Introduction - Hello and welcome!

Hi there, welcome to my blog about progressive muscle relaxation!

I am currently in my 3^rd year studying occupational therapy and I am writing this blog for the ‘Transition to Practice’ course. We were required to choose a topic of interest that we think may benefit our peers, potential colleagues and others who it could appeal to.

I first encountered progressive muscle relaxation (PMR) when I was on my Mental Health placement at the beginning of the year. I was working alongside an occupational therapist that worked with clients out in the community who suffered from a mental illness. She performed PMR on me and I also watched as she would use it on her clients. Once I had seen it and experienced it a few times, I started to use it on a few clients myself and the feedback I received from those clients was always positive. Since that placement, I have been very keen on this intervention and I think it can be useful for others to know about, which is exactly why I chose to write this blog about it.

Over a period of time, my blog will cover several aspects of PMR, including:

• Defining PMR, the different types and where it all came from.
• Diaphragmatic breathing and why this is important.
• The benefits of PMR.
• Client’s perspectives on PMR.
• Where PMR can be carried out.
• How PMR is carried out.

If you find any of this information useful or you would like to share your thoughts or experiences, please don’t hesitate as I would love to hear from you :-)

References:

Image retrieved August 2, 2013 from http://weheartit.com/entry/12929300

What is PMR?

When I was initially introduced to PMR I thought it was a really complex intervention technique and that I would have to observe and practice countless sessions in order to be confident enough to carry it out on other clients. I soon came to find out that it is not very complex at all and it is very simple to follow the instructions if you are in the client’s position, and it is similarly very straightforward to perform as the therapist.

Bourne (2005) explains that Dr. Edmund Jacobson first developed progressive muscle relaxation more than 50 years ago and it is described as a systematic technique which is used to reach a state of deep relaxation. Dr. Jacobson discovered that relaxation occurs when muscles are tensed and then released after a short period of time. It is the tensing and releasing of all muscle groups in the human body that causes the state of deep relaxation, and Dr. Jacobson found that this technique was capable of managing and relieving a vast amount of conditions such as stress, high blood pressure, insomnia… and the list goes on.

Over time, PMR has been developed by several people and the two main types of PMR are overt PMR and covert PMR (Smith, 2005).

Overt PMR is generally the most common type and it refers to tensing a muscle group for 5-10 seconds followed by the release of that muscle group for approximately 30 seconds. This is repeated with up to 16 muscle groups throughout our body, carried out systematically, generally from head to toe (Smith, 2005).

Covert PMR is similar as it involves releasing the tension in each of the muscle groups, but without initially tensing up. Smith (2005) explains that this type of PMR may be considered as an advanced session following several weeks of training in overt PMR.

Personally, I haven’t experienced Covert PMR nor have I seen others perform or experience it. During my Mental Health placement when I was initially introduced to PMR, I assumed there was only one type (overt), but I guess you learn something new every day right?

References:

Bourne, E. J. (2005). The anxiety & phobia workbook (4^th ed.). Oakland, CA: New Harbinger.

Smith, J. C. (2005). Relaxation, meditation & mindfulness: A mental health practitioner’s guide to new and traditional approaches. New York, USA: Springer.  

Image retrieved August 5, 2013 from elearningserv.com/blog/impact-of-story-based-learning

Deep breathing/diaphragmatic breathing

Wasnick (2007) explains that deep breathing, also referred to as diaphragmatic breathing, abdominal breathing and belly breathing, is very beneficial to our health. He states that it improves the functioning of our lungs and blood vessels, as well as relieving stress and improving our mental and physical performance at times when our body is tense.

Deep breathing or diaphragmatic breathing is very easy to do, but we tend to forget to do it accurately when we are stressed or when we are simply not concentrating on our breathing properly. Bourne (2005) illustrates that our breathing reflects the level of tension we carry in our body at the present moment. When we are tense our breathing tends to be rapid and shallow and only occurs higher in our chest area, whereas if we were to be relaxed, we generally breathe longer and fuller breaths further down into our abdomen. Deep breathing can create better feelings of connectedness between your mind and body, increases the oxygen supply to your brain and can also act as a relaxation method on its own.

You may be wondering how deep breathing relates to PMR? Well deep breathing and PMR actually combine really well with each other and doing this will simply give you an additional level of relief during the session. On my placement, I would briefly talk to my clients about deep breathing before conducting the PMR session. It’s easy to learn with these few steps:

1. Firstly, you should recognise the tension you are feeling and then place one hand on your abdomen (in the middle of your stomach, right below your rib cage).
2. Inhale slowly and deeply through your nose, right to the bottom of your lungs. You should feel your lungs filling up with air, so your hand that is placed on your abdomen should be rising. Note that your chest will rise slightly, but most predominantly your abdomen.
3. Once you have inhaled a full breath, pause for a few seconds before slowly exhaling out through your nose or mouth (personal preference). Exhale fully and allow all of the air to escape your body. Think of your body as a balloon that is deflating and allow your body to go limp.
4. Repeat this ten times and focus on keeping your breaths slow and regular so that it is the same for each abdominal breath (Bourne, 2005).

