Over the weekend a discussion about relaxation and the how’s and why’s came up in a discussion group I belong to. Several members of the group, including me, contributed our ‘list of do’s and don’ts’, much of it based on years of clinical experience – until I thought (as I do!) what about the literature? What does research tell us about precautions and effectiveness of relaxation?
I have to say that my searches in the literature so far have failed to consider many of the practical tips that the group came up with, but I have found some really helpful reviews of relaxation that support its use in pain management. One of those more recent references is the one I’m focusing on today.
At the same time as wanting to briefly look at the evidence base for relaxation, I’m still musing on the clinical and experiential information that this group of therapists came up with, mulling over a few things like:
- how does this clinical information get passed on from clinician to clinician?
- how ‘true’ are these nuggest of applied wisdom?
- if I’m trying to identify the evidence for these gems, how do I go about it?
- how much of this information is ‘common sense’ – and then again, how much holds up when examined under the light of systematic enquiry?
That last one is especially important to me because so many of the myths about, for example, low back pain are based on ‘common sense’ – like that it’s ‘common sense’ to change the way we lift and move things because ‘everyone knows that the biomechanical models show that it makes sense not to lift things that are too heavy’. The problem is that while ‘common sense’ application of biomechanics to manual handling seems helpful, in practice the model doesn’t make a difference to whether low back pain develops, and can give people a misunderstanding about how ‘safe’ it is to actually move their backs. Common sense – and theoretical models – need to be tested in clinical practice to see whether their predictions hold true.
The group came up with a few tips that I hadn’t considered, such as not driving for 30 minutes after a relaxation session, or avoiding relaxation for two hours after a meal – but by and large the tips and tricks were very similar. Here’s a few that I came up with:
Rationale for introducing relaxation
- Elevated scores on pain-related anxiety and measures such as the TSK and PASS can be indicators for the usefulness of relaxation training.
- Reports of physiological arousal can be a rationale for introducing relaxation
- It can be used as a strategy to delay escape or avoidance behaviour in the presence of an aversive stimuli such as increased anxiety around a particular movement, or during periods of negative affect
- It’s useful to reduce physiological arousal when considering sleep management, and relaxation can form part of the ‘going to bed’ ritual to help with insomnia
Some researchers suggest relaxation is a cognitive strategy for coping with a situation – it provides the individual with a sense of self efficacy and control (ie ‘something to do’) when they’re in a situation they don’t feel comfortable with. Others base the rationale on the inability to maintain both physiological arousal and the relaxation response at once (a behavioural rationale).
There is some evidence to suggest that diaphragmatic breathing increases descending inhibition in some pain disorders (but not fibromyalgia) (Zautra, A., Fasman, R., Davis, M., & Craig, A. (2010). The effects of slow breathing on affective responses to pain stimuli: An experimental study Pain DOI: 10.1016/j.pain.2009.10.001)
Guidelines and precautions
- beware of getting up too fast – BP reduces during relaxation, and it’s important to stretch to restore a normal BP or you may end up with dizziness from postural hypotension
- be aware of paradoxical arousal when carrying out relaxation with an individual who is very hypervigilant and anxious, as they may hyperventilate and/or become distressed due to sensations of ‘floating’, ‘tingling’ and/or being unable to feel the body
- be wary of using imagery without discussing the content of that imagery first, with individuals who have experienced trauma (rape or accidents etc), as it can remind them of the situation they were in
- always remind the person that at any stage they are in complete control, and that they can open their eyes at any time, they will respond to external cues such as telephone or fire alarm. I often describe that relaxed state a person might be in when coming out of the movie theatre or reading a good book as comparable to a relaxation state
- some individuals experience relaxation induced headache especially if they’re not used to diaphragmatic breathing, it’s useful to check this with the individual after relaxing, and encourage them to breathe a little less deeply the next time they carry out a relaxation
There are many different types of relaxation training – while the two that have most research attention are Jacobsen Progressive Muscle Relaxation and Mindfulness Meditation, there are many others. In my clinical experience, it can often be a process of trial and error to identify the method that is most effective, practical and useful for an individual.
