- Email: [email protected]
Progressive relaxation for seizure reduction
1990;3:17-22 0 1990 Demos Publications
j Epilepsy
Progressive Relaxation for Seizure Reduction1 Steven Whitman, Jade Dell, Vicki Legion; Arawn Eibhlyn, and Judith Statsinger
It is widely accepted that stress and other environmental factors often trigger seizures in people with epilepsy. It is thus reasonable to hypothesize that behavioral approaches could minimize stress and improve seizure control, yet there have been very few controlled studies of this hypothesis and none that has involved long-term follow-up. To implement such a study, we involved 12 people with epilepsy in a training program for progressive relaxation therapy (PRT). Baseline seizure frequency of 8 weeks was compared to three 8-week follow-up periods. Median seizure frequency for the group decreased 21% after the first follow-up interval, from 19.5 to 15.5 (p = 0.07) and 54% after the third and final follow-up interval, from 19.5 to 9.0 (p = 0.02). This study also tried to answer two methodological questions. First, is it possible to abbreviate the most common protocol for PRT so that only three training sessions are required instead of lo? Second, is it possible that comparative newcomers to this field can become effective trainers? Both of these questions were answered in the affirmative by this study, although it is acknowledged that much more work needs to be done in these areas. Key Words: Behavioral-Relaxation therapy-Seizure frequency-Tension.
The past several years have seen increasing attention paid to behavioral procedures used as an adjunct to antiepilepsy drugs (AED) in the effort to reduce the number of seizures experienced by people with epilepsy. This emphasis is due in part to the fact that such behavioral methods are in general growing in popularity (1) and in part to the fact that some substantial proportion of epilepsy cases, probably about 20%, remains refractory to standard medical treatment (2). Although behavioral procedures have long offered the promise of helping patients with intractable or poorly controlled seizures, there has been a striking lack of evaluative research in this area. Eleven case From the Center for Urban Affairs and Policy Research, Northwestern University, Evanston, IL, U.S.A. Address correspondence and reprint requests to Dr. S. Whitman at Northwestern University, Center for Urban Affairs and Policy Research, 2040 Sheridan Road, Evanston, IL 60208, U.S.A. ‘We would like to express special appreciation to the Epilepsy Foundation of Greater Chicago and particularly to Barbara L Dershin, President, and James E. Davies, Social Worker.
studies of operant or respondent conditioning procedures were reviewed by Kraft and Poling in 1982 (3) who came to the conclusion that such procedures had great potential but had not yet been examined with any meaningful experimental design. Mostofsky and Balaschak (4) carried out an earlier review of more than 60 studies using 12 behavioral approaches to seizure control and reached a similar conclusion. The first controlled test of the effects of progressive relaxation therapy (PRT) on seizure frequency was reported by Rousseau et al. in 1985 (5). They employed progressive relaxation therapy for eight people with epilepsy, four of whom were first subjected to a sham treatment. Relaxation therapy demonstrated an effect beyond the sham treatment, and all eight of the subjects reported decreased seizure frequency from baseline to follow-up after treatment (p = 0.004). The authors concluded that PRT appeared to hold significant potential for people with epilepsy but that their experiment, with a small sample size, was “best seen as a pilot study that encourages future research” (p. 1212). IEPILEPSY,
VOL. 3, NO. 1, 2990
17
S. WHlTMAN ITAL. Further positive results have recently been reported by Dahl et al. (6). These investigators carried out a behavioral analysis of the circumstancessurrounding seizure occurrence in 18 patients who were subsequently subjected to contingent relaxation procedures. Contingent relaxation is a variation of PRT, used to “interrupt” preseizure indications. Compared to “attention control” groups and “no treatment” groups, the experimental group showed a significant reduction in seizure frequency. Most recently, Puskarich (7) compared a group of 13 patients with epilepsy who had undergone PRT with a group of 12 patients with epilepsy who underwent training in “quiet sitting,” which served as a control treatment. The control group demonstrated a nonsignificant 5.2% increase in seizure frequency from the B-week baseline period to the B-week followup period (from 9.5 seizures to lO.O), whereas the PRT group demonstrated a statistically significant decrease (p < 0.01) of 53.8% (from 13 seizures to 6 seizures) . One advantage that progressive relaxation holds over the procedures reported by Dahl et al. (6) is its simplicity and availability. The PRT trainer does not need to have the expertise to conduct a behavioral analysis of seizure frequency and to adapt the relaxation procedure to individual circumstances, both of which are required in contingent relaxation procedures. However, there are several important questions to be raised if progressive relaxation is to be made widely available. First, to what extent is it necessary to follow the traditional protocols of PRT? One of the most widely used protocols is one provided by Bernstein and Borkovec in 1973, which calls for 10 training sessions (8). Since fewer sessions would be more costeffective and would generate fewer dropouts, an empirical question is whether the number of sessions in this protocol could be reduced without reducing its efficacy. Second, how experienced must therapists be before they can successfully train people in PRT? To our knowledge, few data have yet been gathered about this question. Some studies have employed relaxation therapists who are psychiatrists, medical doctors, or who have extensive backgrounds in PRT, whereas other studies have employed graduate students (4,6, 9-11) or even undergraduates (11). Third, even ifit is the case that PRT has helped people with epilepsy to reduce their seizure frequency in the short run, will such reductions persist over time? This is, of course, a crucial question but one for which there is not yet any empirical answer. The purposes of this study were therefore to at18
1 EPILEPSY, VOL. 3, NO. 2, 1990
tempt to replicate previous findings of the success of PRT for seizure reduction in people with epilepsy, while at the same time addressing some additional questions. In particular, we wanted to know (a) if the Bernstein and Borkovec protocol (B), which is based on 10 sessions, could be abbreviated; (b) whether therapists with no previous experience with epilepsy or PRT could successfully provide PRT to people in this population; and (c) to what extent PRT would be effective for people with epilepsy beyond the immediate follow-up period.
