critical literature review on stress

Stress Management Interventions for Nurses: Critical Literature Review

Affiliation.

1 Mayo Clinic.
PMID: 31014156
DOI: 10.1177/0898010119842693

Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses' stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

Keywords: burnout; nurse; resilience; stress management; systematic review.

Publication types

Nurses / psychology*
Nurses / statistics & numerical data
Stress, Psychological / psychology
Stress, Psychological / therapy*

Stress Management Interventions for Nurses: Critical Literature Review

Research output : Contribution to journal › Review article › peer-review

Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses’ stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

Bibliographical note

stress management
systematic review

Publisher link

10.1177/0898010119842693

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Critical Literature Review Keyphrases 100%
Stress Management Intervention Keyphrases 100%
Literature Review Nursing and Health Professions 100%
Self Care Nursing and Health Professions 50%
Holistic Nursing Nursing and Health Professions 50%
Rigor Nursing and Health Professions 50%
Randomized Controlled Trial Keyphrases 40%
Evidence-based Practice Keyphrases 20%

T1 - Stress Management Interventions for Nurses

T2 - Critical Literature Review

AU - Chesak, Sherry S.

AU - Cutshall, Susanne M.

AU - Bowe, Cassandra L.

AU - Montanari, Katherine M.

AU - Bhagra, Anjali

N1 - Publisher Copyright: © The Author(s) 2019.

PY - 2019/9/1

Y1 - 2019/9/1

N2 - Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses’ stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

AB - Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses’ stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

KW - burnout

KW - resilience

KW - stress management

KW - systematic review

UR - http://www.scopus.com/inward/record.url?scp=85064906169&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85064906169&partnerID=8YFLogxK

U2 - 10.1177/0898010119842693

DO - 10.1177/0898010119842693

M3 - Review article

C2 - 31014156

AN - SCOPUS:85064906169

SN - 0898-0101

JO - Journal of Holistic Nursing

JF - Journal of Holistic Nursing

Stress Management Interventions for Nurses: Critical Literature Review

Nursing Research

Research output : Contribution to journal › Review article › peer-review

Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses’ stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

stress management
systematic review

ASJC Scopus subject areas

Nursing (miscellaneous)

Access to Document

10.1177/0898010119842693

Fingerprint

Nurses Medicine & Life Sciences 100%
Holistic Nursing Medicine & Life Sciences 37%
Knowledge Discovery Medicine & Life Sciences 36%
Randomized Controlled Trials Medicine & Life Sciences 31%
Evidence-Based Practice Medicine & Life Sciences 25%
Self Care Medicine & Life Sciences 24%
Nursing Medicine & Life Sciences 19%
Research Design Medicine & Life Sciences 18%

T1 - Stress Management Interventions for Nurses

T2 - Critical Literature Review

AU - Chesak, Sherry S.

AU - Cutshall, Susanne M.

AU - Bowe, Cassandra L.

AU - Montanari, Katherine M.

AU - Bhagra, Anjali

N1 - Publisher Copyright: © The Author(s) 2019.

PY - 2019/9/1

Y1 - 2019/9/1

KW - burnout

KW - resilience

KW - stress management

KW - systematic review

UR - http://www.scopus.com/inward/record.url?scp=85064906169&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85064906169&partnerID=8YFLogxK

U2 - 10.1177/0898010119842693

DO - 10.1177/0898010119842693

M3 - Review article

C2 - 31014156

AN - SCOPUS:85064906169

SN - 0898-0101

JO - Journal of Holistic Nursing

JF - Journal of Holistic Nursing

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Stress Management Interventions for Nurses: Critical Literature Review

2019, Journal of Holistic Nursing

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Efficacy of Progressive Muscle Relaxation in Adults for Stress, Anxiety, and Depression: A Systematic Review

Syazwina muhammad khir.

1 Department of Psychology, School of Human Resource Development and Psychology, Faculty of Social Sciences and Humanities, Universiti Teknologi Malaysia, Johor, Malaysia

Wan Mohd Azam Wan Mohd Yunus

2 INVEST Research Flagship, University of Turku, Turku, Finland

3 Research Centre for Child Psychiatry, University of Turku, Turku, Finland

Norashikin Mahmud

Siti aisyah panatik, mohammad saipol mohd sukor, nor akmar nordin.

The rise in the prevalence of mental health problems among adults worldwide has raised concerns, highlighting the critical need for evidence-based mental health interventions that are accessible, comprehensive, and effective. Previous research suggests that Progressive Muscle Relaxation (PMR) is a promising intervention widely used to reduce mental health problems. Nevertheless, the current literature on the efficacy of PMR among adults globally is fragmented, indicating a potential gap in this research area. Hence, this paper aims to systematically compile the research evidence on the efficacy of PMR in adults for stress, anxiety, and depression.

The Scopus, Web of Sciences, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials were searched from the earliest available evidence to 28th March 2023. The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analyses) guidelines were followed, and the protocol was registered on the Open Science Framework. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used to assess the quality of the included studies.

A total of forty-six (46) publications from sixteen (16) countries covering more than 3402 adults were included in the review. The results show that PMR are effective in reducing stress, anxiety, and depression in adults. When PMR is combined with other interventions, the combined techniques have also consistently exhibited enhanced efficacy. Moreover, findings also indicate that the efficacy of PMR is heightened when implemented in conjunction with other interventions, surpassing its standalone efficacy.

Funding and Registration

This research was supported/funded by the Ministry of Higher Education (MoHE) under the Fundamental Research Grant Scheme (FRGS) (FRGS/1/2020/SS0/UTM/02/23). The review was registered on Open Science Framework (OSF) on the 7th of March 2023; DOI: https://doi.org/10.17605/OSF.IO/U2HZP .

Introduction

There is more to mental health than the absence of mental disorders. According to the World Health Organization (WHO), 1 the term “mental health” refers to a state of psychological well-being that allows individuals to successfully manage the challenges of life, recognize their strengths, participate in study and work, and make significant contributions to the communities. There is a broad continuum of mental health that is experienced differently by each individual. It carries diverse levels of challenges and distress as well as possibly highly distinct social and psychological impacts. Being typically capable of thinking, feeling, and acting in a way that satisfies one’s desires in life is a sign of good mental health. However, if one has experienced a phase of poor mental health such as stress, anxiety, and depression, they will likely find everyday life as challenging or even impossible to deal with the frequent thoughts, feelings, or responses. These poor conditions could lead to more serious psychiatric disorders or conditions such as clinical anxiety, depression, bipolar disorders, schizophrenia, or even suicide. 2–4 The aforementioned statement emphasizes the critical need to swiftly address stress, anxiety, and depression as these are major contributors to the wider range of mental health issues that people may encounter.

