Relaxation Therapies
Elizabeth L. Pestka
Susan M. Bee
Michele M. Evans
Many people’s lives are very stressful so it is important to have techniques to help lower stress levels to maintain health. Complementary therapies can be used to decrease stress by reducing muscle tension in the body. Relaxation therapies have been shown to manage stress, offer pain relief, and promote health. A great many relaxation therapies exist. The ones discussed in this chapter range from the simple and easily implemented diaphragmatic breathing (DB) to more complex methods such as progressive muscle relaxation (PMR) and autogenic training (AT). Using a combination of these therapies is common because they provide a variety in terms of time to learn and to use.
DEFINITIONS
Relaxation therapies help reduce the tension that exists in muscles and this often generalizes to other areas of the body, including the mind. Learning to relax can reduce the destructive effects and symptoms of stress-induced illnesses and improve a person’s quality of life. Teaching patients relaxation techniques allows them to become more active partners in their health care.
DB, or relaxed deep breathing, uses the diaphragm when taking a breath. The purpose of relaxed breathing is to slow breathing and to reduce the use of shoulder, neck, and upper chest muscles to breathe more efficiently, which improves oxygenation to the entire body.
PMR is the tensing and releasing of successive muscle groups. This treatment was introduced by Jacobson (1938) and is still used widely today. A person’s attention is drawn to discriminating between the feelings experienced when a muscle group is relaxed and when it is tensed.
Autogenic training (AT) is a relaxation method that uses both imagery and body awareness to reduce stress and muscle tension. This technique was developed and published by the German neurologist Schultz (Schultz & Luthe, 1959) and addresses autonomic sensations that lead to muscle relaxation.
SCIENTIFIC BASIS
The aim of relaxation therapies is to reduce stress and the accompanying effects that stress has on the body. Real and perceived events and thoughts can create stress that activates the sympathetic nervous system. This begins a cascade of physical and chemical reactions. The heart pounds and blood pressure rises, respirations become shallow, pupils dilate, and the muscles tense as the body prepares to cope with the stressor. This is often called the fight-or-flight response. The parasympathetic nervous system is known as the rest and digest or rest and restore response. When one response is activated, the other is quiet. Prolonged activation of the sympathetic nervous system over time can have deleterious effects on the body. The desired outcome of relaxation strategies is the mitigation of persisting high levels of stress and activation of the parasympathetic nervous system.
When a person breathes, the body takes in oxygen and releases carbon dioxide. If the body detects an imbalance in these two gases, it signals for changes in breathing that may lead to fast, shallow breathing called hyperventilation, often in response to stressful events or pain. Diaphragmatic breathing (DB) is a relaxation technique that uses the diaphragm to breathe deeply and improve oxygenation to the entire body. It is a learned skill, and practice is required for optimal benefit. Research from Schmidt, Joyner, Tonyan, Reid, and Hooten (2012) provides evidence that using DB for 10 minutes three times per day significantly reduces self-rating of anxiety, depression, fatigue, sleep quality, and pain.
Jacobson (1938) reported that PMR decreased the body’s oxygen consumption, metabolic rate, respiratory rate, muscle tension, premature ventricular contractions, and systolic and diastolic blood pressure, and increased alpha brain waves. Subsequent studies, including that of Zhao et al. (2012), have validated Jacobson’s findings with results indicating a decrease in self-reported anxiety and depression, and an increase in quality of life for persons with endometriosis.
AT reduces excessive autonomic arousal and, in addition, it is effective in raising dysfunctionally low levels of autonomic functions such as
a low heart rate. It is known as a self-regulatory model. AT may not only affect sympathetic tone but may also activate the parasympathetic system as well. The increase in parasympathetic dominance results in peripheral vasodilation and increased feelings of warmth and heaviness in the body. An example of evidence supporting the use of AT is a study by Miu, Heilman, and Miclea (2009) that found heart rate volume and vagal control of the heart were positively impacted by use of this therapy.
a low heart rate. It is known as a self-regulatory model. AT may not only affect sympathetic tone but may also activate the parasympathetic system as well. The increase in parasympathetic dominance results in peripheral vasodilation and increased feelings of warmth and heaviness in the body. An example of evidence supporting the use of AT is a study by Miu, Heilman, and Miclea (2009) that found heart rate volume and vagal control of the heart were positively impacted by use of this therapy.
INTERVENTIONS
Relaxation means more than simply having peace of mind or resting. It means eliminating tension from the body and mind. Learning relaxation skills requires the person to focus on the mind-body connection, such as when muscles are tensed, and practice ways to relax the muscles to improve overall health and wellness.
Techniques
Diaphragmatic Breathing Technique
DB can be used before and during stressful situations, such as a painful procedure, or for overall health enhancement. It is a relatively simple relaxation technique that can be used in any health care setting and does not require extensive training of the instructor or the patient. The instructions for DB are found in Exhibit 18.1. Emphasis needs to be placed on the person practicing DB throughout the day until it becomes a natural way of breathing. For best effect, an individual should practice this technique frequently when neither anxious nor short of breath. Access naturalhealthperspective.com/resilience/deep-breathing.html for succinct information on DB.