If this is continued throughout a PMR session, a higher level of relaxation will be achieved.

References:

Bourne, E. J. (2005). The anxiety & phobia workbook (4^th ed.). Oakland, CA: New Harbinger.

Image retrieved 31 July, 2013 from creativityinlife.wordpress.com/tag/health/

Wasnick, M. S. (2007). U.S. Patent Application 11/716,208.

What are the benefits of PMR?

PMR has many benefits, some of which I have already outlined in previous posts. Relaxation interventions in general are usually applied as an adjunctive therapy for certain conditions such as anxiety. PMR provides clients with self-management coping skills, has shown to reduce anxiety symptoms and, although not as effective, it has proven to also reduce depressive symptoms (Lolak, Connors, Sheridan & Wise, 2008).

Relaxation techniques are the most common non-pharmaceutical means of managing hypertension. More specifically, PMR can have beneficial physiological effects including reducing heart rate, blood pressure, respiratory rate, headache, pain, seizure frequency, and side effects of chemotherapy (Sheu, Irvin, Lin & Mar, 2003).

Furthermore, Bourne (2005) explains the long term beneficial effects PMR practice as a reduction in the frequency of panic attacks, an improvement in concentration, increased self-esteem and increased spontaneity and creativity.

Overall, PMR is widely beneficial to our health. Many of the clients I introduced PMR to on placement were suffering from anxiety or panic attacks. I really enjoyed using this technique with my clients because I could see the change in them, even in a short period of time. This made me feel as though I had assisted in a large way to their recovery and management of symptoms. 

References:

Lolak, S., Connors, G. L., Sheridan, M. J., & Wise, T. N. (2008). Effects of progressive muscle relaxation training on anxiety and depression in patients enrolled in an outpatient pulmonary rehabilitation programme. Psychotherapy and Psychosomatics, 77, 119-125.

Sheu, S., Irvin, B. L., Lin, H., & Mar, C. (2003). Effects of progressive muscle relaxation on blood pressure and psychosocial status for clients with essential hypertension in Taiwan. Holistic Nursing Practice, 17 (1), 41-47.

Bourne, E. J. (2005). The anxiety & phobia workbook (4^th ed.). Oakland, CA: New Harbinger.
Image retrieved July 26, 2013 from www.pickthebrain.com/blog/6-simple-ways-to-be-a-positive-human/

Client’s perspectives on PMR

From my knowledge, including both personal experience and researching literature, there is a large amount of positive responses to PMR from those who have attempted it whether it was only once or multiple times.

During my placement, I was involved in a few one-on-one sessions with the clients as well as being part of a group session. Although I haven’t asked any of the clients whether they have a preference in regards to one-on-one or group sessions, many of them responded in a satisfied tone that they enjoyed PMR and would be thrilled to be involved in the sessions in future.

One woman I was working with in a one-on-one session had trouble with managing her anxiety. After the sessions, she mentioned that she felt “much more relaxed”, more than she had in a “very long time”. She said it put her “mind at ease” so she could “focus on more important things during the day”.

Another woman who I had met during a group session of PMR told me that she “loves coming to this group!” She mentioned that PMR would start her day off nicely and she enjoyed the social aspect as she appreciated the company of others around her who are dealing with similar things as herself.

A study was completed to examine the effectiveness of psycho-educational interventions. One of these interventions included progressive muscle relaxation and the study conducted semi-structured interviews in order to find out the patient’s experiences and perceptions towards these particular interventions. In regards to self-management, one patient stated “It (PMR) is easy to practice, I just lie down, there is no fear of any harm or dangers…” (Case 31 – as cited in Chan, Richardson & Richardson, 2012, p.239).

References:

Chan, C., Richardson, A., & Richardson, J. (2012). Evaluating a complex intervention: A process evaluation of a psycho-education program for lung cancer patients receiving palliative radiotherapy. Contemporary Nurse: A Journal for the Australian Nursing Profession, 40 (2), 234-244.

Where can PMR be carried out?

During my placement I observed/facilitated PMR in various ways. My first experience of PMR was in the mental health inpatient ward, which took place in a large room that was specifically used for group activities. In total, there were 4 clients plus myself taking part in the session and one occupational therapist who read out the script to us. Each of us had a mattress to lie down on and had a choice of a variety of items including blankets, pillows, and weighted objects (e.g. weighted toy dog), to allow maximum comfort. During this session, calming nature music was quietly playing in the background.

