The use of progressive muscle relaxation within psychomotor

Transcription

1 The use of progressive muscle relaxation within psychomotor therapy for patients with schizophrenia. Davy Vancampfort, Marc De Hert, Amber De Herdt, Michel Probst Theoretical background for the use of progressive muscle relaxation within the treatment of schizophrenia. There is compelling epidemiological evidence that psychological distress and associated anxiety are important environmental risk factors for the onset of psychotic episodes, especially in the case of cumulative exposure (van Winkel, Stefanis & Myin-Germeys, 2008). People with schizophrenia experience difficulties in coping with psychological distress and anxiety, and possess a relatively limited repertoire of coping strategies (Achim et al., 2011). It is therefore not surprising that better functional outcomes might be achieved when psychological distress and anxiety are recognised and treated (van Os & Kapur, 2009). This underlines the need for multi-modal care including psychosocial therapies as adjuncts to antipsychotic medications (Vázquez Pérez, Godoy-Izquierdo & Godoy, 2012). Research on psychosocial approaches to treatment of schizophrenia has yielded incremental evidence of efficacy for cognitive behavioral therapy, social skills training, and psycho-education (Kern et al., 2009). Additional research is needed to examine other therapeutic modalities that might help to improve the functional status of patients with schizophrenia. Recently, there has been a growing interest in relaxation techniques in the multidisciplinary treatment of patients with schizophrenia (Probst et al., 2010; Vancampfort et al., 2011a; Vancampfort et al., 2012a, b). Relaxation techniques are a simple clinical rehabilitation method that can be administered after brief training. Probably the most common relaxation techniques are variants of progressive muscle relaxation, but other methods include yoga and mindfulness based stress reduction (Probst et al., 2010). Progressive muscle relaxation can be defined as a successive tensing and relaxing major muscle groups. The method originally developed by Jacobson (Jacobson, 1939) required dozens of sessions where the participant was taught to relax 30 different muscle groups. Bernstein and Borkovec (Bernstein & Borkovec, 1973) later shortened this technique and found it to be equally effective (Bernstein & Carlson, 1993).

2 Key messages: People with schizophrenia experience difficulties in coping with psychological distress and anxiety, and possess a relatively limited repertoire of coping strategies. Relaxation techniques are a simple clinical rehabilitation method that can be administered after brief training. Scientific evidence for the use of progressive muscle relaxation within the treatment of schizophrenia. Within the scope of this book we present a systematic overview of all available progressive muscle relaxation studies. We searched PsycINFO, PubMed, CINAHL and PEDro from their inception until June 1st, Key words were progressive muscle relaxation AND schizophrenia in the title, abstract or index term fields. The reference lists of all located articles were scanned for further relevant literature. Additionally, the bibliographies of relevant book chapters were hand-searched for further articles. Only studies examining patients with a DSM-IV diagnosis of schizophrenia were included. The initial electronic database search resulted in a total of 13 hits (PsycINFO=2, PubMed=5, CINAHL=3 and PEDro=3). Two studies (Chen et al.,2009; Vancampfort et al., 2011b) were of relevance and could be included. These 2 studies are presented in table 1. Both studies were randomized controlled studies comparing progressive muscle relaxation with quiet resting in a room for a same amount of time as the experimental intervention. To ensure program standardization, the PMR in the study of Chen et al. (Chen et al., 2009) was recorded on an audiotape employing an adapted Jacobson s progressive muscle relaxation protocol which included progressive relaxation of groups of muscles and deep breathing for 25 minutes. The tape contained instructions for systematic tensing and relaxation of specific muscle groups, starting with the groups of muscles in the upper body and progressing down to the lower part of the body. In the progressive muscle relaxation in the study of Vancampfort et al. (Vancampfort et al., 2011b) the therapy consisted of successive tensing and relaxing at least 5 major muscle groups,

