TRAUMA RELEASING EXERCISES: A POTENTIAL TREATMENT FOR

CO-OCCURRING POST-TRAUMATIC STRESS DISORDER

AND NON-SPECIFIC CHRONIC LOW BACK PAIN

W
IE
EV

A dissertation presented to the Faculty of

Saybrook University in partial fulfillment of the requirements for
PR

the degree of Doctor of Philosophy (Ph.D.) in Mind-Body Medicine

by

Beverly S. Swann

Oakland, California
March, 2019




ProQuest Number: 13811749




All rights reserved

INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.



W

IE


EV
ProQuest 13811749

Published by ProQuest LLC (2019 ). Copyright of the Dissertation is held by the Author.


All rights reserved.
PR

This work is protected against unauthorized copying under Title 17, United States Code
Microform Edition © ProQuest LLC.


ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346
 W
IE
EV
PR

© 2019 by Beverly S. Swann

All Rights Reserved

 Approval of the Dissertation

TRAUMA RELEASING EXERCISES: A POTENTIAL TREATMENT FOR

CO-OCCURRING POST-TRAUMATIC STRESS DISORDER
AND NON-SPECIFIC CHRONIC LOW BACK PAIN

This Dissertation by Beverly S. Swann has been approved by the committee members below,
who recommend it be accepted by the faculty of Saybrook University in partial fulfillment of
requirements for the degree of

W
IE
Doctor of Philosophy in Mind-Body Medicine
EV

Dissertation Committee:
PR

Selene Vega, Ph.D., Chair Date

Werner Absenger, Ph.D. Date

Stephanie Lindsay, Ph.D. Date

 ii

Abstract

TRAUMA RELEASING EXERCISES: A POTENTIAL TREATMENT FOR

CO-OCCURRING POST-TRAUMATIC STRESS DISORDER
AND NON-SPECIFIC CHRONIC LOW BACK PAIN

Beverly S. Swann

Saybrook University

W
This study examined whether a 4-week, three times per week practice of Trauma

Releasing Exercises (TRE) would reduce symptoms for adults with co-occurring post-traumatic
IE
stress disorder (PTSD) and non-specific chronic low back pain (nsCLBP). There is significant

co-occurrence of nsCLBP and PTSD (Dunn, Passmore, Burke, & Chicoine, 2009; Loncar, Curic,
EV

Mestrovic, Mickovic, & Bilic, 2013). A link between the two conditions is chronic muscle

tension, which may be reduced by using TRE (Berceli, 2005, 2008).

PR

The study design was a randomized-controlled trial with repeated measures. A control

group practiced progressive muscle relaxation (PMR). Participants (n = 11) were adults with

prior diagnoses of both PTSD and nsCLBP. All data were gathered confidentially online using

SurveyMonkey. Four types of data were gathered: screening, demographic, symptom-related,

and self-practice data. Data analysis consisted of measures of central tendency for demographic

data and variables.

Most participants in the control group did not complete the study. With limited data,

most results did not reach statistical or clinical significance and were inconclusive. A

statistically significant decrease in physical distress occurred for the control group after the
 iii

training. There was a clinically significant decrease in PTSD symptoms for the TRE group at the

end of the 4-week self-practice period. Participants in the TRE group did self-practice,

averaging between 2.67 and 3.50 times per week.

Study results did not provide sufficient evidence to support the hypotheses or answer the

research question, but valuable lessons were learned that will contribute to future research.

Major gaps in the literature include: the use of TRE, the role of muscle tension in PTSD, and the

differences between acute and chronic muscle tension. Training and self-practice of TRE

resulted in decreases of PTSD symptoms. This result supports its potential use as a treatment for

PTSD. Participants did self-practice but reported they did so because they were supposed to.

W
These data support the use of self-help techniques, but only with a high degree of accountability.
IE
EV
PR
 Dedication

This work is dedicated to the many people who suffer from both low back pain and post-

traumatic stress injuries, particularly first responders. May the research in some way contribute

to relief and healing for all of you.

