain interventions. This data-
base was developed from a modified search of Medline
and hand-search of over 30 biomedical journals.
The search for this review was undertaken in two stages.
Initially the word ‘relax*’ and variants of the word relax-
ation were used as free text search terms, including combi-
nations of these words, and without restriction to
language. Medical Subject Headings (MESH) were found
to be inadequate in identifying appropriate studies and
thus were not used in a deliberate attempt to maximize
recall, even though this meant over-selection of potential
studies. The second stage of the electronic search includ-
ing searching for studies including imagery, hypnosis, vis-
ualization and cognitive therapy, using a variety of free
text combinations of these terms in attempt to maximize
yield. Additional reports were identified from the refer-
ence lists of retrieved reports, review articles and
textbooks.
Inclusion criteria were full publications, relaxation
alone and not in combination with other interventions
such as cognitive behaviour therapy or imagery. Reports
were included if they were RCTs and had pain outcomes.
Reports of relaxation for the relief of other pain conditions
or those where the numbers of patients per treatment group
were fewer than 10 were excluded. Studies investigating
experimentally induced pain were excluded, and abstracts
and review articles were not considered. Unpublished
studies were not sought. Authors of published studies
were not contacted.
Each study which could possibly meet the inclusion cri-
teria was read by both authors independently and scored
for inclusion and quality using a three-item scale ( Jadad
et al. 1996b). This scale assessed randomization, blinding
and study withdrawals and exclusions. Studies which
were described as randomized were given one point, and
a further point if the method of randomization was given
and was appropriate (for example the use of random
number tables). Where the method of treatment allocation
was unconcealed (alternate allocation, for instance) the
report was excluded. The blinding of relaxation studies
was anticipated to be difficult because of the nature of the
intervention, and this part of the Jadad et al. (1996b) scale
was omitted. Although the person collecting the outcome
data could be blind to treatment allocation, the trainer and
patient could not be blinded. Studies which described the
number and reasons for withdrawals were given one point.
Studies which did not achieve a score of at least 1 for
randomization were not eligible for inclusion in this
review. Any included studies would therefore have a
maximum score of 3 and a minimum score of 1. Agreement
between the two raters on scoring used was 7/7.
467
K. Seers and D. Carroll
Information about the pain condition, site of pain,
number of subjects approached and the number who
entered into the study, aims of the study and its design
were extracted. Additional information on the pain out-
comes, psychological outcomes, and treatment groups
(experimental and control) were summarized (Table 1). If
available, details of the type of relaxation technique, fre-
quency of its use, when and by whom and instructions to
patients were extracted from each study. Any withdrawals
and adverse effects were noted and the overall findings
were summarized. Study interventions were considered to
be effective if P values <0·05 were reported for pain and/or
psychological outcomes. Post-hoc sub-group analyses in
the original study reports were not considered.
RESULTS
Overall, 40 potential studies were identified. However,
only seven studies involving 362 patients were included;
150 patients received relaxation. Summaries of these seven
studies are in Table 1.
Table 1 showed that a variety of different relaxation
techniques were used. Follow-up was over variable time
periods and the outcomes used in the studies showed some
consistency with pain sensation and pain distress, the
McGill Pain Questionnaire (MPQ), anxiety state (STAI) and
analgesic consumption being the most common outcomes.
Two of the seven studies did not use psychological out-
comes, but they did look at pain distress (Ceccio 1984,
Mogan et al. 1985).
Relaxation was most commonly used after surgery (six
studies). The other study used relaxation during femoral
angiography (Mandle et al. 1990).
The results for the quality score ( Jadad et al. 1996b)
covered the whole range of possible scores (1–3). Only two
of the seven studies reported the method of randomization
used. Only three of the seven studies reported withdrawals
and dropouts.
When considering pain outcomes (pain sensation and
pain distress), three studies reported significantly less pain
sensation and/or pain distress in those who had relaxation.
The remaining four studies did not demonstrate any
differences.
Only one of the five studies which assessed psychologi-
cal outcomes reported any significant difference (Mandle
et al. 1990), with those who received relaxation reporting
less anxiety than the other groups.
No adverse events were reported in any of the studies
for any of the treatment or control groups.
Thirty-three studies investigating the use of relaxation
in acute pain were excluded from this review, because
they did not meet the criteria for inclusion (Table 2).
Of the 33 excluded studies, 22 were RCTs, 11 were not.
