Relaxation therapy and continuous ambulatory blood pressure in mild hypertension: a controlled study

Yoga for epilepsy

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library, Issue 5, 2015.Yoga may induce relaxation and stress reduction, and influence the electroencephalogram and the autonomic nervous system, thereby controlling seizures. Yoga would be an attractive therapeutic option for epilepsy if proved effective.

OBJECTIVES

To assess whether people with epilepsy treated with yoga:(a) have a greater probability of becoming seizure free;(b) have a significant reduction in the frequency or duration of seizures, or both; and(c) have a better quality of life.

SEARCH METHODS

For this update, we searched the Cochrane Epilepsy Group Specialized Register (3 January 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 12) in the Cochrane Library (searched 3 January 2017), MEDLINE (Ovid, 1946 to 3 January 2017), SCOPUS (1823 to 3 January 2017), ClinicalTrials.gov (searched 3 January 2017), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (searched 3 January 2017), and also registries of the Yoga Biomedical Trust and the Research Council for Complementary Medicine. In addition, we searched the references of all the identified studies. No language restrictions were imposed.

SELECTION CRITERIA

The following study designs were eligible for inclusion: randomised controlled trials (RCT) of treatment of epilepsy with yoga. The studies could be double-, single- or unblinded. Eligible participants were adults with uncontrolled epilepsy comparing yoga with no treatment or different behavioural treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. The following outcomes were assessed: (a) percentage of people rendered seizure free; (b) seizure frequency and duration; (c) quality of life. Analyses were on an intention-to-treat basis. Odds ratio (OR) with 95% confidence intervals (95% Cls) were estimated for the outcomes.

MAIN RESULTS

We did not identify any new studies for this update, therefore the results are unchanged.For the previous version of the review, the authors found two unblinded trials in people with refractory epilepsy. In total these two studies included 50 people (18 treated with yoga and 32 to control interventions). Antiepileptic drugs were continued in all the participants. Baseline phase lasted three months in both studies and treatment phase from five weeks to six months in the two trials. Randomisation was by roll of a die in one study and using a computerised randomisation table in the other one but neither study provided details of concealment of allocation and were rated as unclear risk of bias. Overall, the two studies were rated as low risk of bias (all participants were included in the analysis; all expected and pre-expected outcomes were reported; no other sources of bias).The overall ORs with 95% CI were as follows: (i) seizure free for six months - for yoga versus sham yoga the OR was 14.54 (95% CI 0.67 to 316.69) and for yoga versus 'no treatment' group it was 17.31 (95% CI 0.80 to 373.45); for Acceptance and Commitment Therapy (ACT) versus yoga the OR was 1.00 (95% Cl 0.16 to 6.42); (ii) reduction in seizure frequency - the mean difference between yoga versus sham yoga group was -2.10 (95% CI -3.15 to -1.05) and for yoga versus 'no treatment' group it was -1.10 (95% CI -1.80 to -0.40); (iii) more than 50% reduction in seizure frequency - for yoga versus sham yoga group, OR was 81.00 (95% CI 4.36 to 1504.46) and for the yoga versus 'no treatment' group it was 158.33 (95% CI 5.78 to 4335.63); ACT versus yoga OR was 0.78 (95% Cl 0.04 to 14.75); (iv) more than 50% reduction in seizure duration - for yoga versus sham yoga group OR was 45.00 (95% CI 2.01 to 1006.75) and for yoga versus 'no treatment' group it was 53.57 (95% CI 2.42 to 1187.26); ACT versus yoga OR was 0.67 (95% Cl 0.10 to 4.35).In addition in Panjwani 1996 the authors reported that the one-way analysis of variance revealed no statistically significant differences between the three groups. A P-Lambda test taking into account the P values between the three groups also indicated that the duration of epilepsy in the three groups was not comparable. No data were available regarding quality of life. In Lundgren 2008 the authors reported that there was no significant difference between the yoga and ACT groups in seizure-free rates, 50% or greater reduction in seizure frequency or seizure duration at one-year follow-up. The yoga group showed significant improvement in their quality of life according to the Satisfaction With Life Scale (SWLS) (P < 0.05), while the ACT group had significant improvement in the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale (P < 0.01).Overall, we assessed the quality of evidence as low; no reliable conclusions can be drawn at present regarding the efficacy of yoga as a treatment for epilepsy.

AUTHORS' CONCLUSIONS

A study of 50 subjects with epilepsy from two trials reveals a possible beneficial effect in control of seizures. Results of the overall efficacy analysis show that yoga treatment was better when compared with no intervention or interventions other than yoga (postural exercises mimicking yoga). There was no difference between yoga and Acceptance and Commitment Therapy. However no reliable conclusions can be drawn regarding the efficacy of yoga as a treatment for uncontrolled epilepsy, in view of methodological deficiencies such as limited number of studies, limited number of participants randomised to yoga, lack of blinding and limited data on quality-of-life outcome. Physician blinding would normally be taken to be the person delivering the intervention, whereas we think the 'physician' would in fact be the outcome assessor (who could be blinded), so that would be a reduction in detection bias rather than performance bias. In addition, evidence to inform outcomes is limited and of low quality. Further high-quality research is needed to fully evaluate the efficacy of yoga for refractory epilepsy.Since we did not find any new studies, our conclusions remain unchanged.

Yoga for asthma

BACKGROUND

Asthma is a common chronic inflammatory disorder affecting about 300 million people worldwide. As a holistic therapy, yoga has the potential to relieve both the physical and psychological suffering of people with asthma, and its popularity has expanded globally. A number of clinical trials have been carried out to evaluate the effects of yoga practice, with inconsistent results.

OBJECTIVES

To assess the effects of yoga in people with asthma.

SEARCH METHODS

We systematically searched the Cochrane Airways Group Register of Trials, which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO, and handsearching of respiratory journals and meeting abstracts. We also searched PEDro. We searched ClinicalTrials.gov and the WHO ICTRP search portal. We searched all databases from their inception to 22 July 2015, and used no restriction on language of publication. We checked the reference lists of eligible studies and relevant review articles for additional studies. We attempted to contact investigators of eligible studies and experts in the field to learn of other published and unpublished studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared yoga with usual care (or no intervention) or sham intervention in people with asthma and reported at least one of the following outcomes: quality of life, asthma symptom score, asthma control, lung function measures, asthma medication usage, and adverse events.

DATA COLLECTION AND ANALYSIS

We extracted bibliographic information, characteristics of participants, characteristics of interventions and controls, characteristics of methodology, and results for the outcomes of our interest from eligible studies. For continuous outcomes, we used mean difference (MD) with 95% confidence interval (CI) to denote the treatment effects, if the outcomes were measured by the same scale across studies. Alternatively, if the outcomes were measured by different scales across studies, we used standardised mean difference (SMD) with 95% CI. For dichotomous outcomes, we used risk ratio (RR) with 95% CI to measure the treatment effects. We performed meta-analysis with Review Manager 5.3. We used the fixed-effect model to pool the data, unless there was substantial heterogeneity among studies, in which case we used the random-effects model instead. For outcomes inappropriate or impossible to pool quantitatively, we conducted a descriptive analysis and summarised the findings narratively.

