Pain Service - Relaxation - what it is and why it is important

Learning relaxation techniques and practising these is one of the major goals of pain management. There are three main reasons for this:

1. To improve your ability to relax your muscles.
2. To have techniques available to reduce tension in general.
3. To achieve peace of mind or calmness as a way of coping with stress in general.

In order to get the most benefit from relaxation techniques they have to be practised regularly. This means every day whilst you are getting used to them and routinely (2 – 3 times a week) once you feel more confident with them.

Almost anybody can learn a relaxation technique. How quickly people learn to relax, and the depth of relaxation achieved varies considerably, but be patient and the rewards will almost certainly follow.

No-one can force you to become relaxed, and if you try too hard you may not achieve a relaxed state. In this sense relaxation can be compared to learning how to float in water. It is impossible to float if one is thrashing around – controlling yourself in water can only be achieved by gradually “letting go”.

Relaxation, therefore, is not only a technique – it is also an attitude or even an approach to life. Relaxation is not something to be achieved or accomplished, it is something that happens naturally once you have learned and practised the exercises. Once you are familiar with each of the techniques, and you have enough practice, you can customise your relaxation practice to suit yourself and your daily routine. This leaflet will cover three different relaxation exercises – diaphragmatic breathing, progressive muscle relaxation and autogenic relaxation.

There are a number of mistakes that can be made, especially in the beginning, so practising to familiarise yourself with the skills is important.

Basic guidelines for relaxation

1. Be patient – it takes some time to actually feel the initial results.
2. Practice regularly – this is the biggest obstacle in learning any kind of relaxation technique. In fact, anybody can learn it as long as they practice it. At first you will need to dedicate time on a frequent and regular basis – even if you do not feel tense or stressed. As you become more skilled it will become something you do almost automatically.
3. Do not use effort or intense concentration – this will prevent relaxation.

Relaxation YouTube links are available below:

During our sessions we use several types of relaxation exercise that form the basis of other techniques that you will be taught. These are available in CD format but also online as Youtube links. Please type the link in the search engine on your electronic device exactly as it is written below.

https://youtu.be/YpDXmTE5-LE - Diaphragmatic breathing

https://youtu.be/H87mwWLK6LE - Progressive muscle relaxation (PMR) information.

https://youtu.be/pvGRVWTm90M - Progressive muscle relaxation (PMR) practice.

https://youtu.be/6ojNQOt3JYU - Autogenic relaxation (female voice).

https://youtu.be/enYnOBaLG2Q - Autogenic relaxation (male voice).

Diaphragmatic Breathing

The diaphragm is a dome-shaped muscle system. It not only helps us to control our breathing, but it acts as a natural partition between our chest and abdominal cavities. When we are breathing our diaphragm moves downward as we breathe in and upward when we breathe out. The more we flatten the diaphragm by pushing out our abdomen, the more our lungs are able to expand, taking in more oxygen and pushing out waste gases such as carbon dioxide that lie deep within the lung. This helps to “switch on” the energy conservation system and induces the relaxation response. The mechanical movement of the diaphragm also helps to improve blood flow in the chest and abdominal cavities and regulate internal muscle contractions.

Diaphragmatic breathing is the most efficient and relaxed way of breathing. While infants and children use diaphragmatic breathing, adults tend to change their breathing pattern, mostly as a result of daily stress. Most people have developed the habit of breathing from the chest and try to increase lung capacity by raising their shoulders – this is neither efficient nor relaxing.

Many adults also try to avoid abdominal breathing since it involves a slight extension of the abdomen. As the abdomen rises with every smooth flow of air into the lungs and out again, the shoulders should not move, and the chest equally should not move. Diaphragmatic breathing is quite easy to learn, and the effect is apparent relatively quickly and is a powerful relaxation technique. It is also practical in that you can practice it anywhere and at anytime. Our breathing is a good indicator of our physical and emotional arousal. The trouble is most of the time we are not aware of our breathing and inefficient breathing becomes a habit.

How to practice and use the diaphragmatic (abdominal) breathing:

• Loosen any tight clothing especially around your abdomen and waist
• Place your feet slightly apart. Rest one hand comfortably on your abdomen near your naval. Place the other hand on your chest
• Initially it might be worth trying it with your eyes closed
• Inhale through your nose because this allows the air to be filtered and warmed
• Exhale through your mouth
• Quietly concentrate on your breathing for a few minutes and become aware of which hand is rising and falling with each breath
• Gently exhale most of the air in your lungs
• Breathe in slowly for a count of 3 or 4, until you have a comfortable breath in, about one second per count. As you inhale gently, slightly extend your abdomen (like inflating a balloon), causing it to rise about one inch. You should be able to feel the movement with your hand. Remember, do not pull your shoulders up or move your chest
• As you breathe in, imagine the warmed and relaxing air flowing in. Imagine this warmth flowing to all parts of your body
• Pause one second after inhaling
• Do all this gently without using any effort, if there are difficulties you might want to try and shorten the count slightly and work up to four. Also, if you experience light-headedness, alter the length or depth of your breathing
• Exhale slowly. Remember to take longer breathing out than you took to breathe in
• Practice this approximately 3 – 4 times a day for at least 4 minutes at a time

Progressive Muscle Relaxation – PMR

This relaxation technique is called the Progressive Muscle Relaxation (PMR). It is especially beneficial for people with chronic low back pain.

