Content uploaded by Deepika Khakha
Author content
All content in this area was uploaded by Deepika Khakha on May 17, 2021
Content may be subject to copyright.
Impact of Jacobson Progressive Muscle Relaxation (JPMR)
and Deep Breathing Exercises on Anxiety, Psychological
Distress and Quality of Sleep of Hospitalized Older Adults
N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
ABSTRACT
This study attempted to investigate the impact of JPMR and deep breathing exercises
in reducing anxiety, psychological distress and improving quality of sleep among
hospitalized older adults. Sixty inpatients, 30 each in experimental and control group
were recruited adopting a quasi-experimental study design. To check contamination,
the experimental group was recruited in the first three and the control group in the
last three months. Geriatric Anxiety Inventory, K-10, and Pittsburgh Sleep Quality
Index were administered. An audio taped Hindi JPMR and 4 steps breathing were
used. Significant improvements were found in the experimental group in reducing
anxiety, and psychological distress, and improving quality of sleep. The significant
improvement in anxiety, psychological distress and quality of sleep showed the
efficacy of JPMR and deep breathing exercises in management of older adults. The
feasibility of integrating relaxation exercises as a part comprehensive quality care
services for hospitalized older adults was highlighted.
Key words: JPMR, Deep breathing, Anxiety, Psychological distress, Quality of sleep.
INTRODUCTION
Old age is a crucial period of life during which mental health related problems may
become a cause or an effect of various physical health related problems, amongst which
anxiety (Wolitzky-Taylor, et al., 2010), psychological distress (Joshi, Kumar & Avasthi,
2003; Rabinowitz, et al., 2005) and sleep difficulties (Lindstrom, et al., 2012) are
commonly reported. The association of anxiety disorders are moderately associated
with reduced sleep quality resulting in poor the quality of life (Ramsawh, et al., 2009).
Recently, studies revealed significant association between higher anxiety, depression
Journal of Psychosocial Research
Vol. 10, No. 2, 2015, 211-223
Corresponding author. Email : nir2290@gmail.com, dckhakha@gmail.com,
dr.sujatasatapathy@gmail.com, abdey@hotmail.com
ISSN 0973-5410 print/ISSN 0976-3937 online
©2014 Prints Publications Pvt. Ltd.
212 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
and poor sleep quality in elderly chronically ill (Suh, et al., 2013). However, remaining
active was associated with lesser psychological distress (Yorston, et al., 2012). A review
of 106 articles on sleep problems among older adults reported the common problems
as waking up too early, trouble falling asleep, daytime napping, and multiple nocturnal
awakenings (Cochen, et al., 2009).
Among the non-pharmacological interventions, deep breathing and other relaxation
exercises (such as Jacobson Progressive Muscle Relaxation – JPMR) have been found to
be effective in for various categories of hospitalized population such as cancer patients
on chemotherapy (Lee, et al., 2012; Hayama & Inoue, 2012), patients with gynecological
diseases (Pan, et al., 2012; Zhao, et al., 2012), patients with COPD (Singh, et al., 2009)
and coronary artery bypass graft surgery (Dehdari, et.al., 2009). Also these resulted in
decreased state anxiety, psychological stress, fatigue, and increased subjective well-
being (Vancampfort, et al., 2011), and positive mood (Jain, et al., 2007; Tsai, 2004),
increased quality of life (Chio, 2010), anxiety (Manzoni, et al., 2008) and positive effects
on sleep quality and fatigue (Demiralp, et.al, 2010) of older adults. However, the
duration of JPMR in studies varied from 12 weeks (Zhao, et al., 2012), to 6 weeks
(Dehdari, 2009), and to 6 weeks twice a day (Yildrim and Fadiloglu, 2006). The one-
week intervention in the present study was decided keeping the average duration of
stay (10 days), number of total beds occupied in a given time (< = 12) in this geriatric
ward and high attrition rate reported by previous studies done here. The present
study design was similar to Tsai (2004) and one-week duration of intervention was
similar to a study reported by Ziv et al. (2008). The use of audio CD in practicing JPMR
was similar to few other studies (Singh, et al., 2009; Cheung, et al., 2001).
With a rapidly ageing population and increasing life expectancy, treatment services
aimed at improving the mental health and quality of life of older adults are extremely
important and therefore, hospital care of the older adults needs to be expanded to go
beyond disease orientation and involve the total multidimensional approach with adjunct
therapies such as JPMR and breathing on a regular basis.
