How does muscle relaxation improve physical function and reduce stress?

Progressive muscle relaxation.

Progressive muscle relaxation is practiced during both meditation and treatment approaches such as Feldenkrais.268,280,281 These methods of relaxation tend to trigger parasympathetic reactions, which in turn slow down heart rate and blood pressure and trigger slow, deep breathing (seeChapters 16 and39). The Alexander technique has also been shown to cause relaxation while simultaneously increasing postural tone.282

Treatment considerations using olfactory, gustatory, auditory, and visual systems. Boxes 8.2 to 8.5 present a summary of treatment considerations using the olfactory, gustatory, auditory and visual systems.

INTRODUCTION

Numerous benefits have been claimed for relaxation training for a variety of health problems associated with stress and anxiety, with a body of research work to its credit (Freeman 2001); this will be reviewed in more detail later in this chapter. Edmund Jacobson, the originator of the progressive muscle relaxation training, had observed in 1905 that deeply relaxed students demonstrated no obvious startle response to sudden noise; this became his life work (Jacobson 1977). He developed a lengthy and meticulous technique, which focused on getting in touch with musculature and learning to control the tension levels. Jacobson's method was designed so that the practitioner would eventually be able to automatically and unconsciously monitor and release unwanted tension. The process has since been adapted and shortened by others, most notably Joseph Wolpe, and has become known as the abbreviated progressive muscle relaxation training. Included in this adaptation is the tension–release cycle (e.g. make a tight fist and then release) combined with a focus on breathing. This variation is part of Wolpe's framework called systematic desensitization, aimed at getting in touch with the individual's tension and the body's response, and then letting it go in a controlled manner. Freeman (2001) suggests that PMR and other muscle-based relaxation variations convey health benefits in three ways:

Utilizing the effects of PMR to manipulate autonomic responses

Increases or activates the production of opiates

Promotes optimal immune function.

Autonomic responses determine whether the body needs to engage in a ‘fight-or-flight’ or ‘rest-and-digest’ scenario or to a state somewhere between these two extremes. The sympathetic division of the autonomic nervous system (ANS), associated with ‘flight-or-fight’ responses, mobilizes the body in emergency and stressful circumstances. Many of these responses are not immediately apparent to our consciousness. Physically, blood flow is redirected away from the digestive process to the smooth muscle, heart rate and blood pressure increase, with these processes triggered by the increase of circulating catecholamines, which include adrenaline and noradrenaline (Hucklebridge & Clow 2002). Associated with the stress response is the release of cortisol, which mobilizes energy reserves, increases sensitivity of tissues to neurotransmitters and inhibits the immune and inflammatory response. Freeman (2001) argues that PMR techniques blunt sympathetic arousal by training the individual to reduce oxygen requirements, achieved by the repetitive release of muscle tension combined with slowing of respirations. This makes it a useful therapeutic intervention for panic, phobias and anxiety states.

Important to well-being, endogenous opioids, such as enkephalins, dynorphins, endomorphins and β-endorphin, have been found to have a variety of effects, including analgesic, anti-inflammatory and bronchodilation (Jessop 2002). These compounds and their receptor sites have been located within immune tissues (Stephanou et al 1990). It has been argued that opioids play an important part in modulating stress responses. It has been noted that opioid production is increased in adults who exercise regularly (Freeman 2001) and is reduced in adults with enduring health problems such as chronic fatigue syndrome (Conti et al 1998). In a laboratory experiment (n = 32) to determine the role of endogenous opioids in the effects of PMR training, McCubben et al (1996) found that PMR significantly reduced diastolic pressure, but when an opioid blockade was administered, it antagonized the PMR training. Hypnotherapists could utilize the potential responses of reduced anxiety and pain relief in the development of anchors and post-hypnotic suggestions, with an intention to help build a patient's resources (Box 6.1).