3 beginning with the upper body and proceeding to the lower parts. In this trials, tensing for about 8 seconds and relaxing for about 30 seconds of each muscle group was practiced twice prior to proceeding to a subsequent muscle group. Both included studies found significant reductions in state anxiety in patients following progressive muscle training compared to those sitting quiet for a same amount of time. In the study of Chen et al. (Chen et al., 2009) the total Beck Anxiety Inventory score (Beck et al., 1988) dropped with 57.3% in acute inpatients (vs.-13.3% in the control subjects) while in study of Vancampfort et al. (Vancampfort et al., 2011b) the total State Anxiety Inventory score (Spielberger, 1983) dropped with 26.1% (vs. +1.1%) in acute inpatients. The latter study found also significant reductions in psychological distress (-35.3% vs. 0%) and improvements in subjective well-being on the Subjective Experiences in Exercise Scale (McAuley & Courneya, 1994) (+28.7% vs. -1.2% respectively) after a single session of progressive muscle relaxation compared with the resting control condition. Overall, the present overview suggests that progressive muscle relaxation can reduce state anxiety and psychological distress and improve subjective well-being. No studies investigated the evidence for progressive muscle relaxation as an add-on therapy method for general psychopathology and positive and negative symptoms in these patients. All studies were short-term, and the maintenance effect of the this kind of psychomotor therapy is unclear. There were no data available to enable conclusions about progressive muscle relaxation in comparison with other treatment modalities. While progressive muscle relaxation appears to be a promising psychomotor therapy intervention for state anxiety and psychological distress, many questions remain unanswered. We need to know for which patients with schizophrenia progressive muscle relaxation is most suitable, including the severity and stage of the disorder. If this kind of psychomotor therapy would be used as a first line, stepped care for reducing psychological stress and anxiety, we need to know the dose-response and at what point other treatments should be included. More research is necessary on a broader range of outcomes besides psychological distress and anxiety symptoms. In particular, we need to know the effect of progressive muscle relaxation on positive or negative symptoms and on longterm outcomes, including relapse rates. It also needs to be demonstrated if the beneficial effects of progressive muscle relaxation can be translated into behavioural outcomes, for example through increasing rates of abstinence from nicotine or illegal drugs. The use of these substances is a common practice among individuals with schizophrenia (Green et al., 2007).

4 Table 2 Details of the included randomised controlled trials Vancampfort (2011b) Belgium 64 (26 ) inpatients with schizophrenia in an acute inpatient setting; age experimental group (n=32):35.7±10.7yrs (vs.35.4±11.2yrs) 25 min two initiation sessions followed by the experimental session sitting in a quiet room with possibility to read and same amount of attention by the therapist SAI, SEES SAI scores decreased from 45.2±10.3 to 33.4±8.6 (vs. from 45.2±11.8 to 45.7±11.0), SEES psychological distress from 11.6±5.0 to7.5±3.6 (vs. from 12.2±5.5 to 12.2±5.4) (pgroup-differences<0.05); SEES subjective well-being increased from 16.7±5.3 to 21.5±4.1 (vs. from 15.7±5.9 to 15.4±5.6); (pgroup-differences<0.05) no CAU Chen (2009) Taiwan 18 (10 ) inpatients with schizophrenia in an acute inpatient setting; age experimental group (n=9): 39.1±16.8yrs (vs. 41.0±16.4yrs) 40 min 11 consecutive days sitting in a quiet room BAI, finger temperature BAI scores decreased from 16.4±4.4 to 7 (vs. from 15.0±3.9 to 13); significant group differences after 11 days (Z=-4.1, p < ) and one week post (Z=-2.0, p=0.0446); increase in finger temperature after last session +0.4 C (vs C) (Mann Whitney U =29.5, p < 0.05 no CAU First Author/year Country Participants Duration Frequency Relevant outcomes (vs. controls) Adverse effects Control condition Measurement instruments Co-intervention CAU= care as usual, BAI=Beck Anxiety Inventory, State Anxiety Inventory, SAI=State Anxiety Inventroy, SEES=Subjective Exercise Experiences Scale.

5 It has been suggested that the mentioned unhealthy behaviours may be attempts to alleviate or to cope with unpleasant affective states and feelings of state anxiety (Gregg, Barrowclough & Haddock, 2007). Also the mechanism by which progressive muscle relaxation works is unclear. The study of Chen et al. (Chen et al., 2009) found evidence for physiological changes (i.e., increase in finger temperature) Key messages: Progressive muscle relaxation might reduce state anxiety and psychological distress and improve subjective well-being. The current evidence on progressive muscle relaxation in the multidisciplinary treatment of schizophrenia is very encouraging but also very preliminary. Any definite conclusions should be avoided since the number of included studies (n=2) and reported outcomes were very limited. Progressive muscle relaxation protocol. Since the included studies demonstrated that beneficial results can obtained very quickly, our review data offer preliminary data that progressive muscle relaxation is a relaxation technique that is easy to learn. For this reason, this kind of psychomotor therapy can be viewed as a very simple intervention, which can be implemented at minimal cost. Suggestions for clinical practice are: If a patient reports any injuries, or a history of physical problems that may cause muscle pain, they should always consult their doctor pr psychiatrist before starting. Progressive muscle relaxation should be practiced in a quiet place. Let patients remove their shoes and ask them to wear loose clothing. Make patients aware that only through practice they can become more aware of their muscles, how they respond with tension, and how they can relax their muscles. Training the body to respond differently to stress is like any training: practising consistently is the key.