The key objective was to assess the effect of progressive muscle relaxation and
deep breathing exercises in reducing anxiety, psychological distress and improving
quality of sleep of older hospitalized adults so as to include this as a regular care
service to the admitted patients as a part of multidimensional health care model.
METHODOLOGY
Study design and Sampling
Older patients admitted to the geriatric ward of a public sector tertiary care level
hospital meeting the inclusion criteria were studied during period of June 2013-
December 2013. A quasi-experimental study design, total enumeration technique in
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
213
J. Psychosoc. Res.
11
which all the consecutively admitted patients were assessed for eligibility and the
consenting individuals were included in the sample.
Inclusion Criteria
1. Hospitalised older adults.
2. Patients who were able to follow instructions and willing to provide written
consents.
3. Able to communicate in Hindi /English.
Exclusion Criteria
1. Unconscious and disoriented patients.
2. Patients having a psychiatric co-morbidity (anxiety disorders and/or depressive
disorders, substance dependence)
3. Patients having H/o cognitive impairment or reporting of severe decline of memory.
4. Exhibiting musculoskeletal problems that might affect PMR training.
5. Patients not able to perform the exercises for specified duration either due to
early discharge or due to illness will be dropped out.
Sample Size
A target of 60 subjects was decided based on statistical analysis of pilot study at = 5%
and power = 80%. A total of 222 patients were assessed for eligibility out of which
only 89 were found to be eligible on basis of inclusion and exclusion criteria. Out of
these 89 patients, only 81 patients consented in written, hence, a total of 81 older
inpatients (48 - experimental group) and (33 - control group) were initially recruited.
At the end of the study 21 patients dropped out (8 - refused to participate, 6 - had
early discharge, 7 - fell severe sick to participate), out of which 18 were from the
experimental group and 3 were from the control group. And finally the target sample
size 60 (30 patients in each group) was retained on the basis of patients who completed
the assessments and interventions.
Tools
Demographic data was collected through an interview schedule developed for this
study.
Geriatric Anxiety Inventory (GAI) (Pachana et al., 2007) containing 20 items was used
and translated to Hindi by back translation method for measuring anxiety among
older adults. The Cronbach’s alpha value is 0.91 and the test retest reliability is 0.879.
The test administration time was 5 minutes.
214 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
The Kessler Psychological Distress Scale (K-10- Kessler, 2003) consisting of 10 items
was used in Hindi to measure psychological distress. The values of Kappa and weighted
Kappa range from .42 and .74. The test retest reliability was 0.83. The test administration
time was 5 minutes.
Pittsburgh Sleep Quality Index (PSQI) (Buysse, 1988) contained 19 items was used in
Hindi to measure the quality and patterns of sleep in the older adults. It measures
sleep in seven domains, viz. subjective sleep quality, sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbances, use of sleep medication, daytime
dysfunction over the last month. The modified one-week version of the PSQI developed
in 2009 with a test retest reliability of 0.922 was used. The test administration time was
5 minutes.
Intervention
Breathing exercises: A 4-step basic breathing exercise was developed in which each step
was done 5 times prior to JPMR. The steps were: 1) Deep inhalation followed by exhalation
through nose, 2) Anulom-vilom (keeping one nostril closed, deep inhalation with the
other nostril and exhalation through the nostril that was closed) 5 times each for left and
right nostril, 3) Deep inhalation and exhalation through mouth, and 4) Deep inhalation
and bring the chin close to the chest, followed by exhalation and bringing the chin to the
original place or normal posture. This last step had 4 sub steps in which the patient
repeats the same in all the directions 5 times each viz upward, downward, left side, and
right side. The average duration of the breathing exercises was 5.30 minutes.
JPMR Audio: A standardized audio CD (standardized during an earlier research study
in 2011), on JPMR, developed by this hospital was used through a laptop for the study.
The audio is of 19:09 minutes, with a female voice instructing the sequence of exercises
in Hindi. The permission for using the tool was taken from the author (Kumari, 2009).
Although the researcher is trained on conducting PMR and deep breathing exercise,
the initial phase of deep breathing and JPMR was supervised directly by a professional
clinical psychologist.
