Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis

Gian Mauro Manzoni; Francesco Pagnini; Gianluca Castelnuovo; Enrico Molinari

BMC Psychiatry

Conclusion

Notwithstanding its limitations, the present meta-analytical study show consistent and significant efficacy of relaxation training in reducing anxiety, coherently with past studies and reviews.^{[26,30,28,27]} The first hypothesis is then confirmed: post-treatment anxiety is lower than baseline level and relaxation training outperforms control conditions on anxiety-specific measures.

While all relaxation trainings reduced anxiety, applied relaxation, progressive relaxation and meditation showed greater effect sizes than other techniques. In particular, this meta-analysis evidences the lower potential of multi-methods relaxation. The use of one of the main relaxation techniques is preferable, at least for anxiety reduction.

Both psychological or psychosomatic patients and volunteer subjects gain more benefits from relaxation training. The reduction of anxiety for medical patients is lower in comparison to the others categories, but relaxation training still has good efficacy.

It is possible, even if it should be investigated by further studies, that young people can have a better decreasing of anxiety levels, compared to old people.

The potential of the training increase together with its intensity. The most effective trainings are long-lasting, especially with the practice of the exercises at home.

The context of application results to be irrelevant. Treatments are equally effective in anxiety reduction, both for in-group or individual sessions.

Different anxiety questionnaires present different sensitivity to anxiety changing. Trait anxiety reductions were lower than state anxiety, assessed with the two scales of the STAI. Studies that used the BAI obtained higher effect sizes, maybe due to a greater sensitivity of this instrument.

This meta-analysis deals with scores obtained by anxiety questionnaires and cannot be generalized to other aspects, even if anxiety can be considered as a construct related to a lot of human dimensions. For this reason, this work does not speak about general efficacy of relaxation trainings, but it is limited to the anxiety dimensions.

The meta-analytic findings parallel qualitative reviews revealing that relaxation training has potential for the treatment of anxiety in different populations. Further, this meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation.

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Next Section

Funding information

The research was supported by the TECNOB Project (Technology for Obesity Project) funded by the "Compagnia di San Paolo" private foundation.

Reprint Address

Gian Mauro Manzoni, Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy; E-mail: gm.manzoni@auxologico.it

BMC Psychiatry © 2008 Manzoni et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this: Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis - Medscape - Jun 02, 2008.

