August, 2006

Dimensions of the Problem
Hypertension (HTN) is defined as a repeated blood pressure reading of greater than 140/90 mm Hg. An estimated 50 million Americans have HTN, and over 31% of those who have it don’t know it. In approximately 90-95% of HTN, there is no specific physiological cause found (High “Blood Pressure Statistics,” undated).

These cases are classified as essential or idiopathic. Predisposing factors include obesity, smoking, diets high in fat or salt, other co-existing conditions including diabetes, and a number of genetic, environmental, and behavioral factors (DiGuiseppi, 1996).

The direct and indirect cost of hypertension in 2000 was $50.3 billion --approximately $37.2 billion in direct costs; $13.1 billion in indirect costs (“Heart Disease and Stroke Statistics,” 2002). HTN is a major contributor to coronary artery disease (740,000 deaths per year in U.S.A.), cerebrovascular disease (150,000 deaths per year), and kidney disease - three of the leading causes of morbidity, mortality, and medical resource utilization in the USA (Dawber, 1980).

According to the National Center for Health Statistics, there were 35 million outpatient visits for hypertension in 2002(Cherry & Woodwell, 2002). In 2000, 44,619 deaths were attributed directly to hypertension in this country, with HTN playing a part in 118,000 more (“High Blood Pressure Statistics,” 2003).

The benefits of controlling even mild hypertension are well accepted. Long-term reductions in mortality from coronary artery and cerebrovascular disease of between 15–25% have been reported in large-scale studies (Five-year Findings, 1979). Incidence of stroke, in particular, can be sharply reduced by controlling hypertension (DiGuiseppi, 1996).

Medical Management
Treatment of HTN with prescription drugs has steadily improved. A class of drugs called ACE inhibitors are now often prescribed as first line treatment. These drugs replaced earlier use of diuretics and beta blockers, whose side effects often led to noncompliance or poor compliance. Lack of compliance with medications is still a major complicating factor in treatment (Patel & Marmot, 1987).

Nonpharmacologic Management of Hypertension
The effectiveness and cost-effectiveness of behavioral interventions, when combined with drug therapy, were shown repeatedly in the 1980s (Agras, 1981; Crowther, 1983; Ginsberg, Viskoper, et al, 1990; Patel & Marmot, 1987). Chief among these interventions are exercise, weight loss programs, and relaxation.

Behavioral approaches also have added advantages: improve quality of life, better patient self-efficacy, reduction in mortality, improved patient feeling of being in control, and improved compliance with therapy (“Five-year Findings,” 1979; Ginsberg, Viskoper, et al; Lorig, Sobel, et al, 1999; Patel & Marmot). Cognitive Behavioral Therapy, even without a relaxation component, is effective at reducing stress (Abgrall-Barbry & Consoli, 2005). Perhaps because of improvements in drug therapy, behavioral approaches have not become mainstream in the U.S.

Mind-Body Management of Hypertension
Guided imagery is a highly effective behavioral intervention for HTN. It combines deep relaxation with positive self-suggestion, both of which reduce blood pressure (Crowther, 1983; Taylor, Farquhar, et al, 1977). Researchers from the Centers for Disease Control and Prevention have stated that “evidence for the efficacy of certain non-pharmacologic approaches to preventing and controlling HBP [high blood pressure] is strong” (Labarthe & Ayala, 2002).

Individual studies support the efficacy of imagery, relaxation training, biofeedback with relaxation training, hypnosis, and autogenic training (Herrmann, 2002; Nakao, Yano, et al., 2003; Stetter & Kupper, 2002).These results were further confirmed by two 2003 reviews of the medical literature. One study found “moderate evidence of efficicacy” for using mind body modalities (relaxation, imagery, hypnosis, CBT) for managing HTN (Astin, Shapiro, et al, 2003).

One researcher reported in his 2002 study that “relaxation techniques (autogenic training or progressive muscular relaxation, behavioral therapy or biofeedback techniques), can lower elevated blood pressure by an average of 10 mmHg (systolic) and 5 mmHg (diastolic)(Herrmann, 2002). A review of 37 studies of the relaxation response confirmed its efficacy (Mandle, Jacobs, et al, 1996).

Meditation (Barnes, Davis, et al, 2004; Barnes, Treiber et al, 2004; Stefano & Esch, 2005; Vyas & Dikshit, 2002), relaxation, and stress reduction (Kurz, Potz, et al, 2005) have also proven beneficial. Breathing exercises can also lower blood pressure (Bernardi, Spicuzza & Sleight, 2005). In two studies of African American women, meditation decreased blood pressure (Schneider, Alexander, Staggers, Orme-Johnson et al, 2005), and significantly decreased mortality (Schneider, Alexander, Staggers, Rainforth, et al, 2005).

One review analyzed 22 biofeedback studies; it was found that only relaxation-assisted biofeedback was able to significantly decrease systolic and diastolic blood pressures, leading the researchers to conclude that its effect may have been from the relaxation component (Nakao, Yano, et al., 2003.

A low cost guided imagery program can be a valuable complement to medical treatment of hypertension by contributing to more effective management of blood pressure, better adherence to therapy, decreased need of doctor’s visits, and higher quality of life for patients.