MAIN RESULTS

We included 15 RCTs with a total of 1048 participants. Most of the trials were conducted in India, followed by Europe and the United States. The majority of participants were adults of both sexes with mild to moderate asthma for six months to more than 23 years. Five studies included yoga breathing alone, while the other studies assessed yoga interventions that included breathing, posture, and meditation. Interventions lasted from two weeks to 54 months, for no more than six months in the majority of studies. The risk of bias was low across all domains in one study and unclear or high in at least one domain for the remainder.There was some evidence that yoga may improve quality of life (MD in Asthma Quality of Life Questionnaire (AQLQ) score per item 0.57 units on a 7-point scale, 95% CI 0.37 to 0.77; 5 studies; 375 participants), improve symptoms (SMD 0.37, 95% CI 0.09 to 0.65; 3 studies; 243 participants), and reduce medication usage (RR 5.35, 95% CI 1.29 to 22.11; 2 studies) in people with asthma. The MD for AQLQ score exceeded the minimal clinically important difference (MCID) of 0.5, but whether the mean changes exceeded the MCID for asthma symptoms is uncertain due to the lack of an established MCID in the severity scores used in the included studies. The effects of yoga on change from baseline forced expiratory volume in one second (MD 0.04 litres, 95% CI -0.10 to 0.19; 7 studies; 340 participants; I(2) = 68%) were not statistically significant. Two studies indicated improved asthma control, but due to very significant heterogeneity (I(2) = 98%) we did not pool data. No serious adverse events associated with yoga were reported, but the data on this outcome was limited.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that yoga probably leads to small improvements in quality of life and symptoms in people with asthma. There is more uncertainty about potential adverse effects of yoga and its impact on lung function and medication usage. RCTs with a large sample size and high methodological and reporting quality are needed to confirm the effects of yoga for asthma.

Yoga for epilepsy

BACKGROUND

This is an updated version of the original Cochrane review published in The Cochrane Library, Issue 1, 2002.Yoga may induce relaxation and stress reduction, and influence the electroencephalogram and the autonomic nervous system, thereby controlling seizures. Yoga would be an attractive therapeutic option for epilepsy if proved effective.

OBJECTIVES

To assess whether people with epilepsy treated with yoga:(a) have a greater probability of becoming seizure free;(b) have a significant reduction in the frequency or duration of seizures, or both; and(c) have a better quality of life.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialized Register (26 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 26 March 2015), MEDLINE (Ovid, 1946 to 26 March 2015), SCOPUS (1823 to 9 January 2014), ClinicalTrials.gov (26 March 2015), the World Health Organization (WHO) International Clinical Trials Registry Platform ICTRP (26 March 2015), and also registries of the Yoga Biomedical Trust and the Research Council for Complementary Medicine. In addition, we searched the references of all the identified studies. No language restrictions were imposed.

SELECTION CRITERIA

The following study designs were eligible for inclusion: randomised controlled trials (RCT) of treatment of epilepsy with yoga. Eligible participants were adults with uncontrolled epilepsy comparing yoga with no treatment or different behavioural treatments.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials for inclusion and extracted data. The following outcomes were assessed: (a) percentage of people rendered seizure free; (b) seizure frequency and duration; (c) quality of life. Analyses were on an intention-to-treat basis. Odds ratio (OR) with 95% confidence intervals (95% Cl) were estimated for the outcomes.

MAIN RESULTS

Two unblinded trials recruited a total of 50 people (18 treated with yoga and 32 to control interventions). Antiepileptic drugs were continued in all the participants. Baseline phase lasted 3 months in both studies and treatment phase from 5 weeks to 6 months in the two trials. Randomisation was by roll of a die in one study and using a computerised randomisation table in the other one but neither study provided details of concealment of allocation and were rated as unclear risk of bias. Overall, the two studies were rated as low risk of bias (all participants were included in the analysis; all expected and pre-expected outcomes were reported; no other sources of bias). The overall OR with 95% confidence interval (CI) was: (i) seizure free for six months - for yoga versus sham yoga ORs of 14.54 (95% CI 0.67 to 316.69) and for yoga versus no treatment group 17.31 (95% CI 0.80 to 373.45); for Acceptance and Commitment Therapy (ACT) versus yoga ORs of 1.00 (95% Cl 0.16 to 6.42; (ii) reduction in seizure frequency - the Mean Difference between yoga versus sham yoga group was -2.10 (95% CI -3.15 to -1.05) and for yoga versus no treatment group -1.10 (95% CI -1.80 to -0.40); (iii) more than 50% reduction in seizure frequency - for yoga versus sham yoga group ORs of 81.00 (95% CI 4.36 to 1504.46) and for the yoga versus no treatment group 158.33 (95% CI 5.78 to 4335.63); ACT versus yoga ORs of 0.78 (95% Cl 0.04 to 14.75); (iv) more than 50% reduction in seizure duration - for yoga versus sham yoga group ORs of 45.00 (95% CI 2.01 to 1006.75) and for yoga versus no treatment group 53.57 (95% CI 2.42 to 1187.26); ACT versus yoga ORs of 0.67 (95% Cl 0.10 to 4.35). In addition in Panjwani 1996 the authors reported that the one-way analysis of variance revealed no statistically significant differences between the three groups. A P-Lambda test taking into account the P values between the three groups also indicated that the duration of epilepsy in the three groups was not comparable. No data were available regarding quality of life. In Lundgren 2008 the authors reported that there was no significant difference between the yoga and ACT groups in seizure free rates, 50% or greater reduction in seizure frequency or seizure duration at one year follow-up. The yoga group showed significant improvement in their quality of life according to the Satisfaction With Life Scale (SWLS) (P < 0.05), while the ACT group had significant improvement in the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale (P < 0.01).

AUTHORS' CONCLUSIONS

Study of 50 subjects with epilepsy from two trials reveals possible beneficial effect in control of seizures. Results of the overall efficacy analysis show that yoga treatment was better when compared with no intervention or interventions other than yoga (postural exercises mimicking yoga). There was no difference between yoga and Acceptance and Commitment Therapy. However no reliable conclusions can be drawn regarding the efficacy of yoga as a treatment for uncontrolled epilepsy, in view of methodological deficiencies such as limited number of studies, limited number of participants randomised to yoga, lack of blinding and limited data on quality-of-life outcome. Physician blinding would normally be taken to be the person delivering the intervention, whereas we think the 'physician' would in fact be the outcome assessor (who could be blinded), so that would be a reduction in detection bias rather than performance bias. In addition, evidence to inform outcomes is limited and of low quality. Further high-quality research is needed to fully evaluate the efficacy of yoga for refractory epilepsy.

Characteristics of randomized controlled trials of yoga: a bibliometric analysis

Background

A growing number of randomized controlled trials (RCTs) have investigated the therapeutic value of yoga interventions. This bibliometric analysis aimed to provide a comprehensive review of the characteristics of the totality of available randomized yoga trials.