Methods Subjects The subjects were selected from clients attending the Epilepsy Foundation of Greater Chicago (EFGC), the local affiliate of the Epilepsy Foundation of America (EFA). EFGC is an organization that provides support and services for people with epilepsy in the greater Chicago area. One staff member from EFGC was assigned as liaison to this research. He examined the records of all clients visiting in a given week and asked if they were interested in participating in a research project that might help them reduce their seizure frequency. There were two conditions for inclusion: a greater than zero seizure frequency in the past year and no mental retardation. If the client met these conditions, was able to speak English, and was interested in participating, he or she was given an B-week calendar for recording seizure activity, along with instructions on its use. In addition, permission was requested to telephone the patient after 2 weeks and again after 8 weeks to answer any questions that the patient might have. Those patients who experienced six or more seizures during baseline were asked to return to EFGC, where they were introduced to the relaxation therapist. The therapist then asked the client to continue to participate in the study. If the client agreed, the therapist explained that three visits would be required for training, and that the project would pay the client a total of $50 to defray his or her expenses. The first $25 would be paid after the training was completed and the second $25 would be paid when the final B-week follow-up calendar was turned in to the therapist. Each client signed a consent form that allowed examination of his or her medical records. The study, including the 6-month follow-up, was conducted in 1987-1988. During this time, 42 people were told about the study and 39 agreed to participate. Of the 17 people who did not complete baseline, 11 were lost to follow-up, two were hospitalized,
PROGRESSWE RELAXATION
two kept inadequate records, one had psychiatric problems that precluded participation, and one moved out of the city. Of the 22 who completed baseline, two had fewer than six seizures, four refused training because of conflicts with working hours, and four kept inadequate seizure frequency records during the study. The remaining 12 comprise the eligible study group.
FOR SEIZURES
respect to their health needs but was unfamiliar with both PRT and epilepsy. She trained the last nine subjects. Since the results obtained by the two groups of clients that were trained by these two therapists were similar according to the outcome measures employed, these two groups have been combined for the remainder of this paper.
Statistical Methods Procedure The PRT protocol that we employed was an abbreviation of the lo-session protocol developed by Bernstein and Borkovec (8). Session one, which combined sessions one through five of Bernstein and Borkovec, trained patients to group their muscles into seven parts in order to facilitate tensing and relaxing. This session lasted about 2 h. Session two, lasting about 1 h, consolidated sessions six and seven of Bernstein and Borkovec and asked patients to tense and relax their muscles into four groups. The third and final session, lasting about l/z h, incorporated the “recall,” “recall and counting,” and “counting” of Bernstein and Borkovec’s sessions eight, nine, and ten. Patients were asked to recall the feelings of the release of tension and to practice this recognition as they relaxed all muscle groups at once while the trainer counted from 1 to 10. The amount of time that elapsed between the first and final sessions varied as a function of each subject’s availability. The protocol called for one session per week, or 14 days between the first and third sessions. In fact, the average time elapsed was 18 days. Subjects were then instructed to continue to practice the procedures twice a day. An g-week calendar was given to the subjects, and they were again instructed to record seizure frequency on a daily basis. Following the initial g-week follow-up period, clients were called every month for 4 months. At each telephone call, the client was asked to report his/her seizure frequency and to tell the therapist how she/he was doing in general.
The Therapists Two individuals with college degrees but no previous training in behavioral sciences served as lay therapists. The first therapist received instruction and training in PRT from a trained clinical psychologist with special expertise in behavioral techniques; this therapist subsequently provided PRT to the first three subjects. The second therapist was hired when the first was about to move out of town; this therapist was trained by the first therapist. The second therapist had substantial experience interacting with people with
Comparisons were made between the g-week baseline period and the first g-week follow-up period, as well as between the second and third g-week followups. Similar to Dahl et al. (6), median seizure frequency was the primary dependent variable, and the sign test and the Wilcoxon signed rank test were employed for this data analysis. Two-tailed Student’s t tests were also employed.
Results Eight (67%) of the subjects were women, the average age was 35.8 years, and the average age at onset of epilepsy was 12.9 years. Six of the subjects had complex partial seizures and six had simple or complex partial seizures in addition to secondarily generalized seizures. Seizure frequencies for the baseline and three follow-up periods (each representing 2-month intervals) are presented in Table 1. Seizure frequency decreased for eight subjects and increased for three (with one client remaining constant), from baseline to the initial follow-up (sign test, p > 0.10). In this same interval, median seizure frequency decreased 21%, from 19.5 to 15.5, a marginally statistically significant result (Wilcoxon Signed Rank Test, p = 0.07). Comparisons between baseline and the last followup, which occurred 6 months after training, were also made. Ten of the 12 clients demonstrated a decrease in seizure frequency, a statistically significant result (Sign test, p = 0.04). Median seizure frequency declined 54%, from 19.5 to 9.0, also a statistically significant decrease (Wilcoxon Signed Rank Test, p = 0.02). Although there was fluctuation in seizure frequency during the three 2-month follow-ups, we can see from Table 1 that eight of the clients had three consecutive follow-up frequencies below baseline, two clients had two of the three follow-up periods below baseline, and for two clients (Sl and S8) PRT did not help lower their seizure frequency. We examined the characteristics of these individuals (e.g., age, age at onset, seizure type, and sex) to determine if there were any patterns that predicted success or failure of PRT, but no such patterns emerged. 1 EPILEPSY, VOL. 3, NO. I, 2990
19
s. WHlTMANETAL. Table 1.
Baseline and follow-up seizure frequencies for the study go-oup
Subject
Baseline
Two-month post-training follow-up
Sl s2 s3 s4 s5 S6 57 S8 s9 SlO Sll s12
22 12 17 17 6 35 29 9 29 24 33 10
22 3 0 5 13 22 27 18 24 5 26 13
36 9 6 10 3 16 12 16 25 6 23 5
36 0 8 0 4 20 13 10 25 8 22 4
Median Mean
19.5 20.3
15.5 14.8
11.0 13.9
9.0 12.5
Wilcoxon Signed-Rank Test between baseline and follow-up period
p = 0.07
p = 0.06
p = 0.02
Paired t test between baseline and follow-up period
p = 0.07
p = 0.05
p = 0.01
.
