Guidelines for Cardiac Rehabilitation 2004
Final editing: E.A.M. Franke, MSc
Reference for this report: Rehabilitation Committee of the Netherlands Society of Cardiology
and the Netherlands Heart Foundation. Guidelines for Cardiac Rehabilitation 2004. The
Hague: Netherlands Heart Foundation 2004
Chapter 5: M. Chatrou, PhD, J.L. van Dijk, MD, J.J. van Dixhoorn, MD, J.A. Iestra, H. Koers,
M.W.A. Jongert, MSc, S. van der Voort
Relaxation programme
J van Dixhoorn
The term 'relaxation training' covers a number of forms of training or methods for relaxation.
Most of them have a set design and a clearly described goal. The relaxation programme in
cardiac rehabilitation uses a completely different approach: the different forms of training are
first reduced to their basic elements and then built up into a new series. This results in a much
greater repertoire of options which can be used to modify the training to suit the patient's
capabilities, rather than having the patient adjust to the method. It is important to find at least
one instruction with which the patient can achieve an evident change. The primary aim of
relaxation is to allow the patients to experience a change, like a looser feeling in their body,
ease in standing upright, slow or clearer in the head, easier breathing or better rested, and to
teach them to do this at home.
Relaxation therapy teaches patients to use internal tools like attention, imagination, muscle
relaxation, small movements, posture and breath regulation to produce a change in tension. In
some situations this can be supplemented by biofeedback or manual procedures. With this
skill they can influence their own state of tension. Also, they become more aware of the effect
of different conditions on their state of tension. This allows them to recognise, create and
utilise moments of relative rest in daily life and to deal better with sources of tension.
In cardiac rehabilitation, patients become acquainted with relaxation training in the exercise
programme, in which relaxation is included. Relaxation training is also incorporated in the
lifestyle programme. In addition, there is a separate relaxation programme, that ideally takes 6
to 8 contact-hours and is given to groups of around 6 patients.
It is very important to test the relaxation skill and discuss its application in daily life. Various
forms and questionnaires have been developed for this (see www.hartstichting.nl). During
testing it appeared that a number of patients did not experience any effect of the training, but
are tense. These patients should be considered for individual relaxation therapy, unless the
tension is due to causes which require another solution.
Those eligible for a relaxation programme include:
 patients who can only be moderately exercised because of a high heart rate and/or a slow
recovery after exertion;
 patients who have difficulty recognising their limits;
 patients with cardiac ischaemia or angina pectoris;
 patients with problems concerning return to work;

patients with a low sense of well-being, who feel insecure, have little self-confidence or
feel anxious, depressed or exhausted.
Along with the practical exercises, a number of themes can be discussed. For example:
 What is real rest? Good and sufficient rest promotes recovery after exertion and ensures
that the body becomes strong again. One can carry out activities with less effort, recovers
more quickly, and relaxes more deeply at the end.
 How do you consciously pay attention to your body? Attention to your body – as during
relaxation training – ensures that someone recognises sooner the signals of immanent
overload (and cardiac symptoms) and can distinguish them from signals of tension.
 When do relaxation exercises work best? It is advisable to practice at times when the
patient already feels somewhat quiet. The experience of relaxation is then more concrete
and obvious, they feel safer and more secure.
 Which stressors (unfavourable conditions) restrict someone from getting enough rest?
Examples include lack of time, wanting to do or doing too much, negative mood that gets
worse at rest, etc.
 What specific stressors counteract a feeling of relaxation, and how do they accomplish
that? Consider the work situation, relationships with colleagues or boss, relationship with
partner or family situation.
 What irrational thoughts might the patient have about tension, relaxation, breathing and
stress?
Refer for the application and evaluation of relaxation training to: Dr. J.J. van Dixhoorn,
Ontspanningsinstructie: principes en oefeningen, Elsevier/Bunge: Maarssen 1998. Website:
www.euronet.nl/users/dixhoorn.
Scientific foundation
There have been 24 controlled and useful studies in which the effect of a form of relaxation
training (as defined above) was investigated. All forms of relaxation training appear to be
associated with cognitive restructuring. The patient receives an explanation of the effects of
stress and of the necessity to practice regularly to reduce the level of tension.
The studies distinguished between the duration and contents of the relaxation training. There
are three forms of relaxation training:
 Type 1: abridged form.
Abridged training lasting 3 hours or less (6 studies). The participating patients are
instructed in one technique, which is demonstrated and supplied on paper or cassette. The
patient is encouraged to practise often and to keep a diary which can be discussed later.
 Type 2: full relaxation training.