When the effectiveness of relaxation was considered,
24/33 (73%) of these studies had broadly positive results.
468 © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475
Even when those studies with no pain outcomes and those
not using relaxation (e.g. ‘muralvision’) were excluded,
15/21 (71%) still presented generally positive findings.
DISCUSSION
There was only weak evidence to support the use of
relaxation for acute pain.
There were few published RCTs that met the inclusion
criteria for relaxation given as the sole intervention for the
relief of acute pain. In the search for reports that fulfilled
this criteria, a number of non-RCTs were found. With the
increasing emphasis on providing health care based on
sound research evidence (Department of Health 1992,
1993), it is important that appropriate research methods
are used to answer questions about the effectiveness of
interventions such as relaxation. RCTs have become the
gold standard when asking questions about relative effec-
tiveness and are considered the strongest level of evidence.
The recent publication of the CONSORT statement on
standards for reporting trials (Begg et al. 1996) should go
some way towards ensuring enough material is included in
a research report to allow an adequate assessment of its
rigour. Many of the studies examined for this review lacked
such rigour. A lack of such a framework in current use gave
rise to concerns which are addressed in the next section.
Quality of studies included in this review
Although all studies were RCTs, randomization only
reflected one aspect of study design and of study quality.
There were some aspects of study design and/or reporting
that gave cause for concern. The results are presented in
the light of these reservations. In addition, a discussion of
clinical as well as statistical significance of the findings
may be helpful and this follows with first a consideration
of studies showing an effect of relaxation on pain and other
outcomes and then those showing no such effects.
Looking at the specific studies, three showed those receiv-
ing relaxation experienced significantly less pain sensation
and/or distress after surgery or a procedure. Ceccio (1984)
only had 10 patients in each treatment group. In addition
the only significant difference in mean incisional pain was
a mean reduction of 1·7 on a 10-point scale. Is a reduction
of this magnitude clinically significant? With such a small
number in each group and a wide range of values, and with-
out use of confidence intervals, this question becomes even
more important. These study findings were also based on
one assessment 20–24 hours after surgery. Mandle et al.’s
(1990) significant findings showed a difference in present
pain intensity scores of 1·8 on a five-point scale between
relaxation and a control, and of 8·2 on the 0–78 score range
of the McGill Pain Questionnaire pain rating index. Again,
is this clinically significant? Wilson (1981) reported results
in a complicated way and it was difficult to extract data.
 Table 1 Studies included in the review

Pain
condition/site of
pain (no of Results for
subjects Pre-study psychological &
entered/ hypothesis/ Psychological Results for pain non-pain Withdrawals & Authors overall Comment/study Quality
Author approached objectives Study design Treatment groups Pain outcomes outcomes outcomes outcomes dropouts comment limitations score

[Ceccio 1984] Surgical repair 1. Relaxation RCT, parallel 1. Modified 1. Pain & None Results for 20 n/a 2 patients Positive result Positive result 3
of fractured would decrease group. Jacobson distress 0–10 patients excluded, in favour of in favour of
hip, adults pain & distress Relaxation relaxation 3 step, ( Johnson). (10/group). respiratory relaxation. relaxation for
56–89 yr on turning taught & involving tongue 2. 24 h ANOVA=sd in complications Results could be all 3 outcomes.
(n=22/24) once within practised pre- & jaw, rhythmic Meperidine favour of (1 from each due to Single
first 24 h post- op. breathing, lack (pethidine) relaxation for group) Hawthorne assessment
op, 2 analgesic Assessments of attention to consumption incision pain effect only on one
consumption done when thoughts, words (taken from (P<0·05), turn.
would be lower patients were & speech medical body distress No. 2 sample
turned post-op. (n=11). records) (P<0·01). parametric or
Single 2. No relaxation Meperidine non-
assessments training intake parametric
within first (n=11) (P<0·05). tests
24 h post-op described.
[Domar et al. Surgical 1. Relaxation RCT, parallel 1. Relaxation tape 1. MPQ post-op. 1. Spielberger Results for 42 Results for 42 5 excluded pre- NSD for pain or NSD overall for 3
1987] removal of skin would reduce group, 20 min/day 2. Total local stale-trait patients patients op., i.e. non- anxiety, except pain or
cancer or pain during relaxation (n=31). anaesthetic anxiety. (21/group). (21/group cancer (3 for sub-group anxiety.
malignant procedure. taught pre-op. 2. Reading used. 2. Brief NSD NSD). relaxation, 2 analysis for
melanoma 2. Pre-surgical Assessments at material of Symptom reading). 7 anxiety.