Goals of this particular relaxation exercise are:

1. Become aware of muscle tension and increase muscle relaxation in different muscle groups
2. Be able to relax different muscles at your will and use this ability in daily life
3. Be aware of and reduce mental tension in daily life.

In the PMR technique we use tensing and relaxing of the muscles to achieve an increase in muscle relaxation. All skeletal muscle groups in the body are systematically tensed and then relaxed in order to achieve physical and mental relaxation.

The general rule is that as a first step you tense a muscle for approximately 5 to 7 seconds which then is followed by a second step in which you try to relax the same muscle for up to 25 seconds.

During both steps, try to concentrate on the feeling of tension and on the feeling of relaxation. The concentration is important because it will enhance the effect and at the same time it shifts your attention from any thoughts and images that come up. It is not necessary to tense your muscles completely. The purpose of the muscle tension is only to make you aware of the difference. So, try not to tense too much – two thirds of the possible tension is enough.

If you feel any pain while tensing a muscle, try and tense only to the point where you feel tension but no pain. In case it is still painful, try focusing on the tension without tensing the muscle.
 
Tensing a muscle is sometimes painful because the muscle is already at a high level of tension and a slight increase may cause pain or muscle spasm. As your relaxation skill improves you will experience a decrease in muscle tension.

Preparation for Progressive Muscle Relaxation

1. Find a time and place where you are able to be undisturbed for the time you will need.
2. Lie down on your back with your legs straight and your arms beside your body and make yourself comfortable. You may use a towel or a pillow under your head, lower back and your knees and start with the diaphragmatic breathing as previously described.
3. You will be given a series of instructions to tense and relax various muscle groups. Taking each of the muscle groups in turn, you will initially be given a description of the muscles to be tensed, followed by the instruction to begin tensing. It is important that you do not begin tensing the muscle groups until instructed.
4. After approximately 5 seconds you will then be asked to relax the muscles by using the word ‘release’. We will repeat each of the muscle groups once.
5. At various points of the exercise you will be asked to focus on your breathing. Make sure that as you go through the exercise you try and breath using diaphragmatic breathing.

If you are unable to access the progressive muscle relaxation audio recording via the link on page 4, a full written script can be found in the appendix.

PMR - Relaxing without tensing

After you have practised the relaxation of the combined muscle groups you should have reached a level of confidence about PMR so that you now don’t need to tense each muscle group. The tensing was a way of learning the difference between tension and relaxation in the muscles. Now that you are more aware of your muscle tension tensing the muscles is no longer necessary.
So as a next step try and concentrate on the different muscle groups and without tensing try and concentrate on the feeling of relaxation.

If you are experiencing difficulties – keep practising. But you can always go back and use the tension-relaxation technique again if it helps you to relax better.

Autogenic Relaxation Training

Autogenic training simply focuses on two aspects of the relaxation response – increased blood flow and muscular relaxation. It does this by focusing on two things that we feel when relaxing – warmth, which is what we feel when more blood gets to the extremities of our bodies and heaviness, which is what we feel when our muscles are relaxed.

Remember, you cannot force yourself to relax, so just sit or lie quietly and ‘let go’. Notice any distracting thoughts and return your attention back to the practice. It is normal to need to do this several times at first.

Preparation for Autogenic Relaxation

1. To begin, sit or lie with your body fully supported, arms and legs uncrossed.
2. Begin diaphragmatic breathing.
3. Listen to the instructions of the autogenic relaxation.
4. After each line, repeat the phrase in your head, like an echo and then gently turn your attention to that part of your body and imagine the sensation that you are thinking about.
5. When the relaxation is over, complete the exercise by taking a deep breath.
6. When you feel ready, stretch out all of your limbs, and slowly move around.
7. Take that feeling of relaxation with you.

If you are unable to access the autogenic relaxation training audio recording via the link on page 4, a full written script can be found in the appendix.

Applying relaxation in daily life

In daily life it is not always possible to practice relaxation when we most need it. Although through regular practice the level of tension you are experiencing will decrease, you will still need to be aware of any muscle tension during the day. We therefore suggest that you practice relaxation in three ways:

1. Normal relaxation: Practising relaxation for 15 to 30 minutes at least once a day. This is especially important in the beginning and during times of increased stress and tension.
2. Brief relaxation: This means a relaxation of about 5 to 10 minutes during the day where you deliberately stop your activities. You can do this in almost any position, sitting or standing and it should be done several times a day in real-life situations. Whether you are at your desk, doing housework or waiting for the bus. Close your eyes or leave them open. Just try and relax despite what is going on around you.
3. Mini relaxation: These are very brief. They can last from a few seconds to a few minutes, and it is helpful to do them as often as you can. It will help you to make relaxation a habitual skill in almost any situation. You can relax any muscle that you do not need for what you are doing at that very moment. For example, when you carry your shopping, you can relax the muscles of your shoulders. To remind yourself to practice these mini relaxations, you could put objects (e.g. little coloured stickers) in different areas of the house or workplace.