Stress may not be typical of the person or the environment; rather, it is a complex system formed by the interplay of specific psychological and physiological elements with the surroundings, 5 while anxiety is a mental condition characterized by unpleasant emotions, unease, anxiety about the future, or dread of reacting to the present without a clear trigger. 6 According to World Health Organization, 7 depression is a widespread mental health condition that impacts over 300 million individuals globally. Depression is commonly characterized by symptoms like poor mood, interest loss, changes in weight or appetite, sleep difficulties, psychomotor changes, guilt feelings, lack of focus, and suicidal thoughts or attempts in the past. 8 An earlier research conducted among adult population in 2020 revealed that nearly half of the study sample (48.1%) were affected with mild to extremely severe stress, anxiety, and depression. 9 These figures are very alarming since they could trigger negative affect, which includes erratic feelings and apathy 10 among the adults.

To address those mental health issues, experts have suggested several recommendations like maintaining physical well-being, partaking in recreational activities, staying positive, socializing, and learning relaxation exercises 11 Relaxation exercises have been found to be effective for a person’s physical and mental well-being by enabling one’s breathing to calm down, decreasing blood pressure, easing stress, and minimizing muscle spasm. 12 , 13 Moreover, there are emerging studies on the use of relaxation exercises as part of an interdisciplinary prevention or intervention approach for stress, anxiety, and depression, 14–17 and relaxation techniques like progressive muscle relaxation (PMR) are capable of successfully tensing and relaxing different muscle groups. 18

Of all the relaxation techniques, the PMR technique is the most straightforward to understand and to be used as it is accessible, affordable, self-induced, and offers no adverse impacts. 19 Utilizing PMR is particularly effective in reducing stress, anxiety, and depression. By differentiating between sensations of tension (a purposeful tensing of the muscles) and relaxation (a conscious, deliberate release of the muscles’ tension), PMR makes it easier to identify muscles or muscle groups that are persistently tense. 18 , 20

Systematic reviews on PMR by previous scholars have focused on the impact of the exercises on patients with serious illnesses such as cancer patients, schizophrenic patients, and those who are undergoing surgery 14 , 21 , 22 in reducing their mental health problems. However, to our knowledge, there are no systematic reviews that assess the efficacy of PMR interventions on stress, anxiety, and depression of the general adult population, thus contributing to the current body of knowledge.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the present study. PRISMA was developed to assist reviewers in clearly describing their studies’ purpose, methods, and findings. 23 Using this guideline, the reviewers developed pertinent research questions based on the PICO framework. This framework aids reviewers in structuring research questions by dividing them into four main parts: Population, Intervention, Comparison, and Outcome. 24 Based on the framework, one research question is formulated: Does Progressive Muscle Relaxation (PMR) effectively reduce stress, anxiety, and depression among adults? In this review, adults are defined as those who are 18 years of age or older. 25 The review’s objectives, inclusion criteria, and methods of analysis were pre-specified and documented in a protocol filed on Open Science Framework (OSF) on the 7th March 2023; DOI: https://doi.org/10.17605/OSF.IO/U2HZP .

Search Strategy

The reviewers conduct a comprehensive search of five electronic databases; Scopus, Web of Sciences, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials. The reviewers used various keywords for the literature search to match the study’s context and succeed in enhancing the keywords while constructing a comprehensive search string (based on phrase searching, field code function, Boolean operator, truncation, and wild card). The search terms utilized for all the databases included are presented in Table 1 .

The Search Terms

Selection Criteria

This review includes publications that fit two distinct criteria: (1) Those that explore the effects of PMR on stress, anxiety, and depression in adults, either as a standalone intervention or in combination with additional intervention approaches; and (2) Studies that implement rigorous methodologies, utilizing either a Randomized Controlled Trial (RCT) or a Quasi-Experimental Design (QED). For this review, the inclusion criteria necessitate studies to includes all studies that investigate the efficacy of PMR on stress, anxiety, and/or depression symptoms, focus on experimental research, look at non-clinical cases among adults, and have been published in English language from earliest time until 28th March 2023. Conversely, the review excludes all meta-analysis papers, systematic review papers, students’ thesis, or unauthorized or unrecognized dissertations, any non-experimental research, all clinical cases, and non-English articles or studies.

Study Search, Selection, and Retrieval Processes

The research procedure includes a methodical flow that starts with a thorough database search, followed by exporting the identified articles into the reference management software EndNote X7. After that, duplicates were removed and both the titles and abstracts were screened for relevancy. The process continued by retrieving the full texts of the publications that had been shortlisted. Some articles were unable to be retrieved due to access restrictions on databases, full-text not available, limited database archive, and is a conference abstracts. Finally, a thorough evaluation of these full texts was done to determine which articles are most significant based on the aforementioned criteria. The process was carried out independently by two different reviewers, who then met to compare their findings and reach a consensus. In cases where a consensus was elusive, the reviewers engaged a senior researcher for guidance and resolution.

Quality Assessment of the Included Study

Following the screening procedure, two (2) reviewers used revised Joanna Briggs Institute (JBI) Critical Appraisal Tools 26 , 27 to complete the quality assessment on all the selected papers. The reviewers used two (2) different checklists from the revised JBI critical appraisal tools.

The first tool was a checklist called the “Revised Randomized Controlled Trial Checklist”. This checklist was used to review papers that used the Randomized Controlled Trial (RCT) design. The checklist provided a thorough, standardized methodology for evaluating many components of RCTs, including internal validity, all types of bias checklists, statistical conclusion validity, randomization protocols, blinding methods, and attrition rates, among other crucial variables. 26 This tool examines thirteen (13) significant components for the systematic review. The checklists consist of four distinct responses: Yes, No, Unclear, and Not Applicable. 28 For this checklist, each of the items received a score for adherence. Items marked with a “Yes” earn a score of one (1), signifying adherence to the checklist criterion, whilst any other replies - “No”, “Unclear”, or “Not Applicable”, receive a score of zero (0), suggesting a lack of assurance or non-relevance to the specific criterion. Previous research on the JBI critical appraisal tool confirms that the attribution of cut-off values or scores that identify a study as being of low, moderate, or high quality is best selected by the systematic reviewers themselves. 29 The aforementioned approach enables reviewers to determine these thresholds based on the specific requirements and circumstances of their assessment, resulting in a more personalized and precise evaluation process. For the current review, the reviewers opted to implement the scoring system from earlier studies. 30 , 31 Under the assessment criteria, studies obtaining 70% or more of the maximum attainable score were classified as “high quality”, those scoring between 50% and 70% were classified as “moderate quality”, while studies with scores falling below the 50% threshold were classified as “poor quality”. Moreover, for this checklist, those earning ten (10) points or more were classified as “high quality”, those that scored between seven (7) and ten (10) points were deemed “moderate quality”, and articles that accrued six (6) points or less were categorized as “poor quality”.

The second tool was the “Revised Checklist for Quasi-Experimental Studies”. This checklist functioned as an evaluative measure for all studies that used a quasi-experimental design (QED), offering a formal framework for examining the robustness and dependability of the procedures used, how they were carried out, and the subsequent validity of the results. 26 This tool examines nine (9) significant components for the systematic review. Similar to RCT tool, this checklist consists of four distinct responses: Yes, No, Unclear, and Not Applicable. Each of the items received a score for adherence. Items marked with a “Yes” earn a score of one (1), signifying adherence to the checklist criterion, whilst any other replies - “No”, “Unclear”, or “Not Applicable”, receive a score of zero (0), suggesting a lack of assurance or non-relevance to the specific criterion. Moreover, studies obtaining 70% or more of the maximum attainable score were classified as “high quality”, those scoring between 50% and 70% were classified as “moderate quality”, while studies with scores falling below the 50% threshold were classified as “poor quality”. 30 , 31 Those earning seven (7) points or more were classified as “high quality”, those that scored between five (5) and seven (7) points were deemed “moderate quality”, and articles that received four (4) points or less were categorized as “poor quality”.

