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Stretch-based relaxation training
/MTiENT EdUCATioN ANd COUNSEbNG ELSEVIER SCIENCE IRELAND
Patient Education and Counseling 23 (1994) 5-12
Review article
Stretch-based relaxation training Charles
R. Carlson*,
Shelly L. Curran
Department of Psychology, University of’Kentucky. Lexington. KY 40506-0044, USA
(Received 6 May 1991: accepted 4 October 1993)
Abstract This paper is a review of progressive relaxation training based on muscle stretching exercises. Stretch-based relaxation training is an alternative to traditional tense-release methods for teaching self-regulation of muscle activity. The rationale and basic procedures for stretch-based relaxation are presented, along with a review of research studies exploring the clinical efficacy of the techniques. Experimental evidence has demonstrated decreases in subjective measures of muscle tension and activation. as well as decreases in EMG activity at selected target muscle sites when stretch-based relaxation procedures are employed. The clinical application of stretch-based relaxation is presented and illustrated with a case study describing the use of these procedures to assist in the treatment of neck tension/pain and anxiety. Discussion centers on the potential role of stretch-based relaxation in the management of anxiety and musculoskeletal disorders. Key words: Stretch-based
relaxation;
Progressive
muscle relaxation;
1. Introduction Relaxation
training
in the clinical
setting
can be
[ 11. Overall, the goal of such training is to enhance the self-control skills of the individual by reducing subjective and objective indices of arousal. While there are many techniques available to reduce arousal, some techniques may be more suited to individual patient needs than other techniques. The purpose of this paper is to explore the development and application of stretch-based relaxation training pro-
accomplished
in a variety
* Corresponding author.
of ways
Anxiety;
Chronic
pain
cedures as an alternative to more commonly used approaches for teaching self-regulation skills. Traditional progressive relaxation procedures have used muscle tension strategies to introduce relaxation training to the patient [2]. Close reading of the early work of Jacobson [3] reveals that his purpose in using muscle tension exercises was to teach the patient to identify very small levels of muscle activity in various body regions. When the individual had learned to discriminate muscle tension and then to relax that tension when it was perceived, Jacobson actually encouraged the elimination of the muscle tension procedures during the practice of relaxation. Most of the popular progressive muscle relaxa-
073%3991/94/$07.00 0 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDl 0738-3991(93)00601-4
6
tion procedures [4] today employ muscle tensionrelease procedures as the primary means to teach progressive relaxation. However, there are conditions for which such procedures may be contraindicated, e.g., cardiac patients with known arrythmias or pain patients for whom muscle tension precipitates more pain [5]. In addition, it is known that isometric contractions will increase musclenerve sympathetic activity [6-71. Therefore, it is useful and important to consider alternative progressive relaxation strategies in order to help patients acquire self-regulation skills without creating further physical or emotional dysfunction. Clinical experiences with chronic pain patients led to the development of stretch-based relaxation training. Early in his clinical training, the first author was working with a chronic pain patient who refused to use the muscle tension-based approach of progressive relaxation training [4] because the patient’s pain was increased with even the slightest increase in muscle tension. This event kindled a search for alternative relaxation procedures to use with pain patients who reported elevated muscle tension. As a part of the search process for alternative relaxation approaches, the first author had several discussions with a physical therapist who specialized in the rehabilitation of orthopedic injuries. In conversations with this physical therapist, the idea to use muscle stretching procedures for progressive relaxation training developed because muscle stretching was commonly used in physical therapy with muscle pain patients to reduce their muscle tension in selected muscle groups and to restore normal functioning [8]. Interestingly, muscle stretching has a long history of use within physical therapy and sports medicine as a technique for relaxing tense muscles. It is known, for example, that muscle stretching produces muscle relaxation as long as the muscle stretching is slow and does not tear the connective tissue [9]. Commonly, when a muscle spasm (e.g. ‘Charley-horse’) occurs, the spasm can be rapidly relieved by gently stretching the muscle so that the intense muscle contractions are eliminated. Muscle stretching is also linked to reduced excitability of the motoneuron pool which can then lead to
C. R. Carlson. S. L. Curran / Patient Educ. Couns. 23 (1994) S-12
reduced muscle activity, ischemia, and pain [lo]. As literature on the consequences of muscle stretching was reviewed, it became obvious that the use of muscle stretching to reduce muscle tension not only had historical precedent within other professional fields, but also was supported by a wellfounded empirical database. Given the physiological basis and the frequent use of muscle stretching in other professional disciplines, a progressive relaxation procedure based on muscle stretching techniques was developed. In cooperation with a specialist in anatomy and biomechanics, the standard progressive relaxation exercises of Bernstein and Borkovec [4] were modified to focus on muscle stretching procedures for each of the major muscle groups included in that traditional progressive relaxation training protocol. This series of modified progressive relaxation procedures thus formed the axis of the stretch-based relaxation approach. The progressive relaxation procedure was modified so that each major muscle group underwent a 15-s period of muscle stretching followed by a 60-s period of relaxation (a complete description of the current relaxation protocol is available from the first author). Additionally, the exercises included instructions for diaphragmmatic breathing [ 1l] as a means to assist in the timing of the muscle stretches and to foster relaxation. Muscle stretching is a natural process that most persons have used to relax themselves and to reduce muscle tension. When an individual is presented with the rationale for a stretch-based approach, there is usually rapid understanding and acceptance because the stretching of muscles for relaxation corresponds with the person’s general experience and practices (e.g. stretching the arms over the head while yawning). Stretch-based relaxation is based on common, natural strategies for muscle relaxation. As a result, we have found that patients generally respond very positively to the presentation of this approach for conducting progressive relaxation training. 2. Empirical evaluation of stretch-based relaxation The first step in the systematic evaluation of the stretch-based approach involved a clinical case
C.R. Carlson, XL.
