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Effects of walking and relaxation exercises on controlling hypertension.

There are 972 million hypertensive patients worldwide, 61 million in the US, and 15 million in Turkey; 7.1% of unexpected deaths are associated with hypertension (1-4). There are high incidences hypertension in Egypt (26.35%), Korea (33.7%), China (27.2%), France (28%), Northern Ireland (31%), Brazil (27.7%), and the US (24%)(4-7).

Epidemiologic studies have determined that there is a 20-25% prevalence of hypertension in people aged 30-39 years, and this increases with age with a 50-59% prevalence in people aged over 60 years.

In Turkey, 27.5% of adult males and 36.1% of adult females are diagnosed with hypertension, with a 31.8% prevalence in the general population--a figure that steadily rises every year. The four-year incidence rate of hypertension in Turkey between 2003 and 2007 was 21.3%(1,3,8-10).

Hypertension is the most important risk factor for cardiovascular disease which is responsible for 20-50% of all deaths worldwide. Moreover, hypertension can lead to renal, cardiac and vascular diseases, loss of vision, permanent disability, stroke and death. Determining and treating hypertension, encouraging individuals to make lifestyle changes, and knowing how to adapt to this condition, are all important for preventing the complications associated with hyperten sion(6,11-15).

Lifestyle changes include changes that need to be made before initiating, or in addition to, pharmacologic treatment. These changes protect individuals from hypertension, prevent the advancement of hypertension in its initial stages and support treatment. Implementing lifestyle changes can also decrease the number and dosage of antihypertensive medications, many of which have side effects, thereby preventing complications.

Lifestyle changes consist of non-pharmacological methods that can lengthen the lifespan of hypertensive and normotensive individuals. Particularly, walking and relaxation exercises have direct and rapid effects on an individual's metabolism.

Administrating these methods may become a nurse's role because nurses are not only care-givers, but also supervisors and consultants in Turkey. Therefore, it is important for nurses to understand the effects of walking and relaxation exercises on primary and resistant hypertensive patients and to incorporate these interventions into their care(12,16-22).

Aim

This study was conducted to evaluate the effects of walking and relaxation exercises (deep breathing and muscle relaxation) on primary and resistant hypertension.

Ethics Approval

Permission to conduct this study was obtained from the Hacettepe University Medical Faculty's Medical, Surgical and Drug Trials Ethics Committee. Written permission was obtained from the faculties in which the research was conducted and from the individuals who agreed to participate in the research.

Design And Sample

The research population was comprised of patients who came to Hacettepe University Adult Hospital Hypertension Clinic. As there were no records relating to primary and resistant hypertensive patients, power analysis and sample size (power: 80%, alpha: 0.05) was used and the research was completed with 30 participants.

According to the clinic protocol in our study, resistant hypertensive patients were not only those whose systolic blood pressure (SBP) was over 140 mmHg and whose diastolic blood pressure (DPB) was over 90 mmHg, and were also patients whose blood pressure could not be controlled and was frequently elevated.

Research Inclusion Criteria

Inclusion criteria consisted of patients who:

* were aged between 18 and 65 years

* had been treated with hypertensive medication for at least one month

* were not going to change their medication or dosage

* had a body mass index between 20 and 30

* had not previously used relaxation techniques (taking deep breaths and relaxing muscles)

* did not have a severe cardiovascular, renal, cerebral, mental, or other illness affecting their blood pressure

* did not have any problems with communicating.

Participants

In this study 63% of the 30 participants were female, 53% were aged 52-65 years (mean 52.3 [+ or -] 8.1; range 39-65), 40% had a primary school education and 73% were married. More than half (54%) of the participants stated that their income met their expenses and 43% were housewives. Adherence to medication was measured.

Outcome Measures

Data were collected using a Patient's Descriptive Characteristics Determination (PDCD) questionnaire, a Lifestyle Evaluation (LE) questionnaire, the State and Trait Anxiety Inventory (STAI), a Blood Pressure Monitoring (BPM) form and a patient diary.

Participants were also supplied with an instrument to measure blood pressure and educational brochures about hypertension, the benefits of walking and undertaking relaxation techniques, as well as instructions about how to use their blood pressure instruments and fill in the relevant documentation.

