Zhang YM, Sun LY, Chi HT. Hyperbaric oxygen with muscle relaxation for sleep quality anxiety and depression in post-gastric cancer sleep disorders. World J Psychiatry 2026; 16(9): 122884 [DOI: 10.5498/wjp.122884]
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Zhang YM, Sun LY, Chi HT. Hyperbaric oxygen with muscle relaxation for sleep quality anxiety and depression in post-gastric cancer sleep disorders. World J Psychiatry 2026; 16(9): 122884 [DOI: 10.5498/wjp.122884]
Author contributions: Sun LY and Chi HT contributed to data collection and paper writing; Zhang YM was responsible for funding application, reviewing and editing, communication coordination, ethical review, copyright and licensing, and follow-up. All authors contributed to research design and data analysis, and approved the final version to publish.
AI contribution statement: The translation software (DeepL) was used to improve the English.
Institutional review board statement: The research was reviewed and approved by the Dalian University Affiliated Xinhua Hospital, No. 2026-037-01.
Informed consent statement: All research participants or their legal guardians provided written informed consent prior to study registration.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Received: May 19, 2026 Revised: June 18, 2026 Accepted: July 9, 2026 Published online: September 19, 2026 Processing time: 96 Days and 20.4 Hours
Abstract
BACKGROUND
Gastric cancer surgery frequently leads to postoperative sleep disorders, anxiety, and depression, which negatively impact recovery and quality of life. Conventional treatments offer limited benefits, and non-pharmacological approaches are gaining interest. While hyperbaric oxygen therapy improves tissue oxygenation and muscle relaxation reduces physiological arousal, their combined effect remains unexplored. Therefore, this study hypothesizes that hyperbaric oxygen therapy combined with muscle relaxation training can significantly improve sleep quality and reduce anxiety and depression in patients with postoperative sleep disorders.
AIM
To evaluate hyperbaric oxygen and muscle relaxation on sleep quality and anxiety/depression in postoperative sleep disorders after gastric cancer surgery.
METHODS
This retrospective cohort study included 96 patients with postoperative sleep disorders after gastric cancer surgery at Dalian University Affiliated Xinhua Hospital Outpatient Clinic (June 2023-June 2025). Based on actual treatment, 48 received hyperbaric oxygen therapy (2.0 atmospheres absolute, 60 minutes, 5 times/week for 4 weeks) plus progressive muscle relaxation (30 minutes daily, 5 times/week for 4 weeks) and 48 received conventional care alone. Outcomes: Pittsburgh Sleep Quality Index, Self-Rating Anxiety Scale, Self-Rating Depression Scale, serum cortisol, adverse events. Independent t tests and χ2 tests were used.
RESULTS
After therapy, both groups improved, but the combined intervention group showed significantly greater benefits: Pittsburgh Sleep Quality Index score [(4.25 ± 0.64):(7.35 ± 1.12), P < 0.001], Self-Rating Anxiety Scale [(31.50 ± 2.29):(41.72 ± 2.43), P < 0.001], Self-Rating Depression Scale [(32.48 ± 5.31):(43.34 ± 2.22), P < 0.001], and serum cortisol (271.20 ± 25.15 nmol/L:360.63 ± 20.52 nmol/L, P < 0.001). The observation group also had a higher proportion of shortened sleep latency (83.33%:58.33%, P = 0.007) and improved sleep efficiency (87.50%:62.50%, P = 0.005). Adverse event rate was lower in the observation group (8.33%:22.92%, P = 0.049). No serious adverse events occurred.
CONCLUSION
Hyperbaric oxygen combined with muscle relaxation training may improve sleep quality, reduce anxiety and depression, and lower serum cortisol more effectively than conventional treatment alone.
Core Tip: This retrospective cohort study of 96 patients with postoperative sleep disorders after gastric cancer surgery suggests that a four-week regimen of hyperbaric oxygen therapy combined with progressive muscle relaxation training may be associated with improved sleep quality (Pittsburgh Sleep Quality Index), reduced anxiety (Self-Rating Anxiety Scale) and depression (Self-Rating Depression Scale), and lower serum cortisol levels compared with conventional treatment alone. This mindbody integrative approach appears to be a potentially safe nonpharmacological rehabilitation strategy for gastric cancer survivors.
