Stu~~'~~-'in, P~0~1 fUlfil~;lent ~f

· _. · · 0 _· _{c ',} ··· _{,,, ,} · _{' .\} " ' _{' '} , _. " _{, ...-/} . ~. ". '

" A thesis-submittedtoth e School"of Graduate

Stu~~'~~-'in, P~0~1 fUlfil~;lent ~f

^the..

-of-

,

requ irements--{or the degree

-

of

?

.

-~'.

. ^,

. .

^-

.

.THE~FFECTS

OF

REIAXATIO NTHBRAPY ON.~.YP~RTENS~_ON ^{.( . '}

« \ by

t:; .

•~dri~nDesmond ~OOmbs" B.Sc. (Hans:,.)

Ma.sterofSCie!1ce

•11:-...'

Oepa'r~ent f Psycno!ogy - Memoria"!Ul'liverityofN~wfoundland

un e1985

"~7-~"

.

⁽

.

\

~I

Newfound land

',,{;'. t.•

.'

.,:~~.

The ~thor (cop¥ri.qht,·~••m~r)

ha s- -reaerv e d o t . her publication'rights •.and n'e i t l'ler the .en ee Le nor extensive extracts from. it ..may be pri'ntedcr otherwise reprodu'ced ...ithout his /her' ...ritten permission.

L'autoris ~tion aete accordee

a

1&·'8 iblioth~que oa('1,ona1e du Canada de micrcfi1mer cette these'et de.preter ou de ve nd r e des exemp1aires du film.<. '\

L'auteur (t.it~iai re'du'dro i t' d'aut.eur) -ee reserve ies autres droi1;s de'p ub l i c a t i o n:

n1 1& these oi de longs e x e r ete e de ce rree et ne doive!1t et.rE! imprimes ou autrement.'r e p rodu l t s sansson' autorisation,~ crit.e•

ISBN 0-315-36979-5

•.

~

,.l,....,••

. .

(:

l _,~ ^{. t}

. I.n,this'st~dYth~effectsof relax~ti~nthrrapy onthe' control ofhype r/t en s i o n wereexamined. From eac h of four..rural

~l~nicai

^settings10 hyper tens ive

SUbj~~ts~ ~g:e$

^{24 to 55}

.

~

,

^{. ' . . -; '"}

,

ye a r s . total of.,18 meIe s and 22 females .,were'a~signedto t-he fol lowingcondit~iol)s: "'0 ...'No':'t r e a t'me n t control; (2) Rela xa- tion;

(1\

Education; and (41 Education Plus

Rel~xation . I(n ')

·the

Re ~a4ation,'conditi~n .

^{. ,.s ub jec t s}

receive~ 1o'u~':~s-minut~

' " .; . . i :. "

~e~Si~nsof <,Jrou^p:.r~laXa tiOn.Wh i l e.the"Educa t.i.~: "con~l~,"." . receivedfour,20-minuteeducacfce eees.tcns. cons is ti ngofa---...

' . .•.. . • . . I ~ .

slide-a nd-tapepreeeneeer.cnand a 20- mi nutegr ou pdiscussio n .' ~

' . .. . - .i· . . .

T~eEducationplusRela~ationconditioncombined the pro- , , ceduxe a of the-Re l axat ionend. th:Educationcondd t.Lona , 'Fo r

" , . T- ' " . "

" ',C~~~itio.nsth:~ubiects'blOO~press urem~asure"s" "

·taken on..fo_ur.-oc.casions, at'a pr e t r e atment...sessi.on,--<iller - - _

l " ". ~ . " - •

the fi naltreatmen~session ,andduring thea-weekand 4- we e k fol low- upsessions. A 3-way-a naly sis or-variance-(Conditions :'xSessionsxPress u res)was per f ormed with the sub jects

·

~ested_

^:under'th.e 'fl?ur

~onditions .

^'

A.si gn if i c a n.t Sessi o nseffect. , a sigJ1 ifica nt.Session s x Condit io nsin t e r a ct i on,and a signi~icant"S~8sion,sx Pr e s":- e ures interact~on~ereEo u nd, Although~thi swas no t. t.he ma in in t en t ionof thi s st ud yi t didma kemetho d olo gi calco n-"

tribut~ons,by d-emonstrat ing the,we a k n e s s oft~e's~n9legro up 'desi g n ~nwhioChoth~r^{st u cHesin',th is-ar.ea,have f}requen t l"y

·~elied" ^Inthe futur e"muchm~re at:~ention^mustbe pa':'id to a ca!ef u l and standard~zed _ meth~dology·.'

";" . " """"" ·r. "··

\ .

I

'..0<\":,,,,

.

_I

^,

/

I

I -/

~~ , -'

^;

. ^,

ACKNOWLEDGEMENTS

.,: The

fOll.~wing

^{stuc!y was}

~de PO~Sible

^by

t"h~ support~

^{of- .}

th'eGran d

F" ~ '

Central 'hos p i ti " particularlyjlrs. Mackey ,.', ..

A88istan~in'ist:~tor

^{I and Ms.}

~baluna .

^Headf'f.Psyc.hOl 0 9 Y.

Spe cialtha nk.sar~exte~dedtothe',i ndi vid ua l s who partici- pated in the study.

Furthe~ore "

^{I'wo-ld'lik e-to}

t~an'k

^the

~~e_rS _Of

,my committee, Dr.

Pr~ston

^{IChai;man)( Or. aecees}

a'~~ ~~ ":.FOdor.

^{Anumber of}

frie~ds wer~

^verysup po r tive:

.'

-. . ' . . ,

Bill, Brian'.and9~1Sra .

-This paperis"de di c a t e d ee Sond x;a:;;:::y

Wlf~ ,, : a:n~'

^Marc,

my 'Son ,wh o'provide dthe

motivati~n to .c;mPl~te

^the'study.

- -- - - - --,-

: i)-· ·

~.~

--'\:J.\';~:~,~ ... ~'"

I .

'i ii

",...•,\~..-.. ..'...:~:..~~-". '.-,·f;',...,~.~

.

- . .

^'.

·r

~ABLE'OFCONT ENTS

Abstract. . . . . I

Acknowledgements

~.

•Page

·u iii

~

'"

vi •

,.

114

.1

15· lS 15

·17

~5 31

34

35 3.

37 3.

: : :\

APPENDIX E: Analysis

of

^VarianceS.ummaryTable_.

~PENDIX^Fl·Procedur~'.JMimual . . . • •: ~~!i

INTRODUCTION List of Tables .

METHOD', • • SUbject s . Appara tus MatWals Procedure -, Li~tof Figures

J .

RESULTS ••

DIS CUS S I?N

---'.·-.RE""FERENe~~z-rr-·;-- -;

APPENDIX A:Table of Subjects' Ages,Geride:r.s and Education ', .

APPENDIXB:Tableof-dne-w~y^A"naly si:s'Of Variance on A?es of Subjects.

APPENDI X.C:Behayioul'al ccnurece APPENDIX0: Data'Shee t • . . . .

iv.

T.'"

. . .

.;":,

Table

v '·

^:e.

· · - .· ^. .

\../'\,,'.

1.' The Means.for significant Elfet;itsShown

"c e c e s Section . . . . . . . .

2...:rhe_~sJ.on)...:;':lits of the Tukey' s

~ethod

^Performed

x Pressure J.

.

,, " ' ,

3. Tneltesultsof:t he·.Tuke y's et 'Performed on the Sessionx Condit' a Inter-

action .

-';

/ 19 '( .

20

23

".

'1

.: _{I ~ .}

LIS;rOFFIGU~E.S

24 Page 1. A_{for a}graph of_{l l}·Cond i t i on s bysys to li"candSessIons

dias~oU.c'-;;;hure

. ~ •. . ^'.

2. ~he 'i{r~·Of the SessionsJb Y Cond itions

~nte radJ.on • . • •.•.

.! . . . . . . . .

Figure

/

I

!

./

. /"

^".,

"

..:

- '

INTRODUCTI Ol\

Hyp ert e n s i o n; or h!.qhtb1ood.pressur.e.'is a major cause" .

. . , .

of he etrtfailure , strokeandkidney failurewhi~c~.aC;count a

. .

for ~lacq e proportionof adul t deaths in the UnitedStates

oilnd Cana da. The best..kn~~dmostwi delyaccep't~ defin~-

<,( ..., . -

.tion of hyp e r t ensi o nhas.beenprov i~ ~dby.the Wo r l d He al th.

'•.~j

:.~

,i.

I

.

.

O,cqani z a"tion(.~H~ l E?~rt:CO~i tte.eon

""?"

