Relaxation therapies

DEFINITION: Techniques to reduce everyday stress.

PRINCIPAL PROPOSED USES: Cancer chemotherapy support, chronic pain, hypertension, insomnia, labor, stress, surgery support

OTHER PROPOSED USES: Angina, asthma, anxiety, back pain, bulimia nervosa, colds (prevention), congestive heart failure, depression, fibromyalgia, herpes prevention, human immunodeficiency virus infection support, immune support, interstitial cystitis, irritable bowel syndrome, menopause, migraine headaches, nightmares, osteoarthritis, premenstrual syndrome, pregnancy support, psoriasis, rheumatoid arthritis, stroke rehabilitation, smoking cessation, tension headaches, tinnitus, temporomandibular joint dysfunction, ulcerative colitis

Overview

Constant stress is one of the defining features of modern life and the source of many common health problems. Stress plays an obvious role in nervousness, anxiety, and insomnia, but it is also thought to contribute to a vast number of other illnesses.

In the past, most people engaged in many hours of physical work daily, an activity that reduces the effects of psychological stress. Life was also slower then and was more in harmony with the natural cycles of day and season. Today, however, a person is relatively sedentary, while the mind is forced to respond to the rapid pace of a society that never stops. The result is high levels of stress and a reduced ability to cope with that stress.

There are several ways to mitigate the damage caused by stress. Increased physical exercise can help, as can simple, commonsense steps such as taking relaxation breaks and vacations. If these approaches do not have adequate results, more formal methods may be helpful.

This article discusses a group of stress-reduction techniques, often called relaxation therapies. In addition to these methods, other methods that can help include yoga, Tai Chi, qigong, hypnosis, massage, and biofeedback.

What Are Relaxation Therapies?

There are many types of relaxation therapies, and they use a variety of techniques. However, most of them share certain related features.

In many relaxation techniques, one begins by either lying down or assuming a relaxed, seated posture in a quiet place and then closing the eyes. The next step differs depending on the method. In autogenic training, relaxation response, and certain forms of meditation, a person focuses their mind on internal sensations, such as the breath. Guided-imagery techniques employ deliberate visualization of scenes or actions, such as walking on a quiet beach. Progressive relaxation techniques involve gradual relaxation of the muscles. Finally, some schools of meditation incorporate the repetition of a phrase or sound silently or aloud.

All of these techniques are best learned with the aid of a trained practitioner. The usual format is a group class supplemented by regular home practice. However, many at-home options exist, such as mobile applications like Calm and Headspace, relaxation guidance devices like the Hatch Restore, podcasts, and YouTube channels. Many other sources of relaxation technique education exist that fit all lifestyles and price points. If a person is diligent enough, experience suggests they can develop the ability to call on a relaxed state at will, even during a very stressful situation.

Uses and Applications

Relaxation therapies are commonly used in medical circumstances in which stress is believed to play a particularly large role, such as insomnia, surgery, chronic pain, and cancer chemotherapy. A specific form of guided visualization has also been used in an attempt to actually treat cancer. It is important to use relaxation techniques in combination with professional medical treatment for best results. No relaxation method is a cure for physical or mental illness, and relaxation is not a replacement for proper medical care.

Scientific Evidence

Although many studies have been performed on relaxation therapies, most of these studies are inadequately designed. To be fair, there are considerable difficulties in the path of any researcher who wishes to scientifically assess the effectiveness of a relaxation therapy such as hypnosis. There are several factors involved, but the most important is fairly fundamental: It is difficult to design a proper double-blind, placebo-controlled study of relaxation therapy. Researchers studying the herb St. John’s wort, for example, can use placebo pills that are indistinguishable from the real thing. However, it is difficult to design a form of placebo relaxation therapy that cannot be detected as such by both practitioners and participants.

One clever method used by some researchers involves the use of intentionally neutral visualizations. Instead of imagining lying in bed and sleeping peacefully, participants in the placebo group might be told to visualize something like a green box. The problem here is that researchers teaching the visualization method to participants may inadvertently convey a sense of disbelief in the placebo treatment. This can be solved by using relatively untrained people who are themselves deceived by experimenters to teach the method, but the practical obstacles are significant.

