EFFECT OF DIFFERENT RELAXATION TECHNIQUES ON DEPRESSION IN ADOLESCENT GIRLS: A RANDOMIZED CLINICAL TRIAL

EFFECT OF DIFFERENT RELAXATION
TECHNIQUES ON DEPRESSION IN ADOLESCENT
GIRLS: A RANDOMIZED CLINICAL TRIAL
Khadiga S. Abdelaziz1 ; Afaf M. Botla 2 ; Aya M .Hassan3
and Mohamed Fawzy4
1Professor of Physical Therapy for Women's Health, Faculty of Physical Therapy, Cairo
University
2Lecturer of Physical Therapy for Women's Health, Faculty of Physical Therapy, Cairo
University,
3B. Sc. of Physical Therapy for Women's Health, Faculty of Physical Therapy,
CairoUniversity.
4 Professor of Gynecology and Obstetrics in Om El Masryeen Hospital.
Key Words: Different Relaxation Techniques - Adolescent Depression -
Depression Anxiety Stress Scale-21.
ABSTRACT
Background: depression in adolescents is recognized as a serious
psychiatric illness with extensive acute and chronic morbidity and
mortality. Relaxation techniques considered as a tool for managing
anxiety and depression by activation of the parasympathetic nervous
system and diverting attention from negative thoughts, thereby helping to
relieve anxiety, stress and tension in the body that lead to depression.
Purpose of this study: To investigate the effect of effect of different
relaxation techniques on depression in adolescent girls. Subjects and
methods: This study was carried upon 40 adolescent girls suffering from
mild to moderate depression. Their age ranged from 15 to 20 years old
and their BMI were not exceeded 30 kg/m². They were selected from
Damietta middle and high schools. The participants were randomly
distributed in two groups equal in number. Group (A) consisted of 20
girls who received progressive muscle relaxation and deep breathing
exercises for 3 month 3 sessions / week, 30 minutes /session. Group (B)
consisted of 20 girls who received yoga and deep breathing exercises for
3 month 3 sessions / week, 30 minutes /session. All females in both
groups (A and B) were assessed pre- and post-treatment by using,
Depression Anxiety Stress Scale 21. Results: The results revealed that
there was statistically significant reduction in both groups (A & B) in
mean value of DASS-21 (total score) with p-value was (p=0.00001), the
results also revealed that there was a non- statistically significant
difference between two groups in mean value of DASS-21 (total score) in
both pre-treatment and post-treatment with p-value were (P=0.116) &
Egypt. J. of Appl. Sci., 35(12) 2020 151-160
(p=692) respectively. Conclusion: progressive muscle relaxation
technique and yoga could be used as an effective treatment on
depression in adolescent girls as it is safe and non-pharmacological
therapeutic technique.
INTRODUCTION
Depression, is defined as a major public health problem that has a
substantial impact on individuals and on society. Depressive disorders
are common in the general population. Depression is characterized by
behavioral, cognitive, and emotional features. Depressed patients often
exhibit signs of dysphoric mood, loss of interest in normally enjoyable
pursuits, self-neglect and social withdrawal, poor appetite or overeating,
insomnia or hypersomnia, fatigue or loss of energy, low self-esteem, poor
concentration or difficulty making decisions, and feelings of
hopelessness [1].
Adolescent depression is a serious public health. Depression in
adolescents is under-recognized and under treated despite its poor longterm
outcomes, including risk for suicide [2]. Depression in adolescence
can affect all areas of development, particularly social and educational,
which may then confer further disadvantage on the depressed adolescent.
Although the gender balance is equal in childhood, depression also
becomes more common in girls than boys by adolescence [3].
Depression rates increase substantially during adolescence, and by
age 18, an estimated 15% of teens will have experienced at least one
episode of major depressive disorder (MDD), with females twice as
likely as males to have developed MDD [4]. Depression leads to serious
social and educational impairments and an increased rate of smoking,
substance misuse, and obesity. It is important to recognize and treat this
disorder. Depression in adolescents is a major risk factor for suicide, the
second-to-third leading cause of death in this age group with more than
half of adolescent suicide victims reported to have a depressive disorder
at time of death [5].
Physiotherapy may be indicated to help girls with depression as it
addresses human movement, function, physical activity and exercise in
individual and group therapeutic settings. Additionally, it connects the
physical and mental health needs of humans at a low cost and nonpharmacological
alternative. For such, there are several extensive ranges
of physical approaches such as physical activity, exercise, movement,
relaxation techniques and body and movement awareness. These
152 Egypt. J. of Appl. Sci., 35(12) 2020
approaches are aimed at symptom relief, the enhancement of self -
confidence and the improvement of quality of life [6].