The quality assessment instructs reviewers to include articles with high and moderate qualities only. Two reviewers made decisions on the study’s eligibility and quality. All possible disagreements were settled through discussion. If no conclusion was achieved, a third reviewer who is a senior researcher is brought in to assist in reaching a final decision. The careful assessments ensured that the research included in the review met a high standard of methodological quality. Next, two independent reviewers extracted the data, and the findings are provided in the next section.

Data Extraction

Data extraction was done by one independent reviewer and subsequently cross-checked by another reviewer to ensure accuracy and consistency. Following a meticulous data extraction procedure, relevant data addressing the study questions were collected from the reviewed publications and systematically organized into tables. For this review, the findings are divided and presented in two separate tables. The first table focuses primarily on the effects of Progressive Muscle Relaxation (PMR) procedures on the stress, anxiety, and depression in adults, whereas the second table presents on the effects of PMR on stress, anxiety, and depression when paired with other interventions. The extraction tables consisted of: (1) General information (Authors, Publication Years, and Country); (2) Training Duration (minutes/length); (3) Frequency of Training (per week); (4) Participants (Sample Size, Setting, Dropout Rates); (5) Study Design (RCT or QED, Pre-test, Post-Test, and Follow-Up); (6) Research Instruments; (7) Components/Contents of the PMR; (8) Outcome Measures (with effect size where available); (9) Key Findings; and (10) Quality of the Article. The categories were constructed based on reading knowledge and extensive systematic literature reviews by previous scholars. 21 , 32 , 33 The data extraction for the current study is illustrated in Table 2 and Table 3

Progressive Muscle Relaxation (PMR)

Abbreviations : PMR, Progressive Muscle Relaxation; EXP, Experiment; F-Up, Follow up; S, Setting; DO, Dropouts; RCT, Randomized control trial; QED, Quasi-experimental design; IG, Intervention group; CG, Control group; d, Cohen’s d ; TAS, Test anxiety scale; STAI, State-trait anxiety inventory; SAS, Zung Self-Rating Anxiety Scale; DASS, Depression; anxiety; stress scale; BDI, Beck Depression Inventory; CSAI-2, Competitive State Anxiety Inventory-2; RESTQ-Sport, Recovery-Stress Questionnaire for Athletes; PSS, Perceived Stress Scale; JSS, Job Stress Scale; GDS, Geriatric Depression Scale; WSS, Work Stress Scale; SRSI3, Smith Relaxation States Inventory 3; BDS, Beck Depression Scale; SRLE, Survey of Recent Life Experiences; STAS, Sarason test anxiety scale; EMAS-S, Endler Multidimensional Anxiety Scale—State; SQST, Smith Quick Stress Test; SRI, Stress Response Index.

Progressive Muscle Relaxation with Other Interventions

Abbreviations : PMR, Progressive Muscle Relaxation; EXP, Experiment; F-Up, Follow up; S, Setting; DO, Dropouts; RCT, Randomized control trial; QED, Quasi-experimental design; IG, Intervention group; CG, Control group; d, Cohen’s d ; EMR, Education & Muscle Relaxation; HE, Health Education; HADS, Hospital Anxiety and Depression Scale; NS, Nature sound; DASS-21, Depression; anxiety; stress scale-21; CBT, Cognitive Behavioral Therapy; MT, Music Therapy; CS, Counseling services; PEPSAEE, Pan-Hellenic Association for Psychosocial Rehabilitation and Professional Reintegration; MM, Mindfulness Meditation; PSS, Perceived Stress Scale; STAI, State-trait anxiety inventory; SC, Stress Control; RT, Relaxation Therapy; GI, Guided Imagery; HAM-A, Hamilton’s Anxiety Scale; DB, Deep Breathing; BDI, Beck Depression Inventory; SMS Stress management skills.

Results of the Search

A thorough database search yielded 3205 findings. During the initial screening phase, two reviewers identified and eliminated 1336 duplicate papers. Following that a thorough screening of research titles and abstracts was performed to eliminate another 1708 publications from the remaining findings. Next, 65 articles were not retrieved due to access restrictions on databases, full-text not available, limited database archive, or is a conference abstracts. The remaining 96 full-text publications were then screened based on the inclusion and exclusion criteria. Finally, based on the specified criteria, the reviewers eliminate additional 50 findings that did not meet the inclusion criteria due to clinical studies. As a result, the final phase of the selection approach yields 46 articles from 16 countries ( Figure 1 ) that match all of the inclusion requirements. Figure 2 illustrates the PRISMA flow diagram for the included and excluded studies.

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List of Countries Involved (16 Countries).

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PRISMA flow diagram for the included and excluded studies.

Quality of the Included Studies

Two independent reviewers conducted a quality assessment of each included study. As a results, twenty-four (24) studies were rated as high quality, whereas twenty-two (22) studies were rated as moderate quality. The quality of the studies is presented in the extraction tables from high to moderate quality ( Table 2 and Table 3 ).

Standalone Progressive Muscle Relaxation (PMR) Studies Vs PMR Combined with Other Interventions Studies

Progressive muscle relaxation (pmr) studies.

Following the completion of the systematic review procedure, the reviewers identified thirty-one (31) papers concentrating on Progressive Muscle Relaxation (PMR), laying a complete framework for the synthesis and interpretation of the data. The summary of the systematic findings of the studies can be referred on Table 2 . The efficacy of each outcome measures was illustrated in Figure 3 .

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The Efficacy of PMR on Stress, Anxiety and Depression.

Randomized Controlled Trial (RCT)

Using the “Revised Randomized Controlled Trial Checklist”, 28 the reviewers found three (3) studies of high quality, 43 , 54 , 57 and seven (7) studies of moderate quality. 59–62 , 64 , 66 , 68

Following an exhaustive review, major findings demonstrated a significant trend in three (3) studies 43 , 59 , 64 that reported a substantial decrease in stress outcomes among adult volunteers, nurses and university students at posttest compared to pretest within the PMR group. Moreover, one (1) study 64 among university students discovered the potential efficacy of PMR, finding a substantial decrease in stress outcomes in the PMR group compared to the control group at the posttest evaluations. Nonetheless, one (1) study 59 found no significant reduction in stress levels among adult volunteers in the PMR group when compared to the control group at the post-test intervention stage.

For the anxiety outcomes, the systematic review’s key findings revealed that six (6) studies 43 , 57 , 59 , 62 , 66 , 68 showed a significant reduction in anxiety levels on adult volunteers, nurses, and university students at posttest compared to pretest within the PMR group. Additionally, two (2) studies 59 , 62 further underscored the potential efficacy of PMR on anxiety among adult volunteers, and nursing students, respectively, finding a significant outcome in the PMR group in comparison to the control group at the posttest assessments.

