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In some patients, especially those with an avoidant coping style, giving too much information
or asking them to make too many decisions may exacerbate anxiety and pain (Wilson, 1981
Level II). However, later evidence suggested that this may not be a strong effect (Miro and
Raich 1999 Level II). Nevertheless, it may be useful to assess a patient's normal approach to
managing stress to identify the best option for that patient. A more recent study with over
3000 surgical patients identified four information factors that were each associated with
global evaluations — surgical information, recovery information, general information and
sensory information (Krupat et al, 2000 Level III‐3).

8.1.2 Stress and tension reduction
Relaxation
Relaxation training usually involves teaching a patient ways of reducing their feelings of
stress/tension by various techniques. The techniques may be taught by recorded audiotape,
written or spoken instructions. The use of audiotapes often includes the use of suitable
(calming) music. The use of relevant imagery (mental pictures of relaxing scenes) is also often
encouraged as an element of relaxation techniques. Typically, all methods require the patient
to practise the technique regularly, especially when feeling stressed. Some methods focus on
altering muscle tension, often sequentially, while others focus on altering breathing patterns
(eg emphasising releasing tension with exhalation). Relaxation techniques are closely related
to, and often indistinguishable from, forms of meditation and self‐hypnosis.
A systematic review of relaxation techniques, when used alone for the management of pain
after surgery and during procedures, concluded that there was some (weak) evidence to
support the use of relaxation in these settings — three of the seven studies reported
significant reductions in pain and distress (Seers & Carroll, 1998 Level IV). Methodological
shortcomings in the studies included in the review meant that a meta‐analysis was not
possible, limiting the strength of the findings. Similar conclusions were made in another
systematic review which found that eight of fifteen studies (again, most had weaknesses in
CHAPTER 8 progressive muscle relaxation for arthritis pain and a systematic relaxation technique for
methodology) demonstrated reductions in pain; the most supported methods were

postoperative pain, little evidence was found for autogenic training, and no support for
rhythmic breathing or other relaxation techniques (Kwekkeboom & Gretarsdottir, 2006 Level IV).
Another review of studies using relaxation techniques for burns pain also found insufficient
high quality evidence to draw any conclusions, but did recommend further research into the
use of a technique that combined focusing on breathing and jaw muscle relaxation (de Jong &
Gamel, 2006 Level IV). There was no difference found in pain scores after surgery in patients
given either relaxation training or routine information prior to spinal surgery; however
morphine use was higher in the relaxation group (Gavin et al, 2006 Level II).
In contrast, studies of relaxation techniques with cancer patients (with acute pain) provided
moderately strong (clinical) support for its effectiveness in improving nausea, pain, pulse rate
and blood pressure, as well as emotional adjustment variables (depression, anxiety and
hostility) (Luebbert et al, 2001 Level I).
Hypnosis
Hypnosis shares many features of relaxation with imagery and has a long history of use in
acute pain conditions. While there are many versions of hypnosis, they share the common
feature of one person responding to suggestions made by another on experiences involving
changes in perception, memory and voluntary actions (Kihlstrom, 1985). The variable or
unstandardised nature of hypnotic procedures has made it difficult to compare studies or

222 Acute Pain Management: Scientific Evidence