This nonparametric analysis was utilized to be consistent with Dahl et al. (6). However, parametric analysis would also be appropriate for these data. To determine if results would differ in a parametric analysis, we calculated mean seizure frequencies and performed matched t tests comparing the baseline average to those of the first follow-up (p = 0.07) and last follow-up (p = 0.01). The means can be found in Table 1. They are similar to the medians, and the general pattern is virtually identical, as are the significance test results.
Discussion Median seizure frequency decreased 21% from baseline to first follow-up, although this was only marginally statistically significant (p = 0.07). This trend generally continued, resulting in a statistically significant 54% decrease (p = 0.02) after 6 months, with 10 of the 12 subjects appearing to benefit from PRT. Whereas short-term effectiveness of PRT has been demonstrated previously (5,7), this is, to our knowledge, the first time that long-range follow-up has demonstrated the continuing effectiveness of PRT for people with epilepsy. Two other questions were asked at the beginning of 20
J EPILEPSY, VOL. 3, NO. I, 1990
Four-month post-training follow-up
Six-month post-training follow-up
this study. One was whether the traditional lo-session protocol of Bernstein and Borkovec (8) could successfully be condensed for people with epilepsy. In our first study (5) we utilized a one-session protocol to train the patients and required substantial home practice and continuing dialogue with the trainer over the telephone and during repeat visits. In the second study (7), we utilized a six-session protocol. We found that clients experienced difficulties in showing up for their appointments because of transportation problems, child care problems, and other similar difficulties. The study now being reported, which consisted of a condensation to three sessions, was also effective. However, we have no way of knowing if utilization of the full Bernstein and Borkovec protocol would have been even more effective than the abbreviated protocols. In 1981, Hillenberg and Collins (12) carried out an extensive review of the relaxation training literature published from 1970 to 1979. Of the 68 studies that they located, almost all (94%) utilized fewer than 10 sessions. On the other hand, in 1979, Borkovec and Sides (13) found that studies demonstrating PRT effectiveness typically employed four or more sessions. The optimal number of sessions is an interesting topic that should be pursued in future controlled investigations. The other question we posed was whether or not
PROGRESSIVE RELAXATION
lay therapists could be effectively trained to provide PRT to people with epilepsy. As noted in the Methods section, neither of the therapists in this study had prior experience in the fields of epilepsy or PRT, although one was an experienced teacher and the other had years of experience in a clinical setting. Despite their lack of formal training in clinical psychology, both were able to obtain good results with their clients. This leads us to believe that lay people who are sensitive and dedicated can learn to teach PRT without any previous training in the field. Several other PRT investigators have commented that they have used graduate students (4,6,9-11) as well as undergraduates (11) with good success. Although the results obtained by our trainers were positive, they might have been even better had we been able to employ a therapist experienced in PRT. The one controlled study in this area that we have been able to locate points in this direction. Carey and Burish (14) compared three treatment strategies to determine their effectiveness in reducing the sideeffects of cancer chemotherapy: relaxation taught by experienced professionals; relaxation taught by briefly trained hospital volunteers; and relaxation selftaught through the use of audiotaped cassettes. The control group was given the standard antiemetic drug therapy. The experienced professional relaxation trainers, who had a minimum of 3 years’experience in teaching PRT, obtained results significantly better Although there were than the other strategies. methodological limitations of this study, the results are in the expected direction and certainly merit further examination. For example, further research in this area could examine the degree of benefit accruing from various amounts of additional therapist training and experience. Then, an appropriate calibration could be made by those instituting programs in this area. Some caution must be exercised in interpreting the results from our study and in determining to which groups generalizations can be made. In our previous two reports (5,7), we utilized eligible patients presenting consecutively for care at two different clinics at a major medical center. For this study, we utilized clients referred to us by the EFGC. Although EFGC tried not to screen the clients before referring them to us, we have no idea how successful they were and thus do not know to what extent clients may have been selected for potential success before they entered our study. Nonetheless, we believe that EFGC is probably representative of EFA affiliates, at least of urban EFA affiliates, and that our results can be generalized to such a population. A second matter that suggests caution is that some investigators have noticed that trainer expectation
FOR SEIZURES
and interaction can help to increase the apparent effectiveness of PRT (15,16). There was no control for these factors in this study because we had previously demonstrated that PRT has positive effects above and beyond nonspecific treatment factors such as interactions with a therapist and expectation for improvement (5). In addition, Puskarich (7) did control for these factors and found PRT to be effective beyond experimenter interactions. Even if one assumes that such interactions did play a role in the positive results of this study, such expectation presumably would be a part of continuing work in this field. A third important methodological difficulty with this study is that we were not able to monitor AED levels. However, we did ask the subjects about their AED regimens throughout the study. One had his AEDs changed, three had their dosages altered, and one had both her AED type and dosage altered. The other seven reported no changes. Of the five who reported AED changes, three (S6, SlO, and S12) did well, one (S8) showed no improvement, and one (Sl) did poorly. One final methodological concern is the extent to which the subjects continued to practice after the completion of training. It is widely recognized in the literature that such practice may be a determining indicator of success with PRT (17,18), but no one has yet devised a good way to understand this dynamic. We asked the subjects at every follow-up telephone call if and how much they were practicing. Over the 6month follow-up interval, the subjects reported practicing an average of 1.7 times a day, compared to the twice-a-day protocol that we recommended. Only one of the subjects reported practicing less than an average of once a day. The finding that behavioral techniques can decrease seizure frequency, reported in this paper and in three recent publications (5-7), is consistent with a prominent theory of what triggers seizures in people with epilepsy. A frequently reported precursor of seizures in people with epilepsy is stress or tension (19). Although many people with epilepsy reported that stress causes additional seizures, it was not until 1984 that the first controlled study in this area was carried out by Ternkin and Davis (20). Their results were consistent with anecdotal reports in that they found daily self-reported levels of stress to be associated with subsequent seizure frequency. They therefore suggested that one reasonable mechanism for reducing seizures by behavioral techniques would be to minimize stress and tension. Our results, and the results of other recent studies, coincide with this perspective. There is much about PRT that is not yet clear: issues like the optimal number of sessions, the amount of practice that is needed, whether training may be live J EPILEPSY, VOL. 3, NO. 1, 1990
21
S. WHITMAN
ET AL.
