Introduction

Relaxation techniques are therapeutic exercises designed to assist individuals with decreasing tension and anxiety, physically and psychologically. Strategies to assist patients with relaxation have long been a hallmark component of psychotherapy; however, they can be utilized throughout healthcare environments as complementary therapies to treat patients experiencing various types of distress, including but not limited to anxiety, depression, pain, and stress[1]. Relaxation techniques encompass an array of strategies to increase feelings of calm and decrease feelings of stress. Feelings of stress can include physiological responses such as increased heart rate, shortness of breath, and muscle tension, along with the subjective emotional experience; and relaxation techniques can aid in the reduction of these symptoms[2]. Many variations of relaxation strategies exist and can be facilitated by a variety of health professionals and learned via self-help.

Indications

Relaxation techniques are therapeutic exercises indicated to assist patients in decreasing physical and psychological tension and anxiety.

Preparation

The following are step-by-step examples of relaxation techniques that can be relayed to patients by health professionals. It is helpful to know a variety of relaxation techniques to offer to patients as different strategies work for different patients. Relaxation techniques have been shown to reduce cortisol levels in patients, leading to a decrease in somatic and subjective experiences of stress[3]. Like all beneficial, healthy activities, each relaxation technique should be practiced over time and implemented regularly for optimal stress reduction.

Technique

Box Breathing 

While there are many different forms of deep breathing exercises, box breathing can be particularly helpful with relaxation. Box breathing is a breathing exercise to assist patients with stress management and can be implemented before, during, and/or after stressful experiences. Box breathing uses four simple steps. Its title is intended to help the patient visualize a box with four equal sides as they perform the exercise. This exercise can be implemented in a variety of circumstances and does not require a calm environment to be effective.

• Step One: Breathe in through the nose for a count of 4. 
• Step Two: Hold breath for a count of 4. 
• Step Three: Breath out for a count of 4. 
• Step Four: Hold breath for a count of 4. 
• Repeat 

Note: The length of the steps can be adjusted to accommodate the individual (e.g., 2 seconds instead of 4 seconds for each step).

Guided Imagery

Guided imagery is a relaxation exercise intended to assist patients with visualizing a calming environment. Visualization of tranquil settings assists patients with managing stress via distraction from intrusive thoughts. Cognitive behavioral theory suggests that emotions are derived from thoughts, therefore, if intrusive thoughts can be managed, the emotional consequence is more manageable. Imagery employs all five senses to create a deeper sense of relaxation. Guided imagery can be practiced individually or with the support of a narrator.

• Step One: Sit or lie down comfortably. Ideally, the space will have minimal distractions.
• Step Two: Visualize a relaxing environment by either recalling one from memory or created one through imagination (e.g., a day at the beach). Elicit elements of the environment using each of the five senses using the following prompts:

1. What do you see? (e.g., deep, blue color of the water)
2. What do you hear? (e.g., waves crashing along the shore)
3. What do you smell? (e.g., fruity aromas from sunscreen)
4. What do you taste? (e.g., salty sea air)
5. What do you feel? (e.g., warmth of the sun)

• Step Three: Sustain the visualization as long as needed or able, focusing on taking slow, deep breaths throughout the exercise. Focus on the feelings of calm associated with being in a relaxing environment.

Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is a relaxation technique targeting the symptom of tension associated with anxiety. The exercise involves tensing and releasing muscles, progressing throughout the body, with the focus on the release of the muscle as the relaxation phase. Progressive muscle relaxation can be practiced individually or with the support of a narrator.

• Step One: Sit or lie down comfortably. Ideally, the space will have minimal distractions.
• Step Two: Starting at the feet, curl the toes under and tense the muscles in the foot. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Three: Tense the muscles in the lower legs. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Four: Tense the muscles in the hips and buttocks. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Five: Tense the muscles in the stomach and chest. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Six: Tense the muscles in the shoulders. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Seven: Tense the muscles in the face (e.g., squeezing eyes shut). Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.
• Step Eight: Tense the muscles in the hand, creating a fist. Hold for 5 seconds, then slowly release for 10 seconds. During the release, focus attention on the alleviation of tension and the experience of relaxation.

 Note: Be careful not to tense to the point of physical pain, and be mindful to take slow, deep breaths throughout the exercise. 

Clinical Significance

Relaxation strategies are used as therapeutic interventions for patients experiencing stress. It is widely accepted that high stress, particularly sustained rates of high stress, have negative effects on physical and mental health. Chronic stress in childhood and adulthood can lead to increased blood pressure and mental health issues among other health concerns[4]. Additionally, chronic stress has been shown to affect brain development, specifically the amygdala which is essential for emotion regulation and the pre-frontal cortex which is necessary for executive functioning and decision-making; therefore, it is useful to have relaxation strategies as coping tools to share with patients to decrease stress.[5][6][7][8]

Enhancing Healthcare Team Outcomes

The healthcare profession is stressful for physicians, nurses, pharmacists and other related professionals. Burnout from stress is common. Thus, many types of relaxation techniques have been developed to help ease the tension and relieve the stress. There is literature to show that stress free individuals are more efficient and effective compared to stressed individuals.[9]