In terms of depression, the key outcomes revealed that in four (4) studies 54 , 59–61 among adult volunteers, caregivers of elders, and elderly women, there was a significant decrease in depression post-test compared to pretest within the PMR group. Two (2) studies, 60 , 61 which further support the evidence for PMR, found a significant decrease in depressive outcomes in the PMR group compared to the control group among the caregivers of elders, and elderly women at the post-test measurement. However, a notable exception was observed in one (1) study 59 where there is no significant reduction in depression levels among adult volunteers in the PMR group compared to the control group at the post-test stage, adding a layer of complexity to the overall findings. The researcher points out, emphasizing the implications of the study’s findings, that the PMR intervention may lack the requisite potency to effectively improve depression outcomes, underscoring the need for more comprehensive or integrated procedures. These results emphasize the potential of PMR as an effective relaxation training in the therapy for stress, anxiety, and depression. In numerous studies, the consistent reduction in stress, anxiety, and depression produces in the PMR group indicates its efficacy as a relaxing technique on adults’ population.

Quasi-Experimental Design (QED)

Using the “Revised Checklist for Quasi-Experimental Studies”, 28 the reviewers identified fifteen (15) studies of high quality, 34 , 36 , 38 , 40–42 , 45–47 , 49–53 , 56 and six (6) studies of medium quality. 44 , 58 , 67 , 69 , 71 , 72

Following a thorough assessment, nine (9) studies 38 , 40 , 41 , 45 , 46 , 51 , 52 , 58 , 67 revealed noteworthy insights, indicating a discernable pattern of considerable drop in stress outcomes posttest in contrast to pretest within the PMR group among the female health care workers, nurses, university students and employees. Moreover, two (2) more studies 36 , 72 reported a significant reduction in stress outcomes in the PMR group compared to the control group among the athletes and female clerical workers, adding weight to the information at hand.

Next, when anxiety outcomes were analyzed, seven (7) studies 42 , 44 , 50 , 52 , 56 , 69 , 71 reported a significant decrease in levels of anxiety among university students, and nurses at posttest compared to pretest in the PMR group, highlighting the effective role of PMR in anxiety reduction. Besides, two (2) further studies 36 , 56 supported the discussion for PMR by demonstrating a substantial reduction in anxiety outcomes among athletes, and nursing students in the PMR group compared to the control group in the posttest phase. Interestingly, two (2) studies 42 , 50 conducted among university students and nurses, respectively, found a significant reduction in anxiety in the control group, a finding that calls for more research to uncover the underlying causes. However, in contrast to the great majority of the findings, three (3) studies 34 , 49 , 51 found no significant reduction in anxiety levels among university students, beginner athletes, and female nurses, respectively, at posttest compared to pretest in the PMR group.

Lastly, in analyzing depression outcomes, three (3) studies 47 , 51 , 53 found a notable decrease in depression levels among the elders, and female nurses’ posttest compared to pretest in the PMR group, showing PMR’s potential efficacy in battling depression. In addition, one (1) study among elders 47 reported a significant reduction in depression outcomes in the PMR group compared to the control group at the posttest stage. PMR has significant potential for cultivating mental well-being as a non-drug-based intervention, particularly or adults dealing with stress, anxiety, and depression.

Overall, the comprehensive analysis of the PMR studies in this review reveals a spectrum of Cohen’s d effect sizes, spanning from d=0.29 to d=4.57 for stress, suggesting a range from small to large impact. Similarly, the effect sizes for anxiety fall between d=0.25 and d=2.54, indicative of a spectrum from small to large, while for depression, the range of d=0.58 to d=1.95 suggests a medium-to-large effect size. The effect sizes for each PMR studies are displayed in Table 2 .

PMR Combined with Other Interventions Studies

Following a thorough systematic analysis, the reviewers identified fifteen (15) studies that explicitly explore the effects of Progressive Muscle Relaxation (PMR) in combination with other interventions that include: Health education, 89 Nature Sound, 66 Music therapy, 68 , 80 , 83 Counseling Services, 76 Other relaxation techniques, 73 , 77 , 81 , 86 Stress control skills, 74 , 78 and Deep breathing. 79 , 85 , 88 The summary of the systematic findings can be referred on Table 3 . The efficacy of each outcome measures was illustrated in Figure 4 .

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The Efficacy of PMR combined with other interventions on Stress, Anxiety and Depression.

Using the “Revised Randomized Controlled Trial Checklist”, 28 the reviewers found eight (8) studies of moderate quality. 66 , 68 , 80 , 81 , 83 , 85 , 86 , 89

Upon the completion of an in-depth review, three (3) different research 80 , 81 , 85 evaluating stress outcomes found a significant decrease in stress levels among nursing students, general adults, and caregivers’ posttest compared to pretest in the group receiving PMR paired with music therapy (MT), mindfulness meditation (MM), and deep breathing (DB), respectively. Furthermore, two (2) additional studies 80 , 83 found a significant reduction in stress outcomes in the PMR group, where PMR was combined with MT, when compared to the control group among nursing students, and nurses, respectively, at the posttest stage, adding to the evidence for the integrative approach.

When it comes to anxiety outcomes, three (3) studies 66 , 68 , 86 clearly demonstrate a significant decrease in levels of anxiety among university students, and caregivers following posttest compared to pretest within the group receiving PMR when coupled with nature sound (NS), MT, and guided imagery (GI), respectively, reinforcing the efficacy of this combined therapeutic approach in managing anxiety. In addition, a study among caregivers of patients 89 found a substantial reduction in anxiety outcomes in the group receiving PMR paired with health education (HE), when compared to the control group at posttest, lending credence to these findings. Nonetheless, one (1) study 81 found no statistically significant decrease in levels of anxiety among general adults at posttest compared to pretest in the group that received PMR alongside MM, highlighting the complexity and variability of coping with anxiety.

In terms of depressive outcomes, only one (1) study 89 demonstrating a significant reduction in depressive outcomes among caregivers of patients at the posttest stage in the group receiving PMR in combination with HE, when compared to the control group.

Using the “Revised Checklist for Quasi-Experimental Studies”, 28 the reviewers identified six (6) studies of high quality, 73 , 74 , 76–79 and one (1) study of moderate quality. 88

Following an extensive assessment, five (5) studies 73 , 74 , 76 , 79 , 88 found a substantial decline in levels of stress among elderlies, general adults, unemployed individuals, male automotive workers, and caregivers, respectively, at the posttest stage compared to pretest in groups receiving PMR alongside relaxation therapy (RT): music, physical exercise and laughter therapy, stress control (SC), counseling services (CS), and DB, respectively, highlighting the significant efficacy of this integrated approach in alleviating stress. Furthermore, three (3) other studies 76 , 77 , 79 strengthen these findings, indicating a significant reduction in stress outcomes among nursing students, unemployed individuals, and male automotive workers at the posttest phase in groups where PMR was administered in conjunction with cognitive behavioral therapy (CBT), CS, and DB, respectively, when compared to the control group.