or taped, and how investigator expectation influences results (12,13). Only controlled investigations of these topics can precisely answer these *questions. What is clear is that PRT is effective in decreasing the number of seizures experienced by some people with epilepsy. In addition, PRT seems to help in other ways as well. Rousseau et al. (5) conducted openended questions in their investigation, and patients revealed that they were sleeping better, were less aggravated and tense during the day, had improved feelings of control over their epilepsy, and were less afraid of their seizures. All indicated experiencing a greater sense of well-being. This echoes research findings on the use of relaxation therapy for other maladies. For example, in a literature review of the use of relaxation for hypertension, Pate1 and Marmot (21) summarized studies showing the concomitant reduction of anxiety, depression, and a variety of psychosomatic symptoms, while increasing a sense of well-being.
Conclusions Along with our two previous reports (5,7), this investigation provides strong evidence for the therapeutic benefit of progressive relaxation therapy for seizure reduction. When combined with the recent report by Dahl et al. (6) on similar positive effects obtained with contingent relaxation therapy (their subjects had a 66% reduction in median seizure frequency,
with
a very
small
sample
size), we are con-
vinced that such behavioral techniques now merit clinical consideration. The fact that long-term effectiveness was also demonstrated in this report is another encouraging piece of evidence. In addition to being effective, progressive relaxation has many other positive features. First, the proSecond, the procedure is cedure is noninvasive. inexpensive and could easily be made an adjunct to treatment at most medical facilities. Third, the nature of the treatment is easily comprehended by patientsthere is no sophisticated equipment involved, no complicated medical terminology, and very little technical
expertise
required.
Finally,
the patient
par-
takes in his or her own therapy, assuming a more active role in the treatment process rather than a passive role confined only to taking medicine. Study participants frequently reported positive reactions to this feature of progressive relaxation training.
References 1. Burish TG, Bradley LA, eds. Coping with chronic disease: research and application. New York: Academic Press, 1983. 22
J EPILEPSY, VOL. 3, NO. 2,199O
2. Commission for the Control of Epilepsy and Its Consequences. Plan for nationwide action on epilepsy. Washington, DC: US Government Printing Office, 1978; DHEW publication no. NIH 78-276. 3. Kraft KM, Poling AD. Behavioral treatment of epilepsy: methodological characteristics and problems of published studies. Appl Res Ment Retard 1982;3:151-62. 4. Mostofsky DI, Balaschak BA. Psychological control of seizures. Psycho1 Bull 1977;84:723-50. 5. Rousseau A, Hermann BP, Whitman S. Effects of progressive relaxation on epilepsy: analysis of a series of cases. Psycho1 Rep 1985;57:1203-12. 6. Dahl J, Melin L, Lund L Effects of a contingent relaxation treatment program on adults with refractory epileptic seizures. Epilepsia 1987;28:125-32. 7. Puskarich CA. The effects of progressive muscle relaxation on seizure frequency in adults with epileptic seizures [Dissertation]. Chicago, IL: University of Illinois, 1989. 8. Bernstein DA, Borkovec TD. Progressive relax&ion training. Champaign, IL: Research Press, 1973. 9. Wadden TA. Predicting treatment response to relaxation therapy for essential hypertension. J Nerv Ment Dis 1983;11:683-9. 10. Beiman I, Israel E, Johnson SA. During training and posttraining effects of live and taped extended progressive relaxation, self-relaxation, and electromyogram biofeedback. J Consult Clin Psycho1 1978;46:31421. 11. Borkovec TD, Grayson JB, Cooper KM. Treatment of general tension: subjective and physiological effects of progressive relaxation. J Consult Clin Psycho1 1978;46: 518-28. 12. Hillenberg JB, Collins F Jr. A procedural analysis and review of relaxation training research. Behav Res 7’her 1982;20:251-60. 13. Borkovec TD, Sides JK. Critical procedural variables related to the physiological effects of progressive relaxation: a review. Behnv Res Ther 1979;17:119-25. 14. Carey MP, Burish TG. Providing relaxation training to cancer chemotherapy patients: a comparison of three delivery techniques. 1 Consult Clin Psycho1 1987;5:7327. 15. Shaw ER, Blanchard EB. The effects of instructional set on the outcome of a stress management program. Biofeedback Self Regal 1983;8:555-65. 16. Agras WS, Home M, Taylor CB. Expectation and the blood-pressure-lowering effects of relaxation. Psychosom Med 1982;44:389-95. 17. Hillenberg JB, Collins FL Jr. The importance of home practice for progressive relaxation training. Behav Res Ther 1983;21:633-42. 18. Flanders P, McNamara JR. Relaxation and home practice in the treatment of anxiety. Psycho1 Rep 1987;61: 819-22. 19. Amtson P, Droge D, Norton R, Murray E. The perceived psychosocial consequences of having epilepsy. In: Whitman S, Hermann BP, eds. Psychopathology in epilepsy: social dimensions. New York: Oxford University Press, 1986:143-61. 20. Ten&in NR, Davis GR Stress as a risk factor for seizures among adults with epilepsy. Epilepsia 1984;25: 450-6. 21. Pate1C, Marmot MG. Stressmanagement, blood pressure, and quality of life. J Hypertens Suppl1987;5:S218.