Curran / Patient Educ. Couns. 23 (1994) 5-12
study [12]. An individual was referred to the research clinic of the first author for treatment of muscle tension and anxiety. The clinical evaluation indicated this patient met the diagnostic criteria for generalized anxiety disorder [ 131 that included frequent headaches, sleep disturbances, feelings of hurriedness, restlessness, worry, and stomach discomfort. Following the evaluation, she was introduced to a series of stretching exercises for the eyes (obicularis oculi), shoulders (trapezius), chest (pectoralis), and forearms (wrist flexors). The instructions for the stretch-based exercises were similar to the directions given by Bernstein and Borkovec [4] in the presentation of tense-release progressive relaxation except for the emphasis on muscle stretching rather than muscle tensing procedures. Each muscle group was stretched for a short period and followed with a 60-s period of relaxation or rest. The patient was instructed to perform this series of exercises daily over a 6-week period. The results of this initial clinical trial with the stretch-based approach were encouraging at the end of treatment and were maintained at a 6month follow-up. The patient reported less muscle tension overall during her daily activities after the program (X = 1.5) and at the 6-month follow-up (X = 1.5) than at the beginning of treatment (X= 3.2), F(2,18) = 24.7, P < 0.001, and a decrease in the frequency of anxiety symptoms from pre-treatment (State-Trait Anxiety Inventory T X = 35) to post-treatment (X = 28). Data from physiological evaluation after treatment also indicated that muscle activity in four sites (frontalis, -0.21 mV; r. masseter, -0.11 mV; r. trapezius, -0.06 mV; and r. brachioradialis., -0.09 mV) was reduced following the application of the stretch-based relaxation exercises. Overall, these results suggested that the application of the structured stretch-based relaxation exercises was effective in reducing both subjective and objective indices of arousal. The second research project directed towards exploring the efficacy of stretch-based relaxation was a controlled experimental study [14]. In this study, patients (n = 24) who described themselves as moderately tense and anxious were recruited via public advertisement and assigned randomly to
I
one of three experimental groups (stretch-based relaxation, tension-based relaxation, and a wait-list control). The same set of stretching exercises that was used for the case study was compared to a group of tense-release exercises developed by Bernstein and Borkovec [4] for the same four muscle groups. The results of this controlled trial indicated that subjects in the stretch-based group reported less muscle tension at four muscle sites (r. trapezius, F(1,12) = 5.37, P C 0.03; r. brachioradialis, F( 1,12) = 4.57, P < 0.05; 1. tricep, P C 0.08; and r. tricep, F(1,12) = 3.50, F(1,12) = 8.98, P C 0.01) and displayed less muscle activity in the r. masseter region (X = 0.97 mV) than persons using the tense-release strategies (X= 1.14 mV), F(1,12) = 10.86, P C 0.01. Based on the findings of this controlled clinical trial, the stretch-based relaxation procedures were expanded to a program of 14 muscle stretching exercises administered over a formal eight-session program [ 151. This program was then presented to 15 subjects recruited via public advertisements or physician referral, either individually or in small groups [ 141. These subjects all reported reductions in overall muscle tension following their participation in the training, F(1,16) = 5.44, P < 0.001. Furthermore, persons categorized as responding to stressors with primarily muscle tension showed lowered EMG activity (-1.35 mV, f(9) = 1.84, P C 0.05) in the trapezius region and reduced respiration rates (-2.9 rbm, t(3) = 2.54, P < 0.05) after application of stretch-based procedures than prior to treatment. Persons responding to stressors with primarily changes in cardiovascular parameters (e.g. heart rate and blood pressure) had lowered diastolic blood pressure (-8.2 mmHg, r(4) = 2.97, P C 0.02) following completion of the treatment protocol. These results were consistent with the two previous reports and suggested that the stretch-based approach offered a viable clinical alternative to traditional tense-release relaxation training. Further confirmatory evidence for the utility of the stretch-based approach was provided by two controlled experimental studies with distinct clinical syndromes characterized primarily by muscle tension and pain. The first project involved patients diagnosed with masticatory muscle pain
8
disorder [16]. Patients with masticatory muscle pain disorder complain of muscle pain in the masseter region of the face, but show no clinical evidence of temporomandibular joint pathology or dysfunction on physical examination by a dentist and radiographs. From a sample of 34 of these patients recruited via personal interview in a comprehensive Orofacial Pain Center, one group of subjects (n = 17) was assigned randomly to a muscle-stretching condition where, following a laboratory stressor, they were instructed to rest in a relaxed position and to perform a series of muscle stretching exercises extracted from the stretchbased relaxation protocol. These muscle stretching exercises included the bilateral frontalis, oblicularis oculi, masseter, and trapezius regions. Another group of patients (N = 17) was asked to rest in a relaxed position [17] only, following a stressful laboratory experience. The results of this study showed that persons with elevated muscle activity in the stretch-based group had greater reductions in 1. (-3.70 mV vs. -1.63 mV) and r. (-3.13 mV vs. -1.43 mV) masseter EMG activity following the stressor than persons in the postural relaxation only conditions, t( 15) = 1.94 and 2.07, respectively, P < 0.05.Interestingly, however, subjects in both conditions rated themselves as experiencing approximately equal levels of muscle tension following the stressor (246 SUTs vs. 250 SUTs), t( 15) = 0.04, P < 0.49. The results of this study offer additional evidence supporting the potential utility of stretch-based relaxation procedures for reducing levels of physiological activity. However, they also raised an important question regarding the role of perceived muscle relaxation versus actual muscle relaxation documented by reductions in EMG activity in the treatment and management of muscle pain disorders. It may be that reductions in clinical symptoms may require actual EMG reductions rather than self-perceptions of relaxed muscles. However, this issue awaits further experimental investigation. The second, controlled clinical trial of this series was conducted among a group of 60 persons who were reporting chronic neck tension [18]. In this study, subjects were equally divided and assigned randomly to either a stretch-based, tense-release,
C. R. Carlson. S.L. Curran / Parienl Educ. Couns. 23 (1994) 5-12
or resting control condition. The two relaxation conditions consisted of eight exercises for the same muscle groups from the abdominal muscles to the frontales muscles. The stretch-based approach employed the revised Carlson protocol [19], whereas the tense-release group used the method described by Bernstein and Borkovec [4]. As in the previous study, subjects were given the relaxation instructions after being exposed to a laboratory stressor. At the end of the relaxation or rest period, persons in the stretch-based condition reported greater reductions in muscle tension (-284 SUTs) and displayed lower 1. trapezius EMG activity (-1.80 mV) than persons in the tense-release (-207 SUTs, -0.48 mV) or rest control (-100 SUTs, - 1.00 mV) groups, F(2,56) = 5.83, P < 0.01 and F(2,56) = 5.47, P < 0.01, respectively. Moreover, peripheral skin temperature following the relaxation procedures showed an increase among the stretch-based group (+1.35 dF), whereas in the tense-release (- 0.22 dF) and resting control (-1.19 dF) conditions, skin temperature declined following the relaxation procedures, F(2,56) = 3.76, P < 0.05. The changes in self-report, EMG activity, and peripheral skin temperature can be interpreted as indications that arousal has been reduced overall. Thus, these results also supported the efficacy of the stretchbased approach to relaxation training. Presently. empirical and experimental evidence substantiates the utility of muscle stretching procedures for achieving both self-reported and actual muscle relaxation. In order to ensure standardization of treatment delivery, the clinical procedures are operationalized in the form of a comprehensive manual presenting a five-session individual program and a six-session group based program [ 191. This treatment manual includes therapist scripts for presentation of stretch-based relaxation training, as well as handouts, audiotapes, and selfmonitoring forms for patients to use in the process of learning the relaxation skills. These materials enable therapists to deliver stretch-based relaxation training in a timely and efficient manner to their patients. The stretch-based relaxation approach provides a reasonable alternative to traditional progressive relaxation training procedures. The following case
