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.

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