Methods

All RCTs of yoga were eligible. Medline/PubMed, Scopus, the Cochrane Library, IndMED, and the tables of content of yoga specialty journals not listed in medical databases were screened through February 2014. Bibliometric data, data on participants, and intervention were extracted and analyzed descriptively.

Results

Published between 1975 and 2014, a total of 366 papers were included, reporting 312 RCTs from 23 different countries with 22,548 participants. The median study sample size was 59 (range 8–410, interquartile range = 31, 93). Two hundred sixty-four RCTs (84.6%) were conducted with adults, 105 (33.7%) with older adults and 31 (9.9%) with children. Eighty-four RCTs (26.9%) were conducted with healthy participants. Other trials enrolled patients with one of 63 varied medical conditions; the most common being breast cancer (17 RCTs, 5.4%), depression (14 RCTs, 4.5%), asthma (14 RCTs, 4.5%) and type 2 diabetes mellitus (13 RCTs, 4.2%). Whilst 119 RCTs (38.1%) did not define the style of yoga used, 35 RCTs (11.2%) used Hatha yoga and 30 RCTs (9.6%) yoga breathing. The remaining 128 RCTs (41.0%) used 46 varied yoga styles, with a median intervention length of 9 weeks (range 1 day to 1 year; interquartile range = 5, 12). Two hundred and forty-four RCTs (78.2%) used yoga postures, 232 RCTs (74.4%) used breath control, 153 RCTs (49.0%) used meditation and 32 RCTs (10.3%) used philosophy lectures. One hundred and seventy-four RCTs (55.6%) compared yoga with no specific treatment; 21 varied control interventions were used in the remaining RCTs.

Conclusions

This bibliometric analysis presents the most complete up-to-date overview on published randomized yoga trials. While the available research evidence is sparse for most conditions, there was a marked increase in published RCTs in recent years.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6882-14-328) contains supplementary material, which is available to authorized users.

A randomized controlled trial comparing the effects of yoga with an active control on ambulatory blood pressure in individuals with prehypertension and stage 1 hypertension

The purpose of this study was to compare the effects of yoga with an active control (nonaerobic exercise) in individuals with prehypertension and stage 1 hypertension. A randomized clinical trial was performed using two arms: (1) yoga and (2) active control. Primary outcomes were 24-hour day and night ambulatory systolic and diastolic blood pressures. Within-group and between-group analyses were performed using paired t tests and repeated-measures analysis of variance (time × group), respectively. Eighty-four participants enrolled, with 68 participants completing the trial. Within-group analyses found 24-hour diastolic, night diastolic, and mean arterial pressure all significantly reduced in the yoga group (-3.93, -4.7, -4.23 mm Hg, respectively) but no significant within-group changes in the active control group. Direct comparisons of the yoga intervention with the control group found a single blood pressure variable (diastolic night) to be significantly different (P=.038). This study has demonstrated that a yoga intervention can lower blood pressure in patients with mild hypertension. Although this study was not adequately powered to show between-group differences, the size of the yoga-induced blood pressure reduction appears to justify performing a definitive trial of this intervention to test whether it can provide meaningful therapeutic value for the management of hypertension.

Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the HARMONY randomized controlled trial

BACKGROUND

The HARMONY study was a randomized, controlled trial examining the efficacy of an 8-week mindfulness-based stress reduction (MBSR) program for blood pressure (BP) lowering among unmedicated stage 1 hypertensive participants.

METHODS

Participants diagnosed with stage 1 hypertension based on ambulatory BP were randomized to either immediate treatment of MBSR for 8 weeks or wait-list control. Primary outcome analysis evaluated whether change in awake and 24-hour ambulatory BP from baseline to week 12 was significantly different between the 2 groups. A within-group before and after MBSR analysis was also performed.

RESULTS

The study enrolled 101 adults (38% male) with baseline average 24-hour ambulatory BP of 135±7.9/82±5.8mm Hg and daytime ambulatory BP of 140±7.7/87±6.3 mmHg. At week 12, the change from baseline in 24-hour ambulatory BP was 0.4±6.7/0.0±4.9mm Hg for the immediate intervention and 0.4±7.8/-0.4±4.6mm Hg for the wait-list control. There were no significant differences between intervention and wait-list control for all ambulatory BP parameters. The secondary within-group analysis found a small reduction in BP after MBSR compared with baseline, a finding limited to female subjects in a sex analysis.

CONCLUSIONS

MBSR did not lower ambulatory BP by a statistically or clinically significant amount in untreated, stage 1 hypertensive patients when compared with a wait-list control group. It leaves untested whether MBSR might be useful for lowering BP by improving adherence in treated hypertensive participants.

CLINICAL TRIALS REGISTRATION

NCT00825526.

Modified relaxation technique for treating hypertension in Thai postmenopausal women

Aim

To examine the effectiveness of a modified relaxation (MR) technique in reducing blood pressure levels in Thai postmenopausal women with mild hypertension, compared with a control group who received health education.

Methods

This is a 16-week, randomized, parallel, open-label, controlled trial in a menopausal clinic in a tertiary health care center in Northeastern Thailand. The intervention group received a 60-minute session of MR training and were encouraged to practice 15–20 minutes a day, at least 5 days a week. The control group received lifestyle education, including diet and exercise. The primary and secondary outcomes were systolic and diastolic blood pressure (SBP and DBP).

Results

Of 432 participants, 215 and 217 were randomly allocated to the MR and control groups, respectively. Of those, 167 participants in the MR group and 175 participants in the control group completed the study. The SBP was significantly more reduced in the MR group, with a mean of 2.1 mmHg (P < 0.001). There was no significant difference between groups on the changed DBP.

Conclusion

The MR technique may be effective in lowering SBP in Thai postmenopausal women visiting a menopause clinic. Its efficacy may be observed as soon as 4 weeks after start of treatment. Long-term and combined relaxation therapy and antihypertensive agents are warranted in a large cohort of this population. This trial is registered in clinicaltrials.gov (number NCT01429662).

Effectiveness of yoga for hypertension: systematic review and meta-analysis

Objectives. To systematically review and meta-analyze the effectiveness of yoga for reducing blood pressure in adults with hypertension and to assess the modifying influences of type and length of yoga intervention and type of comparison group. Methods. Academic Search Premier, AltHealthWatch, BIOSIS/Biological Abstracts, CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, PsycARTICLES, Natural Standard, and Web of Science databases were screened for controlled studies from 1966 to March 2013. Two authors independently assessed risk of bias using the Cochrane Risk of Bias Tool. Results. All 17 studies included in the review had unclear or high risk of bias. Yoga had a modest but significant effect on systolic blood pressure (SBP) (-4.17 [-6.35, -1.99], P = 0.0002) and diastolic blood pressure (DBP) (-3.62 [-4.92, -1.60], P = 0.0001). Subgroup analyses demonstrated significant reductions in blood pressure for (1) interventions incorporating 3 basic elements of yoga practice (postures, meditation, and breathing) (SBP: -8.17 mmHg [-12.45, -3.89]; DBP: -6.14 mmHg [-9.39, -2.89]) but not for more limited yoga interventions; (2) yoga compared to no treatment (SBP: -7.96 mmHg [-10.65, -5.27]) but not for exercise. Conclusion. Yoga can be preliminarily recommended as an effective intervention for reducing blood pressure. Additional rigorous controlled trials are warranted to further investigate the potential benefits of yoga.

