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Pii: s0895-7061(00)01235-8Device-Guided Breathing
Exercises Reduce Blood Pressure:
Ambulatory and Home Measurements
Talma Rosenthal, Ariela Alter, Edna Peleg, and Benjamin Gavish Slow breathing practiced routinely using an interactive older patients and higher baseline BP. The results provide device has demonstrated a sustained reduction in high additional support for the efficacy of the device as an blood pressure (BP). We reevaluated the BP response of adjunctive lifestyle modification for treating hypertension.
hypertensives (n ϭ 13) to this daily treatment for 8 weeks Am J Hypertens 2001;14:74 –76 2001 American Journal using 24-h ambulatory, home, and office BP measure- ments. A clinically significant BP reduction of similarmagnitude was observed in all BP monitoring modalities Key Words: Lifestyle modification, therapeutic, ambu-
during the daytime. Greater BP reductions were found for latory blood pressure, hypertension.
have led to the search for effective nonpharmaco- addition to standard office measurements.
logic treatment alone or as an adjunct to drug therapy.1 Recently, a randomized controlled study re- ported that device-guided slow breathing with prolonged Subjects
expiration performed daily for 2 months resulted in a The study population included 13 hypertensives, 7 men sustained office blood pressure (BP) reduction of 16.2/ and 6 women, 6 medicated with antihypertensive drugs 10.6 mm Hg from a baseline BP of 158/97 mm Hg (n ϭ with no dose change for 3 weeks before the study, and 7 65).2 A similar study with this device involved home BP unmedicated, aged 25–75 years, excluding patients with BP classified as stage III (systolic BP Ն180 mm Hg or Breathing exercises play a prominent role in behavioral diastolic BP Ն110 mm Hg) and unmedicated patients with methods such as yoga, meditation, and biofeedback, which have had some success in treating high BP.4–6 There may Study Design
be some rationale for the therapeutic effect of the breathingexercises, as the acute response to slow and stable breath- The study included only one treatment group. During the ing includes a number of beneficial effects on the cardio- study a patient visited the clinic five times. Visits 1 and 2, vascular system, both at the systemic and the microvascu- 1 day apart, were used for eligibility and baseline office lar level. These include increasing baroreflex sensitivity, and 24-h ambulatory BP measurements. Treatment and heart rate variability, microvascular flow and venous re- home BP measurement took place during the next 8 turn, and reducing BP and peripheral resistance.7–11 How- weeks. One follow-up visit (No. 3) was scheduled at the ever, some of the observed antihypertensive effect elicited end of 4 treatment weeks. Office and 24-h ambulatory BP by the breathing exercises may be attributed to placebo measurements were done at the end of treatment (visits 4 response, to which office BP measurements are sensitive, and 5, 1 day apart). An assistant trained the patient in but ambulatory and home BP monitor are relatively insen- using the device and the home BP monitor during visit 2 It is the purpose of the present study to reevaluate the Treatment
efficacy of the breathing-guiding device in reducing theBP of hypertensives using 24-h ambulatory BP monitoring Treatment consisted of 15 min daily, breathing exercisesperformed for 8 weeks, musically guided by a device Received May 25, 2000. Accepted June 6, 2000.
Address correspondence and reprint requests to Talma Rosenthal, From the Chorley Hypertension Unit, Chaim Sheba Medical Center MD, Chorley Hypertension Unit, Chaim Sheba Medical Center, Tel (TR, EP), Tel Hashomer and InterCure Ltd. (AA, BG), Neve-Ilan, Israel.
Hashomer, Israel; e-mail: email@example.com 2001 by the American Journal of Hypertension, Ltd. Published by Elsevier Science Inc. AJH–January 2001–VOL. 14, NO. 1 DEVICE-GUIDED BREATHING REDUCES BLOOD PRESSURE
called Respi-Low (InterCure Ltd., Neve Ilan, Israel). Thedevice consists of a belt-type respiration-movement sensormounted on the upper abdomen or chest, attached to acomputerized control unit and headphones. On the basis ofan analyzed monitored breathing pattern, the device com-poses, in real-time, music-like sound patterns with a tem-poral structure similar to the actual breathing pattern butwith prolonged “expiration” (in the sound pattern). Thebreathing pattern modification occurs as the user volun-tarily follows the sound pattern with his or her breathingmovements. This process continues until a steady state isreached at the lowest breathing rate comfortable for theuser. The device also has a data logger that stores anddisplays data including date, time, and duration of use, andperformance parameters for the purpose of technical helpby telephone. The treatment took place at home, during theafternoon or evening. No change was made in the antihy-pertensive medication throughout the study period. Treat-ment started after visit 2 and stopped before visit 4. De-vices were then collected and downloaded.
