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Effects of body–mind training and relaxation stretching on persons with chronic toxic encephalopathy
Patient Education and Counseling 39 (2000) 155–161 www.elsevier.com / locate / pateducou
Effects of body–mind training and relaxation stretching on persons with chronic toxic encephalopathy Lis Engel*, Lars Bo Andersen Institute for Exercise and Sports Sciences, University of Copenhagen, Nørre Alle 51, Copenhagen 2200, Denmark Received 15 August 1998; received in revised form 11 January 1999; accepted 7 February 1999
Abstract The purpose of this project was to investigate the psychological and physical effects of training of body awareness and slow stretching on persons with chronic toxic encephalopathy (CTE). In the present study, a method of self-regulation, a body–mind training, is presented. The body–mind training used was a guided relaxation technique combined with meditative stretching. The techniques are introduced and the psychological and physiological effects of the training is presented. Eight subjects with CTE, 48.5 years, were trained for 8 weeks. Outcome measures were percentage alpha brain waves (alpha%), electromyography (EMG) on the frontalis muscle, state–trait anxiety (STAI), creativity (RAT), and mood measured as anxiousness, humour and mental fatigue. The mean alpha% increased 52% during the training period (P , 0.01), and the EMG decreased 31% (P , 0.001. State anxiety decreased 22% during the training period (P , 0.01), but no changes were observed in trait anxiety and in the creativity score. The level of anxiousness and fatigue before a training session decreased during the training period. In conclusion, the body–mind training resulted in an improved ability for physical and mental relaxation as indicated from the lower EMG, the higher alpha% and the decrease in state anxiety. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Chronic toxic encephalopathy; Body–mind training; Stretching; Alpha brain waves; EMG; State–trait anxiety
1. Introduction People with CTE caused by organic poisoning have major problems, not only because they have reduced work capacity, but also because they suffer from headaches, emotional disorder, aggressiveness, sleep problems, and depression, impairing their *Corresponding author. Tel.: 1 45-35-320816; fax: 1 45-35320870. E-mail address: [email protected] (L. Engel)
0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00017-8
quality of life. Most of these problems are linked with the ability to cope with stress. The influence of stress on various diseases has become increasingly obvious and various stress management techniques are becoming accepted parts of treatment programmes [1,2]. The field of stress management employs a variety of methods. Out of a diversity of psychosomatic-oriented therapies, some methods, such as autogenic training [3], progressive relaxation [4], and certain forms of oriental meditation such as Zen, Yoga and Transcendental meditation, are well
2000 Elsevier Science Ireland Ltd. All rights reserved.
156
L. Engel, L.B. Andersen / Patient Education and Counseling 39 (2000) 155 – 161
documented for their psychological and physiological effects [5–8]. Other procedures also have been used, but there are considerably fewer empirical data available to evaluate their relative effectiveness. These include listening to relaxing music, doing aerobic exercise [9], body awareness and relaxation methods [10,11]. These other techniques are described and evaluated by Lehrer and Woolfolk [12] and Lehrer and Carr [13]. Techniques with both strong cognitive and behavioural components are most effective treating more complex disorders, such as anxiety. It is usual with the CTE to feel extremely tired and all participants did report that they were very tired and felt depressed with their general life and work situations. Psychosomatic training, conscious training of both the body and the mind might be a positive therapy in their situation [11] The aim of this study was to evaluate 8 weeks of a body–mind training. The body–mind technique combines body relaxation and awareness training with slow, rhythmic stretching synchronized with deep breathing and a positive mental focus.
2. Methods Subjects were three women and five men diagnosed with chronic toxic encephalopathy (CTE). The mean age was 48.563.9. The diagnosis CTE was given based on symptoms of headache, emotional disorder, aggressiveness, sleep problems, amnesia, concentration difficulties and depression caused by long-term occupational exposure to neurotoxic chemicals. The subjects were earlier awarded fulltime pension because of CTE. The subjects were trained in a body–mind technique 1 h three times a week during two spring months. Before the training sessions started, a short theoretical introduction of the body–mind relation and the technique was introduced for the participants, and one day was spend with baseline testing including physiological and psychometric tests. The physiological tests were performed with the participants laying down on their back with the eyes closed and measurements were taken after 20 min of rest. After 2, 4 and 6 weeks of training a mood adjective check list was carried out immediately before and after a training section. After
8 weeks of training, the measurements used at baseline were repeated.
2.1. Physiological baseline measurements The resting percentage of alpha wave production (alpha%) and electromyography (EMG) were measured from the frontalis muscle of the forehead after 25 min of supine rest (Biotens III, Biometer I / S) [14–16].