^{ryper t'!Ds.ion.}

~;::' a:

^9:8

~~s~::;c m :::s::::n.:

q ::.:

.::~::t 9::::::1

⁸

t , ::erten- . .

160 nun 8g.:

(2~ . ] '

^KPa

~ and~or

^a

fifth':'Ph~se'

^dias

' ~lic

^{pre s -.}

... . I , . .

aure.eq ualtoor,greate r than95 mm "9. ("12. 7RPa"': Pri or

"

, ' ~ ." t • •

\ _. ^::~::: . :: ::" ::e::::: _.

^t

r::::::j:n::::~::: .::::n:o~·:e::::· _{. r -} ~ .

\ -r e c cemend s, for clinical pur po~i...thea~erage"of'a t least

• three

~ead;n~~

^{on at}

leas~

two differentoccasions to arrive

\

^.

.

\.at a diaqnosis of hy~er~en~ion . :) •

Altho ug h WHO defineshypertensionas a blopdpressure of,16~/96or higher , rese~rchsh9WSth~tthefreque~cyand

1."e ve r,i ty of complicationsincrease at:.'ra p i d rate

W hej ..

.:dia sto li c blood pre s sureetseeabo v e,

'0 ^or

^{Hg. orwhe n ~}

\.systo li c pxe se u r eri'~esa))tve 140-14 5'(P,~1 ; ^{197 5 ).} Furtp e r - Imo re , ~ecent l.~~ature ind i c a tes tha t pa t i,entswith"bl..~od

pressurethatC~xceeds^140/90romHg. sho u ld be tre_ated i(Cho?anian,1983.).

se~O~da~y" hyper~:~sion' fYP~,rt·e.n

^..sion·se conda rYto_a n' .o.rg!"n lcdiso r d er, can .us ua llybe cured}'ysurgeryorothe "r

di r ect method s . Hype r te nsio n witho ut akn~ncau s e is

direct met!,,?ds.

/

"-

~ype;te~'ion witho~t

^{a knownca use is}

•

term.~d·,npr i rnar y ","e a s ent.LeI"or "idiopa t hic-,hyperten si~n.

. ,

Hypertension, indepe nd ently of i tsetiology,involve s ml;lltiple physiological, psych osocial, behavioural'a nd 'di e ta ryfa c t or s which ha ve att~acteda great deal of

research and cli n icalinvestigation fromawide'rang eof

. . "

disc1p~~nesinCluding th e following: phys io logy . ,ph armacol- ogy, publiche !!lth ,epidemiology, qenebLca'a nd psych~gy.

The traditional therapeuticap p r-oa c h.torhyperten~ion

Ca';·tihYi>.~.rtensiv~ '~ru9 therapy .. , Colla b o rat i vestudies '

~~Sh~wn

^that

Ph~AtacO~\h,:rapy ~ea~s

^to

s~9nifican,t

^reduc-

tion'·ot"complicationsof hypertension:"(Vet erans.Admi nis tra-

ti'o~

^Co-op erati ve·StUd Y Group. :/ Ant·ihyperte ns i ve"

Agen~l! '

1967.. 1'970) . The·h~gh·er^th'eJre t r a a tme nt pres sure. the more be"ne fitobteIne dby the/medication. .Among 73treated'

patients 'with-diast~lic p r,!" ure between ll~ and 130..,

. / .

Hg., therewa s an inci dic~of seve re eomp LdcetLon with on ly-2-ove r al~year periodas compared with27 fOFthe 70 patie nt s'treatedwith'Plac e bo.(VACS, 1967).

T'h~·se

^com-

plicat ionsin'C1Uder Uddendeath ,Cadvanced

retin~'l . .

^.

changes.'r enalmalfunction,-s t r o ke s,myo cardialinfarct·ion,

cong~~ar/failure and mali9~ant h ypertension. O n :

:::~::h:~rH'<:: ^{" ::::::::d W ::: k} d::':::::o::::s:r:~:lica_ ^.

.t.Lonover · 5-yea r.periodwas reduced from 55% tJ) 1St. by

tre~tm.i .

^{JVACS ,1970}. Finally,}

patil!!n~,Wit~

^mild

hY~e:r­

tension.unlessthey were over 50 years old or already had

1'-~ -,

^{en "} " ' - ' : " . ,.. .. Lved

,,~

^•

/1l

becauseof'drugi~tolerance{9.8%VS.2%J.

benefit'f r om medication. Thisdecre:.a~edeffecfivenessfor

,

. '

drugs for.mi l d hypez-t.enad cn was confirmed in a rn-vear con-:

I ' , .

t,!,ol'le~rntervention's tud:r:, by Smith'(l9pJ. In th.,is~tUdY

,ca r di ac abnormalit.ieson elec,trocardiD9r~mor'onx-raywere

.more co~oniri p:J,ace bo gr?UPB(S 3 . ~ ,VB,23~8'J, butthe major. compLdcet Lona ofdeat~,myocardial infarctionand stroke coc urred as~requently-inthe pharmac'ol0'1ically t~eatedgroup.as in,the control group. In,a ddi ti o n, alar9~r proport'ionof·pat.ient~in the~reatmEmf:groupdropp\~c:'ut .

'The pharmacologica l·t~eatmentof-\9 ypertens ionha spro-

•

duce;"'markedre d uctJ.ons an blood

press~

^{as wel l: :}

inc r e a s e{ l if e expectancy (Freis, 1971). The incomplete

-- ~Oritr~

^of

blo~ ~ressur~

^{and t}he side e.ffe'ctsof !:'edtca-

· ·r · ·

tion"h-ave created the incentiveto search.f~rother,me thod s

of blood

pr~ssure

^control

t~ >~PPlement

pharmac0;l0qical.

.c.ree tment; , '

Inth e early'1 9 ~ O's , the biofee.db<'l.ckapp r-cach W&S widely,a'tudLe d in·an attempt to find~a nonpharm'acological tr eatment: Alt hobg h numerous,st ud i e s (~enson, Ro~ner'~' Ma .r;z e t t a , 6< Kke Lnchuk , 197 4a; Blanchai'd,&Young, 1973,

? ' .

1~-'4 ;(J\lder ~ R,Ui z·,..~eab1.er, ^&.Di lle nkof f e r,' 19: .'Mille r,'. 1972 )

~ave ~hown th~t tt:Uman~

^{are ableto reducetheirblood}

p.re s s ure,wi th thea~sistance.of'biofeedback. a 11 ce reeure reviewby Blancha rd and Young (1974) concl uded that'most

S~dies

^showed'

c~anges

of small maglli'tud:·a nd

durat~:on

^and

-'-:-fail~tl

^to

d~mons~rate ,g~~e~a lization,

^{'t o}

t~e. nat~ral

^{;l'nvi r'o n:'}

,me nt., Blan c ha rd and Y0l,1n9 (197"4") speculat ed tha t'other;

','

""

/~-

.:e. /

..J.'

"

methods, particularly relaxation:~~erapy.'mightprove'~~be more e f f eccLv e than. b Lofeedback ,,

'

...

:;:~."

... ..

^'

.Th e stiud Le a. of theapplication of relaxationor :

~elaxation -lilte

^{p;oceduresco uld,be.s:l}a s s ifi e d

a ~co~i::l.in9

t~:thref;tr;esearch designs::/singlegroup, group,stu~ ies^{wi th} a n,onra:~?om~yselected'control groupandco~tn:olgroup .with .

;andOln':;s~i9nmE;nt^"? f". s u b j e c t s." ._,.,. ' :~ ThP·ea~i..r.'studies ^{review;d.in the}"fOl'lowin.9:paragr.aphs

use d the:-.sing'l:egroup design•

. Ben~o~,..~o~ner·••~arzet~~. a.~d-·Klei nChUk' ,0974a, 19 ~ ~ b l,

-Ln two uncontrolled$1J.191e.group's t udie s ,.investigated'the

.e ff~c,tof tra nscenden ta l meditat~'f:mon~oderatel'Yhypeeeen-

'~ive ~~~jects. S~bjec~!;a.weres~le~tedbasedon,·the...crite~ion .•

•of'ha v i ng'blood'pr es ,ur e greater 1;han140IJIllIHg.,systolic·o r.• .'

~.Orom H9.d.iastolic'•.. ,The bloodpressure was measuredcnce a week'duri ng a 6":week periodtoobt a i n a-baseline. Aft.er ....