STUDY PROCEDURE
After enrolment, non-concurrent control group (the experimental group were recruited
in the first three and the control group in the last three months) was used in order to
prevent the contamination of watching the intervention process Subjects in the
experimental group were made to perform deep breathing exercises and JPMR for 7
consecutive days for the duration of 25 minutes daily in the evening hours with the
audio taped instructions for JPMR and verbal instructions of breathing exercises. The
patients in the control group received routine care (no specific interventions). The
deep breathing exercises were done for approximately 5 minutes before JPMR.
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
215
J. Psychosoc. Res.
Base line and post-test data was collected from both the experimental and control
group on 1st and 8th day respectively using same tools. Silence, absence of nursing/care
giver interruption, privacy, and comfortable position were ensured in the geriatric
cubicle.
RESULTS
Both the groups were comparable at baseline regarding demographic characteristics
(Table 1), present illness and duration of illness also (Table 2 and Table 3). Majority of
the subjects were male, married, belonged to joint family and Hindu religion with a
monthly income less than 10,000 in both the groups.
Table 1
Frequency distribution of subjects according to demographic variables. N = 81
Variables Experimental Control p value
group (n = 48); n (%) group(n = 33); n (%)
Age
60-64 24 (50) 15 (45.5) 0.735a
65-69 7 (14.6) 8 (24.2)
70-74 12 (25) 7 (21.2)
75 and above 5 (10.4) 3 (9.1)
Sex
Male 41 (85.4) 26 (78.8) 0.438b
Female 7 (14.6) 7 (21.2)
Marital status
Married 39 (81.2) 29 (87.9) 0.544a
Widow 9 (18.8) 4 (12.1)
Type of family
Nuclear 18 (37.5) 10 (30.3) 0.503b
Joint 30 (62.5) 23 (69.7)
Religion
Hindu 45 (93.8) 31 (93.9) 1.000a
Muslim 3 (6.2) 2 (6.1)
Educational status
Illetrate & Primary 22 (45.8) 17 (51.5) 0.790b
Middle 16 (33.3) 11 (33.5)
Higher secondary above 10 (20.8) 5 (15.2)
216 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
Source of income
Pensioner/salary 34 (70.8) 17 (51.5) 0.077b
Dependent on others 14 (29.2) 16 (48.5)
Monthly income
<10,000 29 (60.4) 24 (72.7) 0.252b
>10,000 19 (39.6) 9 (27.3)
Residence
Rural 24 (50) 21 (63.6) 0.225b
Urban 24 (50) 12 (36.4)
Test: aFischer’s exact test, bChi square test.
Table 2
Comparison of the subjects according to present illness
Category of illness Experimental group Controlgroup p value*
(n = 48), n (%) (n = 33), n (%)
Respiratory disorders 21 (43.8) 9 (27.3) 0.491
Cardiovascular disorders 12 (25) 8 (24.2)
Endocrinological disorders 4 (8.3) 2 (6.1)
Nephrological disorders 2 (9.2) 4 (12.1)
Oncological disorders 4 (8.3) 5 (15.2)
Others 5 (10.4) 5 (15.2)
Table 3
Comparison of subjects according to the duration of present illness
Variable Experimental group Control group p value*
(mean ± SD) (mean ± SD)
Duration of illness 87.21 ± 66.354 88.94 ± 62.107 0.724
There were significant improvements in the anxiety scores (p < 0.001),
psychological distress scores (p < 0.001) and quality of sleep scores (p < 0.001) in those
receiving JPMR and deep breathing exercises (Table 4).
1. The difference between the baseline (M = 12.58, SD = ± 6.215) and post-
intervention (M = 7.53, SD = ± 4.478) scores on anxiety in the experimental group
was found significant (p < 0.001), whereas the difference was not significant in
the control group (M = 11.55 ± SD = 7.194 vs. M = 11.50, SD = ± 7.06). The
difference between the experimental and control group on the 8th day post
intervention was also found to be significant (p < 0.05).
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
217
J. Psychosoc. Res.
2. Regarding the baseline average scores of psychological distress in the experimental
group was 30.50 ± 9.930, and the average score after 1 week of intervention was 17.67
± 6.104. In the control group the baseline average score was 27.76 ± 10.038, and the
average psychological distress score after 1 week of standard routine care was 24.63 ±
9.507. The between groups difference, using Mann Whitney U test, baseline psychological
distress scores in the experimental and control group were comparable. After the
intervention in the experimental group and standard routine care in control group, a
significant difference was observed between experimental and control group scores
(p < 0.05). Within group analysis revealed that the pre and post-test scores were
significantly different (p < 0.05) in the experimental group. However, the pre and post-
test scores for the control group were found to be comparable (p > 0.05). Hence there
was significant reduction in psychological distress scores of experimental group only.
