Case study on hypertension, physical exercise and psychophysiological coherence biofeedback

African Journal for Physical Activity and Health Sciences (AJPHES), Vol. 22(2:2), June 2016, pp. 514-524. Case study on hypertension, physical exercise and psychophysiological coherence biofeedback STEPHEN D. EDWARDS Psychology Department, University of Zululand, KwaDlangezwa, South Africa. E-mail: sdedward@telkomsa.net (Submitted: 05 May 2016; Revision Accepted: 21 May 2016) Abstract Hypertension is a serious stress related disorder, typically requiring pharmacology in combination with various methods of health promotion including diet, specific lifestyle and psychophysiological techniques. This case study describes the effective treatment of a hypertensive crisis in a 63 year old woman with special reference to relevant, optimal, physical exercise and psychophysiological, heart rhythm variability, biofeedback interventions. Quantitative findings and client s experiential descriptions provided convergent support for the hypothesis that these interventions would be associated with blood pressure reductions. The single case study is instructive with regard to the typically holistic, multifactorial nature of aetiology, diagnosis and treatment, especially with regard to such common disorders as essential hypertension. Keywords: Introspection, case study, hypertension, blood pressure, physical exercise, HeartMath, psychophysiological coherence. How to cite this article: Edwards, S.D. (2016). Case study on hypertension, physical exercise and psychophysiological coherence biofeedback. African Journal for Physical Activity and Health Sciences, 22(2:2), 514-524. Introduction Hypertension is a serious stress related disorder, which affects at least 1 in 4 adults (Abuldager, 2012; American Heart Association, 2014). It is measured in terms of systolic blood pressure, when the heart contracts, and diastolic blood pressure, when the heart relaxes. Diastolic pressure increases up to middle age and then tends to decline, whereas systolic pressure continues to increase with age and is an important determinant of elevated blood pressure in middle-aged and older adults. Hypertension risks increase with systolic readings above 140 mm Hg and diastolic readings above 90 mm Hg, reaching crisis levels when these readings exceed 180 and/or 110 mm Hg respectively (American Heart Foundation, 2014). In addition to pharmacology, blood pressure reductions are reportedly achievable with various health promoting methods, including specific lifestyle and mind-body techniques, such as optimum physical activity of 150 minutes a week and psychophysiological biofeedback, which are associated with mean systolic reductions of up to 9 mm Hg and 14 mm Hg respectively (Childre,

Hypertension, exercise and psychophysiological coherence biofeedback 515 Martin, Rozman & McCraty, 2016; Department of Health, Physical Activity, Health Improvement and Prevention, 2004; McCraty, Atkinson & Tomasino 2003; Oberg, 2009). These techniques are the focus of the present case study. Physical exercise may be defined as a subset of physical activities that are planned and purposeful attempts to improve performance, health and/or wellness. For example, in addition to vigorous, performance driven, pursuit of athletic excellence, this includes regular, moderate intensity, exercise interventions to promote health (Berger, 2001). Biofeedback involves the use of instrumentation to monitor typically unconscious psychophysiological processes, which may be brought under voluntary control (Thompson & Thompson, 2004). This study used a HeartMath, Inner Balance, biofeedback apparatus to monitor and train psychophysiological coherence, which was characterized by a heart rhythm pattern of elevated amplitude in low frequency heart rate variability of around 0.1 Hz, equivalent to about 5-7 breaths per minute, accompanied by heart focussed breathing and the cultivation of positive emotional states such as contentment, peace and happiness. The goal of this study was to promote health in a hypertensive crisis experienced by a client. In this context, health is viewed as a coherent, dynamic integrity of various interacting energies, components and contexts (Childre et al., 2016; Wilber, 2000). The aim was to evaluate physical exercise and psychophysiological biofeedback interventions. In view of the abovementioned, reported effectiveness of these techniques, it was hypothesized that they would be effective in reducing blood pressure levels. Methodology The case study, with mixed quantitative and qualitative methodology (Creswell & Plano-Clark, 2007), consisted of a health promotion intervention, involving the recording of physical exercise and psychophysiological coherence practice, and related personal experiences. The study began with a hypertensive crisis and extended over a period of exactly two months. A contracted minimum number of 30 BP recordings sessions, taken after both physical exercise and HeartMath practice, was deemed minimal for optimizing and evaluating intervention effectiveness. Participant The client, code name W, was a female, 63 year old, retired, pre-primary school teacher, with a Bachelor s degree in Psychology and Education. A well-known, active member of her local community, W was happily married, with two children and two grandchildren, practised yoga, played tennis twice a week and walked briskly for approximately 6 kilometres a day. This was her second

