M. Hollis
The tension of muscles can be affected by conscious effort and thought and can be relieved by the
application of conscious thought and/or muscular effort on the part of the patient. The difference between tension and relaxation may be observed, for example, in the difference in posture of an athlete at the beginning of a sprint start and that at the end of the race when the line has been crossed; or in the learner driver who sits tensed and hunched over the steering wheel as opposed to the relaxation of the accustomed and experienced driver.
Relaxation can be taught to patients so that a regime can be practised alone, or active resisted techniques may be used for which the presence of the therapist is necessary. Relaxation may be general or local, i.e. the whole body may be taught to relax or only a small part, as required. Relaxation can be practised in any convenient posture, but is more usually taught in lying, half lying, side half lying, modified side lying and right or left lateral positions, prone lying or in an armchair supported with a high back.
There are two physical methods, contrast method and reciprocal method, which the patient may be taught to practise alone.
Contrast Method
The physiology of the contrast method is that a strong contraction of a muscle is followed by an equal relaxation of the same muscle, or
Excitation = Inhibition
The technique consists of a sequence of contractions of muscles performed, usually, in a distal to proximal sequence in each limb or pair of limbs in turn, followed by letting go or relaxation for an equal or longer period of time. Then the contractions for each limb part are usually added to one another so that tension in the limb is total and the relaxation should be controlled in reverse sequence.
The sequence of commands is as follows (alternative or explanatory commands are in brackets):
For the Arm
'Make a fist and let go.'
'Tighten your wrist and let go' (pull your hand back or forwards). 'Tighten your elbow and let go' (bend or straighten).
'Tighten your shoulder and let go' (pull your arm into your side).
For the Leg
'Point your foot down or pull your foot up and let go' (the patient chooses whichever is least likely to give him cramp).
'Tighten your knee and let go' (straighten your knees).
Page 59 'Tighten your hips and let go' (tighten the buttocks). When the above sequences are added together the commands will be:
For the Arm.
'Tighten your fist, wrist, elbow and shoulder and let go shoulder, elbow, wrist and hand' (stiffen the whole arm, and let go).
For the Leg
'Tighten or point your feet, knees and hips and let go your hips, knees and feet' (stiffen the whole leg, and let go).
The commands for both pairs of limbs may be added together as follows:
'Tighten the feet and hands, knees and elbows, hips and shoulders and let go' in reverse order (stiffen your arms and legs and let go).
For the Trunk and Head
'Press your head against your support and let go.' 'Press your shoulders against your support and let go.'
Deep breathing may be practised with relaxation of any part of the body. It is more usual to breathe in while tensing the muscles and to breathe out on letting go.
It is also possible to add the contractions for the trunk on to those for the limbs so that the patient is in whole body tension, but this should not be taught to a patient with high blood pressure, or one who tends to have respiratory incapacity. The value of this technique is that it can be used for a limited part of the body, for example for relaxation of the hand or of the shoulder girdle or the hip adductors and lateral rotators.
Reciprocal Method
The physiology of this method is that the antagonistic groups of muscles always relax reciprocally and equally to the contraction of the agonist groups of muscles. Tension will be relieved by contraction of the antagonistic muscles. In this technique, the muscles which will take the patient out of the tense posture are those which are required to contract with the consequent diminution in tension in the muscles that are maintaining the tense posture.
The patient is allowed initially to remain in his tense posture, and may lie or sit if he prefers, but specially comfortable positioning should not necessarily be offered; better positions will be achieved as the relaxation proceeds. For success with this technique it is important that the patient learns to recognize his own tension at any time and learns what to do to relieve it without necessarily changing his main working position. The sequence used is more usually proximal to distal, and each part of the body is given three commands as follows:
(1) To move so that the tense 'infolded' position of the body is opened up. (2) To stop moving.
(3) To let the brain appreciate the new posture making the patient think about the new position in which his body component is now resting. Time should be allowed for this and the patient should not be hurried.