3. The baseline average quality of sleep score in the experimental group was 12.52 ±
4.238, and the average quality of sleep score after 1 week of intervention was 8.57
± 3.421. In the control group the baseline average quality of sleep score was 11.52
± 5.495, and the average quality of sleep score after 1 week of standard routine
care was 10.70 ± 5.491. The baseline quality of sleep score in the experimental and
control group were comparable (p > 0.05). Within group analysis revealed that in
the experimental group, the pre and post-test scores were significantly different
(p < 0.05). No significant difference was found in the control group.
4. There is significant reduction in quality of sleep scores of experimental group as
compared to control group.
Table 4
Comparison between anxiety, psychological distress and quality of sleep scores
pre and post intervention in experimental and control group
Variable Anxiety scores p Psychological P Quality of P
(Mean ± SD) value*distress value* sleep value*
Pre test Post Pre test Post ) Pre test Post )
(n = 48) test (n = 48) test (n = 48) test
(n = 30) (n = 30) (n = 30)
Experimental 12.58 ± 7.53 ± 0.001* 30.50 ± 17.67 ± 0.001* 12.52 ± 8.57 ± 0.001*
group 6.215 4.478 9.930 6.104 4.238 3.421
Pre test Post
(n = 33) test
(n = 30)
Control group 11.55 ± 11.50 ± 0.841 27.76 ± 24.63 ± 0.217 11.52 ± 10.70 ± 0.521
7.194 7.060 10.038 9.507 5.495 5.491
P value*.630 .023* 0.305 0.003* 0.626 0.081
*Mann Whitney U test, * p value < 0.05.
218 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
Table 5 shows the significant positive correlation found between anxiety,
psychological distress and quality of sleep. Quality of sleep was associated with monthly
income.
Table 5
Correlation of anxiety with psychological distress and quality of sleep
Variables Psychological distress Quality of sleep
r value P value#r value p value#
Anxiety 0.556 0.001* 0.454 0.044*
Test: #Spearman’s rank correlation, *p < 0.05.
Table 6
Correlation of psychological distress and quality of sleep
Variable Psychological distress
r value p value#
Quality of sleep 0.518 0.001*
Test: #Spearman’s rank correlation, *p < 0.05.
DISCUSSION
There was no baseline difference between the groups on the anxiety scores but the
groups were significantly different after the intervention. The finding of significant
reduction in the anxiety scores in the experimental group of older adults was similar
to the findings of studies that reported progressive muscle relaxation to be effective
in reducing anxiety among older adults with variety of medical illnesses (Isa et al.,
2013; Ayers et al., 2007; Wetherell et al., 2005; Nordhus et al., 2003; Choi, 2010).
The combination of music and progressive muscle relaxation exercises revealed the
effectiveness of both the treatments together as well as separately in reducing anxiety
(Singh et al., 2009). In the present study psychological distress scores in the
experimental group were significantly reduced from baseline to one week after the
intervention. There was no baseline difference between the groups at baseline.
This finding is supported by findings of previous studies where significant reduction
in psychological distress was found after relaxation training (Jain et al., 2007). The
finding of quality of sleep was significantly improved from baseline to one week
after the intervention was in line with a study reported by Tsai (2004). Sun (2013)
reported the efficacy of self-relaxation training including progressive muscle
relaxation in improving quality of sleep among elderly.
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
219
J. Psychosoc. Res.
The improvement in quality of sleep can also be attributed to decrease in anxiety
and psychological distress. The finding of significant positive correlation between
anxiety, and quality of sleep was corroborated by Luo et al. (2013) and Suh et al. (2013)
where anxiety was found to be correlated with quality of sleep among elderly.
Ramasawh, et. al. (2009) reported a moderate association between anxiety and reduced
sleep quality and in turn reduced mental health related quality of life. A significant
positive correlation between psychological distress and quality of sleep in this study
was similar to study by Javadpour (2009) although the study population was different.
It may be appropriate to mention that reduction in anxiety and the psychological distress
perhaps resulted in improvement in sleep in the experimental group as a result of
relaxation exercises.
