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Prevention in Practice

Relaxation – an integral part of headache prevention

"An anxious mind cannot exist in a relaxed body” Edmund Jacobson, physician and psychologist

Holistic management of migraine and other types of headache now offers a treatment arsenal that is about much more than medication alone. In fact, it embraces many elements of behavioral therapy. Relaxation techniques are right up there at the top of the list and have become indispensable, powerful tools in the therapeutic armamentarium. An impressive range of different methods have been developed over the years. Initially based primarily on empiricism, i.e. observations made immediately during their use, rigorous studies meeting hard scientific criteria have now demonstrated that such methods have a rightful place in a field largely dominated by the natural sciences. Non-drug approaches are rapidly gaining acceptance in the modern medical community.

A leading expert in pain prevention and therapy, Kiel Pain Clinic founder and director Prof. Hartmut Göbel, comments: "Numerous scientific studies have demonstrated the effectiveness of specific relaxation techniques, such as Progressive Muscle Relaxation, especially in the prevention of headaches, migraines, back pain, fibromyalgia, nerve pain, stress reactions and other conditions."

The main such technique, Jacobson’s progressive muscle relaxation (PMR), is in widespread use and has a remarkable track record of success in headache and other areas. PMR is presented in more detail below. PMR is an easy-to-learn relaxation method that aims to achieve a state of deep relaxation throughout the body by consciously tensing and relaxing specific muscle groups. Practitioners tense and relax a particular set of muscles in succession, paying attention to and actively experiencing the differences between these two states. With the improved body awareness that comes with mastering the technique, practitioners can reduce their muscle tension even below the normal level, with the added bonus of banishing other signs of physical agitation and anxiety as well. By relieving muscle tension, PMR often reduces pain states such as migraine and headache. PMR has also demonstrated impressive results in areas other than pain, including sleep disorders, anxiety states, stress and hypertension (high blood pressure).

A momentous observation

Edmund Jacobson, an American physician and psychologist born in Chicago in 1888, observed that he was unable to startle deeply relaxed students with a sudden loud noise – which would have been the expected response in the circumstances. Jacobson concluded that there must be a connection between the subjects’ state of relaxation and their lack of response to otherwise startling stimuli. Deeply struck by this finding, Jacobson vowed to get to the bottom of it. It was a research project destined to shape his life as a physician from then on and provide a whole series of groundbreaking insights into mind-body interaction.

The PMR story

Jacobson went on to develop Progressive Muscle Relaxation, or PMR for short, a technique as comprehensive as it is meticulous. The aim was to help patients develop a sense of their muscles and a “feel” for muscle tone, allowing them to enter into a kind of conscious communication with their level of bodily tension. The ultimate objective was to enable the person to monitor their body tension almost constantly and largely automatically to detect and eliminate unwanted tension.

The technique, originally designed by Jacobson for no less than 16 muscle groups, was later modified by other scientists to make it more practicable. A ten-minute version that has proven very effective in real-world use and is easy to incorporate into everyday life can be found in the Headache Hurts app and on the start page of this website.

Is relaxation therapy part of evidence-based medicine?

Evidence-based medicine is a buzzword you hear often these days. Basically it describes the expectation among a medically literate section of the public that the efficacy, safety and tolerability of medical devices, medicines and treatment methods have been thoroughly tested in research studies and, ideally, found to be significantly superior to existing procedures. Where conventional medicines are involved, providing evidence of benefit may be simple. If a drug blocks a known metabolic pathway, its efficacy can be demonstrated by measuring how much of that particular metabolite is produced. Then you only need to determine the degree of inhibition you want to accomplish and the dose needed to achieve that effect.

The situation is rather different if you are dealing with concepts that are hard to quantify. When is someone "relaxed"? How would you measure their level of relaxation in percent? And how would you relate their pain perception level to their degree of relaxation? These questions are not amenable to scientific study, one would think. And yet, there are now quite a few studies into the effectiveness of relaxation therapies. In addition to sophisticated questionnaires and assessment algorithms designed to achieve the most objective results possible, researchers sometimes use a special medical electrodiagnostic technique called electromyography (EMG). EMG is a diagnostic tool used in neurology to measure the electrical activity of muscles and nerves. So alongside the subjective statements of test subjects, researchers can use EMG to obtain objective data on the activity of individual muscles and muscle groups before, during and after relaxation exercises. Special sensors also measure skin conductivity, which provides an indirect indication of the degree of tension of the autonomic nervous system. Taken together, all these methods provide a basis for reproducible research into the effects of relaxation therapies.

Studies in students

A substantial number of studies focus on student life and its unique characteristics. Especially before exams, presentations or lectures, the pressures involved give some students panic attacks and/or physical stress symptoms such as rapid heartbeat and high blood pressure. These are states that make it impossible for you to even take in information effectively, never mind impress fellow-students or conference attendees with your presentation. Nobody would blame a person for wanting to avoid the associated mental and physiological stress. Some people keep on postponing exams and may even end up never finishing their studies. But it doesn’t have to be that way. A Mainz+Frankfurt research group observed that regular practice of relaxation techniques over a period of five weeks noticeably reduced anxiety among participants. While physical stress response symptoms persisted, mental well-being improved significantly.

The body of research into university stress is much smaller than the database on stress at work or school. Nevertheless, the evidence so far very clearly shows that stress, anxiety, and associated health consequences including headache and depression are serious and growing problems. Alarmingly, very few people seek medical or psychological help. There is clearly an urgent unmet need for universities to launch programs to, firstly, raise awareness in this area and secondly, to identify appropriate measures to address this challenge.

A review by a Canadian researcher, Cheryl Regehr, shows that such programs can be very successful in combating the catastrophic complex of student stress, exam phobia and reactive headache. Regeher looked at 24 studies in her review and concludes that all approaches with a focus on mental health and promoting relaxation produced significant reductions in anxiety and stress symptoms. She also notes that the results of the studies included in the review are consistent across countries, and that different interventional techniques (relaxation, meditation, cognitive approaches, etc.) are similarly beneficial. The findings are also encouraging with regard to the incidence of depression. Five out of six studies reported a significant reduction in rates of depression in association with the use of relaxation techniques. Regehr concludes that there is an urgent need to initiate more university programs providing or teaching relaxation training to help address what is a manifest health problem. The benefits for student well-being and productivity are obvious. Relieving the cost burden on the health care system would be a welcome extra.

A research group at the University of Missouri compared the effect of a range of relaxation methods on student stress perception, with techniques ranging from complete silence to PMR done to music. Students found the latter – PMR set to their own choice of musical accompaniment – to be the most pleasant method. Self-chosen music apparently boosted the results of the relaxation technique and reduced stress in the most effective way. The authors suggest that the subjects’ active personal contribution to the methodology (music they chose themselves) amplifies the impact and puts subjects in a more positive frame of mind about the relaxation exercise itself.

An experiment in medical students at the University of St. Augustine, Florida showed that PMR produced a balanced state of mind in subjects asked to perform a battery of tasks and also helped them perform better than control subjects. The authors conclude that the relaxed participants benefited from improved recall. Researchers postulate numerous benefits of relaxation techniques on many aspects quality of life – be they precisely measurable or not.


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