Introduction



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

A STUDY TO ASSESS THE EFFECTIVENESS OF RELAXATION

EXERCISE ON REGULATION OF BLOOD PRESSURE

AMONG HYPERTENSIVE CLIENTS ADMITTED

IN SELECTED HOSPITALS AT KOLAR

DISTRICT, KARANATAKA.

PROFORMA FOR REGISTRTION OF SUBJECT FOR

DISSERTATION

MR. PRAVEEN M

A.E & C.S PAVAN COLLEGE OF NURSING KOLAR-563101

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |MR. PRAVEEN M |

| | |1st YEAR, M.Sc. NURSING, |

| | |A.E & C.S PAVAN COLLEGE OF NURSING, |

| | |CHENNAI BANGALORE BY PASS ROAD, |

| | |KOLAR- 563101. |

|2. |NAME OF THE INSTITUTION |A.E &C.S PAVAN COLLEGE OF NURSING, |

| | |KOLAR - 563101. |

|3. |COURSE OF STUDY AND SUBJECT |M.Sc NURSING. |

| | |MEDICAL SURGICAL NURSING |

|4. |DATE OF ADMISSION TO COURSE |13th JUNE, 2008. |

|5. |TITLE OF THE TOPIC |A STUDY TO ASSESS THE EFFECTIVENESS OF RELAXATION EXERCISE ON REGULATION OF BLOOD PRESSURE |

| | |AMONG HYPERTENSIVE CLIENTS ADMITTED IN SELECTED HOSPITALS AT KOLAR DISTRICT. |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

"Ill health of body or of mind,

Is defeat, health alone is victory

Let all men if they can manage it

Continue to be healthy" - Thomas Carlyle

“Silent water, It is said that they are deep and dangerous”. “A volcano is also quiet till interrupts with devastating results”. High blood pressure is somewhat such a situation and if left undetected and untreated it results in brain attack (stroke), heart attack, heart enlargement, heart failure and kidney failure. Unlike volcano, which cannot be predicted, high blood pressure can be detected in the silent phase and if treated adequately the hypertension volcano can be prevented from eruption.1

Hypertension is a major public problem worldwide and in developing countries is different from that in the developed countries. India is a very large populated and typical developing country, community surveys have documented that between three and six decades, prevalence of hypertension has increased by about 30 times among about developers by about 10 times among rural inhabitants, various factors might have contributed to their rising trend and among others, consequences of urbanization such as change in life style pattern, diet and stress increased population and shrinking employment have been implicated. 2

WHO (1999) reported that one out of every three deaths in India is due to heart disease. In India about 10% of adult urban and about 3 to 5% of rural population suffers from high blood pressure. 3

Hypertension or high blood pressure, a common disease in industrial societies, has reached epidemic proportions. Approximately 50 million Americans are hypertensive and, though it can affect anyone, the greatest incidence occurs among middle-aged and older individuals. In addition, generally more men than women and African Americans than Caucasians have hypertension. 4

Results from epidemiologic studies have associated low levels of physical fitness with hypertension, independent of body mass or obesity. 5 Often referred to as the silent killer, hypertension is a leading risk factor for stroke, myocardial infarction, chronic heart disease and renal failure. 6

Hypertension is defined as a repeated blood pressure reading of greater than 140/90 mm Hg with pressures over 120/80 now considered as pre-hypertensive and worthy of lowering, especially with non-pharmacoologic means. Hypertension is generally classified into one of two categories: essential and secondary. Although the cause of essential hypertension is unknown, it is believed to develop in individuals with certain hereditary variations in genes. In contrast, secondary hypertension is a consequence of a known etiology, thus results from other diseases such as renal artery stenosis, coarctation of the aorta, adrenocortical or benign tumors and hypokalemia. 7

Exercise alternating muscle contraction and relaxation, such as in walking, running and cycling produces a different blood pressure response than static or resistance exercise (in which the muscle contraction is held for more than a few seconds before relaxing, such as in strength training and isometric exercise). Although antihypertensive drugs reduce blood pressure, some may also dampen exercise performance. Non-pharmacologic interventions can serve as definite therapy for selected hypertensive patients and adjunctive therapy for many others. 8