The finding of no significant correlation between age and anxiety was in contrast
to the studies reporting older adults between 60-74 years were more anxious than > 75
older (Richardson, 2011) and older age as a protective factor for lower anxiety (Gum,
et al., 2009). This difference could be attributed to sample size (N = 60 vs 378 and 2049
respectively) and community sample. Similarly, the finding of no significant correlation
between age, psychological distress and sleep quality was in contrast to findings (Atkins
et al., 2013; Luo et al., 2013) reporting older age as a risk factor for psychological
distress and poor quality of sleep. The reason may be the smaller sample size and
study design. No significant association between gender, anxiety, quality of sleep was
opposite to studies found females reporting more anxiety and poor sleep quality than
elderly males (Manzoni, 2008; Luo et al., 2013). This could be due to the skewed gender
ratio in the present study.
The concordance of present findings with the literature suggested that progressive
muscle relaxation and deep-breathing exercises reduced anxiety and psychological
distress, and improved quality of sleep in hospitalized older adults. Similar findings, on
patients with different medical conditions, are also reported for efficacy of progressive
muscle relaxation and deep breathing exercises in reducing anxiety and psychological
distress (Georgiev et al., 2012; Lee et al., 2012; Pan et al., 2012; Hayama et al., 2012) and
in improving quality of sleep (Demiralp et al., 2010; Ziv et al., 2008; Tsai, 2004).
CONCLUSION
The significant reduction in the anxiety and psychological distress and improvement
in the quality of sleep following the intervention in the hospitalized older adults
suggested that progressive muscle relaxation and deep breathing exercises together as
a package are effective. This study showed a strong possibility of integrating this
evidence based simple, brief, cost effective, and less time consuming combined package
in reducing anxiety, psychological distress and improving quality of sleep among the
hospitalized older adults. The study fulfilled one of the key inbuilt but silent purposes
220 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
of this study to develop some brief standard relaxation exercises package for the
hospitalized older adults in the geriatric word to be included in the regular service
delivery so that it can facilitate the overall health care delivery services. Thus, the use
of evidence based complementary therapies in general health care services may enhance
quality care and promote positive health care service delivery.
The intervention needs to be tested further on a larger sample size, for a longer
duration, at different timings of doing the intervention for increasing the generalizability
of the findings to other hospitalized older adults. Longitudinal study designs may
explore long term effects of JPMR and deep breathing exercises can also be very
motivational.
REFERENCES
Atkins, J., Naismith, S.L., Luscombe, G.M., and Hickie, I.B. (2013). Psychological distress and quality
of life in older persons: relative contributions of fixed and modifiable risk factors. BMC Psychiatry,
13(1), 249.
Ayers, C.R., Sorrell, J.T., Thorp, S.R., and Wetherell, J.L. (2007). Evidence-based psychological treatments
for late-life anxiety. Psychology and Aging, 22(1), 8–17.
Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., and Kupfer, D.J. (1989). The Pittsburgh Sleep
Quality Index (PSQI): A new instrument for psychiatric research and practice. Psychiatry Research,
28(2), 193-213.
Cheung, Y.L., Molassiotis, A., and Chang, A.M. (2001). A pilot study on the effect of progressive
muscle relaxation training of patients after stoma surgery. European Journal of Cancer Care
(Engl), 10(2), 107–114.
Choi, Y.K. (2010). The effect of music and progressive muscle relaxation on anxiety, fatigue, and
quality of life in family caregivers of hospice patients. Journal of Music Therapy, 47(1), 53–69.
Cochen V., Arbus C., Soto M., et al., (2009). Sleep disorders and their impacts on healthy, dependent,
and frail older adults. J Nutr Health Aging. 13, 322–9. [PubMed]
Dehdari, T., Heidarnia, A., Ramezankhani, A., Sadeghian, S., and Ghofranipour, F. (2009). Effects of
progressive muscular relaxation training on quality of life in anxious patients after coronary
artery bypass graft surgery. Indian Journal of Medical Research, 129(5), 603–608.
Demiralp, M., Oflaz, F., and Komurcu, S. (2010). Effects of relaxation training on sleep quality and
fatigue in patients with breast cancer undergoing adjunct chemotherapy. Journal of Clinical
Nursing, 19 (7-8), 1073-1083.
Gum, A.M., King-Kallimanis, B., and Kohn, R. (2009). Prevalence of mood, anxiety, and substance—
abuse disorders for older Americans in the National Comorbidity Survey Replication. Am J
Geriatr Psychiatry, 17, 769–781.