Guidelines for developing yoga interventions for randomized trials

Little guidance is available to assist researchers in developing treatment protocols for research on yoga for health concerns. Because yoga is a complex multifactorial mind-body discipline historically developed for nonmedical purposes, numerous decisions must be made in order to thoughtfully develop such protocols. In this paper, a systematic approach is proposed to assist researchers in selecting an intervention that is appropriate for the condition under consideration and explicitly developed. Researchers need to consider the type or “style” of yoga, the components to include (e.g., breathing exercises, postures) as well as the specific protocol for each component, the dose to be delivered (frequency, duration of practice, and the total duration of practice), and issues related to selection of instructors and monitoring the fidelity to the intervention. Each of these domains and the key issues for the development of protocols is discussed. Finally, some areas for further research related to protocol development are recommended.

Effects of swimming training on blood pressure and vascular function in adults >50 years of age

Swimming is ideal for older adults because it includes minimum weight-bearing stress and decreased heat load. However, there is very little information available concerning the effects of regular swimming exercise on vascular risks. We determined if regular swimming exercise would decrease arterial blood pressure (BP) and improve vascular function. Forty-three otherwise healthy adults >50 years old (60 ± 2) with prehypertension or stage 1 hypertension and not on any medication were randomly assigned to 12 weeks of swimming exercise or attention time controls. Before the intervention period there were no significant differences in any of the variables between groups. Body mass, adiposity, and plasma concentrations of glucose and cholesterol did not change in either group throughout the intervention period. Casual systolic BP decreased significantly from 131 ± 3 to 122 ± 4 mm Hg in the swimming training group. Significant decreases in systolic BP were also observed in ambulatory (daytime) and central (carotid) BP measurements. Swimming exercise produced a 21% increase in carotid artery compliance (p <0.05). Flow-mediated dilation and cardiovagal baroreflex sensitivity improved after the swim training program (p <0.05). There were no significant changes in any measurements in the control group that performed gentle relaxation exercises. In conclusion, swimming exercise elicits hypotensive effects and improvements in vascular function in previously sedentary older adults.

Spirituality and aging

Interest in spirituality and aging has increased recently, owing to overwhelming evidence of positive health outcomes linked to spirituality and religious participation. Increasing longevity in modern society puts spiritual needs of older adults at the forefront of societal priorities. Understanding individual spiritual perspectives becomes increasingly important, given the issues of loss, physical illness and mortality that are confronted in old age. There are multiple barriers to the proper assessment of spirituality in clinical practice and research (e.g., the lack of professional training for healthcare professionals, shortage of time and comfort for healthcare providers when discussing spiritual issues and needs). Integrating an individual’s spiritual practice into their healthcare can help shape personalized medical care for older adults and improve health outcomes. This article reviews literature and research on spirituality, as well as spiritual interventions and their putative neurobiological mechanisms in relation to aging, mental and physical health, and coping with death and dying.

Strategies for initial management of hypertension

High blood pressure (BP) is a major public health problem in India and its prevalence is rapidly increasing among urban and rural populations. Reducing systolic and diastolic BP can decrease cardiovascular risk and this can be achieved by non-pharmacological (lifestyle measures) as well as pharmacological means. Lifestyle changes should be the initial approach to hypertension management and include dietary interventions (reducing salt, increasing potassium, alcohol avoidance, and multifactorial diet control), weight reduction, tobacco cessation, physical exercise, and stress management. A number of pharmaceutical agents, well evidenced by large randomized clinical trials, are available for initial treatment of high BP. These include older molecules such as thiazide diuretics and beta-blocking agents and newer molecules, dihydropyridine calcium channel blockers (CCB), angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARB). In view of the recent clinical trials data, some international guidelines suggest that CCB, ACE inhibitors or ARB and not beta-blockers or diuretics should be the initial therapy in hypertension management. Comprehensive hypertension management focuses on reducing overall cardiovascular risk by lifestyle measures, BP lowering and lipid management and should be the preferred initial treatment approach.

Psychological predictors of the antihypertensive effects of music-guided slow breathing

BACKGROUND

The possibility that daily sessions of music-guided slow breathing may reduce 24-h ambulatory blood pressure (ABP), and predictors of efficacy were explored in a randomized, placebo-controlled trial with parallel design.

METHODS

Age-matched and sex-matched hypertensive patients were randomized to music-guided slow breathing exercises (4-6 breaths/min; 1: 2 ratio of inspiration: expiration duration) (Intervention; n = 29) or to control groups who were thought to relax while either listening to slow music (Control-M; n = 26) or reading a book (Control-R; n = 31). At baseline and at follow-up visits (1 week and 1, 3 and 6 months), ABP monitoring was performed.

RESULTS

At mixed model analysis, intervention was associated with a significant reduction of 24-h (P = 0.001) and night-time (0100-0600 h) (P < 0.0001) systolic ABP. The average reduction of systolic 24-h ABP at 6 months was 4.6 mmHg [confidence limits at 95% 1.93-7.35] and 4.1 mmHg (95% confidence limits 1.59-6.67) vs. Control-M and Control-R groups, respectively, (P < 0.001 for both). Antihypertensive treatment was selected as negative predictor of BP reduction at multivariate stepwise analysis. When antihypertensive treatment was inserted as covariate in a generalized linear model, psychological subscales assessed at baseline by the Mental Health Inventory questionnaire were found to affect systolic blood pressure reduction at 6-month follow-up (general positive affect P < 0.001; emotional ties, P < 0.001; loss of behavioral control, P = 0.035). In particular, a level of general positive affect higher than the 75th percentiles was found to be significantly associated with low treatment efficacy (odds ratio 0.09; 95% confidence limits 0.01-0.93).

CONCLUSION

Daily sessions of voluntary music-guided slow breathing significantly reduce 24-h systolic ABP, and psychological predictors of efficacy can be identified.

Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis

Substantial evidence indicates that psychosocial stress contributes to hypertension and cardiovascular disease (CVD). Previous meta-analyses of stress reduction and high blood pressure (BP) were outdated and/or methodologically limited. Therefore, we conducted an updated systematic review of the published literature and identified 107 studies on stress reduction and BP. Seventeen trials with 23 treatment comparisons and 960 participants with elevated BP met criteria for well-designed randomized controlled trials and were replicated within intervention categories. Meta-analysis was used to calculate BP changes for biofeedback, -0.8/-2.0 mm Hg (P = NS); relaxation-assisted biofeedback, +4.3/+2.4 mm Hg (P = NS); progressive muscle relaxation, -1.9/-1.4 mm Hg (P = NS); stress management training, -2.3/-1.3 mm (P = NS); and the Transcendental Meditation program, -5.0/-2.8 mm Hg (P = 0.002/0.02). Available evidence indicates that among stress reduction approaches, the Transcendental Meditation program is associated with significant reductions in BP. Related data suggest improvements in other CVD risk factors and clinical outcomes.