For this reason, many studies of relaxation therapy have made major compromises to the double-blind, placebo-controlled model. Some randomly assigned participants receive either relaxation therapy or no treatment. In the best of these studies, results were rated by examiners who did not know which participants were in which group (in other words, the examiners were “blinded observers”). However, it is unclear whether benefits reported in such studies come from relaxation therapy or less specific factors, such as mere attention.

Other studies have compared relaxation therapies to different techniques, such as hypnosis or cognitive psychotherapy. However, the same difficulties arise when trying to study these latter therapies, and the results of a study that compares an unproven treatment to one that is also imperfectly documented are not very meaningful.

Even less meaningful studies of relaxation therapies simply involved giving people the therapy and monitoring them to see whether they improved. Such open-label trials prove nothing. Given these caveats, the following is a summary of what science knows about the medical benefits of relaxation therapy.

Possible Benefits

Insomnia. Numerous controlled studies have evaluated relaxation therapies for the treatment of insomnia. These studies are difficult to summarize because many involved therapy combined with other methods, such as biofeedback, sleep restriction, and paradoxical intent (trying not to sleep). The type of relaxation therapy used in the majority of these trials was progressive muscle relaxation. Many of these trials used the clever form of placebo treatment described in the foregoing section; others simply compared relaxation therapy to no treatment.

Overall, the evidence indicates that relaxation therapies may be somewhat helpful for insomnia, although not dramatically so. For example, in a controlled study of seventy people with insomnia, participants using progressive relaxation showed no meaningful improvement in the time to fall asleep or sleep duration, but they reported feeling more rested in the morning. In another study, twenty minutes of relaxation practice was required to increase sleeping time by thirty minutes.

The American Academy of Sleep Medicine began recommending an insomnia treatment plan called cognitive behavioral therapy for insomnia (CBT-I) in 2021. This plan involves cognitive restructuring, stimulus control, sleep restriction, sleep hygiene, and relaxation technique education. The most commonly used relaxation techniques in CBT-I are progressive muscle relaxation, visualization, and meditation. This evidence-based plan helps people fall asleep and stay asleep.

Asthma. A review article published in 2002 found fifteen published controlled trials that evaluated relaxation therapies for the treatment of asthma. Most of the studies were rated as very poor or poor quality. Overall, the results failed to demonstrate improvement, although a muscular relaxation technique called Jacobsen’s relaxation did show some benefit. Several subsequent studies suggest breathing exercises may improve the quality of life among those with asthma, as did one study involving mindfulness training.

Further research analysis found muscle relaxation, biofeedback, or a combination of the two were marginally helpful for individuals with mild asthma. Research was lacking concerning the efficacy of relaxation therapy training in individuals with asthma who rely on steroids and those with severe asthma. Other studies investigating progressive relaxation techniques for asthma symptoms were most successful using a method called forced expiratory flow, but in evaluations of participant pulmonary function, no improvement was observed.

Anxiety. A fair amount of evidence supports relaxation therapies for treating the symptoms of anxiety, at least in the short term. In a 2008 review of twenty-seven studies, researchers concluded that relaxation therapies (including Jacobson’s progressive relaxation, autogenic training, applied relaxation, and meditation) were effective against anxiety. However, not all of the studies were randomized, controlled trials.

According to a fifty-study meta-analysis published in 2018, cognitive behavioral therapy (CBT) may be more effective than relaxation techniques in treating post-traumatic stress disorder and obsessive-compulsive disorder and equally effective for generalized anxiety disorder, panic disorder, phobias, and social anxiety disorder. However, few studies have been done on specific anxiety disorders, and research biases may limit the findings. Further research found that CBT with mindfulness-based stress reduction was comparable to the results of the medication escitalopram.

Hypertension. It seems intuitive that relaxation should lower blood pressure. Indeed, many studies have evaluated the benefits of relaxation therapies for hypertension and related cardiovascular risks. The results, however, have been mixed at best.

In a 2008 review of twenty-five studies of various relaxation therapies for high blood pressure (with 1,198 participants), researchers found that those studies employing a control group had no significant effect on lowering blood pressure compared with sham (placebo) therapies. However, a separate review of nine randomized trials concluded that the regular use of Transcendental Meditation (TM) may significantly reduce systolic and diastolic blood pressure compared with a control. Similarly, an analysis of seventeen randomized-controlled trials of various relaxation therapies found that only TM significantly reduced blood pressure; biofeedback, progressive muscle relaxation, and stress management training produced no such benefit. In addition, a trial of eighty-six persons with hypertension suggested that daily, music-guided slow breathing reduced systolic blood pressure measured in a twenty-four-hour period. There is some evidence that TM might help improve exercise capacity and general quality of life in people with congestive heart failure.

