Download 2.2. The object of the study

KAUNAS UNIVERSITY OF MEDICINE
Aura Leonaitė-Evans
ALTERNATION OF
THE CARDIOVASCULAR SYSTEM
FUNCTIONAL STATE DURING
TWO RELAXATION TECHNIQUES
IN MEN AFTER MYOCARDIAL
INFARCTION
Doctoral Dissertation
Biomedical Sciences, Nursing (11 B)
Kaunas, 2010
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The doctoral dissertation was prepared in 2005–2010 at Kaunas University
of Medicine.
Scientific Supervisors:
2007–2010
2005–2007
Prof. Dr. Habil. Alfonsas Vainoras (Kaunas University of
Medicine, Biomedical Sciences, Nursing – 11 B).
Prof. Dr. Habil. Abdonas Tamošiūnas (Kaunas University
of Medicine, Biomedical Sciences, Public Health – 10 B).
Consultants:
Assoc. Prof. Dr. Algė Daunoravičienė (Kaunas University of Medicine,
Biomedical Sciences, Nursing –11 B)
Assoc. Prof. Dr. Laimonas Šiupšinskas (Kaunas University of Medicine,
Biomedical Sciences, Nursing –11 B).
Dr. Vytautas Zabiela (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B).
2007–2010 Prof. Dr. Habil. Abdonas Tamošiūnas (Kaunas University
of Medicine, Biomedical Sciences, Public Health – 10 B).
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KAUNO MEDICINOS UNIVERSITETAS
Aura Leonaitė-Evans
VYRŲ ŠIRDIES IR KRAUJAGYSLIŲ
SISTEMOS FUNKCINĖS BŪKLĖS KAITA
DVIEJŲ ATSIPALAIDAVIMO TECHNIKŲ
METU PO MIOKARDO INFARKTO
Daktaro disertacija
Biomedicinos mokslai, slauga (11 B)
Kaunas, 2010
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Disertacija rengta 2005–2010 metais Kauno medicinos universitete.
Moksliniai vadovai:
2007–2010
2005–2007
prof. habil. dr. Alfonsas Vainoras (Kauno medicinos
universitetas, biomedicinos mokslai, slauga – 11 B).
prof. habil. dr. Abdonas Tamošiūnas (Kauno medicinos
universitetas, biomedicinos mokslai, visuomenės sveikata – 10 B).
Konsultantai:
doc. dr. Algė Daunoravičienė (Kauno medicinos universitetas, biomedicinos mokslai, slauga – 11 B).
doc. dr. Laimonas Šiupšinskas (Kauno medicinos universitetas, biomedicinos mokslai, slauga – 11 B).
dr. Vytautas Zabiela (Kauno medicinos universitetas, biomedicinos
mokslai, medicina – 07 B).
2007–2010 prof. habil. dr. Abdonas Tamošiūnas (Kauno medicinos
universitetas, biomedicinos mokslai, visuomenės sveikata – 10 B).
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CONTENTS
ABBREVIATIONS ...................................................................................... 7
INTRODUCTION ........................................................................................ 8
Novelty, scientific and practical value of the study............................ 10
1.
LITERATURE REVIEW ................................................................ 11
1.1. Epidemiology, Etiology and Clinical Manifestations
of Ischemic Heart Disease ......................................................... 11
1.2. Psychosocial Stress and Ischemic Heart Disease ...................... 12
1.2.1.
1.2.2.
1.2.3.
Acute versus Chronic Psychosocial Risk Factors ....... 15
Acute Mental Stress .................................................... 16
Anxiety, Depression and Ischemic Heart Disease ...... 17
1.3. Psychophysiological Effects of Relaxation ............................... 19
1.4. The Possibilities of Using Relaxation Techniques for
Patients after Myocardial Infarction.......................................... 22
1.5. Mindfulness Body Scan Meditation .......................................... 27
1.6. Progressive Muscle Relaxation ................................................. 31
1.7. The Heart as a Complex System ............................................... 32
2.
THE DESIGN OF THE STUDY AND METHODS ...................... 37
2.1. The contingent of subjects ........................................................ 37
2.2. The object of the study .............................................................. 38
2.3. The methods of the study .......................................................... 39
2.3.1.
2.3.3.
2.3.4.
2.3.5.
2.3.6.
2.3.7.
2.4.
2.5.
2.6.
2.7.
Interview ..................................................................... 39
Electrocardiography .................................................... 40
A method of quantifying heart rhythm coherence ...... 41
Measurement of arterial blood pressure ...................... 42
Mindfulness Body Scan Meditation............................ 43
Progressive Muscle Relaxation ................................... 44
The protocol of the study .......................................................... 44
Mathematical statistics .............................................................. 45
The model of integral health evaluation.................................... 47
The author’s input into this study.............................................. 48
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3.
RESULTS .......................................................................................... 49
3.1. The short-term effect of relaxation techniques on
cardiovascular system indices ................................................... 49
3.1.1.
3.1.2.
The short-term effect of relaxation techniques
on heart rate and arterial blood pressure ..................... 49
The short-term effect of relaxation techniques
on ECG parameters ..................................................... 51
3.2. Correlation of ECG parameters while performing two
different relaxation techniques .................................................. 60
3.3. The alternation of variability of ECG parameters during
two relaxation techniques .......................................................... 63
3.4. The alternation of heart complexity during the relaxation
techniques .................................................................................. 81
3.5. Alternation of cardiovascular indices in patients with and
without anxiety during the relaxation techniques ..................... 83
4.
DISCUSSION .................................................................................... 97
CONCLUSIONS ...................................................................................... 115
PRACTICAL RECOMMENDATIONS AND GUIDELINES FOR
FUTURE STUDIES ................................................................................. 117
REFERENCES ......................................................................................... 118
Published work on the subject of dissertation .................................. 138
Reports at conferences on the subject of dissertation ....................... 138
Articles from other published work: ................................................. 138
APPENDICES .......................................................................................... 139
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ABBREVIATIONS
ABP
AR
AST
–
–
–
AT
–
CAD
CoPr
CVS
DBP
DJT
DQRS
–
–
–
–
–
–
ECG
HF
HR
HRC
HRV
IHD
JT
LF
MBSM
MBSR
MI
P
PMR
Post-MI
PTSD
QOL
R
r
RR
S
SBP
SD
ST
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
VLF
–
arterial blood pressure
R-wave or heart contraction amplitude
ST amplitude, describing the inner cardiac metabolic
system
T-wave amplitude, describing the inner cardiac metabolic
system
coronary artery disease
complexity profile
cardiovascular system
diastolic blood pressure
duration of JT interval
duration of the QRS complex or the spread of excitation in
the heart
electrocardiogram
high frequency band of variability
heart rate
heart rhythm coherence
heart rate variability
ischemic heart disease
interval in ECG from junction point J to T wave end
low frequency band of variability
Mindfulness Body Scan Meditation
Midfulness-Based Stress Reduction
myocardial infarction
Periphery (executive) system
Progressive Muscle Relaxation
post-myocardial infarction
post-traumatic stress disorder
quality of life
Regulatory system
the Spearman correliation coefficient
time interval between two heart contractions (RR interval)
Supplying system
systolic blood pressure
mean standard deviation in the sample
ST segment depression or elevation recorded in
electrocardiogram (ST segment amplitude)
very low frequency band of variability
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INTRODUCTION
Ischemic heart disease (IHD) is the leading cause of death in developed
countries around the world [251]. Psychosocial factors are now recognized
as playing a significant and independent role in the development of IHD and
its complications [192]. Mental stress has been implicated as a trigger of
myocardial infarction (MI) and sudden death in patients with coronary
artery disease [219, 85]. Although anxiety exerts a profoundly negative
effect on quality of life (QOL) and adversely influences the outcomes of
IHD from many standpoints, including recurrent hospitalization, an
increased incidence of ischemic events and higher mortality [108], there has
been little investigation of it to date [1].
MI is a major cause of mortality and morbidity in the western world.
Despite a decrease in mortality from MI during the past ten years, many
patients suffer adverse emotional reactions subsequent to the heart attack.
As MI is a life threatening event it is hardly surprising that it often causes
distress and impairment of QOL for the patients. Cardiac surgery is known
to be accompanied by postoperative anxiety [201]. Most patients are
clinically anxious on admission to hospital. This anxiety generally remits
over the next couple of days but rises again just before discharge, when
many patients may again become clinically anxious. This distress is often
deliberately hidden from the staff and other patients [231].
Psychological intervention reduces pain, severe anxiety, hostility and
depression in these patients and thus improves QOL [221]. The addition of
psychosocial treatments to standard cardiac rehabilitation regimens reduces
mortality and morbidity, psychological distress, and some biological risk
factors [140]. Relaxation therapy is a well-established psychological therapy
for alleviating psychological distress in patients with chronic illnesses [73].
Scientists Dixhoorn and White have concluded that relaxation training
enhances recovery from an ischemic event, independent of the effect of
psycho-education and of exercise [70]. They explained that relaxation
therapy can enhance recovery after a cardiac ischemic event and that it
encompasses all domains of rehabilitation.
There are many exercises and techniques for achieving relaxation. There
are many similarities in the physiological effects of various forms of
relaxation technique, but differences have also been observed [69].
Progressive Muscle Relaxation (PMR) is a primary method that is easily
learned. Previous studies have shown that PMR has beneficial physiological
and psychological effects for various groups of patients. Research has
demonstrated that PMR significantly lowers patients' perception of stress,
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and it enhances their perception of health. PMR is beneficial for patients
with essential hypertension [64]. Recent research findings also show that
PMR training may be an effective therapy for improving psychological
health and quality of life in anxious heart patients [207].
Studies of the therapeutic effects of meditation show benefits ranging
from reduced cardiovascular risk factors to improved psychological state
[117]. Mindfulness Body Scan Meditation (MBSM) is a part of the
Mindfulness-Based Stress Reduction (MBSR) program which is a
meditation training course developed by Dr. Kabat-Zinn and colleagues at
the University of Massachusetts Medical School [94]. “Mindfulness” is
defined as moment-to-moment nonjudgmental attention and awareness
actively cultivated and developed through meditation [142]. In the USA the
use of mindfulness training in treating specific pain conditions,
hypertension, myocardial ischemia, weight control, irritable bowel
syndrome, insomnia, human immunodeficiency virus (HIV), and substance
abuse is presently under investigation in research supported by the National
Institutes of Health [94, 142].
In other countries the relaxation techniques are often guided by physical
therapists and nurses [38, 8]. Lithuanian scientists have been investigating
the relationship between psychoemotional state and other indices in
coronary artery disease patients [27, 214, 88, 36]. But there is very little
practical application of psychoemotional factor-reducing techniques for
ischemic heart disease patients in Lithuanian hospitals. We think it might be
because of a common misunderstanding that there is a long period of time
needed for achieving the benefits of relaxation. Therefore it is important to
research the psychosocial risk factor reducing methods, particularly their
short-term effects.
While long-term relaxation therapies improve psychological well-being
in heart disease patients, there is little information regarding the short-term
effects of relaxation techniques on beat-to-beat dynamics of heart functional
indices. We analyzed the ECG parameters in accordance with complex
systems theory seeking integrative analysis, which includes interactions
between the systems and interactions between their components.
The hypothesis of the study. Relaxation techniques have a significant
short-term effect on the functional state of the cardiovascular system in men
after myocardial infarction. The short-term effects of Progressive Muscle
Relaxation and Mindfulness Body Scan Meditation are expected to differ.
Differences also reflect the individual peculiarities of body complexity.
The aim of the study. To evaluate and compare the functional state of
the cardiovascular system in men after myocardial infarction and to explore
the peculiarities of its reactions during two relaxation techniques.
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The tasks of the study:
1.
To evaluate the short-term effects of relaxation on the functional
state of the cardiovascular system.
2.
To compare the short-term effects of two relaxation techniques on
the functional state of the cardiovascular system.
3.
To compare the short-term effects of two relaxation techniques on
the functional state of the cardiovascular system given different
clinical situations (with anxiety and without).
Novelty, scientific and practical value of the study
The alternation of the cardiovascular system’s functional parameters
(except RR interval) during the practice of different relaxation techniques
has been studied for the first time in Lithuania.
There was a new relaxation technique applied – Mindfulness Body Scan
Meditation. This technique was translated into Lithuanian and audiorecorded. It is simple to use and patients do not require any particular
physical or psychological skills. Once permission has been obtained from
the Center for Mindfulness at the University of Massachusetts Medical
School a CD will be released. It will include a simple explanation, so that
anyone can use this relaxation technique easily.
Heart rhythm coherence index has been evaluated for the first time in
post-MI patients. The study evaluated the peculiarities of the dynamics of
this index during relaxation techniques.
For evaluation of physiological indices the new nonlinear method of
analysis – analysis of the second order matrices – was applied. Complexity
profiles revealing the peculiarities of the heart as a complex system were
designed. Conjunction of the parameters of the different fractal level was
investigated.