<80 yr relaxation diagnosis, pre-, choice 20 Index on relaxation non-
(n=54/56) would reduce intra- & post- min/day diagnosis & compliant.
anxiety pre-, op, 1 week (n=23). pre-op.
intra & post-op. post-biopsy 3. Surgeon

© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475

rating of
anxiety 1–7
post-op.
[Good 1995] Major elective 1. To study the RCT, parallel 1. Flaherty & 1. Pain & Spielberger Results for 84 Results for 84 2 withdrew, 16 NSD overall but NSD, but only 2
abdominal relative group Fitzpatrick jaw distress Stale-trait pre- patients. patients. excluded (4 89% of jaw relaxation
surgery, age differences in relaxation ( Johnson). op. & on first NSD NSD surgery subjects
21–65 yr sensory & Pre-op use of (n=21). 2. MPQ. ambulation cancelled, 2 perceived
(n=102/126) affective pain tape, post- 2. Choice of 5 3. Analgesic unable to treatments to
between op. 60 minute types of music consumption ambulate, 9 be helpful.
relaxation, interventions (n=21). @24 h post & PCA, 1
music & for 2 days 3. Jaw 2·5 h pre- treatment
combination of relaxation+music ambulation error)
relaxation & (n=21).
music. 4. Control
standard care
(n=21).
[Laframboise Elective 1. Relaxation RCT, parallel 1. Focused 1. MPQ. 1. Spielberger Results for 30 Results for 30 Not reported. NSD NSD 1
1989] cholecystectomy training would group. relaxation 2. Sensation & state anxiety. patients. patients. Except sub Note chapter in
(n=30/30) reduce post-op Training given (n=15), 25 min distress 2. General trait- NSD NSD group analysis. book, peer
pain. pre-op, used as tape, structured ( Johnson). physical review
2. Relaxation required post- breathing, 3. Length of danger sub- uncertain.
training would op up to 3 muscle hospital stay. scale (Endler).
reduce pre- & days. relaxation, 4. Analgesic
post-op pleasant consumption.
anxiety. imagery.
2. routine care
(n=15).
Relaxation techniques

469
470
Table 1 (Continued)

Pain
condition/site of
pain (no of Results for
subjects Pre-study psychological &
entered/ hypothesis/ Psychological Results for pain non-pain Withdrawals & Authors overall Comment/study Quality
Author approached objectives Study design Treatment groups Pain outcomes outcomes outcomes outcomes dropouts comment limitations score
K. Seers and D. Carroll

[Mandle et al. Femoral 1. Relaxation RCT, parallel 1. Contemporary 1. MPQ. 1. Spielberger During Relaxation sig. Probably no Sig. less pain Positive result 1
1990] angiography response is group music (n=14). 2. 7 point nurse state/trait. procedure. less anxiety withdrawals, and anxiety for in favour of
for peripheral easily learned treatment given 2. Progressive assessment of 2. 7-point nuse Relaxation sig. during but not stated relaxation relaxation for
vascular & requires pre- & intra- muscle pain. assessment of lower pain procedure compared to pain & anxiety.
disease minimal procedure. relaxation with 3. Fentanyl anxiety. rating index & compared to music and Validity of
(n=45/45). exposure prior 1 staff member cognitive consumption. 3. Diazepam pain intensity music blank tape nurse ratings?
to surgery. gave tratments, relaxation consumption than music (P<0·05) and
2. Relaxation assessments (n=15). therapy & blank tape
can reduce pre- & post-tx 3. Blank tape blank tape (P<0·01).
pain, anxiety & (n=16). (P<0·001). Nurse rating of
fear. Nurse rating of anxiety sig.
pain sig. less lower for
for relaxation relaxation
than music compared to
and blank tape music & blank
(P<0·001). tape
Relaxation sig. (P<0·001).
less fentanyl Relaxation sig.
compared to less diazepam
blank tape & compared to
music blank tape &
(P<0·001). music
(P<0·001).