C.R. Carlson, S.L. Curran / Patient Educ. Cows. 23 (1994) 5-12
example illustrates the application of these procedures and highlights the essential role of the therapist in the training process. It is especially valuable to note the importance of adapting the relaxation training to the needs of the individual who is learning self-regulation skills. The therapist should be vigilant in attempting to match the training experience to the circumstances and symptoms that the patient presents at the onset of treatment. 3. Clinical case example MS BZ was a 30-year-old married white female who was referred to the first author for relaxation training by her physician. The patient’s primary complaint was chronic neck tension and pain of several years duration that had not resolved with medication, regular physical activity, or intensive physical therapy. There was no reported history of trauma or injury to the affected regions; the physician’s diagnosis was primary fibromyalgia syndrome. Primary Iibromyalgia syndrome is commonly characterized by chronic muscle pain, fatigue, and weakness; the syndrome appears to be responsive to several behaviorallyoriented interventions [20]. During the initial interview, the patient appeared to be physically tired, but spoke in a rapid, intense manner about her own history. She was interested in a program of concentrated relaxation training and was willing to take time from work responsibilities to devote herself to getting better because of her frustrations with the unremitting neck tension/pain. Prior to beginning relaxation training, BZ underwent a comprehensive clinical and laboratory evaluation. The evaluation was conducted to rule out any underlying psychological or physiological disorder that may be contributing to her symptoms. The initial evaluation also included a physiological stress profile [2 I-221 to determine baseline levels of muscle tension and relaxation ability. The results from her clinical evaluation indicated that her blood chemistries and urine cortisol were within normal limits; these data were gathered to verify that the patient did not have any underlying physiological disorder. However, her psychological test data suggested the presence of
9
anxiety and moderate depression; moreover, the patient noted a history of anxiety/panic attacks that had been ongoing for several years. Marked and variable muscle activity in the upper trapezius regions was also noted via EMG monitoring, as well as an inability to reduce muscle activity to a relaxed state (C 1 mV) following activation from a stressor. These results were discussed with the patient and an intensive program of stretch-based relaxation training was initiated. An intensive approach to training was selected because of the willingness of the patient to devote her complete attention to determining whether or not her symptoms could be controlled with relaxation training. The intensive relaxation program consisted of multiple (two to three per day) relaxation training sessions at the clinic, along with three, daily home practice sessions. This was continued for 6 consecutive days of training; after the intensive phase, the subject was seen once a day on days 1, 6, 13, 22, and 52 following completion of the intensive phase. The patient was also encouraged to continue with regular home practice (two times per day) after the intensive phase was finished. Patient compliance to the home practice regimen during the intensive and follow-up phases was assessed by verbal self-report and indicated regular practice was sustained. The relaxation training followed the sequence and elements of the stretch-based relaxation program outlined by Carlson and Collins [ 191. Moreover, the patient also (a) began a walking program during the intensive phase by taking two 45min walks per day, (b) reduced caffeine consumption such that it was totally eliminated from her diet over a 2-week period, and (c) restricted social contact (e.g. work attendance, telephone calls, or personal visits with friends or relatives) during the initial phase of the training program. In short, the patient was encouraged to make significant changes in her daily routines/habits to reduce stressors and to practice skills that enabled her to determine whether or not her neck symptoms might be controlled within the training period. This intensive approach to treatment was based on the first author’s belief that relaxation training is effective when it reaches a ‘therapeutic life level’; the ‘therapeutic life level’ of relaxation training is
10
analogous to the therapeutic blood level of a medication - unless the medication reaches a therapeutic level in the bloodstream, there is little likelihood of effective symptom management. Relaxation training may operate similarly; unless a person learns the relaxation skills to the point that physiological relaxation can actually be achieved on a regular basis, there will not likely be any noticeable change in the patient’s symptoms [23]. Therefore, an attempt was made to provide the patient with an opportunity to learn and to practice relaxation skills to the point where they might reach a ‘therapeutic life level’ and actually make a difference in the physical functioning of the patient. After 2 weeks of training, the patient underwent another psychological and physiological evaluation. The results of this evaluation indicated reductions in depression (Beck Depression Inventory score of 16 vs. 24 at beginning of treatment) and anxiety (State-Trait Anxiety Inventory trait score of 42 vs. 59 at the beginning of treatment). Moreover, physiological evaluation indicated the patient had reduced baseline levels of EMG activity in the 1. corrugator and r. trapezius regions, heart rate, and respiration rate. Twenty-four hour urinary cortisol levels were reduced from 42 J.@. prior to treatment to 28 &l. following treatment. Interestingly, the patient reported on the fourth day of the intensive training program that neck pain was no longer present; the neck pain did not return during the 2-week treatment phase of the program. It did, however, return intermittently when the patient reentered a highly stressful work situation. In contrast to before treatment, however, she was able to recognize the relationship between her response to stressful life events and her experience of neck tension/pain at the work setting after completion of the treatment program and attempted to initiate strategies for managing the tension/discomfort. On the third day of training, the patient reported an episode of anxiety during the afternoon clinic session when she was actively engaged in relaxation training. She described the event as similar to several others she had experienced prior to beginning the intensive relaxation training, in that she felt her hands shaking and her heart rac-
C.R. Carlson, S.L. Curran/ Patient Educ. Couns. 23 (1994) 5-12
