The Relaxation Response in the Treatment of Chronic Pain
February 1998; Volume 1: 13-16
By Dennis deLeon, MD
Chronic pain is often one of the most troublesome treatment challenges clinicians face. The underlying conditions and etiology are frequently unclear or refractory to treatment or cure. Patients with chronic pain invariably have many concurrent difficulties that compound the pain. I have often found that prescribing pain medication is not enough for many patients.Effective treatment of chronic pain requires a more inclusive approach that calls on the patient to take over some of the work of treatment. One technique that shows promise and that has some basis in clinical research is the relaxation response—which calls on the patient to take control of factors that affect the pain he or she bears.
History
The relaxation response is a popular phrase used to describe physiologic changes that are the antithesis of the "fight or flight" response first described by Cannon in 1915.1 These classic experiments demonstrated that substances now known as catecholamines caused increased heart rate, blood pressure, and respiratory rate when injected into cats. Subsequent work showed that the same "fight or flight" response was produced by electrical stimulation of certain areas in the cats’ hypothalamus, but that stimulation of other areas elicited an opposite reaction—a hypo-arousal or hypo-metabolic state. This same physiologic response was later demonstrated in studies of various meditative practices by yogis and Zen masters2 and was postulated to serve as a protective mechanism against stressful stimuli and the resulting fight-or-flight response.
Although meditation has been present throughout recorded history, these were the first scientific studies of meditation, prayer, and biologic response. A more recent body of research has investigated the ability of this "relaxation response" to ameliorate or cure various disease conditions. Beneficial effects of varying magnitude have been suggested in studies of hypertension, sleep-onset, or initial insomnia, infertility, somatization, premenstrual syndrome, migraine, postoperative cardiac arrhythmias, depression, cancer pain, and chronic pain of other etiology.3
History and Culture of the Tradition
An extensive review of meditation-style practices, many with centuries-long traditions, was undertaken by Benson.4 Techniques similar to those that now have been shown to evoke the relaxation response have been a part of all world religions, including Christian and Jewish mysticism, Buddhist monastic practice, and Islam. In studying common features of these practices, Benson initially identified four components necessary to elicit the relaxation response by mediation:
1. A quiet environment to minimize distractions.
2. A mental device such as repeating silently a sound, word, phrase, or prayer. This device does not need to be religious. Other mental devices include repetitively focusing on breathing or mental imagery.
3. A passive attitude that involves keeping the mind as empty as possible of invasive thoughts and distractions.
4. A comfortable position that helps to minimize muscular tension.
Subsequent research, however, has shown that only the second and third components are absolutely necessary. A quiet environment and comfortable body position can contribute to the likelihood of evoking the relaxation response, but the response can also be elicited in busy and noisy environments like a commuter train or hospital ward.
Many related techniques from the fields of psychotherapy and psychology bear strong resemblance to meditative methods for eliciting the relaxation response. For example, progressive muscle relaxation, guided imagery, autogenic training, and hypnosis achieve similar effects; in fact, the pre-suggestion phase of hypnosis is physiologically the same as the relaxation response. In contrast, conventional stress management techniques employed in psychological treatment of physical illness include cognitive restructuring, assertive expression of feelings, and the modification of irrational thinking. Instead of evoking the autonomic effects of the relaxation response, of course, these approaches focus on the role of human cognition in pain, depression, and other disorders.5
Mechanism of Action
Physiologic alterations caused by the relaxation response are consistent with decreased autonomic nervous tone, such as decreased oxygen consumption and reduced heart rate, respiratory rate, and muscle tension. Other physiologic characteristics of the relaxation response include increased alpha waves on EEG and maintenance of blood pressure in normotensive subjects.6 Although many of these changes are also characteristics of sleep and hibernation states, oxygen consumption in sleep has been shown to decrease by 8% gradually over 4-5 hours, whereas the relaxation response results in a 10-17% decrease in oxygen consumption within three minutes.3 Unlike hibernation, body temperature does not decrease with the relaxation response. The precise neurologic mechanism that links meditative practice, the relaxation response, and effects on pain, hypertension, depression, and other states is not understood.
Technique
As described by Benson,3 the two steps necessary to elicit the relaxation response are simply to:
1. repeat a word, sound, prayer, phrase, or muscular activity, and to
2. disregard or ignore everyday thoughts that come to mind and return to the repetition.