[Mogan et al. Elective 1. Relaxation RCT, parallel 1. Relaxation 1. Pain None NSD n/a None reported Positive result Weak positive 2
1985] abdominal will reduce group, training sensation and in favour of result for pain
surgery, pain & distress treatments including pain distress relaxation for distress only,
22–70 yrs. post-surgery. taught pleasant ( Johnson). pain distress sub-group
(n=72/72). 2. Relaxation preoperatively, memory, jaw 2. Analgesic only despite analysis.
will reduce assessments for relaxation & consumption. NSD overall.
time in up to 4 post-op breathing 3. Total time in Sub-group
hospital. days. techniques hospital. analysis
3. Relaxation (n=40). showed some
will reduce 2. Standard pre- positive
analgesic surgical results.
consumption. instructions
with deep
breathing &
coughing
(n=32).
[Wilson 1981] Elective To determine RCT, parallel 1. Routine care 1. pain distress. 1. Mood 4-point Relaxation sig. No extracable None reported Positive result Positive effect 1
cholecystectomy the group (n=18). 2. Total scale. reduction in data for simple in favour of of relaxation
& abdominal effectiveness of assessments 2. Information injections of 2. Various pain distress effects of relaxation. on pain
hysterectomy, extensive 30 min pre- taped (n=17). orphine & personality (P<0·01). relaxation on distress.
mean relaxation study. 3. Relaxation pethidine. variable NSD for pain psychological Complicated
42·3±10·47 yr training pre- & training taped assessments. indications. outcomes. reporting of
(n=70/73) post-op. (n=17). 3. Coping results,
4. Relaxation & (18-item difficult to
information author design). extract data
(n=18). 4. Social
support.

© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475

5. Fear 7 point.
 Table 2 Reports excluded from this review
Author and Date of Publication
(Aiken & Henrichs 1971)
(Bafford 1977)
(Corah, Gale & Illig 1979)
(Daake & Gueldner 1989)
(Egbert et al., 1964)
(Field 1974)
(Flaherty & Fitzpatrick 1978)
(Frenn et al. 1986)
(Gessel & Alderman 1971)
(Hase & Douglas 1987)
© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475
(Horowitz et al. 1984)
(Katcher et al. 1984)
(Korol & von Baeyer 1992)
(Kuttner et al. 1988)
(Levin et al. 1987)
(Lobb et al. 1984)
(Madden et al. 1978)
(Manyande et al. 1995)
(Miller 1987)
471
Details Reason for exclusion Overall outcome
Non-RCT, case control. Control vs taped relaxation, male open Not RCT Positive result in favour of relaxation
heart surgery (n=30)
Non-RCT, progressive relaxation vs daily visits vs control, open Not RCT NSD
heart surgery (n=30)
RCT dental procedures. Control vs relaxation vs perceived No pain outcomes Relaxation and distraction effective in
control vs active distraction vs control (n=80). Behavioural reducing discomfort
outcomes
RCT, information+imagery vs information only (n=32) Imagery only, not relaxation Significant result in favour of imagery
RCT, information+deep breathing+how to move vs usual care RCT, not only relaxation Positive result in favour of relaxation
(n=57) combination.
RCT. Relaxation (taped) vs control, orthopaedic surgery RCT, no pain outcomes NSD
(n=160), outcomes nervousness & speed of recovery
Non-RCT, relaxation vs control, elective surgery (n=50) Not RCT Positive result in favour of relaxation
RCT. Relaxation vs control, cardiac catheterisation (n=20). RCT, no pain outcomes Significant difference in favour of
Outcomes state anxiety and vital signs relaxation
Non-RCT. Uncontrolled progressive muscle relaxation. Non-RCT, no pain outcomes Positive result in favour of relaxation
TMJ (n=11) Psychological outcomes
Non-RCT. Taped relaxation vs control, acute myocardial Non-RCT, no pain outcomes Positive results in favour of relaxation for
infarction (n=40). Outcomes recovery psychological some outcomes
Non-RCT, jaw relaxation vs systemic relaxation vs control, Non-RCT NSD for incisional pain, but some
open heart surgery (n=45) differences for pain distress
RCT. Contemplation aquarium vs poster vs poster plus RCT. No pain outcomes, less NSD
hypnosis vs aquarium plus hypnosis vs control. Dental than 10 per group
surgery (n=42)
RCT. Relaxation vs information, ante natal care (n=60) RCT. No pain outcomes NSD
RCT. Distraction vs imaginative involvement vs control. Bone RCT, not relaxation Positive result in favour of active
marrow aspiration (n=59) treatments
RCT, tape rhythmic breathing vs relaxation vs attention RCT, less than 10 per group NSD although SD when pain sensation
distraction vs control, elective cholecystectomy (n=40) and distress were combined, between
relaxation and attention control group
only
RCT. Biofeedback & relaxation & desensitisation vs friendly RCT, not relaxation alone Significant result in favour of
visitor vs control experimental group
RCT. EMG feedback (2 types) vs control (n=15) RCT less than 10 per group Positive result in favour of abdominal
EMG feedback
RCT. Guided imagery & relaxation tape vs information on RCT, not relaxation alone Positive result in favour of imagery.