The PDCD questionnaire was prepared by the researcher in light of related literature to determine which characteristics could affect blood pressure. It was administered during the first session (Week 0). The form had 26 questions; the first seven were related to socio-demographics and the remaining were related to characteristics associated with hypertension. The LE questionnaire was also prepared by the researcher and consisted of 17 questions. The LE questionnaire was intended to determine lifestyle factors such as stress, cigarette use, alcohol use, diet, and health status.

The State and Trait Anxiety Inventory (STAI) was developed in 1970 in the USA. The inventory comprises of two sections (state and trait) each of which has 20 questions for a total of 40 questions. The score obtained from the inventory varies between 20 and 80--a higher score indicates an increase in anxiety levels. It was hypothesised that the participants undertaking relaxation exercises in this research would decrease their anxiety level and, associated with this, their blood pressure(23).

The BPM form was given to participants before intervention for the purpose of recording their blood pressure values during the 13-week study period. Patient diaries were also given to participants prior to intervention so that they could record their walking and relaxation exercises. All the blood pressure instruments were calibrated before being distributed to participants.

Interventions

The study was conducted between May 2007 and January 2008 with patients who met the research inclusion criteria and agreed to participate. Hypertensive participants were followed for 13 weeks. They were asked to monitor their blood pressure for 13 weeks as well as do relaxation exercises and go for walks for 12 weeks.

Blood Pressure Monitoring

Participants were asked to monitor their blood pressure twice daily, once in the morning and once in the evening for the first week of intervention (Week 0). All blood pressure measurements were recorded on the BPM form.

After one week, blood pressure monitoring was evaluated and the relaxation exercises and walking program phase began. Blood pressures continued to be monitored and recorded twice daily throughout the following 12 weeks.

Relaxation Exercises And Walking Program

During weeks 1 to 12, participants were asked to do deep breathing and relaxation exercises once a day while listening to relaxation music recommended by the Turkish Psychologists Association.

They were also asked to walk for 45 minutes, three times a week. The frequency and duration of participants' walking and exercises was determined from a review of the literature. Participants used their patient diary daily to record their relaxation exercises and walking sessions.

Education And Data Collection

In the first stage of the study (Table 1), participants attended an information session during which they were educated about the research. This session also included a one-on-one interview about participants' socio-demographic and hypertension-related characteristics (PDCD), their lifestyle (LE) and their state and trait anxiety (STAI). In addition, instructions were given about the study's walking/relaxation protocols and how to accurately measure and record their blood pressure.

Interviews were also conducted during weeks 4, 8, and 12. At these interviews, participants' blood pressures and ability to complete the walking and exercise programs were evaluated. During weeks 8 and 12, the STAI and the LE forms were completed. In addition, participants were telephoned once a week to motivate them to carry out the intervention.

Data Analysis

Data obtained from the research were coded and entered into the Statistical Package for the Social Sciences (SPSS) Version 11.5 and evaluated in the same database. The One Way Analysis of Variance in Repeated Measures (ANOVA) and the Bonferroni Multi Comparison Test were used to determine the significance of differences in blood pressure and anxiety levels from baseline values and during the intervention phase of the study.

To determine the significance of decreases in blood pressure according to independent variables, Chi Square Analysis and Fisher's Exact Test were used(24,25). During intervention, three mean systolic and diastolic blood pressure measurements were used: week 1 (SBP1, DBP1); weeks 1-8 (SBP2, DBP2) and weeks 9-12 (SBP3, DBP3).

Results

At SBP1, participants' mean systolic blood pressure was 130.83 mm Hg; SBP2, 121.93 mmHg; and SBP3, 119.87 mmHg (Table 2). The difference between mean measurements SBP1 and SBP3 was significant (F+32.034; p=0.000).

At DBP1 participants' mean diastolic blood pressure was 83.40 mmHg, DBP2, 77.20 mm Hg; and DBP3, 76.40 mm Hg. The difference between mean measurements DBP1 and DBP3 was significant (F=30.486; p=0.000).

Compared to baseline values, at the conclusion of the study participants' SBP decreased 10.96 mmHg and DBP decreased 7 mmHg (Graph 1).

The status of decreases in SBP and DBP as a result of lifestyle changes according to subgroups by age, gender, educational level and employment status was evaluated. No significant differences were found (Age-SBP, p=0.696; Age-DBP, p=0.464; Gender-SBP, p=0.389; Gender-DBP, p=0.705; Education-SBP, p=0.491; Education-DBP, p=0.713; Employment Status-SBP, p=0.389; Employment Status-DBP, p=0.705).