Aerobic exercise and diet-induced weight loss have emerged as the most effective and physiologically desirable approaches. Studies have also indicated exercise training lowers blood pressure in individuals with essential hypertension and those taking hypertensive medications. Moderate intensity exercise can reduce both systolic and diastolic blood pressure by 7mmHg. A review by the National Institutes of Health (NIH) demonstrated that in 70 percent of all exercising subjects, blood pressure lowered an average of 10.5/8.6mmHg from an average starting level of 154/98mmHg. 9

Additionally, population of older hypertensive females, aerobic exercise training improved insulin sensitivity and lowered blood pressure without a reduction in plasma tumor necrosis factor levels. 10

There are several types of relaxation techniques to overcome stress, like meditation, progressive muscle relaxation, bio feed back, imagery and autogenic training. However the selection of exercise for each patient depends upon his or her choice and physical ability to tolerate. Relaxation is the need of the time. The present study aims to verify the immediate effects of relaxation exercise on blood pressure in hypertensive patients.

6.1 Need for the study

One of the leading causes of morbidity as well as mortality in most developed and developing countries today are cardiovascular disease.

At the opening meeting of the WHO expert committee on hypertension control meet at Geneva, it was pointed out that hypertension is the commonest cardiovascular disorders, posing a major public health challenges to societies in socio-economic and epidemiological transition. It is one of the major risk factors for cardiovascular mortality, which allocates for 20-50% of all deaths. The report also highlights that adults aged 40-55 years had higher levels of blood pressure and Indian men had higher levels as compared to those of 20 other developing countries. The meta analysis of Gupta agrees that, the prevalence of hypertension in India is almost similar to those in USA. He also agrees with the findings of the urban-rural difference in hypertension. The prevalence is more among urban population than rural population. 11

The prevalence of hypertension has increases by 30 times among the urban population over a period of 36 years. Various hypothesis have been put forward to explain this rising trend, consequences of urbanization such as change in life style pattern, diet and stress have been implemented. The current urbanization rate in India is 35% compared to 15% in the 1950. Undiagnosed prevalence of hypertension is more than 15 million (more than 30% of 50 million are undiagnosed). Undiagnosed prevalence rate for hypertension is approximately 5.51% of 15 million people in USA.

The report of the WHO expert committee for hypertension (WHO, 1996) and the VI Report of the Joint National Committee on prevention, detection, evaluation and treatment of high B.P. Non-pharmacological treatments as the first measure in the control of hypertension. A study suggested daily exercise like walking and relaxation exercises and meditation as the first measure in the control of mild hypertension12, only those who cannot achieve normal tension by use of exercise should initiate drug therapy and even while on drug therapy, he said that all patients must continue to follow non-pharmacological therapy all through. 13

Standard exercise methods and protocols may be used for individuals with hypertension. Graded exercise can reduce the degree of blood pressure response during exercise, rate of recovery and incidence of arrhythmias during the test. When undergoing a exercise, individuals should be taking their usual medications. A resting Systolic Blood Pressure equal to or greater than 200mmHg or a Diastolic equal to or greater than 115mmHg is considered a contraindication to exercise. During the test, if Systolic bold pressure rises above or equals 260mmHg or Diastolic rises above or equals 115mmHg, the test should be terminated immediately. 14

At about 20 to 60 minutes of aerobic exercise, three to five days per week, at 50 to 85 percent of maximal oxygen uptake is appropriate for individuals with mild hypertension. However, for individuals with hypertension, exercise should be at 40 to 70 percent of maximal oxygen uptake after patients begin pharmacological therapy. Resistance training is recommended as an adjunct to aerobic exercise. It should be performed independently, since research has not shown it can decrease blood pressure consistently, with the exception of circuit weight training. This type of training should use low resistance and high repetitions. The American Heart Association recommends mild to moderate resistance training at 30 to 60 percent of maximal effort for improving muscle strength and endurance. 15

An abundance of evidence suggests increasing physical activity in sedentary individuals and maintaining it in active ones can significantly impact hypertension. The amount of activity required for benefit is feasible for almost everyone. Counseling by health care providers is one important, but underutilized, method of encouraging adults to engage in physical activity and exercise. Moreover, physical activity opportunities in schools and communities should be encouraged for hypertension prevention and intervention across all age groups.