Relaxation techniques used in a wide scope of disorders. They are
used for managing anxiety and depression [7].
Progressive muscle relaxation (PMR) is effective in reducing
negative states of anxiety and stress that lead to depression by increasing
positive feeling of relaxation. PMR designed to induce feelings of deep
relaxation by systematically tensing and relaxing 16 muscle groups and
by learning to discriminate between the sensations of tension and
relaxation. PMR produce both cognitive and physiological relaxation.
Participants instructed to focus on sensations associated with release of
muscle tension and feelings of comfort [8].
Deep breathing exercise is a simple technique that can be practiced
by almost anyone. Deep breathing exercises with prolonged exhalation
with a 1:2 ratio inhalations and exhalations, stimulate the
parasympathetic nervous system and diverting attention from negative
thoughts and help to relieve anxiety, stress and tension in the body. It
may be practiced sitting up or lying down. Breathing techniques can help
to calm the nervous system very quickly; teens can use these techniques
to relax before exams, help with sleep, and calm themselves down during
emotional upheaval [9].
Yoga is a comprehensive system of practices for physical and
psychological health and well-being that consist of four techniques:
physical postures/exercises to promote strength and flexibility, breathing
exercises to enhance respiratory functioning, relaxation strategies that
focus on reducing tension and stress, and meditation/ mindfulness
practices to enhance mind–body awareness and improve attention and
emotion regulation skills [10]. Yoga practices reduce allostatic load in
stress response systems. Stress induces imbalance of the autonomic
nervous system (ANS) with decreased parasympathetic nervous system
(PNS) and increased sympathetic nervous system(SNS) activity,
underactivity of the inhibitory neurotransmitter, gamma amino-butyric
acid (GABA) and increased allostatic load. Yoga practices correct
underactivity of the PNS and GABA system through stimulation of the
vagal nerves and reduce allostatic load resulting in relief symptoms of
stress and depression [11].
Consequently, the purpose of this randomized controlled study was
to investigate the effect of different relaxation techniques on depression
in adolescent girls.
Egypt. J. of Appl. Sci., 35(12) 2020 153
MATERIALS AND METHODS
Design of study:
Two groups pre- test and post- test experimental design. The
participants were randomly distributed in two groups equal in number.
group (A): This group consisted of 20 girls with mild to moderate
depression, they received progressive muscle relaxation techniques, in
addition to diaphragmatic breathing exercises. group (B): This group
consisted of 20 girls with mild to moderate depression, they received yoga,
in addition to diaphragmatic breathing exercises.
Participant:
This study was carried upon forty adolescent girls with mild to
moderate depression. They were selected randomly from the high and
middle school in Damietta, on the following criteria: (1) their ages ranged
from 15 to 20 years old; (2) their body mass index (BMI) was not exceeding
30 kg/m²; (3) they were suffering from mild to moderate depression; (4) all
participants were conscious and free from any medical disease (detailed
medical history was obtained to screen for other pathological conditions).
Measurement Procedures:
All participants were given a full explanation for the evaluation and
treatment procedures and informed consent form was signed by each
participant. All information including name, age, address, occupation was
recorded at a recording data sheet.
The Depression Anxiety Stress Scale - 21 (DASS-21): Severity of
depression was assessed through DASS-21 for each female in both groups A
& B before and after treatment. It has been developed as a measure of
anxiety and depression. DASS-21 is a measure of three distinct negative
affects: depression, stress, and anxiety. It is a 4-point Likert scale ranging
from 0 (Did not apply to me at all) to 3 (Applied to me very much, or most
of the time) which indicate the extent the respondents experience each of the
symptoms [12].
Treatment procedures:
Group A:
This group consisted of 20 females, all participants in group (A)
received progressive muscle relaxation training for 30 min. / session, three
sessions per week for three months. The patients were instructed to contract
and relax the 16 muscle groups while sitting on a chair with back supported
as follow: first, force tension with the muscles, and concentrate on the
feeling of tension; try to hold this feeling of tension for 3 to 5 seconds, and
then relax for 10 to 15 seconds. The patient should experience the sensation
of muscle relaxation. patients were taught to relax muscles of foot, leg, hip
and waist, chest, arm, shoulder, and face. Patients were taught to relax
muscles of foot, leg, hip and waist, chest, arm, shoulder, and face. In
addition to diaphragmatic breathing exercises were done in lying down,
154 Egypt. J. of Appl. Sci., 35(12) 2020
sitting position or any other comfortable position. In the supine position one
hands placed on the epigastric area and the other hand placed on the chest,
they were asked to breathe in air through their nose and bulge the abdomen
outward as far as Possible, hold their breath for a few seconds, and then
exhale slowly through their mouth. They were instructed to perform
breathing exercises 3 times/ day or when experience anxious or stressful
situation during a day as 3 breaths per time and not exceed 4 breathes per
time to prevent hyperventilation
Study group (Group B):
This group consisted of 20 females, they treated with yoga in addition
to breathing exercise as described for group A.
