Effects of Benson's relaxation technique on sleep quality of patients with cardiovascular diseases: A narrative review

Article Type : Reviews


1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Islamic Azad University, Urmia, Iran

2 Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

3 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 Department of Medicine, Guilan University of Medical Sciences, Rasht, Iran

5 Department of Medicine, Tehran University of Medical Sciences, Tehran, Iran


Cardiovascular disease (CVD) counts at the forefront of death causes and has become a significant global issue due to its high prevalence rate. The Benson's relaxation technique (BRT) can benefit general health conditions in CVD patients. However, there is still controversy over the efficacy of BRT on sleep quality improvement. This narrative review aims to summarize the evaluation of the effects of BRT on sleep quality of patients with CVD. This narrative review was conducted via online databases, such as PubMed, Web of Science, Embase, and Scopus and Google Scholar search engine. Published articles were included in the search from the first until September 10, 2023. Additionally, the bibliographies of pertinent publications were looked up. These databases were searched using a strategy string that combined free text keywords with Medical Subject Heading phrases. The search terms for "cardiovascular disease" with synonyms AND "quality of sleep" with synonyms were combined with search terms for "Benson's relaxation technique". English-language published articles that matched the inclusion criteria were evaluated and included. The study results showed BRT can increase the sleep quality of patients in terms of mental sleep quality, sleep onset delay, useful sleep, sleep disorders, and overall sleep quality. To further increase the sleep of patients after open heart surgery, the BRT is recommended as a complementary method in addition to drug therapy. BRT increases sleep quality in patients with CVD. Therefore, this method can be used as a suitable complementary treatment to improve the sleep quality of these patients.


1 Introduction

Cardiovascular disease (CVD) counts at the forefront of death causes and has become a significant global issue due to its high prevalence rate [1]. Despite its mortality, its morbidity is also essential as it can impact various general health conditions, including sleep hygiene [2]. Sleep is a fundamental requirement in living beings and maintains health conditions and physiological recovery of the body [3]. Sleep disorders are highly prevalent among CVD patients [2]. Several studies demonstrated a meaningful correlation between sleep quality and cardiovascular disorders and investigated that sleep disorders can simultaneously count as both the result and cause of CVD [4-6]. Sleep deprivation and poor sleep quality are associated with increased sympathetic nervous system activity, which can induce tachycardia, elevated blood pressure, and subsequent increased cardiac workload, leading to ischemia and deterioration of general health conditions in patients with CVD [7].

On the other hand, the nature of the CVD can also induce the development of sleep disorders as these patients suffer from various disease-related issues, such as the psychological stress of having severe illness and other complications [4]. Consequently, sleep quality in these patients is a significant concern [7]. The most frequent medical approach in insomnia (the most common sleep disorder amongst patients with CVD) has been pharmacological agents [8]. Implementing complementary methods such as relaxation seems essential since pharmacological agents are not usually cost-effective and may have serious adverse effects [9]. Benson relaxation technique (BRT) is one of the most well-known methods, which was first introduced in 1975 by Herbert Benson, a Harvard physician who declared that BRT could evoke relaxation response by diminishing the activity of the autonomic nervous system [8]. This technique invokes both faith factors and relaxation response techniques [10]. It is also one of the most well-known techniques that can be learned and implemented quickly and benefit patients with CVD considerably [11]. It can reduce cardiac workload and demand by decreasing muscle contraction, pulse, and respiratory rates [9]. According to Benson, BRT yields relaxation response by covering the following steps: First, it requires sitting quietly in a comfortable position with eyes closed and inspiration through the nose slowly.

This is followed by relaxing all muscles deeply and keeping them continuously relaxed while scanning the body for any areas of tension that can be settled further. Repeating a single positive word simultaneously during exhalation can help boost one's attention. After at least 5 minutes, one can start thinking regular thoughts and gradually open their eyes. Benson recommended doing this for 10 minutes in the morning to elicit the healing benefits of being relaxed [12]. Several studies investigated meaningful relationship between application of BRT and reducing blood pressure [13]. The speculated rationale behind this technique is that inflammation forms in the respiratory system during a long period of inspiration, stimulating lung stretch receptors to produce a signal. Subsequent signals will be sent to the medulla oblongata, which will forward information regarding increased blood flow to the brainstem. Consequently, parasympathetic nerves' activity rises, and sympathetic nerves' activity diminishes. Resultant elevated blood pressure and, the initial lung inflammation reduces the heart rate and bring about vasodilation in several blood vessels. According to the mentioned mechanism, the BRT can benefit general health conditions in CVD patients [10]. However, there is still controversy over the efficacy of BRT on sleep quality improvement. Our narrative review aims to summarize the evaluation of the BRT's effectiveness on sleep quality amongst patients with CVD.