Though there have been studies showing the positive effects of stress reduction and relaxation by various means, their use is very limited in practice. The present study aims to verify the immediate effects of relaxation exercise on blood pressure in hypertensive patients. There have not been a study earlier on the same topic and the researcher is interested to promote the use of relaxation exercise in the treatment of hypertension. Most of all it does not involve financial burden either in learning or in its use. Minimum life style modifications are required. On the other side, life long drug therapy is a great financial burden to the people of our economically developing country. The drug therapy through effective has enormous amount of side effects and complications in the long run.

Based on the review of literature and personal experience of investigator during his clinical posting, found that in many hospitals hypertension is one of the common reported problem. Care of hypertension involves such as diet control, stress control, relaxation exercise, anti hypertensive drugs to control the blood pressure and prevention from complication. Hence the investigator is interested to conduct a study on effectiveness of relaxation exercise to control hypertension.

6.2 Review of Literature

The review of literature for the present study was done on both research and non-research materials. The review was considered under following three headings:

1. review related to High blood pressure and its effects on body.

2. review related to Stress – a contributing factor.

3. review related to The effects of relaxation on blood pressure.

1. Review related to High blood pressure and its effects on body.

A study conducted with objectives to determine the prevalence of essential and borderline hypertension in a population of blood donors and their families and to determine if there is a correlation between blood pressure and lifestyle and/or other cardiovascular risk factors. The diastolic blood pressure was dependent on BMI, heart rate, and alcohol in both sexes, and glycemia, LDL cholesterol, and uricemia in the men. In the second group, primary and borderline hypertension are significantly correlated with age, BMI, and uricemia in both sexes and glycemia in females. A program of health and nutritional education could modify some factors related to blood pressure, such as obesity and alcohol consumption. The result would be a reduction of the prevalence not only of essential and borderline hypertension, but also of metabolic diseases such as dyslipidaemias, diabetes and hyperuricemia, with a global reduction of the cardiovascular risk. 16

A study aimed to determine the frequency and risk factors of hypertension among individuals aged 50 years and over, and to examine its effect on the health related quality of life (HRQOL). A questionnaire concerning life habits associated with hypertension, medical histories, and demographic characteristics was filled by face to face interview. The overall prevalence rate of hypertension was 59.5% (n=710), being 58.0% in men and 60.9% in women. The variables that most positively influenced hypertension were older age, single, no health insurance, consumption of animal fat in meals, and family history of hypertension. The HRQOL of the patients with hypertension was lower than that of those without hypertension. The HRQOL was better in hypertensive patients whose blood pressure was under control, whereas it was worse in those with at least one chronic disorder accompanying hypertension. Great emphasis should be placed on the need for a public health program for the detection, prevention, and control of hypertension, including other risk factors, as well as for the modification of foods and life habits, specifically in individuals who are most likely to be at risk of hypertension. 17

Hypertension experts still debate on the level of blood pressure (BP) considered abnormal. A great deal of effort has been devoted to search for dividing line between normotension and hypertension. According to the study18 there is no dividing line between normotension and hypertension. The relationship between arterial pressure and mortality is quantitative, the higher the pressure the worse the prognosis. The report of WHO expert committee evidenced that hypertension as the level of B.P. at which detection and treatment do more good than harm. This level can be determined only by intervention trials demonstrating of benefits from blood pressure reduction. According to the study the currently accepted dividing line based on epidemiological and intervention studies are stated as systolic BP > 140 mm-Hg and/or diastolic BP > 90 mm-Hg.19

A study on prevalence of left ventricular hypertrophy in essential hypertension was done at Tirupati. Fifty patients with essential hypertension were studied by echocardiography and its correlation to ECG. The result showed the prevalence of left ventricular hypertrophy in essential hypertensive patients was 74% and it increased with age. Echocardiography is more sensitive than ECG as 76% of patients who had no ECG evidence showed left ventricular hypertrophy by echocardiography. 20

An article on mild hypertension states that easily determined signs of target organ damage are angina pectoris, prior myocardial infarction, prior coronary angioplasty or CABG surgery, congestive cardiac failure, stroke and renal failure. Sustained elevations in blood pressure have severe consequences even when they are considered to be mild elevations. 21

2. review related to Stress – a contributing factor.

