Research
Perspect Psychiatr Care. 2021;57:1791–1797. wileyonlinelibrary.com/journal/ppc © 2021 Wiley Periodicals LLC | 1791
Received: 3 December 2020 | Revised: 28 January 2021 | Accepted: 30 January 2021
DOI: 10.1111/ppc.12750
OR I G I NA L A R T I C L E
The effects of progressivemuscle relaxation exercises on the anxiety and sleep quality of patients with COVID‐19: A randomized controlled study
İbrahim Özlü MD1 | Zeynep Öztürk PhD2 | Zeynep Karaman Özlü PhD3 |
Erdal Tekin MD1 | Ali Gür MD1
1Emergency Department, Atatürk University,
Erzurum, Turkey
2Department of Psychiatric Nursing, Faculty
of Nursing, Ataturk University, Erzurum,
Turkey
3Department of Surgical Nursing, Faculty of
Nursing, Anesthesiology Clinical Research
Office, Ataturk University, Erzurum, Turkey
Correspondence
Zeynep K. Özlü, Department of Surgical
Nursing, Anesthesiology Clinical Research
Office, Faculty of Nursing, Atatürk University,
25240 Erzurum, Turkey.
Email: zynp_krmnzl@hotmail.com
Abstract
Purpose: This study aimed to determine the effects of progressive muscle relaxation
exercises on the anxiety and sleep quality of patients with coronavirus disease 2019
(COVID‐19). Materials and Methods: This is an experimental study. Its data were collected in the
infectious diseases clinic of a research hospital from May to August, 2020. This
study was carried out with 67 COVID‐19 patients (33 in the experimental group and
34 in the control group). The data were collected using a personal information form,
the state‐trait anxiety inventory, and the Richards–Campbell Sleep Questionnaire.
The progressive muscle relaxation exercises were performed twice a day for 5 days
with the researcher's supervision. The data were analyzed using means, numbers,
percentage distributions, the χ2 test, the dependent t test, and the independent
t test.
Results: Statistically significant differences were found between the experimental
and control groups' mean posttest scores on the State‐Trait Anxiety Inventory and
the Richards–Campbell Sleep Questionnaire (p < 0.05). The in‐group comparison of
the experimental group found a statistically significant difference between their
mean pretest and posttest scores on the State Anxiety Scale (p < 0.05). The in‐group comparison of the control group found no statistically significant changes in their
mean pretest and posttest scores on the State Anxiety Scale (p > 0.05).
Conclusion: The progressive muscle relaxation exercises effectively reduced the
anxiety and improved the sleep quality of patients with COVID‐19.
K E YWORD S
anxiety, COVID‐19, progressive muscle relaxation exercises, sleep quality
1 | INTRODUCTION
Coronavirus disease 2019 (COVID‐19), which was detected at the
end of 2019 and quickly led to a pandemic, is now a global health
issue.1 More than 24 million people have been infected and
821 thousand people have died of COVID‐19.2 There are not
effective antivirals or vaccines even though studies are ongoing.3
Therefore, it is critical to reduce the spread of the virus and to
strengthen patients' immune systems.4,5
Healthy lifestyle, regular exercise, healthy state of mind, and
quality of sleep are related to strengthening the immune system.4
Studies conducted with quarantined COVID‐19 patients have shown
that a major part of the patients experience serious psychological
problems.6‐10 Corona viruses can cause psychopathological sequelae
through direct viral infection of the central nervous system (CNS) or an
indirect immune response.11 Important psychological stressors include
pathophobia, stigmatization, uncertainty about the future, disease‐ related traumatic memories, and immunological mechanisms.7,8,11,12
A number of researchers have also noted that COVID‐19 responses
such as quarantines may also contribute to mental problems.13
Studies of the psychological states of patients with COVID‐19 in
hospitals have reported that they have high levels of anxiety.6,10
Researchers have found that problems related to the anxiety and stress
of patients receiving COVID‐19‐related treatment can cause serious
damage as the disease progresses.9 Chong et al.14 found that people
with pandemic‐related anxiety have high levels of posttraumatic stress
disorder, health anxiety, and suicidal ideation. However, there are not
enough studies of COVID‐19 patients' anxiety and related problems.6,10
Most of the studies of anxiety concerning COVID‐19 have focused on
health‐care professionals and the general public.15‐17 More research is