, , " ' ,' -

.

initiat ionof x.he meditationees atcne , the SUbj ectswerefob..

l.~~ed f~r

^{. :}

a:vera~e ~~ :2~- 2:' w~ks . 'Bio~d

^pres.sure

rfeas~re-

•m..en~swere"tak'Cl:~with a r~ndomze~oSp~ygm~.manomet.erat a .:

time whentihe sub je cc s~erenot meditating. Thesestudie~

differed.in one reepeces medication was no t used in th.e

·~irst (,Bensonet al.,'197 ~), b~t'.i~the second anti hyper-. tensive

medi'Ca~ion """ w::"s. k~pt

at a con!!tant

' dd~e

^{,ievel (Benson}

~. 197 4b ) . 'I n the firststudyLnwhic hmedication~as .J

. \. ' . , ' , '

.

no t'used (B~nson.~. f97 4a l ...~he...re s,ult s ind! cate(:r ~ri aV:.eragere.duct~o~cif blood pressure'of 7.0 (p'<;2 01) nun'~9':

f~rsystolic 'anci:3.9 (p <..•?02) nun.H9' for~i.astolic,pr,es-'

's ure fromanaverage"'prelreat~ellt level.of 146 .5 / 94':6

., ^{_ .}

^. ritm^,"g.

It.

- .

' .

^in'the,].2 subjects.. In the second stoq.y {Benao n~r l.974b:jwhich kept....the

medic~tion

^{do;econstant ,\he}

l~

^eub-

..~~ jects--fe~uc1!d...,theirbloodpressure byan averaqe'.l>Q.f 10 .6 /4.9

if', ,,.,,

m1h"H'=!'. from,anaverage pretes~'leveiof 145.6/.9 1 4 mm Hg.

'. ~<~!Y

These results were_{l . ,.}

;e~orted

_{, _.- ..}^{to be}_',.

signifi~ant

_' ^{at p}_.^{<.01for -,}

sy s t o l i c; and p-~ ~0 5 . fo;-,..dias to~i c pre s sure.

.

_~ .

^{_' __.}

Bfa~kwe-l~

^.•.

Bloomf~ei.d . ~arts,~d~.;.

',Ro b i n s on .

(ttanne~an .

'..Magenheim~_.~idichcand~igl'er(l~6)r_ejlJ.icated the; Berl;son ',gf,

.~l. (.197.~b) -lt~~d¥ .w~~.h s:~~n'su~.jects '~hO w~re

^ona.:sta'ble · .

~.

..

".':'c a u u e of antidhyper-cena Lve,medi cati p_~ . Statisticalte s ts f~r~l~)f.i~~nt:t~,~a.t~en~:eff.e_~~S,'wer~.p~r£ormed o~'~ndiYfd'"-.

ua.l.sU~je~t.~.~ta ~'.,Fo ur o;ut.-0.£'seven·.s~owe~,'s.t9n ~£~ca~t" . reductions~n~bo:tl1·systo.I~Candd~astolfcpr e s s u re. whereas

, ' . .

" . ,

one veubject;.sho~ed.,a·significa!lt:in c r e a s eJh,systolic and di~stoi.lCl'pressure. The mean decr~ase.~orthe g~o.uJwas 4.2/1.6'

~ '_H9.