Labor and childbirth. A 2016 systematic review of nine randomized trials involving more than 2,900 patients found that self-hypnosis or hypnotherapy reduced the use of medicinal pain relievers and anesthesia and slightly lowered the need for assisted vaginal childbirth. However, two of the largest studies found no significant differences in pain reduction or epidural use. Similarly, there has been mixed evidence for the use of biofeedback therapy, music therapy, and breathing techniques in pain reduction.

Other conditions. Other conditions that have at least minimal supporting evidence for response to relaxation therapies include the following: angina, back pain, bulimia nervosa, cancer treatment support (including cancer pain), chronic pain, congestive heart failure, depression, fibromyalgia, interstitial cystitis, irritable bowel syndrome, menopause, nightmares, obsessive-compulsive disorder, osteoarthritis, premenstrual syndrome, pregnancy support (reducing perceived stress), psoriasis, rheumatoid arthritis, stroke rehabilitation, surgery support (primarily reducing pain and stress before or after surgery), smoking cessation, tension headaches, tinnitus, temporomandibular joint dysfunction, and ulcerative colitis. In many cases, the results are marginal at best, and contradictory outcomes between trials are common.

One study suggests that visualizations before surgery reduce the need for pain medications and the chance of developing hematomas (collections of blood under the skin). However, more research is needed to verify this somewhat difficult-to-believe result. A more easily accepted study found that relaxation therapy or aerobic exercise can improve fatigue after cancer surgery, and each approach is about as effective as the other.

Myriad research focuses on relaxation techniques and their ability to improve the quality of life of individuals with cancer. For example, persons with cancer who were exposed to empathetic care along with self-hypnotic relaxation experienced significantly less pain and anxiety during an uncomfortable, invasive procedure than similar persons receiving only empathetic or usual care. These results suggest that pain under these circumstances is more effectively relieved when the patient relies on self-coping abilities rather than another person’s kindness.

Researchers in Taiwan studied the role of relaxing music in reducing cancer pain. Randomly selected were 126 hospitalized persons. In one group, participants listened to music for thirty minutes and were given pain medication; participants in the other group were given the medication only. The group that listened to music experienced significantly more pain relief than the group that did not. Some studies have evaluated highly specific guided visualizations rather than general relaxation. For example, it has been suggested that a systematic program of imagining microscopic soldiers shooting down one’s cancer cells can improve the chances of surviving cancer. Despite much enthusiasm, no meaningful evidence supports this appealing idea. Nonetheless, some evidence from small trials indicates that specific immune-oriented visualizations can enhance protection against herpes flare-ups and winter colds in immunocompromised individuals.

Researchers in Taiwan have also studied the role of relaxing music in reducing cancer pain. Randomly selected were 126 hospitalized persons. In one group, participants listened to music for thirty minutes and were given pain medication; participants in the other group were given the medication only. The group that listened to music experienced significantly more pain relief than the group that did not.

Numerous studies have also investigated the benefits of relaxation therapies for persons with human immunodeficiency virus (HIV) infection. A careful review of thirty-five randomized trials found that relaxation therapies may be generally helpful in improving the quality of life of HIV-positive persons and in reducing their anxiety, depression, stress, and fatigue. These interventions, though, had no significant effect on the growth of the virus, nor did they influence immunologic or hormonal activity. Subsequently, however, a small study involving forty-eight HIV-positive persons found that mindfulness meditation, a popular method for inducing the relaxation response, slowed the loss of the specific immune cells destroyed by the virus, though more research needs to be done to confirm this result.

Some studies have evaluated highly specific guided visualizations rather than general relaxation. For example, it has been suggested that a systematic program of imagining microscopic soldiers shooting down one’s cancer cells can improve the chances of surviving cancer. Despite much enthusiasm, there is still no meaningful evidence to support this appealing idea. Nonetheless, there is some evidence from a set of small trials that specific immune-oriented visualizations can provide enhanced protection against herpes flare-ups and winter colds.

A careful review of twenty trials found psychological interventions such as cognitive behavioral therapy, biofeedback, relaxation, and coping were associated with reduced chronic headache or migraine pain in 589 children compared with sham (placebo), standard therapies, waiting list control, or other active treatments.

