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Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia

Relaxation Techniques
Relaxation techniques are a group of behavioral therapeutic approaches that differ widely in their philosophical bases as well as in their methodologies and techniques. Their primary objective is the achievement of nondirected relaxation, rather than direct achievement of a specific therapeutic goal. They all share two basic components: (1) repetitive focus on a word, sound, prayer, phrase, body sensation, or muscular activity and (2) the adoption of a passive attitude toward intruding thoughts and a return to the focus. These techniques induce a common set of physiologic changes that result in decreased metabolic activity. Relaxation techniques may also be used in stress management (as self-regulatory techniques) and have been divided into deep and brief methods.

Deep Methods
Deep methods include autogenic training, meditation, and progressive muscle relaxation (PMR). Autogenic training consists of imagining a peaceful environment and comforting bodily sensations. Six basic focusing techniques are used: heaviness in the limbs, warmth in the limbs, cardiac regulation, centering on breathing, warmth in the upper abdomen, and coolness in the forehead. Meditation is a self-directed practice for relaxing the body and calming the mind. A large variety of meditation techniques are in common use; each has its own proponents. Meditation generally does not involve suggestion, autosuggestion, or trance. The goal of mindfulness meditation is development of a nonjudgmental awareness of bodily sensations and mental activities occurring in the present moment. Concentration meditation trains the person to passively attend to a bodily process, a word, and/or a stimulus. Transcendental meditation focuses on a "suitable" sound or thought (the mantra) without attempting to actually concentrate on the sound or thought. There are also many movement meditations, such as yoga and the walking meditation of Zen Buddhism. PMR focuses on reducing muscle tone in major muscle groups. Each of 15 major muscle groups is tensed and then relaxed in sequence.

Brief Methods
The brief methods, which include self-control relaxation, paced respiration, and deep breathing, generally require less time to acquire or practice and often represent abbreviated forms of a corresponding deep method. For example, self-control relaxation is an abbreviated form of PMR. Autogenic training may be abbreviated and converted to a self-control format. Paced respiration teaches patients to maintain slow breathing when anxiety threatens. Deep breathing involves taking several deep breaths, holding them for 5 seconds, and then exhaling slowly.

Hypnotic Techniques
Hypnotic techniques induce states of selective attentional focusing or diffusion combined with enhanced imagery. They are often used to induce relaxation and also may be a part of CBT. The techniques have pre- and postsuggestion components. The presuggestion component involves attentional focusing through the use of imagery, distraction, or relaxation, and has features that are similar to other relaxation techniques. Subjects focus on relaxation and passively disregard intrusive thoughts. The suggestion phase is characterized by introduction of specific goals; for example, analgesia may be specifically suggested. The postsuggestion component involves continued use of the new behavior following termination of hypnosis. Individuals vary widely in their hypnotic susceptibility and suggestibility, although the reasons for these differences are incompletely understood.

Biofeedback Techniques
BF techniques are treatment methods that use monitoring instruments of various degrees of sophistication. BF techniques provide patients with physiologic information that allows them to reliably influence psychophysiological responses of two kinds: (1) responses not ordinarily under voluntary control and (2) responses that ordinarily are easily regulated, but for which regulation has broken down. Technologies that are commonly used include electromyography (EMG BF), electroencephalography, thermometers (thermal BF), and galvanometry (electrodermal-BF). BF techniques often induce physiological responses similar to those of other relaxation techniques.

Cognitive-Behavioral Therapy
CBT attempts to alter patterns of negative thoughts and dysfunctional attitudes in order to foster more healthy and adaptive thoughts, emotions, and actions. These interventions share four basic components: education, skills acquisition, cognitive and behavioral rehearsal, and generalization and maintenance. Relaxation techniques are frequently included as a behavioral component in CBT programs. The specific programs used to implement the four components can vary considerably. Each of the aforementioned therapeutic modalities may be practiced individually, or they may be combined as part of multimodal approaches to manage chronic pain or insomnia.

Relaxation and Behavioral Techniques for Insomnia
Relaxation and behavioral techniques corresponding to those used for chronic pain may also be used for specific types of insomnia. Cognitive relaxation, various forms of BF, and PMR may all be used to treat insomnia. In addition, the following behavioral approaches are generally used to manage insomnia:

Sleep hygiene, which involves educating patients about behaviors that may interfere with the sleep process, with the hope that education about maladaptive behaviors will lead to behavioral modification.
Stimulus control therapy, which seeks to create and protect conditioned association between the bedroom and sleep. Activities in the bedroom are restricted to sleep and sex.
Sleep restriction therapy, in which patients provide a sleep log and are then asked to stay in bed only as long as they think they are currently sleeping. This usually leads to sleep deprivation and consolidation, which may be followed by a gradual increase in the length of time in bed.
Paradoxical intention, in which the patient is instructed not to fall asleep, with the expectation that efforts to avoid sleep will in fact induce it.

A number of well-defined behavioral and relaxation interventions now exist and are effective in the treatment of chronic pain and insomnia. The panel found strong evidence for the use of relaxation techniques in reducing chronic pain in a variety of medical conditions as well as strong evidence for the use of hypnosis in alleviating pain associated with cancer. The evidence was moderate for the effectiveness of cognitive-behavioral techniques and biofeedback in relieving chronic pain. Regarding insomnia, behavioral techniques, particularly relaxation and biofeedback, produce improvements in some aspects of sleep, but it is questionable whether the magnitude of the improvement in sleep onset and total sleep time is clinically significant.


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