^{from an}

' aver~ge· baseJ;in~

^{or-lJ8:8/97.7tnrnHg:.}

" ,

three mon'ths. '-The patients'we r e:in,structed'to relaxin

s4i~~'posi~ion, a~d t'o

con"cent ra t,eon

Ph·r:~e~ . · si~i~ar

^to

~~~·se'

^{used'i n}

·autqgenic·t~aining·

^{wi th}

e~cn e~Ii~~at~on

^.

.' ~, ,' -: . • '. ... . . r ,.,- :~_

Afte r'tre a t me nt:~hemean r eductifon of_bloodpressure was

·2 4 . 6h4~4 ~'H9' ^{from an},aYe~a:ge··pre~r,~a.t·ment^{le v el}~f .'l~9. l/100·.1ilIJ!!Hg·.- ina"':l~·ter ·l~"'~_Qnth'iollow-upst,u:dy

··.pat'el

(19 75)r~por~~d ~ha.t

cbe changes in systolic-a nd

' V "

:'.:'',~.- .,.

.' /

..

,.'-:"'"

,

⁾

diastoli'c pressurecontinu'i!d tobe sign~ficantlydi ffe r e n t (p <~O.O l l .·

As po i nted.out by Jacob,Kraemar andAgca s (1971)in a reviewof rel a x a t ~ontherapyinth e trea-t;.ment-of hyperten - si on,these s1ngle-group studiesprovide l i t t l eevi d e n c e,f o r th e ef f i cac y of relax~t+(mbeCaUsethesinglegroup des ign didnot.control 'for alternativevariablessuch as: (1) regu- l~ rvisits't oa~thera~istor.experimenter: (2 ) unplanned con - e equeace e of treatment (e.g.,.changesin dletorlif e - s ty l e ):

•

.cx (3)effectsof environmentalchanges unrelate dto therapy te

o .? ,

a.ltera,tions

in

physicalor social surroundingsI.

In't he fol lowing'sectLcns,-experlmentsth~t"i ncl uded.a ~ controi..groupin

an -

attempt to ,rcLe out the se al t e r n a tive

,-

-

^"-' ' ~.

,

explanations will be rlescri.b ed. First, two stu dies withnon - random ized ,control groupsare'reported.

Patel (1 9 7 5 )fo'llowed'up t~esubjects'Qf her,,1973study and addedNo mc;>re trjiininq

~

^control

.

ses aLons.,were^{groupthatwas.'}9iven--~

~atched

however

'f~r

, ^a';j;the^'an~reatme n t^{d-.sex .. ,,'} subjects ...ere encouraged-tocontInue.practll=ingt1\\~ r~laxa­

"tion,proc~~ure,during·the(OllOW- Up' period. Theco n tro l ,gro up was,r~qui red^{to attend8,.}!=li~ic^three"t: j.m;s, weekly

,dUZ::i~g"Whi?h~hey^werea5ked~0^{,ri :s t " a}COU~h^{wi thout}

'r~ c~\vi ngspecificrelaxatio?'instructions. '.Th e treatme n t

'9 r o uP sh?weda'5 i 9n i fic a nt reduction'i n bl ood pre~sure

. - -(2 4',6/14'.4'mmHg. Jfroman average'pret rea t me n t .l~ve·lof

. .

"1 ~ 9..l/l00..1"inm Hg.,and th e t.reatment;effect was maintained

. "

-'

afte r ,Jmonths 11 43. 9/8 4. 0 mm Ag.) ,a.fte r 6 months (146.7/

88 .3 mmHg .) , and after 12 months (1'44. 4/8 6. 7 mm 8g.). The co ntra_I.

grouP.-!!,~ed

^an

initia~ chan~

^from

l6~/99.1

^to

162'.6 /97 . 0, a red uc t i on th a t w~ s rep o rte dnot t~ ~statisti - cally sign iti'cant; moreov er,no significa nt change s duri n g thefo llow- up pe r iod s were obtai n e d.

I,na similargr o u p, Stone an dDeLe o {197 6Jce pcr tee th eeffe c t s of a tech-niq ue ba sedO? Bud d histmeditat~on . Th eSib jects'we r erequ.irea.t o5i t in a cha i r in an upright -:j position. Lccse'n ti'ghtclothing , relaxth~irmuscles,and

conce~trate

^on.

"coun~in9 tte~r

breAthing cyc l e s . Afte'r f'iva

20-';.n~t~

l...--

·traini~g

ses"ons, the,' ·subjeCt; ;;er e. .os t;ru cte d,. ,

t~

repeat't he te chn ique tWic~da il y for a d~["at:.i ~nof 10to 15 minut e s. The,trea tm ent gr o up.sh o wed'a mean'reduction of b1ocielpr e 5s ur e of 9.0/ lt.l as comp ared.ec acon tro l grou p' that showed'an"""1ncre'iS'eTn bloo dpressure +1.1/ 2-.1. In both sxud Ies(Pa tel , 1975; Ston e &De Leo. 1976), avcon -' trol' group was added r,

hPw~ver~,

the assignment Of\subj eqtsto, treatmentor control ~as ~otrandom. ~lthoughthe de s i g n' of their experIme nt; may,control'for someplace boef f e c t s (effects due toco n ta c t withthe cli n icor resear cht~am ),-- it doesnot~ontrolforany~ys tematic bi~stha.tcould b~

present in the assignment of subjectsto~treatment or con- trol'g r.ou p.

Although'the abovest u d ies withnOQra nd om i ze d control group~^{make a}more convincingarglfment fdr the,e f'f icae y of ...;-.elaxation':like technique~^{than-t h e.singlegroupstudies,}

I

c "-.

the y st i lllack the m~thodolog ical st ri ngencyof the follow-

/ .

iogqr oupsof studies..In thi s final sect i on,studies pre sen ted which used randOl1laS 5 i9I1111e~~o.fsu bject s to treatment_{Pat e l}

.

or_{and North}control._{U97S J.st u died th e}eff e c t s of con - . tro ll-ed-t r-ialsof yo ga in thema nagem e nt of hypertension.

In this study educational mater~alabouthy-p e rte n s ion. the eff ec t sofemotions onbodilyprc ceaa e a and thephys i oloqy of

~elaxatiOn

^{waspresented.'\Trea'tme}n t la sted12

session~.

two per week, andeub jeotiawereenco u ragedtopracti ce at

.~~,

^{h ome}

't~ice da~lY' , The.- con:r~l

^{.g r o,up}

'atten~e'd

^the

sa~~

^Rumbe;

~~se s s ions for,.the same. le ng t h of t~me ~s theexperim e ~ tal subje c ts,during thesesessions they we r easkedtorelax1n'"' a couc h ot

re C:l;nin~1 ~hai r" ~ith out

^re ce i vi n g

instructi ~ns

ⁱⁿ

the te chniqueofrel a xation.' Bloodpressur e was ta ke n by a

. .

. ,

nurse who-wa s blind totheexpe ri.e~ta lcond i ti ons" The17 SUbjectsQf thetreatment grou p showe d

..

arlaverage bl ood

^.

pre s surereduc tion of.2~.1/1 ~ .2N Hg . from.a nave ~ge pr e- t re atme nt level.of 16 7. 5/99,6 mtIl Hg. An~eq ua lnum be r of sU~je'ctsin theTt~ol·g roup showed anave ~agedecreas e of - -'8.9/4.2 M8g.,fro manaver age pre t re atment level of

168 .9 /10 0.6 mm Hg-. The dif f er.e nces betwe en t,reatment and contro l groups were rep~rtedtobe'sta tisti c:allY--.S.i9~i f ic~n~"

(p<~OO~for systolic and.'pc ,DOl fo r di a s t o li c pre s su r e ).

Taylor~._.Farq~har, Nel·son.-and-Agorae{1 977I, .i n a we ll- de signedthTee qro u pexp erime n t atte mpted tocont r o l the effectsof

differentia~

^{treatmentintensi t y and.}

~perimenter

I 'I enthu siasm. Thesubject s of the relaxa tiongroupwere

informedthat reducingteitsion.wou ld lead to.areduction in blood pre ssure ,an d they we r e given instruct i onin re LaxatLon accordingtoast a n da rdi ze?tape--rec~rdedprogram. Su b je ct s

,

receivedanaverage of five.weekl y 30 -m,inu t eses si ons. duri n g which their progres s in' relaxat i on

~as

^{',mo ni tor ed. The v J ,-}

-: J

jeceewere requested~o r:racticerelaxationathome at lea st oncedaily andEo record the time,:\n d place oftheir",p-ractice'

,,I on a se,lf -moni"tor cnart; ;.An\altern1"tivetr.eatment.grouf receivedan ave rageof ~i'l/e30-minutesessions,of "non -

" ,

speci ficth~ rap y " inwhichsub j e ~ts-Were-fir~informed 6f

the'relationship:heti.teen

.

^" .;hYp'ertensiem. and., li f e stress and.

encouragedto find alternativ.e wayst(;~deal'with ttm$ion. Using

a

^{'se l f-}moni t? r"form the s;bjectsrecordedstr essful situationson a.d ~ i l ybasis. The thi:+:dg~ o upwa s .:1- medicati on-onlygroup. _A~.lthr eeqroupswere given ph a rma- cologi c a lt r eatnene;" The 11 subjects'of th~'re l a xa ti o n group, wfthaverage,pret'reat~entpre e sure of149.8/96•.2mm 8g., showed an averagereduction;i n sy.stolicpressure'of,.

13. 6mmI:Ig,: as compare dto2.8 mm 1:19. 'for thel~ subjeces- of·thenon-speciflC'the r a p y groupand1.1mmHg: for'the 10 subjectscf"the,medication-onlygroup. Statisticalanalysis

\ .

.

^,

Lndf ce t.ed th a t'relaxation was significantly more effect ive thanno nllpe c ! fi c ther'apy or

medication':~n~y

^{(p<.•05 and}

p<.0 11, respectively . The dif ferencebet we en the non- specific therapygroup'andthe~edi~ation-onlyflroupwa s..