The scientific and practical value of the study consists in the fact that
there is a great need for data that would adequately characterize the
functional state during various relaxation techniques in people after MI. In
cardiovascular medicine practice there is also a shortage of methods that
help patients to reach a relaxation state without increasing arterial blood
pressure. Therefore the conclusions made in the study allow one to give
more accurate recommendations aimed at individualizing relaxation
methods for patients after MI, depending on their anxiety symptoms.
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1. LITERATURE REVIEW
1.1. Epidemiology, Etiology and Clinical Manifestations of Ischemic
Heart Disease
Ischemic heart disease (IHD), which is also known as coronary artery
disease (CAD), is the leading cause of death in most developed countries,
despite decreases in mortality over the last few decades. Although mortality
has declined, morbidity has increased, as more patients live with the
consequences of ischemic heart damage [63].
Cardiovascular disease claims almost as many lives each year as the next
seven leading causes of death combined, and 33% of people who die of
heart disease die prematurely (i.e., before their average life expectancy).
Nearly 150,000 people who die of cardiovascular disease each year are
under 65 years of age. Mortality with acute infarction is approximately 30%,
with more than half of the deaths occurring before the stricken individual
reaches the hospital. An additional 5 to 10 percent of survivors die in the
first year following myocardial infarction [5].
In the United Kingdom, approximately 2 million people suffer from
angina; and the prevalence of CHD in the United States is more than 12
million [63]. According to the data of the Lithuanian Health Information
Centre [102], in Lithuania circulatory system diseases (CSD) affect 22.2
percent of adults (over 18 years old). IHD prevalence is of 55.7 per 1000
adults, of which acute and secondary MI is 2.6 per 1000 adults (in the
period 2004–2008). In 2008 in Kaunas there were 22,636 people with IHD,
of whom 1016 had MI. Of these, the MI morbidity was 2.9 per 1000 adult
population (1.4 per 1000 of population 18–64 years of age and 12.4 per
1000 65 years and older).
In Lithuania 33% of the deaths in 2008 were due to IHD. In 2008
standardized mortality rates from CSD for 100,000 adults were 701.4 for
men and 400.5 for women. This is significantly more compared to the
average of all European countries (547.18 males and 345.87 for women) and
to the average of the European Union countries (310.12 males and 203.16
for women) [102].
The pathogenesis of IHD is now known to be atherosclerosis of the
epicardial vessels. This process begins early in life, often not clinically
manifesting until the middle–aged years and beyond. IHD may present as an
acute coronary syndrome, which includes unstable angina, non-ST-segmentelevation myocardial infarction, and ST-segment-elevation myocardial
infarction, and MI diagnosed by biomarkers only, chronic stable exertional
angina pectoris, and ischemia without clinical symptoms or owing to
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coronary artery vasospasm (variant or Prinzmetal’s angina). Other manifestations of atherosclerosis include heart failure, arrhythmias, cerebrovascular disease (stroke), and peripheral vascular disease [225]. Myocardial
ischemia is the result of inadequate myocardial oxygen supply in relation to
the demand being placed on the heart and involves inadequate perfusion of
cardiac tissue, anaerobic metabolism, diminished or abnormal left ventricular contraction, and electrophysiological changes. Ischemia may also
cause chest pain [191]. The presence of ischemia is associated with increased risk of adverse cardiac events, independent of coronary anatomy and left
ventricular impairment [242].
Thrombotic occlusion of a coronary artery previously narrowed by
atherosclerosis leads to MI. Factors such as cigarette smoking, hypertension,
and lipid accumulation lead to vascular injury. In the majority of cases,
infarction occurs when an atherosclerotic plaque fissures, ruptures, or
ulcerates, and, with conditions favoring thrombogenesis (factors which may
be local or systemic), a mural thrombus forms leading to coronary artery
occlusion. Patients at increased risk of developing acute MI include those
with unstable angina, multiple coronary risk factors and Prinzmetal's variant
angina. Less common etiologic factors include hypercoagulability, coronary
emboli, collagen vascular disease, and cocaine abuse. In roughly one-half of
cases no precipitating factor appears to be present. In other cases, triggers
such as physical exercise, emotional stress, and medical or surgical illnesses
can often be identified [77].
It has long been believed that acute exercise may result in clinical
manifestations of CAD [157], but more recent evidence suggests that other
behavioral factors, including mental stress, sexual activity, and acute
emotions may also trigger coronary events [87, 76, 240]. Research regarding
the effects of behavioral factors and triggers on the development and
manifestations of cardiovascular disease has thus far largely focused on
myocardial ischemia and infarction.
1.2. Psychosocial Stress and Ischemic Heart Disease
A rapidly growing body of evidence supports a relationship between
psychosocial factors and cardiovascular disease. Psychosocial stressors can
be both a cause and a consequence of cardiovascular disease events [79].
The scientific studies provide clear and convincing evidence that
psychosocial factors contribute significantly to the pathogenesis and
expression of CAD [193]. This evidence is composed largely of data
relating CAD risk to 5 specific psychosocial domains: (1) depression, (2)
anxiety, (3) personality factors and character traits, (4) social isolation, and
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(5) chronic life stress. Pathophysiological mechanisms underlying the
relationship between these entities and CAD can be divided into behavioral
mechanisms, whereby psychosocial conditions contribute to a higher
frequency of adverse health behaviors, such as poor diet and smoking, and
direct pathophysiological mechanisms, such as neuroendocrine and platelet
activation.
In caring for patients with cardiovascular disease, psychosocial factors
are an important consideration for several reasons. Buselli and Stuart have
identified three areas for discussion in their article [38]. First, the
association between psychosocial factors, specifically depression, anxiety,
social isolation, anger, hostility, and coronary-prone behavior pattern and
increased risk of physiologic arousal as well as morbidity and mortality
from cardiovascular disease has been demonstrated in the literature. Second,
not treated psychological symptoms have been associated with higher cost,
both to the patient and the health care system. In one study, patients who
had higher rates of psychological distress in the hospital were more likely to
be readmitted to the hospital for a recurrent cardiovascular event within 6
months of discharge when compared with non-distressed patients [3]. In
addition, mean re-hospitalization costs were significantly higher ($9,504
versus $2,146) in the distressed patients. Psychosocial factors have been
associated with increased risk for non-adherence with recommended
lifestyle changes. Depressed, socially isolated, anxious, angry, and
pessimistic individuals are less motivated and less able to make the lifestyle
changes that are recommended for risk factor modification. Third, humans
are unitary beings. The mind and body are connected. To apply the
reductionist biomedical model to this chronic illness negates the interaction
of mind and body on hemodynamic stability, coronary ischemia, platelet
aggregation, lipid metabolism, glucose metabolism, blood pressure, and
vasomotor tone as well as emotional well-being, social support, and
connection [38].
Many studies have linked stress with negative cardiovascular events [28,
66]. One would have to conclude that the overall data suggests that stress
contributes to adverse clinical cardiac events and provides a milieu of
increased vulnerability for the heart [68]. Stress is no different from other
background cardiac risk factors such as genetics or age. However, stress can
be modified through numerous approaches. It remains to be proven if such
stress modifications consistently decrease the risk for MI and cardiac death
[187]. Diverse and effective stress intervention programs have been tested in
heart patients, programs that provide formal psychotherapy, psychotropic
medications, time-management training, progressive relaxation training,
meditation, or regular exercise. The majority of these intervention programs
13
improves patients’ morale and functioning and decrease suffering.
Increasingly, such programs are tracking markers of cardiovascular risk
(such as endothelial function) as opposed to cardiac events and find that the
psychosocial intervention programs have positive effects [32]. When the
stressor continues there are adverse effects on the heart. These stress effects,
like other settings of cardiac risk, are potentially modifiable, if not by
cardiologists themselves, then by their colleagues who help patients change
their behaviors and cognitions [68].
Stress can be a primary or secondary contributor to illness via excessive
and sustained sympathetic arousal leading to ischemic heart disease,
hypertension, stroke, obesity, and mental ill health, or through related
behaviors such as smoking, substance abuse, and over or inappropriate
eating [193]; or as a contextual variable in terms of risk factor and lifestyle
outcome [192]. In addition, psychosocial stress can impair recovery from
any pathological insult or injury. Most assessments of stress relate to life
events, and both past and current life stressors, acute and chronic, play a
major role. However, beyond the impact of stressors, it is the reported state
of feeling stressed that is the critical predictor of illness [166]. Scientists
have found that the experience of stress may contribute to the development
of clinical manifestations of IHD, irrespective of the presence of
conventional risk indicators [166].
When talking about stress after MI, it is important to mention posttraumatic stress disorder (PTSD) – a recognized psychiatric disorder,
featuring a triad of symptoms: intrusions (flashback, nightmares); avoidance
and emotional numbing (avoidance of reminders of the traumatic event,
social withdrawal); and hyperarousal (sleeplessness, exaggerated startle
response) [246]. Diagnosis of PTSD requires that a person has been exposed
to a traumatic event (in this case, MI), and that his or her response was
characterized by intense fear, helplessness or horror, leading to persistence
of the above three symptoms for one month or more and causing significant
distress or impaired functioning. It has been documented that after MI,
patients (ranging from 0% to 22%) are affected by post-MI PTSD [89, 4].
Symptoms indicative of PTSD have been reported by people in the months
after acute myocardial infarction (MI) and cardiac surgery [246]. Compared
with healthy controls, these patients run a 3-fold risk of having PTSD and
more comorbidity such as depression [170] and anxiety [89, 172, 18]. MI
patients with PTSD experience higher levels of somatic complaints and
poorer social functioning than those who did not develop PTSD [89]. PTSD
after MI is associated with poorer general functioning, reduced adherence to
drug treatment and increased likelihood of cardiac readmission [89, 205].
14
Resent research in Lithuania [34] found that PTSD prevalence among
cardiac patients is running at 25% and it manifests equally among patients
who have had and have not had heart operations. This study also showed that
cardiac patients have high levels of anxiety and depression.
1.2.1. Acute versus Chronic Psychosocial Risk Factors
Psychosocial factors that affect the manifestations of coronary heart
disease generally fall into one of three categories: acute stress, chronic
environmental factors, and psychological traits [161]. Chronic risk factors
are longstanding and influence the development or progression of coronary
disease over a period of time (elevated LDL cholesterol, smoking, obesity,
hypertension, chronic environmental factors and psychological traits). Acute
risk factors are transient pathophysiological changes resulting from external
factors, such as physical exercise or acute mental stress. Acute factors do
not necessarily contribute to the development of chronic disease, but instead
may trigger clinical events, such as myocardial ischemia, myocardial
infarction, and sudden death, among individuals who already have CAD.
Acute and chronic psychosocial risk factors are hypothesized to combine
to increase the risk of clinical cardiac events. Acute risk factors are often
“triggered” by patient behaviors. Chronic risk factors serve to form a base
level of risk, which may decrease the severity of the acute risk factor needed
in order to elicit an event. A third category, episodic risk factors, refers to
behavioral characteristics, such as depression, that are neither acute nor
chronic, but range in duration from several months to several years [126].
According to a model proposed by Muller and colleagues [161], physical
and mental activities of the patient may elicit physiological changes that
precipitate clinical events. These behaviors are described as “triggers.” The
physiological changes they elicit are considered to be acute risk factors for
adverse cardiac events. A patient’s behavior may lead to an acute risk factor,
such as autonomic changes that lead to reduced heart rate variability. In the
presence of vulnerable cardiac substrate, such as myocardial tissue that has
been damaged by prior infarction, those autonomic changes could ultimately
result in arrhythmia.
Identifying, and subsequently blocking, the acute processes triggering the
onset of manifestations of CAD may ultimately reduce the number of
cardiac deaths each year [161].
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1.2.2. Acute Mental Stress
Mental stress is one of the possible triggers of cardiac events. Mental
stress, defined as a negative state of affect dependent on interpretation or
appraisal of threat, harm, or demand is generally accompanied by autonomic
arousal, resulting in increased release of glucose into the bloodstream,
increased cellular metabolism, and redirection of blood flow from the
gastrointestinal tract and kidneys to skeletal muscle [97]. Stress has further
been associated with a number of physiological processes that may affect
the development or progression of IHD, including hemodynamic, endocrine,
and immunologic changes. Stress causes the release of catecholamines and
corticosteroids, as well as increases in heart rate, heart contractility, blood
pressure, and cardiac output, and decreases in parasympathetic tone [127,
167]. Stress may also result in changes affecting the blood clotting process,
such as coronary vasoconstriction, platelet aggregation, increased blood
viscosity, or plaque rupture [162, 169, 160]. These physiological changes
may increase the incidence of coronary symptoms or adverse outcomes in
patients with IHD. Stress-related changes may also contribute to the risk of
adverse outcomes and clinical events by promoting the development of
atherosclerosis, causing endothelial dysfunction within coronary arteries,
triggering arrhythmias, or affecting metabolic risk factors, such as insulin
resistance [162, 119, 149].
Laboratory data confirm that acute stress can trigger manifestations of
CAD, such as myocardial ischemia, in many individuals with CAD [92, 33].