A study revealed that mental stress induces significant peripheral arterial vasoconstriction, with consequent increases in heart rate and blood pressure. These changes are thought to underlie the development of myocardial ischemia and other mental stress-induced adverse cardiac events in patients with CAD. The study examined for gender-related differences in peripheral arterial response to mental stress in a cohort of patients with CAD using a novel peripheral arterial tonometric (PAT) technique.. Hemodynamic and PAT measurements were recorded during rest and mental stress. The PAT response was calculated as a ratio of pulse wave amplitude during stress to at rest. PAT responses were compared between men and women. The PAT ratio (during stress to at rest) was significantly higher in women compared with men. Mean PAT ratio was 0.80 +/- 0.72 in women compared with 0.59 +/- 0.48 in men (p = 0.032). This finding remained significant after controlling for possible confounding factors (p = 0.037). In conclusion, peripheral vasoconstrictive response to mental stress was more pronounced in men compared with women. This finding may suggest that men have higher susceptibility to mental stress-related adverse effects. 22

A study conducted to investigate the psychobehavioral factors involved in the isolated clinic blood pressure elevation and hypertension induced by mental stress. It was studied among 73 untreated patients with essential hypertension. The amount of isolated clinic blood pressure elevation was examined in terms of the difference between clinic and daytime ambulatory blood pressures. Blood pressure were continuously monitored with subjects at rest and under mental stress to examine the cardiovascular response to the stress. The anger score was inversely correlated to the clinic-ambulatory blood pressure difference for the systolic (r = -0.308, P < 0.01) and diastolic (r = -0.233, P < 0.05) blood pressures. The clinic-ambulatory blood pressure difference was not related to the blood pressure rise induced by mental stress The isolated clinic blood pressure elevation and hypertension due to mental stress were related to different psychobehavioral factors. 23

A 47 year old woman with pure autonomic failure complained of dizziness during emotional stress. Emotional stimuli have not previously been reported to cause hypotension in patients with autonomic failure. In the patient, ambulatory blood pressure recording revealed severe hypotension (50/30 mm Hg) after a stressful event. During a tilt table test, hyperventilation was shown to cause a significant fall of blood pressure. This suggests that emotional stress can induce hypotension, probably through hyperventilation, in subjects with autonomic failure. 24

A study conducted to know the effect of isometric exercise and mental stress on B.P. among eleven male volunteers within age group of 27-37 years were familiarized with arithmetic as well as isometric exercise. The arithmetic subjects were asked to stand for three minutes and then perform the mental exercise which consisted of subtracting the number ‘7’ backwards from a given 3 digit number for a period of 2 minutes. Blood pressure was recorded before performing mental exercise and after two minutes of mental exercise. Isometric exercise consisted of lifting a suitcase weighing 20 kg for a period of two minutes. The stress of mental arithmetic consistently produces increase in mean arterial pressure both in normotensives as well as hypertensive subjects. Lifting the load of 20 kg produced blood pressure elevations of 45/30 mmHg consistently within 1-2 minutes of lifting in all subjects. 24

In a summary of the Canadian consensus conference suggested that stress reduction through individualized cognitive behaviour modification is effective in reducing blood pressure in hypertensive. They recommended health care professionals to advice cognitive behaviour intervention in hypertensive patients. The Joint National Committee (1997) in its VI report recommends non-pharmacological measures to reduce mild hypertension and to initiate drug therapy in only those who fail to normalise the blood pressure with non-pharmacological measures. 25

3. review related to The effects of relaxation on blood pressure.