A few words about regular practice of relaxation

Having practiced Diaphragmatic breathing, PMR and Autogenic Relaxation Training you are now able to work with these three techniques and use them as needed. Practice regularly and consistently to build confidence in your practice.

Regular practising is probably the most difficult discipline in relaxation. We know from experience that everyone is able to learn relaxation. This is because it is such a basic human capability. Keeping up regular practice is the real difficulty. Try and make yourself aware of the benefits and of the good feeling you get out of it and remember, even if you do not practice for a certain period of time, you can always pick it up again. Not practising for a while is not a disaster – you can always start again!

APPENDIX

How to go about the PMR Relaxation

First of all find time and space (place) where you are able to be undisturbed for the time you will need. Make this an important daily routine, just as you make a tea break an important routine.

Lie down on your back with legs straight and your arms beside your body and make yourself comfortable. You may use a towel or a pillow under your head, lower back and your knees. Start with the diaphragmatic breathing as described above. Then tense and relax the following muscle groups and repeat every group once.

1. Make a fist in your right hand to tense the muscles of your right hand and the muscles of your whole right arm.
2. Same exercise for the left arm/hand.
3. Shrug your shoulders to tense the muscles of the shoulders.
4. Carefully press your head against the pillow (floor, wall) to tense the muscles of your neck.
5. Push your eyebrows upwards as if you were surprised to tense the muscles of the forehead.
6. Screw your eyes up tightly to tense the muscles around your eyes.
7. Press your lips together, grit your teeth together and press your tongue against the roof of your mouth to tense your jaw muscles.
8. Bring your shoulders slightly forward to tense the muscles of your chest.
9. Press your back against the floor to tense the muscles of your tummy.
10. Make a slight arch of your lower back to tense the muscles of your lower back.
11. Press your buttocks together and tense the muscles of your buttock.
12. Tense the muscles of your right thigh by pushing the right toes down and bringing the right heel back.
13. Same exercise for the left thigh.
14. Tense the muscles of your right calf by pushing the right heel outwards and pulling the right toes backwards.
15. Same exercise for the left calf.

As you go through these exercises try to breathe normally (using the diaphragmatic breathing). Inhale as you tense the muscle, and exhale as you relax the muscle – then breathing normally for two ‘breathing cycles’. Once you are finished with your relaxation exercise you must make sure that you really finish by stretching all your limbs, taking a deep breath, opening your eyes and slowly moving around.

Instructions for Autogenic relaxation

Phrases:

Breathing evenly, breathing calmly, breathing peacefully

I feel quite quiet
I feel quite quiet

My right arm is warm
Right arm, warm
Warmth flowing in to my right arm
It’s warm, warm

My left arm is warm
Left arm, warm
Warmth flowing in to my left arm
It’s warm, warm

My right leg is warm
Right leg, warm
Warmth flowing into my right leg
It’s warm, warm
 
My left leg is warm
Left leg, warm
Warmth flowing into my left leg
It’s warm, warm

My neck and my shoulders are warm
Neck, shoulders, warm
Warmth flowing across my neck and shoulders
They’re warm, warm

Breathing evenly, breathing calmly, breathing peacefully

My right arm is warm and heavy
Right arm, warm, heavy
Warmth, heaviness coming over my right arm
It’s warm, heavy

My left arm is warm and heavy
Left arm, warm, heavy
Warmth, heaviness coming over my left arm
It’s warm, heavy
 
My right leg is warm and heavy
Right leg, warm, heavy
Warmth, heaviness coming over my right leg
It’s warm, heavy

My left leg is warm and heavy
Left leg, warm, heavy
Warmth, heaviness coming over my left leg
It’s warm, heavy

My neck and shoulders are warm and heavy
Neck, shoulders, warm, heavy
Warmth, heaviness coming over my neck and shoulders
They’re warm, heavy

Breathing calmly, breathing evenly, breathing peacefully

My tummy is warm and calm
Tummy, warm, calm
Warmth, calmness coming over my tummy
It’s warm, calm
 
My forehead is cool and calm
Forehead, cool, calm
Coolness, calmness coming over my forehead
It’s cool, calm

I feel quite quiet
I feel quite quiet

Calm, warm, heavy, comfortable, relaxed
Calm, warm, heavy, comfortable, relaxed

I can remain relaxed even when I open my eyes and become completely alert. When I am ready to open my eyes, I will become alert feeling warm, comfortable and relaxed.

Contact details

Manchester and Salford Pain Centre - 0161 206 4002
Email: paincentre@nca.nhs.uk

The images used in this publication have been reproduced with permission from ReConnect2Life - Torbay and South Devon NHS Foundation Trust.