j Epilepsy
Progressive Relaxation for Seizure Reduction1 Steven Whitman, Jade Dell, Vicki Legion; Arawn Eibhlyn, and Judith Statsinger
It is widely accepted that stress and other environmental factors often trigger seizures in people with epilepsy. It is thus reasonable to hypothesize that behavioral approaches could minimize stress and improve seizure control, yet there have been very few controlled studies of this hypothesis and none that has involved long-term follow-up. To implement such a study, we involved 12 people with epilepsy in a training program for progressive relaxation therapy (PRT). Baseline seizure frequency of 8 weeks was compared to three 8-week follow-up periods. Median seizure frequency for the group decreased 21% after the first follow-up interval, from 19.5 to 15.5 (p = 0.07) and 54% after the third and final follow-up interval, from 19.5 to 9.0 (p = 0.02). This study also tried to answer two methodological questions. First, is it possible to abbreviate the most common protocol for PRT so that only three training sessions are required instead of lo? Second, is it possible that comparative newcomers to this field can become effective trainers? Both of these questions were answered in the affirmative by this study, although it is acknowledged that much more work needs to be done in these areas. Key Words: Behavioral-Relaxation therapy-Seizure frequency-Tension.
The past several years have seen increasing attention paid to behavioral procedures used as an adjunct to antiepilepsy drugs (AED) in the effort to reduce the number of seizures experienced by people with epilepsy. This emphasis is due in part to the fact that such behavioral methods are in general growing in popularity (1) and in part to the fact that some substantial proportion of epilepsy cases, probably about 20%, remains refractory to standard medical treatment (2). Although behavioral procedures have long offered the promise of helping patients with intractable or poorly controlled seizures, there has been a striking lack of evaluative research in this area. Eleven case From the Center for Urban Affairs and Policy Research, Northwestern University, Evanston, IL, U.S.A. Address correspondence and reprint requests to Dr. S. Whitman at Northwestern University, Center for Urban Affairs and Policy Research, 2040 Sheridan Road, Evanston, IL 60208, U.S.A. ‘We would like to express special appreciation to the Epilepsy Foundation of Greater Chicago and particularly to Barbara L Dershin, President, and James E. Davies, Social Worker.
studies of operant or respondent conditioning procedures were reviewed by Kraft and Poling in 1982 (3) who came to the conclusion that such procedures had great potential but had not yet been examined with any meaningful experimental design. Mostofsky and Balaschak (4) carried out an earlier review of more than 60 studies using 12 behavioral approaches to seizure control and reached a similar conclusion. The first controlled test of the effects of progressive relaxation therapy (PRT) on seizure frequency was reported by Rousseau et al. in 1985 (5). They employed progressive relaxation therapy for eight people with epilepsy, four of whom were first subjected to a sham treatment. Relaxation therapy demonstrated an effect beyond the sham treatment, and all eight of the subjects reported decreased seizure frequency from baseline to follow-up after treatment (p = 0.004). The authors concluded that PRT appeared to hold significant potential for people with epilepsy but that their experiment, with a small sample size, was “best seen as a pilot study that encourages future research” (p. 1212). IEPILEPSY,
VOL. 3, NO. 1, 2990
17
S. WHlTMAN ITAL. Further positive results have recently been reported by Dahl et al. (6). These investigators carried out a behavioral analysis of the circumstancessurrounding seizure occurrence in 18 patients who were subsequently subjected to contingent relaxation procedures. Contingent relaxation is a variation of PRT, used to “interrupt” preseizure indications. Compared to “attention control” groups and “no treatment” groups, the experimental group showed a significant reduction in seizure frequency. Most recently, Puskarich (7) compared a group of 13 patients with epilepsy who had undergone PRT with a group of 12 patients with epilepsy who underwent training in “quiet sitting,” which served as a control treatment. The control group demonstrated a nonsignificant 5.2% increase in seizure frequency from the B-week baseline period to the B-week followup period (from 9.5 seizures to lO.O), whereas the PRT group demonstrated a statistically significant decrease (p < 0.01) of 53.8% (from 13 seizures to 6 seizures) . One advantage that progressive relaxation holds over the procedures reported by Dahl et al. (6) is its simplicity and availability. The PRT trainer does not need to have the expertise to conduct a behavioral analysis of seizure frequency and to adapt the relaxation procedure to individual circumstances, both of which are required in contingent relaxation procedures. However, there are several important questions to be raised if progressive relaxation is to be made widely available. First, to what extent is it necessary to follow the traditional protocols of PRT? One of the most widely used protocols is one provided by Bernstein and Borkovec in 1973, which calls for 10 training sessions (8). Since fewer sessions would be more costeffective and would generate fewer dropouts, an empirical question is whether the number of sessions in this protocol could be reduced without reducing its efficacy. Second, how experienced must therapists be before they can successfully train people in PRT? To our knowledge, few data have yet been gathered about this question. Some studies have employed relaxation therapists who are psychiatrists, medical doctors, or who have extensive backgrounds in PRT, whereas other studies have employed graduate students (4,6, 9-11) or even undergraduates (11). Third, even ifit is the case that PRT has helped people with epilepsy to reduce their seizure frequency in the short run, will such reductions persist over time? This is, of course, a crucial question but one for which there is not yet any empirical answer. The purposes of this study were therefore to at18
1 EPILEPSY, VOL. 3, NO. 2, 1990
tempt to replicate previous findings of the success of PRT for seizure reduction in people with epilepsy, while at the same time addressing some additional questions. In particular, we wanted to know (a) if the Bernstein and Borkovec protocol (B), which is based on 10 sessions, could be abbreviated; (b) whether therapists with no previous experience with epilepsy or PRT could successfully provide PRT to people in this population; and (c) to what extent PRT would be effective for people with epilepsy beyond the immediate follow-up period.