2.2. Psychological baseline measurements State–trait anxiety is a personality inventory (STAI) [17]. Spielberger [17] defined state anxiety as a transient emotional state characterized by a subjective and conscious feeling of anxiety and tension and an activation of the sympathetic nervous system. Trait anxiety is defined as a relative stable condition related to the experience of different dangerous and threatening situations and assessed by 20 questions of the subjects general level of anxiety. State anxiety was assessed using 20 questions related to how subjects felt at the moment. They could choose between four levels in each question of the experience of the moment. Creativity was measured by Remote Associates Test (RAT) [18,19]. The test is based on associative interpretation of the creative thinking process. Creativity was defined by Mednick [19] as ‘the forming of associative elements into new combinations which either meet specified requirements or are in some way useful. The more mutually remote the elements of the new combination, the more creative the process or solution’. The test had 24 items which were randomly separated into an initial and a final version. The original version described by Mednick and Mednick [18] was used after translation into Danish.
2.3. Mood adjective check list ( MACL) test after 2, 4 and 6 weeks The mood of the participants were assessed after 2, 4 and 6 weeks of training immediately before and after the training session. We used a short form of Nowlis’ Mood Adjective Check List with 24 items [20]. The items were separated into three categories
L. Engel, L.B. Andersen / Patient Education and Counseling 39 (2000) 155 – 161
(MACL 1, 2 and 3) by a factor analysis with varimax rotation. MACL 1 included 8 items and described the level of anxiousness (level of control), MACL 2 used five items to describe humour (level of pleasentness) and MACL 3 used five items to describe fatigue (level of activation).
3. The training The training technique is divided into two sections: part I: body awareness, and part II: meditative stretching. The technique is inspired from meditative practice and theoretical and practical studies of different meditation and movement techniques [21– 24].
3.1. Body awareness The aim of this part was to teach the participants a technique of focussing their awareness on their body and to help them to relax. The exercise was a guided awareness through the whole body in slow motion, one side at a time, and the guiding voice was soft, slow and rhythmic. The participants were explained to follow the guidance in a very relaxed manner. They were asked to lay down on their back on a thin mat as relaxed as possible, eyes closed, palms resting on the stomach below the navel or by the side of the body and the legs spread apart naturally. A sound tape with gentle ocean waves was playing in the background. The guided exercise began: ‘Take a deep breath through the nose down to the stomach... keep the breath for a little while... feel the tension in the body... and then make a deep, slow expiration with the sound ‘aaaah’... and feel the body becoming more relaxed. Repeat this deep breathing in your own rhythm twice more. Let the breathing throughout the rest of the exercise continue in a slow and calm manner (stomach breathing) in your own tempo... and now let your awareness be in your body. Be aware of your body as it is right now and compare the feeling in the two sides of the body and just registrate for yourself if there is any difference. Begin by choosing one side of the body. Feel the foot... the toes... the heel... the ankle and then continue and let your awareness stream through your leg... the knee... the thigh... feel your awareness
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streaming through your whole leg... and now continue and let the awareness stream through your hip... the side of the waist... the side of the back. Feel the awareness streaming up along the side of the spine as a warming stream of energy filled with glowing light... and now feel the side of the chest... the shoulder... the elbow... the underarm... the wrist... the hand... the palm... the fingers... and feel the centre of the palm... and the fingertips’. After one side of the body was finished, the participants were again asked to take a deep breath, hold the breath with a feeling of ‘floating balance’ and then to make a deep, slow expiration with the sound ‘aaaah’. Again the participants were asked to be aware of their bodies and to register for themselves if they felt any differences of the two sides of the body. The whole procedure was repeated for the other side of the body. Then the guidance continued through the neck and the head. ‘... and now feel the throat, let the awareness continue up through the neck... and feel the chin... and the face... the cheeks... the lips... the eyes... the eyebrows... the forehead... the ears... the back of the head... and the top of the head’. This part of the exercise again ended with the awareness floating through the whole body and a silent comparison of the feeling in the two sides of the body. Part I took 20 min.
3.2. Meditative stretching This part was a series of 14 basic stretching exercises chained together in a continuous slow motion movement synchronized with deep breathing and positive imagery such as ‘floating balance’ and ‘a warming, stream of energy filled with glowing light’. After the passive body awareness part, the participants were asked to make a flowing transition to the active part, moving fluently into seiza (sitting on the knees) or if this was not possible, just moving softly into sitting cross legged (eventually on a small pillow) keeping the back in a long, relaxed balance. The awareness should be in the deep, rhythmic breathing, feeling the movements from the breath streaming through the whole body. The eyes should be half open and ‘soft’ (unfocused).We used the metaphor that they should imagine that they were looking at something lovable and beautiful and that they were breathing the smell of a beautiful flower,
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softening and relaxing the whole face. Before beginning the stretching exercises the participants were asked to do three deep breathings in the same way as at the beginning of the passive body awareness exercise. Then the slow, rhythmic series of stretching exercises began (a video of the series of exercises is available at the Institute). Each movement began with a deep breathing through the nose down to the stomach, then the breath was kept for a little while with a feeling of ‘floating balance’ and as soon as the expiration began the participants moved out into the first stretching position. They stayed there for two or three more deep breaths and on the end of the last expiration they moved back into the seiza or the cross-legged sitting. Then each person waited for the next deep inspiration, the back in a long, fluid position, and then holding the breath for a little while with the feeling of ‘floating balance’. As soon as the expiration began, they moved out into the next stretching position and so on. The whole program took about 20 min. When the exercises were well known and the participants felt secure, the background formula was added. On the inspiration the participants said inside themselves: ‘I am balanced’ and on the expiration: ‘Energy is floating through me’. The end and transition back to normal way of being was quite simple. The program ended with the participants laying down with the awareness in the breathing and with the feeling of the background formula in his body: ‘I am balanced’ and ‘Energy is floating through me’. Then the program was finished in a simple way, every body stretching their bodies in a natural way as if they were waking up from a beautiful dream..