W
IE
EV
PR
 iv

Acknowledgments

Many people have provided support, guidance, assistance, and knowledge toward my

dissertation. Although it is not possible to list everyone who has been on this journey with me, I

want to acknowledge those who have played key roles. I cannot personally acknowledge the

brave volunteers who participated in the study, but I am very grateful to them for their courage

and persistence.

This dissertation almost did not happen. In the spring of 2014, I was enrolled in a

different PhD program and made the very difficult decision to drop from the program. I

W
discovered I could not perform the cognitive integration of ideas that is required for academic

writing, something I had previously enjoyed and found relatively easy prior to two mild
IE
traumatic brain injuries. Dr. Rachyll Dempsey and Dr. David Hawkey, I can never thank you

enough for helping me to identify and accept the cognitive disabilities. Working with you was a
EV

turning point in being able to understand what was happening and how to work with and around

the blocks.
PR

For their guidance, flexibility, humor, and unwavering belief in my work, I am very

grateful to my committee chairperson, Dr. Selene Vega, and committee members Dr. Werner

Absenger and Dr. Stephanie Lindsay. I could not have asked for a more wonderful team! Dr.

Devorah Curtis, who served multiple roles in the College of Integrative Medicine and Health

Sciences during my time at Saybrook University, has also been a great source of support and

inspiration.

Several people took the time to review part or all of this voluminous work and provide

feedback. Dr. David Berceli provided expertise about Trauma Releasing Exercises (TRE) and

assisted in recruiting participants. Dr. Deirdre Rogers consulted on data analysis as well as
 v

provided general support. Carrie Lin and Katherine Segal generously volunteered to test and

proofread all of the online materials. Ladies, you did a fantastic job at catching my typos! Mary

Shriver, Nkem Ndefo, and Ranji Ariaratnam provided valuable insight into uses of TRE as well

as connecting me to folks who were researching TRE. Brooke Deputy helped with recruiting

efforts and was a wonderful support.

My good friend Nancy Cowell-Miller created the original artwork that became the logo

for my recruiting materials. It provided a lovely focal point for the study in my mind, and it now

hangs in my Integrative Wellness Studio. Other good friends Julie Levin, Joyce Caldeira, and

Valerie Keim have been my cheerleaders, as has my sister Nila Jamerson. Fellow students Dr.

W
Ashlie Bell and Dr. Katrina Anderson joined me early on in peer support meetings because our
IE
dissertation topics were related. Thank you for all the support along the way, particularly

through some of the tougher times.

EV
Finally, I am grateful to Woody Schuldt for his generous permission to use his

Progressive Muscle Relaxation Script©, along with Dr. Charles Morin for permission to use his

Insomnia Severity Index® in my work.

PR
 vi

Table of Contents

List of Tables ................................................................................................................................ xii

List of Figures .............................................................................................................................. xiv

CHAPTER 1: INTRODUCTION ................................................................................................... 1

Background ..................................................................................................................................... 2

Tension and Trauma Releasing Exercises (TRE) ..................................................................... 2

Interventions Related to TRE.................................................................................................... 4

Key Terms and Definitions ....................................................................................................... 5

W
Post-Traumatic Stress Disorder (PTSD) ................................................................................... 5
IE
Non-Specific Chronic Low Back Pain (nsCLBP) .................................................................... 7

Co-Occurring PTSD and nsCLBP ............................................................................................ 8

EV
Treatment Barriers .................................................................................................................... 9

Rationale ....................................................................................................................................... 10

Theoretical Models ................................................................................................................. 10

PR

Mutual maintenance theory............................................................................................... 10

Complex psychogenic pain theory .................................................................................... 12

Fear-avoidance model ....................................................................................................... 12

Hyperarousal subtype model............................................................................................. 13

Research Question ........................................................................................................................ 14

Hypotheses .............................................................................................................................. 14

Sub-Problems .......................................................................................................................... 14

CHAPTER 2: LITERATURE REVIEW ...................................................................................... 16

 vii

Literature Review Objective ......................................................................................................... 16

Literature Review Methods........................................................................................................... 16

Protocol and Registration ........................................................................................................ 16

Eligibility Criteria ................................................................................................................... 17

Information Sources ................................................................................................................ 17

Database Search ...................................................................................................................... 20

