NIH releases statement on behavioral and relaxation approaches for chronic pain and insomnia

American Family Physician,  April, 1996  

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Behavioral and relaxation approaches should be considered along with standard clinical procedures for the treatment of chronic pain and insomnia, according to a National Institutes of Health technology assessment conference statement. The purpose of the conference was to examine the usefulness of integrating behavioral and relaxation approaches with biomedical interventions to improve the care of patients with chronic pain and insomnia.

The conference participants reviewed data on the relative merits of specific behavioral and relaxation interventions and identified biophysic and psychologic factors that might predict the outcome of applying these techniques and examined the mechanisms by which behavioral and relaxation approaches could lead to increased clinical efficacy. Participants included experts in behavioral medicine, pain medicine, sleep medicine, psychiatry, nursing, psychology, neurology, and behavioral and neurosciences.

Copies of the technology assessment statement may be obtained from the NIH Consensus Program Information Service, P.O. Box 2577, Kensington, MD 20891; telephone: 800-644-6627; fax: 301-816-2494, or from the NIH Office of Medical Applications of Research, Federal Building, Room 618, 7550 Wisconsin Ave., MSC 9120, Bethesda, MD 20892-9120. The NIH address on the World Wide Web is http://text.nlm.nih.gov.

The following information has been excerpted from the statement:

Selection Criteria

The specific behavioral and relaxation approaches examined in the conference were drawn from a subset of those reported in the scientific literature and represent those selected by the conference organizers as most commonly used in clinical settings in the United States. These include relaxation, meditation, hypnosis, biofeedback and cognitive-behavior therapy. There is insufficient evidence that one technique is more effective than another for a given condition.

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 are divided into deep and brief methods.

Deep methods. Deep methods include autogenic training, meditation and progressive muscle relaxation. 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 variety of meditation techniques are used; each has it 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, 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 walking meditation in Zen Buddhism. Progressive muscle relaxation 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 progressive muscle relaxation. 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 five seconds, and then exhaling slowly

Hypnotic Techniques

Hypnotic techniques induce states of selective attentional focusing or diffusion combined with enhanced imagery. The techniques have pre- and post-suggestion components. The pre-suggestion component involves attentional focusing through the use of imagery, distraction and/or relaxation. The postsuggestion component involves continued use of the new behavior following termination of hypnosis. Individuals vary widely in their hypnotic susceptibility and suggestibility.

Biofeedback Techniques