Recently, laboratory studies utilizing sensitive non-invasive means of
measuring ischemia, such as radionuclide ventriculography, positron
emission tomography, continuous monitoring of left ventricular function,
and two-dimensional echocardiography, have revealed that mental stress can
trigger ischemia in a substantial subset of CAD patients [127]. It should be
noted that mental stress-induced ischemia typically occurs in patients in
whom ischemia is also inducible via physical exercise [127]. Myocardial
ischemia induced by mental stress has prognostic value with regard to
adverse cardiac outcomes, including mortality. In a study of 126 CAD
patients with documented exercise-induced ischemia, those patients who
experienced ischemia as a result of mental stress were almost three times
more likely to die or to have a cardiac event, such as nonfatal infarction,
coronary artery bypass graft surgery, or angioplasty, during the 5-year
follow-up period than those patients who had no ischemia in response to
mental stress. [110]. Similarly, a follow-up study of 196 CAD patients who
underwent mental stress testing as part of the Psychophysiological
Investigations of Myocardial Ischemia (PIMI) study revealed that the
16
presence of ischemia in response to mental stress predicts subsequent
mortality [206].
It has also been determined that stressful experiences can provoke
ischemia in CAD patients during their normal daily activities [87, 95].
Gullette and colleagues confirm that high-intensity mental activities increase
the risk of ischemia during daily life [95].
1.2.3. Anxiety, Depression and Ischemic Heart Disease
In patients with IHD, anxiety and depression are predictive of adverse
short- and long-term outcomes [9, 82, 254]. Patients who have anxiety or
depression during hospital admission are at increased risk for higher rates of
in-hospital complications such as recurrent ischemia, re-infarction, and
malignant arrhythmias. They also suffer higher mortality and re-infarction
rates months to years after their initial cardiac event [82]. Thus, it is
important to determine those factors that contribute to patients’
psychological distress and intervene when possible.
Anxiety has been defined as a future-oriented negative affective state
resulting from perceptions of threat, characterized by perceived inability to
predict, control, or obtains desired results in upcoming situations [10].
Anxiety, a state of uneasiness or apprehension toward a vague or
nonspecific threat, is prevalent in cardiac patients [98]. Estimates are as high
as 70% to 80% during the acute phase, and it persists long-term in 20% to
25% of patients. Anxiety inflicts its toll through 3 major pathways. In the
physiological pathway, anxiety affects the musculoskeletal system by
causing muscular tension; the autonomic nervous system by arousing
sympathetic responses; and the psychoneuroendocrine system
(hypothalamic-pituitary-adrenal axis) by triggering secretion of
catecholamines and glucocorticoids. The psychological pathway elevates
negative mood states, whereas the social-behavioral pathway promotes
disconnection from self and others and stress inhibition with resultant
unhealthy lifestyle behaviors. The deleterious effects of this
psychophysiological stress response are troublesome because anxiety is an
independent predictor of arrhythmic/ischemic complications and increased
mortality in cardiac patients [98].
Nurses have evaluated the tools used to assess patients’ anxiety levels to
see if they are detrimental to the patients’ psychological state and could
activate a stress response. The authors concluded that the use of these
instruments was not stressful for stable patients 24 to 48 hours after AMI.
Nurses can therefore be confident that raising the issue of anxiety to patients
is not in itself a contributing factor to anxiety level [53].
17
The link between anxiety and cardiovascular disease was first explored
among individuals with Panic Disorder and other anxiety-related
psychopathology [58]. A higher risk of coronary disease has been found
among individuals with nonpathological levels of anxiety as well. For
example, in a large prospective study of 34,000 men who were initially free
of disease, those men who scored highest on an index of phobic anxiety (the
Crown Crisp index) were 2.2 times more likely to have fatal myocardial
infarctions and 7.7 times more likely to experience sudden death compared
to men who scored lowest [122]. Similarly, a 32-year follow-up of 2271
men in the Normative Aging Study yielded similar odds ratios for fatal heart
disease and sudden death for those men reporting two or more symptoms of
anxiety of the Cornell Medical Index compared to men who reported no
symptoms [123].
The scientist Riegel et al. has established that anxiety during the inhospital phase of acute myocardial infarction is associated with increased
risk for in-hospital arrhythmic and ischemic complications that is
independent of traditional sociodemographic and clinical risk factors. This
relationship is moderated by the level of perceived control such that the
combination of high anxiety and low perceived control is associated with the
highest risk of complications [159].
Smith et al. in their study have found that the frequency of ventricular
ectopy 12 weeks following MI was associated with daily stress levels and
state anxiety, such that patients reporting more stress or greater state anxiety
experienced more ectopic beats. These findings underscore the importance
of psychological stress during daily life as a risk factor for ventricular
ectopy in CHD patients [210].
Although more of an episodic condition than a personality trait,
depression has also been associated with the development and progression
of IHD [81]. Depression rates are higher among IHD patients than among
the general population, especially among post-MI patients. As many as 1623% of cardiac patients have Major Depressive Disorder [83], and an
additional 30% have depressive symptoms [84]. Depression rates do not
appear to increase markedly with severity of cardiovascular disease or
increased disability [84]. IHD patients are also more likely to exhibit
atypical depressive symptoms than the general psychiatric patients [125].
Among individuals with coronary disease, studies have consistently
shown that Major Depressive Disorder affects morbidity and mortality.
Carney and colleagues [48] demonstrated that patients with cardiovascular
disease who met the criteria for Major Depression were 2.5 times more
likely to develop a serious cardiac complication over the next 12 months
than non-depressed patients. Similarly, in a later study, 222 cardiac patients
18
were followed after their first myocardial infarction. These patients received
structured psychiatric evaluations within 15 days of their heart attack and
were followed for 18 months. After controlling for other independent risk
factors, Major Depressive Disorder was associated with a 3.5-fold risk of
mortality. This risk is comparable to other major risk factors for mortality,
such as congestive heart failure and left ventricular function [83, 84].
It appears that the risk of cardiovascular disease associated with
depression increases in a linear manner [6, 182] and that depressive
symptoms are sufficient to increase risk in the absence of Major Depression
[6]. A number of physiological and behavioral mechanisms have been
proposed to explain the link between depression and cardiovascular disease.
Depressed individuals are more likely to engage in risk-related behaviors,
such as cigarette smoking or lack of physical activity [49]. However,
depression is still associated with poor cardiac outcomes, even after
statistically controlling for traditional risk factors and risk-related behaviors
[90].
About 1 week after discharge many AMI patients experience symptoms
of anxiety. Patients showing symptoms of anxiety and depression after
discharge following an AMI are at risk for experiencing a persistence of the
same symptoms. Assessment and treatment of anxiety and depression, and
encouraging lifestyle changes after AMI, continue to be important in postAMI care that maximizes the outcomes for AMI patients [99]. It has been
noticed that the psychosocial risk profile after AMI may be different for
male and female patients, and interventions may need to take account of
each gender's specific needs [153].
1.3. Psychophysiological Effects of Relaxation
Relaxation is an integrative therapy that can be used as a part of
autonomous nursing or physical therapy practice. The beauty of relaxation is
that it can be used in any setting, and only a basic set of instructions and a
quiet, comfortable environment are needed. The relaxation response,
consisting of a mental device, passive attitude, and decreased muscle tone
may be evoked through many techniques [98].
In the acute care or critical care setting, many techniques that nurses have
traditionally used draw empirical value from the psychophysiological
interactions inherent in the mind-body connection [38]. Consider the effect
of calming presence, touch, music, massage, and empathic listening in
lessening the symptoms of physiological arousal, anxiety, and stress during
this critical time. Interventions to decrease physiological arousal are
numerous. Demystifying care by inviting the patient to be a partner in his or
19
her care and decision-making, providing the patient with choices, allowing
unrestricted visiting, providing information, teaching self-management
skills, incorporating humor, and promoting therapeutic uninterrupted sleep
and rest allows the patient to feel more in control over the environment and
situation, which in turn changes perception of threat and thus may reduce
anxiety and physiological arousal as well as promote mind-body awareness
and connection with others [74, 75].
Relaxation reduces the risk of depression recurrence by 50 percent.
Approximately 10-30% of people will suffer at least one episode of
depression in their lives. Relaxation techniques in conjunction with
medication reduce the risk of recurrence of depression significantly more
than medication alone [143]. Relaxation helps treat anxiety and panic
attacks. A study at the University of Massachusetts showed that patients
who suffered from generalized anxiety or panic disorder felt significantly
better after learning relaxation techniques, and continued to use those
techniques over the long-term [114]. Relaxation training can strengthen the
immune system. One study showed that after just eight weeks of learning
how to relax, participants had a stronger immune system [61].
Many scientists have investigated the effects of relaxation in individuals
with certain diseases, most having a cardiovascular disorder, experiencing
pain, anxiety, depression etc. [151, 13, 101]. The effect of relaxation
training is normalized cardiovascular indices (reduced heart rate, arterial
blood pressure), which is especially important in the treatment of
hypertension and other cardiovascular diseases, because the cardiovascular
system is the first one reacting to stress [214].
Relaxation relieves chronic pain, and relieves chronic low-back pain. In
one study, after a ten-week Mindfulness Body Relaxation (MBR) course
many patients needed less pain medication. After fifteen months, not only
did they suffer less pain, but because they suffered less pain they also
suffered less from depression and anxiety [152]. MBR reduces the
symptoms of fibromyalgia. In one study, 51 percent of the patients
experienced moderate to marked improvement in their fibromyalgia
symptoms. That is rare in most treatments of fibromyalgia [120].
Relaxation is defined as a state of relative freedom from anxiety and
skeletal muscle tension, that manifests as calmness, peacefulness, and being
at ease [145]. In short, relaxation can be defined as psychological and
physiological stress reduction [27]. It is intended to bring about a response
opposite to the fight-or-flight response. When relaxed, individuals typically
exhibit normal blood pressure and decreases in oxygen consumption,
respiratory rate, heart rate, and muscle tension [19, 105]. Different
relaxation techniques often promote specific psychological and physiolo20
gical changes, which are also called the relaxation response [27]. There are
two basic elements necessary to elicit the relaxation response: (1) focused
awareness on a thought, word, phrase, prayer, or repetitive motion; and (2)
passive disregard of intruding thoughts [21].
There are certain physiological processes in the body happening while
relaxing and breathing slowly and deeply: reduction of the heart rate (HR),
respiratory rate, blood pressure and heart variability; decrease in oxygen
consumption and carbon dioxide removal [91, 60, 245]; reduction of muscle
tension, pain and the electrical conductivity of the skin; return to normal
bowel function [150, 39]. Relaxation also increases EEG alpha waves [60,
245], normalizes the levels of thyroid hormone and decreases glucose and
cholesterol levels [91]. Relaxation is hypothesized to affect pain by (a)
reducing tissue oxygen demand and lowering levels of chemicals such as
lactic acid that can trigger pain, (b) releasing skeletal muscle tension and
anxiety that can exacerbate pain, and (c) releasing endorphins [145].
Performing relaxing exercises stabilizes the autonomic nervous system
and activates the parasympathetic nervous system, which influences the
above-mentioned physiological changes in the body [253]. Self-control
skills training develops resistance to stress [40], increases stamina, energy
level, improves the quality of sleep, strengthens immunity [27]. After the
relaxation exercises the body quickly reaches a state of rest. There is a
temporary drag of electrophysiological processes in peripheral and central
nervous systems during the relaxation that conditions the state which is
close to a healthy sleep or meditation [133]. Eliciting the relaxation
response, an innate physiological response opposite to the fight-or-flight
response, can decrease physiological reactivity as well as symptoms of
anxiety, stress, anger, impatience and hostility and can promote openness to
different ways of seeing things [21].
Talking about relaxation it is important to mention a new term - heart
rhythm coherence (HRC). This term was introduced by The Institute of
HeartMath [147], where scientists have found that it is the pattern of the
heart’s rhythm that is primarily reflective of the emotional state. HRC is a
stable, sine-wave-like pattern in the heart rate variability waveform. The
method of evaluating HRC brings a new perspective, focusing on the pattern
of the rhythm of heart activity and its relationship to emotional experience.
It is important to differentiate heart coherence from the relaxation effect.
Relaxation is characterized by a higher frequency, lower amplitude rhythm,
and a virtually steady heart rate once the system has stabilized in this mode
[147]. This happens when the research subjects sit or lie quietly and do not
engage in any active cognitive or emotional technique.
21
HRC is a highly ordered, smooth, sine-wave-like heart rhythm pattern
which is associated with sustained, modulated positive emotions, such as
appreciation or love. The scientists found strong differences between quite
distinct rhythmic beating patterns that were readily apparent in the heart
rhythm trace and that directly matched the subjective experience of different
emotions [147]. They have found that changes in the heart rhythm pattern
are independent of heart rate: one can have a coherent or incoherent pattern
at high or low heart rates. Thus, it is the rhythm, rather than the rate, that is
most directly related to emotional dynamics and physiological
synchronization. They found that the pattern of the heart’s activity was a
valid physiological indicator of emotional experience and that this indicator
was reliable when repeated at different times and in different populations.
Coherence is a very beneficial mode which leads to resetting of
baroreceptor sensitivity; increased vagal afferent traffic; increased cardiac
output in conjunction with increased efficiency in fluid exchange, filtration,
and absorption between the capillaries and tissues; increased ability of the
cardiovascular system to adapt to circulatory requirements; and increased
temporal synchronization of cells throughout the body. This results in
increased system-wide energy efficiency and metabolic energy savings
[137].