6 Progressive muscle relaxation can be practiced lying down or sitting in a chair. Each muscle or muscle group is tensed to about 1/3 to 2/3 of the maximum tension for 6 to 8 seconds, and then relaxed for 20 to 30 seconds. If a particular muscle is difficult to relax, the patient can repeat the procedure of tensing and releasing it up to 5 times. Once this procedure has been mastered they can do a shorthand version in which whole muscle groups are tensed and relaxed simultaneously such as: all the facial muscles together, or: hands, arms, and shoulders, or: legs, feet and toes. Example of a basic progressive muscle relaxation script. Allow your attention to focus only on your body. If you begin to notice your mind wandering, bring it back to the muscle you are working on. Take a deep breath through your nose, hold for a few seconds, and exhale twice as long through your mouth. Repeat. Again, as you breathe notice your stomach rising and your lungs filling with air. As you exhale, imagine the tension in your body being released and flowing out of your body. And again inhale...and exhale. Feel your body already relaxing. As you go through each step, remember to keep breathing. Now let s begin. Tighten the muscles in your forehead by raising your eyebrows as high as you can. Hold for about eight seconds. And release. Pause for about 30 seconds. Repeat. Now smile widely, feeling your mouth and cheeks tense. Hold for about 8 seconds, and release, appreciating the softness in your face. Pause for about 30 seconds. Repeat. Next, tighten your eye muscles by squinting your eyelids tightly shut. Hold for about 8 seconds, and release. Pause for about 30 seconds. Repeat. Gently pull your head back as if to look at the ceiling. Hold for about 8 seconds, and release. Pause for about 30 seconds. Repeat. Now, tightly, but without straining, clench your fists and hold this position until I say stop. Hold for about 8 seconds, and release. Pause for about 30 seconds. Repeat. Flex your biceps. Feel that buildup of tension. Hold for about 8 seconds, and release, enjoying that feeling of limpness. Breath in...and out. Repeat. Now tighten your triceps by extending your arms out and locking your elbows. Hold for about 8 seconds, and release. Pause for about 30 seconds. Repeat.

7 Lift your shoulders up as if they could touch your ears. Hold for about 8 seconds, and quickly release. Pause for about 30 seconds. Repeat. Tense your upper back by pulling your shoulders back trying to make your shoulder blades touch. Hold for about 8 seconds, and release. Pause for about 30 seconds. Repeat. Gently arch your lower back. Hold for about 8 seconds, relax. Pause for about 30 seconds. Repeat. Tighten your buttocks. Hold for about 8 seconds, release. Pause for about 30 seconds. Repeat. Tighten your thighs by pressing your knees together, as if you were holding a ball between them. Hold for about 8 seconds and release. Pause for about 30 seconds. Repeat. Now flex your feet, pulling your toes towards you and feeling the tension in your calves. Hold for about 8 seconds, and relax, feel the weight of your legs sinking down. Pause for about 30 seconds. Repeat. Curl your toes under tensing your feet. Hold for about 8 seconds, release. Pause for about 30 seconds. Repeat. Now imagine a wave of relaxation slowly spreading through your body beginning at your head and going all the way down to your feet. Feel the weight of your relaxed body. [2min] Breathe in and out in out.in out. Key messages: Each muscle or muscle group is tensed to about 1/3 to 2/3 of the maximum tension for 6 to 8 seconds, and then relaxed for 20 to 30 seconds. If a particular muscle is difficult to relax, the patient can repeat the procedure of tensing and releasing it up to 5 times. Once the basic procedure has been mastered patients can do a shorthand version in which whole muscle groups are tensed and relaxed simultaneously Patients need to start with exercising in a quiet room, afterwards the techniques can be implemented in daily life. Progressive muscle relaxation can be practiced lying down or sitting in a chair.

8