ing without being aware of any precipitating events or anxious thoughts. The experience lasted for several minutes until the symptoms subsided as she continued with the relaxation training. Following the completion of the relaxation exercises, the experience was discussed with the patient in an effort to determine whether or not there were any noteworthy thoughts or mental images that might have triggered the anxiety. Since none appeared to be present, she was encouraged to continue with her regular practice of relaxation training in light of her demonstrated ability to control the symptoms of the anxiety and panic during the session by maintaining a regular breathing pattern and continuing to engage in the stretch relaxation exercises. With this strategy, she did not report any further difficulty with anxiety or panic attacks during the remainder of the treatment program. These events describing the episode of panic illustrate the importance of the therapist being aware of the potential negative side effects of relaxation training [24-251. Relaxation procedureinduced anxiety is well-documented in the literature [26]. Given the patient’s history of prior panic attacks, it is not unreasonable to have predicted the possibility that such would occur in the present case. Several authors [24-251 have noted that persons with a history of panic attacks may be predisposed to experience an increase in anxiety during relaxation training. The reasons for this are varied and the interested reader is referred elsewhere [24-251 for further information. In such cases where a history of anxiety or panic disorder is present, it is prudent for the therapist to discuss with the patient the possibilities that anxiety during the relaxation training might occur and the steps that will be taken with the patient to help manage such an event. Moreover, the patient should be helped to understand that the frequency of such events should diminish as relaxation training progresses over time. The fact that the patient was not symptom-free following the termination of the formal relaxation training program is also important to note. So often, patients are hoping that relaxation will provide a ‘once and for all time’ cure of their presenting complaints. It is the therapist’s responsibility
11
C. R. Carlson. S. L. Curran / Patienl Educ. Couns. 23 (1994) 5-12
to help the patient understand the nature and limitations of relaxation training prior to the initiation of treatment. Relaxation training is a palliative strategy for coping with the increases in activation that result from sources of tension and anxiety. It is not a ‘direct-action’ strategy [27] in the sense that it does not focus on the causes of physical and mental activation, but rather on the consequences of such activation. If persistent problems with over-activation present themselves, therapists should be sensitive to the importance of addressing the sources of such activation, as well as, providing the individual with resources such as progressive relaxation training to cope with the over responding. Finally, it is helpful to remember that as illustrated in the present case, relaxation training is seldom introduced as a ‘stand alone’ intervention. Therefore, the patient’s effective symptom management is likely a result of a combination of factors rather than on the application of stretch-based relaxation training itself. 4. Conclusion The majority of the relaxation literature focuses on the effects of relaxation techniques based on muscle tense-release methods in order to learn how to control or reduce levels of arousal. However, a technique focused primarily on muscle stretching has emerged as a reasonable alternative to the tense-release approach, especially in situations where the use of tense-release procedures may be contraindicated as in the case for cardiac patients or muscle pain patients, for whom the traditional methods may increase risk or pain. This paper reviews the rationale and basic procedures for stretch-based relaxation. Research-based evaluations of this technique when used alone or in comparison to other methods, indicate beneficial effects of the stretch-based technique in the clinical areas of generalized anxiety, muscle tension, and selected muscle pain disorders. Further clinical research using the current protocol with selected populations is needed. Target populations that may be especially appropriate given the available data would include persons diagnosed with TMD or borderline hypertension. Our research and clinical findings suggest four
key points to consider when using stretch-based relaxation techniques. The first is the importance of achieving a ‘therapeutic life level’ of the relaxation training. Relaxation skills must be acquired and practiced to the extent that muscle relaxation can be achieved reliably in response to stressful life events in order for adequate symptom control. Second, the possibility of transient negative side effects of relaxation training should be considered, especially when a history of anxiety or panic attacks are present. Third, the role of the therapist is important in the delivery of relaxation training [24]. The therapist must not only explain the rationale of relaxation training and train the person properly, but is also responsible to mediate possible negative side effects with the patient. Finally, stretch-based relaxation is not a ‘cure all’, but rather a component of multifaceted treatment. While complete symptom resolution occurs with some patients, it is unlikely that symptoms will always disappear immediately upon the application of stretch-based relaxation training. Moreover, even if symptoms remitted with treatment, they may reoccur upon exposure to additional stressors. Ideally, stretch-based relaxation should be viewed as but one important part of an overall treatment program designed to alter an individual’s lifestyle so that s/he is able to cope more effectively with unwanted levels of arousal.
5. References Smith JC. Relaxation dynamics: nine world approaches to self-relaxation. Champaign, IL: Research Press, 1985. Bernstein DA, Carlson CR. Progressive relaxation: Abbreviated methods. In: Lehrer PM, Woolfolk R editors. Principles and practices of stress management. 2nd ed. New York: Guilford, 1982. Jacobsen E. Progressive relaxation. Chicago: University of Chicago Press. 1938. Bernstein DA, Borkovec TD. Progressive relaxation training: a manual for the helping professions. Champaign, IL: Research Press, 1973. Turk DC. Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive-behavioral perspective. New York: Guilford Press, 1983. Farrell P, Ebert T, Kampine J. Naloxone augments muscle sympathetic nerve activity during isometric exercise in humans. Am J Physiol 1991; 260: E379-E388. Saito M. Mano T, lwase S. Sympathetic nerve activity re-
C. R. Carlson. S. L. Curran / Patient Educ. Couns. 23 (1994) 5-12
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17
lated to local fatigue sensation during static contraction. J Appl Physiol 1989; 67: 980-984. Anderson B. Stretching and sports. In: Appenzeller 0, Atkenson R, editors. Sports medicine, 2nd ed. Baltimore: Urban & Schwarzenberg, 1983. Urbscheit N: Reflexes evoked by group II afferent fibers from muscle spindles. Phys Ther 1979; 59: 1083. Travel1 J, Rinzler G, Herman M. Pain and disability of the shoulder and arm. J Am Med Assoc 1942; 120: 417-422. Fried R. The hyperventilation syndrome: research and clinical treatment. Baltimore, MD: Johns Hopkins, 1987. Carlson CR, VenTrella MA, Sturgis, ET. Relaxation training through muscle stretching procedures: a pilot case. J Behav Ther Exp Psychiatry 1987; 18: 121-126. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed. American Psychiatric Association, 1987; 251-253. Carlson CR, Collins FL, Nitz AJ, Sturgis ET, Rogers JL. Muscle stretching as an alternative relaxation training procedure. J Behav Ther Exp Psychiatry 1990; 21: 29-38. Carlson CR, Collins FL. Stretch relaxation: a training manual. Wheaton, IL: Behavioral Health Associates, 1986. Carlson CR, Okeson JP, Falace DA, Nitz AJ, Anderson D. Stretch-based relaxation and the reduction of EMG activity among masticatory muscle pain patients. J Craniomandib Disord Facial Oral Pain 1991; 5: 205-212. Poppen R. Behavioral relaxation training and assessment.