needed to mitigate or prevent the intense anxiety of COVID‐19 pa-
tients who experience the devastating effect of the virus firsthand.6
Studies have shown that many patients experience serious sleep
problems during the COVID‐19 treatment18‐21 Sleeping is a physiological
and behavioral process required to live, and it plays an important role in
strengthening the immune system.21,22 Sleep deprivation negatively af-
fects immune responses by disrupting the circadian rhythm.19 A retro-
spective cohort study found that the poor sleep quality of COVID‐19 patients is related to slow recovery and increased need for care in in-
tensive care units.21 The use of sleep‐inducing drugs such as benzodia-
zepine with COVID‐19 patients may cause respiratory depression and
delay monitoring the disease. Some researchers recommend the use of
nonpharmacological methods to reduce the sleep problems of COVID‐19 patients.23
There are numerous studies in literature on the use of progressive
muscle relaxation exercises to reduce the anxiety levels and sleep pro-
blems of patients with a chronic disease.24‐27 Progressive muscle re-
laxation is a deep relaxation technique based on the principle that
muscle strain is a physiological response of the human body to
disturbing thoughts. This technique leads to a voluntary and regular
relaxation of the major muscle groups and thus relaxes the entire
body.28 Progressive muscle relaxation exercises are easy to learn and
can be done anywhere at any time. They are also economical because
they do not require special technology or equipment.23,28,29 Studies have
shown that muscle relaxation exercises help patients reduce their an-
xiety and improve their sleep quality because they reduce tension,
stress, blood pressure, heart rate, lactic acid production, and sensitivity
to pain when regularly performed with proper techniques.24,25,27‐29
This study can contribute to literature as a guide or health‐care professionals' efforts to eliminate the anxiety and sleep problems of
patients with COVID‐19 that cannot be treated with pharmacologi-
cal methods and can thus cause long‐term serious problems. This
study aimed to determine the effects of progressive muscle relaxa-
tion exercises on the anxiety and sleep quality of patients with
COVID‐19.
2 | METHODS
2.1 | Study type
This is an experimental study.
2.2 | Study setting
This study was conducted in the COVID‐19 clinic of a research
hospital from May to August, 2020.
2.3 | Study population and sample
The study population consisted of COVID‐19 patients who were re-
ceiving treatment in the clinic. Its sample consisted of 73 patients. All
patients who met the inclusion criteria were included in the study.
Simple randomization was used. After being informed about the study,
36 patients were assigned to the experimental group, and 37 patients
were assigned to the control group. This study was completed with
67 patients with COVID‐19, 33 for experimental group and 34 for
control group, because 2 patients in the experimental group and
1 patient in the control group were discharged, the clinical status of
1 patient worsened to the extent of being unable to perform progressive
muscle relaxation exercises, and 2 patients in the control group were
transferred to a different hospital (Figure 1). Post hoc power analysis was
performed to determine the adequacy of the sample size of the study. In
the power analysis performed to determine the sample's power to re-
present the population, it was found that the power was 0.99 at the
medium effect size and significance level of .05.
The inclusion criteria were being diagnosed with COVID‐19, being at least 18 years old, having no visual or hearing impairments, being
able to perform progressive muscle relation exercises, and voluntary
participation.
2.4 | Data collection tools
2.4.1 | The Personal Information Form
A personal information form was developed by the researcher. It
includes 11 questions concerning age, gender, marital status, place of
residence, profession, income level, previous hospitalizations, chronic
disease, smoking, alcohol consumption, and regular exercise.
2.4.2 | The State‐Trait Anxiety Inventory (STAI)
This inventory was developed by Spielberger et al.30 to assess state
and trait anxiety levels. Öner & LeCompte31 did the validity and
reliability study of its Turkish version. It consists of two scales that
can be administered to people who are 14 or older. The State
1792 | ÖZLÜ ET AL.