Citation: Zhang YM, Sun LY, Chi HT. Hyperbaric oxygen with muscle relaxation for sleep quality anxiety and depression in post-gastric cancer sleep disorders. World J Psychiatry 2026; 16(9): 122884
Gastric cancer is among the most frequent malignancies across the globe, diagnosed mainly in East Asia, Eastern and Central Europe and South America[1], with over 1 million new patients each year[2]. Radical resection is the main therapeutic option for gastric cancer and is used to eliminate the tumor and adjoining lymph nodes, promote long term survivability and control of the disease[3]. Sleep disorders are a common complication after surgery[4]. Researches have shown that the rate of sleep disturbances in people with terminal cancer is twice that of the average population[5]. This sleep disorder seriously impacts not only the patient’s life quality, but is also associated with increased fatigue, impaired immune function and poor prognosis[6]. Meanwhile, the prevalence of postoperative anxiety and depression is also significantly increased, which may reduce patients’ treatment compliance and even have a negative impact on clinical outcomes[7]. Therefore, it is of great clinical urgency to explore a comprehensive rehabilitation program that can improve the sleep and mood status of postoperative gastric cancer patients.
Hyperbaric oxygen therapy is commonly used to treat hypoxic diseases by administering 100% pure oxygen or high-concentration oxygen in a specialized hyperbaric chamber, either via a mask or through direct environmental exposure, under an atmospheric pressure exceeding 1.4 atmospheres absolute, which significantly enhances oxygen dissolution in plasma and improves tissue oxygenation[8]. Studies have shown that hyperbaric oxygen therapy can not only improve sleep quality but also effectively alleviate daytime hypersomnia in Parkinson’s disease patients, likely by enhancing cerebral oxygenation and modulating neural activity[9]. Furthermore, research indicates that muscle relaxation training, particularly when integrated with mindfulness meditation, constitutes an effective non-pharmacological intervention for patients on hemodialysis. This combined mind-body approach not only promotes significant improvements in subjective sleep quality by reducing physiological arousal and easing tension but also demonstrates efficacy in alleviating symptoms of anxiety and depression. The synergy of these techniques helps enhance overall psychological resilience and quality of life[10].
Therefore, through this, the purpose of this paper is to carry out a retrospective study to investigate the effect of hyperbaric oxygen treatment combined with muscle relaxation exercises in influencing sleep quality, as well as in relieving anxious and depressive moods among patients suffering from post-surgical sleep disorder following surgery for gastric cancer. Through the evaluation of psychological factors and sleep quality in patients undergoing the treatment, this study hopes to produce preliminary clinical evidence to support the design and improvement of a comprehensive rehabilitation program for these patients.
MATERIALS AND METHODS
General information
Retrospectively collection of patients with postoperative gastric cancer with sleep disorders seen at Dalian University Affiliated Xinhua Hospital Outpatient Clinic from June 2023 to June 2025. Inclusion criteria: (1) Pathologically confirmed gastric cancer and radical surgery; (2) Presence of postoperative sleep disturbance, with a Pittsburgh Sleep Quality Index (PSQI) score ≥ 7[11]; (3) Age 18-75 years; (4) Conscious and capable of finishing the scale evaluation; (5) Varying degrees of anxiety and depression; and (6) Complete clinical data, including treatment plan and relevant scale assessment data.
Exclusion criteria: (1) Severe failure of vital organs of heart, liver, and kidney; (2) Severe mentally illness (schizophrenia, bipolar disorder, etc.) or cognitive impairment; (3) Contraindications to hyperbaric oxygen therapy; and (4) Recent use of sedative-hypnotic drugs or anti-anxiety and antidepressant drugs. Based on the above criteria, a totally of 96 patients were included and divided into an observation group (receiving hyperbaric oxygen therapy combined with muscle relaxation training, n = 48) and a control group (receiving conventional treatment alone, n = 48) according to the actual treatment regimen received.