Participants' mean State Anxiety Level (SAL) at week 1 was 27.90; at week 8, 28.03 and at week 12, 24.80 (Table 3). The difference between groups was significant between weeks 1 and 12 (F=22.106; p=0.000).

The mean Trait Anxiety Level (TAL) at week 1 was 44.43; week 8, 41.67 and week 12, 35.97. The difference between groups was significant between week 1 and week 12 (F=5.213; p=0.018). Compared to baseline, the state anxiety level decreased by 3.10 points and the trait anxiety level decreased by 8.46 points (Graph 2).

No differences were found in participants' lifestyles in terms of stress, cigarette use, alcohol use, diet and health status. Compared to baseline values, the results showed that the interventions were effective on primary and resistant hypertension conditions.

[GRAPHIC 1 OMITTED]

[GRAPHIC 2 OMITTED]

Discussion

At the conclusion of this study, participants recorded a 10.96 mmHg decrease in SBP and a 7 mmHg decrease in DBP. In a study by Volger et al, in which lifestyle changes were implemented for 12 weeks, there was an 11.5 mmHg decrease in mean SBP and a 4.7 mmHg in DBP(26).

In research conducted by Applegate et al, hypertensive patients lost weight, controlled their use of salt, and undertook an exercise program(27). In the fourth month of the study, there was an 11.4 mmHg decrease in SBP and a 7.4 mmHg decrease in DBP. In a study conducted by McGuire et al, in which lifestyle changes were implemented, the participants' SBP decreased 14.2 mmHg and DBP decreased 7.4 mmHg and there was a 17% decrease in the hypertension prevalence(28).

Hayashi et al determined that walking inhibits hypertension(29). In a study by Cox which examined exercise and blood pressure, it was emphasised that exercise, and walking in particular, regulated blood pressure(30). Studies have shown that isotonic exercises, such as walking, swimming and biking, have an effect on hypertension(27,29-32).

Inadequate exercise, as well as stress, anger and anxiety are among the risk factors for hypertension. Individuals experiencing high levels of stress and anxiety are candidates for chronic illnesses such as hypertension. Ghosh and Sharma examined the anger and anxiety levels in hypertensive patients and found high levels of both anger and anxiety(33).

Schneider et al examined the effect of stress reduction in hypertensive patients and found a significant decrease in blood pressure(34). The diagnosis of hypertension can also cause individuals to experience stress, anger and anxiety. The stress/anxiety occurring at this level needs to be addressed together with hypertension. Effective coping with stress is therefore an important lifestyle regulation(34-39).

In a study by Alexander et al, in which stress reduction methods were implemented, the participants' SBP decreased by a mean of 11.5 mmHg and their DBP decreased by a mean of 7 mmHg(38). In a study by Linden et al, in which stress management was administered to participants with primary hypertension, there were significant decreases in blood pressure (SBP 7.8 mmHg and DBP 5.2 mmHg)(37).

In a study conducted by Amigo, Gonzalez and Herrera with hypertensive individuals who exercised and did relaxation techniques, there was a significant decrease in patients' blood pressure and the decrease in blood pressure was greater in the group that used relaxation techniques(40). Similarly, in a study by Forghieri et al, using exercise and relaxation methods in hypertensive patients, a significant decrease in blood pressure was found(41). In a study by Irvine and Logan, in which relaxation and supportive treatments were administered to hypertensive patients, a significant decrease in blood pressure was also seen(42).

Yung, French and Leung examined the effect of relaxation exercises on blood pressure and found a significant decrease in participants' blood pressure after exercise.(43). In a study-conducted by Kaushik et al, in which mental relaxation and deep breathing methods were implemented by patients with essential hypertension, it was determined that there were statistically significant decreases in systolic and diastolic blood pressure(35).

In our study, comparisons with baseline anxiety levels showed a 3.10 point decrease in state anxiety levels and an 8.46 point decrease in trait anxiety levels (Table 3). This result can be explained by participants doing regular walking and relaxation exercises. The relaxation exercises decreased patients' anxiety by making them psychologically comfortable.

In a study by Lim and Locsin, music was found to help make participants comfortable and decrease their pain, stress and anxiety(44). Decreasing anxiety by doing regular relaxation exercises, while continually listening to music, provides both psychological and physiological benefits and keeps blood pressure under control for patients with primary and resistant hypertension.

