The twelfth variable that I will be manipulating across a two week period to examine its impact on sleep is relaxation. I will be seeing if abdominal breathing, progressive muscle relaxation or imagery have a positive impact on sleep quality.
I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective relaxation strategies are at improving sleep.
HOW COULD RELAXATION STRATEGIES HELP?
As I’ve previously mentioned, hyper-arousal is one of the main problems for people with sleep difficulties. It can be especially problematic for individuals who are suffering from insomnia, parasomnias, bruxism, restless legs and periodic limb movement issues.
Anything that helps us to lower these arousal levels both during the day and before we go to bed at night will improve our chances of falling asleep quickly, sleeping more, and having a great quality of sleep. Learning relaxation strategies is therefore definitely worthwhile if you have ever felt “tired but wired” and were unable to get a good night’s sleep even though you were exhausted before you went to bed.
Abdominal, or diaphragmatic breathing is the simplest relaxation strategy to learn. It is also something that is helpful to work on first before trying any other relaxation strategies because most of these will also incorporate the breath to some degree for them to be beneficial.
If you are interested in trying this out, then there are three things that are important to focus on:
- rate of breath – if you breathe too quickly it will lead to you feeling more anxious and worked up. By actively trying to slow it down, it can help you to feel more calm and relaxed. Some people try the 4-7-8 breathing pattern and breathe in for 4 seconds, hold for 7 seconds then breathe out for 8 seconds. Personally I find this too long, and tend to breathe in for about 3 seconds, pause for 1 or 2 seconds, and then breathe out for about 4 seconds. Anything slower than 10 breaths per minute is thought to be potentially relaxing, so experiment with what is comfortable and what works best for you.
- depth of breath – if you breathe too shallowly it can make you feel more anxious and worked up. To see if this is you, place one hand on your chest and one hand on your stomach and take in a nice big breath. If the hand on your chest moved more than the one on your stomach, you are probably not breathing deeply. To breathe more deeply, you want to actively engage your diaphragm and push out your stomach as you breathe in. The deeper it is, the more calming and relaxing it should be for you.
- the exhale – when people first start to practice breathing deeply, they will often try to take nice deep breaths in, and not worry about breathing out. This is the quickest pathway to hyperventilating, which can even bring on a panic attack if you do it long enough. Focus on breathing out all of the air with each breath first, which will balance out the oxygen to carbon dioxide ratio, and help you to feel more calm and relaxed.
Progressive muscle relaxation
Progressive muscle relaxation (PMR) is a really good strategy to do in the last hour or so before bed if you notice that you are particularly tense in your body. It may be that you have had a stressful day, have been on your feet all day or have been sitting at a computer screen for too long. If this is the case, or you just notice that you are tense in your shoulders, neck, jaw, back, stomach or legs, then this strategy would be worth a try.
It goes as following:
- start with your arms. Clench them as tightly as you can, bringing your forearms up to your biceps so that they are clenched too. Really notice the tension. Then, whilst still clenching, take in a nice deep breath. pause. then exhale all of the air, and as you do release the tension in your arms and let them drop down, hanging loosely by your side. Notice the difference between when they were tensed and how relaxed they feel now. Repeat one more time.
- move to your face and jaw. raise your forehead, furrow your brow, shut your eyes tightly, scrunch your nose and clench your jaw. Really notice the tension. Then, whilst still clenching, take in a nice deep breath. pause. then exhale all of the air, and as you do release the tension in your face and let your jaw hang loose with your mouth slightly open. Notice the difference between when you were tense and how relaxed you feel now. Repeat one more time.
- move to your shoulders. raise them up to your neck, pushing them up as highs you can whilst pushing your head and neck down. Then, whilst still clenching, take in a nice deep breath. pause. then exhale all of the air, and as you do release the tension, let you shoulders be as loose as possible and let your head droop down, no longer using your neck to support it. Really observe the difference between how you felt when you were tensed and how relaxed you feel now. Repeat one more time.
- move to your stomach. tense. breathe in. pause. breathe out. relax the stomach. repeat.
- move to your upper legs and buttocks. tense. breathe in. pause. breathe out. relax the stomach. repeat.
- move to your calves and feet. tense. breathe in. pause. breathe out. relax the stomach. repeat.
Sometimes known as visualisation, this strategy is based on the neuroimaging findings that the same areas of our brain light up when we are actually tapping our fingers as when we are only imagining ourselves tapping our fingers. What this means is that our thoughts can have a huge impact on how we feel emotionally and physically, and what we then do behaviourally. If you are worried about sleeping and imagining yourself not sleeping, this can raise your arousal levels. But if you are instead imagining yourself lying on a nice hammock on a tropical island on a warm sunny day, it could help you to feel calm and relaxed instead. I like to do this in bed at times, but if you haven’t tried it yet I would encourage you to practice it outside of bed first.
The instructions are as follows:
- Find somewhere nice and quiet to sit or lie down where you are unlikely to be disturbed for the next 5-10 minutes.
- Take a few deep breaths to centre yourself in the here and now.
- Then close your eyes and try to picture yourself in the most calming, peaceful and relaxing environment that you can imagine. It can be a place from your childhood, from a favourite holiday, or a place that is entirely made up. A lot of people find a beach, forest, lake or mountain to be especially relaxing, but it can be a nice and cosy room too. Just wherever you feel safe, calm and relaxed.
- Try to engage as many of your senses as possible in the place that you are. If you are on the beach, feel your feet on the sand or the sun on your skin, hear the waves crashing in or the seagulls chirping as they fly overhead. Smell the salty water or the coconut in your sun lotion, or sip on a nice refreshing drink.