Treatment methods
Control group: In the control group, patients were subjected to standard care in an outpatient setting and health education for four weeks continuously. The particularities of the treatment involved: Close observation of vital signs, meticulous administration of analgesics, anti-infective measures, nutrition, hydration, and electrolyte balance as per the medical prescription; doctors provided standardized pain evaluation and management, counseling for mental well-being, and basic clinical care, including improvement of sleep conditions. The health education was performed using a one-to-one approach involving verbal instructions, providing illustrated leaflets, and demonstrating bedside practices to impart comprehensive knowledge to patients and their family members regarding postoperative rehabilitation skills for stomach cancer, significance of medications, healthy dietary advice, exercise restrictions, and good sleeping habits (e.g., maintaining a consistent schedule every day, creating a suitable sleeping atmosphere, and preventing too much excitement prior to bed). Patients attended an outpatient clinic once a week for four consecutive weeks, at which doctors monitored their recovery course, sleeping, and emotional state and responded to relevant queries during rehabilitation.
Observation group: Apart from the control group, another treatment method that was employed alongside hyperbaric oxygen therapy was muscle relaxation training, and it was administered for 4 weeks consecutively, with 5 treatments each week. (1) Hyperbaric oxygen therapy: The procedure involved the use of a multi-place air pressure chamber. The therapy pressure level was set at 0.2 MPa, pressurization time lasted 20 minutes, and stabilization time lasted 60 minutes. During the stabilization process, the patient wore a mask while taking in pure oxygen, and the decompression time took 20 minutes. The therapy was administered daily, with 5 treatments each week for 4 consecutive weeks. The outpatient therapy was provided daily for 5 treatments each week for 4 consecutive weeks. During the therapy, the patient’s vital signs were monitored[12]; and (2) Muscle relaxation training: Muscle relaxation training method was adopted and guided by professional rehabilitation therapists. Before training, helped the patient to take a comfortable lying position and kept the environment quiet. During training, guided the patient to start from the feet and perform tension-relaxation training on the muscles of the calves, thighs, abdomen, chest, back, upper limbs, neck, and face in sequence. Each muscle was tensed for 5 to 10 seconds to feel the soreness of the muscle tension, and then relaxed for 30 to 40 seconds to experience the comfort after muscle relaxation. During the training, guided the patient to focus on the tension and relaxation state of the muscles and eliminate distracting thoughts. Each outpatient session lasted 30 minutes, with 1 training session per day, followed by 5 training sessions per week for four consecutive weeks[13].
Observation indicators
(1) Sleep quality: The PSQI score was utilized to assess the quality of sleep before and after therapy in both groups. The score included seven constructs: Subjective quality of sleep, sleep latency, duration of sleep, sleep productivity, sleep disruption, utilization of sleep drugs, and daylight functional deficits. The score range for each category was 0 to 3, and the overall score was the summation of the seven categories (score range 0 to 21). A PSQI rating of ≥ 7 means that there is a sleep disturbance, and higher scores indicate poorer sleep quality[11]; (2) Anxiety symptoms: The Self-Rating Anxiety Scale (SAS) was evaluated. This scale had 20 entries, 1-4 points for each entry, for a sum score of 20 to 80 points. A higher score indicated more severe anxiety. A score of 50 indicated the existence of anxiety symptoms[14]; (3) Depressive symptoms: The Self-Rating Depression Scale (SDS) was utilized for evaluation, with 20 entries, 1-4 points for each entry, and a sum score of 20-80 points. The higher the score, the more severe the depressive mood. A score of 53 indicated the presence of depressive symptoms[15]; (4) Serum cortisol level detection: 5 mL of empty fasting venous blood was gathered from both groups before and after therapy. After centrifugation to separate the serum, the serum cortisol level was measured by enzyme-linked immunosorbent assay. This procedure was strictly in keeping with the instruction manual of the kit; and (5) Postoperative complications: The frequency of adverse effects during therapy of the two groups, including ear pressure discomfort, dizziness, nausea and emesis, and the rates of adverse changes were counted.
