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NCCIH Clinical Digest

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Stress and Relaxation Techniques:
What the Science Says

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December 2014
Clinical Guidelines, Scientific Literature, Info for Patients: 

Anxiety

Studies have shown relaxation techniques may produce modest, short-term reduction of anxiety in people with ongoing health problems such as heart disease or inflammatory bowel disease, and in those who are having medical procedures such as breast biopsies or dental treatment. Relaxation techniques have also been shown to be useful for older adults with anxiety. In people with generalized anxiety disorder, studies indicate that cognitive-behavioral therapy is more effective over the long term than relaxation techniques.

The Evidence Base

The current evidence base on the efficacy of relaxation techniques for anxiety consists of a few reviews and meta-analyses and many randomized trials; however, many of these studies have been small and of poor quality.

Efficacy

  • A 2009 review of five randomized trials and two meta-analyses, in more than 2,700 cardiac patients, found small but significant reductions in anxiety in this patient population with greater effects expected from more intensive training.
  • A 2012 randomized controlled trial in 39 patients with inflammatory bowel disease found that those receiving relaxation training intervention showed statistically significant improvement in anxiety levels, quality of life and mood, and stress and pain, compared to the control.
  • A 2006 randomized trial in 236 women undergoing large core needle breast biopsies assessed the effects of self-hypnotic relaxation on anxiety and pain compared to standard treatment or empathic attention. The study found that women’s anxiety increased significantly in the standard group, did not change in the empathic group, and decreased significantly in the relaxation group. Pain increased significantly in all three groups.
  • A 2008 randomized controlled trial of 90 patients examined the effects of a brief relaxation method on dental anxiety compared to music distraction and to a control. Both treatment groups significantly reduced dental anxiety, but the brief relaxation intervention was significantly superior to music distraction. Patients in the control group did not exhibit a significant change in their anxiety level.
  • Findings from a 2009 meta-analysis of 19 trials suggest that relaxation and cognitive behavioral therapy are effective psychosocial treatments for older adults with anxiety disorders or symptoms.

Depression

Studies suggest that relaxation techniques may have modest benefit on symptoms of depression but are not as effective as psychological treatment, such as cognitive behavioral therapy.

The Evidence Base

  • The best evidence to date on the efficacy of relaxation techniques (e.g., progressive muscle relaxation, relaxation imagery, and autogenic training) on depressive symptoms, consists of a Cochrane review and several randomized trials.

Efficacy

  • A 2008 Cochrane review of 15 trials concluded that relaxation techniques were more effective at reducing self-rated depressive symptoms than no or minimal treatment, but were not as effective as psychological treatment. Evidence on clinician-rated depressive symptoms was less conclusive.

Fibromyalgia

In general, research on complementary health approaches for fibromyalgia must be regarded as preliminary. Studies of guided imagery for fibromyalgia have had inconsistent results, while studies of other relaxation techniques have shown modest improvements in pain, but only in the short term.

The Evidence Base

  • The best evidence to date on the efficacy of relaxation techniques for fibromyalgia consists of a few systematic reviews, a meta-analysis, and many randomized controlled trials.

Efficacy

  • A 2014 Cochrane review of 37 studies involving more than 2,000 children and adolescents concluded that psychological treatments (e.g. relaxation techniques, hypnosis, coping skills training, biofeedback, cognitive behavioral therapy) were found to beneficial for pain and disability for non-headache conditions post-treatment, but these effects were not maintained at follow-up.
  • A 2013 meta-analysis and systematic review concluded that electromyographic (EMG) biofeedback helped reduce fibromyalgia pain for short periods of time; however, EMG biofeedback did not have an effect on sleep problems, depression, fatigue, or health-related quality of life, and its long-term effects have not been established.

Headache

Results of research on relaxation training and biofeedback for headaches suggest that these approaches may help relieve headaches and may be helpful for migraines.

The Evidence Base

  • The best evidence on the efficacy of relaxation techniques for headaches is reviews of data from randomized controlled trials.
  • The best evidence on the efficacy of biofeedback for headaches comes from only a few small, randomized controlled trials.

Efficacy

  • A 2014 Cochrane review of 37 studies involving more than 2,000 children and adolescents concluded that psychological treatments (e.g. relaxation techniques, hypnosis, coping skills training, biofeedback, cognitive behavioral therapy) delivered in-person by a therapist are effective in reducing pain intensity and disability for children (17 years of age and younger) with headache. These treatments also have a beneficial effect in reducing anxiety symptoms post-treatment for headache.
  • The efficacy of biofeedback has been evaluated in numerous studies for tension headaches, with positive results. However, a 2009 systematic review of 11 randomized controlled trials concluded that there is conflicting evidence on the effectiveness of biofeedback compared with placebo to prophylactic drugs or any other treatment.
  • Several studies have shown biofeedback decreased the frequency of migraines. A 2007 meta-analysis of 55 studies found a modest effect for biofeedback interventions and was seen lasting over an average follow-up phase of 17 months. However, a 2008 review found a medium average effect size for biofeedback compared to untreated control groups but no reliably higher biofeedback treatment gains compared to placebo. The reviewers concluded that although there is strong evidence for efficacy, there is weak evidence for the treatment specificity of biofeedback in migraine.
  • There is limited evidence to support the efficacy of relaxation techniques for tension-type headaches. A 2009 systematic review of 8 studies comparing relaxation training to wait list conditions found inconsistent results. Authors of the review concluded that there is no indication, based on current evidence, that relaxation training is better than no treatment or a placebo. A 2008 meta-analysis of 53 studies suggests that relaxation training is less effective than biofeedback.
  • The US Headache Consortium guidelines (85KB PDF) for management of migraines include behavioral and physical treatment recommendations based on evidence from 39 controlled trials. The guidelines indicate that relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine and combined with preventive drug therapy to achieve additional clinical improvement for migraine relief.