Study Selection ....................................................................................................................... 20

Study inclusion criteria ..................................................................................................... 21

Study exclusion criteria..................................................................................................... 21

W
Data Collection Process and Data Items ................................................................................. 21
IE
Risk of Bias in Individual Studies .......................................................................................... 21

Summary Measures ................................................................................................................. 21

EV
Synthesis of Results ................................................................................................................ 22

Risk of Bias Across Studies .................................................................................................... 22

Literature Review Search Results ................................................................................................. 22

PR

Study Selection ....................................................................................................................... 22

Study Characteristics .............................................................................................................. 24

Search 1: nsCLBP and muscle tension ............................................................................. 24

Search 2: PTSD and muscle tension ................................................................................. 29

Search 3: TRE and related interventions. ......................................................................... 30

Risk of Bias Within Studies .................................................................................................... 41

Search 1: nsCLBP and muscle tension ............................................................................. 41

Search 2: PTSD and muscle tension. ................................................................................ 41

 viii

Search 3: TRE and related interventions .......................................................................... 42

Results of Individual Studies .................................................................................................. 43

Synthesis of Results ................................................................................................................ 50

Searches 1 and 2: nsCLBP, PTSD, and muscle tension ................................................... 50

Search 1: nsCLBP and muscle tension ............................................................................. 50

Search 2: PTSD and muscle tension ................................................................................. 56

Search 3: TRE and related interventions .......................................................................... 58

Risk of Bias Across Studies .................................................................................................... 64

Searches 1 and 2: Muscle tension and nsCLBP or PTSD ................................................. 64

W
Search 3: TRE and related interventions .......................................................................... 64
IE
Literature Review Discussion ....................................................................................................... 64

Summary of Evidence ............................................................................................................. 64

EV
Literature Review Limitations ................................................................................................ 66

Literature Review Conclusion ...................................................................................................... 67

CHAPTER 3: METHODOLOGY ................................................................................................ 68

PR

Methods and Procedures Overview .............................................................................................. 68

Choice of Method ......................................................................................................................... 69

Participants .................................................................................................................................... 70

Sample Size............................................................................................................................. 71

Inclusion Criteria .................................................................................................................... 72

Exclusion Criteria ................................................................................................................... 73

Recruitment ................................................................................................................................... 74

Research Setting............................................................................................................................ 75
 ix

Instruments .................................................................................................................................... 75

Screening Data ........................................................................................................................ 76

Eligibility1 Survey ............................................................................................................ 76

Severity of Dissociative Symptoms–Adult/Brief Dissociative Experiences Scale

(DES-B)-Modified ............................................................................................................ 76

Demographic Data .................................................................................................................. 77

Symptom-Related Data ........................................................................................................... 77

Subjective Units of Distress (SUDS) ................................................................................ 77

Oswestry Low Back Pain Disability Questionnaire Version 2.0 (ODI) ........................... 78

W
PTSD Checklist for DSM-5 (PCL-5)................................................................................ 78
IE
Defense and Veterans Pain Rating Scale (DVPRS) ......................................................... 79

Insomnia Severity Index (ISI) ........................................................................................... 79

EV
Self-Practice Data ................................................................................................................... 80

Procedures ..................................................................................................................................... 80

Confidentiality and Safety ...................................................................................................... 81

PR

Screening/Informed Consent .................................................................................................. 83

Randomization and Scheduling .............................................................................................. 84

Training and Data Collection .................................................................................................. 84

Data Analysis ................................................................................................................................ 86

Methodology Limitations and Research Issues ............................................................................ 87

CHAPTER 4: RESULTS .............................................................................................................. 89

Participants .................................................................................................................................... 90

Demographic Data ........................................................................................................................ 93

 x

Data Analysis ................................................................................................................................ 94

Summary Results .................................................................................................................... 94

Non-specific chronic low back pain assessments ............................................................. 96

Post-traumatic stress disorder assessments ....................................................................... 98

Sleep quality assessments ................................................................................................. 99

Effect of Training: TRE Compared to PMR ......................................................................... 101

Effect of training on nsCLBP symptoms ........................................................................ 101

Effect of training on PTSD symptoms ............................................................................ 103