4. Results
4.1. Comparison before and after the training period To evaluate physiological and psychological effects of the body–mind technique, the alpha brain wave percentage of the total amount of brain waves in the frontal area, EMG, state–trait anxiety and creativity were measured before and after the training period (Table 1).
Table 1 Mean and standard deviation (S.D.) of percentage alpha waves (alpha%), EMG, state–trait anxiety and creativity (RAT) before and after 8 weeks of training
Alpha% EMG (FV) State anxiety Trait anxiety RAT
Before training
After training
Mean
S.D.
Mean
S.D.
20.7 2.6 48.4 55.4 6.8
7.4 0.6 12.6 11.3 4.3
31.5 1.8 39.6 52.6 6.6
7.8 0.5 9.9 11.6 3.7
P,
0.01 0.001 0.01
The mean alpha% increased 52% during the training period (P , 0.01), and the EMG decreased 31% (P , 0.001. State anxiety decreased 22% during the training period (P , 0.01), but no changes were observed in trait anxiety and in the creativity score (Table 1). Before training, no relationship was found between physiological (EMG, EEG) and psychological (state and trait anxiety, creativity) measurements. After the training period a close relationship was found between EMG and state anxiety (r 5 0.85, P , 0.01). Both before and after training a close relationship was found between state and trait anxiety (r 5 0.83, P , 0.01). No relationship was found between changes in these variables over the training period. This may be caused by the limited number of participants, as r values below 0.65 don’t reach significance level with only eight participants.
4.2. Changes during the training period The effects of a single training session on anxiousness (MACL 1), humour (MACL 2) and mental fatigue (MACL 3) were measured during the training period after 2, 4 and 6 weeks of training. The checklists were filled out immediately before and after the training session in order to measure the acute mood effects of the training. The scale range from 2 4 to 1 4.The higher the number, the less anxiousness (MACL 1), the better humour (MACL 2), and the less mental fatigue (MACL 3) (Table 2). The participants had a high level of anxiousness, when they arrived to the training. The level before the training session decreased from 2 to 6 weeks of training. Also, a tendency to a decrease during the single training session (here and now effect) was
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Table 2 Acute effects of a single training session on anxiousness, humour and mental fatigue (Higher values are better scores and values are given as mean and (S.D.) P,
Before the training session
After the training session
Mean
S.D.
Mean
S.D.
MACL 1 (anxiousness) After 2 weeks After 4 weeks After 6 weeks
2 1.32 2 1.1 2 0.57*
1.54 1.77 1.21
2 0.58 2 0.78 2 0.31
1.29 1.33 1.34
MACL 2 (humour) After 2 weeks After 4 weeks After 6 weeks
2 0.24 0.28 0.26
0.89 1.33 1.49
0.5 0.38 0.48
1.15 1.07 1.37
MACL 3 (mental fatigue) After 2 weeks After 4 weeks After 6 weeks
0.3 0.02 2 0.23*
0.63 0.69 0.95
0.61 0.27 2 0.14
0.74 0.92 0.59
0.01
* Denotes that the initial level before the training session was lower (both MACL 1 and MACL 3) after 6 weeks of training compared to after 2 weeks of training (P , 0.05).
observed both after 2, 4 and 6 weeks and the decrease was significant after 2 weeks of training (P , 0.01). Thus, the participants felt less anxious both directly after a training session, but also as an accumulating effect over time. The scores on MACL factor two (humour) showed a tendency towards better humour both over time and as a here and now effect (here and now effect after 2 weeks of training, P 5 0.08). However, the scores did not change significantly neither over time nor on the here and now effect of the training session. A tendency was found towards a decrease in mental fatigue (MACL 3) during a training session, but analysed after 2, 4 and 6 weeks, separately, the decrease was not significant. However, the initial level of fatigue increased over time (from 2 to 6 weeks of training).