Exhibit 18.1. Instructions for Diaphragmatic (Deep) Breathing
Sit comfortably with feet flat on the floor.
Loosen tight clothing around abdomen and waist.
Hands may be placed in lap or at sides.
Breathe in slowly (through nose if possible) allowing abdomen to expand with inhalation.
Exhale at normal rate.
Pursed-lip breathing—which creates a very small opening between lips through which to breathe out—may be used.
Progressive Muscle Relaxation Technique
Numerous techniques for muscle relaxation have been developed since Jacobson published his technique in 1938. Often the procedures include attention to breathing (Schaffer & Yucha, 2004). The instructor assists the individual in identifying a place that is quiet and restful in which to practice relaxation. A comfortable chair that provides support for the body is recommended. Clothing should be loose and not restrictive; shoes, glasses, and contact lenses should be removed. The person may wish to use the bathroom before practicing muscle relaxation.
The PMR therapy developed by Bernstein and Borkovec (1973) is widely used. They combined the 108 muscles and muscle groups of Jacobson’s original technique into the initial tensing and relaxing of 16 muscle groups. Subsequently, the number of groups was reduced to seven and then four (Exhibit 18.2). Although Bernstein and Borkovec included instructions for tensing muscles of the feet, those are not included in Exhibit 18.2 because spasms in the foot may result when tensing these muscles. The ultimate goal is to achieve muscle relaxation throughout the body without initially having to tense the muscles. Through practice, the individual acquires a mental image of how the muscles feel when they are relaxed and is able to relax them using this image.
Education on the scientific basis for the use of PMR is provided during the first session. Stressors, the impact of stress on the body, and the signs and symptoms of high levels of stress are discussed. Descriptions and demonstrations for achieving tension of each muscle group are given, and participants then practice tensing each of the muscle groups.
After progressing through all the muscle groups, the instructor asks the patient to identify whether tension remains in any of them. The instructor observes the patient to assess for general relaxation focusing on slowed, deeper breathing; arms relaxed and shoulders forward; and feet apart with toes pointing out. At the conclusion of the session, 2 or 3 minutes are provided for the patient to enjoy the feelings associated with relaxation. Terminating relaxation is done gradually. The instructor counts backward from four to one. The individual is given the opportunity to ask questions or discuss the feelings experienced.
Bernstein and Borkovec proposed using 10 sessions to teach PMR. However, in many studies instruction has been limited to fewer sessions with positive results. A critical factor in determining the number of teaching sessions needed is ensuring that people have mastered relaxing the muscle groups and have integrated PMR into their lifestyles.
An essential factor in the effectiveness of PMR and other relaxation techniques is daily practice. At least one 15-minute practice session a day is recommended. Schaffer and Yucha (2004) suggest two 10-minute sessions.
Helping patients find a time of day to practice relaxation is an important component of instruction. Often an audiotape of the instructions is provided for home practice. Persons are also instructed to use the relaxation technique anytime they feel tense or before an event that may cause them to become anxious and tense. Refer to www.guidetopsychology.com/pmr.htm for comprehensive instructions on PMR.
Helping patients find a time of day to practice relaxation is an important component of instruction. Often an audiotape of the instructions is provided for home practice. Persons are also instructed to use the relaxation technique anytime they feel tense or before an event that may cause them to become anxious and tense. Refer to www.guidetopsychology.com/pmr.htm for comprehensive instructions on PMR.
Exhibit 18.2. Guidelines for Progressive Muscle Relaxation for 14 Muscle Groups
General Information
Instruct persons to tense a specific muscle group when they hear “tense” and to release the tension when they hear “relax.” Tension is held for 7 seconds. Draw attention to the feeling of tension and relaxation. When muscles are relaxed, attention is drawn to the differences between the two states.
Tensing Specific Muscle Groups
Dominant hand and forearm: Make a tight fist and hold it.
Dominant upper arm: Push elbow down against the arm of the chair.
Repeat instructions for the nondominant arm.
Forehead: Lift eyebrows as high as possible.
Central face (cheeks, nose, eyes): Squint eyes and wrinkle nose.
Lower face and jaw: Clench teeth and widen mouth.
Neck: Pull chin down toward chest but do not touch chest.
Chest, shoulders, and upper back: Take deep breath and hold it, pull shoulder blades back.
Abdomen: Pull stomach in and try to protect it.
Dominant thigh: Lift leg and hold it straight out.
Dominant calf: Point toes toward ceiling.
Repeat instructions for the nondominant side.
Adapted from Bernstein and Borkovec (1973).