Characteristics of yoga users: results of a national survey

BACKGROUND

There are limited data on the characteristics of yoga users in the U.S.

OBJECTIVE

To characterize yoga users, medical reasons for use, perceptions of helpfulness, and disclosure of use to medical professionals.

METHODS

Utilizing cross-sectional survey data from the 2002 National Health Interview Survey (NHIS) Alternative Medicine Supplement (n = 31044), we examined correlates of yoga use for health. The estimated prevalence from 2002 NHIS of yoga for health was 5.1% corresponding to over 10 million adults.

RESULTS

In 2002, yoga users were predominately Caucasian (85%) and female (76%) with a mean age of 39.5 years. Compared to non-yoga users, yoga users were more likely female (OR 3.76, 95% CI 3.11-4.33); less likely black than white (OR 0.65, 95% CI 0.53-0.80); tended to be younger; and more likely college educated (OR 2.70, 95% CI 2.37-3.08). Musculoskeletal conditions (OR 1.61, 95% CI 1.42-1.83), mental health conditions (OR 1.43, 95% CI 1.22-1.67), severe sprains in the last 12 months (OR 1.49, 95% CI 1.22-1.81), and asthma (OR 1.27, 95% CI 1.05-1.54) were independently associated with higher yoga use, while hypertension (OR 0.78, 95% CI 0.64-0.95) and chronic obstructive lung disease (OR 0.69, 95% CI 0.48-1.00) were associated with lower use. Yoga was most commonly used to treat musculoskeletal or mental health conditions, and most users reported yoga to be helpful for these conditions. A majority of yoga users (61%) felt yoga was important in maintaining health, though only 25% disclosed yoga practice to their medical professional.

CONCLUSIONS

We found that yoga users are more likely to be white, female, young and college educated. Yoga users report benefit for musculoskeletal conditions and mental health, indicating that further research on the efficacy of yoga for the treatment and/or prevention of these conditions is warranted.

Relaxation therapies for the management of primary hypertension in adults

BACKGROUND

Lifestyle interventions are often recommended as initial treatment for mild hypertension, but the efficacy of relaxation therapies is unclear.

OBJECTIVES

To evaluate the effects of relaxation therapies on cardiovascular outcomes and blood pressure in people with elevated blood pressure.

SEARCH STRATEGY

We searched the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, ISI Proceedings, ClinicalTrials.gov, Current Controlled Trials and reference lists of systematic reviews, meta-analyses and randomised controlled trials (RCTs) included in the review.

INCLUSION CRITERIA

RCTs of a parallel design comparing relaxation therapies with no active treatment, or sham therapy; follow-up >/=8 weeks; participants over 18 years, with raised systolic blood pressure (SBP) >/=140 mmHg or diastolic blood pressure (DBP) >/=85 mmHg); SBP and DBP reported at end of follow-up.

EXCLUSION CRITERIA

participants were pregnant; participants received antihypertensive medication which changed during the trial.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Disagreements were resolved by discussion or a third reviewer. Random effects meta-analyses and sensitivity analyses were conducted.

MAIN RESULTS

29 RCTs, with eight weeks to five years follow-up, met our inclusion criteria; four were excluded from the primary meta-analysis because of inadequate outcome data. The remaining 25 trials assessed 1,198 participants, but adequate randomisation was confirmed in only seven trials and concealment of allocation in only one. Only one trial reported deaths, heart attacks and strokes (one of each). Meta-analysis indicated that relaxation resulted in small, statistically significant reductions in SBP (mean difference: -5.5 mmHg, 95% CI: -8.2 to -2.8, I2 =72%) and DBP (mean difference: -3.5 mmHg, 95% CI: -5.3 to -1.6, I2 =75%) compared to control. The substantial heterogeneity between trials was not explained by duration of follow-up, type of control, type of relaxation therapy or baseline blood pressure. The nine trials that reported blinding of outcome assessors found a non-significant net reduction in blood pressure (SBP mean difference: -3.2 mmHg, 95% CI: -7.7 to 1.4, I(2) =69%) associated with relaxation. The 15 trials comparing relaxation with sham therapy likewise found a non-significant reduction in blood pressure (SBP mean difference: -3.5 mmHg, 95% CI: -7.1 to 0.2, I(2) =63%).

AUTHORS' CONCLUSIONS

In view of the poor quality of included trials and unexplained variation between trials, the evidence in favour of causal association between relaxation and blood pressure reduction is weak. Some of the apparent benefit of relaxation was probably due to aspects of treatment unrelated to relaxation.

Systematic Review of the Efficacy of Meditation Techniques as Treatments for Medical Illness

BACKGROUND

Meditative techniques are sought frequently by patients coping with medical and psychological problems. Because of their increasingly widespread appeal and use, and the potential for use as medical therapies, a concise and thorough review of the current state of scientific knowledge of these practices as medical interventions was conducted.

PURPOSE

To systematically review the evidence supporting efficacy and safety of meditative practices in treating illnesses, and examine areas warranting further study. Studies on normal healthy populations are not included.

METHODS

Searches were performed using PubMed, PsycInfo, and the Cochrane Database. Keywords were Meditation, Meditative Prayer, Yoga, Relaxation Response. Qualifying studies were reviewed and independently rated based on quality by two reviewers. Mid-to-high-quality studies (those scoring above 0.65 or 65% on a validated research quality scale) were included.

RESULTS

From a total of 82 identified studies, 20 randomized controlled trials met our criteria. The studies included 958 subjects total (397 experimentally treated, 561 controls). No serious adverse events were reported in any of the included or excluded clinical trials. Serious adverse events are reported in the medical literature, though rare. The strongest evidence for efficacy was found for epilepsy, symptoms of the premenstrual syndrome and menopausal symptoms. Benefit was also demonstrated for mood and anxiety disorders, autoimmune illness, and emotional disturbance in neoplastic disease.

CONCLUSIONS

The results support the safety and potential efficacy of meditative practices for treating certain illnesses, particularly in nonpsychotic mood and anxiety disorders. Clear and reproducible evidence supporting efficacy from large, methodologically sound studies is lacking.

Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials

PURPOSE

To quantify effectiveness of lifestyle interventions for hypertension.

DATA SOURCES

Electronic bibliographic databases from 1998 onwards, existing guidelines, systematic reviews.

STUDY SELECTION AND DATA ABSTRACTION

We included randomized, controlled trials with at least 8 weeks' follow-up, comparing lifestyle with control interventions, enrolling adults with blood pressure at least 140/85 mmHg. Primary outcome measures were systolic and diastolic blood pressure. Two independent reviewers selected trials and abstracted data; differences were resolved by discussion.