Characteristics of the Studies
Study	N° Subjects	N° Controls	Mean Age	% Women	Country	Type of training	Type of Subjects	Instrument	Individual/group	Homework	Duration	Session	Effect size BT	Effect size WT
* Kanji, White,& Ernst^[16]	30	29	64,5	36,7	UK	Autogenic Training	Patients undergoing coronary angioplasty	Stai - State anxiety	Group	Yes	2 Months	ND	0,470	0,513
* Tomioka & Kubo^[50]	21	12	43,3	72,7	Japan	Autogenic Training	Psychosomatic patients	Stai - State anxiety	Group	Yes	8 Weeks	8	0,318	0,399
* Pawlow, O'Neil & Malcolm^[21]	10	10	38	90	USA	Progressive Relaxation	Night Eaters	Stai - State anxiety	Group	Yes	1 Day	1	1,358	1,305
* Yung, Fung, Chan, & Lau^[24]	17	30	37	100	Hong Kong	Stretch Release Relaxation Group;	Nurses	Stai - State anxiety	Group	Yes	4 Weeks	4	0,397	0,210
* Yung, Fung, Chan, & Lau^[24]	18					Cognitive Relaxation					4 Weeks	4	0,623	0,331
*Roykulcharoen & Good^[23]	51	51	42	82,3	Thailand	Systematic Relaxation	Patients underwent abdominal surgery	Stai - State anxiety	Individual	No	1 Day	1	0,176	0,371
* McComb & Clopton^[51]	26	24	19	100	USA	Autogenic Training and Visualization	Pazients affected by bulimia nervosa	Stai - State anxiety	Group	No	8 Weeks	8	0,030	0,262
* Deckro et al.^[52]	46	44	24	60,2		Relaxation response and other cognitive-behavioral techniques	Students	Stai - State anxiety	Group	Yes	6 Weeks	6	0,700	0,575
* Pawlow & Jones^[20]	44	15	23,2	47,8	USA	Progressive Relaxation	Students	Stai - State anxiety	Individual	No	1 Day	1	1,389	1,054
* Knowlton & Larkin^[53]	12	12	20,8	100	USA	Progressive Relaxation, recommended voice	"Very anxious" students	Stai - State anxiety	Individual	No	1 Day	1	0,160	0,731
* Knowlton & Larkin^[53]	12					Progressive Relaxation, conversational voice					1 Day	1	0,537	1,491
* Knowlton & Larkin^[53]	12					Systematic Relaxation					1 Day	1	0,497	0,929
Wachholtz & Pargament^[54]	22		19,40	63,6	USA	Unspecified Relaxation	Students	Stai - Trait anxiety	Individual	Yes	2 Weeks	2		0,188
Wachholtz & Pargament^[54]	25		18,90	76		Spiritual Meditation					2 Weeks	2		0,679
Wachholtz & Pargament^[54]	21		19,10	61,9		Secular Meditation					2 Weeks	2		0,211
* Bagheri-Nesami, Mohseni-Bandpei, & Azar^[55]	26	24	48	96	Iran	Benson's Technique	Rheumatoid arthritis patients	Stai - State anxiety	Individual	Yes	8 Weeks	1	0,950	1,200
* Rasid &Parish^[56]	18	17	18	50	USA	Behavioral Relaxation	High school students	Stai - State anxiety	Group	Yes	2 Weeks	4	0,900
* Rasid &Parish^[56]	20		18	55		Progressive Relaxation		Stai - State anxiety	Group	Yes	2 Weeks	4	0,900
Wright, Courtney, & Crowther^[57]	18		40	ND	Irland	Autogenic Training	Patients with cancer	Hospital Anxiety and Depression scale - HADS;	Group	Yes	10 Weeks	10		1,350
* Boyce, Talley, Balaam, Koloski, & Truman^[58]	19	25	42,3	81	Australia	Progressive Relaxation	Patients with Irritable Bowel Syndrome	Hospital Anxiety and Depression scale - HADS;	Individual	Yes	4 Weeks	4	0,096	0,411
* Norton, Holm, & McSherry^[59]	17	16	20,3	70	USA	Progressive Relaxation	Students	State-Trait Personality Inventory	Individual	Yes	2 Weeks	2	0,265	1,138
Carlbring, Ekselius, & Andersson^[60]	11		37,4	63	Sweden	Applied relaxation	Pazients with panic	Beck Anxiety Inventory	Individual	Yes	7 Months	9		0,950
Muhlberger, Herrmann, Wiedemann, Ellgring^[61]	15		42,2	86,7	Germany	Progressive Relaxation after the exposure of Virtual Reality	Flight phobics	Anxiety Expectancy Scale	Individual	No	1 Weeks	4		0,072
Viens, De Koninck, Mercier, St-Onge, & Lorrain^[62]	10		36,1	80	Canada	Progressive Relaxation, management of anxiety	Subjects with sleep disorders	Stai - State anxiety	Individual	Yes	9 Weeks	1		0,865
* Davidson et al^[63]	25	16	36	76	USA	Meditation	Employers	Stai - Trait anxiety	Group	Yes	8 Weeks	8	0,747	0,545
* Lukins, Davan, & Drummond^[64]	43	52	47	50,8	Australia	Imaginative Relaxation	Patients undergoing magnetic resonance	Stai - State anxiety	Individual	No	1 Day	1	0,526	0,174
* Lukins, Davan, & Drummond^[64]	44					Imaginative Relaxation with re-calling during MRI					1 Day	2	0,384	0,050
* Cheung, Molassiotis, & Chang^[17]	8	10	48,8	37,5	Hong Kong	Progressive Relaxation	Patients after stoma surgery	Stai - State anxiety	Individual	Yes	1 Day	2	0,479
Kominars^[65]	76		nd	nd	USA	Progressive Relaxation and Visualization	Patients alchol addicted	Stai - State anxiety	Group	nd	3 Weeks	6		1,010
Arntz^[31]	20		35,9	60	Netherland	Applied relaxation	Patients with Generalized Anxiety Disorder	Stai - Trait anxiety	Individual	Yes	12 Weeks	12		0,369
Engel & Andersen^[66]	8		48,5	37,5	Denmark	Guided Relaxation and Meditative Streching	Patients with chronic toxic encephalopathy	Stai - State anxiety	Group	No	8 Weeks	8		0,549
* Jablon, Naliboff, Gilmore, & Rosenthal^[67]	10	10	58,9	50	USA	Progressive Relaxation and EMG biofeedback	Patients with type II diabetes	Stai - State anxiety	Individual	Yes	4 Weeks	4	0,254	0,412
* Clarl et al.^[68]	19	20	31,95	44	UK	Applied relaxation	Patients with social phobia	Beck Anxiety Inventory	Individual	Yes	14 Weeks	14	0,949	1,029
* Lowe et al.^[69]	20	20	63,1	20	Germany	Progressive Relaxation	Patients After Acute Myocardial Infarction	Hospital Anxiety and Depression Scale	Group	No	1 Week	2	0,189	-0,061