n?t significant. 'T he'average re~ucti on9for diastolic

... ...

(

-,

'i

.

^;

~'-"

1--

10

pr e s s ur e for all three groupswerenot foundto be si g n if i- cant•

.In a st rin ge n tl y.des ilJl'edexperimen t

by

^{Shoema ker and}

Tasto'bl975)lS SUbjec tswe r e IlIatc hedfor diast olic bloOd press u reand randa;lYaS9i~edtic r~laxat ion.biof ee dback, and control gro u ps. When pr e t rea tmen.tand post t r ea tme nt mea s u r e s werecampared. the"follow i ngev ere s ered ucti on s in diasto~ ic pr e s sure wer e,rep ;'rted : 7. 6 (re l a xati on); 1.2

(biof~edb"ack), ~nd^-1.2 (,"ont.roU mm~9' Fur th e r ana lysis' showe d that the treatme nteffects forbotnthe rel a xa t i on

.~ -.

'.

i'~~d bi of e e d baqk groups'w~re statist~cal1 yBi 9~i fica n t. ,o~.

.the'o t hE!:.ha~d~ there<:1 ~ctionsof syst~~ic pre.~ sur.~ (~.81

-0.6, and)-1. 2mm8g.)we re notsi g nifi cantlydiff17rent. Oneshould note that th e.Ta ylori1-..AL.(1977 )and Shoemake r andT';"sto(19 75)'studi esdiffer-~^whetber sy~- .tol ieordia st ol i cpr e a screa-uce si gnifi ca nt l y red uced while ."

both clai mto·de~on.tratetheeffectIvene ssof -relaxati on

. . ' . I .

eree eeene• .This inc~nsisfel)cyrai s e.s.twoqueS~ iols. Fir stly, wha t · are the componentsof the-procedure~thlltelicit the

resu~t ~n:d ,' - sec~ndly..( W~i~h

pr i : 8,rion or.

ci:iteri.; tl red~cti~m'

^."

in sy stolic,redu ction in diastol ic,or Jlcombi na ti on of both I shouLd be u~ed^toneeeuretheeff~ctivenes~'~f ^{r lax ati on} t;~atment . ^This'fir,at ~etho.dologicalque sti orl equi~eB ^• further re.s eu e h in' id e n t ify in g arrdstandardiz"g themost ,ef fe ct i.ve rela,,:ation~eehn ique, The'met hod~l ie al issue

willbe addressed fur the r in the oi8cu s si on. ~rio-rto ans we ri ng thesecon dque8ti~oncori~ernin9886ssmentcrit er ia,

.' \

f

,

^'

\-

11

the issue of whether reduc t ions insys tolicve rsus diastoli c press ure bes t repr e s en t san improvemen t in tQe controlof

~yperten;ion

^{requi r e,s}

Clari1 i;ati~.-

^{,However , thi s 15:\1e}

has not yet be e n'resolved inthe

lite~ature {J<anne ~ .

^Gordon,

&-Schwa rtz, 197 11 .

Furt hermore , it should be noted thatthe'i-elax~ tion st u~ies , cur re nt ly reported in the lit e ra t ur e in rega r d to nype r t en s i on, ba se d _the~rc la ims .ondatacbtsaLnedP..t"imar i ly in noncl ini~al"set~ i~ 9s., It see msap~ropria,t~ . the refo~e. tha t.th e next :'~~?in.t h~research,WOUldatte mptto eV,al uate thE;eff e ctivene's s~f re laxa tionprc:'cedu~e sinlower inci blood (~re ssure,in a ~1J.nica l &.et t inq. onlya~terps ychologic~~

met hods_. ,have.s u·cce s s_. f u llybe eni.nc or po r a t edin t oba si c,_.me di-

C~l

^{care will t.hey}

~ccompli.sh

^{,th,e irful i}

PC?te~'tial

^{in the}

treatme n t ofhyper t en s io n. Bas le r,Bri nkmeie r,Buser ,Haeh ~ ,

, .

and Mold e r s-Kobe r11 9.82)studied the ef f ects of psyphologica l ,qro up treatm e ntof essenti a l hyperte ns i oningenera}pr~ctice' set~inqs•

,In thE;,Ba sleret aL (1992) study~ 107'o be se pati ent:s wi thessentia l hy~er tensi o'nfrom9 gene ralpra ctic~swe r e as si,gned to~roupsof_up to 15 subj ec ee a?d receive done of thefollowing psy chol o gi calgrOup-ther~pypeoceeue ee-(i.) mo difi ca tiono'f nut ri tio~a lpatterns ; (2 )modi fi cati onof hu t: r1 ti o na l patte'rns plus self-monitor ingof bl? od 'p res s ure and traini ng.iri

so~al

compe t ence ;(3):'modi fi c ation of!' nutri ti o nal

pattern~

^{plu s}Jacobson's .relaxatl; 0n tra ining;

an d 14 1inf01:"mationabout the ca usesan dcons e quen c e'of high

12

blood pressure. Anapproximate lyeq ualn,urnberof patie nts served as a '(ia i tin g-c o nt r ol grou p.. All patientsha dre ce ived pharmacological tr e a t me n t for a t least aye a r.' Aft e r1.2 we e kl y sessions,th ebl~odpressure valuesrnea s u r e dbefo[~

andaft~rinterventionshowed a si9'nifi'ca~t^reducti-onin bloodpr e ss u r einthe tre-atment groupsc~.mparE:dto the

~ait,ing-con trolgroup. No different ia leffect amo n gtr eat- me nt p.rocedu reswasfound.

Ba s l er &..AL.. (19B~ ).~attempted to evaluatethe aeccbeo n-a relaxat ion~:thO(l1nc vever ,they combi ned ~he. rel a ~a-t i o np:t;0cedu re wit;h rnodi f i,cationof nutri t iona lpa t-

- . ' . ~

te r ns . Thi s cortta minatio nof the relaxat i ontreatment by ano t h e r inde pende n t varia b le preve n"t sada f i n'Hive analysis of

th~

^{d:t.a: In}

the'pre5~nt~,~ ,"tiJere fore,

^thee'xperi-

ment~l, desi gnwil l, prov i de fo r'"ii) gro" u pof sub ject s'who- -~~--- ee ce tve onl y rela xation train i l'lg,,

In view~fthe ambiguiti es inthe pres ent.stat,e,o f knowled geas revealedin the abovesurveyof the curren t ce seaxeh.Li,ie r a:u r e ,itseemed import ant fo rthe present experiment to attemptan evalua tion otthe.follow ingquea-

- - I

ti ons :

",(!lIn addition to th'ereduction bro ughtabout,by medica tio n , canqrouprelaxa~ion ^{in a c}lini c a l se t t i ngsh~w^{st i ll}

furth~ r reduct i on.in bl ood pressure?

.(21woul.d·biloOclpres~ ure' r~duc tionbe .tur cbe renha nced.

an d/or mainta inedby suppl e ment. i ng the group rel a xation treat mentwi t h aneducatio~pro g r am?

i.

Finlay , 1979 ) ! "xcveve e,if thepati~nt ^hasU~dersto~

,y

13

Theeducationprogram consisted of four 20 -mi~utesli d eand. tape pr es e n t atio n s , "Hy pertension" , -LOw Fat Diet ", "Exer-

. . • ·".(tr

et ee v,and "Str~BS" fromTrai ne x Hea lt h Care Counsell .inq Pr o gra m(Ale xan d e r ,19 76). Th o s,epr~5en tations we r e fol l ow e d byl1roupdiscussions. Thefu nctio nof thegro u pdiscuss ions was to cla rify and summarize the presentations. The ed uca- ti cn progra m was desi g nedto pr omote the pat"ie n ts ' co- opera tion a_. ndhelprel ieve anxiet y (Alexa nde l",

.

"1918). The effec tive nes sof-suppi y inged ucat ion'alinforma~io;:;^{ab out,}

hypertens ion-r isk s has notye t been uneq uivoca l l y.est ab-

- I . ' •

.Hah e d (Sa ckett . Gi bs on •.Tayl o r,Hayne s~ ~acke.~t ,Rob erts, ' J oh nson , 1975 ; Levi n e,Gre en ,De e d s, chw.alow. Rus s ell,

the'mat er~ alpr.esented , heW~l~be aw\r e of his responsibil -

.\

ities inma i nt ai n i ng hi sown he al th. - -

Thepr e sent experi ment wa s designe d to testthe follow":' inghypothe ~ eswhi c hemergef rom th epreceding survey of the exist ing l it er a ture.' Fi rst,.tha t afte r rela xati on therapy

there ,will be an immed~a teandendu ring re du cti on in blood

pres s ure. sec c nd, that pr e sen t i ng ed uc at i on a ~mate r i al i~l.a gr oup's ett i ngw:i.th sub sequ ent ~is cus s1on willLn creae e the

probabil~tY

^{ofThe subjec tstakin g}

~.O:·Sitive.

^{he,\l t hme asure s,}

andthat this1'1111also bereflec ted inaflre du c t ion in blood pre ssu r ea.r eer t re a t ment a.ndat fo l lowwup.; Third"tha t a

•com~inationcond .i:t i on, Educat ion Pl usRelaxation , wou l dsho w a compo und i. ngeffe ct of the ed uca t i onprogram andrel a xation at.follow-upgreater than the eff ect that.wOUld.resul t in

0",_.-

\

~the case of eitherthe relaxation ther a py,OJ; the ed ucatio n programa Lone ,

The fpl10wing;es~rthparadigm is desig nedto test the above hypotheses ,and has three features that disti n guis h it from the previousstudies: (1)I tevaluates the effective - ness of a group admi'Ristlrationof relaxation proceduresin"