High Blood Pressure

Relaxation techniques have shown modest, short-term reductions in blood pressure; however, many of these studies were of poor quality.

The Evidence Base

  • The best evidence to date on efficacy of relaxation technique for high blood pressure in adults, which has no clearly identified cause, is a systematic review and data from several randomized controlled trials.

Efficacy

  • A 2009 Cochrane systematic review of 25 randomized controlled trials involving 1,198 participants found that overall, relaxation techniques resulted in small average reductions in blood pressure, but many trials were not well designed and had inconsistent results. The reviewers concluded that the evidence of causal association between relaxation and the reduction of blood pressure is weak.

Insomnia

Evidence suggests that using relaxation techniques before bedtime can be helpful components of a successful strategy to improve sleep habits. Other components include maintaining a consistent sleep schedule; avoiding caffeine, alcohol, heavy meals, and strenuous exercise too close to bedtime; and sleeping in a quiet, cool, dark room.

The Evidence Base

  • The best evidence on efficacy of relaxation techniques for insomnia consists of systematic reviews and meta-analyses, and inclusion of specific recommendations in independent clinical guidelines.

Efficacy

  • A 2006 systematic review of 37 studies found evidence that psychological and behavioral therapies, including relaxation techniques, produced reliable changes in several sleep parameters of participants with primary insomnia or insomnia associated with medical and psychiatric conditions. Relaxation was one of five treatments that met criteria for empirically-supported psychological treatments for insomnia. This review was conducted by a task force commissioned by the American Academy of Sleep Medicine (AASM) in order to update its practice parameters on psychological and behavioral therapies for insomnia.
  • The accompanying 2006 practice parameter report published by the AASM concluded that several psychological and behavioral interventions, including relaxation training, stimulus control therapy, and cognitive behavioral therapy are effective, and recommended inclusion of at least one in initial treatment strategies for chronic primary and comorbid (secondary) insomnia.
  • A 2009 meta-analysis of five randomized controlled trials evaluating the efficacy of music-assisted relaxation for sleep quality in adults found that music-assisted relaxation had moderate benefits.

Irritable Bowel Syndrome

Although no complementary health approach has definitively been shown to be helpful for irritable bowel syndrome, some studies on hypnotherapy have been promising.

The Evidence Base

  • The best evidence on the efficacy of relaxation techniques for irritable bowel syndrome (IBS) comes from a few large, well-designed studies and other studies with methodological flaws.

Efficacy

  • A 2009 systematic review by the American College of Gastroenterology Task Force on Irritable Bowel Syndrome concluded that relaxation therapy has not been shown to be beneficial for irritable bowel syndrome. However, there is evidence that other psychological therapies, including cognitive-behavioral therapy and hypnotherapy, can be useful.
  • Findings from a 2013 systematic review indicated that hypnotherapy may provide beneficial clinical effects for managing IBS symptoms; however, the studies were of poor quality. Another 2013 systematic review of three randomized controlled trials in children showed benefits of hypnotherapy over standard medical care. A 2007 Cochrane review of 147 patients found that the quality of the trials was insufficient to draw conclusions about the efficacy of hypnotherapy for IBS.

Post-Traumatic Stress Disorder

Relaxation techniques may provide some benefit on symptoms of post-traumatic stress disorder, including sleep disturbance, anger, pain, and hyper-arousal.

The Evidence Base

  • The best evidence on efficacy of relaxation techniques for PTSD consists of clinical practice guidelines issued by the Department of Veterans Affairs and the Department of Defense as well as several randomized controlled trials.

Efficacy

  • Clinical practice guidelines (1.2MB PDF) issued in 2010 by the Department of Veterans Affairs and Department of Defense on the management of post-traumatic stress recommend that relaxation techniques be considered as a component of treatment approaches for acute stress disorder or PTSD in alleviating symptoms associated with physiological hyper-reactivity. The guidelines also state that complementary health approaches that facilitate a relaxation response (e.g., mindfulness, yoga, acupuncture, massage, and others) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques.
  • These guidelines also suggest relaxation techniques may be helpful, as adjunct treatment, for specific symptoms including sleep disturbance; irritability, severe agitation, or anger; pain; and hyper-arousal.

Safety and Side Effects

  • Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control.
  • There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.

References

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NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH's Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH Web site at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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This page last modified September 30, 2016