A study evaluated the efficacy of relaxation technique as an adjunctive therapy for control of Hypertension with a single blind randomized controlled design, 220 patients with newly diagnosed moderate to severe hypertension who needed drug therapy. Patients were systematically randomized to receive standard plus relaxation therapy, two times per week, for eight weeks, or standard therapy alone. Mean BP level was 192.86/105.16 and 192.09/102.25 mmHg on admission in the case and the control groups, which decreased to 133.46/81.48 and 146.21/83.57 mmHg, respectively, at the end of study. The difference of BP on admission was not statistically significant, but became significant at the end of the study. Fifty nine percent in the case group and 36% in the control group had good control of blood pressure. Relaxation therapy on the background of standard antihypertensive drug treatment results in better control of blood pressure. 26

The purpose of the study was to investigate the difference in relaxation between subjects participating in music relaxation techniques (n=14) and subjects participating in their daily group sessions (n=13). Measurements of perceived anxiety and relaxation were taken by means of the State form of the State Trait Anxiety Inventory, a Visual Analogue Scale and a questionnaire written by the researcher. The experimental group used music with relaxation techniques such as Tense Release, Autogenic Training, Yoga Meditation, Passive Relaxation and Mindfulness Breathing exercises. Music was selected on the basis of being slow, quiet, non-vocal and/or claiming to be effective in relaxation. While the experimenter hypothesized subjects in the experimental group would show an increase in relaxation, there were no significant differences found between the two groups. Further study may develop more appropriate relaxation techniques useful to people with mental illnesses. 27

A study was conducted to determine the effectiveness of a yoga program on blood pressure and stress, a group of hypertensive patients in Thailand. The experimental group showing significantly decreased mean stress scores and blood pressure, heart rate, and body mass index levels compared with the control group. Further studies are suggested to determine the effects of yoga on hypertension in Thailand. 28

A study conducted to investigate the behavioral therapy like meditation, relaxation, bio-feedback and yoga in reducing the blood pressure among hypertensive clients. Yogic relaxation and bio-feedback administered among 20 hypertensive clients. It was made a 12-month follow-up of yoga and bio-feedback to reduce hypertension. Age and sex matched hypertensive controls were similarly followed up. The study revealed that reduction in blood pressure and drug requirement were satisfactorily maintained in the treatment group while repetition of blood pressure measurements and increased medical attention did not reduce blood pressure in the control group.29

A study conducted on seven hypertensive patients in Ohio, USA assessed the transcendental meditation and was seen weekly, took their own blood pressure several times daily. After 12 weeks of transcendental medication six subjects showed psychological changes and reduced anxiety scores. Six subjects showed significant reduction in B.P. in home and four subjects showed reduction in B.P. in clinic. Six months later four subjects continued to derive psychological benefit and two showed significant blood pressure reductions at home and clinic. 30

STATEMENT OF THE PROBLEM

a study to assess the effectiveness of relaxation exercise on regulation of blood pressure among hypertensive clients admitted in selected hospitals at kolar district.

6.3 Objectives of the Study

a. To assess the existing blood pressure among hypertensive clients.

b. To determine the effectiveness of relaxation exercise in reducing blood pressure among hypertensive clients.

c. To find out the association between the effect of relaxation exercise with their selected demographic variables.

1 Operational Definitions

1. Assess: It refers to measuring the blood pressures of the hypertensive clients.

2. Effectiveness: It refers to determine the extent to which the relaxation exercise

reduce the blood pressure among the hypertensive clients by

comparing pre test and post test scores.

3. Relaxation exercises: Relaxation exercises are deep breathing and passive

progressive relaxation exercise done with active

participation of the subjects under study.

4. Hypertensive patients: Patients with systolic blood pressure 140 mmHg or more,

Or diastolic blood pressure 90 mmHg or more.

6.5 Hypothesis

H0: There will be no significant effect on relaxation exercise in regulation of blood pressure among hypertensive clients.

6.6 Variables

6.6.1 Dependent Variable:

Blood pressure.

6.6.2 Independent Variable:

Relaxation exercise

7. MATERIAL AND METHODS

7.1 Source of Data:

Clients who admitted with diagnosis of hypertension in selected

hospitals, Kolar.

7.2 Method of Data Collection:

7.2.1 Research Design:

Experimental Design.

7.2.2 Settings:

The study will be conducted in Sri Narasimharaja Hospital, kolar, which is

2 km away from Pavan college of nursing,having 500 bed strength. And

R.L.Jallapa hospital, tamaka kolar which is 5km away from pavan college

Of nursing, kolar, which is having 850 bed strength.