hospital (n=51) Randomization method may be flawed
Non-RCT, relaxation group only (n=15) Non-RCT Positive result
Relaxation techniques
472
Table 2 (Continued)
Author and Date of Publication
(Miller et al. 1992)
(Miller & Perry 1990)
(Mullooly et al. 1988)
(Perri & Perri 1979)
(Pickett & Clum 1982)
(Scott & Clum 1984)
(St. James-Roberts et al. 1983)
(Swinford 1987)
(Syrjala et al. 1992)
(Voshall 1980)
(Wells 1982)
(Zelter & LeBaron 1982)
(Ziemer 1983)
(Zimmerman-Tansella et al.
1979)
© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475
K. Seers and D. Carroll
Details Reason for exclusion Overall outcome
RCT. Burn dressing changes. Used distraction/relaxation RCT, less 10 per group and Positive result in favour of muralvision
(‘muralvision’) vs control (n=17) intent distraction, not relaxation (less pain and anxiety)
Non-RCT (alternate allocation of weeks), relaxation & rhythmic Non-RCT, not relaxation alone NSD, but 73% said relaxation etc helpful
breathing & information vs information only (n=29)
RCT. Calming music vs control (n=28) RCT, calming music, rather than Positive result in favour of calming music
relaxation (less pain and anxiety)
RCT. Relaxation vs control (n=26) RCT. Abstract only NSD
Non-RCT, relaxation training vs relaxation information vs Non-RCT NSD
cognitive distraction vs control, gallbladder surgery (n=59)
Non-RCT, relaxation vs standard care control with coughng Non-RCT, sequential treatment NSD, except for sub-group analysis
and deep breathing, mixed surgery (n=64) allocation
RCT. EMG biofeedback (2 types) vs control (n=48) RCT, not relaxation alone Beneficial in early labour, not later on.
Non RCT, quasi experimental. Relaxation & imagery vs control Non-RCT, not relaxation alone Positive result in favour of relaxation
(n=20)
RCT. Relaxation & imagery & suggestion vs relaxation & RCT, not relaxation alone Suggestion group less oral pain
cognitive coping vs therapist contact vs control (n=45)
RCT. Relaxation & information vs information (n=30) RCT, not relaxation alone NSD pain and distress
RCT. Relaxation vs control, cholecystectomy (n=12) RCT, less than 10 per group Sig.less distress in relaxation group, but
NSD for pain sensation
RCT. Hypnosis & imagery vs distraction and deep breathing RCT, not relaxation Positive effect of hypnosis
(n=33)
RCT. procedural information vs procedural+sensory vs RCT, not relaxation alone NSD pain intensity or distress
both+coping strategies, including relaxation. (n=111)
RCT. Respiratory Autogenic training (relaxation+lectures and RCT, not relaxation alone Less pain during labour in autogenic
group discussions) vs psychoprophylaxis (n=53) group

Pain distress was part of a recovery inventory score.
In addition, no mean data were presented, so clinical
significance could not be assessed.
Four studies did not demonstrate any effect on pain out-
comes with relaxation. The first three studies listed had
between 15 and 21 per group, and it is not known whether
this sample size was large enough to detect a difference if
one existed. Domar et al. (1987) did not present mean pain
scores, so clinical significance could not be assessed. Good
(1995), one of the better designed studies, used jaw relax-
ation. How this very specific relaxation technique might
equate to a total body relaxation is uncertain. However,
this sort of comparison would be useful when considering
time and resource implications for both health pro-
fessionals and patients using relaxation. The pre to post
changes in pain scores were in the order of one point on
a 10-point scale in this study. Laframboise (1989) did not
report any means or standard deviations, so clinical sig-
nificance could not be judged. Mogan et al. (1985) describe
a positive finding for pain distress. However, this was only
found when they excluded the fourth day from the analy-
sis, so any positive finding could only be described as
weak and based on post hoc analysis.