5. Discussion A randomized and controlled trial would have been optimal, but the group was too small to be divided in two groups. The group had already been treated in many ways in the official health care system trying to improve their overall situation and because of the difficulty of their situation we decided
to do the research, even if we could not control for internal invalidity. One could argue that the positive effects that we found, could be caused by positive expectations and the positive atmosphere that was created in the group during the training period. As this technique is a holistic body–mind training, it is not possible to conclude which of the elements were more important. However, even if this is the case, the benefit seen in the present study is more than the health care system has achieved for these persons over years of rehabilitation. The main results showed that this body–mind technique produced a better ability to physical and mental relaxation as indicated from the lower EMG, the higher alpha% and the decrease in state anxiety. These results may all reflect a change in sympathetic nervous activity. Thus the mean frequency of the EEG increases with activation. Each ordinary state of consciousness (waking, deep sleep and rapid eye movement sleep) is accompanied by a unique subjective description of experience as well as state specific EEG, EMG and eye movement patterns [25]. Such transcendental states are described as deeply restful yet alert. Such experiences have been shown to be correlated with a stable, theta–alpha (7–9 Hz) pattern [22]. Cornelius et al. [26] found that the mean frequency was more closely related to the level of anxiety than to the level of activation. After training
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we found a higher alpha% (P , 0.01) and a lower state anxiety (P , 0.01). This point at the possibility that the participants have learned to lower their state anxiety and that this might be related to a greater percentage of the slow alpha waves indicating a state of relaxed wakefulness. There has not been a lot of research on slow motion, deep breathing exercises and EEG, but an increase in alpha% in the frontal is reported as characteristic of Qi Gong training, a Chinese system of deep breathing exercises [21]. In contrast to ordinary wakefulness with closed eyes the Qi Gong state is characterised by the alpha activity predominantly in the anterior regions. Our study did indeed show a significant increase in the total amount of alpha% in the frontal area. Of course, we do not indicate that our participants did experience the special Qi Gong state, but we intended to help our participants to experience states of being active and alert and at the same time relaxed, and the increase of alpha waves in the frontal area point in this direction [22]. Some studies have found higher EMG in anxious individuals and the general relaxation response would hypothesize that a lower EMG also would indicate a lower anxiety [27]. Different kinds of training of deep muscle relaxation techniques is a standard for teaching relaxation to tense persons and changes in muscular tension provide a valuable index of the efficacy of such strategies [28]. In the present study, the decrease in EMG and the reduction in state–anxiety could be seen as important indicators of a psycho-physical relaxation effect. The testing of the mood (MACL 1) in combination with the training show that the participants were very anxious and tense, when they came to the training, and they were less tense after the training. The humour (MACL 2) showed a tendency toward better humour after each training session and over time. These observations were congruent with the spontaneous subjective reports. All in the group expressed spontaneously that they generally felt in better humour and that they felt much more optimistic about what they would be able to do in their life. The subjective statements were not systematically recorded and are therefore not included in the results. The interpretation of the tiredness (MACL 3) were less obvious and scores conflicted with the feelings the participants expressed spontaneously. A possible
explanation could be that the MACL testing was performed immediately after the training and the participants told us that they found it difficult to choose the word that best suited their mood immediately after training. MACL self-report scales on fatigue have been shown to measure fatigue but they did not correlate with an objective measure of fatigue [29]. To concentrate for such a long time, 45 min, was really a strain for the participants. In the beginning they were nervous that they could not do the exercises well enough. They had problems with the stretching exercises and we had to modify some of the exercises individually, but they expressed that they gradually felt less strain and more and more enjoyed doing the training. For some it meant that they were able to sleep better, make love better, and not becoming as easily tired or irritated. They still had problems concentrating for longer periods of time, but being generally more optimistic they felt happier and more patient both with themselves and with their surroundings.
References [1] Dantzer R. Stress and disease: a psychobiological perspective. Ann Behav Med 1991;13:205–10. [2] Pelletier KR. Mind–body health: research, clinical and policy applications. Am J Health Promot 1992;6:345–58. [3] Luthe W. Autogenic Therapy, New York: Grune and Stratton, 1969. [4] Jacobsen E. The Progressive Relaxation, Chicago: University of Chicago Press, 1929. [5] Hiray T. Zen and the Mind, Tokyo: Japan Publications, 1978. [6] Anand BW, China GS, Singh B. Some aspects of electroencephalographical studies in yogis. Electroencephalogr Clin Neurophysiol 1961;13:452–6. [7] Wallace RK, Benson HJ. The physiology of meditation. Sci Am 1972;226:85–90. [8] Ikemi A, Tomita Y, Ikemi Y. Self-regulation method: Psychological, physiological and clinical considerations. Psychother Psychocom 1986;46:184–95. [9] King AC, Taylor CB, Haskell WL, DeBusk RF. Influence of regular aerobic exercise on psychological health: A randomized, controlled trial of healthy middle-aged adults. Health Psychol 1989;8:305–24. [10] Barlow W. The Alexander Technique, New York: Knopf, 1973. [11] Feldenkrais M. Body Awareness as Healing Therapy: the Case of Nora, Berkeley, CA: UCLA Press, 1993.