In terms of anxiety outcomes, four (4) studies 73 , 74 , 76 , 78 reported a substantial reduction in levels of anxiety among elderlies, general adults, unemployed individuals, and caregivers, respectively, in the posttest as compared to the pretest in groups receiving a combination of PMR with RT: music, physical exercise and laughter therapy, SC, CS, and stress management skills (SMS), respectively. Besides, three (3) further papers 76–78 found a substantial reduction in depressive outcomes among unemployed individuals, nursing students, and caregivers at posttest in the group receiving PMR paired with CS, CBT, and SMS, respectively, when compared to the control group. However, one (1) study 79 contradicted the dominant discoveries, presenting a lack of significant decrease in levels of anxiety among male automotive workers at posttest compared to pretest, and also when compared with the control group, in the group that received PMR combined with DB, indicating the need for a more comprehensive investigation of this therapeutic approach.

When analyzing depression outcomes, reports from three (3) studies 73 , 76 , 78 revealed a significant reduction in levels of depression among elderlies, unemployed individuals, and caregivers, respectively, at the posttest compared to the pretest within the group that received PMR in combination with RT: music, physical exercise and laughter therapy, CS, and SMS, respectively. Along with the previous findings, another two (2) studies 76 , 78 have reported a substantial reduction in depressive outcomes among unemployed individuals, and caregivers, respectively, at the posttest stage in the group that got PMR integrated with CS, and SMS, respectively, when compared to the control group. Two (2) studies, 74 , 79 however, deviated from the majority of outcomes, presenting no significant decrease in symptoms of depression among general adults and male automotive workers, respectively, at posttest compared to pretest in the group receiving PMR alongside SC, and DB, respectively, and also when compared with the control group. Unexpectedly, one (1) study 78 found a significant increase in levels of depression among adults in the wait-list control group at posttest, where no interventions were provided. It is a finding that warrants additional investigation to determine the underlying causes, and therefore highlighting the need for further studies.

Overall, for the PMR combined with other intervention studies, the Cohen’s d effect sizes are ranging from d=0.40 to d=2.24 for stress, signifying an impact spectrum spanning from small to large. Similarly, the effect sizes for anxiety, falling between d=0.15 and d=2.10, indicate a spectrum from small to large impact. In the case of depression, the range of d=0.27 to d=0.74 suggests a small-to-medium effect size. The effect sizes for each study are displayed in Table 3 .

This paper presents a systematic literature review on the efficacy of Progressive Muscle Relaxation (PMR) in adults for stress, anxiety, and depression. Our review identified 46 studies, from sixteen (16) countries, covering 3402 total sample. This review is a pioneering endeavor in that it is the first to systematically assembled and report findings relating to the efficacy of PMR and PMR combined with other interventions among general adult, thus contributing to the current body of knowledge. Furthermore, this review is notable for its comprehensive approach, providing studies employing Randomized Controlled Trial (RCT) and Quasi-Experimental Design (QED) research designs. As a result, it provides a thorough view of the many approaches used to examine the efficacy of PMR. This comprehensive approach not only broadens the spectrum of evidence reviewed but also allows for the analysis of a diverse variety of study designs, resulting in a deeper comprehension of PMR’s conceivable effect. Besides, this review attempted to look at the impact of PMR as a stand-alone intervention as well as those that explore PMR in combination with other interventions. By presenting in this way, this review promotes a broad knowledge of PMR’s efficacy in various therapeutic conditions by offering evidence from both methods. The comparison of PMR itself versus PMR paired with various interventions may aid in identifying potential synergistic benefits, directing future study and potential therapeutic application.

Based on the outcome measures, overall, PMR has been demonstrated to be beneficial in reducing stress, anxiety, and depression in adults. When PMR is combined with other interventions, the combined techniques have also consistently exhibited enhanced efficacy, particularly for stress (n=10) and anxiety (n=9). There are a total of 24 studies that support PMR’s efficacy in reducing stress, 21 studies in reducing anxiety, and 11 studies in reducing depression, either on its own or in combination with other interventions.

There is a consistent trend in this review that emerges where the majority of studies using Jacobson’s Progressive Muscle Relaxation (PMR) exercise show that it is beneficial in reducing stress, anxiety, and depression in adults, whether used in its original form 18 or as adapted by later research. 35 , 37 , 55 , 63 , 70 , 90 In our review, we discovered that when people engaged in PMR exercises on their own in private spaces, the lengths of the sessions varied, with the lowest session lasting 5 minutes 45 and the longest lasting 28 minutes. 54 , 61 When combining with other interventions or variables, the shortest duration becomes 15 minutes, 74 while the longest is 37 minutes. 85 In our analysis, we observed that the duration of the PMR exercises, whether shorter or longer, did not significantly influence the outcome measures. Our study shows that there was a pervasive pattern of decreasing mental health outcomes across time. Moreover, our findings show that the regularity, whether daily or only a few days a week, does not significantly change the outcomes when analyzing the frequency of PMR implementation. Regardless of the exact frequency of PMR sessions, the overall trend in the majority of studies consistently demonstrates a reduction in outcome measures.

When delving deeper into individual outcome measures, for stress, one (1) study 59 found no significant reduction in stress level when compared to the control group at posttest. For anxiety, there are five (5) studies 34 , 49 , 51 , 79 , 81 reported no reduction in anxiety at the posttest. Interestingly, there are two (2) studies 42 , 50 that show a significant reduction of anxiety in the control group which calls for more research to uncover the underlying causes. Lastly, the majority of the studies on depression involved elderly people and those who looked after patients and senior citizens. There are three studies 59 , 74 , 79 revealed no significant reduction compared to control groups. Alarmingly, one study 78 even indicated an increase in depression levels post-intervention of a wait-list control group.

For the record, we found an interesting pattern in our thorough review. It seems that statistically insignificant results tend to occur when PMR is explored in the context of a general adult population, without defining or focusing on specific subgroups. 59 , 74 , 81 This recurring trend of non-significant results in wider adult populations raises the possibility that the efficacy of PMR may depend on particular demographic, psychographic, or clinical traits that are unusually absent from a generalized group. However, it does not reduce PMR’s potential benefit in specific therapeutic applications, where its efficacy can be clearly seen. Future studies should investigate the efficacy of PMR in specific demographics or under predetermined circumstances to identify where its advantages are most noticeable.

When measuring the efficacy of PMR combined with other interventions versus PMR as a standalone relaxation technique, there are two (2) studies in this review 66 , 68 that found combining PMR with other variables to be more effective compared to the PMR training alone in their respective study. Korkut, Ülker, Çidem, Şahin 66 found combining PMR with nature sound to be more effective in reducing anxiety among the nursing students, while Robb 68 highlighted that combination of PMR with music to be more effective in reducing anxiety among the university students compared to PMR alone.