Anxiety Scale (SAS) determines how people feel at a specific time and
under specific conditions, and the Trait Anxiety Scale (TAS) de-
termines how they feel independently of their current situation. This
scale consists of 40 items. The first 20 items assess state‐dependent anxiety, and the last 20 items assess trait anxiety. This is a 4‐point Likert‐type scale. Scores on both scales range from 20 to 80, and
higher scores indicate higher levels of anxiety. The Cronbach's α
coefficients were .84 for the SAS and .80 for the TAS. The Cronbach's
α coefficients in this study were .67 for the SAS and .63 for the TAS.
2.4.3 | The Richards–Campbell Sleep Questionnaire (RCSQ)
The RCSQ was developed by Richards32 to assess patients' percep-
tions of sleep. Özlü and Özer33 did the validity and reliability study of
the Turkish version of the RCSQ. The RCSQ consists of six items that
assesses sleep depth, sleep latency, awakenings, returning to sleep,
sleep quality, and noise. Each item is scored from 0 to 100 using the
visual analogue scale. Scores from 0 to 25 indicate poor quality of
sleep, and scores from 76 to 100 indicated high quality of sleep.
Higher scores indicate higher levels of sleep quality. The Cronbach's
α coefficient was .91 for the RCSQ. The Cronbach's α coefficient in
this study was .91 for the RCSQ.
2.5 | Data Collection and Implementation
The data were collected from May to August, 2020. Pretests and
posttests were conducted with patients in both the experimental and
control groups. The patients in the control group did not receive any
specific intervention, only routine care. The patients in both groups
continued their pharmacological treatments and the routine prac-
tices of the clinic during the specified period of time. After the data
were collected from the patients in the control group, they were
informed that they also could receive progressive muscle relaxation
exercises at any time.
The scheduling of the progressive muscle relaxation exercises
was determined with the patients in the experimental group.
A compact disc (CD) prepared by the Turkish Psychologists Asso-
ciation was used to teach the muscle relaxation exercises. The
muscle relaxation exercises were shown on the TVs in the patients'
rooms, and the patients exercised along with their TVs to minimize
direct patient contact. The CD included instructions for muscle
F IGURE 1 CONSORT flow diagram
ÖZLÜ ET AL. | 1793
relaxation exercises and music to help the patients relax. Permission
to use the Progressive Muscle Relaxation Exercise CD was obtained
from the Turkish Psychologists Association by email. The progressive
muscle relaxation exercises were done by the experimental group
twice a day for 5 days in accordance with an expert's advice. It took
approximately 20–30min to perform the exercises. Posttests were
conducted with the experimental group after the muscle relaxation
training was completed.
TABLE 1 Distribution of patients according to sociodemographic features (n = 67)Features
Experiment
group, n = 33 %
Control
group, n = 34 %
Test value
and
significance
Sex
Female 12 36 18 53 χ2= 1.861
Male 21 64 16 47 p = 0.172
Marital status
Married 19 58 16 47 χ2= 0.742
Single 14 42 18 53 p = 0.389
Living place
City 25 76 28 82 χ2= 0.441
Town 8 24 6 18 p = 0.507
Occupation
Labor‐officer 19 58 19 56
Housewife 5 15 4 12 χ2= 1.122
Retired 2 6 2 6 p = 0.891
Unemployed 2 6 1 3
Student 5 15 8 23
Income status
Income < expenses 13 39 12 35 χ2= 1.853
Income = expenses 19 58 18 53 p = 0.396
Income > expenses 1 3 4 12
Previous hospitalization
No 18 54 15 44 χ2= 1.298
Once 12 37 13 38 p = 0.523
Twice 3 9 6 18
Chronic illness
No 7 21 7 21 χ2= 0.004
Yes 26 79 27 79 p = 0.950
Smoke
No 10 30 14 41 χ2= 0.906
Yes 19 58 17 50 p = 0.636
Give up smoking 4 12 3 9
Drinking
No 30 91 31 91 χ2= 0.001
Yes 3 9 3 9 p = 0.969
Exercise regularly
No 27 82 24 71 χ2= 1.162
Yes 6 18 10 29 p = 0.281
Age 36.48 ± 11.63 33.15 ± 11.90 t = 1.161
p = 0.250
Abbreviation: t, independent groups t test.
1794 | ÖZLÜ ET AL.