Over three decades, Herbert Benson and colleagues (1984) have investigated the psychological and physiological effects associated with the relaxation response, elicited from PMR, meditation, yoga and physical exercise routines, many of which appear to be the opposite of the stress response. Stefano et al (1996: 3) have acknowledged that repetition is crucial to the relaxation response, but surmise that ‘trust or belief in expected outcomes’ can help to regulate immunological function via cognitive and neurological processes. This sense of improved well-being associated with the relaxation response has been labelled ‘remembered wellness’, which Benson (1996) has ascribed to memories of nurturance and maternal attachment. Lazar et al (2000) have investigated the relaxation response to meditation with functional magnetic resonance imaging (MRI) and mapped areas of the brain, which are responsive to opioids. Stefano et al (1996) suggests that this work demonstrates the mind–body wiring that could modulate the relationship between cognitive and physiological processes. In this review of neural processes and the relaxation response, Stefano and colleagues (1996) note that increased circulatory levels of opioids improve mood and sense of well-being, and refer to earlier work on enkephalins, which they found to have the additional benefit of stimulating immune cells. Aside from effects of opioids on heart rate, blood pressure, respiration, immune cells and mood, these compounds have also been found to stimulate antibacterial peptides in human studies (Tasiemski et al 2000). This information can provide a wealth of ideas for hypnotherapists using PMR and tailored suggestions, to enable patients to connect with feelings of being nurtured and supported.

The PMR method has a strong record of clinical efficacy and is an acknowledged standard strategy for a number of somatic states, including anxiety and stress, and features as part of clinical training in psychology (Pawlow & Jones 2002, Turner et al 1992). It is recommended that patients receive individual live instruction; indeed Lehrer and Woolfolf (1994) have argued that one-to-one training is crucial to effective training as well as any evaluative research. Relaxation techniques are increasingly being used as a non-pharmacological intervention by nurses, occupational therapists and medical practitioners in a variety of healthcare settings. DeMarco-Sinatra (2000), a nurse practitioner in the USA, believes that teaching relaxation techniques can be an appropriate role for nurses in both in-patient and out-patient settings. He argues that the activity supports patient autonomy and is cost-effective as a method of health promotion. We argue here that PMR and other forms of relaxation training are valuable additions to the hypnotherapy toolbox. Aside from being part of standard hypnotherapy induction training, PMR skills need to be updated and developed in ongoing training and supervision.

Relaxation Training

It is common for patients with pain, especially those with chronic pain, to experience stress along with comorbid anxiety, anger, and depression.19 These can predate the pain but nonetheless are capable of heightening the pain experience. Conversely affective disorders can also emerge after pain events, especially when pain is prolonged.19 Physiological stress responses occur in reaction to fear or perceived threats to safety.22 Epinephrine, norepinephrine, and cortisol are released, and when this happens repeatedly or when levels remain elevated for prolonged periods, the body develops a sensitized physiological stress response, which is easily triggered. This leads to prolonged elevation of cortisol, systemic inflammation, and increased pain. The stress–cortisol–pain cycle becomes self-perpetuating. The ability to break the cycle and invoke a relaxation response may help to reduce both stress and pain. Two widely used relaxation techniques are diaphragmatic breathing and progressive muscle relaxation. Diaphragmatic breathing trains patients to breathe slowly and deeply, engaging the diaphragm in abdominal excursion, the diaphragm in abdominal excursion rather than shallow, rapid chest breathing, which uses smaller accessory muscles. Diaphragmatic breathing has been demonstrated to impact emotions by decreasing negative cognitions and has also been shown to decrease cortisol levels and thus directly impacts the stress cycle.23

Progressive muscle relaxation is a whole-body relaxation technique in which participants alternately tense and relax muscle groups and regions of the body. It is thought that over time, with prolonged states of stress, the body “learns” to be tense. This state of muscle tension is often so persistent that it becomes “normal.” Through progressive muscle relaxation exercise, patients are able to feel the difference between tense and relaxed states, and it is thought that over time, muscle relaxation can be relearned.20

Both diaphragmatic breathing and progressive muscle relaxation fall within the scope of therapist’s practice expertise and can be performed in the clinic and issued as part of a home exercise program. Numerous online resources can be found to assist patients with home practice of these techniques. It is always prudent for therapists to curate a list of reliable digital and online resources to guide patients in their independent practice of these techniques at home.

Progressive muscle relaxation

Progressive muscle relaxation (PMR) involves a process of tightening and loosening muscle groups in a systematic way throughout the body. This practice aims to counteract a state of chronic muscle tension derived from pain-related sympathetic arousal by increasing the child’s awareness of when their muscles are tense and when they are relaxed, subsequently promoting a relaxation response.