RESULTS

We categorized trials by type of intervention and used random effects meta-analysis to combine mean differences between endpoint blood pressure in treatment and control groups in 105 trials randomizing 6805 participants. Robust statistically significant effects were found for improved diet, aerobic exercise, alcohol and sodium restriction, and fish oil supplements: mean reductions in systolic blood pressure of 5.0 mmHg [95% confidence interval (CI): 3.1-7.0], 4.6 mmHg (95% CI: 2.0-7.1), 3.8 mmHg (95% CI: 1.4-6.1), 3.6 mmHg (95% CI: 2.5-4.6) and 2.3 mmHg (95% CI: 0.2-4.3), respectively, with corresponding reductions in diastolic blood pressure. Relaxation significantly reduced blood pressure only when compared with non-intervention controls. We found no robust evidence of any important effect on blood pressure of potassium, magnesium or calcium supplements.

CONCLUSIONS

Patients with elevated blood pressure should follow a weight-reducing diet, take regular exercise, and restrict alcohol and salt intake. Available evidence does not support relaxation therapies, calcium, magnesium or potassium supplements to reduce blood pressure.

Biofeedback-assisted Relaxation Training for Essential Hypertension

The main purpose of this study was to develop a way to predict which persons with essential hypertension would benefit most from biofeedback-assisted relaxation (BFAR) training. Second, the authors evaluated the effect of BFAR on blood pressure (BP) reduction, which was measured in the clinic and outside the clinic using an ambulatory BP monitor. Fifty-four adults with stage 1 or 2 hypertension (78% taking BP medications) received 8 weeks of relaxation training coupled with thermal, electromyographic, and respiratory sinus arrhythmia biofeedback. Blood pressure was measured in the clinic and over 24 hours using an ambulatory BP monitor pretraining and posttraining. Systolic BP dropped from 135.0 +/- 9.8 mmHg pretraining to 132.2 +/- 10.5 mmHg posttraining (F = 6.139, P = .017). Diastolic BP dropped from 80.4 +/- 8.1 mmHg pretraining to 78.5 +/- 10.0 mmHg posttraining (F = 4.441, P = .041). Data from 37 participants with baseline BP of 130/85 mmHg or greater were used to develop a prediction model. Regression showed that those who were able to lower their SBP 5 mm Hg or more were (1) not taking antihypertensive medication, (2) had lowest starting finger temperature, (3) had the smallest standard deviation in daytime mean arterial pressure, and (4) the lowest score on the Multidimensional Health Locus of Control-internal scale. Since these types of persons are most likely to benefit from BFAR, they should be offered BFAR prior to starting hypertensive medications.

Biobehavioral approaches to the treatment of essential hypertension

Despite recent advances in the medical management of hypertension, chronically elevated blood pressure remains a major health problem in the United States, affecting almost 50 million Americans. It is widely recognized that lifestyle factors contribute to the development and maintenance of elevated blood pressure. This article critically reviews current approaches to the nonpharmacological treatment of high blood pressure and highlights outcome studies of exercise, weight loss and dietary modification, and stress management and relaxation therapies. Methodological issues in the assessment and treatment of hypertension are discussed, along with possible mechanisms by which lifestyle modification may reduce elevated blood pressure.

Catecholamine levels in practitioners of the transcendental meditation technique

With the aim of evaluating the sympathetic-adrenal medulla system in subjects practicing transcendental meditation (TM), their plasma catecholamine levels were determined at two different times of day. The study group consisted of 19 subjects who regularly practice either TM or Sidhi-TM technique, with a control group made up of 16 healthy subjects who had not previously used any relaxation technique. Catecholamine plasma levels were determined by high performance liquid chromatography, at 0900 and 2000 h. Morning and evening norepinephrine (NE) levels and morning epinephrine (E) levels were significantly lower in the TM group than in the control subjects (morning NE levels, pg/ml, mean+/-S.E.: TM group 136.6+/-13.0, control 236.8+/-21.0, P=.0001; evening NE levels: TM group 119.7+/-10.8, control 175.6+/-17.4, P=.009; morning E levels, pg/ml: TM group 140.2+/-10.6, control 196.7+/-23.8, P=.019). No differences were recorded for evening E levels and dopamine (DA) levels. No significant differences were found for catecholamine levels measured at different times of day in the TM group, demonstrating a lack of daily hormonal rhythm. Anxiety levels were similar in both groups. Based on the results obtained, it can be considered that the regular practice of TM has a significant effect on the sympathetic-adrenal medulla system. A low hormonal response to daily stress caused by sympathetic tone regulation through regular TM could explain our results, as well as the physiological and other effects related to the field of health described in those who practice meditation.

Yoga for epilepsy

BACKGROUND

Stress is considered an important precipitating factor for seizures. Yoga is believed to induce relaxation and stress reduction. The effect of yoga on the EEG and the autonomic nervous system have been reported. Yoga would be an attractive therapeutic option for epilepsy (if proved effective), in view of its nonpharmacological nature, minimal side effects and international acceptance.

OBJECTIVES

To assess the efficacy of yoga in the treatment of patients with epilepsy.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group trial register, the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 1998), MEDLINE for articles published up to the middle of 1998, and also registries of the research council for complimentary medicine were searched. In addition, we searched the references of all the identified studies. Finally, we contacted the members of the Neurological Society of India, several neurophysiology institutions and yoga institutes to seek any ongoing studies or studies published in nonindexed journals or unpublished studies.

SELECTION CRITERIA

Randomized control trials and controlled clinical trials of treatment of epilepsy with yoga.

DATA COLLECTION AND ANALYSIS

The data were extracted independently by both reviewers and any discrepancies were resolved by discussion. The main outcomes assessed were percentage of patients rendered seizure free, number of patients with more than 50% reduction in seizure frequency or seizure duration and the overall reduction in seizure frequency. Analyses were on an intention to treat basis.

MAIN RESULTS

Only one study met the selection criteria, and recruited a total of 32 patients, 10 to sahaja yoga and 22 to control treatments. Antiepileptic drugs were continued in all. Randomization was by roll of a dice. The results of this study are as follows: (i) Four patients treated with yoga were seizure free for six months compared to none in the control groups. The Odds Ratio (OR) (95% Confidence Interval (CI)) for yoga versus sham yoga group was 14.5 (0.7, 316.7) and for yoga versus no treatment group 17.3 (0.8, 373.5). (ii) Nine patients in the yoga group had more than 50% reduction in seizure frequency compared to only one among the controls. The OR (95% CI) for yoga versus sham yoga group was 81 (4.4, 1504.5) and for the yoga versus no treatment group was 158.3 (5.8, 4335.9). (iii) There was a decline in the average number of attacks per month compared to the baseline frequency among the patients treated with yoga. The weighted mean difference ( 95% CI) between yoga versus sham yoga group was -2.1 (-3.1, -1.0) and for the yoga versus no treatment group -1.1 (-1.8, -0.4). (iv) More than 50% reduction in seizure duration was found in seven of the 10 patients treated with yoga, compared to none among the 22 controls. The OR (95%CI) for yoga versus sham yoga group was 45 (2.0, 1006.8) and for yoga versus no treatment group 53.57 (2.4, 1187.3).

REVIEWER'S CONCLUSIONS

No reliable conclusions can be drawn regarding the efficacy of yoga as a treatment for epilepsy. Further studies are necessary to evaluate the efficacy of yoga in the treatment of epilepsy.