* = Studies with control group

Effect Sizes in Between Analysis (BT)
Variable	ES BT
Relaxation technique
Autogenic Training	,41791
Progressive Relaxation	,55404
Meditation	,85881
Applied relaxation	,94900
Multi-modality	,42650
Other techniques	,43118
Typology of subjects
Students/Volunteers	,73034
Patients with physical diseases	,38598
Patients with psychological of psychosomatic diseases	,46727
Group/Individual
Group	,55136
Individual	,48369
Homework
Yes	,61482
No	,39472
Assessment
STAI - State anxiety	,53128
STAI - Trait anxiety	,74700
Hospital Anxiety and Depression Scale	,14055
Beck Anxiety Inventory	,94900
Other questionnaires	,61879

Effect Sizes in Between Analysis (BT)
Variable	ES BT
Relaxation technique
Autogenic Training	,41791
Progressive Relaxation	,55404
Meditation	,85881
Applied relaxation	,94900
Multi-modality	,42650
Other techniques	,43118
Typology of subjects
Students/Volunteers	,73034
Patients with physical diseases	,38598
Patients with psychological of psychosomatic diseases	,46727
Group/Individual
Group	,55136
Individual	,48369
Homework
Yes	,61482
No	,39472
Assessment
STAI - State anxiety	,53128
STAI - Trait anxiety	,74700
Hospital Anxiety and Depression Scale	,14055
Beck Anxiety Inventory	,94900
Other questionnaires	,61879

Correlation Between Effect Sizes and Moderators (BT)
Moderator	r with ES BT	P
Mean age	-.237	<.001
Women presence	-.213	<.01
Duration of training	.186	<.01