All participants in group (B) practice yoga for 45 min. / session, three
sessions per week for three months. A typical yoga session consisted of the
following segments: breathing exercises (5 min), warm-ups (5 min), yoga
poses (30 min), and relaxation (5 min). Commonly practiced poses included
Sukhasna, cat cow pose, mountain pose, tree pose, five-pointed star, one
legged wind removing and Warrior II Pose.
Data analysis: Statistical analysis was conducted using SPSS for windows,
version 23 (SPSS, Inc., Chicago, IL). The data has been collected before and
after three months of treatment for the two groups through: descriptive
statistics: the mean and standard deviation and inferential statistics: by using
t-test (test of difference).
RESULTS
The current study was conducted on 40 participants. They were
assigned into two equal groups. Group (A) consisted of 20 participants
who received progressive muscle relaxation training in addition to
breathing exercises. Group (B) consisted of 20 participants who practice
yoga in addition to breathing exercises. There were no significant
differences (p>0.05) in the mean values of age, body mass, height and
BMI between both tested groups (Table1).
Table (1): Physical characteristics of participants in both groups
(A&B).
Items Group A Group B Comparison
S
Me
an ± SD
Mean ± SD MD t-value Pvalue
Age (years) 17.8 ± 1.36 18.35 ± 1.34 -0.55 -1.284 0.207 NS
Body mass (Kg) 60.9 ± 11.52 61.95 ± 9.86 -1.05 -0.31 0.759 NS
Height (cm) 161.25 ± 4.86 164.1 ± 6.18 -2.85 -1.62 0.113 NS
BMI (kg/m2) 23.4 ± 3.95 22.89 ± 3.13 0.515 0.457 0.651 NS
*SD: standard deviation, MD: Mean Difference P: probability, S: significance,
NS: non-significant.
As presented in table (2), Multiple pairwise comparison tests
revealed that there was significant reduction of DASS-21 (total score) at
Egypt. J. of Appl. Sci., 35(12) 2020 155
post treatment in compare to pre-treatment in group A with (P-value
=0.00001). Considering the effect of the tested group on DASS-21 (total
score).
Table (2): Mean ±SD and p values of DASS-21 (total score) pre and
post-test at group A.
DASS-21 (total score)
Pre-treatment
Mean & SD
Post-treatment
Mean & SD
t- value
P- value
Sig.
Group (A) 25.775 ± 4.91 5.6 ± 1.66 24.91 0.00001 S
: Mean P-Value: Probability value SD: Standard Deviation t-value: paired
t-test S: significant
As presented in table (3), Multiple pairwise comparison tests
revealed that there was significant difference of DASS-21 (total score) at
post treatment in compare to pre-treatment (P-value =0.00001) in group
(B). Considering the effect of the tested group on DASS-21 (total score).
Table (3): Mean ±SD and p values of DASS-21 (total score) pre and
post-test at group B.
DASS-21 (total score)
Pre-treatment
Mean & SD
Post-treatment
Mean & SD
t- value
P- value
Sig.
Group (B) 27.95 ± 3.64 5.4 ± 1.5 31.32 0.00001 S
: Mean P-Value: Probability value SD: Standard Deviation t-value: paired
t-test S: significant
As presented in table (4), The results revealed that there was a nonstatistically
significant difference between the two groups in mean value
of DASS-21 (total score) in both pre-treatment and post-treatment with
p-value were (P=0.116) & (p=692) respectively.
Table (4) Mean ±SD and p values of DASS-21 (total score) pre and
post-test in both groups
DASS-21 (total
score)
Group (A) Group (B) MD t- value P- value Sig.