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
221
J. Psychosoc. Res.
Hayama, Y., and Inoue, T. (2012). The effects of deep breathing on tension-anxiety and fatigue in
cancer patients undergoing adjuvant chemotherapy. Complementary Therapy Clinical Practice,
18(2), 94–98.
Isa, M.R., Moy, F.M., Abdul, Razack, A.H., Zainuddin, Z.M., and Zainal, N.Z. (2013). Impact of applied
progressive deep muscle relaxation training on the level of depression, anxiety and stress
among prostate cancer patients: a quasi-experimental study. Asian Pacific Journal of Cancer Preview,
14(4), 2237–2242.
Jain, S., Shapiro, S.L., Swanick, S., Roesch, S.C., Mills, P.J., and Schwartz, G.E. (2007). A randomized
controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive
states of mind, rumination, and distraction. Annals of Behavioral Medicine, 33(1),11–21.
Javadpour, (2009). Sleep Disruption and its Correlation to Psychological Distress Among Medical
Students. S E Medical Journal, 11(1), [Internet]. [cited 2014 Jan 9]. Available from: http://
semj.sums.ac.ir/vol11/jan2010/88002.htm.
Joshi, K., Kumar, R., and Avasthi, A. (2003). Morbidity profile and its relationship with disability and
psychological distress among elderly people in Northern India. International Journal of
Epidemiology, 32 (6), 978–987. DOI: 10.1093/ije/dyg204.
Kessler, C., Barker, P., Colpe, L., Epstein, J., Gfroerer, J., Hiripi, E., Howes, M., Normand, S.,
Mandershield, R., Walters, E., and Zaslavsky, A. (2003). Screening for serious mental illness in
the general population. Archives of General Psychiatry, 60, 184-189.
Kumari, M. (2009). A study to assess the effectiveness of progressive muscle relaxation training on
anxiety levels and quality of life of patients on maintainance hemodialysis. An unpublished
M.Sc Nursing dissertation. College of Nursing, AIIMS. New Delhi, India.
Lee, E.J., Bhattacharya, J., Sohn, C., and Verres, R. (2012). Monochord sounds and progressive muscle
relaxation reduce anxiety and improve relaxation during chemotherapy:a pilot EEG study.
Complementary Therapy Medicine, 20(6), 409–416.
Lindstrom, V., Andersson, K., Lintrup, M., Holst, G., and Berglund, J. (2012). Prevalence of sleep
problems and pain among the elderly in Sweden. Journal of Nutrition, Health, and Aging, 16, 180–
183.
Luo, J., Zhu, G., Zhao, Q., Guo, Q., Meng, H., and Hong, Z., et al. (2013). Prevalence and risk factors of
poor sleep quality among Chinese elderly in an urban community: results from the Shanghai
aging study. PLoS ONE, 8(11), 181-261.
Mackereth, P.A., Booth, K., Hillier, V.F., and Caress, A.L. (2009). Reflexology and progressive muscle
relaxation training for people with multiple sclerosis: a crossover trial. Complement Therapy
Clinical Practice, 15 (1),14–21.
Manzoni, G.M., Pagnini, F., Castelnuovo, G., and Molinari, E. (2008). Relaxation training for anxiety:
222 N. Kalra, D. C. Khakha, S. Satapathy and A. B. Dey
J. Psychosoc. Res.
a ten-years systematic review with meta-analysis. BMC Psychiatry, 8, 41.
Nordhus, I.H., and Pallesen, S. (2003). Psychological treatment of late-life anxiety: An empirical
review. Journal of Consulting and Clinical Psychology, 71(4), 643–651.
Pachana, N.A., Byrne, G.J., Siddle, H., Koloski, N., Harley. E., and Arnold, E. (2007). Development and
validation of the Geriatric Anxiety Inventory. International Psychogeriatrics, 19, 103-114.
Pan, L., Zhang, J., and Li, L. (2012). Effects of progressive muscle relaxation training on anxiety and
quality of life of inpatients with ectopic pregnancy receiving methotrexate treatment. Research
in Nursing Health, 35(4), 376–382.
Ramsawh, H.J., Stein, M.B., Belik, S.L., Jacobi, F., and Sareen, J. (2009). Relationship of anxiety disorders,
sleep quality, and functional impairment in a community sample. Journal of Psychiatric Research,
43 (10), 926-933.