There is typically increased parasympathetic activity during periods of
rest or relaxation. Although the coherence mode is also associated with
lower heart rate variability, the relaxation techniques which focus attention
to the mind, and not on a positive emotion, in general do not induce
coherence.
The associated psychological states between relaxation and coherence are
also markedly different. The psychological states associated with coherence
are directly related to activated positive emotions, whereas other relaxation
techniques are essentially disassociation techniques.
1.4. The Possibilities of Using Relaxation Techniques for
Patients after Myocardial Infarction
Management of the MI patient may extend beyond the physiological to
include psychosocial factors that may adversely affect cardiac health.
Relaxation therapy enhances the physical and psychical outcome of
rehabilitation in MI patients [71].
Various interventions including cognitive-behavioral therapies,
techniques that elicit the relaxation response, meditation, exercise, and
increasing social networks, may play a role in improving health outcomes
[38]. A nurse-led experimental trial was conducted to assess the effect of a
22
patient-nurse contract on patients’ sense of control and psychological state.
Educational, cognitive, and advisory nursing approaches were associated
with reduced distress in men, but being listened to reduced distress in
women. Such approaches could significantly improve outcomes in
hospitalized patients, although research has shown that critical care nurses
do not systematically assess or manage anxiety in patients with acute MI
[63].
The goal of psychosocial interventions in the acute phase of an event is to
mitigate or prevent symptoms of distress, which has implications across the
biological, psychosocial, and spiritual domains. The specific aims of the
interventions are fourfold: (1) to decrease physiological arousal; (2) to
increase the patient's ability to identify cognitive distortions and realistically
appraise stressors; (3) to promote healthy lifestyle habits to enhance coping;
and (4) to promote connection with self, others, and life meaning and
purpose. These interventions provide a framework for acquiring selfmanagement skills that are critical for successfully coping with stress,
modifying risk factors, and adapting to a chronic illness [38].
Relaxation techniques have long been practiced for various health-related
purposes. Interventions such as rhythmic breathing and progressive muscle
relaxation (PMR) are basic nursing interventions included in nursing
fundamentals textbooks [75]. Unlike the body of work done with patients
with heart failure, research by nurses into programs of care that may
decrease cardiovascular events, mortality, and hospitalizations has not been
adequately developed. Although nursing interventions in acute care (e.g.
monitoring patients for ischemia, reducing anxiety), chronic illness
management, and secondary prevention may have significant effects on
mortality, morbidity, and costs, few investigators have measured these
outcomes and explicated the links between action and outcome [63].
Relaxation reduces the risk of heart disease by 30 %, and reduces deaths
due to heart disease by 23 %, according to a study in the American Journal
of Cardiology, which also showed that relaxation increases life expectancy
[198]. Furthermore it has been known for many years that relaxation
techniques significantly reduce the risk of high blood pressure, heart attacks,
and fatal heart attacks [168]. Not only does relaxation reduce the risk of
heart disease, it actually reverses hardening of the arteries according to a
study published in the American Heart Association journal, Stroke [50].
In the acute care setting, techniques to elicit the relaxation response
might include guided diaphragmatic breathing; progressive muscle
relaxation; visualization; and breath-focused, mindful massage [21]. Patients
can be guided in a practice once or twice a day for 10–20 minutes and
instructed to use brief minis (stop, take a breath, and release physical and
23
mental tension) whenever they feel stressed. During the acute phase,
patients do better when guided through the process [38].
After a myocardial infarction or a revascularization procedure attempting
to preempt such an event, it has become customary to recommend cardiac
rehabilitation to the patient [232]. This process often begins while the
patient is under acute care in the hospital [244] and may extend over a
period of 6 months to a year after discharge. Cardiac rehabilitation services
aim to facilitate physical, psychological and emotional recovery and to
enable patients to achieve and maintain better health. This is achieved
through exercise, patient education and advice, relaxation, drug therapy, and
specific help for patients with psychological sequela [230, 42, 43]. The
majority of cardiac rehabilitation programs in the UK are hospital-based
combined programs including exercise, psychological and educational
interventions [230, 42, 43]. Meta-analyses of the effectiveness of combined
programs suggest that they can achieve a reduction in cardiac mortality of
20–26% over a 1–3 year time frame [111].
Stress management is a vital tool in cardiac rehabilitation because of its
ability to counteract the physiologically destructive effects of stress [28].
Stress management can take many forms, from group activities designed to
foster enhanced social support to psychophysiological interventions such as
biofeedback and hypnosis, along with nonstandard approaches such as yoga,
meditation, and massage. All of these methods have been found
experimentally to have beneficial effects on cardiovascular function and to
result in a decrease in morbidity.
Dixhoorn et al. [72] investigated the value of relaxation therapy and
exercise training in post-MI patients. The results suggest that a combination
of a behavioral treatment such as relaxation therapy with exercise training is
more favorable for the long-term outcome after MI than is exercise training
alone. Subsequent cardiac events, including death, recurrent infarction,
unstable angina, and further bypass grafting occurred in 37% of the
exercise-only group compared with just 17% of the combination treatment
group. Further investigations indicated that relaxation therapy enhanced the
benefits of exercise training for normalizing bradycardia and improving ST
segment abnormalities [73]. Although in one study it was concluded that
aerobic exercise can be used as a method of stress management itself [80].
Relaxation maneuvers appear to achieve maximal stress-reducing effects
when training is provided concurrently with the stressor than when
temporally dissociated [55].
There is abundant evidence that different stress reduction techniques alter
the activity of the body’s physiological systems [185]. Yet the vast majority
of this scientific evidence concerns the effects of negative emotions and
24
relaxation [139]. Only a few researchers have begun to investigate the
effects of positive emotions: their objective, interrelated physiological and
psychological benefits [104, 86]. Although there are many similarities in the
physiological effects of various forms of relaxation techniques, differences
have also been observed [69]. These differences may suggest that some
techniques are better suited to certain clinical populations than others.
Various techniques are used in medicine practice to improve patient’s
state of relaxation. Some of the methods are performed alone, and some
require the help of another person, often a trained professional; some
involve movement, while some focus on stillness; and some methods
involve other elements. Certain relaxation techniques known as passive
relaxation exercises are generally performed while sitting or lying quietly,
with minimal movement. These include autogenic training [218],
biofeedback [41], deep breathing and pranayama [57], various meditations
[66], progressive Muscle Relaxation [249], visualization [241]. Movementbased relaxation methods incorporate exercise such as walking, yoga, Tai
chi [227], Qigong [217], and more.
Some relaxation methods can also be used during other activities, for
example, Autosuggestion and Prayer. Music interventions have also been
used to reduce anxiety and distress and improve physiological functioning
in medical patients. The results of Bradt and Dileo [35] indicated that music
listening has a moderate effect on anxiety in patients with CHD: listening to
music reduces heart rate, respiratory rate, blood pressure, anxiety and pain
in persons with CHD.
One of the most popular relaxation methods is Biofeedback relaxation
(BFR). It is the process by which a physiological response is made
discernible to the patient; the biological function is transduced into an
electrical signal, which can be converted to an audible or a visible display
[41]. This information is rendered such that the patient or subject can detect
even minute changes in the physiological response, creating an enhanced
awareness and a means for the participant to learn to modify the response
through operant conditioning. Biofeedback has been used in cardiovascular
rehabilitation [31] primarily so that patients could learn to relax via
electromyographic activity reduction and cutaneous thermal elevation
(indicating peripheral vasodilatation, a relaxation response [78]). Hawkinns,
Hart [101] and Barton, Blanchard [13] examined relation between relaxation
and pain. These authors state that through BFR people learn to reduce a
psychophysiological arousal and gradually change the pain. Khanna et al.
[124] and Kappes [121] worked with two different relaxation techniques.
According to these authors, progressive muscle relaxation (PMR) was more
effective in reducing physiological indices such as heart rate, while BFR is
25
more effective on psychological parameters as anxiety. Kappes states that
both of these relaxation techniques are equally effective in reducing muscle
tension and increasing finger temperature [121].
Bieliauskaite, Perminas et al. [27] have investigated physiological effects
of applying BFR. The results of the research show that subjective muscle
tension decreased during relaxation for the persons who took part in BFR
sessions. The physiological tension decreased in the experimental group
after four sessions. In the group of BFR were detected statistically
significant changes of skin resistance and skin temperature, indicating
higher relaxation of respondents [27].
Hypnosis [20, 220] has also been used for intervention in cardiovascular
disorders, for the promotion of relaxation, and for assistance with
compliance in diet management and smoking cessation. Kroger [130] relates
a number of ways in which hypnosis can be helpful in treating
cardiovascular disorders and enhancing compliance. Hypnosis-related
relaxation can reduce hyperventilation as a stress response, with associated
reduction of 1) catecholamine release, 2) tension-related cholesterol
elevation, and 3) electrolyte retention, all of which can be beneficial in
patients with congestive heart failure. Hypnosis-related relaxation has also
been associated with lowering blood pressure, increasing the pain threshold
for angina, and reducing the frequency of extrasystoles, especially those
associated with sustained anxiety.
Autogenic training was developed by the German psychiatrist Johannes
Schultz in 1932. Schultz emphasized parallels to techniques in yoga and
meditation. Intensive supervised practice of autogenic training enhances
recovery from an ischemic cardiac event and contributes to secondary
prevention [70].
There is a growing interest in meditation within the medical community –
both in terms of studying its physiological effects and using it with patients
[238, 174, 134, 47]. A review of scientific studies identified relaxation,
concentration, an altered state of awareness, a suspension of logical thought
and the maintenance of a self-observing attitude as the behavioral
components of meditation [175]. It is accompanied by a host of biochemical
and physical changes in the body that alter metabolism, heart rate,
respiration, blood pressure and brain chemistry [134]. Meditation has also
been studied specifically for its effects on stress [113, 61]. Overall, there is
an extensive literature examining the physiological effects of different forms
of meditation. The effects of Transcendental Meditation have been most
studied [11, 12, 197, 233]. A lot of other meditative techniques derived from
various Asian traditions have been investigated, as well as the physiological
correlates of prayer [173, 22, 136, 135, 196, 224, 131]. Lehrer et al.
26
observed a significant decrease in respiration rate and a significant increase
in heart rate variability associated with respiration (respiratory sinus
arrhythmia (RSA)), as well as a general increase in heart rate variability,
among Rinzai and Soto Zen practitioners while they were meditating [136].
Rinzai practitioners breathed more slowly before and during meditation.
Bernardi et al. observed similar changes in mantra-based yoga and rosary
prayer and an increase in baroreflex sensitivity during these activities [22].
Given the importance of parasympathetic activity (indexed by RSA) an
increase in blood-pressure-buffering baroreflex activity might be expected.
Peng et al. observed both similarities and differences in the physiological
effects of three forms of meditation, two of which involved specific
manipulations of breathing patterns [173]. The one that did not specifically
attempt to alter respiration still produced a significant decrease in respiration
rate, an increase in RSA, and a decrease in the frequency within the heart
rate variability spectrum where RSA was observed. Perhaps most
interesting, the authors argue that the pattern of heart rate variability results
support the idea meditation involves active, arousal-promoting processes as
well as relaxing processes [109].
Dr. Herbert Benson of the Mind-Body Medical Institute, which is
affiliated with Harvard and several Boston hospitals, reports that meditation
induces a host of biochemical and physical changes in the body collectively
referred to as the "relaxation response" [21]. The relaxation response
includes changes in metabolism, heart rate, respiration, blood pressure and
brain chemistry. Benson and his team have also done clinical studies at
Buddhist monasteries in the Himalayan Mountains. Dr. Benson conclusively
proved the mind-body connection by showing that simple relaxation
techniques could lower people's blood pressure, slow their heart rate, and
calm their brain waves.
In the following chapters two other popular relaxation techniques,
MBSM and PMR, which have been used in our research, will be described
at length.
1.5. Mindfulness Body Scan Meditation
“Mindfulness” is defined as moment-to-moment nonjudgmental attention
and awareness, actively cultivated and developed through meditation [142].
The essence of mindfulness is learning to focus one's attention on presentmoment experience in a nonjudgmental way. Learning to pay attention to
present moment experience offers an alternative to the constant worrying
about past and future events, which tends to diminish the quality of one's
life [94]. Mindfulness-based interventions aimed at reduction of
27
psychological symptoms of distress and enhancement of quality of life, are
increasingly applied and popular in various kinds of settings in both mental
health care and somatic health care [116]. Several studies have been
performed, especially in recent years, which have examined the effects of
mindfulness-based stress reduction interventions, mainly in the form of the
original Mindfulness-Based Stress Reduction (MBSR) protocol or
derivatives thereof [29, 94].
The Mindfulness Body Scan Meditation (MBSM) is a part of the MBSR
program which is a meditation training course developed by Dr. Kabat-Zinn
and colleagues at the University of Massachusetts Medical School [94]. It is
non-religious technique with no requirement for change of lifestyle or
adaption to any system of belief.