Effect of training on sleep quality................................................................................... 104

W
Effect of Training Plus Self-Practice .................................................................................... 105
IE
Effect of training plus self-practice on nsCLBP symptoms............................................ 105

Effect of training plus self-practice on PTSD symptoms ............................................... 106

EV
Effect of training plus self-practice on sleep quality ...................................................... 107

Weekly Self-Practice Results................................................................................................ 107

Motivators for and barriers to self-practice .................................................................... 108

PR

Results Summary ........................................................................................................................ 110

CHAPTER 5: DISCUSSION ...................................................................................................... 112

Discussion Overview .................................................................................................................. 112

Summary of Study ...................................................................................................................... 112

Major Findings ............................................................................................................................ 113

Effect of Training Session .................................................................................................... 116

Effect of Training Plus Self-Practice .................................................................................... 118

Effect at 1-Month Follow-Up ............................................................................................... 119

 xi

Self-Practice Findings ........................................................................................................... 119

Additional Findings .................................................................................................................... 121

Lessons Learned.......................................................................................................................... 122

Study Limitations ........................................................................................................................ 126

Recommendations for Future Research ...................................................................................... 127

Conclusion .................................................................................................................................. 129

REFERENCES ........................................................................................................................... 131

APPENDICES ............................................................................................................................ 141

Appendix A: Recruitment Flyer.................................................................................................. 141

W
Appendix B: Financial Interest Disclosure Statement ................................................................ 142
IE
Appendix C: Website Screen Shots ............................................................................................ 143

Appendix D: Eligibility Survey .................................................................................................. 150

EV
Appendix E: Healthcare Accessibility Statement ....................................................................... 154

Appendix F: Healthcare Professional Release Form (Optional)................................................. 155

Appendix G: Demographic Data Survey Items .......................................................................... 157

PR

Appendix H: Subjective Units of Disturbance Worksheet ......................................................... 159

Appendix I: Self-Practice Tip Sheet ........................................................................................... 160

Appendix J: Weekly Self-Practice Assessment Survey .............................................................. 161

 xii

List of Tables

Table 1: Key Terms and Definitions ............................................................................................6

Table 2: Electronic Databases Included in Search .....................................................................17

Table 3: Studies Included for Search 1 nsCLBP and Muscle Tension ......................................25

Table 4: Studies Included for Search 2 PTSD and Muscle Tension ..........................................27

Table 5: Studies Included for Search 3 TRE and Related Interventions and Muscle

Tension .........................................................................................................................28

Table 6: Summary of Characteristics of Studies Included in Search 1 nsCLBP and

Muscle Tension Analysis .............................................................................................31

W
Table 7: Summary of Characteristics of Studies Included in Search 2 PTSD and
IE
Muscle Tension Analysis .............................................................................................37

Table 8: Summary of Characteristics of Studies Included in Search 3 TRE and Related

EV
Interventions and Muscle Tension Analysis ................................................................38

Table 9: Risk of Bias Within Studies for Search 1 nsCLBP and Muscle Tension

Analysis........................................................................................................................44
PR

Table 10: Risk of Bias Within Studies for Search 2 PTSD and Muscle Tension Analysis .........47

Table 11: Risk of Bias Within Studies for TRE and Related Interventions and Muscle

Tension Analysis ..........................................................................................................48

Table 12: Sample Size Scenario Calculations ..............................................................................72

Table 13: Participant Demographic Characteristics .....................................................................95

Table 14: Symptom-Related Data Summary for Four Assessment Points by Condition ............96

Table 15: Subjective Units of Disturbance (SUDS), Physical, Pre- Compared to

Post-Training..............................................................................................................101
 xiii

Table 16: Oswestry Low Back Pain Disability Index 2.0 (ODI), Pre- Compared to

Post-Training..............................................................................................................102

Table 17: Defense and Veterans Pain Rating Scale (DVPRS), Pre- Compared to

Post-Training..............................................................................................................103

Table 18: Subjective Units of Disturbance (SUDS), Emotional, Pre- Compared to

Post-Training..............................................................................................................103

Table 19: PTSD Checklist for DSM-5 (PCL-5), Pre- Compared to Post-Training ...................104

