Electronic ISSN 2287-0237

VOLUME

PRELIMINARY STUDY OF SLOW DEEP BREATHING IN MINDFULNESS EXERCISE EFFECTS ON PHYSICAL HEALTH OUTCOME AMONG HYPERTENSIVE PATIENTS

SEPTEMBER 2018 - VOL.14 | ORIGINAL ARTICLE

Hypertension from major vital organ complications in cardiovascular, cerebrovascular diseases, retinopathy and nephropathy, are major causes of morbidity and mortality.1-3 Most hypertensive patients have uncontrolable hypertension and need support to reach their goal of blood pressure 3,4 which poses a high risk of side effects and drug interaction from long term drugs therapy. Recently nonpharmocological treatment observed that slow breathing in mindfulness has been used to promote an alternative complementary treatment and has managed to lower blood pressure based on scientific data. The definition of consciousness is that the mind recognizes and accepts experience that arrives mentally, it is a form of concentration with a relaxed and clear mind in conjunction with brain processes.5-7 However, its effects on the reduction of physical health outcome is still seen as controversial with BP and HR. For example, D’Silva et al.8 found that there was no significant reduction in BP and HR after deep breathing exercise for patients with hypertension, coronary disease and diabetes mellitus. Meanwhile, other studies revealed that slow breathing was linked to beneficial effects on resting BP and HR in hypertensive patients.9

Slow deep breathing affects the bio-physical scientific mechanism.10 It is integrated in mindfulness-based stress reduction that is useful for BP and HR. These benefits of mindfulness showed in vascular disease studies such as hypertension, heart disease, stroke and diabetic mellitus.11,12 Moreover, the mental benefit of relaxation for hypertension response was reported by Benson H et al.13 Although, slow deep breathing has benefits for both mental and physical health outcomes, the results of studies are controversial that slow deep breathing can control in BP and HR. There are few studies on the effect of mindful-group conversation about awareness in breathing based on PCU treatment.

Thus, the purpose of the current study was to see how hypertensive patients could perform slow breathing by observing mindfulness. From the result of the review, we hypothesized that after intervention, hypertensive patients would promote slow deep breathing, and this would lead to better physical health-related outcomes.

A quasi-experimental research was conducted with two-group three repeated measures design for this study. The area of study was from two PCU in two districts of Pathumthani province from July 2017 to September 2017. All subjects met the following inclusion criteria:

  1. Aged 35 - 59 years old 14
  2. Stage I hypertension3 (SBP140–159 mmHg and/or DBP90–99 mmHg)
  3. Taking antihypertensive drugs
  4. No underlying complication of hypertc blood pressure (SBP) 1.0 (p = 0.783). At the follow up on the 12th week, there was a statistically significant in RR 9.0 (p < 0.001), and DBP 5.6 (p = 0.002), meanwhile, there was no statistically significant difference in SBP 1.9 (p = 0.600), and HR 0.2 (p = 0.959) respectively, as show in Table 2 and Figure 3.

There is a statistical significance at baseline in the physical outcome in DBP and HR but no significant difference in SBP between groups. However, the adjusted mean for this effect by GLM for repeated measure was used and the result found was that the observed breathing in mindfulness had been directly induced for a normal reduction of RR (19.4 ± 1.2, 13.6 ± 1.2, and 11.0 ± 1.3 breaths/min respectively). This mechanism began with 15 minutes going up to 30 minutes per day and had enhanced inner self-efficacy empowerment. The DBP and especially HR were lower and this reduction was statistically significant.21-22 Although the non intensive training for follow up at 3 weeks may be affecting minimal increase in DBP there was no detemination of HR. This study showed that the principal of slow and deep breathing with a natural breath flow approach had been created by individual intention, attention and attitude. The opened-heart in group conversation about mind and body symptoms also helped. This experience of everything happened in everyday life, experienced by the participants’ themselves.5-7 When there was a feeling of any thoughts, which come back and go out through the mind, the participants were able to understand and to see more clearly and come back to the new breathing. This breathing is based on true physical and affective states. An opened-heart discussion in a group process allows for an individual self-reflection progress that ultimately increased the basic performance levels of concentration.7

Table 1: The general demographic data between control and experiment group

Table 2: Adjusted means and standard error of physical health outcomes between control and experimental group 

 

Figure 3: Charts A, B, C, and D presented the effects of slow deep breathing in mindfulness for an improved physical health outcome. Data are presented as means and SE for experiment and control group.