Many of the PMR sessions that I facilitated with my clients took place in a sensory room at the office I was based at. Sensory environments/rooms are designed to be a space where the client’s senses are stimulated and the client has complete control over how this is done. Senses are stimulated through the use of light, sound, touch and smell, and the overall aim of these types of environments is to ensure that the client feels safe (Fava & Strauss, 2010). The particular sensory room that I used had a range of equipment that the clients could choose from, including a massage chair, a rocking chair, foot stools, pillows, blankets, weighted blankets and animals, a large variety of scents, lighting with the ability to dim, music, a television screen with calming images, stress balls, and I’m sure there was a lot more that I didn’t see! I noticed that all 3 of my clients chose to sit in the massage chair, although other aspects differed between them. Some clearly enjoyed music playing in the background, whereas one didn’t and some enjoyed the lights dimmed, whereas one wanted the lights on full brightness. I found it very interesting to see how people relax in different ways to others and I also noticed that the clients who engaged in the one-on-one sessions in the sensory room were more focussed than those in the group sessions.

Another way PMR can be carried out is in the client’s home. I didn’t facilitate PMR in any of my client’s homes but I believe it would be an appropriate space for this intervention to be carried out as home is where the client feels most comfortable.

This is an example of what a sensory room may look like:

References:

Fava, L., & Strauss, K. (2010). Multi-sensory rooms: Comparing the effects of the Snoezelen and the Stimulus Preference environment on the behaviour of adults with profound mental retardation. Research in Developmental Disabilities, 31(1), 160-171.

Image retrieved July 19, 2013 from www.littleowlnursery.co.uk/day-nursery/sensory-room/sensoryroom1/

How is PMR carried out?

Finally we are at the stage where you find out how to perform PMR! Some people carry out this technique in different ways, but the simplest way is to go through each muscle group individually from head to toe.

Before we get into the step-by-step instructions, it is important to set up the environment appropriately for the client, whether the session is going to be carried out in an activities room on the ward, in a sensory room or at the client’s home. For example, the occupational therapist that facilitated the PMR session on the inpatient ward during my previous placement (mentioned in the previous post), set up the room before the clients had arrived at 9am. She lay out the correct amount of mattresses according to the number of clients that were attending, pulled the curtains , set up the stereo in order to start playing the calming nature music, and brought the blankets/weighted items out of the cupboard so the clients were able to choose these individually if desired. It is important to organise the environment in such a way as it provides the client to freedom of choice, which is what us occupational therapists strongly believe in! It is also vital that the client is comfortable during the PMR session as the key aim of this intervention is to generate feelings of relief and ensure the client feels safe and secure.

To begin the PMR session, start with closing your eyes and taking in three deep breaths (deep breathing explained in a previous post). When exhaling, imagine all of the tension from your body flowing away.

Now clench both of your fists and hold them tightly clenched for 7-10 seconds. Now release your fists and relax for 15-20 seconds. These time intervals can be used for each of the muscle groups.

Moving on to the next muscle group, tighten your biceps by drawing your forearms up to your shoulders and hold… now relax (Bourne, 2005).

That was a short preview of what the facilitator would say to the client during the PMR session. Sessions can vary in time from 20-40 minutes, but here is a short video that you may want to watch which provides more detail:

http://www.youtube.com/watch?v=9x3tl81NW3w

References:

Bourne, E. J. (2005). The anxiety & phobia workbook (4^th ed.). Oakland, CA: New Harbinger.

Reflection

Overall, I believe PMR is a useful intervention that should be used if possible and when appropriate. On my placement when my supervisor introduced PMR to me, I felt overwhelmed and assumed that it was a complex intervention that would take me a long time to get my head around. To my surprise, after that placement I felt confident in using this intervention in my future occupational therapy practice and I feel as though I would be able to clinically reason why I am using it as a key intervention with clients.

I have learnt a lot in regards to PMR throughout my experiences both on placement as well as completing research to complete this blog. When I first started using PMR on my clients I felt very nervous and thought I was going to do something incorrect and embarrass myself. The only way I could eliminate these feelings was to continue practising the technique whether it was on a friend/family member or on my clients. I also encourage you to use the deep breathing technique in conjunction with PMR as I believe it is effective and is an additional level of relief for the client. I found that reminding the client to continue their deep breathing throughout the entire session was useful as they would usually forget. By constantly communicating these reminders, it filled in those quiet moments between reading out the instructions, which broke the silence.

I hope this blog has been interesting and useful to you. If you haven’t already, I encourage you to introduce PMR to your clients (if applicable) or try using it yourself so you can experience the benefits first-hand!

Thank you for reading :-)

References:

Image retrieved July 9, 2013 from spiceboxdesigns.blogspot.com/2012/05/happy-happy-joy-joy.html