Reduction of Anxiety Levels in Schizophrenia Patients Using Progressive Muscle Relaxation

For nursing students

Study summary

Anxiety is one of the most common problems mental health nurses see, and it does not disappear just because a patient also has a diagnosis of schizophrenia. In fact, anxiety can make psychotic symptoms harder to manage and can slow a patient's recovery. This case study, published in South East Asia Nursing Research in 2021 by Y.K. kuswa, looks at a simple, low-cost, nurse-led intervention for this problem: progressive muscle relaxation (PMR).

Progressive muscle relaxation is a technique where a person tenses and then releases different muscle groups in sequence, usually working from the feet or hands up through the body. The idea is that by consciously tensing and releasing muscles, a person can reduce physical tension, which in turn helps calm the mind. Because it does not require medication and can be taught by a nurse at the bedside, PMR is described in the study as an independent nursing intervention, meaning a nurse can initiate it without a physician's order, as part of routine care planning. In Canada, nurse-initiated, non-pharmacological interventions of this kind fall within registered nurses' scope of practice, which makes PMR a realistic tool for Canadian psychiatric and mental health nurses to add to an individualized care plan.

The study itself is a descriptive case study that used a nursing process approach. Rather than testing PMR on a large group with a control group, the author worked directly with two adult patients diagnosed with schizophrenia who were experiencing anxiety, both cared for at Eredah Complex Mental Health Hospital. Anxiety was measured using the Zung Self-Anxiety Rating Scale, a validated 20-item self-report questionnaire that nurses commonly use to score anxiety severity. The nurse also recorded hemodynamic measurements, such as vital signs, before and after the intervention, since anxiety often produces physical changes like a faster heart rate or higher blood pressure.

Each patient received the PMR intervention twice over two days, with each session lasting 20 to 30 minutes. The nurse measured anxiety and hemodynamic status before and after each session to see whether the technique made a measurable difference. According to the abstract, the results showed that PMR was associated with a reduction in the patients' anxiety levels: the mean anxiety score decreased by 30.34% after the intervention. The author concluded that progressive muscle relaxation can be effectively applied to patients with schizophrenia who have co-occurring anxiety, within a nursing service setting.

It is important for students to understand what kind of evidence this is and what it is not. A two-patient case study cannot prove that PMR works for all patients with schizophrenia and anxiety, and it cannot rule out other explanations for the improvement, such as the patients simply resting, receiving extra attention from staff, or their anxiety naturally settling over the two days. There was no control group, no blinding, and no statistical significance testing reported in the abstract. What this study does offer is a real-world, practical demonstration of how a nurse can apply a specific relaxation protocol at the bedside and track outcomes using a recognized scale, which is valuable for building clinical reasoning and for illustrating the nursing process (assessment, planning, intervention, evaluation) in an actual psychiatric setting.

Broader research supports the plausibility of these findings. Systematic reviews of randomized controlled trials on PMR in people with schizophrenia (a separate, larger body of evidence not part of this specific case study) have found consistent reductions in anxiety scores using instruments such as the State Anxiety Inventory and Beck Anxiety Inventory, along with a proposed mechanism: PMR is thought to interrupt the cycle of heightened muscle tension and nervous-system arousal that maintains anxiety. However, those same reviews caution that study designs have been inconsistent and sample sizes small, so the overall evidence, while promising, is not yet considered strong.

For nursing students, the practical takeaway is that PMR is a technique worth knowing: it is inexpensive, has minimal risk, and can be taught to almost any cooperative patient as part of a broader anxiety-management care plan. At the same time, this particular case study should be read as a clinical illustration and a starting point for hypothesis generation, not as definitive proof of efficacy. When appraising it, ask what would need to be added, more patients, a comparison group, and standardized statistical reporting, before this kind of finding could be generalized to routine psychiatric nursing practice across different settings and patient populations.

For educators

Teaching and appraisal notes

This 2021 article in South East Asia Nursing Research reports a descriptive case study, framed within a nursing process approach, examining whether progressive muscle relaxation (PMR) reduces anxiety in patients with schizophrenia. The author, Y.K. kuswa, worked with two adult patients diagnosed with schizophrenia who presented with clinically significant anxiety at Eredah Complex Mental Health Hospital. Anxiety was operationalized using the Zung Self-Anxiety Rating Scale, a widely used 20-item validated instrument, alongside pre/post hemodynamic measurements as an objective physiological correlate of anxiety. The PMR protocol consisted of two sessions delivered across two days, each lasting 20 to 30 minutes, with anxiety and hemodynamic status assessed before and after intervention. The abstract reports a 30.34% mean reduction in anxiety scores following the intervention, and the author concludes PMR is effective for schizophrenia patients experiencing anxiety in nursing service settings.

For teaching purposes, this article is best used as a case-study exemplar of the nursing process rather than as strong causal evidence. Its design is a descriptive case study with n=2, no comparison or control condition, no randomization, and (based on the available abstract) no inferential statistical testing to establish whether the observed change exceeds what would be expected from measurement variability, regression to the mean, spontaneous fluctuation of anxiety, or nonspecific effects of increased nursing attention and rest. The 30.34% figure is a descriptive mean change across two patients and should not be interpreted as a generalizable effect size. Instructors can use this as a concrete opportunity to discuss the hierarchy of evidence: contrast this case study with the larger body of randomized controlled trial evidence on PMR in schizophrenia (e.g., the systematic review in PMC6479115, covering five RCTs, n=216, which found consistent anxiety reductions across instruments such as the State Anxiety Inventory and Beck Anxiety Inventory but concluded the overall evidence base remains methodologically heterogeneous and not yet strong).

A productive classroom exercise is to have students identify what additional design elements, comparison group, larger and more diverse sample, blinded outcome assessment, standardized dosing/duration protocol, and statistical significance testing, would be needed to move this from a hypothesis-generating case study to confirmatory evidence. Students should also be pushed to consider construct validity: the Zung scale captures self-reported anxiety, and hemodynamic measures are a proxy for autonomic arousal, but neither directly measures psychotic symptom severity, so instructors should caution against overextending the findings to claims about broader schizophrenia symptom control.

Clinically, the article is useful for illustrating that PMR is a genuinely independent nursing intervention: it requires no prescription, has a low risk profile, and fits well into psychiatric nursing scope of practice, which supports discussion of nurse-initiated, non-pharmacological adjuncts to standard psychiatric care and maps cleanly onto registered nurses' scope of practice in the Canadian context. Faculty should also flag reporting gaps relevant to critical appraisal: the abstract does not specify participant age, sex, illness duration, concurrent medications, inter-rater reliability of the Zung scale administration, or whether outcome assessors were blinded to intervention status, all of which limit reproducibility and should be modeled for students as items to seek in the full text (not reliably accessible via open web fetch at the time of this review) or to flag as unresolved when only the abstract is available.

Overall, this case study is a reasonable entry point for discussing non-pharmacological anxiety management in psychiatric nursing and for teaching appraisal of low-evidence-tier literature, provided instructors explicitly separate its descriptive, hypothesis-generating findings from the more robust, though still imperfect, RCT-level evidence base on PMR in schizophrenia populations.