516 Edwards hypertensive crisis. Following the initial episode, she was previously maintained on the beta blocker, Bisoprolal fumerate (Cardicor), 2.5 mg by her medical practitioner for the past four years. This second episode followed a period of three weeks of fluctuating blood pressure, anxiety and stress related to a crisis involving a close relative. Additional medication, angiotensin receptor antagonist, Adco-Zetomax 5 mg, was prescribed. However acute symptoms of dizziness, headache, loss of balance and left sided sensations of tingling and numbness eventually led to emergency hospitalization. CT and MRA scans were not clinically significant. Aware of the possible iatrogenic effects of medication, as well as negative concomitants of anxiety and stress related activities, W committed to focus on minimizing negative stresses, and optimizing health promoting physical exercise and psychophysiological coherence interventions, to complement existing medical hypertension prevention measures. Ethics Ethical approval for community projects involving health and/or sport promotion was granted by the University to which the author, a clinical, sport psychologist and certified HeartMath coach, is attached. In addition to providing written informed consent, W was thoroughly informed on stress reduction with special reference to optimal amounts of physical exercise as well as HeartMath research and practice. Instruments A clinically validated, portable, battery operated, Dis-Chem Medic Upper Arm Blood Pressure Monitor, Model KD558, was used to measure hypertension levels. The cuff, which has a circumference of 22-30 cm, is inflated by an automatic electric pump. The LCD display, and metric oscillations measuring method, provides automated readings of date, time, systolic and diastolic blood pressure, and pulse rate. The instrument, which has diastolic and systolic ranges of 40-199 and 60-260 mm Hg respectively, can record pulse rates of 40-180, with a pressure accuracy of approximately 3mm Hg and a pulse accuracy of approximately 5%. Heart Rate Variability (HRV) is well established as a diagnostic, training and performance monitoring tool for promoting health, physical activity, exercise and sport (Aubert, Seps & Beckers, 2003; Makivic, Nicik & Willis, 2013). Heart Rate Variability Biofeedback (HRVB) equipment typically utilizes Fast Fourier techniques for mathematical transformation of HRV into power spectral density (Lehrer & Gevirtz, 2014; Shaffer, McCraty & Zerr, 2014). The HeartMath biofeedback tool, Inner Balance, gives readings of psychophysiological coherence practice with regard to date, time, session duration, heart rate variability, average heart rate, achievement score, coherence score, challenge

Hypertension, exercise and psychophysiological coherence biofeedback 517 level; which ranges from 1 to 4, coherence ratio, in terms of percentage of time spent in low, medium or high coherence, time elapsed, and graphic display of practice activity spent in a demarcated, coherent, zone of optimal, autonomic nervous system functioning. Biofeedback consists of red, blue and green coloured bars, with percentage indications and accompanying tones for low, medium and high coherence levels respectively, as well as coherence points accumulated. Session measurements are continuously monitored and recorded on a Heart Cloud. Physical exercise was simply measured in terms of its duration in minutes, and intensity, using the Borg 10 point Category scales with Ratio properties (CR10) of perceived exertion as a rough guide (Borg & Kaijser, 2005). Data collection Data collection simply took the form of recording 5 baseline or pre-test measures and 30 blood pressure readings after both some form of physical exercise and HeartMath practice sessions. W typically practised approximately one minute of relaxation after each activity before recording BP in a sitting position in the same chair. As indicated in the following experiential description, this brief relaxation time was an additional source of improved resilience, insight and self-efficacy. Data analysis Data analysis took place after W had recorded 30 blood pressure readings following some form of physical exercise or HeartMath practice. Quantitative data were analysed with the Statistical Package for the Social Science (SPSS) non parametric programmes for Kruskal Wallis, Mann Whitney, Wilcoxon and Chi Square statistics. Results Quantitative findings. W s records lasted exactly two months. Her 30 physical exercise sessions consisted of 16 walks, 5 individual sessions of tennis, 3 of yoga, 3 shopping and 3 of house cleaning. The records indicated a mean duration of 56.8 minutes, with a standard deviation (SD) of 35.0, at an intensity level of 4.8 (SD = 1.4) spent on physical exercise. Thus her physical exercise was typical of regular, moderate intensity, interventions, known to promote health (Berger, 2001). Her 30 HeartMath sessions, recorded at the basic or beginner challenge level, averaged 11.1 minutes (SD = 4.3), with a mean Achievement level of 358.4 (SD = 171.6) points accrued at a mean coherence level of 2.7 (SD = 0.6). The HeartMath Institute recommends a minimum of 300 points a session. The Coherence Score