redu cing blood press u reratherthanind ividualadministra- tion; (2 ) i tteststhe eiffectivenessof relaxation"p r oced u r e in,a clin i c al rathe:;. than a labor ',ato"r y sett.ing;(3) i tinV"es..-

' \ .'

----

tigatesthe effectsno t ohlyof rklaxationtraini ng-eln-aan

. I .

education program,'but also the e

1

^fectsof,co mbiningthese ina unified treatmen t. \.

METHOD: d

<SUb-jects

From each of foursettings, 10subjects , ages 24 to 55 years (total of 18 males to 22 ie.'.llales) were assignedto the

if

^{lowi ng} conditions: (1 1.No- t r e a t men t Control;(2)

Rela~a­

t~; (3) Education; and (4 )...Education Plus Relaxation. Sub- jectswere-eefecees from~out -pa tie ntpopulatio n of a Regional Me di cal.Clinic·~St. Albans·and"t hr-e ehOSP.i1;a~

sett i ngs, ~ievert.e , Bucha ns and Har bourBreton, Newfoun d - -La nd, TheC1onditi<;mswere rando m1yassigned tos~ttings (St.

Albans--Co ntro l ,HarbourBreton- -Relaxa tion ,.a ucoane v- scuc e - tion, and Baie Verte--Re laxation

,

PlusEducation).

Altho ugh it was notpos s i bl e:rand omly toas si gn subje ct.e

·t o theconditio ns ,thedistributi o nsof the subjects 'ages, genders, and educ atio ndo notdiffe r sys tema tica ll y·in an y

I

15

.wayfromlocation to loc a ti o." (s,:eAppe ndi c esA and B), I t islegiti mate, therefore, totreatthe.data as thoughindivid-

'I

ua l su b j e c t s had bee'nrandomly assignedto four('£o~dition8 . Al l subjects'we r e onmedicat ion whic hwas kept cons tant overthliitimeof the

~tUdY,

^The

se leC~ion

^{criteriawere:.}

(1)a

di~gnosis Of ~~ertens~on;

^{(2) a bjocd}

pre~sule

^{lev.e l.}

at the most re ce nt doctof:'svisit of.atle a s t 140 miii"Hg. systolicand/or

90

nun Hg .diastolic; (J)th e same'bf6'~'~pre s­

sure le v el (140romHg.'and/or,9 0mml ;) on th~pret~,eatment measu re; and (4') informedcons e nLa n d willingness to partic i-

pate in the _{p~oj ect}as _i~dicatedby _{~ignin g}'a behavd cur.e L -c on t r a ct (Appendi xC);..

Appar a t us

'r.ape recorder and fi l m str i pproje ctorwere us ed. Blood pressu remee suxementawe r e takenwit h a mercury SPh'gm Omanometer

an~

eeee ncs ccp e.

Mater ia ls

~he'materials for th erelaxation prog r amconsisted of

instr uc ~ionsandta pe s on..progressivemusc le relaxa t .j,on .:;tnd differ entia l rela xati on (Budzynski , 1978). The.educat ion material s co n sist ed of fo ur tape - and-f ilm sttiPS'

~n'~Hyper­

tens ion ,.Exer cise,

stre~,' \

^{and LowFat Diet}

( AleX~~~~r,

^{1978 ).}~~

Pretr e a tm ent bloodpre s s ur e meaSQrea we re obtai ned for allsUb ject s. OncetheSUbject had :",dapte d to a sitting

. .

posi tion'for appr oximate l y5 minute s , the fir s t orthree

.... - - .

.

.-/

16

blood pre ssuremeasureme ntsus i ng sphygmoma nometerand

ste thoscope wastaken . Dur ing the pretreatment inter view ~. - l

informat~on

^re l ate d to the

.sUbje~~ '

^{s ea ting,}

ex~~rCLsing

^and

/ smoking habitswasob t ain e d {Appendi x

m.

^{At thefif t hand}

tenth mi nute s(If thein t e r vi e w the'second and thirdblood press are mea'sfG s we r e taken. Theme a nof thesethr e e'-

.

^{. ~~~,}

.

~

measur es wa s ~'asthepretreatment measu re.

The subject s 9f the°No-t r e at me nt'~ontrol^qz-ouphadccn- tact withth e iexperimen te.[during!=-hepr'et reatment~essiQn and'fou rad d i tion a l consecutive weekl ys~ssions. Each ses:,"

edenwa s simi lar"tothe pretrea'~entsessionin,whi ch the', blood pressu re\ were :taken.andbri e: nond Lrect e dconve rs~ti on took pl ace wit h theexperimen te r, Theblood,pre.saur e meashe- ments at the pret reatme ntand at the fou r t h weeklysession

" : r

were taken as the pret.est; and posttestme a sure s. __

.!...:-

In't he Relax a ti on condi t io nin addit ionto theabo ve

procedures of the controlcon d ition. the subject recei ved a

4-~ee~

^{grou p rel a xationi?!ogram}{Bu d z ynsk i ,1978). Wee ks one and two concentrated onpro gr e s s ive muscle re la xat;i on , whil e wee ks three andfou r concentra tedon differen t ia,l I ~ rela x ation . Inadditionto theapp roxi mate ly 4S-minu t,e

rel axa t i on.ses s ion admi niste redby~heexperime nter s.~~ j ects rece i vedta ped rel axat i o n ins t ructio n san~wer e encour aged toprac; i c e thetechnique.~

The SUb jects in th eEdu c~ ti~nprogram cond i tion recei'ved 'i n eddLt.Lon tothe':'proc~dure s ^{appli ed to the}cont~l.g ~ouP .,

"'\~.a-week educ.a ti o ll alprqqrll.rnconsi s t i ngOf.ll15 -,0rn~nute.

. ".

17

I ~,

.slide-\aQd -tape prese~ tati~~ and a groupdi sc u s s i on. The ru nc etcn ofthegroupdiScussion was to'c~r~fYand summarize thesride-and- tape pre sent a t i on. Thefou~'~eas^of concen- tration'were: ' III Hypertension , (2).LowFat Di et ;

~

^zxe-c-

cise:and (4)S"t.ress.

The EducationPlusRelaxat ion condi t ion was a combina- .t .L o no,f.th e proceduresof.•the relaxationand theEducation .programconditi~ms. The'subjects pa~tic~pate;d~ 45~

mi n u te.le ~axationses:io~followedbya l5.-2 0-min~eedu- cat iona l

.,!SSiO~ . y,.

..:J

~h.e'blood·~ress.ur~ measu~es'~eretakenbyth~ sam~

.,m et h;~aa in Ui e'pre tr'eatmentsess ion , by the experi.ment e r ,

." . .

on comple tionof't r e a_tment,n't.t he fourthsese Len, The 2- week and4- week fcl Low-up-meaa sur e ss for all groupswe r e ',obtain'ed in the same

w ay

by nur s e s who were blind,t'o the

experimen t-a lconditi0l?-s (s e e Appendi~-F). RESULT S

A th ree -wayanalysisof varia nce (Condi tionsx Sessions

" "

xPre s ~ u r e s)wi thsub j ects ne st ed unde r the Conditions factor w~sperfor medonthe data. In this.experiment,t he r e.isOril y one dependentvartabte,bt~od pres~~re in-~ Hg. , wh ichha's two<LeveLe,sys tolic,anddia s t oli co'-':rhe r e'werefou r Condi - tions (Con t ro l,,n" O;Rel axat i on,n=-7;Educati o n, n=6; and )"

Relaxa.~~~n· Pl~

.'Edu,cation, ne 9l,'and

""?" _{measu~in9 .}

sessions\ . / {pre~rE!atmen~, ~reatmenti,one throug~ f~ur ,_and'fol ~ow-ups one andewcl, and two'revet .eo~Pre s sur'e.(sys toli c-e nd dia s toli c ). Se ~s'!~'n¹i'~pretreatme~t1 's e esa.c ns2 to'S,ar~'

. . .. .

I.,

"

_ .t re atm e n t sessipns.wh Ue Sessions 6"an d 7 arefol 1tlw~up aessfon s.' The analys es showeda signi fi ca nt Sessi?n~.effe.ct

(Ffl6.1561·'l..J.67, ps:.001),,4 sig ni t"ic a n t Se s s ions x Cond i t i o nsinteractionIF-IJB,156i. 2.)4, p's. .051and a siqnlficantse esrenexpre91iure s·.i~t.era cti on(l..(6.156 ) • 2.22, P S.:05) (see Appe ndix E)_ The me ans fo~^{th e}sig n ifi~

ca nC e f f ect s-a zeshownin Table L,

Th e Se s sio nseffect wasanalyzed us inq Tultey' smet hod

,

.

~( Be rens on^{•.r.evrn e; & G}o l d ste+n •.~9B31^{. .,. The resul'ts}iod 1- ca\ed :-ha~ sessi~ns'2.th r oug h '. were Signi ~icantlYQif fe r-:nt from se ssi ~n 1 (0. 9 6, 6 , 1'58 = 4.36,P S..:OSI. As sJl0wn',i n .Ta bl e1 th~atm.e~tsess,i.ons (s ess i on2t.o,'5) an d the;

f~llow-- up"essi o,ns C.Se ssion~6 and.7) aresig nif i c a ntl y d~.f.-: ferent"f rom.the pretreatme nt ses si~n.(S e s sion11.

TheSes s ionsx Pre ss u r e s int,era cti o nwas furt;her a~alyzedusing the Tu~ey met~od . Th~esul tsind lc:te d't.hat .for th e syst o l icpzeasur e,Sess i o n ) ( theeecena treatment

" s~sS1.0n )

^{thr o u 9 h}

~ssion

^7'were

si~niiicant ly dlffer~nt

f"rOlll

seISSlO~l'

^the pre t :eatme ntse ssiofl- (Q .

~ J -6~15B

^{· 5.4 6J "}

P

s .» );