L. Engel, L.B. Andersen / Patient Education and Counseling 39 (2000) 155 – 161 [12] Lehrer PM, Woolfolk RL. Principles and Practice of Stress Management, 2nd, New York: Guilford Press, 1993. [13] Lehrer PM, Carr R. Stress management techniques: are they all equivalent, or do they have specific effects? Biofeedback Self-regul 1994;19:353–60. [14] Delmonte MM. Electrocortical activity and related phenomena associated with meditation practice. A literature review. Int J Neurosci 1984;24:217–31. [15] Echenhofer FG, Coombs MM. A brief review of research and controversies in EEG biofeedback and meditation. J Transpers Psychol 1998;19:161–71. [16] DeGood DE, Crisholm RC. Multiple response comparison of parietal EEG and frontalis biofeedback. Psychophysiology 1977;14:258–65. [17] Spielberger CD, Gorsuch RL, Lushene E. Manual For State Trait Anxiety Inventory, Palo Alto: Consulting Psychologists Press, 1970. [18] Mednick SA, Mednick MT. Examiners Manual. Remote Associates Test (Danish version By Hans Weltzer, Boston: Houghton Mifflin, 1967. [19] Mednick SA. The associative basis of the creative process. Psychol Rev 1962;69:220–32. [20] Nowlis V. Final report on the development of a mood adjective check list (MACL, Washington DC: Office of Naval Research, 1966, Contract no. 668 (12).
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[21] Zhang J-Z, Zhao J, He Q-N. EEG findings during special physical state (Qi Gong state) by means of compressed spectral array and topographic mapping. Comput Biol Med 1988;18:455–63. [22] Wallace RK. Physiological effects of Transcendental meditation. Science 1970;167:1751–4. [23] Tart CT. Consciousness, altered states and worlds of experience. J Transpers Psychol 1986;18:159–70. [24] Feldenkrais M. Awareness Through Movement, Arkana, 1990. [25] Niedermeyer E, Lopes da Silva F. Electroencephalography: Basic Principles, Clinical Applications and Related Fields, Baltimore: Urban & Schwarzenberg, 1987. [26] Cornelius JR, Schulz SC, Brenner RP, Soloff PH, Ulrich RF. Changes in EEG mean frequency associated with anxiety and with amphetamine. Biol Psychiatry 1988;24:587–94. [27] Benson H, Beary JR, Carol MP. The relaxation response. Psychiatry 1974;37:37–46. [28] Hillenberg JB, Collins FL. A procedural analysis and review of relaxation training research. Behav Res Ther 1982;20:251–60. [29] May J, Kline P. Problems in using an adjective checklist to measure fatigue. Pers Individ Diff 1988;9:831–2.
Effects of body–mind training and relaxation stretching on persons with chronic toxic encephalopathy Lis Engel*, Lars Bo Andersen Institute for Exercise and Sports Sciences, University of Copenhagen, Nørre Alle 51, Copenhagen 2200, Denmark Received 15 August 1998; received in revised form 11 January 1999; accepted 7 February 1999
Abstract The purpose of this project was to investigate the psychological and physical effects of training of body awareness and slow stretching on persons with chronic toxic encephalopathy (CTE). In the present study, a method of self-regulation, a body–mind training, is presented. The body–mind training used was a guided relaxation technique combined with meditative stretching. The techniques are introduced and the psychological and physiological effects of the training is presented. Eight subjects with CTE, 48.5 years, were trained for 8 weeks. Outcome measures were percentage alpha brain waves (alpha%), electromyography (EMG) on the frontalis muscle, state–trait anxiety (STAI), creativity (RAT), and mood measured as anxiousness, humour and mental fatigue. The mean alpha% increased 52% during the training period (P , 0.01), and the EMG decreased 31% (P , 0.001. State anxiety decreased 22% during the training period (P , 0.01), but no changes were observed in trait anxiety and in the creativity score. The level of anxiousness and fatigue before a training session decreased during the training period. In conclusion, the body–mind training resulted in an improved ability for physical and mental relaxation as indicated from the lower EMG, the higher alpha% and the decrease in state anxiety. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Chronic toxic encephalopathy; Body–mind training; Stretching; Alpha brain waves; EMG; State–trait anxiety
1. Introduction People with CTE caused by organic poisoning have major problems, not only because they have reduced work capacity, but also because they suffer from headaches, emotional disorder, aggressiveness, sleep problems, and depression, impairing their *Corresponding author. Tel.: 1 45-35-320816; fax: 1 45-35320870. E-mail address: [email protected] (L. Engel)
0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00017-8
quality of life. Most of these problems are linked with the ability to cope with stress. The influence of stress on various diseases has become increasingly obvious and various stress management techniques are becoming accepted parts of treatment programmes [1,2]. The field of stress management employs a variety of methods. Out of a diversity of psychosomatic-oriented therapies, some methods, such as autogenic training [3], progressive relaxation [4], and certain forms of oriental meditation such as Zen, Yoga and Transcendental meditation, are well
2000 Elsevier Science Ireland Ltd. All rights reserved.
156
L. Engel, L.B. Andersen / Patient Education and Counseling 39 (2000) 155 – 161
documented for their psychological and physiological effects [5–8]. Other procedures also have been used, but there are considerably fewer empirical data available to evaluate their relative effectiveness. These include listening to relaxing music, doing aerobic exercise [9], body awareness and relaxation methods [10,11]. These other techniques are described and evaluated by Lehrer and Woolfolk [12] and Lehrer and Carr [13]. Techniques with both strong cognitive and behavioural components are most effective treating more complex disorders, such as anxiety. It is usual with the CTE to feel extremely tired and all participants did report that they were very tired and felt depressed with their general life and work situations. Psychosomatic training, conscious training of both the body and the mind might be a positive therapy in their situation [11] The aim of this study was to evaluate 8 weeks of a body–mind training. The body–mind technique combines body relaxation and awareness training with slow, rhythmic stretching synchronized with deep breathing and a positive mental focus.