Pre-treatment 25.77 ± 4.91 27.95 ± 3.64 -2.20 -1.606 0.116 NS
Post-treatment 5.6 ± 1.66 5.4 ± 1.5 0.2 0.399 0.692 NS
: Mean P-Value: Probability value SD: Standard Deviation t-value: paired
t-test S: significant
DISCUSSION
This study was conducted to determine the effect of effect of
different relaxation techniques on depression in adolescent girls. This
study demonstrates that the study group A which received progressive
muscle relaxation techniques in addition to breathing exercises and the
study group B which practiced yoga in addition to breathing exercises
showed improvement in severity of depression.
156 Egypt. J. of Appl. Sci., 35(12) 2020
Regarding the effect of relaxation techniques, the results of this
study were in agreement with Merakou et al [7] who indicated the
positive effect of the PMR technique on anxiety and stress reduction as
well as providing relief from symptoms of depression and depression
related behaviors
Vázquez, et al. [13] indicated that prevention of depression in
university students can be done by using relaxation techniques which are
a simple psychological treatment that can be administered after brief
training especially muscle relaxation training which has been reported to
reduce depressive symptoms.
The results of this study were agreed with Hauenstein, who found
that using progressive muscle relaxation reduce anxiety and decrease
depressive symptoms in adolescents [14].
Liao et al. [15] found that after using PMRT, patients who suffer
from mild and moderate depression showed improvement in depression
symptoms.
Regarding the mechanism of PMR in improving severity of
depression it is based
on the finding that anxiety states are usually accompanied by
increased muscle tension, while in resting states the muscles are relaxed
[7].
Regarding the effect of yoga in improving severity of depression.
The results of our study agreed with de Manincor et al. [16] who found
that yoga practice reduce symptoms of depression and anxiety, and
associated with increase in positive emotions and well-being for a person
with mild or moderate depression.
The results of this study come in agreement with Gwalani, and
Perumal [17] who indicated that yoga should be implemented at young
age so it can help to reduce stress, balance emotions, improve mood and
develop physical fitness. Yoga builds self-esteem and boosts selfconfidence
in children and adults. It reduces absence and violence in
school children. Encourages love and self-care, and promotes
mindfulness. Also improves the quality of sleep. Boosts immunity and
improves physical appearance.
Regarding the mechanism of yoga in improving severity of
depression Kumar, [18] found that. Yoga not only direct or redirect
physical action and behaviors but it stimulates various glands, muscles
and parts of the body related to emotional reactivity or states of mind.
The nervous system can be activated or soothed through asana, breath
and the metaphors of the poses. So that yoga could help the teenagers to
get healthy, physically as well as mentally.
Egypt. J. of Appl. Sci., 35(12) 2020 157
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تأثير وسائل الاسترخاء المختمفة عمى الاکتئاب لدى الم ا رهقين
خديجة سيد عبد العزيز*، عفاف محمد محمود بتمة ** ، آية محمد أبو الحسن ***
و محمد فوزي أبو العينين****
* أستاذ بقسم صحة الم أ رة، کمية العلاج الطبيعي ، جامعة القاىرة
**مدرس العلاج الطبيعي، قسم صحة الم أ رة ، کمية العلاج الطبيعي، جامعة القاىرة
* **باحث علاج طبيعي بقسم صحة الم أ رة .جامعو القاىره
****استشاري و رئيس قسم ام ا رض النساء و التوليد مستشفى ام المصريين العام
الهدف: أجريت ىذه الد ا رسة لمعرفة تأثير وسائل الاسترخاء المختمفة عمى الاکتئاب لدى
الم ا رىقين. الطريقة: مجموعو من 84 شخصًا شارکوا في ىذه الد ا رسة تت ا روح أعمارىم بين 59
Egypt. J. of Appl. Sci., 35(12) 2020 159
و 64 عامًا خضعوا لتمارين الاسترخاء التدريجى لمعضلات و تمارين التنفس في )المجموعة
التجريبية 64 شخصا( و تمارين اليوجا و النفس في )مجموعة الجريبية شخصا 64 (. تم
تقييميم قبل العلاج وبعد 7 شيور باستخدام مقياس الاکتئاب والقمق و التوتر . النتائج: أظيرت
النتائج انخفاضًا معنويًا في کل من المجموعتين التجريبيتين في القيمة الکمية لمقياس الاکتئاب و
القمق و التوتر. الاستنتاج: وسائل الاسترخاء المختمفة يمکن انا يکون ليا تأثير عمى علاج
الاکتئاب لدى الم ا رىقين من البنات.
الکممات الداله: وسائل الاسترخاء المختمفة ،الم ا رىقين ، اکتئاب، مقياس الاکتئاب والقمق و
التوتر.
160 Egypt. J. of Appl. Sci., 35(12) 2020