For the dias~Oh~pre;sur~Se ss i o n2 thr o u 9h aesercn 7were siCJn~ficantly'-dJ.f feren't fromSession1

v

{Q.95J'.6,158 . 5.46:P.5,.OS } : The ~e slul.ts Of Tuke y.'s .method are sh o wnin Tab le2, while the Sessions x Pre ssures -.int'efac t ion'iSdisp layed CJraphic~llY^{,i nFi}g ure 1. The Ses<

siqnsx Pressure sin t e r a cti onwa ssim'ilar t-o the Session s

_ !

ef~,:ct; e~cept^{tha.t.for Session'2} (t~.e.^U:st trea~men?' ^{S - . :}

sipnl ; thesystolic was

.

. notsignificantly

^-

^"

.

^\differen t

^- '

f. .', . - - --^:

... ....

^~

.

^{~- : '}

. .

,~:

:: '

"

^{".\ ':':, :}

i ~

^{-].' .I: .'':l,}

~r."

.The ~eans^for'siq n.it^TableLcane,

^l

E~iect .

^'

,s~ownCr o s ssec eicn

<1' .

:Pretreatment

·1 2 /'

SESSI9NS Treatmen t 3. .4

~.

5'

.

Follow-up

.16 1

...

:'.,.

:

....

M e ans' .

J". •

Se !iu jli o n '1 2 2 ;:~>.::t~:·1l 7 114 : III 112

Effect· ':,>

;...se~~ic:inx presaure 1.

,Srst o l ic ... 147 '.14 3 137 .1 34' 13 5

o.Asta l ic - 97 "' , 91 .' 9'0 87 .88 Condi ti o n.xses s ion's* :,.f

C W ' . .

·'·Co ntr ol 120 117 112. ·110 117

"Rel a x a t ion 126 1'24 114· 1 110 .113

educ ation/R eI .. 116 110 117 .1 0 7 107

Educa-t i on 124 11~_ .~II3 11~ '.109

111.

135

..

113 113 107 111

112

13.

"

115\

nf

'108'

"115

' :N~te t.h~~e ^{m ean s} r~presint

^the

m~~n8'

^of

s¥st~i~c""!lnd ~~a~t.olic combi.n~J..·

'-

~.

~

..'""' ^{' ,: ; 0 ~}

. : .~ .~

. _ Table'2,

'The,"'R~sults

^{of the}

'~ukey "so M';t~od P~rfO~ o n :~~ss.ion

^xPrenure

pretr~atment. l' ,.

..

S.ystol ic 0147.:

i

.Pretreatme n t Sess ion

"Cri t i c al Value" 5.46"

D1ait'?~i-c ,-

⁰ ,,9 7 Pret reatmentsession

:"Critic al

vaLae.>5.46

,'NS- Notsig n ifican t

.' ":' ~" ; :,g"~ "

./

/",'

SESSIONS Tre a-blIent

\

^{Follow- up}

.'4 5 ^"

14)- ^137'. "13.4 ~35 1,3.4 136

10 13 12 LJ II.

NS

. . ^. .. . .

91 90

.7

88

tS

;

ee

.7 10 9 9 9

~.

•

t

•

;;

J

l.,

"

. I

Press ur e IIIIl.Hg.

l~O 14.5

"~1 40

.Systolic,i35

n o

100 95 Diastolic

. 90

.5.

j

I .\

".

eeee, Treat.l · Treat.2 Tr e at'.3 Treat. 4

F '1'

^FU2

;:<.

Fig ure 1. Aljraphof systolicanddiastolic'pressure.f o'ra·llCondi t ionsbysessfcna,

t

~

22

Session1 (7hepretr eetrne nt,session I.

An artefact of the statisticalanalysis occurred in bu t onl y"one, of the interactions . Although th is wo u l d be difficult to'ln'terpret, the means of the two level s of th e dependent variables (sys t o l i c and diasto l icpressures) we r e averagedwh e ncaiculatlngthe Session x Conditions interaction. Althoug hthe meansre s ul t i ng from.thiscombina- tianof systolicand di a s t oli c pressuresaredif fi cul t to inter pre t cli n i ca lly, yet~"heydopr o v i d e.a rea ecnebae measure of chaT';ge inarteria lpress ure from,s e s sionto ee e-.

5ioff.

Tho roughan a lysisoftheme an s,o f the slgn i t: icant' sess rcas x'Cond i tio n s interacti on,doe s not.yield anymean - - ingfulcamp·arison. The meansfor theSessionsxCon d it i on s

i~eraction^arepr~sented ^inTable

i

and,grap hedin"Fi gure 2.

The resultsof the st ati s t i c al anal ys isof th e compar·ison.s

'a~

^{e'Lso sh ownin}

T~ble

^3.

I~ summary, the,re s u lts sho wed a signif ica n t Se s s ion s effect anda signi f icant Sess i o ns x P~e s s u r e sintera cti o n.

.

. .

The Se s s i on s ef fec t.i nd ica tedtha t the mean s fo rall condi- ti on s for both sy~tolicanddiast~licpre s surewere s'i gnifi- can t ly'd if ferent for't:.ne treatmentsessi~ns (Ses~ions2 to 5).an d ·fo r .ehefoll ow-up'

S~~.SiO~S

^{(Sess ions'6and 7) as.co m-}

pare d~o't.he pr etreatmen t session (Se s si~n1). The Sess i ons

"~^X'Pre s sure si.ntera"cti onshow~d^a similar ' ~attern l'h',l"ev er, for the systo li c pres s u r e .a sig n i fican t dif~ erencecc mpe red tothe pr et.reacm entdi dnot.oc cur uritilthe'seco nd tl"eatmen t

~~SBure ¹³⁰

\ .Hg. I.'

125

.12 0

115'

110

(

'1::._

\

.'

~ 'Il ~. ^{' . p}

~ ^{' ~ .., /}

. " "">,

..h

+;~ -~... ^{. . . . / .} ..." " / .'6:::::::-, _~~ ~ . _'-. -"-~X _{< .. / ""} ~~..o' _{', _.,}

. --- _~ . '0--

10 5

100

Relaxation·r....-n- coJ1lltrol :-+- Educa tian :--0-- -

~ =~~~ :~

Pret, Treat .l Tre at.2 Treat.) Treat.4 rui F~2

Figure 2. The gra ph of thesee s tens by Cond itions Ineereeatcn ,

~

/ ,"

G

25

session("Sessi on") ), while for the dia~toli~^{pres suresig-} nificant diff e r e n c e oc c u r r e d afterthe firsttreatmen t session- (Se s s ion 2).

DISCUSS I ON {

In ~hepresentex ~ er i men t, ;th,:ee hypothe se swere:

fo r mu l ated. The fir s t .h yp oth esi s pred icted th ataf t er r-eLaxec Lcntherapy, therewouldbe an immed iateandendu ri ng·

reduction inblood pres sure. Forth e relaxa tiongroup, there~a s^{areductionof 13 /11rnm Hg.after the,f i ? al} tre~t":

ment sessioriand16/9,mm Hg_'and-e>1~/14^{mm Hg.,}redu ction s duringthefo.llow-u~session. In fact, :the.pre~i ctedreduc- tionsdid occ u r , however', th e s e re duction swere not'signifi- ca n tl y differ"eot

.

from those of the~"cnt rolgr o u p. Forthis reaso nthe results of thepresent studycast doubtson the conclusionsof the single group stud i e s (Bensonet al.,~ 1974a,1974blBlackwell et al., 19761. The Benson

\~t -al'7­

(1974a,1974b\ studies, f·orexample , showed reductionsOf, 7.0/3.• Hg.and 10.6/4.9mm Hg., respe~tively; wh ile Blackwell et a1. (1976) showeda red'u~tion^{of 4.2/1.6 .mrnHg .}

-,

The single groupstudies.c l a i med significantresultswhile the present study demonet.reeedthatthe greater reduc tion of 19/14 mm Hg.was not significantly-"differentfromthe control group. The presentstu~alsosh owed great~r reduc -:- tions than the statistical lysignificantreductionsreported by Ta yl o r et a1. (1977) (13.6- mrn Kg.systolic) and' Shoemaker and Tasto (1975) (7.6 rnmHg. diastolic), al thoughin the present-study'these.reduct"ionswere.not st';tistically

/

26

di f f er en t from the contr o l ,'

The second hyp othe si s sta tedtha t pr ese nting edu c a tional materialina gro up set t i n g ra t h er than on an individu a l - basiswo ul dinc r ea s e t,hepr ob ab i l i t y.ofth~subject staki ng positi v e health mea s ur e s . aeid tha t the se mea sure swou l d.a l so be refl ectedina red uctionin blo o d pre s suceafte r treat- "

me n tan d duringfol low-u p. Al t hough the r ewer e7/11~ Hg.

re du c t i o n s·from·'~re.treatmen t·^{ec t}h e final sessio n and 7/8 an d 4/ 7mm Hg. re duc t i ons;fro~pret re a tmentto follow-up ses s ions forthe EducatIonalCl?~di tion . ^{these r}ed uct ions we re not

significantlYidiffere~tfr~m..thecon t eo l gro up ' s . The thirdhyp othe s is wa s th a t a c~ bin ati oncon d i t ion, Educ ation plusRel axati o n, wo uldshowanenhancing effe c t of

;',

the~ucational'prog r a monthe relaxa tion trea t ment . As 'tiith these c ond hypot he s i s.the resu l tsobta ined did not sup po r t thisthird hypothe s i s .

The re su l t s sho wed a sign i fica n t Sessions Effe ctind i- cati n g thatall experimentalcond i t io.ns sh o wedsignificant , re duction,for both sys t o lican d diastol ic pre ss ure aft er tr e a t me nt/an d during fo l l o w- up . The ge ssLona x sr eesucea

.

.

in t eraction sho wed a simi l ar pa t t e r n; however,si gn i fic a n t .

r e du c t ion.occurredon;v afte r the seccnc.e reee nenese s s i on .for th e

syst~lic

^whilesignificant

redu~tions

^were

'rea~hed