2. Methods Subjects were three women and five men diagnosed with chronic toxic encephalopathy (CTE). The mean age was 48.563.9. The diagnosis CTE was given based on symptoms of headache, emotional disorder, aggressiveness, sleep problems, amnesia, concentration difficulties and depression caused by long-term occupational exposure to neurotoxic chemicals. The subjects were earlier awarded fulltime pension because of CTE. The subjects were trained in a body–mind technique 1 h three times a week during two spring months. Before the training sessions started, a short theoretical introduction of the body–mind relation and the technique was introduced for the participants, and one day was spend with baseline testing including physiological and psychometric tests. The physiological tests were performed with the participants laying down on their back with the eyes closed and measurements were taken after 20 min of rest. After 2, 4 and 6 weeks of training a mood adjective check list was carried out immediately before and after a training section. After
8 weeks of training, the measurements used at baseline were repeated.
2.1. Physiological baseline measurements The resting percentage of alpha wave production (alpha%) and electromyography (EMG) were measured from the frontalis muscle of the forehead after 25 min of supine rest (Biotens III, Biometer I / S) [14–16].
2.2. Psychological baseline measurements State–trait anxiety is a personality inventory (STAI) [17]. Spielberger [17] defined state anxiety as a transient emotional state characterized by a subjective and conscious feeling of anxiety and tension and an activation of the sympathetic nervous system. Trait anxiety is defined as a relative stable condition related to the experience of different dangerous and threatening situations and assessed by 20 questions of the subjects general level of anxiety. State anxiety was assessed using 20 questions related to how subjects felt at the moment. They could choose between four levels in each question of the experience of the moment. Creativity was measured by Remote Associates Test (RAT) [18,19]. The test is based on associative interpretation of the creative thinking process. Creativity was defined by Mednick [19] as ‘the forming of associative elements into new combinations which either meet specified requirements or are in some way useful. The more mutually remote the elements of the new combination, the more creative the process or solution’. The test had 24 items which were randomly separated into an initial and a final version. The original version described by Mednick and Mednick [18] was used after translation into Danish.
2.3. Mood adjective check list ( MACL) test after 2, 4 and 6 weeks The mood of the participants were assessed after 2, 4 and 6 weeks of training immediately before and after the training session. We used a short form of Nowlis’ Mood Adjective Check List with 24 items [20]. The items were separated into three categories
L. Engel, L.B. Andersen / Patient Education and Counseling 39 (2000) 155 – 161
(MACL 1, 2 and 3) by a factor analysis with varimax rotation. MACL 1 included 8 items and described the level of anxiousness (level of control), MACL 2 used five items to describe humour (level of pleasentness) and MACL 3 used five items to describe fatigue (level of activation).
3. The training The training technique is divided into two sections: part I: body awareness, and part II: meditative stretching. The technique is inspired from meditative practice and theoretical and practical studies of different meditation and movement techniques [21– 24].
3.1. Body awareness The aim of this part was to teach the participants a technique of focussing their awareness on their body and to help them to relax. The exercise was a guided awareness through the whole body in slow motion, one side at a time, and the guiding voice was soft, slow and rhythmic. The participants were explained to follow the guidance in a very relaxed manner. They were asked to lay down on their back on a thin mat as relaxed as possible, eyes closed, palms resting on the stomach below the navel or by the side of the body and the legs spread apart naturally. A sound tape with gentle ocean waves was playing in the background. The guided exercise began: ‘Take a deep breath through the nose down to the stomach... keep the breath for a little while... feel the tension in the body... and then make a deep, slow expiration with the sound ‘aaaah’... and feel the body becoming more relaxed. Repeat this deep breathing in your own rhythm twice more. Let the breathing throughout the rest of the exercise continue in a slow and calm manner (stomach breathing) in your own tempo... and now let your awareness be in your body. Be aware of your body as it is right now and compare the feeling in the two sides of the body and just registrate for yourself if there is any difference. Begin by choosing one side of the body. Feel the foot... the toes... the heel... the ankle and then continue and let your awareness stream through your leg... the knee... the thigh... feel your awareness
157
streaming through your whole leg... and now continue and let the awareness stream through your hip... the side of the waist... the side of the back. Feel the awareness streaming up along the side of the spine as a warming stream of energy filled with glowing light... and now feel the side of the chest... the shoulder... the elbow... the underarm... the wrist... the hand... the palm... the fingers... and feel the centre of the palm... and the fingertips’. After one side of the body was finished, the participants were again asked to take a deep breath, hold the breath with a feeling of ‘floating balance’ and then to make a deep, slow expiration with the sound ‘aaaah’. Again the participants were asked to be aware of their bodies and to register for themselves if they felt any differences of the two sides of the body. The whole procedure was repeated for the other side of the body. Then the guidance continued through the neck and the head. ‘... and now feel the throat, let the awareness continue up through the neck... and feel the chin... and the face... the cheeks... the lips... the eyes... the eyebrows... the forehead... the ears... the back of the head... and the top of the head’. This part of the exercise again ended with the awareness floating through the whole body and a silent comparison of the feeling in the two sides of the body. Part I took 20 min.