Methods Subjects The subjects were selected from clients attending the Epilepsy Foundation of Greater Chicago (EFGC), the local affiliate of the Epilepsy Foundation of America (EFA). EFGC is an organization that provides support and services for people with epilepsy in the greater Chicago area. One staff member from EFGC was assigned as liaison to this research. He examined the records of all clients visiting in a given week and asked if they were interested in participating in a research project that might help them reduce their seizure frequency. There were two conditions for inclusion: a greater than zero seizure frequency in the past year and no mental retardation. If the client met these conditions, was able to speak English, and was interested in participating, he or she was given an B-week calendar for recording seizure activity, along with instructions on its use. In addition, permission was requested to telephone the patient after 2 weeks and again after 8 weeks to answer any questions that the patient might have. Those patients who experienced six or more seizures during baseline were asked to return to EFGC, where they were introduced to the relaxation therapist. The therapist then asked the client to continue to participate in the study. If the client agreed, the therapist explained that three visits would be required for training, and that the project would pay the client a total of $50 to defray his or her expenses. The first $25 would be paid after the training was completed and the second $25 would be paid when the final B-week follow-up calendar was turned in to the therapist. Each client signed a consent form that allowed examination of his or her medical records. The study, including the 6-month follow-up, was conducted in 1987-1988. During this time, 42 people were told about the study and 39 agreed to participate. Of the 17 people who did not complete baseline, 11 were lost to follow-up, two were hospitalized,
PROGRESSWE RELAXATION
two kept inadequate records, one had psychiatric problems that precluded participation, and one moved out of the city. Of the 22 who completed baseline, two had fewer than six seizures, four refused training because of conflicts with working hours, and four kept inadequate seizure frequency records during the study. The remaining 12 comprise the eligible study group.
FOR SEIZURES
respect to their health needs but was unfamiliar with both PRT and epilepsy. She trained the last nine subjects. Since the results obtained by the two groups of clients that were trained by these two therapists were similar according to the outcome measures employed, these two groups have been combined for the remainder of this paper.
Statistical Methods Procedure The PRT protocol that we employed was an abbreviation of the lo-session protocol developed by Bernstein and Borkovec (8). Session one, which combined sessions one through five of Bernstein and Borkovec, trained patients to group their muscles into seven parts in order to facilitate tensing and relaxing. This session lasted about 2 h. Session two, lasting about 1 h, consolidated sessions six and seven of Bernstein and Borkovec and asked patients to tense and relax their muscles into four groups. The third and final session, lasting about l/z h, incorporated the “recall,” “recall and counting,” and “counting” of Bernstein and Borkovec’s sessions eight, nine, and ten. Patients were asked to recall the feelings of the release of tension and to practice this recognition as they relaxed all muscle groups at once while the trainer counted from 1 to 10. The amount of time that elapsed between the first and final sessions varied as a function of each subject’s availability. The protocol called for one session per week, or 14 days between the first and third sessions. In fact, the average time elapsed was 18 days. Subjects were then instructed to continue to practice the procedures twice a day. An g-week calendar was given to the subjects, and they were again instructed to record seizure frequency on a daily basis. Following the initial g-week follow-up period, clients were called every month for 4 months. At each telephone call, the client was asked to report his/her seizure frequency and to tell the therapist how she/he was doing in general.
The Therapists Two individuals with college degrees but no previous training in behavioral sciences served as lay therapists. The first therapist received instruction and training in PRT from a trained clinical psychologist with special expertise in behavioral techniques; this therapist subsequently provided PRT to the first three subjects. The second therapist was hired when the first was about to move out of town; this therapist was trained by the first therapist. The second therapist had substantial experience interacting with people with
Comparisons were made between the g-week baseline period and the first g-week follow-up period, as well as between the second and third g-week followups. Similar to Dahl et al. (6), median seizure frequency was the primary dependent variable, and the sign test and the Wilcoxon signed rank test were employed for this data analysis. Two-tailed Student’s t tests were also employed.
Results Eight (67%) of the subjects were women, the average age was 35.8 years, and the average age at onset of epilepsy was 12.9 years. Six of the subjects had complex partial seizures and six had simple or complex partial seizures in addition to secondarily generalized seizures. Seizure frequencies for the baseline and three follow-up periods (each representing 2-month intervals) are presented in Table 1. Seizure frequency decreased for eight subjects and increased for three (with one client remaining constant), from baseline to the initial follow-up (sign test, p > 0.10). In this same interval, median seizure frequency decreased 21%, from 19.5 to 15.5, a marginally statistically significant result (Wilcoxon Signed Rank Test, p = 0.07). Comparisons between baseline and the last followup, which occurred 6 months after training, were also made. Ten of the 12 clients demonstrated a decrease in seizure frequency, a statistically significant result (Sign test, p = 0.04). Median seizure frequency declined 54%, from 19.5 to 9.0, also a statistically significant decrease (Wilcoxon Signed Rank Test, p = 0.02). Although there was fluctuation in seizure frequency during the three 2-month follow-ups, we can see from Table 1 that eight of the clients had three consecutive follow-up frequencies below baseline, two clients had two of the three follow-up periods below baseline, and for two clients (Sl and S8) PRT did not help lower their seizure frequency. We examined the characteristics of these individuals (e.g., age, age at onset, seizure type, and sex) to determine if there were any patterns that predicted success or failure of PRT, but no such patterns emerged. 1 EPILEPSY, VOL. 3, NO. I, 2990
19
s. WHlTMANETAL. Table 1.
Baseline and follow-up seizure frequencies for the study go-oup
Subject
Baseline
Two-month post-training follow-up
Sl s2 s3 s4 s5 S6 57 S8 s9 SlO Sll s12
22 12 17 17 6 35 29 9 29 24 33 10
22 3 0 5 13 22 27 18 24 5 26 13
36 9 6 10 3 16 12 16 25 6 23 5
36 0 8 0 4 20 13 10 25 8 22 4
Median Mean
19.5 20.3
15.5 14.8
11.0 13.9
9.0 12.5
Wilcoxon Signed-Rank Test between baseline and follow-up period
p = 0.07
p = 0.06
p = 0.02
Paired t test between baseline and follow-up period
p = 0.07
p = 0.05
p = 0.01
.