Individuals such as chronic pain patients may not have the time or ability
to fully participate in MBSR programs. Furthermore, it may be difficult to
disseminate the beneficial effects of meditation to the general population if
it is perceived that meditation’s palliative effect requires an extensive time
commitment. Therefore it is interesting and potentially important to
examine the physiological effects of different parts of MBSR.
Although MBSR programs have been researched widely, there have been
few studies of MBSM on its own. The research findings indicate that a brief
3-day mindfulness meditation intervention is effective at reducing pain
ratings and anxiety scores when compared with baseline testing and other
cognitive manipulations. The brief meditation training is also effective at
increasing mindfulness skills [252]. One study focused on the short-term
effects of MBSM [69]. It was found that participants displayed significantly
greater increases in respiratory sinus arrhythmia while meditating than while
engaging in other relaxing activities. A significant decrease in the cardiac
pre-ejection period was observed while practicing MBSM. Female
participants exhibited a significantly larger decrease in diastolic blood
pressure during MBSM than other activities, whereas men had greater
increases in cardiac output during MBSM compared to other activities [69].
MBSR teaches participants to notice and relate differently to thoughts
and emotions, with a sense of compassion for self and others underlying the
endeavor. By continually bringing the mind back to the present moment,
mindfulness meditation is thought to increase clarity, calmness, and wellbeing. This 8-week outpatient program was developed originally for patients
with chronic illness and stress-related disorders who had reached the endpoint of what modern medicine could offer to relieve their suffering.
Currently both individuals with chronic disease and those who simply want
tools to manage stress more effectively participate in this program. During
the 8 weeks participants are taught a variety of formal mindfulness
28
techniques (such as meditation, yoga and body scanning) which they
practice at home using CDs, and the integration of mindfulness into daily
living by attending to normal daily tasks which are usually performed
mindlessly or automatically. Participants are encouraged to explore their
observed experience in both the group and in-between sessions with an
attitude of curiosity and kindness, and to investigate how this attitude and
attentional stance might, in their immediate experience, be used to
ameliorate distress, reduce reactivity, elicit relaxation and enhance skilful
responsiveness in the face of challenges.
The duration of the MBSR program was designed by Kabat-Zinn (1982)
to be long enough that participants could grasp the principles of selfregulation through mindfulness and develop skill and autonomy in
mindfulness practice [117]. The current standard form involves 26 hours of
session time consisting of eight weekly classes of 2-1/2 hours each plus an
all-day 6-hour class on a weekend day during the sixth week [116]. In its
earlier forms the program ranged from 20 to 24 hours of class time; meeting
for eight or ten weekly 2-hour sessions and sometimes including the all-day
session [112].
The MBSR program focuses on systematic, intensive meditation practice,
in combination with other interventions broadly related to contemporary
cognitive behavior therapy [115]. Because the concept of meditation within
the framework of mindfulness primarily involves the systematic regulation
of attention, it is possible to construe virtually any activity or intervention a
form of meditation practice. The so-called "formal" meditation encompasses
systematic instruction in three practices: the body scan; hatha yoga; and
sitting meditation.
The body scan is a guided exercise (30 to 45 minutes) in which attention
is systematically directed throughout the body, from one region to another.
It is practiced in a quiet state which promotes (but does not mandate)
relaxation. Hatha yoga involves gentle movements taught with moment bymoment attention to encourage greater body awareness and help overcome
the "disuse atrophy" (muscle deterioration) so common with advancing age
and as a result of illness. Sitting meditation involves developing a capacity
for sustained self-observation, in which one learns to direct attention in a
systematic manner, initially to a range of specific phenomena, including the
breath, sensory stimuli, physical sensations, thoughts, and eventually
culminating in an attentive state of "choiceless awareness" which involves
simply attending to whatever comes into consciousness without any effort at
control [116]. This is one important characteristic of mindfulness meditation
that clearly distinguishes it from, for example, the point-centered meditation
technique that is at the foundation of Benson's relaxation response [21]. In
29
addition to these three formal meditation practices, there is an emphasis on
bringing moment-by-moment attention to other, more ordinary daily
experiences such as eating, interacting with other people, driving a car, etc.
In recent years, the MBSR program has become a popular clinical stress
reduction technique [69]. It has been used widely in the treatment of
medical problems such as chronic pain and cancer as well as psychiatric
problems such as anxiety, depression, and panic [29, 94] and is finding
increasing use in other areas such as cardiovascular disease. That said, the
research to date has emphasized clinical trials of the effectiveness of MBSR
with diverse medical conditions, as opposed to research on its physiological
effects. One important question that has been studied little is whether the
physiological effects of this program are any larger or different compared to
those of other popular relaxation and stress reduction techniques [146, 46,
190]. In America the use of mindfulness training in treating specific pain
conditions, hypertension, myocardial ischemia, weight control, irritable
bowel syndrome, insomnia, human immunodeficiency virus (HIV), and
substance abuse is presently under investigation in research supported by
the National Institutes of Health [94, 142].
Jon Kabat-Zinn and his colleagues have studied the effects of
mindfulness meditation on stress [113, 61]. A number of descriptive and
controlled studies have provided evidence that MBSR leads to improvement
of various measures of psychological symptoms in patients with chronic
pain [112], anxiety disorders [154], fibromyalgia [243], cancer [212, 203],
multiple sclerosis [155], heart disease [223], rheumatoid arthritis [180] and
in recovery from organ transplant [93, 128]. MBSR has been associated
with reductions in depressive symptoms [212, 45, 93, 188] and has been
shown to significantly reduce relapse among patients in remission for major
depressive disorder [228]. MBSR has also shown positive effects in
different groups, such as medical and premedical students [204], and health
care professionals [202].
Although the therapeutic use of mindfulness meditation is often
associated with the MBSR program or a variant of it, there is a substantial
and growing clinical literature on integrating mindfulness meditation into
individual therapy [129]. Mindfulness is used not only in MBSM but also in
other forms of meditation. It goes by many different names, including
mindfulness-based stress reduction, mindful meditation and mindbody
meditation. The term mindbody is spelled either as mind-body or as
mindbody, to emphasize the connection between the body and mind.
30
1.6. Progressive Muscle Relaxation
Progressive Muscle Relaxation (PMR) is a simple relaxation method,
which focuses on the sense of relaxation coming after tensing and releasing
the muscles [25]. PMR was developed by American physician Edmund
Jacobson in the early 1920s. Dr. Jacobson explicitly stated that by relaxing
the muscles of the body an individual would feel more relaxed in general
[106]. He argued that since muscular tension accompanies anxiety, one can
reduce anxiety by learning how to relax the muscular tension. Jacobson
trained his patients to voluntarily relax certain muscles in their body in order
to reduce anxiety symptoms. He also found that the relaxation procedure is
effective against ulcers, insomnia, and hypertension. There are many
parallels with autogenic training, which was developed independently.
Jacobson's Progressive Relaxation has remained popular with modern
physical therapists.
PMR involves alternately tensing and relaxing 16 different muscle
groups [44, 170]. The essence of this exercise is to remove the whole body
tension, both physical and psychological [133]. A person using PMR may
start by sitting or lying down in a comfortable position. The procedure
involves contraction followed by relaxation of 16 isolated muscle groups,
including dominant and nondominant hand and forearm, dominant and
nondominant biceps, forehead, upper cheeks and nose, lower cheeks and
jaw, neck and throat, chest with shoulders and upper back, abdomen and
stomach, dominant and nondominant thigh, dominant and nondominant calf,
and dominant and nondominant foot. With the eyes closed, patients are
asked to focus all of their attention on their muscles, first focusing on the
sensations of tension for approximately 5–7 seconds, and then, as the
tension is released, focusing on sensations of warmth, softening, and
relaxation for approximately 30 seconds [150].
It was found that PMR decreases muscle tension, improves mood and
well-being [25], strengthens the nervous and immune systems [170],
moderates the activity of the sympathetic nervous system and reduces the
workload of the heart [250]. Rausch and other authors state that PMR
technique effectively helps to control anxiety, reduces cortisol levels,
relieves pain, regulates physiological processes and improves the overall
quality of life [186]. PMR reduces the heart rate, respiration, skin resistance,
slows metabolism and brain activity. But Lohaus and other authors’ study
showed only a statistically significant rise in body temperature [141].
Pawlov and Jones [170] examined the cardiac pulse during PMR. The
results showed that heart rate significantly decreased in an experimental
group after PMR. This is due to the increased level of relaxation and
31
domination of the parasympathetic nervous system. McCubbin and other
authors’ [148] study showed a statistically significant difference between
the systolic and diastolic blood pressure and heart rate. These data confirm
Gustainiene’s study made in Lithuania [96]. It was found that after
preventive PMR sessions systolic and diastolic blood pressure decreased in
both men and women. In that study there was also observed a long-term
effect on arterial blood pressure of this relaxation technique.
Yildirim and Fadiloglu [249] found that PMR training can improve QOL
and decrease state anxiety and trait anxiety in dialysis patients. Cheung et al.
[54] evaluated the effect of PMR on anxiety and quality of life after stoma
surgery in colorectal cancer patients. They noted that the use of PMR
significantly decreased state anxiety and improved quality of life in the
experimental group. Davison et al. [62] demonstrated that 7 week PMR
therapy reduced trait anxiety in Caucasian males with borderline
hypertension. They suggested that PMR training is a cost-effective
intervention which needs minimal training. It could easily be offered to
those patients who would like to use it as part of the specialist care provided
to patients with chronic disease. Tsai [234] evaluated the long-term effect of
an audiovisual relaxation training (RT) treatment involving deep breathing,
exercise, muscle relaxation, guided imagery and meditation compared with
routine nursing care for reducing anxiety in Chinese adults with cardiac
disease. He found that RT significantly decreased state anxiety in the
treatment group compared to the control group. Bastani et al. [14] showed
that applied relaxation caused significant reduction in state anxiety level in
the experimental group. Collins and Rice [56] in a pre-post control study
observed the short-term effects over 6 week of PMR and guided imagery on
adults with cardiovascular disease in rehabilitation following a MI or CABG
surgery, and showed no difference in state anxiety in the experimental and
control group, but depression was reduced in the experimental group. They
suggested that more instruction sessions on the relaxation method may
result in more positive outcomes.
1.7. The Heart as a Complex System
The CVS is complex and spatially distributed. The many connections
between the system’s components enable efficient regulation of blood flow
through a closed system of vessels [216]. The CVS plays a key role in
complex living organisms since it provides supplies for maintaining vital
functions and, at the same time, gets rid of waste materials. It is formed by
highly specialized subsystems that interact with each other to accomplish
tasks (e.g. the optimization of arterial and pulmonary circulation) and even
32
compete for resources as in, for example, the maintenance of the cerebral
circulation during a massive haemorrhage. Subsystems have their own local
regulatory mechanisms (e.g. mechanisms regulating blood flow in proximal
microvascular districts) that interact with central neural commands
reflecting the activity of the vasomotor and respiratory autonomous
oscillators, with reflex neural commands occurring in response to changes in
some controlled variables (e.g. arterial pressure) and with humoral factors.
All these regulatory mechanisms act rhythmically, producing incessant
adjustments in cardiovascular variables visible from beat-to-beat recordings.
These variations are referred to as ‘cardiovascular variability’ and occur
over a wide frequency range including very slow rhythms (e.g. ultradian
periodicities) and oscillations even faster than heart rate. The magnitude of
these variations depends on the gross amount of the activities of the
autonomous central oscillators, on the resonance of the closed-loop
mechanisms, on the gain of the relationship between variables and on the
possibility that a network of distributed oscillators with negligible activities
becomes entrained or remains sparse [178].
The presence of multiple regulatory mechanisms contemporaneously
active over different time scales and capable of varying over time the
relationships among variables generates the dynamic complexity of
cardiovascular variables [178].
Taking a broad system-based interpretation, the human organism is a
complex system or, more accurately, it is a complex system of complex
systems. The host response to sepsis, shock, or trauma is an example of a
complex biological system [199]. Measuring the complexity of various
biosignals, such as human voice, ECG, EEG, a protein sequence or DNA is
a common practice in medicine. The complexity of such signals is an
important characterization of a process and might be used as a diagnostic
tool [209].
Biological systems are complex systems; specifically, they are systems
that are spatially and temporally complex, built from a dynamic web of
interconnected feedback loops marked by interdependence, pleiotropy and
redundancy. Complex systems have properties that cannot wholly be
understood by understanding the parts of the system. The properties of the
system are distinct from the properties of the parts, and they depend on the
integrity of the whole; the systemic properties vanish when the system
breaks apart, whereas the properties of the parts are maintained. Illness,
which presents with varying severity, stability and duration, represents a
systemic functional change in the human organism [200]. Most, if not all,
dynamics of physiological systems involve nonlinear control. For example,
33
nonlinear feedback control mechanisms are important for maintaining
homeostasis in the CVS [216].
Current evidence suggests that the assessment of the complexity of
cardiovascular regulation could provide important information about the
underlying regulatory mechanisms. In particular, it has been shown that a
modification of complexity indices, resulting from depressed organ
function, a loss of interaction among subsystems, an overwhelming action
of a subsystem over others and an impairment of regulatory mechanisms, is
a clear hallmark of a pathological situation. Interestingly, since the
complexity of cardiovascular regulation can be evaluated from variables that
are routinely and non-invasively estimated during the most common
medical examinations, this assessment does not require additional
procedures and devices [178].