For the Shoulders
'Push your shoulders towards your feet.' For the Arms
'Lift your arms outwards and slightly straighten your elbows.' For the Hands
Page 60 For the Hips
'Separate the thighs.' For the Knees
'Straighten your legs slightly.' For the Feet
'Point your feet away from you.' For the Head.
'Press your head into the support or backwards.' For the Upper Trunk
'Press your back into the support or backwards.' For the Jaw
'Without necessarily opening your lips push the lower jaw away from the upper jaw or towards your feet.' Breathing for this technique is usually achieved at greater depth by asking the patient 'to sigh' and to
appreciate what is happening to the waist. To be aware that the waist is becoming smaller, and even that the 'ribs are folding down like a bird's wing'.
In fact in both these methods asking the patient to sigh as though at the end of a heavy day is the best method of gaining deep breathing because if a good breath out is taken the amount of air that is subsequently taken into the lungs will be slightly increased. Note that in these two techniques the word relax is never used and only in the contrast method is the patient asked to let go. The positions which may be used for the reciprocal method are the same as those for the contrast method and in neither of these methods is it important that the patient should be in a particularly quiet atmosphere. It is, in fact, much better to teach the reciprocal method against a normal background noise and not to create a soothing hypnotic atmosphere round the patient.
Suggestion Method
A third method which may be used for some patients and which is entirely for those who may not perform much muscle work is the suggestion method. In this technique the therapist provides comfortable relaxing conditions for the patient:
(a) A warm well-ventilated room (b) A comfortable support (c) Light covering.
Then, by using quiet, hypnotic, mellow tones, suggest that the thoughts be directed to personally enjoyable but repetitive noises or scenes. The patient is told to think about each part of the body in turn. To think that it is 'very heavy' and the suggestion is repeated several times until the limb gives the appearance of relaxation, e.g. until the lower limb is rolled out. The patient may be invited to try to raise the limb, while the suggestion is made that it will be impossible to do so and that it may feel as though it is floating. The patient is then instructed to direct attention to the other leg and to each arm in turn and then to the whole body. Deep,
Pendular Swinging
This is used for relaxation of the limbs. The arm(s) or leg(s) may be swung back and forth until they feel numb. The sensory receptors have accommodated to the constant movement. This type of swinging may be aided by adding a 1/2 to 1 kg weight to the limb keeping it within
Page 61 the length of the limb, i.e. grasped in the hand or fastened to the ankle. This type of swinging is of particular value to reduce the rigidity of Parkinsonism, but is also used for shorter periods to mobilize joints by patient activity. It is most suitable for the shoulder, hip, knee and lumbar spine.
Active Resisted Techniques for Local Relaxation Hold Relax
This technique is described more fully in Chapter 23 on neuromuscular facilitation. Briefly it consists of offering resistance to a muscle group which is in tension. The patient is commanded to 'hold' the limb in position while the therapist applies resistance to the patient's contraction, which produces isometric
contraction of the tense muscles. No movement should occur. When the therapist feels that the patient has reached the limit of his potential contraction, she should grasp the limb firmly, but comfortably, and at the same time tell the patient to 'relax' or 'let go' and allow a time to elapse which is at least as long as, or perhaps longer than, the time taken to build up the maximum contraction. This technique is of special use when a patient has no movement because of pain-spasm.
Contract Relax
This technique may be used when a patient has a small range of movement and then is prevented from moving further by the spasm of the muscles which are antagonist to the movement. The therapist places her hands on the limb on the same side as the antagonist muscles which are in spasm and asks the patient to make a small strongly resisted contraction back to the original position of rest. At the end of the movement the part is grasped firmly, but comfortably, and the patient is told to 'relax'. Again the period of relaxation should be an adequate length of time. Then the original movement should again be attempted either passively or actively. A gain in range may be found and a further contract–relax should now allow a small range
movement which should not return the limb to the original resting position, but should be less than the total range, i.e. the patient should not return each time to the original position in which the limb was resting. This technique is described more fully in Chapter 23.