3.2. Meditative stretching This part was a series of 14 basic stretching exercises chained together in a continuous slow motion movement synchronized with deep breathing and positive imagery such as ‘floating balance’ and ‘a warming, stream of energy filled with glowing light’. After the passive body awareness part, the participants were asked to make a flowing transition to the active part, moving fluently into seiza (sitting on the knees) or if this was not possible, just moving softly into sitting cross legged (eventually on a small pillow) keeping the back in a long, relaxed balance. The awareness should be in the deep, rhythmic breathing, feeling the movements from the breath streaming through the whole body. The eyes should be half open and ‘soft’ (unfocused).We used the metaphor that they should imagine that they were looking at something lovable and beautiful and that they were breathing the smell of a beautiful flower,
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softening and relaxing the whole face. Before beginning the stretching exercises the participants were asked to do three deep breathings in the same way as at the beginning of the passive body awareness exercise. Then the slow, rhythmic series of stretching exercises began (a video of the series of exercises is available at the Institute). Each movement began with a deep breathing through the nose down to the stomach, then the breath was kept for a little while with a feeling of ‘floating balance’ and as soon as the expiration began the participants moved out into the first stretching position. They stayed there for two or three more deep breaths and on the end of the last expiration they moved back into the seiza or the cross-legged sitting. Then each person waited for the next deep inspiration, the back in a long, fluid position, and then holding the breath for a little while with the feeling of ‘floating balance’. As soon as the expiration began, they moved out into the next stretching position and so on. The whole program took about 20 min. When the exercises were well known and the participants felt secure, the background formula was added. On the inspiration the participants said inside themselves: ‘I am balanced’ and on the expiration: ‘Energy is floating through me’. The end and transition back to normal way of being was quite simple. The program ended with the participants laying down with the awareness in the breathing and with the feeling of the background formula in his body: ‘I am balanced’ and ‘Energy is floating through me’. Then the program was finished in a simple way, every body stretching their bodies in a natural way as if they were waking up from a beautiful dream..
4. Results
4.1. Comparison before and after the training period To evaluate physiological and psychological effects of the body–mind technique, the alpha brain wave percentage of the total amount of brain waves in the frontal area, EMG, state–trait anxiety and creativity were measured before and after the training period (Table 1).
Table 1 Mean and standard deviation (S.D.) of percentage alpha waves (alpha%), EMG, state–trait anxiety and creativity (RAT) before and after 8 weeks of training
Alpha% EMG (FV) State anxiety Trait anxiety RAT
Before training
After training
Mean
S.D.
Mean
S.D.
20.7 2.6 48.4 55.4 6.8
7.4 0.6 12.6 11.3 4.3
31.5 1.8 39.6 52.6 6.6
7.8 0.5 9.9 11.6 3.7
P,
0.01 0.001 0.01
The mean alpha% increased 52% during the training period (P , 0.01), and the EMG decreased 31% (P , 0.001. State anxiety decreased 22% during the training period (P , 0.01), but no changes were observed in trait anxiety and in the creativity score (Table 1). Before training, no relationship was found between physiological (EMG, EEG) and psychological (state and trait anxiety, creativity) measurements. After the training period a close relationship was found between EMG and state anxiety (r 5 0.85, P , 0.01). Both before and after training a close relationship was found between state and trait anxiety (r 5 0.83, P , 0.01). No relationship was found between changes in these variables over the training period. This may be caused by the limited number of participants, as r values below 0.65 don’t reach significance level with only eight participants.
4.2. Changes during the training period The effects of a single training session on anxiousness (MACL 1), humour (MACL 2) and mental fatigue (MACL 3) were measured during the training period after 2, 4 and 6 weeks of training. The checklists were filled out immediately before and after the training session in order to measure the acute mood effects of the training. The scale range from 2 4 to 1 4.The higher the number, the less anxiousness (MACL 1), the better humour (MACL 2), and the less mental fatigue (MACL 3) (Table 2). The participants had a high level of anxiousness, when they arrived to the training. The level before the training session decreased from 2 to 6 weeks of training. Also, a tendency to a decrease during the single training session (here and now effect) was
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Table 2 Acute effects of a single training session on anxiousness, humour and mental fatigue (Higher values are better scores and values are given as mean and (S.D.) P,
Before the training session
After the training session
Mean
S.D.
Mean
S.D.