Thus both the positive and negative studies had method-
ological weaknesses, demonstrating the need for well
designed and executed RCTs in this area.
The quality scoring system helped to focus on randomiz-
ation, but to call it a quality score may be misleading as it
reflected only part of the overall quality of a study. It could
be argued that accepting only studies which were properly
randomized (not, for example, alternate allocation) was
over-stringent. However, it was felt that the reduction of
bias was so important in this area, that this criteria was
justified.
A meta-analysis was not undertaken as appropriate data
were not available. However, even if the data had been
available, using this approach with such a heterogeneous
group of studies would give rise to concerns about its
appropriateness in this instance.
When the excluded studies were considered, the gener-
ally positive results (Table 2) have important implications.
If one was reading relaxation articles, the impression might
thus be gained that relaxation was effective. However, the
review of RCT evidence suggests that this would be an
over-optimistic interpretation of the available or existing
evidence.
Several obstacles were encountered when reviewing this
literature:
$ Definitions of relaxation used in the studies were some-
times unclear or just described as relaxation. Many dif-
ferent methods come under the generic title ‘relaxation’.
For example, Payne (1995) divides such techniques into
12 physical and six psychological types.
$ Interventions used could sometimes include several
© 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 27, 466–475
Relaxation techniques
elements including progressive muscle relaxation
( Jacobson 1938, Bernstein & Borkovec 1973), imagery,
meditation, cognitive strategies, exercise and breathing.
When such a combination of interventions are used it
is impossible to determine the effectiveness of the
different individual elements of the package.
$ Resource implications of delivering a complex package
when individual components are not evaluated need to
be considered. A systematic review of relaxation in
combination with other interventions could be
undertaken.
$ Perceptions of what is relaxing may vary. For example,
Katcher et al. (1984) had an intervention group who
contemplated an aquarium, and Mullooly et al. (1988)
used ‘calming music’. It is open to speculation whether
or not these interventions would be relaxing for all
people.
$ Studies tended not to assess patients’ perceptions of the
extent of relaxation.
$ The skill of the relaxation teacher was unknown, and
the minimal level of training needed to teach relaxation
is unclear.
$ Even if a paper described the intervention as ‘relax-
ation’, one cannot be sure whether or not patients used
additional techniques, such as imagery, as they relaxed.
$ After surgery, it is unlikely only relaxation will be
used — other interventions, such as analgesic drugs,
will be common.
Recommendations
Future research looking at the effectiveness of relaxation
for acute pain should include randomized controlled trials
with adequate randomization, adequate size and well-
defined samples, standard methods of relaxation, a clearly
defined setting and reliable and valid outcomes, and take
into account concomitant administration of analgesics.
More work is needed to allow us to tailor relaxation to the
individual.
The extent to which various types of relaxation effect
pain and other outcomes in different ways is unclear, and
more information from RCT research studies is needed in
this area, as methods chosen have cost and resource impli-
cations. Other considerations such as patient acceptability,
the timing and duration of the intervention, the length of
use, amount of practice, frequency of use, whether it is
used to prevent pain or for mild or moderate or severe
pain, who trains and who trains the trainers, are all issues
on which there is little evidence.
Future reviews could perhaps include wider literature
searching such as EMBASE, and the grey (unpublished)
literature as this may provide additional evidence on the
effectiveness of relaxation. Other types of pain, for
example cancer or chronic non-malignant pain could be
considered.
473
K. Seers and D. Carroll
Another area to consider is the reason behind teaching
relaxation for use in acute pain. One of the reasons for
doing this is probably to reduce pain. However, if pain is
well assessed and well controlled by methods such as anal-
gesics, then the reason for teaching relaxation may become
less clear. There may be other sound rationale for using it
(such as altering anxiety levels or increasing perceptions
of control) but it would seem sensible to ensure these are
clearly stated.
Conclusions
If relaxation is used alone for acute pain, there is no evi-
dence that it is harmful, and some weak support for its
potential to reduce acute pain. However, many studies in
this area suffer from methodological weaknesses and more
well-designed RCTs are needed. Any use of this technique
in the clinical area should be carefully and systematically
evaluated.
Acknowledgements
The study was supported by Pain Research funds and by
The Royal College of Nursing Institute, Oxford. We wish
to thank Andrew Moore for his helpful comments.
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