fqrdia~tolicpressureafter the firsttr e a tm ent session. As shewn'in Table2, the averagereductionst'orall condi-_

tionsafte r treatment session four and follow-upsessions were12/9. 13/9, and11/9nun Hg., r-espect.LveLy ,

27

One canon lyconject u rewhic hfactor or-fac t orsexpl ai n th e sig nificanteffects inthe pr e s e n t study., A.possible ex p Uma"::..onfor t-he red uc tfOn couldbe the reactivityof the bloc?press u remeasure duetoin c r e a s e d fami liarity withth e'expe r i me nter. a contextfamiliari t yeffect. The ef fec t t ma'y eeerec e th.e subjectsbecominqmore comfort.abl"e .and le s sanxi o u ~with theexperimenter-and the experi me nta l

con dft.Lon s, Beforeacce pting this explanationf howe v e r.

conside ra t ion'shou l dbe given (seeMe th o d section).to th e ,fa ct thatthefollow-upeeaeueeewe r e'tdk,enby nurseswho were bli nd t~the experimenta l co ndi ti0l!'s, If a context.

f~inil.i.arityeffectwas'a signi'ficantfactor,onewould expect

an'i nc r ea s e in bloodpressure whe nthe nov e l nurseobtai ned

the·llIea su~e s.

Ano.t h e r possibleexp lanationfor the reduct i onover conditionswoul d be presente? in terms of a Timesr recc. This exp lanationinfe rs tha tthe bl o odpr e s s ur e red u c t i on s wotr.Ld occur over,ti me in d epend e n~ yof anyvariable. One shou l d note tha t the subjects were ref erre d tothe experi - men t because·t h e i r hyp e.r t e n s i o n wasresistant topas~

in t e rven t i ons . Thiswould.indicate tha t th esub je c t s' hyperte ns ion wes consistent l y hi gh overtime . Given.th at the su b j e c ts'anti-hyp erte n siv e medi cat ion wa s held const a nt throu9~ outthe tim eof study , onewou ld suspe ctthat reduc- tions found-inthi sstUdywe r '!= mor ethana ti~eeffect.

t The thirdand mos t plausibl e~exp lana t ionis th~t the reduction s inblo?dpre ssu reare the refle c t ion s of unco n- 'tr?lied'variable s. Possibleunc ont r olled varia~leswhich

. ..

2' may hav e influencedblo od pressurered uctio n incl udedI

(1)a high e r tha n ave rage le v el of motivat io nasrndLc gted by the willingnessto participate in the exp e rime n t as shown by the subjects ',signingof a behlviour a l con trac t and their, ac;tiv epar tici pati0,PI (2) the encourageme ntandsup por t received from th e exper im e n t e r; (3 ) the sUb~cts'knowled ge of tl;te exp e r imen ter's effort/ c os t - - the expe r im e n t ertrav e i l e d

~ween

^{100and 200 km to see} SUb j e c ts ; (4)the.SUbj e c t s' re c eivin g.reed cack'on thei r b.l ood pre s s'ure wh i c h wa s taken ona we e kly basisfor fourweeks andev~ry~econ~iweek for a mon th.

The r e are.s ev,: r a l issue s whicl;1fut ~reres ea r ch sho u l d' ad dre ss. Twq",of these arestandardi'Z~ tion.of treatment t.echnLques and't;.he us~_C!f"con t r o l groups.

Fut ur e st udies'sho uldatt~mpttoid ent ifythe most .;- effecti v e relaxa ti on techn {q~eand to,sta n da rd iz e the pro- ce du re . Inth e ID s tud i es reviewed in the intro du cti on;at least four di ffe re nt technique s wereadmin ~ st.e r ed. These t.echn i.ques ran ge d fr omtec~qu.es with a str o ng cog n i t i v e emph as issuc h as T; a nscen den t a l Me d i t a ti o n:to.t h o se witha pr i maril yphysicalemphasis suc hasJacobson's Relaxa tnon Training. "Th e lack ofsta nd a r d i z a t i o n in techniqu e'makes i tdifficulr~;-r-;P1icate^{,a nd.to}compare studies.

The"p reeen t;stfdY demon stratedtheLmpcxtanc es-o f making.

appi~p"r~te

^use

~

co n t r o l

9roup'~i .

^{The.fact that.the data}

obta ineddonot showsignific a ~tdiff erence"between control

---:.

. ^..

29

and treatment groups castsdoubt en the va lidi t y of the con- el u sions basedon single group stU;d ies . As~escr ibed .ea rli e r in the Discus.sian, three's ingl e group stud i e s of relaxation therapyemhypertensi on (Bensonet al., 19 74 a , 19740.; Black- well et al., 1976) havecited comparat ivel y. lower reducti on in blood pressureas beingsignifi cant. Benson~ 1l974a.. 1974b)re p o r t ed reductions-of 7.0/3.9nun "g. and 10',6/4.9rnrnHg. and Blackwell et al. (1976)reported a'. , uc t i o n of'4.2/ 1. 6nun

"g.

^{In theabsenceof}"a control group however.the reasons f'Ot" th,:"reductionsareopen to questions

esp~cii'lily

wheninthe

\P-r~sent

studyan even greater reductionof 19/14 mm Hg".,was foundnot to be'5ig,- nLfLcant.Lydifferent fromthere d uct i o ns in the contr,ol group. 'rtreee inconsistencies__clearly,demonstrateth e need for studieswith proper experimental control.

Furthe -r di r ect i ons for future

r~

^include

~he

,.\:

..~'.!

foll owi ngis s ue s. Is.the r e an interac tionbetween t~ et.ype o"frelaxation te chn i q ue.and the type of anti-hyper tensive medication? woulddifferent types ofsub jecte.tr e apond to different ~ormsof therapy?^I Wha t are the ,individua l charac~eristics,~{thehyp e rtens ive patientthatwo uldp~e­

d~i ctthe successof a relaxation~reatment? None'of thli!

past studies , inclUdingthis present one,.ha s investigated /

t1mlllc~u!!e

of thehyp ot he s i z e d sympathetic arousal i.nhyper- L

tensivs·patients. Prior to at,tempt,ingto research these, .questions, th~reis.a needfo r a more aophds t.Lca t.ed

psyc t'!o l~g i c~ landps ychophys iqlog i c a,lassessment prccedu re .

onl y after adeta U e:d standa rdi zedassessme n t procedure :Ls devel o p ed wi l l researche rsbe ab leto predictwhic h hype r-· tensivepati e nt s will res po n d'towh i c h form of re laxa i t o'n therapy underwhat'ccndtttons. .

r:-

(

I

30

. , .

':.

'REFERENCES

Alexander , Sidney. Tr a i ne x , HealthCa r e Counselli ng Program, 1978.

Arteri.al Hype r teris ~ on : Repor,t ofa WHO E'We~t;.~ommit tee (Geneva, 1978). Technical Report Series, No. 628, 1978.

Basler, H.O. , Br.Lnkme Le r , U., Buser, K., Haehn, K.D.,and Mo l d e r s -K o be r,R. (1982 ). Psycholog.ica1 group treatmentof essent ia l hyper tensionin general precct ce • BritishJo urnal .£J f Clinica l Psycho logy ,

21, 29 5- 3 0 2. \

Benson, H.,Rosner, B.A.,Marz etta, B.R .,and Kleinc huk,.

H.P., (197 4a).' Decreasedbl o od pressure in border - line hyp erten siv e su bject swh o pract i ced -me d Lt.at Lcn, Jour n a l of-Chronic.Diseases ,-27, 16 3-16 9.

Benson, H., Rosne,t:'",'B;A., Marz~tta,B.R . , and Kleinch uk, H.P. (19.74b ). De creased,blood press urein pharma - cologica l lytreateP.hyper te n s ivepat ients wh o regu lar l yelici tedt,he rel a x a tion re sp o n s e . Lancet

.!.-, 289- '291. ' .- -

Black~=~~S~: ~~~o~;~:~~~i::"~

^H

~,jr~~~1~h ,

^p

5: , ~~~~n~~~ie~:

^'

R. (1'976)-: Tr iln s c e nd e n t al medication in'hyp ee-

~~~~i~~~ Ind ~ vidua lresponse patterns. La n c e t.!., Blancha rd, E.B."and.Y.ou ng, L.D. (19 731. Self-controlof . cardiacfunctioning: Apr.omis'eas'yet unfulfilled.

Psyc ho logical Bulletin ,J.:i, 145-1 6 3.

Bla nc h ard. E.B .,a'n dYo ung,r;-.D. (19 74) . Clin ica l ap p Ldca t.L c .rsof bi of e e dba c ktr a i ni ng: A'rev iewof evLdence, Arc~. Ge n. p,chia~ry,lQ.. 753- 589 . Br-enan, M.L."Le vi ne.D. M., and olde't.eLn , M. (19"83).

Intermed iate St a t i s t i c a l Mehods and A 'ric a t ion s • Toronto : Prentic e-Ha 1 Can da Inc.

Budz yn skt,,'T.R. 1.19 7 8 ):'Ma nu al'and·Gui d e ': Rela xati o n Tra i n ing program . BMA Aud10 caeaeeeee ,Guildf o r d Pub lication Inc.

Chob a nia n. Ara~V. (1983 ).' Clinical Sympos ia, CIBA , Hypfrtens io~ . Volti~E!"',35 ,'Number 1. .

31.