Table 20: Insomnia Severity Index (ISI), Pre- Compared to Post-Training ..............................105

Table 21: Oswestry Low Back Pain Disability Index 2.0 (ODI), Pre- Compared to

W
Post-Self-Practice .......................................................................................................106
IE
Table 22: Defense and Veterans Pain Rating Scale (DVPRS), Pre- Compared to

Post-Self-Practice .......................................................................................................106
EV
Table 23: PTSD Checklist for DSM-5 (PCL-5), Pre- Compared to Post-Self-Practice ............107

Table 24: Insomnia Severity Index (ISI), Pre- Compared to Post-Self-Practice .......................107

Table 25: Weekly Self-Practice Frequency................................................................................108

PR

Table 26: Top Six Motivators for and Barriers to Self-Practice ................................................109

Table A1: Demographic Data Survey Items ...............................................................................157

 xiv

List of Figures

Figure 1: Relationships Between Theories, Conditions, Treatments, and Muscle Tension .........11

Figure 2: Literature Flow Diagram ...............................................................................................23

Figure 3: Study Flow Diagram .....................................................................................................82

Figure 4: Participant Recruitment and Data Collection ................................................................91

Figure 5: nsCLBP Symptoms – ODI – For Four Assessment Points ...........................................97

Figure 6: nsCLBP Symptoms – DVPRS – For Four Assessment Points .....................................98

Figure 7: PTSD Symptoms – PCL-5 – For Four Assessment Points ...........................................99

Figure 8: Sleep Quality – PSQI – For Four Assessment Points .................................................100

W
IE
EV
PR
 1

CHAPTER 1: INTRODUCTION

There is significant co-occurrence of post-traumatic stress disorder (PTSD) and non-

specific chronic low back pain (nsCLBP) in adults, ranging from 16% (Dunn, Passmore, Burke,

& Chicoine, 2009) to 25.1% (Loncar, Curic, Mestrovic, Mickovic, & Bilic, 2013) of people

being treated for either of the conditions. Very little is known about effective treatment for

people with both conditions. Multiple factors affect traditional treatment, and multiple barriers

prevent people from seeking or receiving treatment (Kempson, 2007; Lewis, Roberts, Vick, &

Bisson, 2013; Sayer et al., 2009; Slade, Molloy, & Keating, 2009).

A promising technique that may be helpful for treating both conditions is Trauma

W
Releasing Exercises (TRE), a self-help method developed to release chronic muscle tension and
IE
reduce anxiety (Berceli, 2005, 2008, 2015). It can be used as a self-help tool or with a facilitator,

and either individually or in groups. To date the only peer-reviewed research on TRE is a pilot
EV
study focused on anxiety (Berceli, Salmon, Bonifas, & Ndefo, 2014), leaving a large gap in the

literature regarding the use and effectiveness of TRE. Psychological theories and treatments

featuring muscle tension as a primary cause of pathology date back to Freud and Janet (Atarodi
PR

& Hosier, 2011; Ruden, 2008). They provide a basis for proposing the use of TRE as a treatment

for PTSD and nsCLBP.

The objective of TRE is to utilize tremoring, theorized as a natural response to stress, to

release chronically-held muscle tension (Berceli, 2005, 2008). Tremoring, or shaking, has been

observed in humans and many mammals after they have experienced a stressful event (Berceli,

2005, 2008; Levine, 1997). The TRE technique specifically targets the iliopsoas muscles, more

commonly known as psoas muscles, as the center of chronic muscle tension (Berceli, 2005,

2008, 2015). The psoas muscles attach to the spine as well as to the top of the femur. They are
 2

the only muscles that connect the upper part of the body to the lower part (Staugaard-Jones,

2012). Chronic tension in the psoas muscles is indicated in nsCLBP (Andersen, Andersen,

Vakkala, & Elklit, 2012; Arbanas et al., 2013; Iglesias-González, Muñoz-García, Rodrigues-de-

Souza, Alburquerque-Sendín, & Fernández-de-las-Peñas, 2013). Tension in the psoas muscles

has been linked to PTSD in rat studies, which may indicate the potential for similar tension in

humans (Nelson, DeMartini, & Heinrichs, 2010). There is also some evidence that connects

muscle tension to PTSD in humans (Kim & Yu, 2015; McDonagh-Coyle et al., 2001; Nyboe,

Bentholm, & Gyllensten, 2017). This dissertation study investigated whether TRE is an effective

treatment technique for people who have co-occurring PTSD and nsCLBP.