Zazen and cardiac variability

OBJECTIVE

This study examined the effects of "tanden breathing" by Zen practitioners on cardiac variability. Tanden breathing involves slow breathing into the lower abdomen.

METHODS

Eleven Zen practitioners, six Rinzai and five Soto, were each studied during 20 minutes of tanden breathing, preceded and followed by 5-minute periods of quiet sitting. During this time, we measured heart rate and respiration rate.

RESULTS

For most subjects, respiration rates fell to within the frequency range of 0.05 to 0.15 Hz during tanden breathing. Heart rate variability significantly increased within this low-frequency range but decreased in the high-frequency range (0.14-0.4 Hz), reflecting a shift of respiratory sinus arrhythmia from high-frequency to slower waves. Rinzai practitioners breathed at a slower rate and showed a higher amplitude of low-frequency heart rate waves than observed among Soto Zen participants. One Rinzai master breathed approximately once per minute and showed an increase in very-low-frequency waves (<0.05 Hz). Total amplitude of heart rate oscillations (across frequency spectra) also increased. More experienced Zen practitioners had frequent heart rhythm irregularities during and after the nadir of heart rate oscillations (ie, during inhalation).

CONCLUSIONS

These data are consistent with the theory that increased oscillation amplitude during slow breathing is caused by resonance between cardiac variability caused by respiration and that produced by physiological processes underlying slower rhythms. The rhythm irregularities during inhalation may be related to inhibition of vagal modulation during the cardioacceleratory phase. It is not known whether they reflect cardiopathology.

Excess catecholamine syndrome. Pathophysiology and therapy

In addition to genetic factors, lifestyle has a predominant influence on primary hypertension and noninsulin-dependent diabetic mellitus (NIDDM). We initiated studies using radiotelemetry for characterizing molecular events linked with excess calorie intake and psychologic stress. An increased calorie intake was associated with raised (p < 0.05) systolic and diastolic blood pressure as well as heart rate independent of day-night cycle. Sympathetic activity was in excess when related to the unchanged motility. The hyperkinetic hypertension is expected to result in adverse remodeling of resistance vessels and to aggravate insulin resistance. To examine adverse effects of psychological stress, rats were subjected to intermittent food pellet feeding. Urinary catecholamines and cardiac norepinephrine stores were increased (p < 0.05). The depressed (p < 0.05) rate of Ca2+ uptake of sarcoplasmic reticulum is expected to contribute to cellular Ca2+ overload. These lifestyle influences strengthen the notion of an excess catecholamine syndrome which requires selective reduction of sympathetic outflow of the brain by I1-receptor agonists.

Mind-body therapy in the management and prevention of coronary disease

Conventional mind-body therapy has been proven a valuable noninvasive way to manage coronary disease. Yoga practice, especially, has been found to be valuable in preventing adverse outcomes of coronary disease by improving resistance to stress.

Treino de controle do stress para hipertensos: uma contribuição para a medicina cornportamental

Dentro do referencial da Medicina Comportamental, o presente estudo teve por objetivo verificar a eficácia de um treino de controle do stress na redução da reatividade cardiovascular de hipertensos, gerada pelo stress dos contactos interpessoais. A pressão arterial média de 20 sujeitos, hipertensos leves e moderados, foi aferida durante sessões experimentais que envolviam a necessidade de ser assertivo, antes e após o tratamento comportamental do stress. Os resultados indicaram que a maioria dos participantes era altamente inassertiva, tendo muito dificuldade de expressar tanto sentimetnos positivos como negativos, que o stress social é capaz de eliciar uma reatividade excessiva na pessoa hipertensa e que esta reatividade pode ser reduzida com o tratamento do stress.

Reproducibility of twenty-four-hour finger arterial blood pressure, variability and systemic hemodynamics

OBJECTIVE

At present, non-invasive continuous monitoring of finger arterial blood pressure by the volume-clamp technique is considered the best approach to obtain reliable assessments of beat-to-beat blood pressure. However, data on the reproducibility (accuracy and precision) of prolonged recordings and of the hemodynamics derived from wave-form analysis are not available.

DESIGN

Ten patients with untreated essential hypertension and eight normotensive subjects were monitored by Portapres over 24 h in the hospital on two occasions with 1-4 weeks in-between. Physical and mental activities were standardized as far as possible to minimize intra- and intersubject biological variability. Stroke volume was obtained by the Modelflow method. Differences between the two recordings were computed separately for the day (0700 to 2300 h) and the night (2300 to 0700 h) and for all hours. Differences in stroke volume were calculated as percentage change from the first recording.

RESULTS

Accuracy was good in both groups and bias was close to zero. Precision was also remarkable in the daytime, and at least as good as values reported in studies that used the standard intra-arterial recording. The SD of the differences in systolic and diastolic pressure in the hypertensives in the daytime were 6.6 and 4.7 mmHg, respectively. At night, precision was less good, possibly because of the 30 min finger-cuff switching: 12.5 and 6.5 mmHg for systolic and diastolic pressure, respectively. The average stroke volume did not change more than 8% at most between the first and the second recordings.

CONCLUSION

These results indicate that the Finapres and Portapres devices are a reliable substitute for intra-arterial recording, and are most useful instruments for the study of blood pressure regulation.

A controlled study of the effects of mental relaxation on autonomic excitatory responses in healthy subjects

OBJECTIVE

Circumstantial evidence indicates that, in the presence of a suitable substratum, sudden, behaviorally induced increases in sympathetic drive to the cardiovascular system might play an important physiopathological role in various conditions, ranging from arterial hypertension to sudden coronary death. Accordingly, it might be useful to study the effects of behavioral interventions, such as mental relaxation, that might be capable of blunting excitatory autonomic responses. It would also be preferable to study healthy subjects in whom autonomic control is not modified by the presence of disease, and to use noninvasive approaches to minimize the possible emotional impact produced by invasive recordings.

METHODS

We examined healthy subjects who were either subjected to relaxation training (N = 13) or sham relaxation (N = 12). An additional group, treated with beta-adrenergic blockade (N = 12), was also examined. Spectral and cross-spectral analysis of RR interval and systolic arterial pressure (SAP) variabilities provided quantitative markers of sympathovagal balance modulating the sinoatrial (SA) node, of sympathetic vasomotor modulation, and of the gain of the arterial pressure/heart period baroreflex (index alpha). Subjects were studied at rest, during standing, and during mental arithmetic.

RESULTS

Data indicate that both beta-adrenergic blockade and relaxation training significantly blunted the excitatory autonomic responses to standing and to mental arithmetic. Indices of sympathetic modulation also seemed reduced by beta blockade at rest. No changes were observed with sham training.

CONCLUSIONS

Frequency domain analysis of cardiovascular variabilities, using a totally noninvasive approach, indicates that relaxation training significantly blunts the excitatory autonomic changes produced by standardized behavioral laboratory stimuli.