This nonparametric analysis was utilized to be consistent with Dahl et al. (6). However, parametric analysis would also be appropriate for these data. To determine if results would differ in a parametric analysis, we calculated mean seizure frequencies and performed matched t tests comparing the baseline average to those of the first follow-up (p = 0.07) and last follow-up (p = 0.01). The means can be found in Table 1. They are similar to the medians, and the general pattern is virtually identical, as are the significance test results.
Discussion Median seizure frequency decreased 21% from baseline to first follow-up, although this was only marginally statistically significant (p = 0.07). This trend generally continued, resulting in a statistically significant 54% decrease (p = 0.02) after 6 months, with 10 of the 12 subjects appearing to benefit from PRT. Whereas short-term effectiveness of PRT has been demonstrated previously (5,7), this is, to our knowledge, the first time that long-range follow-up has demonstrated the continuing effectiveness of PRT for people with epilepsy. Two other questions were asked at the beginning of 20
J EPILEPSY, VOL. 3, NO. I, 1990
Four-month post-training follow-up
Six-month post-training follow-up
this study. One was whether the traditional lo-session protocol of Bernstein and Borkovec (8) could successfully be condensed for people with epilepsy. In our first study (5) we utilized a one-session protocol to train the patients and required substantial home practice and continuing dialogue with the trainer over the telephone and during repeat visits. In the second study (7), we utilized a six-session protocol. We found that clients experienced difficulties in showing up for their appointments because of transportation problems, child care problems, and other similar difficulties. The study now being reported, which consisted of a condensation to three sessions, was also effective. However, we have no way of knowing if utilization of the full Bernstein and Borkovec protocol would have been even more effective than the abbreviated protocols. In 1981, Hillenberg and Collins (12) carried out an extensive review of the relaxation training literature published from 1970 to 1979. Of the 68 studies that they located, almost all (94%) utilized fewer than 10 sessions. On the other hand, in 1979, Borkovec and Sides (13) found that studies demonstrating PRT effectiveness typically employed four or more sessions. The optimal number of sessions is an interesting topic that should be pursued in future controlled investigations. The other question we posed was whether or not
PROGRESSIVE RELAXATION
lay therapists could be effectively trained to provide PRT to people with epilepsy. As noted in the Methods section, neither of the therapists in this study had prior experience in the fields of epilepsy or PRT, although one was an experienced teacher and the other had years of experience in a clinical setting. Despite their lack of formal training in clinical psychology, both were able to obtain good results with their clients. This leads us to believe that lay people who are sensitive and dedicated can learn to teach PRT without any previous training in the field. Several other PRT investigators have commented that they have used graduate students (4,6,9-11) as well as undergraduates (11) with good success. Although the results obtained by our trainers were positive, they might have been even better had we been able to employ a therapist experienced in PRT. The one controlled study in this area that we have been able to locate points in this direction. Carey and Burish (14) compared three treatment strategies to determine their effectiveness in reducing the sideeffects of cancer chemotherapy: relaxation taught by experienced professionals; relaxation taught by briefly trained hospital volunteers; and relaxation selftaught through the use of audiotaped cassettes. The control group was given the standard antiemetic drug therapy. The experienced professional relaxation trainers, who had a minimum of 3 years’experience in teaching PRT, obtained results significantly better Although there were than the other strategies. methodological limitations of this study, the results are in the expected direction and certainly merit further examination. For example, further research in this area could examine the degree of benefit accruing from various amounts of additional therapist training and experience. Then, an appropriate calibration could be made by those instituting programs in this area. Some caution must be exercised in interpreting the results from our study and in determining to which groups generalizations can be made. In our previous two reports (5,7), we utilized eligible patients presenting consecutively for care at two different clinics at a major medical center. For this study, we utilized clients referred to us by the EFGC. Although EFGC tried not to screen the clients before referring them to us, we have no idea how successful they were and thus do not know to what extent clients may have been selected for potential success before they entered our study. Nonetheless, we believe that EFGC is probably representative of EFA affiliates, at least of urban EFA affiliates, and that our results can be generalized to such a population. A second matter that suggests caution is that some investigators have noticed that trainer expectation
FOR SEIZURES
and interaction can help to increase the apparent effectiveness of PRT (15,16). There was no control for these factors in this study because we had previously demonstrated that PRT has positive effects above and beyond nonspecific treatment factors such as interactions with a therapist and expectation for improvement (5). In addition, Puskarich (7) did control for these factors and found PRT to be effective beyond experimenter interactions. Even if one assumes that such interactions did play a role in the positive results of this study, such expectation presumably would be a part of continuing work in this field. A third important methodological difficulty with this study is that we were not able to monitor AED levels. However, we did ask the subjects about their AED regimens throughout the study. One had his AEDs changed, three had their dosages altered, and one had both her AED type and dosage altered. The other seven reported no changes. Of the five who reported AED changes, three (S6, SlO, and S12) did well, one (S8) showed no improvement, and one (Sl) did poorly. One final methodological concern is the extent to which the subjects continued to practice after the completion of training. It is widely recognized in the literature that such practice may be a determining indicator of success with PRT (17,18), but no one has yet devised a good way to understand this dynamic. We asked the subjects at every follow-up telephone call if and how much they were practicing. Over the 6month follow-up interval, the subjects reported practicing an average of 1.7 times a day, compared to the twice-a-day protocol that we recommended. Only one of the subjects reported practicing less than an average of once a day. The finding that behavioral techniques can decrease seizure frequency, reported in this paper and in three recent publications (5-7), is consistent with a prominent theory of what triggers seizures in people with epilepsy. A frequently reported precursor of seizures in people with epilepsy is stress or tension (19). Although many people with epilepsy reported that stress causes additional seizures, it was not until 1984 that the first controlled study in this area was carried out by Ternkin and Davis (20). Their results were consistent with anecdotal reports in that they found daily self-reported levels of stress to be associated with subsequent seizure frequency. They therefore suggested that one reasonable mechanism for reducing seizures by behavioral techniques would be to minimize stress and tension. Our results, and the results of other recent studies, coincide with this perspective. There is much about PRT that is not yet clear: issues like the optimal number of sessions, the amount of practice that is needed, whether training may be live J EPILEPSY, VOL. 3, NO. 1, 1990
21
S. WHITMAN
ET AL.