Statistical analysis
Data was implemented utilizing SPSS 21.0 software. Measured data were presented as mean ± SD, and intergroup was analyzed by independent samples t-test. Count data were shown as n (%), and intergroup was analyzed by the χ2 tests or Fisher’s exact tests. A P < 0.05 was regarded as the difference was clinically meaningful.
RESULTS
Comparison of baseline data between the two groups
Table 1 shows that there were no significant between-group differences in age (64.37 ± 4.03 years:65.48 ± 4.62 years, P = 0.213), gender distribution (P = 0.681), educational level (P = 0.238), or postoperative time (3.21 ± 0.94 months:3.14 ± 0.96 months, P = 0.727).
Table 1 Comparison of baseline data between the two groups, mean ± SD/n (%).
Comparison of sleep quality between the two groups
Table 2 indicates that before treatment, PSQI scores were similar between the control and observation groups [(18.28 ± 1.63):(18.13 ± 1.75), t = 0.435, P = 0.665]. After 4 weeks of treatment, the observation group had a significantly lower PSQI score (4.25 ± 0.64) compared with the control group (7.35 ± 1.12, t = 16.614, P < 0.001). Moreover, the observation group showed a higher proportion of patients with shortened sleep latency (83.33%:58.33%; χ2 = 7.261, P = 0.007) and improved sleep efficiency (87.50%:62.5%; χ2 = 8.000, P = 0.005).
Table 2 Comparison of sleep quality between the two groups, mean ± SD/n (%).
Comparison of anxiety and depression symptom scores between the two groups
Table 3 reveals that there were no significant differences in baseline SAS [(57.42 ± 2.30):(57.68 ± 2.35), P = 0.573] and SDS [(59.50 ± 3.02):(58.88 ± 3.08), P = 0.323] scores between the two groups. After treatment, the observation group achieved significantly lower SAS [(31.50 ± 2.29):(41.72 ± 2.43), P < 0.001] and SDS [(32.48 ± 5.31):(43.34 ± 2.22), P < 0.001] scores than the control group.
Table 3 Comparison of anxiety and depression symptom scores between the two groups, mean ± SD.
Comparison of serum cortisol levels between the two groups of patients
Table 4 shows that before treatment, serum cortisol levels were comparable between the two groups (475.20 ± 24.15 nmol/L:483.52 ± 19.91 nmol/L, t = -1.842, P = 0.069). After treatment, cortisol levels decreased in both groups, but the reduction was greater in the observation group, with a final level of 271.20 ± 25.15 nmol/L:360.63 ± 20.52 nmol/L in the control group (t = 19.086, P < 0.001).
Table 4 Comparison of serum cortisol levels between the two groups, mean ± SD.
Comparison of adverse reaction occurrences between the two groups of patients
Table 5 shows that the total incidence of adverse reactions was significantly lower in the observation group than in the control group (8.33%:22.91%, χ2 = 3.872, P = 0.049).
Table 5 Comparison of adverse reaction occurrences between the two groups, n (%).
Gastric cancer represents a major global public health issue, ranking fifth in terms of its prevalence and fourth in mortality from the disease worldwide. According to statistics, in 2020, one million new stomach cancer diagnoses are expected, causing 769000 deaths[16]. However, despite the significant advances achieved in medical oncology over the last decades, including the introduction of targeted treatments and immunotherapy, which has revolutionized the field of oncology, surgery remains the key component of curative treatment of stomach cancer[17]. Sleep disorders represent one of the most frequently observed symptoms in cancer patients; according to co-morbidity studies, 60% of patients reported sleep disorder symptoms during their active treatment phase, while 59.7% experienced them three months or more following treatment[18]. The adverse impact of sleep disorders on cancer patient health is not restricted only to the quality of their lives but also affects their disease prognosis, as persistent sleep disorders are significantly associated with higher incidence of morbidity and mortality rates, as well as adverse reactions to tumor progression and cancer development in cancer patients[19]. On the other hand, stress responses to surgery can lead to a variety of post-surgical complications, including neuro-psychological manifestations, such as anxiety and depression[20]. Clinical research has revealed that older patients with sleep disorders have a significantly higher rate of postoperative anxiety and depression symptoms than age-matched patients with normal sleep[21]. Therefore, exploring comprehensive treatment options that can enhance the sleep and emotional status of patients after gastric cancer surgery is of great clinical significance for promoting their full recovery.