Choosing a Practitioner

There is no widely accepted license for practicing relaxation therapy. However, it is often practiced by licensed therapists and psychologists.

Safety Issues

There are few safety risks with relaxation therapies. Some adverse experiences may include intrusive thoughts, heightened anxiety, fear of losing control, and rarely, worsened symptoms from epilepsy or mood disorders. Relaxation therapies should be used in conjunction with, rather than as a substitute for, conventional medical treatment.

Bibliography

Anderson, J. W., C. Liu, and R. J. Kryscio. “Blood Pressure Response to Transcendental Meditation.” American Journal of Hypertension 21, 2008, 310–16.

"Comfort Measures (Nonpharmacologic) During Labor." DynaMed, 9 Aug. 2023, www.dynamed.com/management/comfort-measures-nonpharmacologic-during-labor. Accessed 20 Sept. 2024.

Eccleston, C., et al. “Psychological Therapies for the Management of Chronic and Recurrent Pain in Children and Adolescents.” Cochrane Database of Systematic Reviews 2009. CD003968. Available through EBSCO DynaMed Systematic Literature Surveillance www.ebscohost.com/dynamed.

Hanstede, M., Y. Gidron, and I. Nyklicek. “The Effects of a Mindfulness Intervention on Obsessive-Compulsive Symptoms in a Non-clinical Student Population.” Journal of Nervous and Mental Disease 196, 2008, 776–79.

Heather, O. D., et al. “Relaxation Therapies for the Management of Primary Hypertension in Adults.” Cochrane Database of Systematic Reviews (2008): CD004935. EBSCO DynaMed Systematic Literature Surveillance www.ebscohost.com/dynamed.

Huang, S. T., M. Good, and J. A. Zauszniewski. “The Effectiveness of Music in Relieving Pain in Cancer Patients.” International Journal of Nursing Studies 47, 2010, 1354–62.

Jayadevappa, R., et al. “Effectiveness of Transcendental Meditation on Functional Capacity and Quality of Life of African Americans with Congestive Heart Failure.” Ethnicity and Disease 17, 2007, 72–77.

Jorm, A. F., A. J. Morgan, and S. E. Hetrick. “Relaxation for Depression.” Cochrane Database of Systematic Reviews, 2008. CD007142. Available through EBSCO DynaMed Systematic Literature Surveillance www.ebscohost.com/dynamed.

Lahmann, C., et al. “Brief Relaxation Versus Music Distraction in the Treatment of Dental Anxiety.” Journal of the American Dental Association 139, 2008, 317–24.

Lahmann, C., F. Röhricht, and N. Sauer. “Functional Relaxation as Complementary Therapy in Irritable Bowel Syndrome.” Journal of Alternative and Complementary Medicine 16, 2010, 47–52.

Lehrer, P., and Moritz, G. "Biofeedback Has Therapeutic Effects on Asthma, Although Additional Research Is Needed to Document Specificity." Policy Insights from the Behavioral and Brain Sciences, vol. 10, no. 1, 2023, pp. 83-89. doi.org/10.1177/23727322221145306.

“Mind and Body Approaches for Stress and Anxiety: What the Science Says.” NCCIH Clinical Digest for Health Professionals, National Center for Complementary and Integrative Health, Jan. 2024, www.nccih.nih.gov/health/providers/digest/mind-and-body-approaches-for-stress-science#relaxation-techniques. Accessed 20 Sept. 2024.

Modesti, P. A., et al. “Psychological Predictors of the Antihypertensive Effects of Music-Guided Slow Breathing.” Journal of Hypertension 28, 2010, 1097–1103.

Susyanti, Susan, and Rizki Rahayu. "The Analysis of Nursing Care for the Elderly with Hypertension Using the Practice of Progressive Muscle Relaxation Therapy: A Case Study." Journal of Health Science and Nursing Studies, vol. 1, no. 1, 2022, DOI: 10.58516/jhsns.v1i1.27.

Trow, Terence K., editor. "Alternative Treatments for Asthma in Adults and Adolescents." DynaMed, 30 Aug. 2024, www.dynamed.com/management/complementary-and-alternative-treatments-for-asthma-in-adults-and-adolescents. Accessed 20 Sept. 2024.