Richardson, T.M., Simning, A., He, H., and Conwell, Y. (2011). Anxiety and its correlates among older
adults accessing aging services. International Journal of Geriatric Psychiatry, 26 (1), 31–38.
Rabinowitz, J., Shayevitz, D., Hornik, T., and Feldman, D. (2005). Primary care physicians’ detection
of psychological distress among elderly patients. American Journal of Geriatric Psychiatry. 13,
773- 780.
Singh, V.P., and Rao, V. (2009). Comparison of the effectiveness of music and progressive muscle
relaxation for anxiety in COPD—A randomized controlled pilot study. Chronic Respiratory
Disease, 6(4), 209–216.
Suh, S., Ellis, R.J., Sollers, J.J., Thayer, J.F., Yang, H.C., and Emery, C.F. (2013). The effect of anxiety on
heart rate viariability, depression, and sleep in chronic obstructive pulmonary disease. Journal
of Psychosomatic Research, 74 (5), 407-413.
Sun, J., Kang, J., Wang, P., and Zeng, H. (2013). Self-relaxation training can improve sleep quality and
cognitive functions in the older: a one-year randomised controlled trial. Journal of Clinical
Nursing, 22 (9-10), 1270–1280.
Tsai, S.L. (2004). Audio-visual relaxation training for anxiety, sleep, and relaxation among Chinese
adults with cardiac disease. Research in Nursing Health, 27(6), 458–468.
Vancampfort, D., De Hert, M., Knapen, J., Maurissen, K., Raepsaet, J., Deckx, S., et al. (2011). Effects
of progressive muscle relaxation on state anxiety and subjective well-being in people
with schizophrenia: a randomized controlled trial. [Article]. Clinical Rehabilitation, 25(6), 567-
575.
Wetherell, Loebach J., et al. (2005). Psychological interventions for late-life anxiety: a review
and early lessons from the CALM study. Journal of Geriatric Psychiatry and Neurology, 18(2), 72-82.
Wolitzky-Taylor, K.B., Castriotta, N., Lenze, E.J., Stanley, M.A, and Craske, M.G. (2010). Anxiety
Impact of Jacobson Progressive Muscle Relaxation (JPMR) and Deep Breathing Exercises on
Anxiety, Psychological Distress and Quality of Sleep of Hospitalized Older Adults
223
J. Psychosoc. Res.
ABOUT THE AUTHORS
Kalra, Neeru, Msc Nursing student (Psychiatry) —All India Institute of Medical Sciences, AIIMS, New
Delhi.
Khakha, C. Deepika, Lecturer, CON —All India Institute of Medical Sciences (AIIMS), New Delhi.
Satapathy, S., Assistant Professor —Clinical Psychology, Department of Psychiatry, All India Institute
of Medical Sciences (AIIMS), New Delhi.
Dey, AB, Prof. and Head —Department of Geriatric Medicine, All India Institute of Medical Sciences
(AIIMS), New Delhi.
disorders in older adults: a comprehensive review. Depression and Anxitey, 27 (2), 190-211.
Yildirim, Y.K., and Fadiloglu, C. (2006). The effect of progressive muscle relaxation training on
anxiety levels and quality of life in dialysis patients. EDTNA ERCA Journal, 32(2), 86–88.
Yorston, L. C., Kolt, G. S., and Rosenkranz, R. R. (2012). Physical Activity and Physical Function in
Older Adults: The 45 and Up Study. Journal of the American Geriatrics Society, 60, 719–725.
doi: 10.1111/j.1532-5415.2012.03906.x
Yu, D.S.F., Lee, D.T.F., and Woo, J. (2007). Effects of relaxation therapy on psychologic distress and
symptom status in older Chinese patients with heart failure. Journal of Psychosomatic Research,
62(4), 427–437.
Zhao, L., Wu, H., Zhou, X., Wang, Q., Zhu, W., and Chen, J. (2012). Effects of progressive muscular
relaxation training on anxiety, depression and quality of life of endometriosis patients under
gonadotrophin-releasing hormone agonist therapy. European Journal of Obstetrics, Gynecology
and Reproduction Biology, 162(2), 211–215.
Ziv, N., Rotem, T., Arnon, Z., and Haimov, I. (2008). The effect of music relaxation versus progressive
muscular relaxation on insomnia in older people and their relationship to personality traits.
Journal of Music Therapy, 45(3), 360–380.