Hyperbaric oxygen therapy is a physiotherapy in which patients breathe 100% oxygen at an absolute pressure of 2.0 to 2.5 atmospheres, thereby significantly increasing the partial oxygen pressure in the bloodstream[22,23]. These mechanisms highlight the role of hyperbaric oxygen in promoting tumor rejuvenation, decreasing inhibition of inflammation, and combating infection in a variety of therapeutic clinical settings. In sleep disturbances, hyperbaric oxygen therapy may enhance sleep disorders by boosting brain oxygenation, decreasing inflation, and possibly destabilizing autonomic nervous function[24]. Researches had revealed that hyperbaric oxygen therapy has proven to be an effective therapy for sleep disorders in children suffering from cerebral palsy and mild traumatic brain injuries[25]. At the same time, hyperbaric oxygen therapy can promote wound healing and improve patients’ life quality and their anxieties and depressive levels[26]. Muscle relaxation training is a technique of continuous release exercises using[27]. This training allows the patient to recognize the transition from a tense to a relaxed state of the muscles, and achieves this via the strengthening of the muscles in different areas of the body, helping to optimize the mental state and regulate abnormalities in the patient’s physical function[28]. Muscle relaxation training has been proven to be applicable to conditions like cancer, pregnancy pain and insomnia, and for the purpose of improving patients’ life quality, pain, and insomnia[29,30].
Against this backdrop, this study retrospectively evaluated the therapeutic effect of hyperbaric oxygen therapy in combination with muscle relaxation training on patients with gastric cancer sleep disorders. The research data provided preliminary support for the feasibility and effectiveness of this combined regimen. Regarding sleep quantity, the PSQI total score in the observation group decreased to 4.25 ± 0.64 after therapy, remarkably less than the 7.35 ± 1.12 in the control group (P < 0.001). This variation was not only clinically meaningful but also clinically significant: The mean PSQI in the observation group had decreased to below the threshold for sleep disorders (7 points), whereas the mean values in the control group remained within the disorder range. Further analysis revealed that the percentage of patients in the observation group with both shortened sleep latency and improved sleep efficiency was considerably greater than those in the control group (both P < 0.05). This clearly indicated that the combined treatment not only helped patients fall asleep faster but also improved sleep continuity and the proportion of deep rest, which was crucial for restoring daytime energy and function. Regarding emotional state, the SAS and SDS scores were markedly reduced in both groups after therapy (both P < 0.001). However, the combined treatment group showed superior mood regulation. The SAS score in the observation group decreased from 57.68 ± 2.35 to 31.50 ± 2.29, and the SDS score decreased from 58.88 ± 3.08 to 32.48 ± 5.31, a significantly greater decrease than in the control group (both P < 0.001). Most importantly, the mean mood scores fell below the clinical threshold in the observation group after therapy (SAS < 50, SDS < 53), indicating that the combined treatment had a significant advantage in alleviating clinical-level anxiety and depression symptoms. Regarding physiological stress levels, the serum cortisol index introduced in this study provided objective biological evidence for the aforementioned clinical improvements. After therapy, the cortisol levels of both patients dropped markedly, but the decrease in the observation group (from 483.52 ± 19.91 nmol/L to 271.20 ± 25.15 nmol/L) was much greater than that in the control group (from 475.20 ± 24.15 nmol/L to 360.63 ± 20.52 nmol/L), and the intergroup variation was highly statistically meaningful (P < 0.001). As the core terminal hormone of the hypothalamus-pituitary-adrenal axis, a marked reduction in cortisol levels marked the relief of chronic physiological stress[31]. This change occurred simultaneously with the improvement of sleep and mood, suggesting that combined treatment may promoted postoperative physical and mental recovery in multiple dimensions by effectively regulating excessive stress response. Although the reduction in serum cortisol indicates relief of chronic physiological stress, the specific synergistic mechanism between hyperbaric oxygen therapy and muscle relaxation training cannot be determined from the current data. However, previous studies have offered suggestive evidence that each intervention may contribute to improved sleep and mood when combined. Hyperbaric oxygen therapy has been reported to reduce neuroinflammation by downregulating interleukin-6 and tumor necrosis factor-alpha, and to increase brain-derived neurotrophic factor expression in the central nervous system[32]. Concurrently, progressive muscle relaxation training may decrease sympathetic nervous system tone, may increase heart rate variability, and may reduce muscle tension, potentially facilitating sleep onset and lowering anxiety[33]. A plausible interaction can be hypothesized based on the existing literature: The improved central nervous system environment from hyperbaric oxygen therapy (e.g., reduced oxidative stress and enhanced neuroplasticity) might augment the patient’s capacity to learn and sustain relaxation techniques, while the peripheral relaxation response could further lower cortisol and inflammatory mediators, potentially creating a bidirectional brain-body loop. Direct evidence for this synergy is lacking due to the absence of singleintervention control groups. Future randomized controlled trials with factorial designs should include objective measures such as inflammatory cytokines, heart rate variability, and polysomnography to test these mechanistic pathways.