CVS complexity is confirmed by both its generally variegated structure
of physiological modeling and the richness of information detectable from
processing of the signals involved in it, with strong linear and nonlinear
interactions with other biological systems [51]. In particular, this behaviour
may be accordingly described by means of the so-called MMM paradigm
(Le. multiscale, multiorgan and multivariate). Such an approach to the CVS
emphasizes where the genesis of its complexity is potentially allocated and
how it is possible to detect information from it. The processing signals from
multi-leads of the same system (multivariate), from the interaction of
different physiological systems (multiorgan) and integrating all this
information across multiple scales (from genes, to proteins, molecules, cells,
up to the whole organ) could really provide with a more complete look at
the overall phenomenon of CVS complexity, with respect to the one which
is obtainable from its single constituent parts [51].
The regulation of the CVS is based on a complex adjustment of various
parts of the organism with respect to internal requirements, as well as to
environmental influences. This comprehensive concept was earlier termed
'homeostasis' (Claude Bernard, 1813–1878), which means that diverse
physiological mechanisms follow the common purpose to maintain the
interior of the organism stable. In the last two decades, concepts of nonlinear
dynamics and statistics were found to be essential for complex physiological
control, leading to the updated term 'homeodynamics'. Nowadays, it is
accepted that the organism is a dynamically stable network of communicating
elements from molecular, cellular up to organ-level scales [51].
Cardiovascular control depends on a number of complex interacting
feedback mechanisms that depend on information from several sensor sites.
The information on the state of the system is processed in the central
autonomic control centre in the brain. This control centre generates
34
autonomic nervous system outflow that is conveyed to the CVS by
parasympathetic and sympathetic pathways which, in most instances, elicit
opposite actions to maintain homeostasis. Transport via the blood stream is
subject to both localized control through heart rate and contractility as well
as highly distributed resistive and capacitive modulation in arterial and
venous compartments. The latter, in turn, are governed by both the local
mechanisms and the neural outflow [15].
Furthermore, the several afferent signals converge to the autonomic
centers (signals from the cardiopulmonary, baroreceptive, chemoreceptive,
muscular, etc.) and convey interferences from other processes (breathing,
vasomotion, muscular activity and many others), while central and humoral
processes exert continuous modulation. These signal interactions are
reflected in short-term cardiovascular variability (CVV) [15].
Short-term CVV represents both an invaluable scope on main vital
processes and a challenge to modeling and analysis methods, owing to the
many regulation processes that interact and interfere in a complex fashion [15].
A different approach to studying cardiovascular control mechanisms is
through the analysis of nonlinear dynamics [7]. The importance of nonlinear
behavior of cardiovascular control was underlined by Yamamoto and
Hughson (1991) [247]. These authors have shown that, for persons in the
supine (awake) position, the contribution of nonlinear fluctuations to the
total was 85.5 + 4.4 percent.
The Significance of Variability. The science of complex systems is
intimately related to variability analysis [200]. Every complex system has
'emergent' properties, which define its very nature and function, including
the presence of health versus illness. Variability or patterns of change over
time (in addition to connectivity or patterns of interconnection over space)
represent technology with which to evaluate the emergent properties of a
complex system, which may be physiological or pathological [199]. It is
possible to conceive complex systemic host response in a phase space of
variability parameters, in which health represents stable 'holes' in space,
exhibiting marked systemic stability accompanied by specific patterns of
variability (and connectivity). Illness represents an change from health,
separate 'holes' with distinct patterns of variability. Often, it takes a major
disorder to change a stable healthy state to an illness state, which may have
varying degrees of stability. It is within this complex systems conception of
health and illness that the clinical utility of variability analysis may be
appreciated [200].
Abnormal rhythms are associated with illness and can even be involved
in its pathogenesis; they have been termed 'dynamical diseases'. Indeed,
there is nothing 'static' about homeostasis. Akin to the concept of
35
homeorrhesis (dynamic stability) introduced by Waddington, homeokinesis
describes 'the ability of an organism functioning in a variable external environment to maintain a highly organized internal environment, fluctuating
within acceptable limits by dissipating energy in a far from equilibrium
state' [184].
Clinicians have long recognized that changes in physiological rhythms
are associated with disease [200]. The sophisticated analysis of variability
provides a measure of the integrity of the underlying system that produces
the dynamics. As the spatial and temporal organization of a complex system
define its very nature, changes in the patterns of interconnection
(connectivity) and patterns of variation over time (variability) contain
valuable information about the state of the overall system, representing an
important means with which to prognosticate and treat the patients [199].
Measuring the absolute value of a clinical parameter such as heart rate
yields highly significant, clinically useful information. However, evaluating
heart rate variability (HRV) provides additionally useful clinical information, which is, in fact, more valuable than heart rate alone, particularly when
heart rate is within normal limits [184]. HRV reflects the complex
interactions of many different control loops of the cardiovascular system
[189]. Transient variations in HRV have recently been validated as a
measure of short-term changes in autonomic tone [235, 226]. Chronic
imbalance of the autonomic nervous system is a prevalent and potent risk
factor for adverse cardiovascular events, including mortality [59]. Especially, the imbalance of sympathetic and parasympathetic nervous system
resulting in a relative predominance of the sympathetic tone puts the patient
after MI at a higher risk of fatal outcome [189].
Nonlinear dynamics methods based on deterministic chaos and complex
systems theory have been used for the analysis of complex physiological
systems over the past decade [189]. However, modern methods of analysis
are mainly used to explore HRV [103, 247, 189]. Novel methods assessing
heart rate dynamics have shown new insights into the abnormalities in heart
rate behavior in various pathological conditions, providing additional
prognostic information when compared with traditional HRV measures, and
clearly complementing the conventional analysis methods. Despite a large
body of data documenting the predictive power of various HRV indices,
none of these methods are in widespread clinical use at the moment, mainly
because no prospective studies have yet been carried out to show that an
intervention based on the assessment of these variables would improve the
outcome. Therefore, more clinical studies using new and traditional methods
of HRV will be needed, before the clinical applicability of these methods
can be definitively established [103].
36
2. THE DESIGN OF THE STUDY AND METHODS
The study was made in the 1st Department of Cardiology Clinic at the
Hospital of Kaunas University of Medicine. The main research was made
during period from 09 2009 till 01 2010. The study was approved by the
Institutional Review Boards of the study sites (No. BE–2–24).
2.1. The contingent of subjects
The contingent of subjects consisted of 30 hospitalized men who had had a
percutaneous coronary intervention with stent implantation after acute
myocardial infarction. All the participants signed the informed consent.
The sample size was calculated according to Altman’s nomogram [176].
The calculated standardized difference was 0.8. With the significance level
0.05 the smallest required sample size is 20.
The participants were chosen for the study with the cooperation of their
physicians according to the following inclusion and exclusion criteria:
Inclusion criteria:
1. Male gender.
2. Percutaneous coronary intervention with stent implantation after
acute myocardial infarction.
3. Age from 45 to 64 years.
Exclusion criteria:
1. Implanted cardiostimulator.
2. Congenital heart defect.
3. Mental illness.
4. A stroke.
5. Diabetes mellitus.
6. Obesity (BMI > 30 kg/m²)
7. Oncology diseases.
8. Use of antidepresants.
9. Inflammation.
The participants were approached individually in their wards and asked if
they would be willing to participate in the study. They were given an
information sheet about the study, its scientific and practical value, and an
agreement form to sign. Of all the patients approached, two did not agree to
take part in the study at all. A further 12 people performed the first
technique (MBSM) but declined to do a second one (PMR) after hearing an
explanation of it.
37
The patients who did agree were interviewed before and after the
sessions (described in the chapter “The methods of the study”). The main
characteristics of the participants are shown in Table 2.1.
Table 2.1. Characteristics of the contingent of subjects
Characteristic
Value
Number of participants
Mean age, in years
57.19 ± 6.17
30
BMI, in kg/m²
27.18 ± 1.8
30
More than 10
30
Perceived level of physical activity
Very low
30
Subjective stress feeling
Stressed
Relaxed
27
3
Anxiety symptoms
Presence of symptoms
No symptoms
15
15
Depression symptoms
Presence of symptoms
No symptoms
0
30
Smoking duration, in years
26 pariticipants liked MBSM, but disliked PMR. Three participants had
an opposite opinion. None of the participants had previously tried or
practiced any of these relaxation techniques.
The data of participants who fell asleep during the session were not
analyzed.
Almost all the studied (n=27) subjectively were feeling stressed, but only
half of them had anxiety symptoms (according to HADS, which is described
in the chapter “The methods of the study”). Non of our studied patients had
depression symptoms.
In order to compare the effect of relaxation techniques given different
clinical situations (the third task of the study) the studied were divided into
two groups according to anxiety symptoms:
1. With anxiety symptoms (n=15)
2. Without anxiety symptoms (n=15)
These groups did not differ in terms of age and weight.
2.2. The object of the study
CVS functional ECG indices and their variability during two different
relaxation techniques.
38
2.3. The methods of the study
The following methods were used in the study: interview, HAD scale,
electrocardiography, measurement of arterial blood pressure, two
intervention methods: progressive muscular relaxation and mindfulness
body scan meditation, the model of integral health evaluation, Furje
transformation and matrix analysis methods, statistical mathematical
methods.
2.3.1. Interview
Before the session the participants were asked according to the protocol
(appendix 1) if they were feeling stressed in the hospital, if they smoked
(and for how long), if they had any additional diseases and about their level
of physical activity.
After the sessions the participants were asked if they liked the performed
relaxation technique and if they would like to practise it in the future. The
participants were also asked if they fell asleep during the session.
The answers were marked in the form (appendix 1.) by the researcher.
2.3.2. HAD scale
Hospital Anxiety and Depression Scale (HADS) (appendix 2), developed
by Zigmond and Snaith [255] in 1983, was used to evaluate the emotional
state of the patients. In Lithuania the scale was adapted by Bunevičius and
Žilėnienė, 1991 [37]. Its purpose is to provide clinicians with an acceptable,
reliable, valid and easy to use practical tool for identifying and quantifying
depression and anxiety. It is best used not to make diagnoses of psychiatric
disorders, but for identifying general hospital patients who need further
psychiatric evaluation and assistance.
The HADS is a multiple-choice questionnaire consisting of 14 questions,
seven for anxiety (HADS-A) and seven for depression (HADS-D). The
patients read the instructions on the top of the form and then filled in their
answers. They were asked not to take too long over their replies, on the
basis that the immediate reaction to each item tends to reflect more
accurately the emotional state than a long thought-out response.
The studied person had to choose the answer that best reflected his wellbeing over the previous week. Each item was answered by the patient and
then rated by the researcher on a four point (0–3) response scale, so the
possible scores ranged from 0 to 21 for anxiety and 0 to 21 for depression.
Usually a score of 0 to 7 for either subscale is regarded as being without
39
symptoms, a score of 8 to 10 indicating presence of the intermediate
symptoms and a score of 11 or higher – the presence of the very heavy
symptoms. But in the present study a score of 0 to 7 for either subscale was
regarded as being without symptoms and a score of 8 or higher indicated the
presence of symptoms. Bjelland et al. [30] showed that an optimal cut-off
score on HADS-A and HADS-D is 8 or more points when it is used as a
screening instrument for symptoms of anxiety and depression. Therefore in
this study we considered that patients had symptoms of anxiety if they
scored 8 or more points on HADS-A and/or patients had symptoms of
depressions if they had scored 8 or more points on HADS-D.
2.3.3. Electrocardiography
A computerized ECG analysis system “Kaunas-Load W02”, developed
by the Institute of Cardiology of Kaunas University of Medicine, was
applied for 12-lead ECG recording and analysis. A structure of ECG
recording equipment “Kaunas-Load” is shown in Fig. 2.3.1.
12-lead ECG
recorder
Recognition
Algorithm
Data
Preprocessing
Fourier
Transformation
Data
Measurement
ECG Spectrum
Parameters
Fig. 2.3.1 Structure of ECG recording equipment “Kaunas-Load”
12 synchronically recorded ECG leads were monitored during session
performance for 30 minutes. Signal discretization rate was 500 Hz. The data
for analysis of ECG parameters was used from the II derivation. In this
work six parameters of each cardiocycle were analysed:
 RR interval, measured in ms - the interval between two consecutive
R-waves – the time interval between two heart beats. A total body
condition can be described according to RR interval;
 DJT, measured in ms – the JT time interval – the interval from the
electrocardiogram junction point J to the T-wave end. DJT characterizes duration of ventricular repolarization. The regulatory nervous
system effects the changes of DJT. It is known that the body's
metabolic changes are associated with repolarization changes.
 AR, measured in μV – R wave or heart contraction amplitude;
40



DQRS, measured in ms, – the duration of the QRS complex or the
spread of excitation in the heart, describing the inner regulatory
system of the heart.
AT, measured in μV, – T-wave amplitude, describing the inner
cardiac metabolic system.