2 Methods

This narrative review was conducted via online databases, such as PubMed, Web of Science, Embase, and Scopus and Google Scholar search engine. Published articles were included in the search from the first until September 10, 2023. Additionally, the bibliographies of pertinent publications were looked up. These databases were searched using a strategy string that combined free text keywords with Medical Subject Heading phrases. The search terms for "cardiovascular disease" with synonyms and "quality of sleep" with synonyms were combined with search terms for "Benson's relaxation technique". The final syntax of the statement is (("Cardiovascular Disease*" OR "Major Adverse Cardiac Event*" OR "Cardiac Event*" OR "Adverse Cardiac Event*" OR "Disease* Cardiovascular" OR "Event* Cardiac" OR "Cardiac Event* Adverse") AND ("Benson Relaxation Technique" OR "Benson's Relaxation Therapy" OR "BRT" OR "Benson* Relaxation" OR "BR" OR "Benson's Relaxation Response" OR "BRR" OR "Benson's Relaxation Technique" OR "Relaxation Therapy" OR "RT" OR "Benson Relaxation Application" OR "Bens App" OR "Relaxation Technique" OR "Benson's Relaxation Response") AND ("Quality of Sleep" OR "Sleep Quality*" OR "Quality* Sleep")). A filter was applied for the English language and article publication year up to September 10, 2023. Reproducible search strings for all three databases are appended. All records identified in the database search were screened for eligibility in two steps: title/abstract and full text. English-language publications that demonstrated the connection between the terms "cardiovascular diseases", "Benson relaxation technique", and "quality of sleep" met the inclusion criteria. The search was performed by two authors independently. The investigators excluded all articles for which full texts were unavailable and those in a language other than English. After removing duplicate studies, the titles, abstracts, and full texts of the eligible articles were evaluated by two researchers independently. After exclusions, the remaining eligible papers underwent thorough full-text reviews, and pertinent information was incorporated into our narrative review. The EndNote X8 software were used to manage the data. A total of 118 articles were obtained initially using database searches. Then, the article titles and abstracts were screened to eliminate duplicate studies, excluding 43 articles. Finally, the full texts of selected articles were reviewed, and 26 eligible journal articles were finally included in the review, from which data were extracted for analysis. Lists of references from qualified research were examined to provide the most thorough search possible. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline was used to document the automatic and manual collection, screening, and selection of articles.


3 Results

3.1 CVDs

CVDs are the most common causes of mortality and morbidity worldwide [14]. The most common factors that contribute to the occurrence and development of these diseases are blood pressure, diabetes mellitus, dyslipidemia, obesity, smoking, social isolation, and depression are brought on by these diseases [15, 16]. They interfere with the patient's lifestyle, daily activities, family relationships, and social interactions. The disease's effects may also prevent the patient from getting the best possible sleep [17]. For instance, people with heart failure have trouble sleeping [18].


3.2 Sleep quality in CVD patients

Sleep is a physiological aspect of human life essential to maintaining health and well-being. It is a natural, reversible state mainly controlled by neurobiological processes [19, 20]. The cessation of motor activity and decreased awareness of external stimuli are related to sleep [20]. Numerous variables, including diet [21], exercise [22], genetics [23], and environmental [24], influence sleep quality. Poor sleep affects both physical performance and life quality [25]. Numerous illnesses, such as cancer, depressive disorders, and CVDs, are linked to sleep disorders at the beginning and end of their course [26, 27]. Lack of sleep raises heart rate and blood pressure. Which ultimately presents the danger of a heart attack [7]. According to a systematic review and meta-analysis, short and long sleep durations predict cardiovascular outcomes and are linked to an increased risk of coronary heart disease [28]. A U-shaped relationship between sleep duration and CVD risk was also noted by Yin et al., [29] and inadequate or excessive sleep duration is strongly linked to an increased CVD risk.