While this study confirmed the significant effects of hyperbaric oxygen therapy combined with muscle relaxation training, several limitations remain and require objective consideration. First, this study is a retrospective analysis rather than a randomized controlled trial; although baselines were comparable, it cannot completely avoid selection bias and confounding factors due to its non-randomized nature. Second, this study only included two groups: A “routine medical treatment” control group and a “combined regimen” observation group. The absence of necessary control groups, such as a “hyperbaric oxygen therapy alone” group or a “muscle relaxation training alone” group, represents a methodological flaw. With the current study design, it is impossible to determine whether the efficacy of the combined therapy results from a synergistic effect of the two interventions, is dominated by only one of them, or whether there is any interaction (synergistic or antagonistic) between them. Third, the overall randomized sample size of 96 patients was extremely limited, and all patients came from the same medical institution. Whether the results could be generalized to post-gastric cancer surgery populations in different regions and with different medical resource allocations requires further verification. Fourth, the treatment period and follow-up were only 4 weeks, which is too short to assess the duration of the therapeutic effects. This short duration fails to capture the long-term efficacy maintenance of the combined regimen or clarify its impact on patients’ long-term recovery outcomes (e.g., risk of tumor recurrence and long-term quality of life). Finally, while the study’s outcome indicators included objective serum cortisol levels, sleep quality and anxiety/depression primarily relied on patient self-reported scale scores, lacking corroboration from objective indicators such as polysomnography, neuroimaging examinations, and third-party assessments, potentially leading to subjective reporting bias. Due to the limitations of this study and existing progress of research, future research could be further explored in the following directions: First, conduct large-scale, multicenter, prospective randomized controlled trials. The trial design should include “routine medical treatment group”, “hyperbaric oxygen therapy alone group”, “muscle relaxation alone group”, and “combined treatment group”, using factorial design to clarify the independent effects and interactions of each component. Second, expanded the sample size and include broader population characteristics, prolonged the follow-up cycle to one year or more to systematically estimate the long-term effects of combined treatment on patients’ sleep quality, emotional state, and stress levels, improving the external validity and clinical applicability of the research results. Third, deepen mechanistic research, combining neurotransmitter detection, inflammatory factor levels, and brain functional imaging techniques to reveal the intrinsic mechanisms for the synergistic function of hyperbaric oxygen and muscle relaxation training from a molecular biology and neurophysiological perspective.
CONCLUSION
In summary, this retrospective cohort study suggests that, compared with routine medical treatment alone, the integrated approach combining hyperbaric oxygen therapy and muscle relaxation training may be associated with improved sleep quality, reduced anxiety and depression, and lower serum cortisol levels in patients with postoperative sleep disorders following gastric cancer surgery. However, whether these effects are due to a synergistic interaction or dominated by a single intervention remains unclear. This combined regimen appears to be a potentially beneficial non-pharmacological option for postoperative recovery, but further studies with proper control groups are needed to validate its efficacy.
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