FIG. 1. Age dependence of change in 24-h ambulatory systolic
blood pressure (BP) (awake) in response to treatment. Each pointcorresponds to an individual patient. The regression line is marked.
Office BP was measured in a sitting position, after the The correlation coefficient is r ϭ 0.76 and the slope is Ϫ0.46 mm patient had rested for 5 min, using a standard procedure.
The BP level for each device was taken as the average ofthe last two readings after three consecutive readings.
Twenty-four-hour ambulatory BP was determined at fre- changes were tested for being different from zero by quency of four per hour using Suntech Accutracker (Sun- one-sample t test. Dependence of BP changes on age and tech Medical Instruments, Raleigh, NC). The attached baseline values were determined using linear regression software provided the average BP in the awake and asleep models, where the P values correspond to the regression phases. Home BP was measured with Omron IC, a digital coefficients (eg, the significance of a non-zero slope as BPM that stores all data including BP, heart rate, date, and illustrated in Fig. 1). All P values were two-tailed. Statis- hour up to 350 measurements without a possibility to erase tical significance was associated with P Ͻ .05.
or replace data by the user. Patients were instructed tomeasure BP in the morning three times consecutively in acomfortable sitting position after at least 5 min of rest, and to refrain from smoking, physical exercise, or caffeine Baseline characteristics (mean Ϯ SD) were age 50.5 Ϯ during the 30 min preceding the measurement.
13.9 years and body mass index 25.0 Ϯ 5.2. Systolic/ Subject’s compliance with treatment was checked using diastolic BP were the following: for 24-h ambulatory, data stored in the data logger of the Respi-Low during the 137.1 Ϯ 6.9/82.5 Ϯ 8.4 mm Hg for awake (n ϭ 13) and study (by telephone) and after the study, when the data 117.8 Ϯ 10.3/69.4 Ϯ 10.5 mm Hg for asleep (n ϭ 12).
files were downloaded. Compliance with home BP mea- Office BP was 140.7 Ϯ 13.9/86.1 Ϯ 8.9 mm Hg and home surements was checked by the dates and times of the BP was 146.4 Ϯ 15.4/84.8 Ϯ 8.3 mm Hg. Heart rate was measurements stored in the BPM and downloaded at visits 75.2 Ϯ 6.7 beats/min. The number of patients at each BP classification was 1, 3, 7, and 2 for normal, high normal, Data Analyses and Statistics
stage I, and stage II, respectively.
The response to treatment is summarized in Table 1. In The study outcomes were the average systolic and dia- general, BP changes were similar in all monitoring meth- stolic BP changes from baseline level (visits 1 and 2 for ods. Significant systolic BP reduction was observed in the the office and 24-h ambulatory) to end level (visits 4 and 24-h ambulatory (awake) and the office BP. There was a 5). For the home measurements study outcomes were the 73% correlation between the 24-h ambulatory home mean average daily BP in the first and last 2 weeks. Heart rate arterial pressure (MAP) change (defined as: diastolic ϩ changes were defined accordingly. The primary study out- (systolic Ϫ diastolic)/3). No correlation was found be- come was the 24-h ambulatory BP changes in the awake tween office BP changes and baseline values of either phase, as outcomes of previous studies (office BP changes) ambulatory or home BP or the difference between office were defined at this time phase. The BP and heart rate and home BP, which discloses white coat effect. There was DEVICE-GUIDED BREATHING REDUCES BLOOD PRESSURE AJH–January 2001–VOL. 14, NO. 1
office systolic BP change between the present and the previous study can be explained quantitatively by its de- BP Change (mm Hg)
pendence on the baseline BP, which was higher in the BP Monitoring Modality
In conclusion, the present study provides additional evi- dence of the benefit of routine breathing exercises guided by the tested device as a safe and efficacious adjunctive lifestyle modification for treating hypertension.
* P Ͻ .05.
† P Ͻ .01.
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The Sixth Report of theJoint National Committee on Prevention, Detection, Evaluation, andTreatment of High Blood Pressure. Arch Intern Med 1997;157: no significant change in heart rate (Ϫ1.0 Ϯ 5.2 beats/min) Schein M, Gavish B, Herz M, Rosner-Kahana D, Naveh P, Knish-kowy B, Zlotnikov E, Ben-Zvi N, Melmed RN: Self-treatment of The BP reduction effect of the treatment was found to hypertension with device-guided breathing exercises: a double-blind increase with age in the ambulatory systolic BP (awake), randomized study. J Human Hypertens 2000 (In press).
as shown in Fig. 1 and the corresponding MAP reduction Grossman E, Grossman A, Schein MH, Zimlichman R, Gavish B: (P ϭ .02). Using a similar analysis, MAP reduction at Breathing-control lowers blood pressure (BP). J Human Hypertens home was found to increase with age (P ϭ .05) and Patel C, North WRS: Randomised controlled trial of yoga and baseline home MAP (P ϭ .01), whereas office systolic biofeedback in management of hypertension. Lancet 1975;ii;93–95.