W
Background
IE
The rationale for proposing TRE as a treatment for co-occurring PTSD and nsCLBP

draws on several concepts: (a) the theory behind TRE; (b) key terms and definitions; (c) co-
EV
occurring PTSD and nsCLBP; (d) treatment considerations when both conditions are present; (e)

current barriers to treatment; and (f) theories related to one or both conditions. This section

provides background information on each of these concepts.

PR

Tension and Trauma Releasing Exercises (TRE)

Tension and Trauma Releasing Exercises (Berceli, 2005, 2008, 2015) was developed to

invoke self-induced therapeutic tremoring (SITT). Tremoring is thought to release chronically

held muscle tension. The TRE technique can be used as a self-help tool or with a facilitator, and

either individually or in groups. Once learned, TRE requires no special equipment or travel to a

treatment facility.

Berceli (2005, 2008) spent many years providing humanitarian aid in war-torn countries.

He became curious about two reactions to traumatic experience that seemed to be present in
 3

people regardless of culture or class. First, he noticed that people always curled their bodies

inward when bombs exploded. Second, he noticed that children shook when bombs exploded,

but adults did not. He asked the adults about his observations, and they responded that they did

not want the children to know they were scared (Berceli, 2005, 2008).

From these observations, Berceli (2005, 2008) theorized that curling the body required

muscle contraction, particularly of the psoas muscles. He believed that shaking, also referred to

as tremoring, was the way the body released muscle contraction. He also theorized that adults

learned to suppress tremors to avoid appearing scared or weak, and that suppressed tremoring led

to chronic muscle contraction or tension (Berceli, 2005, 2008, 2015).

W
Using seven sequential exercises to progressively activate and relax muscles gently and
IE
safely, TRE specifically targets the psoas and other hip flexor muscles as the central location of

chronic muscle tension (Berceli, 2005, 2008, 2015). The psoas muscles attach to the mid-spine
EV
and the tops of the femurs in both legs, making them the only muscles connecting the upper and

lower body (Koch, 2012; Staugaard-Jones, 2012). The psoas muscles are key in curling the body

inward, and chronic tension in the psoas muscles is linked to both nsCLBP and PTSD (Andersen
PR

et al., 2012; Flor, Turk, & Birbaumer, 1985; Iglesias-González et al., 2013; Nelson et al., 2010).

The goal of TRE is to allow the body to tremor naturally. These tremors are currently

known as self-induced therapeutic tremors (SITT) but have also been called neurogenic tremor

and self-induced unclassified tremor (Berceli, 2005, 2008, 2015; Berceli et al., 2014). The

tremors vary widely from person to person, session to session, and even within a session.

According to Berceli (personal communication, June 26, 2015), frequency and velocity of

tremors are irrelevant to therapeutic benefit. Following the individual body's urge to tremor

through to completion is thought to release muscle tension (Berceli, 2008, 2015).

 4

Interventions Related to TRE

As with most complementary and alternative medicine interventions, research on TRE is

in its infancy. There is some research available on other interventions that are based on similar

concepts of stored muscle tension and release of that tension. These interventions are: Somatic

Experiencing (SE), Rosen Method Bodywork (RMB), and Bioenergetics (BE).

Somatic Experiencing is a form of somatic psychotherapy that was developed based on

observations of animals in the wild. The creator of SE, Peter Levine, observed predator and prey

animals and noticed that prey animals always shook after reaching safety (Levine, 1997). He

developed a psychotherapy method based on building self-awareness of body sensations and

W
releasing stored tension related to trauma. Berceli (2008) connected his theory to Levine’s work
IE
in terms of the similarity between shaking and tremoring.