3.3 Effects of BRT on sleep quality of patients with CVD

Relaxation methods are complementary alternative therapies, also known as interventions for anxiety reduction. People's breathing, heart rate, blood pressure, and muscle tension all drop when they are relaxed, which in turn causes them to pay less attention to external stimuli [30]. Nursing interventions like relaxation are frequently used as supplemental and occasionally alternative therapies. It was developed to help patients sleep better [31, 32]. BRT, progressive muscle relaxation, relaxation with mental imagery, meditation, massage, hypnosis, breathing exercises, yoga, and music therapy are standard relaxation techniques [33, 34]. The BRT is appealing because it is simple to understand and impart to others. Pulse, breathing, blood pressure, and heart workload are all decreased using this technique [35]. Additionally, this method can help systolic heart failure patients sleep better [8]. BRT can enhance patients' sleep quality in subjective sleep quality, sleep onset delay, beneficial sleep, sleep disorders, and overall sleep quality, according to the findings of research by Bagheri et al., To further enhance patients' sleep after open heart surgery, the BRT is recommended as a complementary method in addition to drug therapy [36]. According to the study findings by Rakhshani et al., the BRT is a complementary therapy. In chronic heart patients, it can improve sleep quality [37].


4 Limitations

Our evaluation is based on our expertise in Iranian medical practice because we are here. We used a narrative review methodology that included two independent researchers' independent study selection and extraction, a highly sensitive search strategy in electronic databases, and a pre-specified process. Given the continuously evolving body of research on the efficacy of the BRT on sleep quality, a limitation of our narrative review is that the research being reviewed may have only recently been published and, as a result, still needs to be summarized in reviews. However, knowing the study's limitations is essential while evaluating the findings. We could not include all available studies since our search strategy and eligibility requirements did not aim for all studies reporting these outcomes. There might have been the omission of potentially relevant studies despite adopting a comprehensive search strategy. Only accessible databases were examined, including PubMed, Web of Science, Scopus, Google Scholar, and SID. This constraint may result in low power in analyses of the adverse impacts of the included therapies. Finally, we did not assign a grade to the degree of certainty of each piece of evidence confirming each outcome. This was minimized by hand-searching the references of the included articles, which was done in addition to our search strategy. The conclusion is limited to information gathered from research published in English-language databases since we only retrieved English-language publications. However, the level of evidence confidence could have been higher because there were so few studies in these fields.


5 Implications for clinical nursing practice

The current study's findings may pave the way for a thorough examination of the studied variables to determine the effects of the BRT on patients' cardiovascular quality of sleep. Given that our study was a pioneer in this field, it is recommended that nurses, doctors, and other medical staff use the findings to inform their policy decisions.


6 Recommendations for future research

A recommendation is made to undertake additional interventional and comparative research endeavors to investigate the effects of BRT on sleep quality of patients with CVD.


7 Conclusions

In summary, BRT increases sleep quality in patients with CVDs. Therefore, this method can be used as a suitable complementary treatment to improve the sleep quality of these patients.



Not applicable.


Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: HZ, ME, AMN, AK, MMP, ST, SMTO; Drafting the work or revising it critically for important intellectual content: HZ, ME, AMN, AK, MMP, ST, SMTO; Final approval of the version to be published: HZ, ME, AMN, AK, MMP, ST, SMTO; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: HZ, ME, AMN, AK, MMP, ST, SMTO.





Ethics approval and consent to participate

Not applicable.


Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.


Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.


Using artificial intelligent chatbots



This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).

© 2024 The Author(s).