Because of its diverse approach, PMR and its combination with other therapies appear to be viable interventions for stress, anxiety, and depression in adults. Combining PMR with different interventions may simultaneously access several relaxing mechanisms. Moreover, additional interventions might concentrate on other psychological or physiological aspects in addition to PMR, which can only alleviate muscular tension and relaxation. Compared to employing PMR alone, this holistic approach may provide a more comprehensive course of relaxation that potentially results in increased efficacy. With the assistance of an increasing amount of evidence and research, 66 , 74 , 76 , 79 these interventions provide an approachable and well-researched way to manage stress, anxiety, and depression.

There is certain limitation to the current review that could be addressed in future research. First, while this research provides invaluable findings, it is crucial to highlight that due to limited resource, it only included studies in English from English-language databases. This linguistic and database limitation may unintentionally exclude important studies published in different languages or databases. Future reviews may thereby strengthen the extent of coverage and generalizability of data by including papers in other languages and expanding the search to non-English databases. This will ensure a more thorough understanding of the efficacy of PMR among adults for stress, anxiety, and depression in varied cultural and language areas.

In conclusion, there has been large amount of evidence that supports the efficacy of PMR in reducing stress, anxiety, and depression among adults. Studies also shows that PMR combined with other interventions are more effective compared when applied by itself. Given these findings, researchers could find it beneficial to consider combining or integrating PMR with other interventions to enhance its potential in reducing stress, anxiety, and depression. Future research could also expand on the current review’s findings by incorporating a more targeted goal such as focusing PMR interventions among the wider working population, rather than to mostly health care workers, which may further refine our knowledge of PMR’s potential advantages and appropriate implementation in diverse circumstances.

Acknowledgment

Authors acknowledge the Ministry of Higher Education (MoHE) for funding under the Fundamental Research Grant Scheme (FRGS) (FRGS/1/2020/SS0/UTM/02/23).

The authors report no conflicts of interest in this work.

Fatigue behavior of 4D printed materials: a review

Review Article
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Published: 21 May 2024

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Md Jarir Hossain ORCID: orcid.org/0009-0008-2919-1804 1

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4D printing presents a new direction in additive manufacturing through the incorporation of the time dimension into objects, thereby empowering them to modify their shape, properties, or functioning in stimulus to external influences. It is critical to investigate the fatigue behavior of these materials to comprehend their durability and reliability in the context of repeated stress or environmental changes. However, there has been limited effort to study this phenomenon. The purpose of this literature review is to consolidate the current understanding of the fatigue properties of 4D printed materials and identify areas where research is lacking. The impact of this work is to establish a foundation through a literature review for advancements in material science and manufacturing research that can improve the understanding of the fatigue behavior of 4D printed materials.

Mechanical Behavior of 3D Printed Polymeric Materials: Impact of Process Parameters

Material Characterization of 3D Printed Components with Different Layup Orientation

A critical review on 4D printing and their processing parameters

Avoid common mistakes on your manuscript.

1 Introduction

Within the dynamic realm of additive manufacturing, 4D printing emerges as a revolutionary progression [ 1 , 2 ], augmenting the functionalities of conventional 3D printing (material extrusion [ 3 ], vat photopolymerization [ 4 ], powder bed fusion [ 5 ], etc.) through the incorporation of the time dimension [ 2 ]. The term “4D Printing” was first coined in 2013 [ 6 ]. This groundbreaking technological advancement enables the fabrication of intelligent materials and structures that can undergo predetermined changes in shape, property, or functionality [ 7 ] in response to environmental stimuli including temperature [ 8 ], humidity [ 9 ], light [ 10 ], magnetic fields [ 11 ], etc. By facilitating the development of objects capable of self-assembly [ 12 ], repair [ 13 ], or adapt [ 14 ] to external conditions, this technology has the potential to significantly transform numerous industries, including biomedical engineering [ 15 ] and aerospace [ 16 ] industries. The immense potential of 4D printing to facilitate innovative applications and sustainable solutions underscores its importance as a manufacturing technology of the next generation.

The growing number of 4D printing applications indicates the criticality of comprehending the fatigue characteristics of materials—specifically, their ability to endure prolonged periods of stress or strain. Fatigue strength is one of the highest priorities, particularly for 4D printed materials that are intended to operate in dynamic environments and endure programmed transformations [ 17 ]. In practical applications, the reliability, safety, and durability of materials are directly impacted by their capacity to maintain their adaptive properties amidst cyclic loading conditions [ 18 ]. When designing and selecting materials for 4D printing, fatigue behavior becomes a crucial factor to consider; the durability of the adaptive response over time is equally as important as the initially demonstrated characteristics.

Extensive research has been dedicated to reviewing the studies of the fatigue behavior of 3D printed materials in the last 5 years [ 18 , 19 , 20 , 21 ], which signifies an increasing concern for their ability to withstand cyclic loading conditions and maintain their long-term dependability. The fatigue properties of a wide range of 3D printed materials, such as metals [ 19 ], polymers [ 20 ], and polymeric composites [ 18 ], have been the subject of extensive research. This has unveiled how printing parameters, layer orientation, and post-processing procedures affect the fatigue life of these materials. These inquiries yield significant knowledge regarding the optimization of 3D printing procedures to achieve improved mechanical characteristics, specifically for implementations in the aerospace [ 22 ], automotive [ 23 ], and biomedical [ 24 ] applications. Nevertheless, although extensive research has been conducted on the fatigue behavior of 3D printed materials, the investigation of fatigue properties in 4D printed materials is still largely unexplored. This gap in research highlights a critical need for comprehensive studies on the fatigue behavior of 4D printed materials, considering the additional complexity introduced by their time-dependent responses. There are more than 50 review articles found in Google Scholar for the year 2023. However, there is no review article in the literature solely focused on the fatigue behavior of 4D printed materials . Some research have been found in the literature evaluating 4D printed materials for fatigue behaviors. Despite this progress, the area of research concerning the fatigue characteristics of 4D printed materials is still in its early stages, where substantial deficits in knowledge persist.

The goal of this review paper is to bring together what is known about fatigue behaviors of 4D printed materials and point out the key study results, problems, and areas that could be explored further in the future. This paper will undertake a critical analysis of prior research and identify knowledge gaps to make a positive contribution to the wider implementation and progress of 4D printing technology.

2 Fatigue behavior of 4D printed materials

Zhang et al. [ 25 ] studied 4D Printable shape-memory polymer (SMP) using the DLP (Digital Light Processing)-based 3D printing method. In this process, a digital screen projects a single image of each layer onto the build platform to cure photopolymer resin into three-dimensional object (Fig. 3 a) [ 25 ]. The objective of this study is to improve the mechanical robustness, deformability, and fatigue resistance of a newly designed tert-butyl acrylate (tBA) aliphatic urethane diacrylate (AUD) SMP specifically designed for 4D printing purposes. Superior fatigue resistance is considered as an important factor for SMPs and, consequently, 4D printed materials, as it guarantees their functionality and long-term dependability, particularly in applications that require the material to endure multiple shape transformations throughout its lifetime. The research methodology comprises an extensive set of tests that have been specifically developed to assess the performance of the SMP across a range of conditions. Mechanical tensile tests are employed to evaluate the strength and elasticity of the material, while fatigue testing determines its shape-memory and endurance, respectively, over thousands of loading cycles. In contrast to previously documented UV-curable SMPs, the tBA–AUD SMP exhibits exceptional fatigue resistance, as evidenced by its ability to endure more than 10,000 loading cycles without damage (Fig. 1 a). On the other hand, other compounds such as Vero, tBA–PEGDA (PEGDA: Poly (ethylene glycol) diacrylate) (Fig. 1 b), and BMA–PEGDMA (PEGDMA: Poly(ethylene glycol) dimethacrylate) (Fig. 1 c) exhibited a lifespan of under 100. This finding suggests that the tBA–AUD SMP system has made substantial strides in terms of durability and suitability for dynamic applications.