MACL 1 (anxiousness) After 2 weeks After 4 weeks After 6 weeks
2 1.32 2 1.1 2 0.57*
1.54 1.77 1.21
2 0.58 2 0.78 2 0.31
1.29 1.33 1.34
MACL 2 (humour) After 2 weeks After 4 weeks After 6 weeks
2 0.24 0.28 0.26
0.89 1.33 1.49
0.5 0.38 0.48
1.15 1.07 1.37
MACL 3 (mental fatigue) After 2 weeks After 4 weeks After 6 weeks
0.3 0.02 2 0.23*
0.63 0.69 0.95
0.61 0.27 2 0.14
0.74 0.92 0.59
0.01
* Denotes that the initial level before the training session was lower (both MACL 1 and MACL 3) after 6 weeks of training compared to after 2 weeks of training (P , 0.05).
observed both after 2, 4 and 6 weeks and the decrease was significant after 2 weeks of training (P , 0.01). Thus, the participants felt less anxious both directly after a training session, but also as an accumulating effect over time. The scores on MACL factor two (humour) showed a tendency towards better humour both over time and as a here and now effect (here and now effect after 2 weeks of training, P 5 0.08). However, the scores did not change significantly neither over time nor on the here and now effect of the training session. A tendency was found towards a decrease in mental fatigue (MACL 3) during a training session, but analysed after 2, 4 and 6 weeks, separately, the decrease was not significant. However, the initial level of fatigue increased over time (from 2 to 6 weeks of training).
5. Discussion A randomized and controlled trial would have been optimal, but the group was too small to be divided in two groups. The group had already been treated in many ways in the official health care system trying to improve their overall situation and because of the difficulty of their situation we decided
to do the research, even if we could not control for internal invalidity. One could argue that the positive effects that we found, could be caused by positive expectations and the positive atmosphere that was created in the group during the training period. As this technique is a holistic body–mind training, it is not possible to conclude which of the elements were more important. However, even if this is the case, the benefit seen in the present study is more than the health care system has achieved for these persons over years of rehabilitation. The main results showed that this body–mind technique produced a better ability to physical and mental relaxation as indicated from the lower EMG, the higher alpha% and the decrease in state anxiety. These results may all reflect a change in sympathetic nervous activity. Thus the mean frequency of the EEG increases with activation. Each ordinary state of consciousness (waking, deep sleep and rapid eye movement sleep) is accompanied by a unique subjective description of experience as well as state specific EEG, EMG and eye movement patterns [25]. Such transcendental states are described as deeply restful yet alert. Such experiences have been shown to be correlated with a stable, theta–alpha (7–9 Hz) pattern [22]. Cornelius et al. [26] found that the mean frequency was more closely related to the level of anxiety than to the level of activation. After training
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we found a higher alpha% (P , 0.01) and a lower state anxiety (P , 0.01). This point at the possibility that the participants have learned to lower their state anxiety and that this might be related to a greater percentage of the slow alpha waves indicating a state of relaxed wakefulness. There has not been a lot of research on slow motion, deep breathing exercises and EEG, but an increase in alpha% in the frontal is reported as characteristic of Qi Gong training, a Chinese system of deep breathing exercises [21]. In contrast to ordinary wakefulness with closed eyes the Qi Gong state is characterised by the alpha activity predominantly in the anterior regions. Our study did indeed show a significant increase in the total amount of alpha% in the frontal area. Of course, we do not indicate that our participants did experience the special Qi Gong state, but we intended to help our participants to experience states of being active and alert and at the same time relaxed, and the increase of alpha waves in the frontal area point in this direction [22]. Some studies have found higher EMG in anxious individuals and the general relaxation response would hypothesize that a lower EMG also would indicate a lower anxiety [27]. Different kinds of training of deep muscle relaxation techniques is a standard for teaching relaxation to tense persons and changes in muscular tension provide a valuable index of the efficacy of such strategies [28]. In the present study, the decrease in EMG and the reduction in state–anxiety could be seen as important indicators of a psycho-physical relaxation effect. The testing of the mood (MACL 1) in combination with the training show that the participants were very anxious and tense, when they came to the training, and they were less tense after the training. The humour (MACL 2) showed a tendency toward better humour after each training session and over time. These observations were congruent with the spontaneous subjective reports. All in the group expressed spontaneously that they generally felt in better humour and that they felt much more optimistic about what they would be able to do in their life. The subjective statements were not systematically recorded and are therefore not included in the results. The interpretation of the tiredness (MACL 3) were less obvious and scores conflicted with the feelings the participants expressed spontaneously. A possible
explanation could be that the MACL testing was performed immediately after the training and the participants told us that they found it difficult to choose the word that best suited their mood immediately after training. MACL self-report scales on fatigue have been shown to measure fatigue but they did not correlate with an objective measure of fatigue [29]. To concentrate for such a long time, 45 min, was really a strain for the participants. In the beginning they were nervous that they could not do the exercises well enough. They had problems with the stretching exercises and we had to modify some of the exercises individually, but they expressed that they gradually felt less strain and more and more enjoyed doing the training. For some it meant that they were able to sleep better, make love better, and not becoming as easily tired or irritated. They still had problems concentrating for longer periods of time, but being generally more optimistic they felt happier and more patient both with themselves and with their surroundings.
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