Characteristics of the Studies
Study	N° Subjects	N° Controls	Mean Age	% Women	Country	Type of training	Type of Subjects	Instrument	Individual/group	Homework	Duration	Session	Effect size BT	Effect size WT
* Kanji, White,& Ernst^[16]	30	29	64,5	36,7	UK	Autogenic Training	Patients undergoing coronary angioplasty	Stai - State anxiety	Group	Yes	2 Months	ND	0,470	0,513
* Tomioka & Kubo^[50]	21	12	43,3	72,7	Japan	Autogenic Training	Psychosomatic patients	Stai - State anxiety	Group	Yes	8 Weeks	8	0,318	0,399
* Pawlow, O'Neil & Malcolm^[21]	10	10	38	90	USA	Progressive Relaxation	Night Eaters	Stai - State anxiety	Group	Yes	1 Day	1	1,358	1,305
* Yung, Fung, Chan, & Lau^[24]	17	30	37	100	Hong Kong	Stretch Release Relaxation Group;	Nurses	Stai - State anxiety	Group	Yes	4 Weeks	4	0,397	0,210
* Yung, Fung, Chan, & Lau^[24]	18					Cognitive Relaxation					4 Weeks	4	0,623	0,331
*Roykulcharoen & Good^[23]	51	51	42	82,3	Thailand	Systematic Relaxation	Patients underwent abdominal surgery	Stai - State anxiety	Individual	No	1 Day	1	0,176	0,371
* McComb & Clopton^[51]	26	24	19	100	USA	Autogenic Training and Visualization	Pazients affected by bulimia nervosa	Stai - State anxiety	Group	No	8 Weeks	8	0,030	0,262
* Deckro et al.^[52]	46	44	24	60,2		Relaxation response and other cognitive-behavioral techniques	Students	Stai - State anxiety	Group	Yes	6 Weeks	6	0,700	0,575
* Pawlow & Jones^[20]	44	15	23,2	47,8	USA	Progressive Relaxation	Students	Stai - State anxiety	Individual	No	1 Day	1	1,389	1,054
* Knowlton & Larkin^[53]	12	12	20,8	100	USA	Progressive Relaxation, recommended voice	"Very anxious" students	Stai - State anxiety	Individual	No	1 Day	1	0,160	0,731
* Knowlton & Larkin^[53]	12					Progressive Relaxation, conversational voice					1 Day	1	0,537	1,491
* Knowlton & Larkin^[53]	12					Systematic Relaxation					1 Day	1	0,497	0,929
Wachholtz & Pargament^[54]	22		19,40	63,6	USA	Unspecified Relaxation	Students	Stai - Trait anxiety	Individual	Yes	2 Weeks	2		0,188
Wachholtz & Pargament^[54]	25		18,90	76		Spiritual Meditation					2 Weeks	2		0,679
Wachholtz & Pargament^[54]	21		19,10	61,9		Secular Meditation					2 Weeks	2		0,211
* Bagheri-Nesami, Mohseni-Bandpei, & Azar^[55]	26	24	48	96	Iran	Benson's Technique	Rheumatoid arthritis patients	Stai - State anxiety	Individual	Yes	8 Weeks	1	0,950	1,200
* Rasid &Parish^[56]	18	17	18	50	USA	Behavioral Relaxation	High school students	Stai - State anxiety	Group	Yes	2 Weeks	4	0,900
* Rasid &Parish^[56]	20		18	55		Progressive Relaxation		Stai - State anxiety	Group	Yes	2 Weeks	4	0,900
Wright, Courtney, & Crowther^[57]	18		40	ND	Irland	Autogenic Training	Patients with cancer	Hospital Anxiety and Depression scale - HADS;	Group	Yes	10 Weeks	10		1,350
* Boyce, Talley, Balaam, Koloski, & Truman^[58]	19	25	42,3	81	Australia	Progressive Relaxation	Patients with Irritable Bowel Syndrome	Hospital Anxiety and Depression scale - HADS;	Individual	Yes	4 Weeks	4	0,096	0,411
* Norton, Holm, & McSherry^[59]	17	16	20,3	70	USA	Progressive Relaxation	Students	State-Trait Personality Inventory	Individual	Yes	2 Weeks	2	0,265	1,138
Carlbring, Ekselius, & Andersson^[60]	11		37,4	63	Sweden	Applied relaxation	Pazients with panic	Beck Anxiety Inventory	Individual	Yes	7 Months	9		0,950
Muhlberger, Herrmann, Wiedemann, Ellgring^[61]	15		42,2	86,7	Germany	Progressive Relaxation after the exposure of Virtual Reality	Flight phobics	Anxiety Expectancy Scale	Individual	No	1 Weeks	4		0,072
Viens, De Koninck, Mercier, St-Onge, & Lorrain^[62]	10		36,1	80	Canada	Progressive Relaxation, management of anxiety	Subjects with sleep disorders	Stai - State anxiety	Individual	Yes	9 Weeks	1		0,865
* Davidson et al^[63]	25	16	36	76	USA	Meditation	Employers	Stai - Trait anxiety	Group	Yes	8 Weeks	8	0,747	0,545
* Lukins, Davan, & Drummond^[64]	43	52	47	50,8	Australia	Imaginative Relaxation	Patients undergoing magnetic resonance	Stai - State anxiety	Individual	No	1 Day	1	0,526	0,174
* Lukins, Davan, & Drummond^[64]	44					Imaginative Relaxation with re-calling during MRI					1 Day	2	0,384	0,050
* Cheung, Molassiotis, & Chang^[17]	8	10	48,8	37,5	Hong Kong	Progressive Relaxation	Patients after stoma surgery	Stai - State anxiety	Individual	Yes	1 Day	2	0,479
Kominars^[65]	76		nd	nd	USA	Progressive Relaxation and Visualization	Patients alchol addicted	Stai - State anxiety	Group	nd	3 Weeks	6		1,010
Arntz^[31]	20		35,9	60	Netherland	Applied relaxation	Patients with Generalized Anxiety Disorder	Stai - Trait anxiety	Individual	Yes	12 Weeks	12		0,369
Engel & Andersen^[66]	8		48,5	37,5	Denmark	Guided Relaxation and Meditative Streching	Patients with chronic toxic encephalopathy	Stai - State anxiety	Group	No	8 Weeks	8		0,549
* Jablon, Naliboff, Gilmore, & Rosenthal^[67]	10	10	58,9	50	USA	Progressive Relaxation and EMG biofeedback	Patients with type II diabetes	Stai - State anxiety	Individual	Yes	4 Weeks	4	0,254	0,412
* Clarl et al.^[68]	19	20	31,95	44	UK	Applied relaxation	Patients with social phobia	Beck Anxiety Inventory	Individual	Yes	14 Weeks	14	0,949	1,029
* Lowe et al.^[69]	20	20	63,1	20	Germany	Progressive Relaxation	Patients After Acute Myocardial Infarction	Hospital Anxiety and Depression Scale	Group	No	1 Week	2	0,189	-0,061