Comparative fatigue resistance of SMP samples. a The endurance of a tBA–AUD SMP sample with 10 wt% AUD, showcasing its ability to withstand over 10,000 loading cycles. b The fatigue behavior of tBA-PEGDA (9:1, w/w) at 74 °C, highlighting a strain range of 10–20%. c The fatigue performance of BMA-PEGDMA (9:1, w/w) at 87 °C, with a strain tolerance between 20 and 40%. Reproduced with permission from [ 25 ]

In another work, J.N. Chapuis and K. Shea [ 26 ] describe the application of PLA (Polylactic Acid) in the direct 4D printing of bilayer actuators to fabricate polymer wave springs. By integrating fused filament fabrication (FFF) with direct 4D printing, PLA bilayer actuators can be produced. In FFF, the material is formed into a filament, and the filament is pushed through a nozzle, which is heated to its melting point and then deposited layer by layer to create a three-dimensional (3D) object (Fig. 3 b) [ 27 ]. By effectively integrating a pre-strain imbalance between active and passive layers, this technique enables the induction of bending or twisting. The principal material utilized is PLA (Polylactic Acid), which was selected due to its desirable printability, thermoplastic shape-memory characteristics, and compatibility with cold and hot programming methods. Taking advantage of a single material, the actuators are constructed to prevent delamination and guarantee robust adhesion, thereby improving cyclic performance. Active and passive layers are incorporated into the design to regulate deformation via the pre-strain imbalance. The print direction and process parameters are considered to regulate the nature and extent of deformation. Passive layers remain stationary during activation, whereas active layers undergo controlled deformation by contracting. Printed in a planar configuration, the actuators are patterned into a wave ring; upon activation, it takes on the form of a wave. This exemplifies the capability of direct 4D printing to produce durable, and functional components that are complex. The results of the research concerning the fatigue characteristics of direct 4D printed PLA bilayer wave springs provide important information regarding the structural soundness of the springs when subjected to cyclic loading. The springs exhibited remarkable resistance to fatigue during rigorous testing, as evidenced by the minimal damage observed even after 10,000 cycles (Fig. 2 b). On closer inspection, however, initial fracture nucleation was observed (Fig. 2 e), which signifies the initiation of fatigue damage. However, cracks (Fig. 2 c) and fatigue striations (Fig. 2 f) have been observed after deployments. This observation highlights the significant influence that thermal stresses have on the durability of the material during the redeployment process. The failure mechanisms of the 4D printed springs were not associated with layering, which contrasts with the early fatigue failure observed in conventional FFF parts. This finding emphasizes the engineering benefit of employing this printing technique to prolong the lifespan of components subjected to cyclic stress. The significance of material behavior and failure mechanisms in the design and fabrication of 4D printed components for applications involving recurrent loading is highlighted by this analysis.

Fatigue and Redeployment Analysis of 4D Printed PLA Wave Springs. a The spring post-initial deployment, showing its original condition. b The wave ring's tension side after 10 4 cycles without redeployment, revealing no visible damage. c The tension side of a spring subjected to redeployment tests, where active PLA has experienced cracking and failure. d The tension side in a different section of the wave spring in its printed state. E The tension side of the same wave ring post-10^4 cycles, with a small crack nucleation visible upon detailed inspection. f Fatigue striations on the tension side of a spring after redeployment tests, indicating fatigue damage. Reproduced with permission from [ 26 ]

In another work, Yousuf et al. [ 28 ] utilize a thermoplastic shape-memory polymer (SMP) to 3D print an array of samples, including dogbone samples for testing and multi-cell and simple honeycomb structures. This particular polymer, which is suggested for deposition at a temperature of 200 °C, enables the fabrication of structures whose mechanical properties can be adjusted. Precise layer adhesion and infill density are key considerations during the printing process to ensure that the material's functionality corresponds to the intended experimental objectives, especially when analyzing local strain in particular structural regions. As a result of the accumulation of residual strains, repeated programming and recuperation cycles have a substantial impact on the mechanical properties of 4D printed structures. The deterioration is subject to the influence of both cycle frequency and programming intensity, highlighting the crucial significance of functional fatigue concerning the durability and dependability of 4D printed materials.

One research [ 29 ] describes a 4D printing technique for composite materials that embeds long fibers in polymeric resins to produce composites that are rigid, fatigue-resistant, and robust. The procedure entails the automated application of thin layers featuring a range of fiber orientations. These layers undergo differential rates of contraction as a result of the distinct thermal contraction coefficients after curing and chilling. This process initially transforms planar layers into curved structures without requiring complex molds. In particular, it employs carbon/epoxy materials, automated fiber positioning, and a cure temperature of 177 °C to demonstrate how the anisotropic properties of layered materials can be utilized to efficiently fabricate complex composite structures via 4D printing. The article also analyses the fatigue characteristics of composite materials produced via 4D printing by analyzing a 24-inch-long specimen that underwent a fatigue test involving three-point deformation. The experiment encompassed 175,000 cycles and recorded maximum and minimum displacements of 2.4 mm and 0.24 mm, respectively. The results demonstrated that the spring constant of the laminate remained unchanged throughout the fatigue test, indicating that the material possesses exceptional fatigue resistance. The significance of this result lies in the fact that it illustrates the capacity of these 4D printed composites to retain their mechanical integrity and functionality despite extended cyclic loading. This property is critical for the implementation of the composites in sectors where materials endure repetitive strain, such as the automotive and prosthetic device industries.

Another research [ 30 ] investigates the evolution, mechanical characteristics, and degradation structure of polylactic acid (PLA) peripheral vascular stents produced via 4D printing. The study centers on the performance of the stents when subjected to fluid shear stress after deployment. It provides evidence that degradation is expedited more significantly by microstructural damage resulting from deployment compared to shear stress in isolation. The stents exhibit commendable mechanical strength and hemocompatibility; the degradation characteristics are notably impacted by dynamic environmental conditions and microstructural damage. This research offers significant contributions to the understanding and assessment of forthcoming biodegradable stents, emphasizing the criticality of incorporating degradation characteristics and mechanical attributes during their formulation. The fatigue resistance of the stents was assessed to replicate the vasodilation effects. The findings suggest that stents featuring wall thicknesses of 0.2 mm and 0.3 mm exhibit considerable resistance to fatigue. Oppositely, the fatigue resistance of the stent measuring 0.4 mm in thickness is significantly lower. The observed discrepancy can be ascribed to the wall thickness of the stents when subjected to identical deformation conditions. Additionally, plastic deformation took place in the 0.4 mm stent when exposed to 37 °C. Also, it has been found that the fatigue resistance test results reveal a smooth curve with the compression force and recovery ratio experiencing a decline of approximately 21% and 13%, respectively, after 100 cycles.