  1. Gaziano T, Reddy KS, Paccaud F, Horton S. Cardiovascular Disease. In: Jamison D BJ, Measham A, Alleyne G, Cleason M, Evans D, Jha P, Mills A, Musgrove P, editors. Disease Control Priorities in Developing Countries. New York: Oxford University Press and The World Bank; 2006. p. 645–662.
  2. Grandner MA, Alfonso-Miller P, Fernandez-Mendoza J, Shetty S, Shenoy S, Combs D. Sleep: important considerations for the prevention of cardiovascular disease. Curr Opin Cardiol. 2016;31(5):551-565.
  3. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, van den Berg JF, Verschuren WM. Sleep duration and sleep quality in relation to 12-year cardiovascular disease incidence: the MORGEN study. Sleep. 2011;34(11):1487-1492.
  4. Babaii A, Adib-Hajbaghery M, Hajibagheri A. Effect of Using Eye Mask on Sleep Quality in Cardiac Patients: A Randomized Controlled Trial. Nurs Midwifery Stud. 2015;4(4):e28332.
  5. Tobaldini E, Costantino G, Solbiati M, Cogliati C, Kara T, Nobili L, et al. Sleep, sleep deprivation, autonomic nervous system and cardiovascular diseases. Neurosci Biobehav Rev. 2017;74(Pt B):321-329.
  6. Wolk R, Gami AS, Garcia-Touchard A, Somers VK. Sleep and cardiovascular disease. Curr Probl Cardiol. 2005;30(12):625-662.
  7. Lao XQ, Liu X, Deng HB, Chan TC, Ho KF, Wang F, et al. Sleep Quality, Sleep Duration, and the Risk of Coronary Heart Disease: A Prospective Cohort Study With 60,586 Adults. J Clin Sleep Med. 2018;14(1):109-117.
  8. Bakavoly ME, Sajjadi M, Ghasemi R, Ajamzibad H. Comparison of the Impacts of Benson Relaxation Technique and Foot Reflexology Massage on Sleep Quality of Patients with Systolic Heart Failure: A Randomized Clinical Trial. Iran J Nurs Midwifery Res. 2023;28(4):448-454.
  9. Seifi L, Najafi Ghezeljeh T, Haghani H. The effects of benson relaxation technique and nature sound’s on anxiety in patients with heart failure. Nurs Midwifery J. 2017;15(2):147-158.
  10. Sutrisno S, Nursalam. The Effect of Benson and Autogenic Relaxation Therapy on Sleep Quality, Blood Pressure and Anxiety of Hypertension Patients. J Nurs Pract. 2023;6(2):214-220.
  11. Rambod M, Sharif F, Pourali-Mohammadi N, Pasyar N, Rafii F. Evaluation of the effect of Benson's relaxation technique on pain and quality of life of haemodialysis patients: a randomized controlled trial. Int J Nurs Stud. 2014;51(7):964-973.
  12. Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry. 1974;37(1):37-46.
  13. Ramadhani DY, Annisa DR, Suwandi PNS, Apriani U, Aini DQ, Dinata AZA. Blood Pressure Control with Benson Relaxation Technique in Hypertensive Patients. J Vocat Nurs. 2023;4(1):63-68.
  14. Devries S, Dalen J. Integrative cardiology. New York, NY: Oxford University Press; 2010.
  15. Garcia M, Mulvagh SL, Merz CN, Buring JE, Manson JE. Cardiovascular Disease in Women: Clinical Perspectives. Circ Res. 2016;118(8):1273-1293.
  16. Keto J, Ventola H, Jokelainen J, Linden K, Keinänen-Kiukaanniemi S, Timonen M, et al. Cardiovascular disease risk factors in relation to smoking behaviour and history: a population-based cohort study. Open Heart. 2016;3(2):e000358.
  17. Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, et al. Heart failure: preventing disease and death worldwide. ESC Heart Fail. 2014;1(1):4-25.
  18. Türoff A, Thiem U, Fox H, Spießhöfer J, Bitter T, Tamisier R, et al. Sleep duration and quality in heart failure patients. Sleep Breath. 2017;21(4):919-927.
  19. Irwin MR. Why sleep is important for health: a psychoneuroimmunology perspective. Annu Rev Psychol. 2015;66:143-172.
  20. Krueger JM, Frank MG, Wisor JP, Roy S. Sleep function: Toward elucidating an enigma. Sleep Med Rev. 2016;28:46-54.