2.6 | Data Analysis
Data coding and analysis were performed using SPSS 21. The data
were analyzed using means, numbers, percentage distributions, the
χ2 test, the dependent t test, and the independent t test.
2.7 | Ethical considerations
Ethical committee approval was obtained from the Atatürk
University Medical Faculty Clinical Research Ethics Committee
(B.30.2.ATA.0.01.00/249). The participants were informed about the
study before the data collection process and were asked to sign an
informed consent form.
3 | RESULTS
The results of this study, which aimed to determine the effects of
progressive muscle relaxation exercises on anxiety and sleep quality
of patients with COVID‐19, are shown below. Table 1 shows the
sociodemographic characteristics of the participants. No significant
differences were found between the groups in terms of socio-
demographic characteristics (p > 0.05) (Table 1). Table 2 shows the
differences between the pretest and posttest STAI scores of both
groups. The mean pretest scores of the experimental group were
62.33 ± 8.33 for the SAS and 48.12 ± 5.22 for the TAS. The mean
pretest scores of the control group were 60.68 ± 9.17 for the SAS
and 45.35 ± 8.09 for the TAS. No significant differences were found
between the state and trait anxiety levels of the groups, which were
determined to be homogeneous (p > 0.05).
The experimental group's mean posttest score on the SAS was
44.67 ± 5.41, and the control group's mean posttest score on the SAS
was 61.29 ± 7.95. A statistically significant difference was found
between their mean posttest SAS scores. The mean posttest SAS
score of the control group was higher than that of the experimental
group (p < 0.05) (Figure 2).
A statistically significant difference was found between the ex-
perimental group's mean pretest and posttest SAS scores. No sig-
nificant differences were found between the mean pretest and
posttest SAS scores of the control group.
The experimental group's mean posttest score on the RCSQ was
68.33 ± 14.53, and the control group's mean posttest score on the
RCSQ was 46.71 ± 19.71. A statistically significant difference was
found between their mean RCSQ scores. The mean posttest RCSQ
score of the experimental group was higher than that of the control
group (p < 0.05).
4 | DISCUSSION
The psychological dimension of COVID‐19 has been ignored in the
studies conducted with COVID‐19 patients.6,8,10 The diagnosis and
treatment of COVID‐19‐related psychiatric conditions are re-
commended by clinical research; however, few intervention studies in
the literature have attempted to eliminate the psychological problems
of COVID‐19 patients.23 Progressive muscle relaxation exercises were
performed in this study to reduce or prevent the anxiety and sleep
problems of patients with COVID‐19. Here, the results of this study
are discussed along with the relevant literature.
The state anxiety levels of the experimental group decreased sig-
nificantly compared with the control group (Table 2). The SAS determines
TABLE 2 Comparison of the mean STAI scores of the experimental and control groups
Experiment group
(X ± SD)
Control group
(X ± SD) Test value and
significance
Pretest
State Anxiety Scale 62.33 ± 8.33 60.68 ± 9.17 t = 0.773
p = 0.442
Trait Anxiety Scale 48.12 ± 5.22 45.35 ± 8.09 t = 1.658
p = 0.102
Final test
State Anxiety Scale 44.67 ± 5.41 61.29 ± 7.95 t = −9.982
p = 0.000
Test value and
significance
t = 10.618 t = −0.453
p = 0.000 p = 0.652
62.33
44.67
60.68
61.29
30.
40.
50.
60.
70.
Pretest Pos�est
State Anxiety Scale
Experiment Group
Control Group
F IGURE 2 The variation of the mean State Anxiety Scale scores of the experimental and control groups by time of measurement
ÖZLÜ ET AL. | 1795
how people feel at a specific time and under specific conditions.31 Pro-
gressive muscle relaxation exercises may effectively reduce the anxiety
of COVID‐19 patients concerning challenging situations such as hospi-
talization, treatment, and isolation.23 Few studies of anxiety prevention
for COVID‐19 patients have been conducted, even though the literature
emphasizes that they experience high levels of anxiety. Liu et al.23
administered progressive muscle relaxation exercises to COVID‐19 patients 30min a day for 5 days and found that the exercises effectively
reduced their anxiety levels. Manzoni et al.34 did a 10‐year systematic
review with meta‐analysis, which found that muscle relaxation training is
consistently effective and should be considered to reduce anxiety.
