Introduction

Progressive muscle relaxation (PMR) is a widely-used technique to help reduce stress, anxiety, muscle tension, and improve mental health conditions such as generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder. All of these are relevant issues for any patients struggling with chronic pain as they tend to increase both perceive pain intensity as well as lead to behavioral avoidance that can deepen the vicious cycle of chronic pain.

PMR involves systematically tensing and relaxing different muscle groups in a specific sequence to promote relaxation and mindfulness. In practice, for mental health clinicians working with patients struggling with chronic pain and comorbid mental health conditions, implementing PMR can pose some challenges. In this article, we will discuss these obstacles and offer possible solutions to each.

Obstacle 1: Patient Discomfort

One significant challenge in implementing PMR for patients with chronic pain and comorbid mental health conditions is their discomfort during the exercise. Tensing muscles may exacerbate pain and lead to increased anxiety and stress. Many patients are already hypervigilant of pain sensations so putting extra focus on painful body parts can potentially exacerbate catastrophizing thoughts.

Solution: Modify the Technique

Clinicians can modify the PMR technique to accommodate individual patient needs. For example, using a gentler approach, such as only lightly tensing the muscles or focusing solely on relaxation, can alleviate discomfort. PMR without tensing, and simply focusing on relaxing each muscle group, is often simply called “Progressive Relaxation” (PR).

Additionally, incorporating slow, deep breathing and visualization techniques can enhance relaxation without increasing pain. Consider experimenting asking the patient to visualize the tension in their body, perhaps as a dark mist, that is released or expelled by the release of muscle tension and exhalation of breath. You can also start by focusing on body parts that are uninjured or have less pain intensity, and eventually you can work closer and closer to the injured body parts by establishing confidence in the method of PMR. By tailoring the PMR approach to each patient’s unique circumstances, clinicians can help patients feel more comfortable and engaged in the exercise, leading to better outcomes.

Obstacle 2: Lack of Motivation

Patients with chronic pain and comorbid mental health conditions may feel unmotivated to engage in relaxation exercises, as they may not see immediate benefits or may struggle with feelings of hopelessness.

Solution: Educate and Encourage

Educate patients on the long-term benefits of PMR and how it can improve their overall pain management and mental health. There is evidence that PMR provides various health benefits for individuals who practice it regularly including: Reduced anxiety, reduced stress, improved sleep quality/decreased insomnia, reduced depression, improved cardiovascular health (including lower blood pressure), and even potentially decrease pain intensity. By reducing stress, PMR also helps with other related issues such as improved gastrointestinal function, improved immune system, and decreased headaches/migraines.

Consider sharing success stories (patients often respond well realistic examples that they can relate to). Always provide clear instructions, and break down the technique into manageable steps. Try to practice with the patient in person before having them do it on their own so they feel reassured they are doing it properly.

Further, clinicians can set realistic goals. For example: Try PMR 2x/day, 15 minutes each, for 4 weeks. It helps if you track anxiety/stress levels (perhaps through measures such as BAI or GAD7) which helps to celebrate small achievements and demonstrate progress. Provide positive reinforcement to keep patients motivated: if the patient reports they tried PMR at all, that represents a significant achievement, though it may be only the first step. Maintaining open communication and establishing trust with patients can help them understand the value of PMR and encourage them to persevere, even when progress may seem slow.

Obstacle 3: Time Constraints

Integrating PMR into a busy schedule can be challenging for both patients and clinicians. With limited appointment times and numerous treatment options, finding time for relaxation exercises may be difficult. Many patients with chronic pain struggle with time management already, and adding 15-30 minutes of meditation where they cannot be bothered is felt to be an insurmountable obstacle for many.

Solution: Flexibility and Prioritization

PMR can always be incorporated into existing therapy sessions, but ultimately we want to increase the patient’s self-efficacy through encouraging them to use PMR on their own. It may be helpful to give a pre-made recording of PMR, whether of oneself leading the meditation or even a YouTube recording that you’ve found to be acceptable.

Plan ahead: Get the patient to think ahead to at least one time during each day (preferably in the morning or before bed to help with sleep issues), where the patient feels they can set aside 15 minutes to perform this meditation. Remind them the importance of prioritizing PMR as a valuable part of the patient’s treatment plan. Reinforce PMR’s importance for managing chronic pain and improving mental health (as with the previously mentioned health benefits). Encouraging patients to establish a routine and providing guidance on fitting PMR into their daily lives can help them commit to regular practice and maximize the benefits of the technique.

Sometimes adaptation and flexibility will be needed: One patient, for example, could not find time in the morning or evening due to constant needs of attending to their young children. In the end, they succeeded by finding a good YouTube video and having their children actually learn and practice along with them. This both allowed them to actually practice PMR as well as strengthening familial bonds. Now their children are also more well-equipped to deal with stress and anxiety the rest of their lives as well!

Conclusion

Implementing progressive muscle relaxation for patients with chronic pain and comorbid mental health conditions may present challenges for mental health clinicians. Many clinicians can easily get frustrated trying to implement PMR as an intervention. It is important to not collude with patient’s avoidance or one’s own personal issues with meditation/relaxation: relaxation is a fundamentally central skill in chronic pain management and should not be neglected.

By modifying the technique, promoting motivation, and addressing time constraints, these obstacles can be overcome. Integrating PMR into treatment plans can provide significant benefits for patients, helping them manage their chronic pain more effectively, improve their mental health, and ultimately enhancing their overall quality of life.

References

For those who would like to learn more, here is a list of references of how PMR can affect various symptoms:

• Anxiety/stress: Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E. (2008). Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC psychiatry, 8, 41.
• Insomnia: Lichstein, K. L., Wilson, N. M., & Johnson, C. T. (2001). Psychological treatment of secondary insomnia. Psychology and Aging, 16(2), 232-240.
• Pain management/pain intensity: McCracken, L. M., Gross, R. T., & Aikens, J. (1991). The assessment of anxiety and fear in persons with chronic pain: a comparison of instruments. Behaviour Research and Therapy, 29(5), 487-495.
• Muscle tension/stiffness: Vøllestad, N. K., & Vaernes, R. J. (1990). The influence of progressive relaxation and autogenic training on muscle tension, blood flow, and work load during a standardized typing task. Psychophysiology, 27(6), 677-685.
• Depression: Jorm, A. F., Morgan, A. J., & Hetrick, S. E. (2008). Relaxation for depression. Cochrane Database of Systematic Reviews, (4).
• Blood pressure: Carlson, L. E., Ursuliak, Z., Goodey, E., Angen, M., & Speca, M. (2001). The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Supportive Care in Cancer, 9(2), 112-123.
• Cardiovascular health: Sherwood, A., Dolan, C. A., & Light, K. C. (1990). Hemodynamics of blood pressure responses during active and passive coping. Psychophysiology, 27(6), 656-668.
• Immune system: Kiecolt-Glaser, J. K., Glaser, R., Williger, D., Stout, J., Messick, G., Sheppard, S., … & Donnerberg, R. (1985). Psychosocial enhancement of immunocompetence in a geriatric population. Health Psychology, 4(1), 25-41.
• Gastrointestinal function: Blanchard, E. B., Greene, B., Scharff, L., & Schwarz-McMorris, S. P. (1993). Relaxation training as a treatment for irritable bowel syndrome. Biofeedback and Self-regulation, 18(3), 125-132.
• Headaches/migraines: Holroyd, K. A., & Penzien, D. B. (1990). Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: a meta-analytic review of clinical trials. Pain, 42(1), 1-13.