518 Edwards Guide has the following categories: 0.5 = basic good beginner level; 1 = good; 2 = very good; 3+ = excellent. (Most regular practitioner scores fall in the 3 to 6.5 range (R. McCraty, personal communication, 31 May, 2015). Thus, W s HeartMath practise satisfied minimum session achievement recommendations and fell into the very good category of coherence. Her blood pressure, physical exercise and HeartMath practice findings follow in Table 1. Table 1: Means, Standard Deviations (SD), in parenthesis, and Kruskal Wallis analysis of Baseline, Exercise (E) and HeartMath (H) conditions for Systolic Blood Pressure (SPB), Diastolic Blood Pressure (DBP) and Pulse readings Measure Baseline Exercise (E) HeartMath (H) Statistic SPB 175.8 (5.0) 128.2 (9.7) 133.3 (6.5) X 2 = 12.52** DBP 88.6 (6.7) 73.4 (4.8) 75.3 (3.7) X 2 = 12.26** Pulse 72.0 (10.0) 58.9 (4.8) 58.2 (5.9) X 2 = 9.0 ** Table 1 refers to Means, Standard Deviations (SD), in parenthesis, and Kruskal Wallis, Chi Square (X 2 ) comparisons between Baseline, Exercise (E) and HeartMath (H) conditions for Systolic Blood Pressure (SPB), Diastolic Blood Pressure (DBP) and Pulse readings respectively. As observed, there were significant differences for comparisons between baseline, Exercise and HeartMath interventions for: Systolic Blood Pressure (SPB), X 2 = 12.52, p =.00; Diastolic Blood Pressure (DBP), X 2 = 12.26, p =.00; and Pulse recordings, X 2 = 9.0, p =.00 respectively. Individual Mann-Whitney U comparisons indicated that both interventions, separately, were significantly different from baseline. The Baseline versus Exercise comparison indicated significant differences at the 1 % significance levels for: SPB, Z = 3.5, p =.00; DBP, Z = 3.5, p =.00 and Pulse Z = 3.0, p =.00 recordings respectively. The Baseline versus HeartMath comparison indicated significant differences at the 1 % significance levels for: SPB, Z = 3.5, p =.00; DBP, Z = 3.5, p =.00 and Pulse Z = 2.9, p =.00 recordings respectively. When individual comparisons were made between the two interventions, results were as follows for: SPB, Z = 2.1, p =.03; DBP, Z = 1.7, p =.09 and Pulse Z = 0.5, p =.64 recordings respectively. Thus in summary, the quantitative findings provide support for the hypothesis that both Exercise and HeartMath interventions would be associated with improvements in blood pressure. As can be observed from Table 1, although the Exercise intervention appeared to be slightly more effective than the HeartMath intervention, significance was only reached in the case of SPB. This difference could be related to the relatively greater duration of time spent on physical exercise, the basic, beginner level of HeartMath practise and/or various less obvious factors.