- Walk around and explore the area, or find a nice place to sit and look out, taking in the scenery around you.
- Once the 5-10 minutes is up, open your eyes, ground yourself in the present and take that sense of calm with you.
For the first five nights, I practiced PMR for 10-15 minutes each night in the last hour before going to bed. Generally this was done whilst watching the TV.
For the middle five nights, I practiced abdominal breathing for 10-15 minutes in the last hour before going to bed. I also continued to focus on my breath once in bed, exhaling all the air with each breath, as well as breathing slowly and deeply until I was asleep.
For the last four nights, I practiced imagery for 10-15 minutes in the last hour before going to bed. The TV was always off when I did this. Once in bed, I would continue to practice imagery until I was asleep.
Let’s see which relaxation strategy was best for my sleep…
Comparison: PMR vs Abdominal breathing vs Imagery
Based on my sleep diary data, the abdominal breathing relaxation strategy was the most effective for me, followed by imagery, and then progressive muscle relaxation. Here were the findings:
- Number of awakenings:
- Abdominal breathing – 0.4 per night
- Imagery – 0.75 per night
- PMR – 1.2 per night
- Time in bed:
- Abdominal breathing – 8 hours
- PMR – 7 hours 44 minutes
- Imagery 7 hours 30 minutes
- Time to bed:
- PMR – 11:48pm
- Abdominal breathing – 12:06am
- Imagery – 12:15am
- Total sleep time:
- Abdominal breathing – 7 hours 47 minutes
- PMR – 7 hours 16 minutes
- Imagery – 7 hours 6 minutes
- Sleep onset latency:
- Imagery – 6.75 minutes
- Abdominal breathing – 9 minutes
- PMR – 11 minutes
- Wake after sleep onset:
- Abdominal breathing – 4 minutes
- Imagery – 15 minutes
- PMR – 17 minutes
- Rise time:
- PMR – 7:32am
- Imagery – 7:45am
- Abdominal breathing – 8:06am
- Sleep quality:
- Abdominal breathing – 4.8/5
- Imagery – 4.25/5
- PMR – 4/5
- Sleep efficiency:
- Abdominal breathing – 97.29%
- Imagery – 94.72%
- PMR – 93.97%
IS PRACTICING RELAXATION STRATEGIES BEFORE BEDTIME A GOOD SLEEP STRATEGY?
IS IT EFFECTIVE?
Yes. Depending on what your problem is, different relaxation strategies are thought to be better. For a busy mind, imagery is thought to be good. For a tense body, progressive muscle relaxation is thought to be good. For me, simple deep and slow breathing was the most effective, with an excellent sleep quality and sleep efficiency and 7 hours and 47 minutes of sleep per night.
I therefore give the effectiveness of this strategy a 22/25.
CAN IT BE APPLIED?
Yes. Each strategy requires a little bit of training during the day first for it to be effective. Once you feel that it helps you to relax when your arousal levels are high you can then try to add it into your pre-bed wind down strategy. If that is helping it can then be utilised in bed. No technology is needed for any of the strategies either, which means it can be done anywhere.
I therefore give the applicability of this strategy a 22/25.
IS IT SCIENTIFIC?
Progressive Muscle Relaxation (PMR) is the most commonly used relaxation technique in CBT-I, and is efficacious as a stand-alone treatment for insomnia (Morin et al., 2006).
In comparison to autogenic training and biofeedback training, PMR was not significantly different (Freedman & Papsdorf, 1976; Simeit et al., 2004). However, cognitive relaxation techniques such as imagery were found to be more effective for reducing time taken to get to sleep (Morin, Culbert, et al., 1994).
Relaxation has been found to be the most effective when initially practiced during the daytime, so that the participant can practice reducing their arousal levels rather than using the techniques to help them fall asleep (Harsora & Kessmann, 2009). Once arousal levels are being effectively reduced when using relaxation strategies, these strategies can reduce the time taken to get to sleep more than sleep hygiene education or the combination of stimulus control plus sleep restriction (Waters et al., 2003).
Cognitive behavioural therapy for insomnia (CBT-I) is typically superior to relaxation alone for improving insomnia severity (Edinger et al., 2001a). However, the additional benefits that relaxation can have on depression (Jorm et al., 2008), stress (Kaspereen, 2012) and anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) warrant it being used to help people sleep better. Training in relaxation strategies can also be used alongside a CBT-I intervention for people with insomnia.
I therefore give the science of this strategy a 37/50.
Overall, regularly practicing relaxation strategies before bed as a way to sleep better gets a score of 22/25 + 22/25 + 37/50 =
81/100: High Distinction
WHAT I RECOMMEND
If you feel tense and stressed often, or struggle to switch off, unwind and relax at night, this could be one of the main reasons that you are having difficulties sleeping. Try to find a relaxation strategy that helps you to lower your arousal levels whenever you are feeling stressed or wound up. This could be abdominal breathing, PMR or imagery, or it could be yoga or meditation even.
Practice relaxation strategies during the day first so that you can see if they help you to calm down and relax. If they are working during the day, then trial them for a week or two in the last hour before bed. Even 10-15 minutes each night can help. Only use these relaxation strategies in bed if you feel confident that they are a helpful strategy for you.
Lastly, remember that the aim of any relaxation strategy is to lower your arousal level and to keep it low, not to get you to sleep. If you are using something to get you to sleep, it will often backfire and not work, because sleep is an involuntary process that is out of our control. The more we try to get to sleep, the harder it will be.
By winding down before sleep, going to bed once you are sleepy and keeping your focus on something relaxing once you are in bed, you are giving yourself the best chance of having a good night’s sleep.
Dr Damon Ashworth