 

Focused breathing may produce a flexibility of cognitive ability and self management in breathing behavior. The inner awareness and acceptance was opened from experienceinducing compassion for others as the mind.6,7 The conscious mechanism was to observe slow breathing with induced diaphragm movement rather than the chest breathing pattern.21,22 Thus, this linked to the system of the body, the effect of chemical central nervous system23 and the autonomic nervous system24 such as baroreceptors, the parasympathetic nervous system, and many other factors including improved endothelium-dependent vasodilatation, enhancement of baroreceptor sensitivity, and arterial compliance which may also be involved.23,24

The American Heart Association group showed the device-guided slow breathing at a standard level Class IIA, and the level of evidence B which is recommended for BPlowering efficacy.25 According to previous studies, the benefits researched were BP and HR reduction in normal people as well as in hypertensive patients.26,27 From the six studies researched in meta-analysis from 1974 – 2016, it was revealed that 269 cardiovascular patients involved hypertensive patients, who had decreased BP and HR by slow breathing training.28 A consistant aspect in the study showed the importance of the addition of relaxation, mindfulness-based stress reduction, and meditation in hypertensive patients.29 The report showed that 10 minutes of focused attention on breathing movement at the lower abdomen is associated with significanly increased pressure levels of oxygenated haemoglobin as measured by near infrared spectroscopy. These was a significant increase in serotonin levels at 5 minutes and 30 minutes after attention was paid to conciousness through attentive breathing.30 The consistant research shows that breathing less than 10 times than the usual rate of 16.6 ± 2.8 times/minute involved deep exhaling at regular intervals of at least 15 minutes a day which led to reduced BP levels.26,30,31 The findings of breathing awareness meditation research measured office-BP measuring and this was more wildly statistically significant than Ambulatory Blood Pressure Measuring (ABPM). Indeed, the participants might be uncomfortable with ABPM measuring in a 24 hour period32,33

In this study, the DBP on the 12th week increased more than the 6 th week. Perhaps this was because after the 6th week the participants had non-continuous and intensive practice intervention at PCU. Furthermore, the SBP on 6th, 12th week and HR on 12th week were reduced but this was not statistically significant. This variety of factors might influence the physical health outcomes such as exercise or sodium consumption and medication compliance: these should be investigated in an intensive or randomized control trial for further study.

Furthermore, there were some special qualitative data during the group conversation meeting: in daily life, the consciousness of body symptoms observation is useful for physical feeling (i.e., headache, chest pain, cardiac arrhythmias, dizziness). The psychological feeling (i.e., angry, distraction) is also important. In addition, there were an extended data in the final 12th week follow up. They showed that physicians had stopped medication for 2 persons. Moreover they had reduced antihypertensive medication for 2 persons. Thus, these events possibly prevented polypharmacy and side effect of drugs.

The number of samples who missed the follow up was found more in the control group than in the experiment group. Thus, a normality plot was tested and we used the intention-totreat analysis comparing the adjusted means score, standard error, at 95 % CI between groups in order to handle missing data. The allocation was not a truly experimental design according to the limitations of suburban PCU areas.

Slow deep breathing in mindfulness has a positive effect on HR and DBP in physical health outcome as an intervention in lifestyle modification should complement treatment for stage I hypertensive patients. Furthermore, patients can benefit from group processing to raise awareness and to ease acceptance of physical and psychological effects of hypertension. Moreover, the mindfulness-group conversation experience in breathing should be based in the context of the participating PCU.

The authors declare no conflict of interest.

The authors express their gratitude to Associate Professor Chatchawan Silpakit, MD, PhD, Assistant Professor Lampu Kosulwit, MD, Professor Peera Burankitjaroen, MD, Associate Professor Sutreera Phatrayuthawan, PhD, and Assistant Professor Somkiat Sangwatanaroj, MD, MSc, FRCP(T). This study was supported by a grant from Thammasat University and National Science and Technology Development Agency; NSTDA Thailand.