Hypertension, exercise and psychophysiological coherence biofeedback 519 Qualitative findings W s verbatim experiential description of the physical exercise and HeartMath interventions was as follows: I am a health conscious and active person, who enjoys exercise and being outdoors, however at times I tend to drive myself and overdo things. My husband describes me as being: Ever ready. I also do not handle stressful situations very well and tend to internalise them. Two months ago, after a stressful time related to a crisis involving a close relative, I experienced extreme dizziness and an overwhelming feeling of anxiety while playing tennis. I visited my Doctor and my blood pressure was very high and medication was prescribed. As the weeks passed I continued to feel unwell, with headaches, dizziness, a feeling of being uncoordinated and off balance. I also experienced the sensation of numbness and tingling in my limbs and face. I was no longer sufficiently confident to do many of my routine activities like play tennis or drive a car. This lead to increased anxiety on my part. I was admitted to hospital for tests and, besides my potassium being below the normal reading, nothing abnormal was found. I visited my Doctor for a follow up consultation and my blood pressure was still moderately elevated and he again increased my blood pressure medication. I was unhappy that my symptoms were being treated without a cause being found. The medication was causing detrimental side effects and I did not feel I wanted to take these blood pressure medications long term. On doing some intensive research I discovered that many of my symptoms correlated with a magnesium deficiency. I started taking a magnesium supplement and began to sleep much more peacefully. Although I had practiced HeartMath prior to this episode I was not very proficient, nor did I do it regularly. In consultation with my psychologist I agreed to do HeartMath, recording at least 1000 points a day. I also did moderate exercise daily according to how severe my symptoms were at the time. I purchased a home Blood Pressure machine to monitor my BP and began reducing the blood pressure medication. I relaxed and monitored my blood pressure in the same chair after either exercise or HeartMath. With the above interventions my symptoms began to improve. I feel I have taken control of my life again. I am now only on my original medication cardicor. My blood pressure is back to what it was before this episode. I am becoming more proficient in HeartMath and my coherence is improving all the time. I am able to get into the zone quicker and centre positive feelings towards my heart. I have learnt to relax, control my breathing and distance myself from stressful situations. I try to live in the moment and let go of situations I can t control. I am now able to participate in all my sporting activities again and am back to driving a car.

520 Edwards I believe this holistic treatment which includes HeartMath, moderate exercise and the correct balance of magnesium, calcium and potassium have restored my health and wellbeing. For this I have an enormous sense of gratitude and I will continue with the above programme as a way of life. Discussion W s qualitative, experiential description supports and extends the abovementioned brief summary and quantitative data. Clearly, she has experienced emotional insight and change with regard to hypertension, anxiety, stress management and general lifestyle. In addition to her blood pressure reduction, she reports increased confidence, self-efficacy, health and well-being. She attributes her transformation to holistic treatment which includes HeartMath, moderate exercise and the correct balance of magnesium, calcium and potassium. As effective treatment is typically multifactorial, it should be noted that healing could also include many other, specific and non-specific, biopsycho-social-spiritual variables, as, for example, support of family and friends, the relaxation response and biofeedback function of the blood pressure monitor. To complete the scientific rigour of randomized controlled trials with large samples of participants, single case study methodology adds this advantage of readily elucidating the typically holistic, multifactorial nature of aetiology, diagnosis and treatment. The case study is based on and supportive of many research studies, demonstrating the effectiveness of optimal physical exercise in preventing stress, anxiety and depression (Biddle, Fox & Boutcher, 2000; Weinberg & Gould, 2016). Regular, moderate intensity exercise interventions seem particularly valuable in promoting health and well-being, where the type, intensity and duration of the exercise programmes are tailored to suit the particular exercisers (Berger, 2001). Studying desirable changes in mood and meaning in exercise programmes, researchers have emphasized non-competitive movement, involving rhythmic, abdominal breathing of 20 to 30 minutes duration in comfortable, predictable contexts as in Tai Chi, Pilates, Yoga, dance, aerobic exercise and resistance training, which is performed in a slow, controlled way. Various qualitative, quantitative, mixed and integrative methodologies have been used to both describe the experience/meaning and measure such changes (Berger, 2001; Edwards, 2006). Public health interventions attempting to improve quality of life through increased exercise adherence clearly need to take such personal meanings into account, as well as the learning principle that people will repeat behaviours that are intrinsically rewarding. Although the quantitative research evidence base for the benefits of physical exercise interventions in health promotion programmes has become well established internationally (Weinberg & Gould, 2016), there has been a relative