7.2.3 Population:

Hypertensive patients.

7.2.4 Sample:

Hypertensive patients between the age group of 35 to 65 years and

Admitted in selected Hospitals, kolar.

7.2.5 Sample Size:

Experimental group: 30

Control group : 30

7.2.6 Sampling Technique

Simple random sampling technique.

7.2.7 Sampling criteria:

(a) Inclusion Criteria:

(i) Clients admitted with hypertension between age gourp of 35 to 65

years in selected hospital, Kolar.

(ii) Clients of both sex.

(iii) Clients who can understand Kannada or English.

(iv) Clients who are willing to participate in the study.

(b) Exclusion Criteria

(i) Clients who are admitted less than 35 years of age and above 65

years age.

(ii) Clients who cannot understand Kannada or English.

(iii) Clients who are not willing to participate in the study.

7.2.8 Tool for data collection:

Structured interview schedule will be used for the data collection.

Section A:

Demographic data of the subjects including age, sex, education, occupation, income, marital status, religion, type of food, source of health information.

Section B:

Structured Interview questionnaires.

7.2.9 Method of data collection:

The data collection procedure will be carried out for a period of 6 weeks. The study will be conducted after obtaining permission from the concerned authority, rapport will be established with the samples and the purpose of the study will be explained to them so as to get the co-operation in the procedure of data collection.

7.2.10 Data analysis and interpretation:

Data will be analyzed on the basis of objectives by using descriptive and inferential statistics. Descriptive statistics will be used for the frequency, percentage, mean and standard deviation. Inferential statistics will be used for chi – square test and paired “t” test and it will be interpreted and presented in the form of tables, graphs and diagrams.

7.3 Does the study require any investigation to be conducted on patients or other human or animals? If so please describe briefly?

Yes, relaxation exercise will be administered to the hypertensive clients to assess the regulation of blood pressure level among hypertensive clients.

7.4 Has ethical clearance has been obtained from your institution?

Yes, prior to the study permission will be obtained from the concerned authorities to conduct the study in Sri Narasimharaja Hospital, R.L.jalappa hospital Kolar and also from research committees of A.E and C.S. Pavan College of Nursing, Kolar. The purpose of the study will be explained to the clients of the respective areas.

8. LIST OF REFERENCES

1. Linda Brookers, Robert Rowan. Constance Schrader. Control of Hypertension. Community health Science. DASH Collaborative Research Group. NEJM 1997; 336:1117-24.

2. George M. Manesh, Bombardier C. et at Clinical Approach to Hypertension. Harvard publication. 200043:1520-1528.

3. NC VI- The sixth Report of the Joint National Committee on prevention,. Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med. 1997; 15fl4 13-46.

4. Pescatello, Linda S, Franklin, Barry A. Exercise and Hypertension. Medicine & Science in Sports & Exercise. 36(3):533-553, March 2004.

5. Lesniak, Karen T.; Dubbert, Exercise and hypertension Patricia Current Opinion in Cardiology. 16(6):356-359, November 2001.

6. Stephen Archer, MD; Stuart Rich, MD Primary Pulmonary Hypertension A Vascular Biology and Translational Research "Work in Progress". Clinical Cardiology: New Frontiers;Circulation. 2000;102:2781-2791.

7. Erika Zanabria,  Gregory L. Welch..American College of Sports Medicine. "Position Stand: Physical Activity, Physical Fitness, and Hypertension." Med. Sci. Sports & Exercise, 1993, 25: 10, I-X.

Gregory L. :Exercise Management for Persons with Chronic Diseases and Disabilities. American College of Sports Medicine. Human Kinetics: Illinois, 1997, pp. 59-63.

8. Chintanadilok, J. and Lowenthal, D.T. "Exercise in Treating Hypertension." The Physician and Sportsmedicine, 2002, 30: 3, 1-14.

9. Klaus, D. (February 1989). "Management of Hypertension in Actively Exercising Patients: Implications for Drug Selection.". Drugs 37 (2): 212–218.