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New York: Pergamon. 1988. Kay JA, Carlson CR. The role of stretch-based
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25
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27 relaxation
in the treatment of chronic neck tension. Behav Ther 1992; 23: 423-431. Carlson CR, Collins FL. A Guided Approach to Learning Stretch-Relaxation. Frankfort. KY: CR Carbon, 1991. Baumstark KE, Buckelew SP. Fibromyalgia: clinical signs, research findings, treatment implications. and future directions. Ann Behav Med 1992; 14: 282-291. Carbon CR, Collins FL, Stewart JF, Porzelius J, Nitz JA. Lind CO. The assessment of emotional reactivity: a scale of development and validation study. J Psychopath01 Behav Assess 1989; 11: 313-325. Carbon CR, Bernstein DA. Abbreviated progressive relaxation training. In: O’Donohue W, Kramer L, editors. Handbook of skills training. Needham, MA: Allyn, Bacon. In press. Shellenberger R, Green JA. From the ghost in the box to successful biofeedback training. Greeley, CO: Health Psychology Publications, 1986. Carbon CR, Nitz AJ. Negative side effects of selfregulation training: relaxation training and the role of the professional in service deliver. Bio Self-Regul 1991; 16: 191-197. Heide FJ, Borkovec TD. Relaxation-induced anxiety: Paranoid anxiety enhancement due to relaxation training. J Consult Clin Psycho1 51: 17 1- 182. Ley R. Panic attacks during relaxation and relaxationinduced anxiety: a hyperventilation interpretation. J Behav Ther Exp Psychia 1980; 19: 253-259. Lazarus R, Folkman S. Stress, appraisal, and coping. New York: Springer, 1984.
Patient Education and Counseling 23 (1994) 5-12
Review article
Stretch-based relaxation training Charles
R. Carlson*,
Shelly L. Curran
Department of Psychology, University of’Kentucky. Lexington. KY 40506-0044, USA
(Received 6 May 1991: accepted 4 October 1993)
Abstract This paper is a review of progressive relaxation training based on muscle stretching exercises. Stretch-based relaxation training is an alternative to traditional tense-release methods for teaching self-regulation of muscle activity. The rationale and basic procedures for stretch-based relaxation are presented, along with a review of research studies exploring the clinical efficacy of the techniques. Experimental evidence has demonstrated decreases in subjective measures of muscle tension and activation. as well as decreases in EMG activity at selected target muscle sites when stretch-based relaxation procedures are employed. The clinical application of stretch-based relaxation is presented and illustrated with a case study describing the use of these procedures to assist in the treatment of neck tension/pain and anxiety. Discussion centers on the potential role of stretch-based relaxation in the management of anxiety and musculoskeletal disorders. Key words: Stretch-based
relaxation;
Progressive
muscle relaxation;
1. Introduction Relaxation
training
in the clinical
setting
can be
[ 11. Overall, the goal of such training is to enhance the self-control skills of the individual by reducing subjective and objective indices of arousal. While there are many techniques available to reduce arousal, some techniques may be more suited to individual patient needs than other techniques. The purpose of this paper is to explore the development and application of stretch-based relaxation training pro-
accomplished
in a variety
* Corresponding author.
of ways
Anxiety;
Chronic
pain
cedures as an alternative to more commonly used approaches for teaching self-regulation skills. Traditional progressive relaxation procedures have used muscle tension strategies to introduce relaxation training to the patient [2]. Close reading of the early work of Jacobson [3] reveals that his purpose in using muscle tension exercises was to teach the patient to identify very small levels of muscle activity in various body regions. When the individual had learned to discriminate muscle tension and then to relax that tension when it was perceived, Jacobson actually encouraged the elimination of the muscle tension procedures during the practice of relaxation. Most of the popular progressive muscle relaxa-
073%3991/94/$07.00 0 1994 Elsevier Science Ireland Ltd. All rights reserved. SSDl 0738-3991(93)00601-4
6
tion procedures [4] today employ muscle tensionrelease procedures as the primary means to teach progressive relaxation. However, there are conditions for which such procedures may be contraindicated, e.g., cardiac patients with known arrythmias or pain patients for whom muscle tension precipitates more pain [5]. In addition, it is known that isometric contractions will increase musclenerve sympathetic activity [6-71. Therefore, it is useful and important to consider alternative progressive relaxation strategies in order to help patients acquire self-regulation skills without creating further physical or emotional dysfunction. Clinical experiences with chronic pain patients led to the development of stretch-based relaxation training. Early in his clinical training, the first author was working with a chronic pain patient who refused to use the muscle tension-based approach of progressive relaxation training [4] because the patient’s pain was increased with even the slightest increase in muscle tension. This event kindled a search for alternative relaxation procedures to use with pain patients who reported elevated muscle tension. As a part of the search process for alternative relaxation approaches, the first author had several discussions with a physical therapist who specialized in the rehabilitation of orthopedic injuries. In conversations with this physical therapist, the idea to use muscle stretching procedures for progressive relaxation training developed because muscle stretching was commonly used in physical therapy with muscle pain patients to reduce their muscle tension in selected muscle groups and to restore normal functioning [8]. Interestingly, muscle stretching has a long history of use within physical therapy and sports medicine as a technique for relaxing tense muscles. It is known, for example, that muscle stretching produces muscle relaxation as long as the muscle stretching is slow and does not tear the connective tissue [9]. Commonly, when a muscle spasm (e.g. ‘Charley-horse’) occurs, the spasm can be rapidly relieved by gently stretching the muscle so that the intense muscle contractions are eliminated. Muscle stretching is also linked to reduced excitability of the motoneuron pool which can then lead to
C. R. Carlson. S. L. Curran / Patient Educ. Couns. 23 (1994) S-12
reduced muscle activity, ischemia, and pain [lo]. As literature on the consequences of muscle stretching was reviewed, it became obvious that the use of muscle stretching to reduce muscle tension not only had historical precedent within other professional fields, but also was supported by a wellfounded empirical database. Given the physiological basis and the frequent use of muscle stretching in other professional disciplines, a progressive relaxation procedure based on muscle stretching techniques was developed. In cooperation with a specialist in anatomy and biomechanics, the standard progressive relaxation exercises of Bernstein and Borkovec [4] were modified to focus on muscle stretching procedures for each of the major muscle groups included in that traditional progressive relaxation training protocol. This series of modified progressive relaxation procedures thus formed the axis of the stretch-based relaxation approach. The progressive relaxation procedure was modified so that each major muscle group underwent a 15-s period of muscle stretching followed by a 60-s period of relaxation (a complete description of the current relaxation protocol is available from the first author). Additionally, the exercises included instructions for diaphragmmatic breathing [ 1l] as a means to assist in the timing of the muscle stretches and to foster relaxation. Muscle stretching is a natural process that most persons have used to relax themselves and to reduce muscle tension. When an individual is presented with the rationale for a stretch-based approach, there is usually rapid understanding and acceptance because the stretching of muscles for relaxation corresponds with the person’s general experience and practices (e.g. stretching the arms over the head while yawning). Stretch-based relaxation is based on common, natural strategies for muscle relaxation. As a result, we have found that patients generally respond very positively to the presentation of this approach for conducting progressive relaxation training. 2. Empirical evaluation of stretch-based relaxation The first step in the systematic evaluation of the stretch-based approach involved a clinical case
C.R. Carlson, XL.
