This is one of the mainstays of pain management as well as anxiety management. Relaxation is intended to reduce physiological arousal and operates as a means of cognitive coping.

There are many methods for relaxation, but they all start with diaphragmatic breathing. Breathing rate changes in response to effort and anxiety - in a stressed state the breathing rate increases but becomes shallow. Here is my resource for breathing training.

The problem with relaxation training is that for many of us, taking time out during the day to lie down and relax is impossible. We risk giving our patients the message that they need to withdraw from activity if we only teach them a lengthy relaxation method.

Long relaxation methods are useful however, especially in the early stages of learning to relax, and for sleep or when fatigue management is important. In the early stages of learning to relax it can be difficult for the person to become relaxed, and only do so when a long relaxation progressively induces the relaxation response. Long relaxations can be carried out to help the person recognise what relaxation feels like. A long relaxation can be used at bedtime, as part of a pre-sleep ritual for individuals having trouble with sleep onset. In this use, relaxation becomes one way of reducing physiological arousal, occupying the mind to reduce negative rumination, and developing a bedtime ‘habit’ where the brain and body are trained to recognise the cues for sleep.

When long relaxations are used for fatigue management, a long relaxation can be used in the middle of the day instead of sleep - providing rest without disrupting the night requirement for sleep. Techniques to prevent the person from falling asleep during this relaxation will be needed.

Shorter relaxation techniques are also many and varied. These are typified by maintaining awareness of the environment so that activity can be maintained. A range of techniques can be employed including posture (Laura Mitchell Simple Relaxation), selective relaxation (tense-release or Jacobsen relaxation), rapid hypnotic induction (using a cue word or signal), cued relaxation and body scan awareness.

These latter strategies are particularly important for people experiencing persistent pain because of the focus on remaining engaged with activity while at the same time reducing arousal. This process is integral to the graded exposure process used to reduce fear and avoidance of activity related to pain anxiety.

Alongside all of these techniques, it can be helpful to use biofeedback modalities. There are many different types available, some of them including a range of visual images that can be manipulated by the person through biometric monitoring (eg skin conductance or heart rate variability). Biofeedback offers the therapist an opportunity to identify the relaxation strategies that have best effect, while for the person it can provide concrete 'evidence' that they are able to relax despite not feeling much difference.

Relaxation training 'works' through two main modes:

1. Reducing physiological arousal


2. Providing a cognitive interruption to distressed thinking (or a sense of control and therefore increased self efficacy)

To make a clinical decision to use relaxation, consider the following:

• Does this person demonstrate increased arousal during pain flare-ups?


• Is anxiety a feature of their presentation?


• Do they avoid activities, and when they encounter feared activities, do they carry them out with increased arousal?


• During painful episodes do they experience heightened distress and difficulty concentrating or problem-solving?


• Do they have difficulty getting off to sleep, or returning to sleep when they awaken during the night?


• Do they appear to have low energy during the day, and want to take naps?

Any 'yes' answers to these questions suggest that relaxation may be helpful - but ensure you also have a strategy for them to employ relaxation appropriately through the day.

My typical approach to developing relaxation skills:

1. Assess why relaxation may be used (develop my clinical rationale)


2. Develop diaphragmatic breathing


3. Use a cue word with the out breath


4. Choose a long relaxation depending on the person's interest - Jacobsen or a hypnotic induction work equally well. I provide the person with a recording of the relaxation with a music background to mask noises from the environment.


5. Develop a rapid postural relaxation technique for use throughout the day - I find Laura Mitchell Simple Relaxation works well for this, but others are also good.


6. Develop a series of cues that can be used throughout the day, so that the person has opportunity to integrate 'take 5’s' through the day - out-breaths or Simple Relaxation can be useful here.


7. Ensure the person can use a body scan to identify tension during activity. Cue times to do this on a regular basis during activity.