Bioenergetics is also a somatic psychotherapy, based on the work of Alexander Lowen

EV
(1995). Bioenergetics utilizes a combination of talk therapy and physical exercises, which is

meant to facilitate the release of stored tension from the body. The talk therapy approach and

exercises are modified to fit individual needs.

PR

Rosen Method Bodywork is not psychotherapy and is adapted from massage therapy

principles. This intervention includes verbal techniques to help clients increase self-awareness

(Fogel, 2013). Rosen Method Bodywork is purported to result in relaxation and decreased

muscle tension (Fogel, 2013; Hoffren-Larsson, Gustafsson, & Falkenberg, 2009).

A difference between TRE and these related interventions is that the related interventions

are all services that are delivered or facilitated by trained professionals, whereas TRE can be

performed by anyone once an initial training is completed. Although some comparisons can be
 5

made between TRE and these related interventions, TRE is unique in that it was designed to be a

self-help tool for people without access to professionals (Berceli, 2005).

Key Terms and Definitions

Terms from multiple disciplines are used throughout this dissertation. Some terms have

historically been used in different ways, and some do not have consistent, accepted meanings.

To assist the reader, definitions for key terms as they are used here are presented in Table 1.

Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder is defined in the Diagnostic Statistical Manual of Mental

Disorders, Fifth Edition (DSM-5) as a condition that develops after an individual has

W
experienced one or more traumatic events (American Psychiatric Association (APA), 2013a). It
IE
is estimated that 8.7% of people in the US will experience PTSD over the course of a lifetime

(APA, 2013a). Traumatic events occur whenever a person feels endangered or feels that
EV
someone close to them is in danger. Examples of traumatic events include car accidents,

experiences of violence or sexual abuse, and participation in combat or first responder duties.

Multiple symptoms lasting more than one month include intrusive thoughts or memories,
PR

dissociation, avoidance of triggers, negative moods, and hyperarousal (APA, 2013a).

Hyperarousal is of particular interest in this research study. Symptoms related to

hyperarousal are: (a) irritability and aggressive behavior; (b) out of control or self-injurious

behavior; (c) hypervigilance; (d) exaggerated startle response; (e) concentration problems; and

(f) sleep problems (APA, 2013a). Hyperarousal is closely related to fight-or-flight responses

through activation of the sympathetic nervous system (SNS), which regulates muscles and other

body parts in response to threat (Porges, 2011; Siegel, 1999).

 6

Table 1

Key Terms and Definitions

Term Acronym Definition

Electromyography EMG A method of measuring muscle activity and tension through

electrodes placed on the surface of the skin.

Hyperarousal -- A physiological state of high alert where the body is prepared

to deal with danger (Weston, 2014). It is associated with a
symptom cluster of PTSD, including sleep problems,
irritability, reckless or self-harming behavior, concentration
problems, hypervigilance, and exaggerated startle response
(APA, 2013a; Weston, 2014).

W
Non-specific nsCLBP Uncomfortable sensation, stiffness, or muscle tension centered
chronic low back at the lower end of the spine that is not related to injury or
pain IE disease and lasts at least three months (Koes, Van Tulder, &
Thomas, 2006).

Paraspinal muscles Refers to a group of muscles in the low back and hip area that
attach to the spine, including the iliopsoas and other hip flexor
EV
muscles.

Post-traumatic PTSD A psychological diagnosis characterized by both physical and

stress disorder psychological symptoms including hypervigilance,
exaggerated startle response, nightmares, insomnia, and
PR

flashbacks (APA, 2013a).

Self-induced SITT A shaking or tremoring process that is thought to release

therapeutic tremor chronically held muscle tension (Berceli, 2015). SITT is
formerly known as neurogenic tremor (Berceli, 2008) or self-
induced unclassified therapeutic tremor (Berceli et al., 2014).

Somatic -- A general term for many forms of psychotherapy that feature

psychotherapy body-oriented concepts.

Sympathetic SNS Refers to the branch of the autonomic nervous system that is
nervous system responsible for regulating fight/flight/freeze responses.

Tension and TRE A body-based self-help technique that invokes self-induced

Trauma Releasing therapeutic tremoring to release chronic muscle tension and
Exercises reduce anxiety (Berceli, 2005, 2008, 2015).

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.