Turkish nurses can help primary and resistant hypertensive patients to improve physiologically and psychologically by teaching them relaxation exercises, and encouraging them to incorporate these programs into their lifestyles. Nurses' encouraging individuals to walk and do relaxation exercises can therefore help to decrease patients' experiences of primary and resistant hypertension attacks, decrease potential complications, reduce the difficulties of coping with the condition and improve their quality of life(45,46).

For this reason, it is important for nurses to understand the importance of correctly administrating walking and relaxation exercises when caring for hypertensive patients. Families of hypertensive patients should also be involved in educational programs.

Conclusion

This study determined that walking and relaxation exercises are effective interventions for decreasing the blood pressure in primary and resistant hypertension. It was also determined that walking and relaxation exercises are effective in decreasing the state and trait anxiety levels of these patients.

As a result of these findings, it is recommended that walking and relaxation exercises be adopted by primary and resistant hypertensive individuals of every socio-demographic group. Moreover, all members of the health-care team, and particularly nurses, should participate in these interventions with educational programs (posters, brochures, counselling).

Acknowledgements

The authors are grateful to all the nurses and managers at the Hypertension Polyclinic at the Hacettepe University Adult Hospital. The article's abstract was presented at the 19th European Meeting on Hypertension (2009).

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(1) G. Balci Alparslan, Lecturer, School of Health, Department of Nursing, Dumlupinar University, Kutahya, Turkey.

(2) N. Akdemir, Chief of Medical Nursing, Faculty of Health Science, Department of Nursing, Hacettepe University, Ankara, Turkey.

Correspondence: Guler Balci Alparslan, telephone: + 90 535 862 70 69, gbalci80@hotmail.com.
Table 1: Interventions

Intervention Interventions
 Period

 Week 0 Information supplied about study, diet and medication
 use, and protocols for walking and relaxation
 interventions. Also, instructions about how
 to measure and record blood pressure given.
 Blood pressure measurements taken twice a day.
 Participant interviewed to complete PDCD, STAI
 and LE questionnaires.

 Week 1 Participant interviewed to evaluate blood pressure
 status and ability to undertake the walking and
 relaxation intervention. Participant is given
 patient diary and instructed about how to fill it in.
 Participant starts walking three times a week and
 undertakes daily relaxation interventions. Blood
 pressure measurements takes twice daily.

 Week 2-3 Participant continues with walking and relaxation
 interventions and takes blood pressure measurements.

 Week 4 Participant interviewed to evaluate blood pressure
 status and ability to undertake the walking and
 relaxation intervention. Participant continues
 with walking and relaxation interventions and
 takes blood pressure measurements.

 Week 5-8 Participant continues with walking and relaxation
 interventions and takes blood pressure measurements.

 Week 8 Participant interviewed to evaluate blood pressure
 status and ability to undertake the walking and
 relaxation intervention. Participant completes
 STAI and LE questionnaires. Participant continues
 with walking and relaxation interventions and
 takes blood pressure measurements.

 Week 9-11 Participant continues with walking and relaxation
 interventions and takes blood pressure measurements.

 Week 12 Participant interviewed to evaluate blood pressure
 status and ability to undertake the walking and
 relaxation intervention. Participant completes
 STAI and LE questionnaires. Participant continues
 with walking and relaxation interventions and
 takes blood pressure measurements.

Table 2. systolic and Diastolic Blood Pressure Measurements

 Variables X [+ or -] S F P

 SPB1 * 130.83 7.086
 SBP2 ** 121.93 8.246 32.034 0.000
 SBP3 *** 119.87 9.892
 DBP1 * 83.40 4.613
 DBP2 ** 77.20 5.189 30.486 0.000
 DBP3 *** 76.40 6.185

* Before intervention ** Weeks 1-8 *** Weeks 9-12

Table 3. Results of Repeated Measurements of Anxiety Levels
According to STAI

 Variables X [+ or -] S F P

 SAL1 * 27.90 6.769
 SAL2 ** 28.03 7.972 5.213 .018
 SAL3 ** 24.80 5.391
 TAL1 * 44.43 10.833
 TAL2 ** 41.67 10.145 22.106 .000
 TAL3 *** 35.97 8.688

* Before intervention ** Week 8 *** Week 12
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Author:Alparslan, Guler Balci; Akdemir, Nuran
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2010
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