Volpato et al.35 conducted a meta‐analysis of 25 randomized controlled
studies of muscle relaxation exercises with chronic obstructive pulmon-
ary patients (COPD) patients and found that the exercises effectively
reduced anxiety. Turkish and international studies with different samples
have also shown that progressive muscle relaxation exercises effectively
reduce anxiety.29,36‐38 The results of this study are similar to those of
other studies.
The sleep quality of the experimental group significantly in-
creased compared with the control group (Table 3). This finding sug-
gests that progressive muscle relaxation exercises are effective to
eliminate sleep problems of COVID‐19 patients. Studies have shown
that many patients experience serious sleep problems during
COVID‐19 treatment.18‐21 However, only one study in the literature
has reported that progressive muscle relaxation exercises improve the
sleep quality of COVID‐19 patients. Liu et al.23 found that progressive
muscle relaxation exercises help improve the sleep quality of
COVID‐19 patients. Previous studies of the respiratory system, which
the virus can fatally affect, have shown that progressive muscle re-
laxation techniques lead to positive results. Yilmaz and Kapucu39) did
a systematic review of progressive muscle relaxation exercises with
COPD patients and found that the exercises effectively reduce
fatigue, anxiety, and depression, and improve sleep quality. Aksu et al.24
found that progressive muscle relaxation exercises prevent the dete-
rioration of the sleep quality of patients with pulmonary resection.
Chegeni et al.27 conducted a randomized controlled study with COPD
patients and reported that progressive muscle relaxation exercises
effectively reduce fatigue and improve subjective sleep quality.
Studies of a variety of patient groups have shown that progressive
muscle relaxation exercises effectively prevent sleep problems. Studies
conducted with multiple sclerosis patients,25 hemodialysis patients,26
cancer patients,40 and intensive care patients41 have determined that
progressive muscle relaxation exercises effectively improve sleep quality.
The results of this study are similar to those of other studies.
Progressive muscle relaxation exercises can be considered a
nonpharmacological method of reducing anxiety and improving sleep
quality, and this is beneficial because the drugs used for the anxiety
and sleep problems of COVID‐19 patients have a number of side
effects that can prevent the monitoring of their symptoms.
5 | IMPLICATIONS FOR NURSING PRACTICE
Progressive muscle relaxation exercises effectively reduced the an-
xiety and improved the sleep quality of patients with COVID‐19. Health‐care professionals should administer progressive muscle re-
laxation exercises to patients with COVID‐19.
ACKNOWLEDGMENTS
The authors wish to thank and acknowledge the participants for
sharing their experiences with us.
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
AUTHOR CONTRIBUTIONS
Ibrahim Özlü, Zeynep Öztürk, Zeynep Karaman Özlü, Erdal Tekin and
Ali Gür, were responsible for the conception and design of the study.
İbrahim Özlü, Zeynep Öztürk, Zeynep Karaman Özlü, Erdal Tekin and
Ali Gür were responsible for acquisition and analysis of data; fur-
thermore, İbrahim Özlü was in charge of statistical analysis. İbrahim
Özlü, Zeynep Öztürk, Zeynep Karaman Özlü, Erdal Tekin and Ali Gür,
drafted the manuscript and approved the final version. All authors
read and approved the final manuscript.
ORCID
İbrahim Özlü http://orcid.org/0000-0002-0821-7592
Zeynep Öztürk http://orcid.org/0000-0003-3368-4288
Zeynep Karaman Özlü http://orcid.org/0000-0001-8896-5461
Erdal Tekin http://orcid.org/0000-0002-6158-0286
Ali Gür http://orcid.org/0000-0002-7823-0266
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How to cite this article: Özlü İ, Öztürk Z, Karaman Özlü Z,
Tekin E, Gür A. The effects of progressive muscle relaxation
exercises on the anxiety and sleep quality of patients with
COVID‐19: a randomized controlled study. Perspect Psychiatr
Care. 2021;57:1791–1797. https://doi.org/10.1111/ppc.12750
ÖZLÜ ET AL. | 1797
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