Stress, stress reduction, and hypertension in African Americans: an updated review

This is a comprehensive and integrative review of multiple factors underlying the greater prevalence of hypertension in African Americans compared with whites. Evidence linking stress with hypertension and cardiovascular disease in African Americans is reviewed. A survey of mechanisms of hypertension in African Americans and existing behavioral strategies for the treatment of hypertension is presented. Given that the excess of hypertension may be mediated in part by behavioral factors operating through biological mechanisms, a case is presented for behavioral stress reduction measures. This review of stress reduction techniques especially the Transcendental Mediation program for the treatment of hypertension in African Americans highlights current issues facing the field. New information is provided to help direct future nonpharmacological research and practice in hypertension to prevent morbidity and premature mortality in this underserved population.

A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure

Cardiovascular responses to stress reactivity has been proposed as a risk factor for hypertension. In this study, we evaluated the effects of stress reduction on both laboratory cardiovascular reactivity and ambulatory blood pressure in real life on 39 normotensive male subjects who were pretested for ambulatory blood pressure and cardiovascular reactivity to stress using a battery of laboratory stressors. Thereafter, subjects were randomly assigned to practice either the Transcendental Meditation (TM) technique or a cognitive-based stress education control (SEC) for four months. After 4 months, there was no change in cardiovascular response to stressors between the TM and control groups. However, the subjects regularly practicing TM demonstrated a significant reduction of 9 mm Hg (p < .04) in average ambulatory DBP compared to controls. Since ambulatory BP monitoring has been shown to be a better predictor of cardiovascular complications of hypertension than clinic BP, this finding may have important implications for primary prevention of CVD in normotensive subjects.

Trial of stress reduction for hypertension in older African Americans. II. Sex and risk subgroup analysis

Our objective was to test the short-term efficacy and feasibility of two stress-reduction approaches for the treatment of hypertension in older African Americans, focusing on subgroup analysis by sex and by high and low risk on six measures of hypertension risk: psychosocial stress, obesity, alcohol use, physical inactivity, dietary sodium-potassium ratio, and a composite measure. The study involved a follow-up subgroup analysis of a 3-month randomized, controlled, single-blind trial conducted in a primary care, inner-city health center. Subjects were 127 African American men and women, aged 55 to 85 years, with diastolic pressure of 90 to 104 mm Hg and systolic pressure less than or equal to 179 mm Hg. Of these, 16 did not complete follow-up blood pressure measurements. Mental and physical stress-reduction approaches-the Transcendental Meditation technique and progressive muscle relaxation, respectively-were compared with a life-style modification education control and with each other. Both systolic and diastolic pressures changed from baseline to follow-up for both sexes and for high and low risk level (defined by median split) on the six measures of hypertension risk. Compared with education control subjects, women practicing the Transcendental Meditation technique showed adjusted declines in systolic (10.4 mm Hg, P < .01) and diastolic (5.9 mm Hg, P < .01) pressures. Men in this treatment group also declined in both systolic (12.7 mm Hg, P < .01) and diastolic (8.1 mm Hg, P < .001) pressures compared with control subjects. Women practicing muscle relaxation did not show a significant decrease compared with control subjects, and men declined significantly in diastolic pressure only (6.2 mm Hg, P < .01). For the measure of psychosocial stress, both the high and low risk subgroups using the Transcendental Meditation technique declined in systolic (high risk, P = .0003; low, P = .06) and diastolic (high risk, P = .001; low, P = .008) pressures compared with control subjects, whereas for muscle relaxation, blood pressure dropped significantly only in the high risk subgroup and only for systolic pressure (P = .03) compared with control subjects. For each of the other five risk measures, Transcendental Meditation subjects in both the high and low risk groups declined significantly in systolic and diastolic pressures compared with control subjects. Effects of stress reduction on blood pressure were found to generalize to both sexes and diverse risk factor subgroups and were significantly greater in the Transcendental Meditation treatment group. These effects (along with high compliance) even in individuals with multiple risk factors for hypertension clearly warrant longer-term investigation in this and other populations.

Emotional disorder in chronic illness: psychotherapeutic interventions

BACKGROUND

Emotional disorder associated with physical illness falls into two main groups: psychological reaction to physical illness and somatic presentation of psychological disorder Psychological treatments are becoming more widespread in the general hospital setting, but there are few systematic evaluations.

METHOD

A manual and computer (MEDLINE) literature search was performed. Studies which provided insight into clinical practice were selected for discussion, and randomised controlled trials of at least 6 weeks duration and inclusion of 30 or more subjects were selected for review.

RESULTS

Fourteen empirical studies were found: six involving patients with chronic organic disorder and eight involving patients with somatisation.

CONCLUSIONS

There is little empirical evidence that psychotherapeutic interventions are of benefit when applied indiscriminately to patients with organic disease. Further work is required to delineate subgroups of patients who may be responsive. There is mounting evidence that psychotherapy is beneficial in patients with somatisation disorders. Patients with very chronic symptoms may require intensive treatment approaches.

Improved hypertension control after disclosure of decades-old trauma

This report presents the case of a 49-year-old woman who had been treated unsuccessfully for 6 years for longstanding severe and refractory essential hypertension. Although she reported no extraordinary stress or distress, her disclosure of a 3-decade-old rape and the experiencing of previously repressed and unconfided emotions related to it were followed by a dramatic and sustained improvement in her blood pressure. This case suggests that repressed emotions, which patients cannot report, may contribute substantially to the development of essential hypertension, even when they are related to decades-old events. More attention to repressed emotions, and better means of studying them, are needed before the mystery of the links between psychological factors and essential hypertension is unraveled.

Effect of stress management on blood pressure in mild primary hypertension

OBJECTIVE

To establish whether stress management had a larger effect than a control treatment on resting blood pressure, ambulatory blood pressure, and left ventricular mass.

DESIGN

A 12 week baseline period of habituation to measurement of blood pressure was followed by randomisation to either stress management or mild exercise for six months and follow up six months later.

SETTING

General practice, district general hospital, and medical school.

PATIENTS

Of the 184 patients aged under 60 with mild primary hypertension who entered the baseline habituation period, 88 were excluded because they failed to meet the entry criteria or they withdrew from the study. The remaining 46 men and 50 women underwent treatment.

INTERVENTIONS

10 clinical sessions and daily practice at home of either stress management based on relaxation or non-aerobic stretching exercises. Mildly stressful 15 minute interviews before and after treatment.

MAIN OUTCOME MEASURES

Diastolic and systolic blood pressure in the clinic and during 12 hours of ambulatory recording, and left ventricular mass measured by echocardiography.

RESULTS

The patients' blood pressure fell during habituation (systolic pressure from 152 mmHg to 140 mmHg, diastolic pressure from 98 to 93 mm Hg), but neither resting nor ambulatory blood pressure was changed by the treatments. Left ventricular mass was also unchanged. Blood pressure rose during the stressful interview, but this rise was reduced by stress management (systolic pressure rose by 7.4 mmHg before treatment and by 3.7 mmHg after treatment).

CONCLUSION

Stress management of a type advocated for treating mild primary hypertension is ineffective in lowering blood pressure in patients who are well habituated to measuring blood pressure.