or taped, and how investigator expectation influences results (12,13). Only controlled investigations of these topics can precisely answer these *questions. What is clear is that PRT is effective in decreasing the number of seizures experienced by some people with epilepsy. In addition, PRT seems to help in other ways as well. Rousseau et al. (5) conducted openended questions in their investigation, and patients revealed that they were sleeping better, were less aggravated and tense during the day, had improved feelings of control over their epilepsy, and were less afraid of their seizures. All indicated experiencing a greater sense of well-being. This echoes research findings on the use of relaxation therapy for other maladies. For example, in a literature review of the use of relaxation for hypertension, Pate1 and Marmot (21) summarized studies showing the concomitant reduction of anxiety, depression, and a variety of psychosomatic symptoms, while increasing a sense of well-being.
Conclusions Along with our two previous reports (5,7), this investigation provides strong evidence for the therapeutic benefit of progressive relaxation therapy for seizure reduction. When combined with the recent report by Dahl et al. (6) on similar positive effects obtained with contingent relaxation therapy (their subjects had a 66% reduction in median seizure frequency,
with
a very
small
sample
size), we are con-
vinced that such behavioral techniques now merit clinical consideration. The fact that long-term effectiveness was also demonstrated in this report is another encouraging piece of evidence. In addition to being effective, progressive relaxation has many other positive features. First, the proSecond, the procedure is cedure is noninvasive. inexpensive and could easily be made an adjunct to treatment at most medical facilities. Third, the nature of the treatment is easily comprehended by patientsthere is no sophisticated equipment involved, no complicated medical terminology, and very little technical
expertise
required.
Finally,
the patient
par-
takes in his or her own therapy, assuming a more active role in the treatment process rather than a passive role confined only to taking medicine. Study participants frequently reported positive reactions to this feature of progressive relaxation training.
References 1. Burish TG, Bradley LA, eds. Coping with chronic disease: research and application. New York: Academic Press, 1983. 22
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2. Commission for the Control of Epilepsy and Its Consequences. Plan for nationwide action on epilepsy. Washington, DC: US Government Printing Office, 1978; DHEW publication no. NIH 78-276. 3. Kraft KM, Poling AD. Behavioral treatment of epilepsy: methodological characteristics and problems of published studies. Appl Res Ment Retard 1982;3:151-62. 4. Mostofsky DI, Balaschak BA. Psychological control of seizures. Psycho1 Bull 1977;84:723-50. 5. Rousseau A, Hermann BP, Whitman S. Effects of progressive relaxation on epilepsy: analysis of a series of cases. Psycho1 Rep 1985;57:1203-12. 6. Dahl J, Melin L, Lund L Effects of a contingent relaxation treatment program on adults with refractory epileptic seizures. Epilepsia 1987;28:125-32. 7. Puskarich CA. The effects of progressive muscle relaxation on seizure frequency in adults with epileptic seizures [Dissertation]. Chicago, IL: University of Illinois, 1989. 8. Bernstein DA, Borkovec TD. Progressive relax&ion training. Champaign, IL: Research Press, 1973. 9. Wadden TA. Predicting treatment response to relaxation therapy for essential hypertension. J Nerv Ment Dis 1983;11:683-9. 10. Beiman I, Israel E, Johnson SA. During training and posttraining effects of live and taped extended progressive relaxation, self-relaxation, and electromyogram biofeedback. J Consult Clin Psycho1 1978;46:31421. 11. Borkovec TD, Grayson JB, Cooper KM. Treatment of general tension: subjective and physiological effects of progressive relaxation. J Consult Clin Psycho1 1978;46: 518-28. 12. Hillenberg JB, Collins F Jr. A procedural analysis and review of relaxation training research. Behav Res 7’her 1982;20:251-60. 13. Borkovec TD, Sides JK. Critical procedural variables related to the physiological effects of progressive relaxation: a review. Behnv Res Ther 1979;17:119-25. 14. Carey MP, Burish TG. Providing relaxation training to cancer chemotherapy patients: a comparison of three delivery techniques. 1 Consult Clin Psycho1 1987;5:7327. 15. Shaw ER, Blanchard EB. The effects of instructional set on the outcome of a stress management program. Biofeedback Self Regal 1983;8:555-65. 16. Agras WS, Home M, Taylor CB. Expectation and the blood-pressure-lowering effects of relaxation. Psychosom Med 1982;44:389-95. 17. Hillenberg JB, Collins FL Jr. The importance of home practice for progressive relaxation training. Behav Res Ther 1983;21:633-42. 18. Flanders P, McNamara JR. Relaxation and home practice in the treatment of anxiety. Psycho1 Rep 1987;61: 819-22. 19. Amtson P, Droge D, Norton R, Murray E. The perceived psychosocial consequences of having epilepsy. In: Whitman S, Hermann BP, eds. Psychopathology in epilepsy: social dimensions. New York: Oxford University Press, 1986:143-61. 20. Ten&in NR, Davis GR Stress as a risk factor for seizures among adults with epilepsy. Epilepsia 1984;25: 450-6. 21. Pate1C, Marmot MG. Stressmanagement, blood pressure, and quality of life. J Hypertens Suppl1987;5:S218.