10. Stewart, Kerry; et al (April 2004). "Exaggerated Exercise Blood Pressure is Related to Impaired Endothelial Vasodilatory Function". Am. J. Hypertension 17 (4): 314–320. doi:10.1016/S0895-7061(03)01003-3.

11. Willaims B & British Hypertension Society et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18 3: 139−185.

12. Gupta R. Hypertension in India–definition, prevalence and evaluation. Journal of Indian Medical Association 1999; 97(3): 74-80.

13. Chabra MK, Lal A, Sharma KK. Status of life style modifications in hypertension: J Indian Med Assoc. 2001 Sep;99(9):504-8.

14. Kolbe TL, Lambert EV, Charlton KE. Effectiveness of a community based low intensity exercise program for lod adults. J Nutr Health aging. 2006 Jan-Feb; 10(1): 21

15. Bellodi G, Bernini G, Manicardi V, Veneri L, Muratori L, Magnanini G, Rossi G, Bossini P, Descovich G.Arterial hypertension in relation to life style and other cardiovascular risk factors. Epidemiologic study of a population of blood donors. Project AVIS:Minerva Cardioangiol. 1994 Mar;42(3):73-84.

16. Arslantas D, Ayranci U, Unsal A, Tozun M.Prevalence of hypertension among individuals aged 50 years and over and its impact on health related quality of life in a semi-rural area of western Turkey. Chin Med J (Engl). 2008 Aug 20;121(16):1524-31

17. Pincomb GA, Wilson MF, Sung BH, Passey RB, Lovalo WR. Effects of caffeine on pressor regulation during rest and exercise in men at risk for hyhpertension. Am Heart J. 1991 Oct; 122:1107-15.

18. Gupta AK et al. Awareness of hypertension among a north Indian population. Journal of Indian Medical Association 1998; 96: 298-9.

19. Swarnalatha G et al. Prevalence of left ventricular hyptertrophy in essential hypertension–ECG and echocardiographic correlation. Journal of Association Physicians of India 2002; 50(1): 105.

20. Hassan M, Li Q, Brumback B, Lucey DG, Bestland M, Eubanks G, Fillingim RB, Sheps parison of peripheral arterial response to mental stress in men versus women with coronary artery disease. Am J Cardiol. 2008 Oct 15;102(8):970-4.

21. Saini SJ, Cornelism VA . Effect of resistence training on resting blood pressure. J Hypertens.2005 Feb;23(2): 251-9.

22. Munakata, Masanori; Hiraizumi, Takeshi; Tomiie, Tadaaki; Saito. Psychobehavioral factors involved in the isolated office hypertension: comparison with stress-induced hypertension. Journal of Hypertension. 16(4):419-422, April 1998.

R D Thijs, J G van Dijk. Stress induced hypotension in pure autonomic failure. Journal of Neurology, Neurosurgery, and Psychiatry. 2006;77:552-553.

Agras WS, Schnaider JA, Taylor CB. Relaxation training in essential hypertension: a failure of retraining in relaxation procedures. Behaviour Therapy 1984; 15: 191-6.

23. Agarwal A, Dixit SP, Dubey GP. Assessment of EMG biofeedback on neuropsychophysiological parameters among various types and psychomatic disorders. Indian Journal of Clinical Psychology 2000; 27(1): 97-103.

24. F. Ranjbar,  F. Akbarzadeh,  B. Kazemi,  A. Safaeiyan . Relaxation therapy in the background of standard antihypertensive drug treatment is effective

25. In management of moderate to severe essential hypertension. The Journal of the Pakistan Medical Association. Rawal Medical J 2007;32:120-124.

26. Jayne Standley. The effects of music relaxation techniques on stress levels of day treatment clients. Journal of Advanced Nursing; Volume 39 Issue 4, Pages 352 – 359.

27. McCaffrey, Ruth ND, ARNP-BC; Ruknui, Pratum MS, RN; Hatthakit, Urai, RN; Kasetsomboon, Payao MS, RN.The Effects of Yoga on Hypertensive Persons in Thailand. Holistic Nursing Practice. 19(4):173-180, July/August 2005.

28. Patel C. Randomised controlled trial of yoga and bio-feedback in management of hypertension. Lancet . 1975 Jul 19; 2(7925); 93-5.

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