AST, measured in μV, – ST amplitude, describing the inner cardiac
metabolic system.
The chosen ECG parameters are one of the most popular in clinical
practice and include different levels of complexity of cardiac activity: RR,
DJT and AR describe the systemic level; DQRS describes the inner
regulatory processes of the heart; and AT and AST the inner cardiac
metabolic processes.
Spectral analysis, Fourier Transformation [253], was used to determine
high (0.15 to 0.4 Hz), low (0.04 to 0.15 Hz) and very low (below 0.04 Hz)
variability frequency bands. The power of each frequency band was
logarithmically transformed in ms2.
2.3.4. A method of quantifying heart rhythm coherence
We evaluated a heart rhythm coherence (HRC) — a stable, sine-wavelike pattern in the HRV waveform. The term was introduced by the Institute
of HeartMath [147]. HRC is reflected in the heart rate variability (HRV)
power spectrum as a large increase in power in the low frequency (LF) band
(typically around 0.1 Hz) and a decrease in power in the very low frequency
(VLF) and high frequency (HF) bands. A coherent heart rhythm can
therefore be defined as a relatively harmonic (sine-wave-like) signal with a
very narrow, high-amplitude peak in the LF region of the HRV power
spectrum and no major peaks in the VLF or HF regions. Coherence thus
approximates the LF/(VLF + HF) ratio [147].
A method of quantifying HRC is shown in Fig. 2.3.2.
41
Fig. 2.3.2. Heart rhythm coherence ratio calculation [7]
First, the maximum peak is identified in the 0.04–0.26 Hz range (the
frequency range within which coherence and entrainment can occur). The
peak power is then determined by calculating the integral in a window 0.030
Hz wide, centered on the highest peak in that region. The total power of the
entire spectrum is then calculated.
The coherence ratio is formulated as: (Peak Power / (Total Power–Peak
Power)) 2 [147].
The coherence mode is typically associated with increased
parasympathetic activity, but does not necessarily involve a change in heart
rate per se, or a change in the amount of heart rate variability. It depends on
the preceding psychophysiological state of the individual whether a shift in
heart rate occurs or not. The coherence mode is signified by a shift to a
distinctive heart rhythm pattern.
This method provides an accurate measure of coherence that allows for
the nonlinear nature of the HRV waveform over time [147].
2.3.5. Measurement of arterial blood pressure
The arterial blood pressure (ABP) was measured by auscultation of
Korotkov’s tones with a stethoscope in the humeral artery area. Systolic and
diastolic BP was evaluated.
42
2.3.6. Mindfulness Body Scan Meditation
Mindfulness Body Scan Meditation (MBSM) is the main technique used
in the Mindfulness-Based Stress Reduction (MBSR) program, which is a
meditation training course developed by Dr. Kabat-Zinn and colleagues at
the University of Massachusetts Medical School [94]. “Mindfulness” is
defined as moment-to-moment nonjudgmental attention and awareness
actively cultivated and developed through meditation [142]. The body scan
is a closely guided journey through the patient’s body as they bring
moment-to-moment awareness to every region in turn, starting with the toes
of the left foot. It is done lying on the back.
In the USA the use of mindfulness training in treating specific pain
conditions, hypertension, myocardial ischemia, weight control, irritable
bowel syndrome, insomnia, human immunodeficiency virus (HIV), and
substance abuse is presently under investigation in research supported by
the National Institutes of Health [94, 142].
MBSM is the first portion of the first audiotape in the series used by
patients in the Mindfulness-Based Stress Reduction Clinic at the Center for
Mindfulness, University of Massachusetts. The tape is a guided body scan.
Listeners are asked to attend to various parts of their body and their
breathing, gently observing these areas and allowing other thoughts to
recede. The whole body scan is a guided exercise (30 to 45 minutes) in
which attention is systematically directed throughout the body, from one
region to another. It is practiced in a quiet state which promotes (but does
not mandate) relaxation.
We used the short (20 min) version of MBSM (appendix 3), which was
double translated by two independent experts. One expert translated it from
English to Lithuanian and then the other expert translated it back to English.
This text was compared to the original and the inaccuracies were corrected
in the Lithuanian version according to the consensus of the two experts.
The text was then made into a 20-minute audio recording in Lithuanian.
A pilot study using this recording was done with healthy adults before this
research [138].
The participants were asked to breathe regularly and calmly, also to
speak and to move as little as possible; they were also asked to stay awake.
Participants listened via headphone to audio-recorded relaxation instructtions.
43
2.3.7. Progressive Muscle Relaxation
Progressive Muscle Relaxation (PMR) is a classic relaxation technique
which involves tensing and relaxing of different muscle groups. It was
developed by American physician Edmund Jacobson in the early 1920s
[106]. We made a 20-minute audio recording with instructions for a PMR
session taken from the book “Psychology introduction” by Laima
Monginaite, 2004 [158] (appendix 4). Participants listened via headphone to
audio-recorded relaxation instructions.
PMR entails a physical and mental component. The physical component
involves the tensing and relaxing muscle groups in the arms, legs, face,
abdomen and chest. With the eyes closed and in a sequential pattern, tension
in a given muscle group is purposefully held for approximately 7 seconds
and then released for approximately 14 seconds before continuing with the
next muscle group.
The mental component focuses on the difference between the feelings of
tension and relaxation. Because the eyes are closed, one is forced to
concentrate on the sensation of tension and relaxation. In patients with
anxiety, the mind often wonders with thoughts such as "I don't know if this
will work" or "Am I feeling it yet?" If this is the case, the patient is told to
simply focus on the feelings of the tensed muscle. Because feelings of
warmth and heaviness are felt in the relaxed muscle after it has been tensed,
a mental relaxation is felt as a result.
2.4. The protocol of the study
The studied patients participated in two practical sessions in which they
practiced MBSM and PMR. All of them performed both relaxation
techniques:
1.
MBSM on the second day after post-MI stenting.
2.
PMR on the third day after post-MI stenting.
The time of each session including the relaxation technique was 30
minutes (Fig. 2.4.1). Each session was divided into 6 stages of 5 minutes: 5
min of supine rest (A); 5–10 min (B1), 10–15 min (B2), 15–20 min (B3),
20–25 min (B4) of performing a relaxation technique; and 5 min after a
performance (C). The total time of performing a relaxation technique (20
min) was evaluated separately (B total).
44
Fig. 2.4.1. The scheme of both sessions
The HR and ABP were measured only before and after performing
relaxation techniques in order not to interrupt a relaxation state. These
indices were evaluated just after lying down (the 1st min of supine rest –
A1), after 5 minutes of rest (A2), and then the 1st min (C1) and the 5th min
(C2) of recovery time.
2.5. Mathematical statistics
The following statistical mathematical methods were used in the study:
Statistical analysis of the data. The analysis of the research data was
carried out making use of the SPSS 13.0 program. The values are presented
as mean (M) ± standard deviation (SD) of the sample. Statistical
significance of differences was calculated using Student t session for
independent and related samples. Difference, with respect to error
probability less than 0.05, was regarded as statistically significant. For
samples less than 30 persons the reliability of statistical differences was
tested applying the nonparametric Mann-Whitney-Wilcoxson session for
independent samples and the nonparametric Wilcoxson session for related
samples.
Nonlinear mathematical method. The heart is not a periodic oscillator
under normal physiologic conditions and standard linear measures may not
be able to detect subtle, but important changes in heart signals’ time series.
Therefore in order to analyze the conjunction of selected ECG parameters, a
new nonlinear mathematical method – the analysis of the second order
matrices – was applied. The algebraic method of co-integration of the data
[239] was used to analyze the following conjunction of the parameters: the
RR and JT, and JT and QRS.
When elements of a series are determined variables, information about
the object of investigation can be described using mathematical
relationships [239]. To investigate the interaction of two objects, two
synchronous numerical time series xn ; n  0,1,2,...  and  y n ; n  0,1,2,... 
45
representing the exploratory object must be formed. Here xn and y n are real
numbers and represent results of some measurements (in this case the ECG
parameters).
Let two numerical time series xn ; n  0,1,2,...  and  yn ; n  0,1,2,...  be given.
 an
Then the matrix time series  An ; n  0,1,2,...  can be formed. Here An : 
c
 n
bn 

d n 
and an : xn , bn :  xn 1  yn 1  , cn :  xn 1  yn 1  , d n : yn , when parameters
 ,  are at choice dependent on properties of time series xn ; n  0,1,2,...  ,
 yn ; n  0,1,2,...  . In the simplest case coefficients     1 . Though different
methods for data analysis can be applied, in this investigation of matrix time
series the numerical characteristics of second order matrices and main
components of matrices An were used:
TrAn : an  d n (trace of matrix An ),
(1)
dfrAn : an  d n (difference),
(2)
cdp An : bn  cn (co-diagonal product),
(3)
From these initial parameters follow characteristics which have more
applicative sense:
dsk An  dfrAn 2  4 cdp An (discriminant),
(4)
From definitions of matrix characteristics the ones of most interest are
the discriminants of matrices An , and therefore the time series
dskAn ; n  0,1,2,...  investigation is important. In order to escape noise
influence the elements can be averaged [239].
The initial data was normalized to interval [0; 1] according to the
formula:
xnew value 
xold value  xmin
xmax  xmin
,
where xmin and xmax are minimal and maximal physiological values of parameter
[239] (Table 2.5.1).
46
Table 2.5.1. The minimal and maximal physiological values of the parameters [24]
Parameter
Minimal physiological value
Maximal physiological value
RR, ms
140
1500
DJT, ms
50
400
DQRS, ms
30
140
Then the discriminant which showed the conjunction of two ECG
parameters was calculated. If discriminants of matrices become close to
zero, then numeric time series (ECG parameters) become similar, i.e., their
conjunction is high [24]. So the value of the discriminant demonstrates the
complexity: the higher the complexity, the lower the conjunction between
parameters. On the contrary, with a decrease of complexity, the conjunction
between parameters becomes stronger, their individual informativity
reduces, and the relation of parameters is more expressed. The algorithm is
suitable for detection of local changes of ECG parameters’ dynamic
relationships [24].
For a healthy person the values of ECG parameter conjunction are low; if
ischemic heart disease has been diagnosed – values are high. The decrease
of conjunction shows the positive effect of the impact method.
2.6. The model of integral health evaluation
For the evaluation of human functional state we used the model of
integral health evaluation [237], which has also been used in research by
other authors [208, 179, 177, 118, 257, 24, 164].
The model of integral health evaluation (Fig. 2.6.1) integrates the
function of three holistic elements (according Vesalius, 1543): P – periphery
(executive) system (the muscle), R – regulatory system (the brain), S –
supplying system (the heart and blood-vessel system) [237]. Relation
between these systems can be specified by several parameters, but we used
the simplest and easier (non-invasive) calculated – RR interval, JT interval,
systolic (S) and diastolic (D) blood pressure, and DQRS [25].
47
∆S
R
∆RR
Body level
∆(S,D)
∆JT
P
S
MBSM
Hea rt level
RH
ΔDQRS
PMR
SH
PH
stent
Fig 2.6.1. The model of integral health evaluation
We evaluated two fractal levels: human organism level and heart level.
For analyzing the interaction between these two levels we used the idea of
complexity profile suggested by Yanner Bar Yam, 2003 [248]. Such
analysis is possible only using conjunction of the parameters from different
fractal levels. Complexity profile allows comparing the conjunction RR and
JT with conjunction JT and DQRS.
In Fig. 2.6.1 it is schematically shown that PMR influences the heart
through the periphery system (P), whereas MBSM influences the heart
through the regulation system (R). An implanted stent affects the supplying
system of the heart (SH).
2.7. The author’s input into this study
All the work of this study was carried out by the author of this
dissertation. The work included: the recording of the relaxation techniques;
interviewing the patients before and after the practical sessions; guiding the
practical sessions; ECG recording; arterial blood pressure measuring; data
collecting; data analysis and interpretation (with the help of the scientific
supervisor and consultants). The author studied different relaxation and
meditation techniques in Lithuania and abroad before choosing these two.
48
3. RESULTS
3.1. The short-term effect of relaxation techniques on cardiovascular
system indices
In order to evaluate CVS reactions during MBSM and PMR we
compared the alternation of HR, ABP and ECG parameters (RR, DJT,
DQRS, AR, AT, AST,) and their changes registered during these relaxation
techniques.
3.1.1. The short-term effect of relaxation techniques on heart rate and
arterial blood pressure
HR significantly didn’t change (p>0.05) during MBSM and during PMR
(Table 3.1.1, Fig. 3.1.1). There were differences of this index between the
techniques in all stages of the session (p<0.05).