Abgrall-Barbry G, Consoli SM. [Psychological approaches in hypertension management] [Article in French] Presse Med. 2006 Jun;35(6 Pt 2):1088-94.

Agras WS. Behavioral approaches to the treatment of essential hypertension. Int J Obes. 1981 5 suppl 1:173-81.

Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract. 2003 Mar-Apr;16(2):131-47.

Barnes VA, Davis HC, Murzynowski JB, Treiber FA. Impact of meditation on resting and ambulatory blood pressure and heart rate in youth. Psychosom Med. 2004a Nov-Dec;66(6):909-14.

Barnes VA, Treiber FA, Johnson MH. Impact of transcendental meditation on ambulatory blood pressure in African-American adolescents. Am J Hypertens. 2004b Apr;17(4):366-9.

Bernardi L, Porta C, Spicuzza L, Sleight P. Cardiorespiratory interactions to external stimuli. Arch Ital Biol. 2005 Sep;143(3-4):215-21.

Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2002 Summary. Advance data from vital and health statistics; No. 328. Hyattsville, Maryland: National Center for Health Statistics. 2002.

Crowther J. Stress management training and relaxation imagery in the treatment of essential hypertension. J Behavioral Medicine. 1983 Jun 6(2) 169-187.

Dawber TF. (1980). The Framingham study: the epidemiology of atherosclerotic disease. Cambridge, MA: Harvard University Press.

DiGuiseppi C, for the U.S. Preventative Services Task Force. Screening for Hypertension. The Guide to Clinical Preventive Services: Task Force, Second Edition 1996 (excerpt).
Accessed August, 2006.

[No authors listed] Five-year findings of the Hypertension Detection and Follow-Up Program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-Up Program Cooperative Group. JAMA. 1979 242:2562-2572.

Ginsberg GM, Viskoper RJ, Prem S, Bregman L, Mishal Y, Sherf S. Resource savings from non-pharmacological control of hypertension. J Human Hypertension. 1990 Aug; 4 (4): 375-8.

[no authors listed] Heart Disease and Stroke Statistics — 2003 Update. Dallas, Tex.: American Heart Association. 2002.
Accessed August, 2006.

Herrmann JM. Essential hypertension and stress. When do yoga, psychotherapy and autogenic training help? [Article in German] MMW Fortschr Med. 2002 May 9;144(19):38-41.

[no authors listed] High Blood Pressure Statistics. American Heart Association. [undated]. http://www.americanheart.org/presenter.jhtml?identifier=2139
Accessed August, 2006.

Kurz RW, Pirker H, Potz H, Dorrscheidt W, Uhlir H. [Evaluation of costs and effectiveness of an integrated training program for hypertensive patients.] [Article in German] Wien Klin Wochenschr. 2005 Aug;117(15-16):526-33.

Labarthe D, Ayala C. Nondrug interventions in hypertension prevention and control. Cardiol Clin. 2002 May;20(2):249-63.

Lorig KR, Sobel DS, Stewart AL, Brown, Jr. BW, Ritter PL, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care. 1999 37(1): 5–14.

Mandle CL, Jacobs SC, Arcari PM, Domar AD. The efficacy of relaxation response interventions with adult patients: a review of the literature [see comments]. Journal of Cardiovascular Nursing. 1996 Apr, 10(3):4-26.

Nakao M, Yano E, Nomura S, Kuboki T. Blood pressure-lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertens Res. 2003 Jan;26(1):37-46.

Ornish D. (1990). Dr. Dean Ornish's Guide to Reversing Heart Disease. New York: Random House.

Patel C, Marmot M. Stress Management, Blood Pressure and Quality of Life. Journal of Hypertension. 1987 5 (supp 1): S21-S28.

Schneider RH, Alexander CN, Staggers F, Orme-Johnson DW, Rainforth M, Salerno JW, Sheppard W, Castillo-Richmond A, Barnes VA, Nidich SI. A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year. Am J Hypertens. 2005 Jan;18(1):88-98.

Schneider RH, Alexander CN, Staggers F, Rainforth M, Salerno JW, Hartz A, Arndt S, Barnes VA, Nidich SI. Long-term effects of stress reduction on mortality in persons > or = 55 years of age with systemic hypertension. Am J Cardiol. 2005 May 1;95(9):1060-4.

Stefano GB, Esch T. Integrative medical therapy: examination of meditation's therapeutic and global medicinal outcomes via nitric oxide (review). Int J Mol Med. 2005 Oct;16(4):621-30.

Stetter F, Kupper S. Autogenic training: a meta-analysis of clinical outcome studies. Appl Psychophysiol Biofeedback, 2002 Mar;27(1):45-98.

Taylor CB, Farquhar JW, Nelson E, Agras S. Relaxation therapy and high blood pressure. Archives of General Psychiatry. 1977 34:339-42.

Vyas R, Dikshit N. Effect of meditation on respiratory system, cardiovascular system and lipid profile. Indian J Physiol Pharmacol. 2002 Oct;46(4):487-91.

Yucha CB, Tsai PS, Calderon KS, Tian L. Biofeedback-assisted relaxation training for essential hypertension: who is most likely to benefit? J Cardiovasc Nurs. 2005 May-Jun;20(3):198-205.