I have several strategies for going about relaxation training, depending on the clinical rationale for introducing it:
1. Breathing is the most portable and discrete strategy, and forms the basis for almost all of the relaxation techniques we use (with the exception of mindfulness meditation) I don’t progress beyond this much with a lot of individuals. I also focus mainly on the out breath because the in-breath will always happen (just try it and see what I mean!) For many people this is the easiest strategy to use while working or engaged in activity.
I usually won’t introduce other techniques unless they’ve ‘got’ the breathing part first. I often pair breathing out with a cue word and/or cue movement (eg finger to thumb). This is usually a relaxation response I work with the person to develop once they’ve achieved a light hypnotic trance, and I often use hypnosis and posthypnotic suggestion to strengthen the conditioned response to the outbreath and cue word.
2. Postural awareness and becoming aware of the contact of the body against the surface they’re resting on is often the next most important strategy, and I still use Laura Mitchell ‘Simple relaxation’ as one of the easiest to remember and integrate with normal activity as it can be carried out in most positions, and even while driving!
3. I rarely use Jacobsen or the Progressive Muscle Relaxation because it involves tensing then relaxing, which is hard to do. Try it yourself: clench your fists, then relax them. Then make your fingers long, then relax them – which one leads to a more relaxed experience? Tense/release is useful for individuals who have little kinaesthetic awareness.
4. I move quickly from a long and deep relaxation technique to briefer ones that can be integrated within a working situation. While I provide people with a CD of a long relaxation, this is best used prior to going to sleep, rather than one they can use at work, but it is useful when teaching someone the difference between being really relaxed and their usual state.
5. I often use biofeedback (particularly skin conductance and BVP, or heart rate variability) as a monitor for myself to determine how deeply relaxed an individual is, but primarily use it to demonstrate to people with limited body awareness or difficulty ‘getting’ the idea that body and mind are linked to recognise that they have control over what is usually not something they’d be aware of. The main difficulty with biofeedback is that people can’t take it home to practice with it.
6. I’m increasingly using mindfulness meditations now, because of their usefulness for attention management and the literature supporting its use in regulating emotions, physiological arousal, and maintaining engagement with negative experiences such as pain in a nonjudgemental way.
Persson, Veenhuizen, Zachrison & Gard (2008) reviewed 12 studies of relaxation techniques, in which at least 25 individuals were studied, the studies were RCT’s, relaxation techniques as single treatment, or combined with education, and participants were active in the treatment (ie not passive recipients of ‘relaxation’ by therapist).
It’s a good indication of the lack of systematic study of relaxation training in pain management that these authors found only 12 studies that met the inclusion criteria! Does this reflect the lack of ‘status’ of nonpharmacological pain management? Or simply that there is much less funding available for interventions that don’t involve pharmacology or surgery?
Positive effects were found regarding decreases in pain intensity, anxiety, depression, and fatigue (in fibromyalgia), and even reduced health care and medication costs. Participants were more mobile and seemed to use more coping strategies when they’d learned relaxation.
The studies themselves were only of moderate quality – they didn’t always include a training protocol (so it’s not clear whether each participant actually received the same relaxation intervention); control groups weren’t matched for age, gender, or even control intervention; and follow-up periods were fairly short.
It looks like a rich field for further study, despite the long history of relaxation as an intervention for pain and for psychiatric conditions. In the meantime, hopefully this post will introduce some of the ‘tips and tricks’ that could be useful.
Persson, A. L.,, Veenhuizen, H.,, Zachrison, L.,, & Gard, G (2008). Relaxation as treatment for chronic musculoskeletal pain a systematic review of randomised controlled studies Physical Therapy Reviews, 13 (5), 355-365