The focus word or phrase can be a religious one, such as "Peace," "Lord Jesus Christ, have mercy on me," "Shalom," or "Insha’allah," or simply a nonsense noise syllable. The focus can also be the act of walking or running in a cadence. The body position should be a comfortable one but is of secondary importance; one can be seated, standing, walking, or jogging. Study subjects in the literature usually practiced this technique for 10-20 minutes once or twice daily.
Clinical Studies
Most recent clinical studies examine a specific pain syndrome and its response to relaxation using either guided imagery or some variant of Benson’s two-step approach. For example, in a controlled study, postoperative pain in patients who underwent colorectal surgery was shown to be significantly less for those on a program of listening to guided-imagery tapes perioperatively. Differences were found both on self-reported pain scales and in opioid use.7 Similar results have been published for postoperative pain and length-of-stay for children undergoing invasive procedures. In a controlled trial of patients undergoing femoral angiography, those who listened to a guided imagery relaxation tape were observed to exhibit significantly less pain and anxiety and to need significantly less fentanyl and diazepam.8
The relaxation response may also alleviate chronic pain. Women with premenstrual syndrome felt significantly fewer physical pain symptoms and emotional symptoms with relaxation response elicitation than with symptom-charting. This difference was greatest in women with the most severe symptoms.9 In an outpatient managed care facility, among 109 patients diagnosed with chronic pain who participated in a behavioral program using relaxation response techniques, clinic visits were reduced 36% over the following year. A higher level of activity and a higher rate of return to work were also observed.10
Not all studies show such positive responses, however. Although migraine and headache sufferers have been shown to experience fewer and less severe headaches in earlier studies, a more recent trial of guided imagery and biofeedback in migraine showed improved capacity to cope with pain and reduced intensity of pain perception but no reduction in migraine activity or in use of medications.11 A representative study of cancer pain from Australia demonstrated reduced pain sensation and non-opioid analgesic use but no significant difference in opioid use or in pain affect (emotional correlates of pain).12
Office Procedure
The method is simple, involves the patient closely in treatment, and is readily adapted by patients whose spirituality is already a strong source of support.
Ultimately, Benson’s two steps are all that are therapeutically required. In the office setting, basic instruction by the professional should be supplemented by a handout or by widely available books and tapes.2,3
Conclusion
Evidence suggests that eliciting the relaxation response may benefit patients with chronic pain, especially pain complicated by emotional overlay (e.g., fear, loss of hope, alienation from family or friends, clinical depression, or anxiety), by decreasing intensity of pain perception, enhancing coping skills, and reducing the use of medication and medical services.
The relaxation response is most strongly recommended for those chronic pain patients whose conditions are characterized by significant emotional components. Cancer patients and postoperative patients, who not only suffer pain but also fear further pain and further procedures, are excellent candidates. Patients with severe pre-menstrual syndrome who suffer debilitating emotional liability in addition to their pain are also likely to benefit. The literature also suggests that, in these conditions, the relaxation response can reliably be expected to result in decreased use of pain medication.
References
1. Cannon WB. Bodily Changes in Pain, Hunger, Fear, and Rage.
New York: D. Appleton and Co.; 1915.
2. Hirdi T, et al. EEG and Zen buddhism: EEG changes in the course
of meditation. Electroencephalogr Clin Neurophysiol 1959;55 (Suppl
18):52-53.
3. Benson H. Timeless Healing: The Power and Biology of Belief.
New York: Scribner; 1996:146-147.
4 Benson H. The Relaxation Response. New York: William Morrow;
1975.
5. Ellis A, Harper RA. A New Guide to Rational Living. Englewood
Cliffs, NJ: Prentice-Hill, Inc.; 1975.
6. Benson H, et al. The relaxation response. Psychiatry 1974;37:37.
7. Tusek DL, et al. Guided imagery: A significant advance in the care
of patients undergoing elective colorectal surgery. Dis Colon Rectum
1997;40:172-178.
8. Mandle CL, et al. Relaxation response in femoral angiography. Radiology
1990;174(3 Pt 1):737-739.
9. Goodale II, et al. Alleviation of premenstrual syndrome symptoms
with the relaxation response. Obstet Gynecol 1990;75:649-655.
10. Caudill M, et al. Decreased clinic use by chronic pain patients:
response to behavioral medicine intervention. Clin J Pain 1991;7:305-310.
11. Ilacqua GE. Migraine headaches: Coping efficacy of guided imagery
training. Headache 1994;34:99-102.
12. Sloman R. Relaxation and the relief of cancer pain. Nurs Clin
North Am 1995;30:697-709.
Dr. deLeon is the Director of Family Medicine Residency at Loma Linda
(CA) University School of Medicine
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