PMR can begin with the toes and slowly work through the larger muscles of the entire body such as the feet, calves, thighs, arms, hands, and neck. Children are directed to isolate and tense each muscle for approximately 5–10 s while concentrating on the difference between that muscle feeling tense versus relaxed. Like diaphragmatic breathing, PMR can also incorporate imagery. Imagery is particularly important to engage younger children in PMR (e.g., “squeeze your hand like you are squeezing a lemon” or “relax your arms like they are made of spaghetti”). Once the patient has mastered PMR, they can apply this skill to more simple breath-guided or cue-controlled muscle relaxation that is not contingent on first tensing muscle groups.

Progressive muscle relaxation

Progressive muscle relaxation (PMR) aims to teach the individual what it feels like to relax the muscles by contrasting tensing the muscle groups in turn, followed by relaxing them. In this way, athletes learn to be aware of how the muscles feel when they are tense, and then what they can do to relax them. Through practice athletes can learn to recognize the difference between a tensed and relaxed muscle.

PMR is a good exercise to do initially when an athlete is injured, because muscle tension contributes to increased experience of pain. Actively tensing and relaxing the muscles gives the athletes a sense of control over their pain and injury management. The first sessions of PMR can take up to 30 minutes and it is recommended that the athletes follow a script for 16 muscle groups. Studies have demonstrated a variety of benefits of PMR including reducing somatic anxiety (Kolt et al., 2002; Maynard et al., 1995), rheumatic pain (Stenstrom et al., 1996) and muscle tension (Lehrer, 1982).

Progressive Muscle Relaxation

Progressive muscle relaxation is a technique commonly used for eliciting the relaxation response and relieving muscular tension. It is easy to learn and is accessible even to people who may not be familiar with or interested in meditation. It involves sequentially relaxing various muscle groups, often starting at the head and moving down the body to the feet. Participants may tense a muscle before relaxing it (for example, clenching the jaw and then releasing it) or simply bring their attention to a muscle group and intentionally relax it. A sample progressive muscle relaxation script is provided in Appendix A.

Background

Progressive muscle relaxation is one of the most commonly used relaxation techniques. It is based on the notion that it is impossible to be tense in any part of the body in which the muscles are completely relaxed. In addition, tension in involuntary muscles can be reduced if the associated skeletal muscles are relaxed. This technique is taught by tensing a muscle before relaxing it. Passive muscle relaxation involves the release of tension while focusing on muscle groups. Progressive muscle relaxation and other relaxation techniques generate a relaxation response, resulting in normalizing of the blood supply to the muscles, decreasing oxygen consumption, heart rate, respiration, and skeletal muscle activity and increasing skin resistance and alpha brain waves.

Other Mind-Body Practices

Progressive muscle relaxation, meditation, affirmations, journal writing, and prayer would all seem to be helpful in decreasing stress, although no studies have addressed these practices with respect to atopic dermatitis. What seems to be most important is the way each stress is perceived.61 Empowering patients with the knowledge that they do have control over emotions such as worry, guilt, and anxiety may help not only their skin but all aspects of their health. A good resource for patients is the text by Grossman and Sherman (see reference 130).

Relaxation

Progressive muscle relaxation in conjunction with breathing exercises can be effective in decreasing anxiety and controlling shortness of breath. One technique involves tensing muscle groups while slowly inhaling and then relaxing the muscle groups when exhaling twice as slowly through pursed lips. It is helpful to teach the patient a sequence of muscle groups to tense and relax. One common sequence involves tensing and relaxing first the face; followed by the face and the neck; then the face, neck, and shoulders; and so on, down the body to the toes. A calm, quiet, and comfortable environment is important for the novice in learning any relaxation technique. Biofeedback in conjunction with relaxation therapy promotes a more timely mastery of relaxation skills.

Progressive Muscle Relaxation and Breathing Exercises

Both progressive muscle relaxation and breathing exercises, used alone or in combination, are forms of self-regulation that help decrease sympathetic arousal to promote comfort. Progressive muscle relaxation is a way for children to learn to feel the difference between tense and relaxed muscles, and to use this knowledge to cope with abdominal pain. Progressive relaxation reduces anxiety associated with pain by demonstrating the mind-body phenomenon and patient capacity for self-regulation. The benefits of these approaches are that they are easily taught, particularly to school-age children, and can be used anywhere. Scripts can be given to parents to use, or a tape can be made or purchased for home use (see Chapters 94 and 95Chapter 94Chapter 95).