Hypertension, exercise and psychophysiological coherence biofeedback 521 dearth of qualitative research on therapeutic movement interventions (Edwards, 2006). Health professionals need to explore carefully the meaning of physical activity and movement in their clients before, during and after health and physical exercise investigations and interventions. From a phenomenological perspective, the lived body is mediator and anchor in the world. In dialogue with the world, it is the source of pre-reflective intentionality, meaning and goal directed behaviour. Building on positive past experiences that have been bodily re-experienced as anchors is also an experientially grounded, theoretical basis for such healing methods as Yoga, Tai Chi, remedial breathing, progressive relaxation, systematic desensitization, visualization, imagery, multicultural counselling and various forms of psychotherapy (Edwards, 2006; Ivey, Ivey & Simek-Morgan, 1997; Weinberg & Gould, 2016). In W s case, HeartMath practise had been sporadic and, although physical exercise was well established, it was occasionally excessive. Inclusive of and similar to such techniques as transcendental meditation, zen and yoga, research has indicated that the relaxation response (Benson, 1997, 2000) is associated with significant reductions in blood pressure in hypertensive persons. By its very nature, HeartMath practice is a concentrated and/or focussed form of relaxation, associated with positive emotions, psychophysiological coherence, enhanced resilience, insight, intuition, sense of coherence and/or self-efficacy (Childre & Martin, 1999; Childre et al., 2016). In clinical, health and sport contexts, HRV analysis serves as a non-invasive test of neuro-cardiac integrity and autonomic balance, which is valuable in detecting and managing many illnesses. For example, in addition to particular patterns associated with particular conditions, stress, overtraining, ageing, illness and disorders such as diabetes, hypertension, depression, anxiety and anger all also typically present with lowered HRV. In addition to its great value in optimizing HRV, the Inner Balance trainer includes a power spectrum display indicating a zone of optimal sympathetic and parasympathetic functioning, for heart rhythm biofeedback training towards effecting a perfect synchrony of zero degree phase relationship between respiration and heart rate assisted by cultivation of positive emotions and rhythmically stimulated paced breathing at a frequency of about 0.1 Hz, or 10 second rhythm and/or 5-7 breaths per minute (Edwards, 2015). HeartMath research views emotions as energetic happenings generated immediately from the occurrence of discontinuities or novel patterns that do not match familiar, ongoing and recurring inputs (McCraty & Shaffer, 2015). Stress related negative emotions, such as anxiety, are associated with amygdala generated fight/flight/freeze responses. HeartMath theory postulates that HeartMath techniques facilitate an immediate re-patterning effect via the natural emergence of the physiological coherence mode. It is hypothesized that this operates at physiological, emotional and cognitive levels, through changes in the pattern of afferent cardiac signals sent to the brain, a positive feeling pattern

522 Edwards match and associated cortical electrophysiological activity respectively. Rigorous research has provided empirical support for these hypotheses in health and physical activity contexts. (Edwards, 2015; McCraty, Atkinson, Tomasino, & Bradley, 2009). After appropriate practice, their great value is to transform the energy of negative emotions into polar opposites, e.g., anger into assertiveness, feelings of overwhelming panic into centred motivation, overexcitement into relaxed release, sadness into contentment, hatred into love, negative into positively perceived stress. Physiologically, changes in afferent information that occurs with HeartMath self-regulation techniques integrate a bottom up process as well as a top-down cognitive approach. Firstly, energy expenditure is required to better self-regulate, as techniques are practised and anchored. Adherence is facilitated by mentoring. Secondly, the process become less effortful, more automatic and intuitive. Thirdly, continued practice improves resilience, lifts consciousness and brings more consistent, intuitive alignment with the moment to moment intuitive guidance of the deeper Self (McCraty & Zayas, 2014). Conclusion The case study satisfied the objective of health promotion for hypertension with special reference to evaluation of physical exercise and psychophysiological biofeedback interventions. Quantitative and qualitative, evidential and experiential descriptions converged in support of the research hypothesis as to reduction in blood pressure levels and related experiential phenomena. In view of the typically holistic and multifactorial nature of successful treatment, therapy and/or healing, it is probable that many other specific and non-specific, biopsycho-social-spiritual variables, were related to the aetiology and effectiveness of these interventions. Further case studies as well as randomized controlled trials using classic experimental designs, double blind methodologies and large samples of participants will complement and extend evidence and knowledge on the collective and exclusive usage of these and related hypertension interventions. References Abuldager, A.A. (2012). Coherence: A novel nonpharmacological modality for lowering blood pressure in hypertensive patients. Global Advances in Medicine, 1(2), 54-62. American Heart Association (2014). Understanding and Managing High Blood Pressure. Dallas, TX: American Heart Association. Aubert, A.E., Seps, B. & Beckers, F. (2003). Heart rate variability in athletes. Sports Medicine, 33, 889-919. Benson, H. (1997). Timeless Healing. London, UK: Scribner.

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