Full training consists of repeated instructions, given in a series of meetings which total
around nine hours on average (10 studies). In groups with a limited number of participants
(3-10) the patient becomes acquainted with different techniques and learns to apply them.
The focus is on experiences from daily life, like recognising signals of tension, and the
ways of coping with them. The participants are not given a tape.
 Type 3: relaxation training plus cognitive therapy.
Discussion groups in which relaxation exercises are prominent (comparable to type 2), but
more topics are covered (8 studies). Along with information on risk factors, the disease
and lifestyle, a specific psychological theme is considered like depression, anxiety, type A
behaviour, exhaustion or hostility. The average duration of this type of relaxation training
was 11.5 uur. Sometimes the patients did receive a tape.
It has been shown that relaxation therapy reduces the heart rate at rest (level A; class I).
The effect of relaxation training on the heart rate was examined in 8 studies.1,5,9,10,14,23-25 In
seven of them the heart rate dropped. The actual decrease could be calculated with the data
from 5 studies and amounted to 3 to 4 beats per minute (P<0.01).5,9,14,23,25 The effect was
independent of the type of training and was maintained when relaxation therapy was added to
exercise therapy.
It is reasonable to assume that relaxation therapy increases the exercise tolerance (level B;
class IIb).
In four studies the exercise tolerance of patients with chronic heart symptoms rose after
relaxation training.5,7,8,26 The patients in the studies underwent only relaxation therapy (thus
not a combination of relaxation and exercise training). The effect, measured as maximal
wattage or walking time, was moderately good (effect size 0.51; 95% confidence interval
(CI): 0.13-0.74; P<0.05).
It has been shown that relaxation therapy reduces the frequency of symptoms of angina
pectoris, both in patients who have already suffered a myocardial infarction and in those with
stable angina pectoris (level A; class IIa).
The frequency of attacks of angina pectoris dropped in eight studies.1,3,7,8,15,16,18,21 The average
effect size was moderate: 0.59 (95% CI: 0.16-1.02; P<0.01)7,8,15,21. The effect was smallest in
studies with abridged forms of relaxation training (type 1).
It is reasonable to assume that relaxation therapy lowers the frequency of ST-depression or
delays the moment of their occurrence during exercise (level B; class IIb).
Four studies examined the effect of relaxation training on ST-depression.5,14,17,26 All of them
noted a favourable effect. None of the studies used abridged training forms (type 1).
It is reasonable to assume that relaxation therapy reduces heart rhythm disturbances (level B;
class IIb).
Relaxation training has a favourable effect on the occurrence of rhythm disturbances in
patients who have suffered a myocardial infarction (odds ratio 0.22; 95% CI: 0.10-0.49;
P<0.001).3,16,18
It is reasonable to assume that relaxation therapy lowers the level of anxiety (level B; class
IIa).
The effect of relaxation training on anxiety was examined in eleven studies.3,5,6,9,13,15,16,20-23
The level of anxiety dropped significantly (effect size 0.31; 95% CI: 0.14-0.47; P<0.001). The
effect was not smaller when the relaxation therapy was added to exercise therapy. With
abridged training (type 1) no effect was demonstrated, with full relaxation training (type 2)
the effect was moderately good, and with the combination of relaxation and cognitive therapy
(type 3) the effect was small.
It is reasonable to assume that relaxation training promotes the return to work (level B; class
IIb).
Three studies showed a favourable effect on return to work.12,18,19 After six months, the
number of patients who had returned to work in the group who had undergone relaxation
training was higher than in the control group (odds ratio 1.83; 95% CI: 1.18-2.81; P<0.01).
It is reasonable to assume that relaxation therapy can reduce the risk of (new) cardiac
pathology (level B; class IIb).
Seven studies with a total of 916 patients showed that the risk of cardiac death or of a new
cardiac event was reduced after relaxation training (odds ratio 0.39; 95% CI: 0.27-0.57;
P<0.001).2-4,10,11,18,19 The length of the follow-up (6 months to five years), whether
randomisation was done or not, the type of relaxation training (type 1 was not studied), and
whether exercise therapy was given to the control group or not had no or only a slight effect
on this result. Even the four studies examining the occurrence of cardiac death within two
years showed a comparable result (odds ratio 0.29; 95% CI: 0.12-0.70; P<0.01).
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J.J. van Dixhoorn, Md PhD
F van Blankenheymstraat 10
3817 AG Amersfoort
The Netherlands
+31 33 4635292
e-mail: dixhoorn@euronet.nl
website: www.euronet.nl/users/dixhoorn