Autogenic Training
Autogenic training (AT) is a relaxation method that is self-generated or self-guided using relaxation phases. A health care provider familiar with the therapy can recommend the therapy and provide assistance with
learning the method. AT is gaining in worldwide use and is intended to create a feeling of warmth and heaviness throughout the body while experiencing a profound state of physical relaxation, bodily health, and mental health. AT is most effective when done in a quiet place, with the person wearing loose clothing and not wearing shoes. Practice should be done at a time when the individual has not recently eaten a large meal. The person focuses intently on inner experiences, with exclusion of external events. When the session finishes, people relax with their eyes closed for a few seconds and then get up slowly. Instructions for selfguided AT are given in Exhibit 18.3. Refer to www.guidetopsychology .com/autogen.htm for an example of in-depth instructions on phases to be used for relaxation. To maintain proficiency, practicing at least once a day is recommended.
learning the method. AT is gaining in worldwide use and is intended to create a feeling of warmth and heaviness throughout the body while experiencing a profound state of physical relaxation, bodily health, and mental health. AT is most effective when done in a quiet place, with the person wearing loose clothing and not wearing shoes. Practice should be done at a time when the individual has not recently eaten a large meal. The person focuses intently on inner experiences, with exclusion of external events. When the session finishes, people relax with their eyes closed for a few seconds and then get up slowly. Instructions for selfguided AT are given in Exhibit 18.3. Refer to www.guidetopsychology .com/autogen.htm for an example of in-depth instructions on phases to be used for relaxation. To maintain proficiency, practicing at least once a day is recommended.
Exhibit 18.3 Instructions for Self-Guided Autogenic Training
AT consists of a warm-up period of breathing and progressively learning six phases of relaxation that all together may take several months to fully master. On completion, a person will progress through and include:
Warm-up: Focused breathing on slowly exhaling
Phase I: Heaviness—arms and legs are heavy
Phase II: Warmth—arms and legs are warm
Phase III: A calm heart—heartbeat is calm
Phase IV: Breathing—breathing is steady
Phase V: Stomach—stomach is soft and warm
Phase VI: Cool forehead—forehead is cool
Completion: Feel supremely calm
Measurement of Outcomes
Although findings from many studies have shown positive outcomes from the use of relaxation techniques, positive results have not been reported in all the research in which these therapies were explored. Reasons for the differences in outcomes may relate to the wide variation in the types of relaxation techniques, the length and type of instruction, the degree of mastery of the therapy, and irregular or sporadic use of the procedures.
A variety of outcomes have been used to measure the efficacy of relaxation techniques. Physiological measurements that are often used
include respiratory rate, heart rate, and blood pressure. Electromyogram readings are occasionally taken to determine the degree of tension in the specific muscle groups. Practitioners need to be alert to underlying pathology or medications that may interfere with reduction in physiological parameters.
include respiratory rate, heart rate, and blood pressure. Electromyogram readings are occasionally taken to determine the degree of tension in the specific muscle groups. Practitioners need to be alert to underlying pathology or medications that may interfere with reduction in physiological parameters.
Anxiety is the most frequently used subjective measure. The State-Trait Anxiety Inventory (STAI) of Spielberger, Gorsuch, Luschene, Vagg, and Jacobs (1983) has been widely used. People’s self-reports about feelings of relaxation have been included in many studies because satisfaction is a good indicator of whether an individual will continue to use an intervention. Reports of reduction of pain, symptoms of depression, increases in comfort, and improved sleep are other results that have been used to measure the effects of these techniques.
Precautions
Although muscle relaxation techniques have been used with multiple populations and have been proven to be an effective therapy for nurses to use, some cautions should be observed. It is important for practitioners to know whether patients practice the relaxation techniques on a regular basis because this may affect the pharmacokinetics of medications. Adjustment in doses of medication for hypertension, diabetes, and seizures may be indicated.
Relaxation of muscles may produce a hypotensive state. People are instructed to remain seated for a few minutes after practice. Movement in place and gradual resumption of activities helps in raising the blood pressure. Taking a person’s blood pressure at the conclusion of teaching sessions helps in identifying those who are prone to hypotensive states after muscle relaxation, and AT as the relaxation therapy may have caused hypotension.
Some individuals with chronic pain have reported a heightened awareness of pain following the tensing and relaxing of muscles. Concentrating on tensing and relaxing of muscles may draw attention to the pain rather than to the muscle sensation. A good assessment of patients is needed to determine whether negative outcomes are occurring.
Children younger than school age lack the discipline to do AT. Also those with limited mental ability, acute central nervous system disorders, or uncontrolled psychosis may be unable to process the indepth instructions (Linden, 2007). In some patients, AT may produce the side effects of anxiety, sadness, resurfaced memories and suppressed thoughts, or reawakened pain sensation from old illnesses or injuries. These effects may stem from disinhibition of various cortical processes due to the autogenic formulas and the focus on body sensations (Lehrer, 2009).
USES
Promoting an understanding of the anticipated positive benefits of the therapies is critical. Relaxation therapies have been used to achieve a variety of outcomes in diverse populations. Exhibit 18.4 lists conditions and populations, including the country in which the research was conducted, showing widespread use of these therapies. Use of DB, PMR, and AT in reduction of anxiety and stress, relief of pain, and health promotion are discussed. Sidebar 18.1 describes how these relaxation therapies are used in the Republic of Singapore.
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