For the manufacturing of Magnetoactive Soft Material (MASM) objects, the article [ 31 ] describes an innovative 4D printing strategy that combines conventional direct-ink-writing (DIW) with an origami-based magnetization technique. Similar to FFF, in this process, material(ink) is extruded through a syringe under controlled flow rate and deposited over a build platform layer by layer (Fig. 3 c) [ 27 ]. The structures can undergo programmable changes and locomotion subjected to magnetic fields. By avoiding issues such as particle agglomeration and streamlining the fabrication process, this approach facilitates the production of objects featuring intricate three-dimensional magnetization profiles. The authors also found that when subjected to cyclic endurance tests at 40% compression strain and 50% tensile strain, the 4D printed MASM demonstrated an exceptionally high fatigue resistance (see Table 1 ).

Printing technologies for 4D printing. a Digital light processing. Reproduced with permission from [ 27 ]. b Fused filament fabrication Reproduced with permission from [ 27 ] c Direct-ink-write. d Femtosecond laser direct writing. Reproduced with permission from [ 32 ]. e Liquid substrate electric field driven microscale 3D printing. Reproduced with permission from [ 34 ]

Another paper [ 32 ] describes the advancement of femtosecond laser direct writing (Fig. 3 d) for the microscale fabrication of hydrogel materials in botanical-inspired 4D printing. The process utilizes ultra-short laser pulses to fabricate complex micro structures [ 33 ]. This methodology permits the fabrication of hydrogel structures that are responsive to changes in pH. Such structures demonstrate complex and quick transformations in shape, such as contraction, expansion, and torsion, when subjected to varying pH levels. The materials exhibit considerable promise for implementations in drug delivery systems, micromanipulation, and single-cell analysis on account of their exceptional biocompatibility, modifiable characteristics, and rapid response times. Multiple expansion and contraction cycles are utilized to determine the expansion ratio of the cubic plate to assess the fatigue resistance of the printed hydrogel. This validates the hydrogel’s ability to repeat successfully.

Flexible transparent electrodes (FTEs) with embedded metal filaments were created using a novel, low-cost, and efficient liquid substrate electric-field-driven (LS-EFD) microscale 3D printing technique, as described in this article [ 34 ]. In this technique, a layer of liquid is spin-coated on a flexible surface, and the material is extruded through a nozzle under high voltage (Fig. 3 e) [ 34 ]. By utilizing this methodology, liquid film substrates can be imprinted directly with ultrathin metal meshes, resulting in FTEs that exhibit exceptional optoelectronic characteristics such as minimal sheet resistance and substantial transmittance. Enhanced mechanical stability and environmental adaptability are results of the embedded metal structure, which qualifies the material for use in severe environments. The technology's versatility in flexible electronics and optoelectronic devices is exemplified through its use in resistive transparent strain sensors and thermally driven 4D printing structures, among other applications. The reliability and consistent functionality of the flexible strain sensor are validated through an extensive array of tests conducted in the study. The resistance change of the sensor was specifically assessed when subjected to a strain rate of 60% for 1000 cycles to evaluate fatigue resistance. The findings indicate that the strain sensor exhibited consistent performance and stability during the entire testing phase, suggesting its dependability and suitability for uses requiring prolonged operation and robustness. This demonstrates the robustness of the sensor, rendering it appropriate for a wide range of practical applications that involve anticipated repetitive stress and strain.

3 Research gaps in the fatigue study of the 4D printed materials

Insufficient exploration of fatigue testing The principal aims of fatigue testing comprise evaluations of the material testing, the structure testing, and the actual service testing [ 35 ]. The objective of material testing is to clarify the behavior of substances when subjected to cyclic stresses, taking into account a range of environmental conditions, surface treatments, and geometric configurations. In contrast, structural type testing is dedicated to the assessment of various materials or structural configurations to determine the effects of stress concentration, estimate fatigue life, and analyze the consequences of fabrication methodologies. Lastly, the primary goal of service testing is to ensure quality and dependability by simulating real-world applications [ 20 ]. Although the testing methodologies are illustrated clearly on the literature, a substantial knowledge gap has been detected regarding the fatigue testing of 4D printed materials. Comprehension of the performance and durability of 4D printed materials under cyclic loading conditions, which is crucial for their application in engineering and design fields, is limited by the lack of research.

Insufficient exploration of influence of printing parameters on fatigue behavior The advent of 3D Printing technology offers the distinctive advantage of precisely controlling numerous printing parameters. In the context of fused filament fabrication (FFF), parameters such as raster angle, layer thickness, build orientation, raster width, print speed, infill density, air gap, infill pattern, extrusion temperature, platform temperature, nozzle diameter, and filament diameter can be meticulously adjusted [ 36 ]. These parameters significantly influence the mechanical properties and fatigue behavior of the printed parts [ 37 ]. Similar considerations apply to other 3D printing methodologies, each characterized by a unique set of controllable factors affecting the part's performance under cyclic loading. The impact of these printing parameters on the fatigue behavior of 3D printed materials necessitates thorough investigation to optimize their applications in various engineering domains. This exploration is crucial for advancing the understanding and utilization of 3D printing technologies, particularly in designing components with enhanced durability and reliability under operational stresses.

Limited numerical analysis for 4D printed materials In light of the complex structure and financial implications of 4D printing, the application of numerical simulations may present an efficient and economical approach to comprehend and forecast the performance of such materials across diverse circumstances. The fatigue behavior of 3D printed materials has been significantly investigated through numerical investigations, which have yielded valuable insights into fatigue parameters and material performance [ 38 , 39 ]. Likewise, by implementing these numerical methodologies into 4D printing, it would be possible to simulate fatigue behavior, providing engineers and researchers with a valuable instrument for enhancing material formulations and printing processes without necessitating extensive physical prototyping. By adopting this methodology, not only are resources conserved but also the development of more resilient and dependable 4D printed materials is expedited, thereby expanding the limits of what is conceivable with existing technology.

4 Conclusion

The purpose of this literature review was to provide a thorough synthesis of prior research concerning the fatigue characteristics of 4D printed materials, emphasizing significant findings. Additionally, the study aimed to identify areas where further research are needed in the field, thereby guiding future investigations to tackle these obstacles. Significant research gaps remain to be filled in the comprehension of fatigue behavior in 4D printed materials. Present constraints involve an absence of thorough fatigue testing methodologies, inadequate investigation into the impact of 3D printing parameters on fatigue behavior, and a significant void in numerical studies that seek to forecast the performance of these materials across diverse conditions. To effectively tackle these obstacles, a comprehensive strategy is necessary, which integrates progress in mechanical engineering, material science, and computational modeling. This integration enables the complete realization of the capabilities of 4D printed materials in applications that require exceptional durability and adaptability.

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