* = Studies with control group

Effect Sizes in Within Analysis
Variable	ES WT
Relaxation technique
Autogenic Training	,66747
Progressive Relaxation	,82439
Meditation	,66236
Applied relaxation	,73198
Multi-modality	,46241
Other techniques	,21614
Typology of subjects
Students/Volunteers	,58370
Patients with physical diseases	,40239
Patients with psychological of psychosomatic diseases	,75459
Group/Individual
Group	,62322
Individual	,58885
Homework
Yes	,65462
No	,40640
Assessment
STAI - State anxiety	,59195
STAI - Trait anxiety	,40826
Hospital Anxiety and Depression Scale	,49247
Beck Anxiety Inventory	,99956
Other questionnaires	,59871

Effect Sizes in Within Analysis
Variable	ES WT
Relaxation technique
Autogenic Training	,66747
Progressive Relaxation	,82439
Meditation	,66236
Applied relaxation	,73198
Multi-modality	,46241
Other techniques	,21614
Typology of subjects
Students/Volunteers	,58370
Patients with physical diseases	,40239
Patients with psychological of psychosomatic diseases	,75459
Group/Individual
Group	,62322
Individual	,58885
Homework
Yes	,65462
No	,40640
Assessment
STAI - State anxiety	,59195
STAI - Trait anxiety	,40826
Hospital Anxiety and Depression Scale	,49247
Beck Anxiety Inventory	,99956
Other questionnaires	,59871

Correlation Between Effect Sizes of Within Analysis and Moderators
Moderator	r with ES WT	p
Mean age	-.268	<.001
Women presence	.145	<.01
Duration of training	.243	<.001

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Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis

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