  21. Saidi O, Rochette E, Doré É, Maso F, Raoux J, Andrieux F, et al. Randomized Double-Blind Controlled Trial on the Effect of Proteins with Different Tryptophan/Large Neutral Amino Acid Ratios on Sleep in Adolescents: The PROTMORPHEUS Study. Nutrients. 2020;12(6):1885.
  22. Murawski B, Plotnikoff RC, Rayward AT, Vandelanotte C, Brown WJ, Duncan MJ. Randomised controlled trial using a theory-based m-health intervention to improve physical activity and sleep health in adults: the Synergy Study protocol. BMJ Open. 2018;8(2):e018997.
  23. Dashti HS, Jones SE, Wood AR, Lane JM, van Hees VT, Wang H, et al. Genome-wide association study identifies genetic loci for self-reported habitual sleep duration supported by accelerometer-derived estimates. Nat Commun. 2019;10(1):1100.
  24. Ageborg Morsing J, Smith MG, Ögren M, Thorsson P, Pedersen E, Forssén J, et al. Wind Turbine Noise and Sleep: Pilot Studies on the Influence of Noise Characteristics. Int J Environ Res Public Health. 2018;15(11):2573.
  25. Al-Rawashdeh SY, Lennie TA, Chung ML. The Association of Sleep Disturbances With Quality of Life in Heart Failure Patient-Caregiver Dyads. West J Nurs Res. 2017;39(4):492-506.
  26. Kwok CS, Kontopantelis E, Kuligowski G, Gray M, Muhyaldeen A, Gale CP, et al. Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis. J Am Heart Assoc. 2018;7(15):e008552.
  27. Zhai L, Zhang H, Zhang D. Sleep duration and depression among adults: A meta‐analysis of prospective studies. Depress Anxiety. 2015;32(9):664-670.
  28. Cappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J. 2011;32(12):1484-1492.
  29. Yin J, Jin X, Shan Z, Li S, Huang H, Li P, et al. Relationship of Sleep Duration With All-Cause Mortality and Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies. J Am Heart Assoc. 2017;6(9):e005947.
  30. Belchamber C. Payne's Handbook of Relaxation Techniques E-Book: A Practical Handbook for the Health Care Professional: Elsevier Health Sciences; 2021.
  31. Volpato E, Banfi P, Rogers SM, Pagnini F. Relaxation Techniques for People with Chronic Obstructive Pulmonary Disease: A Systematic Review and a Meta-Analysis. Evid Based Complement Alternat Med. 2015;2015:628365.
  32. Xie LQ, Deng YL, Zhang JP, Richmond CJ, Tang Y, Zhou J. Effects of Progressive Muscle Relaxation Intervention in Extremity Fracture Surgery Patients. West J Nurs Res. 2016;38(2):155-168.
  33. Nooner AK, Dwyer K, DeShea L, Yeo TP. Using Relaxation and Guided Imagery to Address Pain, Fatigue, and Sleep Disturbances: A Pilot Study. Clin J Oncol Nurs. 2016;20(5):547-552.
  34. Seyed Ahmadi Nejad FS, Golmakani N, Asghari Pour N, Shakeri MT. Effect of progressive muscle relaxation on depression, anxiety, and stress of primigravid women. Evid Based Care. 2015;5(1):67-76.
  35. Teimouri F, Pishgooie SA, Malmir M, Rajai N. The effect of Benson relaxation on physiological criteria in patients undergoing coronary artery bypass graft surgery. Complement Med J. 2019;9(3):3812-3823.
  36. Bagheri H, Moradi-Mohammadi F, Khosravi A, Ameri M, Khajeh M, Chan SW, et al. Effect of Benson and progressive muscle relaxation techniques on sleep quality after coronary artery bypass graft: A randomized controlled trial. Complement Ther Med. 2021;63:102784.
  37. Rakhshani M, Akbarzadeh R, Koshan M, Hashemi Nik SM. Effect of the benson relaxation technique on quality of sleep in patients with chronic heart disease. J Sabzevar Univ Med Sci. 2014;21(3):492-450.
Volume 2, Issue 2
April 2024
Pages 89-93
  • Receive Date: 01 November 2023
  • Revise Date: 27 November 2023
  • Accept Date: 30 November 2023
  • First Publish Date: 01 December 2023
  • Publish Date: 01 April 2024