Curran / Patient Educ. Couns. 23 (1994) 5-12
study [12]. An individual was referred to the research clinic of the first author for treatment of muscle tension and anxiety. The clinical evaluation indicated this patient met the diagnostic criteria for generalized anxiety disorder [ 131 that included frequent headaches, sleep disturbances, feelings of hurriedness, restlessness, worry, and stomach discomfort. Following the evaluation, she was introduced to a series of stretching exercises for the eyes (obicularis oculi), shoulders (trapezius), chest (pectoralis), and forearms (wrist flexors). The instructions for the stretch-based exercises were similar to the directions given by Bernstein and Borkovec [4] in the presentation of tense-release progressive relaxation except for the emphasis on muscle stretching rather than muscle tensing procedures. Each muscle group was stretched for a short period and followed with a 60-s period of relaxation or rest. The patient was instructed to perform this series of exercises daily over a 6-week period. The results of this initial clinical trial with the stretch-based approach were encouraging at the end of treatment and were maintained at a 6month follow-up. The patient reported less muscle tension overall during her daily activities after the program (X = 1.5) and at the 6-month follow-up (X = 1.5) than at the beginning of treatment (X= 3.2), F(2,18) = 24.7, P < 0.001, and a decrease in the frequency of anxiety symptoms from pre-treatment (State-Trait Anxiety Inventory T X = 35) to post-treatment (X = 28). Data from physiological evaluation after treatment also indicated that muscle activity in four sites (frontalis, -0.21 mV; r. masseter, -0.11 mV; r. trapezius, -0.06 mV; and r. brachioradialis., -0.09 mV) was reduced following the application of the stretch-based relaxation exercises. Overall, these results suggested that the application of the structured stretch-based relaxation exercises was effective in reducing both subjective and objective indices of arousal. The second research project directed towards exploring the efficacy of stretch-based relaxation was a controlled experimental study [14]. In this study, patients (n = 24) who described themselves as moderately tense and anxious were recruited via public advertisement and assigned randomly to
I
one of three experimental groups (stretch-based relaxation, tension-based relaxation, and a wait-list control). The same set of stretching exercises that was used for the case study was compared to a group of tense-release exercises developed by Bernstein and Borkovec [4] for the same four muscle groups. The results of this controlled trial indicated that subjects in the stretch-based group reported less muscle tension at four muscle sites (r. trapezius, F(1,12) = 5.37, P C 0.03; r. brachioradialis, F( 1,12) = 4.57, P < 0.05; 1. tricep, P C 0.08; and r. tricep, F(1,12) = 3.50, F(1,12) = 8.98, P C 0.01) and displayed less muscle activity in the r. masseter region (X = 0.97 mV) than persons using the tense-release strategies (X= 1.14 mV), F(1,12) = 10.86, P C 0.01. Based on the findings of this controlled clinical trial, the stretch-based relaxation procedures were expanded to a program of 14 muscle stretching exercises administered over a formal eight-session program [ 151. This program was then presented to 15 subjects recruited via public advertisements or physician referral, either individually or in small groups [ 141. These subjects all reported reductions in overall muscle tension following their participation in the training, F(1,16) = 5.44, P < 0.001. Furthermore, persons categorized as responding to stressors with primarily muscle tension showed lowered EMG activity (-1.35 mV, f(9) = 1.84, P C 0.05) in the trapezius region and reduced respiration rates (-2.9 rbm, t(3) = 2.54, P < 0.05) after application of stretch-based procedures than prior to treatment. Persons responding to stressors with primarily changes in cardiovascular parameters (e.g. heart rate and blood pressure) had lowered diastolic blood pressure (-8.2 mmHg, r(4) = 2.97, P C 0.02) following completion of the treatment protocol. These results were consistent with the two previous reports and suggested that the stretch-based approach offered a viable clinical alternative to traditional tense-release relaxation training. Further confirmatory evidence for the utility of the stretch-based approach was provided by two controlled experimental studies with distinct clinical syndromes characterized primarily by muscle tension and pain. The first project involved patients diagnosed with masticatory muscle pain
8
disorder [16]. Patients with masticatory muscle pain disorder complain of muscle pain in the masseter region of the face, but show no clinical evidence of temporomandibular joint pathology or dysfunction on physical examination by a dentist and radiographs. From a sample of 34 of these patients recruited via personal interview in a comprehensive Orofacial Pain Center, one group of subjects (n = 17) was assigned randomly to a muscle-stretching condition where, following a laboratory stressor, they were instructed to rest in a relaxed position and to perform a series of muscle stretching exercises extracted from the stretchbased relaxation protocol. These muscle stretching exercises included the bilateral frontalis, oblicularis oculi, masseter, and trapezius regions. Another group of patients (N = 17) was asked to rest in a relaxed position [17] only, following a stressful laboratory experience. The results of this study showed that persons with elevated muscle activity in the stretch-based group had greater reductions in 1. (-3.70 mV vs. -1.63 mV) and r. (-3.13 mV vs. -1.43 mV) masseter EMG activity following the stressor than persons in the postural relaxation only conditions, t( 15) = 1.94 and 2.07, respectively, P < 0.05.Interestingly, however, subjects in both conditions rated themselves as experiencing approximately equal levels of muscle tension following the stressor (246 SUTs vs. 250 SUTs), t( 15) = 0.04, P < 0.49. The results of this study offer additional evidence supporting the potential utility of stretch-based relaxation procedures for reducing levels of physiological activity. However, they also raised an important question regarding the role of perceived muscle relaxation versus actual muscle relaxation documented by reductions in EMG activity in the treatment and management of muscle pain disorders. It may be that reductions in clinical symptoms may require actual EMG reductions rather than self-perceptions of relaxed muscles. However, this issue awaits further experimental investigation. The second, controlled clinical trial of this series was conducted among a group of 60 persons who were reporting chronic neck tension [18]. In this study, subjects were equally divided and assigned randomly to either a stretch-based, tense-release,
