Physical therapists must look beyond the biomedical approach to rehabilitation and integrate pain education when treating patients with persistent sexual pain. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. An integrated biopsychosocial framework is important when approaching patients with pelvic pain and all three components require consideration; the biological drivers, the individual’s thoughts, beliefs and expectations, and the social makeup of the individual in pain.
Pain is multi-factorial and involves structures throughout the entire person. Sexual pain can be produced in the absence of tissue dysfunction, however, when pain is associated with the threat of “potential tissue damage” challenging clinical presentations may present. The central nervous system might determine that there is a need for heightened vigilance because of this “potential” damage correlated to a patient’s beliefs, fears, and expectations. This can result in protective pain response that is unrelated to the health of the pelvic muscles, skin, or visceral systems.
An emphasis of self-management of pain patterns and restoring independence can be ameliorated through use of techniques that decrease vigilance and modify the stress response. A variety of techniques may be chosen such as pain education, mindfulness meditation, cognitive behavioral therapy, yoga, and more. Progressive muscle relaxation is one technique that can be provided as an adjunct therapy to address anxiety, stress, fear avoidance, catastrophizing, and allodynia in patients that may experience pelvic and sexual pain.
What is Progressive Muscle Relaxation (PMR)?
A form of muscle relaxation that aims to reduce anxiety through the use of alternating muscle contraction and relaxation. The purpose is to relieve the symptoms of stress and tension, and ultimately make the individual feel calmer. The aim is for the individual to get in touch with their tension and the body’s response and subsequently allow the release of it in a controlled manner.
When can Progressive Muscle Relaxation (PMR) be used?
Progressive muscle relaxation can be used for a variety of conditions, particularly as a supplementary treatment to primary forms of therapy (cognitive behavioral therapy, relaxation therapy, physical therapy) or pharmacological means. PMR proves to be a safe technique with limited, if any, risk as well as cost-effective. These techniques have been shown to be useful in individuals with schizophrenia, experiencing withdrawal symptoms from smoking cessation, a wide range of chronic pain, and even in non-clinical populations of mentally- and physically-healthy people.
Why does Progressive Muscle Relaxation (PMR) have favorable outcomes?
The body responds to stress with muscle tension, which may cause discomfort or pain. As a result, the tension in muscles signal that the body is stressed. PMR can help to break the stress-muscle-tension cycle by reducing the tension experienced by the body.
Although these techniques will not eliminate the cause of any anxiety, it will allow the individual to increase their ability to deal with it once the tension has been released from the body and mind has been cleared.
PMR and other muscle-based relaxation techniques are thought to convey health benefits in these three ways:
- Helps to manipulate autonomic responses HOW?
- Increases or activates the production of opiates HOW?
- Promotes optimal immune function HOW?
What does Progressive Muscle Relaxation (PMR) consist of?
PMR addresses the entire body, from the feet and ankles, to the arms and shoulders, to the head, neck and eyes. These techniques can be combined with meditation and relaxed breathing as well.
Prepare to relax by finding a warm, quiet place that is free from any disturbances. Allow your body to feel limp and ask a friend, family member, or use a voice recording to instruct you through the techniques. Each muscle should be tensed for roughly 5 seconds, then relaxed for about 10 seconds.
There are many variations available, however, below is an example of the areas of the body and actions that can be performed. Perform techniques on one side of the body, and repeat on the opposite side of the body.
Autonomic responses determine whether the body needs to engage in a ‘fight-or-flight’ or ‘rest- and-digest’ scenario. Many of these responses are subconsciously elicited, such as redirection of blood flow and increased heart rate and blood pressure. It is argued that PMR techniques blunt sympathetic arousal by training the individual to reduce oxygen requirements, achieved by the repetitive release of muscle tension and slowed breathing.
Endogenous opioids have a variety of effects, such as analgesia, anti-inflammatory, and bronchodilation. It is argued that opioids play an important role in modulating stress responses. In addition, opioid production is thought to be increased in those who exercise regularly and reduced in those with chronic health problems. When determining the role of endogenous opioids in the effects of PMR training, diastolic blood pressure was significantly reduced, which was not the case when an opioid blockade was administered.
Research has suggested that repetition is crucial to the relaxation response, but that trust and belief in expected outcomes can help to regulate immunological function via cognitive and neurological processes. In addition, the increased levels of opioids may improve mood, sense of well-being, and potentially stimulate immune cells related to immune function.
- Start with your feet and systematically move up (or reverse the order and start with forehead and move down towards the feet).
- Foot (curl toes downward)
- Lower leg and foot (point toes toward face and tighten calf muscle)
- Entire leg (squeeze thigh muscles while doing the above action) (repeat on other side of the body)
- Hand (clench fists)
- Arm (bend arm at elbow bringing forearm to shoulder and tighten biceps while clenching fist)
(repeat on other side of the body)
- Buttocks (tighten by pulling buttocks together)
- Stomach (suck stomach into a tight knot)
- Chest (tighten by taking a deep breath, hold it, then exhale)
- Neck and shoulders (shrug shoulders up towards ears)
- Mouth (open mouth wide enough to stretch jaw)
- Eyes (close and tightly shut eyelids)
- Forehead (raise eyebrows and wrinkle forehead into a deep frown)
Other Considerations for Progressive Muscle Relaxation
- Shorten your technique!
Once you become familiar with the “tension and relaxation” technique, a shorter version can be practiced. Muscles groups can divided into lower limbs, stomach and chest, arms and shoulders, and face. This approach uses tensing of larger groups of muscles, which takes less time. Instead of working on one specific muscle group at a time, focus on an entire group.
- ‘Release only’ techniques
Tensing and releasing muscles allows individuals to recognize what tense muscles feel like and what relaxed muscles feel like. However, once mastered, removing the “tension” part can help to shorten the time it takes even more. Instead of tensing the stomach and chest, try just relaxing the muscles! It may not feel as drastic in the beginning, but can be just as relaxing.
- Practice, practice, practice!
Practice PMR often, even if anxiety or stress is not present. By doing so, it will make the techniques even more effective when relaxation is really needed. Although the repetitions may feel tedious, they are important in managing stress, anxiety, and tension in daily life.
- Anxiety BC. How to do progressive muscle relaxation. Accessed April 7, 2019. https://www.anxietycanada.com/sites/default/files/MuscleRelaxation.pdf
- Guy’s and St Thomas’ NHS Foundation Trust. Jacobson’s progressive rehabilitation technique. NHS Foundation Trust. Published February 2019. Accessed April 5, 2019. https://www.guysandstthomas.nhs.uk/resources/patient- information/cardiovascular/jacobsons-progressive-relaxation-technique.pdf
- Healthwise Staff. Progressive Muscle Relaxation. Michigan Medicine University of Michigan. Published June 28, 2018. Accessed April 5, 2019. https://www.uofmhealth.org/health- library/ta4146
- Mackereth, P & Tomlinson, L. Progressive muscle relaxation: a remarkable tool for therapists and patients. Integrative Hypnotherapy. 2010; Chapter 6: 82-96.
- Vandyken, C & Hilton, S. Physical therapy in the treatment of central pain mechanisms for female sexual pain. Sex Med Rev. 2017; 5: 20-30.