BP reduction appears to increase for greater baseline sys- Patel C, Margot MG, Terry DJ, Carruthers M, Hunt B: Trail of relaxation in reducing coronary risk: four-year follow up. BMJ The contribution of age and baseline BP level can be demonstrated by calculating the MAP change for three Irvine J, Johnson DW, Jenner D, Marie GV: Relaxation and stressmanagement in the treatment of essential hypertension. J Psycho- groups: group I, all patients (n ϭ 13), group II, patients aged Ն40 years old (n ϭ 9), and group III, patients with de Daly MB: Interaction between respiration and circulation, in baseline home MAP Ն 100 mm Hg (n ϭ 7). The MAP Cherniak NS, Widdicombe JG (eds): Handbook of Physiology, changes obtained with ambulatory (awake), home BP and Section III, Volume 2, Part II. Bethesda, Am Physiol Soc, 1986, pp office BP were, respectively, Ϫ3.9, Ϫ3.9, and Ϫ4.7 mm de Daly MB: Aspects of the integration of the respiratory and Hg (P Ͻ .05) for group I; Ϫ5.7, Ϫ5.8, and Ϫ4.8 mm Hg cardiovascular system, in Jordan D, and Marshall J (eds): Cardio- for group II (P Ͻ .05); and Ϫ5.1, Ϫ7.2, Ϫ6.4 (P Ͻ .01) vascular Regulation. London, Portland, 1995, 15–35.
Pitzalis MV, Mastropasqua F, Massari F, Passantino A, Colombo R,Mannarini A, Forleo C, Rizzon P: Effect of respiratory rate on therelationship between RR interval and systolic blood pressure fluc- Discussion
tuations: a frequency-dependent phenomenon. Cardiovasc Res1998;38:332–339.
In terms of the magnitude of BP reduction by accepted 10. Novak V, Novak P, de Champlain J, Nadeau R: Altered cardiore- lifestyle modifications,14,15 the BP reduction achieved by spiratory transfer in hypertension. Hypertension 1994;23:104 –113.
the treatment device is clinically significant. The similarity 11. Cooke WH, Cox JF, Diedrich AM, Tatlor A, Beighol LA, Ames IV in BP response to treatment obtained with 24-h ambula- JE, Hoag JB, Seidel H, Eckberg DL: Controlled breathing protocolsprobe human autonomic cardiovascular rhythms. Am J Physiol tory, home, and office measurements suggests that the BP reduction is not likely due to the placebo effect.12,13 The 12. Mutti E, Trazzi S, Omboni S, Parati G, Mancia G: Effect of placebo increased BP reduction for greater age or greater baseline on 24-h non-invasive ambulatory blood pressure. J Hypertens 1991; BP, and the absence of any significant change in the heart rate, are of considerable interest for two reasons. First, the 13. Vaur L, Dubroca I, Dutrey-Dupagne C, Genes N, Chatellier G, Bouvier-d’Yvoire M, Elkik F, Menard J: Superiority of home blood benefits of the treatment are greater for patients found at pressure measurements over office measurements for testing. Blood higher risk for cardiovascular disease, older or with a higher BP. Second, these correlations may reflect a vas- 14. Dengel DR, Galecki AT, Hagberg JM, Pratley RE: The independent cular property, that is, beneficially modified by the treat- and combined effects of weight loss and aerobic exercises on blood ment, such as arterial compliance, which is reduced in pressure and oral glucose tolerance in older men. Am J Hypertens1998;11:1405–1412.
older age and higher BP. However, larger sample size and 15. Midgley JP, Matthew AG, Greenwood CMT: Effect of reduced other vascular probes are needed before such speculation dietary sodium on blood pressure: a meta-analysis of randomized can be applied. It is noteworthy that the difference in the controlled trials. JAMA 1996;275:1590 –1597.
CURRICULUM VITAE Dr. LUCA MERTEL Medico Veterinario, Dottore di Ricerca. DATI PERSONALI - Nato a Milano il 14 Novembre 1963. Si é laureato il 9 Novembre 1989 discutendo la tesi intitolata "La cheratocongiuntivite secca (KCS) nel cane" con la votazione di 110/110 e lode. Iscritto all’Ordine Provinciale dei Medici Veterinari di Milano dal 23 Gennaio 1990. Indirizzo e-mail: lucame