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or resting control condition. The two relaxation conditions consisted of eight exercises for the same muscle groups from the abdominal muscles to the frontales muscles. The stretch-based approach employed the revised Carlson protocol [19], whereas the tense-release group used the method described by Bernstein and Borkovec [4]. As in the previous study, subjects were given the relaxation instructions after being exposed to a laboratory stressor. At the end of the relaxation or rest period, persons in the stretch-based condition reported greater reductions in muscle tension (-284 SUTs) and displayed lower 1. trapezius EMG activity (-1.80 mV) than persons in the tense-release (-207 SUTs, -0.48 mV) or rest control (-100 SUTs, - 1.00 mV) groups, F(2,56) = 5.83, P < 0.01 and F(2,56) = 5.47, P < 0.01, respectively. Moreover, peripheral skin temperature following the relaxation procedures showed an increase among the stretch-based group (+1.35 dF), whereas in the tense-release (- 0.22 dF) and resting control (-1.19 dF) conditions, skin temperature declined following the relaxation procedures, F(2,56) = 3.76, P < 0.05. The changes in self-report, EMG activity, and peripheral skin temperature can be interpreted as indications that arousal has been reduced overall. Thus, these results also supported the efficacy of the stretchbased approach to relaxation training. Presently. empirical and experimental evidence substantiates the utility of muscle stretching procedures for achieving both self-reported and actual muscle relaxation. In order to ensure standardization of treatment delivery, the clinical procedures are operationalized in the form of a comprehensive manual presenting a five-session individual program and a six-session group based program [ 191. This treatment manual includes therapist scripts for presentation of stretch-based relaxation training, as well as handouts, audiotapes, and selfmonitoring forms for patients to use in the process of learning the relaxation skills. These materials enable therapists to deliver stretch-based relaxation training in a timely and efficient manner to their patients. The stretch-based relaxation approach provides a reasonable alternative to traditional progressive relaxation training procedures. The following case
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example illustrates the application of these procedures and highlights the essential role of the therapist in the training process. It is especially valuable to note the importance of adapting the relaxation training to the needs of the individual who is learning self-regulation skills. The therapist should be vigilant in attempting to match the training experience to the circumstances and symptoms that the patient presents at the onset of treatment. 3. Clinical case example MS BZ was a 30-year-old married white female who was referred to the first author for relaxation training by her physician. The patient’s primary complaint was chronic neck tension and pain of several years duration that had not resolved with medication, regular physical activity, or intensive physical therapy. There was no reported history of trauma or injury to the affected regions; the physician’s diagnosis was primary fibromyalgia syndrome. Primary Iibromyalgia syndrome is commonly characterized by chronic muscle pain, fatigue, and weakness; the syndrome appears to be responsive to several behaviorallyoriented interventions [20]. During the initial interview, the patient appeared to be physically tired, but spoke in a rapid, intense manner about her own history. She was interested in a program of concentrated relaxation training and was willing to take time from work responsibilities to devote herself to getting better because of her frustrations with the unremitting neck tension/pain. Prior to beginning relaxation training, BZ underwent a comprehensive clinical and laboratory evaluation. The evaluation was conducted to rule out any underlying psychological or physiological disorder that may be contributing to her symptoms. The initial evaluation also included a physiological stress profile [2 I-221 to determine baseline levels of muscle tension and relaxation ability. The results from her clinical evaluation indicated that her blood chemistries and urine cortisol were within normal limits; these data were gathered to verify that the patient did not have any underlying physiological disorder. However, her psychological test data suggested the presence of
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anxiety and moderate depression; moreover, the patient noted a history of anxiety/panic attacks that had been ongoing for several years. Marked and variable muscle activity in the upper trapezius regions was also noted via EMG monitoring, as well as an inability to reduce muscle activity to a relaxed state (C 1 mV) following activation from a stressor. These results were discussed with the patient and an intensive program of stretch-based relaxation training was initiated. An intensive approach to training was selected because of the willingness of the patient to devote her complete attention to determining whether or not her symptoms could be controlled with relaxation training. The intensive relaxation program consisted of multiple (two to three per day) relaxation training sessions at the clinic, along with three, daily home practice sessions. This was continued for 6 consecutive days of training; after the intensive phase, the subject was seen once a day on days 1, 6, 13, 22, and 52 following completion of the intensive phase. The patient was also encouraged to continue with regular home practice (two times per day) after the intensive phase was finished. Patient compliance to the home practice regimen during the intensive and follow-up phases was assessed by verbal self-report and indicated regular practice was sustained. The relaxation training followed the sequence and elements of the stretch-based relaxation program outlined by Carlson and Collins [ 191. Moreover, the patient also (a) began a walking program during the intensive phase by taking two 45min walks per day, (b) reduced caffeine consumption such that it was totally eliminated from her diet over a 2-week period, and (c) restricted social contact (e.g. work attendance, telephone calls, or personal visits with friends or relatives) during the initial phase of the training program. In short, the patient was encouraged to make significant changes in her daily routines/habits to reduce stressors and to practice skills that enabled her to determine whether or not her neck symptoms might be controlled within the training period. This intensive approach to treatment was based on the first author’s belief that relaxation training is effective when it reaches a ‘therapeutic life level’; the ‘therapeutic life level’ of relaxation training is
10
analogous to the therapeutic blood level of a medication - unless the medication reaches a therapeutic level in the bloodstream, there is little likelihood of effective symptom management. Relaxation training may operate similarly; unless a person learns the relaxation skills to the point that physiological relaxation can actually be achieved on a regular basis, there will not likely be any noticeable change in the patient’s symptoms [23]. Therefore, an attempt was made to provide the patient with an opportunity to learn and to practice relaxation skills to the point where they might reach a ‘therapeutic life level’ and actually make a difference in the physical functioning of the patient. After 2 weeks of training, the patient underwent another psychological and physiological evaluation. The results of this evaluation indicated reductions in depression (Beck Depression Inventory score of 16 vs. 24 at beginning of treatment) and anxiety (State-Trait Anxiety Inventory trait score of 42 vs. 59 at the beginning of treatment). Moreover, physiological evaluation indicated the patient had reduced baseline levels of EMG activity in the 1. corrugator and r. trapezius regions, heart rate, and respiration rate. Twenty-four hour urinary cortisol levels were reduced from 42 J.@. prior to treatment to 28 &l. following treatment. Interestingly, the patient reported on the fourth day of the intensive training program that neck pain was no longer present; the neck pain did not return during the 2-week treatment phase of the program. It did, however, return intermittently when the patient reentered a highly stressful work situation. In contrast to before treatment, however, she was able to recognize the relationship between her response to stressful life events and her experience of neck tension/pain at the work setting after completion of the treatment program and attempted to initiate strategies for managing the tension/discomfort. On the third day of training, the patient reported an episode of anxiety during the afternoon clinic session when she was actively engaged in relaxation training. She described the event as similar to several others she had experienced prior to beginning the intensive relaxation training, in that she felt her hands shaking and her heart rac-
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ing without being aware of any precipitating events or anxious thoughts. The experience lasted for several minutes until the symptoms subsided as she continued with the relaxation training. Following the completion of the relaxation exercises, the experience was discussed with the patient in an effort to determine whether or not there were any noteworthy thoughts or mental images that might have triggered the anxiety. Since none appeared to be present, she was encouraged to continue with her regular practice of relaxation training in light of her demonstrated ability to control the symptoms of the anxiety and panic during the session by maintaining a regular breathing pattern and continuing to engage in the stretch relaxation exercises. With this strategy, she did not report any further difficulty with anxiety or panic attacks during the remainder of the treatment program. These events describing the episode of panic illustrate the importance of the therapist being aware of the potential negative side effects of relaxation training [24-251. Relaxation procedureinduced anxiety is well-documented in the literature [26]. Given the patient’s history of prior panic attacks, it is not unreasonable to have predicted the possibility that such would occur in the present case. Several authors [24-251 have noted that persons with a history of panic attacks may be predisposed to experience an increase in anxiety during relaxation training. The reasons for this are varied and the interested reader is referred elsewhere [24-251 for further information. In such cases where a history of anxiety or panic disorder is present, it is prudent for the therapist to discuss with the patient the possibilities that anxiety during the relaxation training might occur and the steps that will be taken with the patient to help manage such an event. Moreover, the patient should be helped to understand that the frequency of such events should diminish as relaxation training progresses over time. The fact that the patient was not symptom-free following the termination of the formal relaxation training program is also important to note. So often, patients are hoping that relaxation will provide a ‘once and for all time’ cure of their presenting complaints. It is the therapist’s responsibility
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to help the patient understand the nature and limitations of relaxation training prior to the initiation of treatment. Relaxation training is a palliative strategy for coping with the increases in activation that result from sources of tension and anxiety. It is not a ‘direct-action’ strategy [27] in the sense that it does not focus on the causes of physical and mental activation, but rather on the consequences of such activation. If persistent problems with over-activation present themselves, therapists should be sensitive to the importance of addressing the sources of such activation, as well as, providing the individual with resources such as progressive relaxation training to cope with the over responding. Finally, it is helpful to remember that as illustrated in the present case, relaxation training is seldom introduced as a ‘stand alone’ intervention. Therefore, the patient’s effective symptom management is likely a result of a combination of factors rather than on the application of stretch-based relaxation training itself. 4. Conclusion The majority of the relaxation literature focuses on the effects of relaxation techniques based on muscle tense-release methods in order to learn how to control or reduce levels of arousal. However, a technique focused primarily on muscle stretching has emerged as a reasonable alternative to the tense-release approach, especially in situations where the use of tense-release procedures may be contraindicated as in the case for cardiac patients or muscle pain patients, for whom the traditional methods may increase risk or pain. This paper reviews the rationale and basic procedures for stretch-based relaxation. Research-based evaluations of this technique when used alone or in comparison to other methods, indicate beneficial effects of the stretch-based technique in the clinical areas of generalized anxiety, muscle tension, and selected muscle pain disorders. Further clinical research using the current protocol with selected populations is needed. Target populations that may be especially appropriate given the available data would include persons diagnosed with TMD or borderline hypertension. Our research and clinical findings suggest four
key points to consider when using stretch-based relaxation techniques. The first is the importance of achieving a ‘therapeutic life level’ of the relaxation training. Relaxation skills must be acquired and practiced to the extent that muscle relaxation can be achieved reliably in response to stressful life events in order for adequate symptom control. Second, the possibility of transient negative side effects of relaxation training should be considered, especially when a history of anxiety or panic attacks are present. Third, the role of the therapist is important in the delivery of relaxation training [24]. The therapist must not only explain the rationale of relaxation training and train the person properly, but is also responsible to mediate possible negative side effects with the patient. Finally, stretch-based relaxation is not a ‘cure all’, but rather a component of multifaceted treatment. While complete symptom resolution occurs with some patients, it is unlikely that symptoms will always disappear immediately upon the application of stretch-based relaxation training. Moreover, even if symptoms remitted with treatment, they may reoccur upon exposure to additional stressors. Ideally, stretch-based relaxation should be viewed as but one important part of an overall treatment program designed to alter an individual’s lifestyle so that s/he is able to cope more effectively with unwanted levels of arousal.
5. References Smith JC. Relaxation dynamics: nine world approaches to self-relaxation. Champaign, IL: Research Press, 1985. Bernstein DA, Carlson CR. Progressive relaxation: Abbreviated methods. In: Lehrer PM, Woolfolk R editors. Principles and practices of stress management. 2nd ed. New York: Guilford, 1982. Jacobsen E. Progressive relaxation. Chicago: University of Chicago Press. 1938. Bernstein DA, Borkovec TD. Progressive relaxation training: a manual for the helping professions. Champaign, IL: Research Press, 1973. Turk DC. Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive-behavioral perspective. New York: Guilford Press, 1983. Farrell P, Ebert T, Kampine J. Naloxone augments muscle sympathetic nerve activity during isometric exercise in humans. Am J Physiol 1991; 260: E379-E388. Saito M. Mano T, lwase S. Sympathetic nerve activity re-
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