Table 3.1.1 Heart rate and arterial blood pressure values before and after
the relaxation techniques
Index
Mindfulness Body Scan Meditation
Progressive Muscle Relaxation
A1
A2
C1
C2
A1
A2
C1
C2
HR,
b/min
68.48
±
12.60*
66.95
±
11.4*
66.29
±
12.08*
66.71
±
12.0*
60.6
±
11.83*
60.6
±
10.98*
60
±
11.25*
61.1
±
11.83*
SBP,
mmHg
126.05
±
20.02●
120.76
±
16.9●*
117.95
±
18.17●*
121.05
123.8
127.8
±
±
± 16.6●
18.79●*
13.19*
125.7
±
17.35*
124.8
± 14.9●*
74.81
73.29
73.14
72.81
76.7
75.1
77.9
77.2
±
±
±
±
±
±
±
±
8.70
8.7
10.2*
9.33*
9.44
8.82
10.13*
9.14*
Notice: In the table the mean value ± SD is presented. HR – heart rate; SBP – systolic blood
pressure; DBP – diastolic blood pressure; A1 – 1st min of rest; A2 – 5th min of rest; C1 –
1st min of recovery; C2 – 5th min of recovery; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
DBP,
mmHg
49
HR, mmHg
70
68
66
64
62
60
58
56
54
KAM
*
A1
PRA
*
*
*
A2
C1
C2
Stages of the session
Fig. 3.1.1 Alternation of heart rate during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques.
SBP, mmHg
SBP decreased during the relaxation techniques (p<0.05) (Table 3.1.1,
Fig. 3.1.2). Comparing the results of MBSM and PMR the significant
differences were found in SBP: although the starting results (A1) didn’t
differ among the groups, the decrease of SBP was greater during MBSM in
all other stages of the session (p<0.05).
130
128
126
124
122
120
118
116
114
112
MBSM
PMR
•
*
*
*
•
•
•
A1
A2
C1
Stages of the session
C2
Fig. 3.1.2 Alternation of systolic blood pressure during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session.
There was a reduction tendency in DBP during MBSM and an increase
during PMR, but the differences in the results were statistically insignificant
50
DBP, mmHg
(p>0.05) (Table 3.1.1, Fig. 3.1.3). The differences between the techniques
were found in C1 and C2 stages of the session (p<0.05).
80
79
78
77
76
75
74
73
72
71
70
MBSM
*
A1
A2
C1
Stages of the session
PMR
*
C2
Fig. 3.1.3 Alternation of diastolic blood pressure during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques.
3.1.2. The short-term effect of relaxation techniques on ECG parameters
We compared the means of ECG parameters (AR, DQRS, RR, AT, AST,
DJT) (appendix 5) and their alternation during two relaxation techniques.
The values of ECG parameters differed between MBSM and PMR
insignificantly (except AST) during almost each stage of the session, but
there have been certain tendencies noticed.
The alternation of RR interval was small during both sessions. The
values of RR interval (Fig. 3.1.4) decreased in the beginning (B1) of MBSM
(883.3 ±164.61 ms) then was slowly increasing till the end (B4) of MBSM
(904.57 ±162.61 ms). After MBSM RR started dropping and kept declining
during all the recovery period (C). RR before MBSM was 893.37 ± 185.36
ms, after MBSM – 897.39 ±155.42 ms. RR was slowly increasing during
PMR, but there was a big rise during the recovery period (C). After PMR
RR interval was longer than before performing it (p<0.05). RR before PMR
was 902.78 ± 173.40 ms, after PMR – 926.84 ± 161.42 ms.
The alternation of RR interval differed among the groups mostly in the
stages B1, B2, B3 and C, although insignificantly (p>0.05).
51
RR interval, ms
1000
980
960
940
920
900
880
860
840
820
800
MBSM
●
●
A
PMR
B1
B2
B3
Stages of the session
B4
C
Fig. 3.1.4 Alternation of RR interval during the relaxation techniques
Notice: ● – p<0.05 comparing different stages of one session; MBSM – Mindfulness Body
Scan Meditation; PMR – Progressive Muscle Relaxation.
JT interval, ms
During both relaxation techniques DJT (Fig. 3.1.5) increased slowly and
after the session the DJT values were higher (p<0.05) compared to stage A
(the resting DJT before MBSM was 268,32 ±56.07 ms, after MBSM –
277,25 ±37,51 ms; the resting DJT before PMR was 254,83 ± 65,42 ms,
after PMR – 266.47 ± 58.40 ms). The values of DJT while performing
MBSM were higher throughout the session time compared to while
performing PMR, although the differences were statistically insignificant
(p>0.05).
300
290
280
270
260
250
240
230
220
210
200
MBSM
PMR
●
●
●
●
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.1.5 DJT alternation during the relaxation techniques
Notice: ● – p<0.05 comparing different stages of one session; MBSM – Mindfulness Body
Scan Meditation; PMR – Progressive Muscle Relaxation.
52
DQRS complex, ms
DQRS was increasing (Fig. 3.1.6) (p<0.05) until the mid-time of both
relaxation techniques (B2), then was still increasing during MBSM, but
stabilized during PMR. The highest value of DQRS was at the end of
MBSM (B4) (90.49 ±11.46). After both relaxation techniques DQRS was a
little bit longer than before performing (the resting DQRS before MBSM
was 89.59 ± 11.58 ms, after MBSM – 89.93 ± 11.22 ms; the resting DQRS
before PMR was 89.79 ± 12.32 ms, after PMR – 90.18 ± 11.84 ms),
although the differences were statistically insignificant (p>0.05).
91.0
90.8
90.6
90.4
90.2
90.0
89.8
89.6
89.4
89.2
89.0
88.8
MBSM
●
●
PMR
●
A
B1
B2
B3
B4
Stages of the session
C
Fig. 3.1.6 DQRS alternation during the relaxation techniques
Notice: ● – p<0.05 comparing different stages of one session; MBSM – Mindfulness Body
Scan Meditation; PMR – Progressive Muscle Relaxation.
The value of AR (Fig. 3.1.7) decreased during the resting time before the
MBSM but started to increase from the beginning of MBSM and was
increasing until the end of technique (p<0.05). The maximum value it
reached was during the last stage (B4) of MBSM (632.14 ± 432.93 µV). AR
started dropping after MBSM and kept declining throughout the recovery
period (C) (p<0.05).
There was an increasing tendency of AR from the beginning till 10–15
min (B2) (617.79 ± 340.81 µV) of the session with PMR, and then it started
to decrease slowly. After both relaxation techniques AR was higher
(p<0.05) than before doing them (the resting AR before MBSM was 616.41
± 421.38 µV, after MBSM – 622.07 ± 441.075 µV; the resting AR before
PMR was 603.41 ± 343.44 µV, after PMR – 612.44 ± 331.95 µV).
53
R amplitude, mkV
650
640
630
620
610
600
590
580
570
560
MBSM
●
PMR
●
●
A
B1
B2
●
B3
B4
C
Stages of the session
Fig. 3.1.7 R amplitude alternation during the relaxation techniques
Notice: ● – p<0.05 comparing different stages of one session; MBSM – Mindfulness Body
Scan Meditation; PMR – Progressive Muscle Relaxation.
T amplitude, mkV
AT (Fig. 3.1.8) was increasing till the mid-time (B2) of both relaxation
techniques (84.92 ± 38.22 µV during MBSM and 85.50 ± 14.21 µV during
PMR), and then started to decrease. AT dropped to the lowest value faster
and lower during PMR (B3) (77.51 ± 29.00 µV) than during MBSM (B4)
(79.99 ± 25.5 µV) and then was rising till the end of both sessions. After
both relaxation techniques AT was higher than before performing them (the
resting AT before MBSM was 78.81 ± 40.83 µV, after MBSM – 83.56 ±
30.51 µV; the resting AT before PMR was 81.15 ± 19.18 µV, after PMR –
81.86 ± 26.43 µV), but only the difference after MBSM was significant
(p<0.05).
88
86
84
82
80
78
76
74
72
70
●
MBSM
PMR
●
●
●
●
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.1.8 T amplitude alternation during the relaxation techniques
Notice: ● – p<0.05 comparing different stages of one session; MBSM – Mindfulness Body
Scan Meditation; PMR – Progressive Muscle Relaxation.
54
ST amplitude, mkV
During both relaxation techniques AST had a mild alternation (Fig.
3.1.9). The values of AST while performing PMR were (p<0.05) greater
than while performing MBSM. It was slowly increasing until the mid-time
(B2) of PMR (–1.24 ± 112.71 µV), then decreased (B3) (–2.60 ± 114.92
µV) and started gradually rising again. During MBSM, AST was increasing
till B4 (–8.23 ±102.01 µV) and then started to decrease. After both
relaxation techniques AST was greater (p<0.05) than before performing
them (the resting AST before MBSM was –13.04 ± 106.04 µV, after MBSM
–11.12 ± 102.09 µV; the resting AST before PMR was –4.17 ± 115.23 µV,
after PMR – 0.75 ± 111.03 µV).
4
2
0
-2
-4
-6
-8
-10
-12
-14
-16
MBSM
PMR
●
●
*
*
*
*
*
*
●
●
●
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.1.9 ST amplitude alternation during the relaxation techniques
Notice: * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of one
session; MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation.
Since there were no differences observed in the alternation of ECG
parameters (except AST) between the two techniques, we evaluated the
changes of the indices in relation to the total time of performance (total B).
In order to session the differences between the techniques there have been
three groups of changes of ECG parameters assessed (table 3.1.2):

AB – the change of the indices during performance (B) compared
with during the resting time (A);

BC – the change of the indices during performance (B) compared
with during the recovery (C);

AC – the change of the indices during recovery (C) compared with
during the resting time (A).
There were no differences in changes of ECG parameters comparing
them between the techniques (p>0.05).
55
Table 3.1.2 Values of changes in the ECG indices
Changes during Mindfulness
Body Scan Meditation
Changes during Progressive
Muscle Relaxation
AB
BC
AC
AB
BC
AC
RR, in ms
–1.67
± 31.03
5.69
± 31.21
4.02
± 54.41
9.32
± 27.29
14.74
± 39.07
24.06
± 50.09
DJT, in ms
7.12
± 8.40
1.81
± 10.92
8.93
± 17.16
9.4
± 7.06
2.24
± 11.23
11.64
± 16.11
DQRS, in
ms
0.65
± 1.95
–0.31
± 1.79
0.34
± 3.21
0.47
± 1.39
–0.08
± 1.81
0.39
± 2.61
AR, in µV
6.07
± 17.59
–0.41
± 15.27
5.66
± 30.48
12.81
± 20.13
–3.78
± 14.44
9.03
± 31.56
AT, in µV
4.84
± 12.96
–0.11
± 24.88
4.75
± 34.77
0.86
± 14.83
–0.15
± 12.26
0.71
± 18.95
Indices
2.08
–0.16
1.92
2.39
2.53
4.92
± 9.68
± 8.29
± 13.73
± 8.64
± 6.32
± 13.34
Notice: In the table the mean value ± SD is presented. AB – the change of the indices
during performance (B) compared with during the resting time (A); BC – the change of the
indices during performance (B) compared with during the recovery (C); AC – the change of
the indices during recovery (C) compared with during the resting time (A).
AST, in µV
The biggest change of RR was AC during PMR (Fig. 3.1.10). The only
one negative change of RR was AB during MBSM. All other changes were
positive during both techniques. AB, BC and AC changes of RR interval
values were bigger during PMR than MBSM however the differences were
statistically insignificant (p>0.05).
56
40
35
30
25
20
15
10
5
0
-5
-10
-15
PMR
RR interval, ms
MBSM
AB
BC
AC
Fig. 3.1.10 Changes of RR interval during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
JT interval, ms
The change BC of DJT (Fig. 3.1.11) during both relaxation techniques
was different compared to AB and AC (p<0.05). There were no statistically
significant differences between MBSM and PMR in any changes of DJT
(p>0.05), however a certain tendency was observed: all changes of DJT
values were greater during PMR than MBSM.
18
16
14
12
10
8
6
4
2
0
-2
MBSM
AB
BC
PMR
AC
Fig. 3.1.11 Changes of JT interval duration during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
57
QRS complex, ms
AB change of DQRS differed from BC during MBSM (p<0.05), other
changes didn’t differ significantly in any technique (Fig. 3.1.12). There were
no statistically significant differences between MBSM and PMR in any
changes of DQRS (p>0.05), however a certain tendency was observed: all
changes were bigger during MBSM than PMR. During both relaxation
techniques changes AB and AC were positive but the BC was negative.
1.2
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
MBSM
AB
BC
PMR
AC
Fig. 3.1.12 Changes of QRS complex duration during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
The greatest R amplitude change was AB during progressive muscle
relaxation (Fig. 3.1.13). During this technique BC change differed
significantly from AB and AC (p<0.05). The changes during MBSM
differed insignificantly (p>0.05). There were no statistically significant
differences between MBSM and PMR in any changes of AR (p>0.05), but a
certain tendency was observed: AB, BC and AC were greater during PMR
than during MBSM. During both relaxation techniques AB and AC changes
were positive but BC change was negative.
58
R amplitude, mkV
18
16
14
12
10
8
6
4
2
0
-2
-4
-6
-8
MBSM
AB
BC
PMR
AC
Fig. 3.1.13 Changes of R amplitude during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
T amplitude, mkV
The AB and AC changes of T wave amplitude were bigger during
MBSM than PMR, but the differences were statistically insignificant
(p>0.05) (Fig. 3.1.14). During both relaxation techniques AB and AC
changes were positive but BC change was negative.
14
12
10
8
6
4
2
0
-2
-4
-6
-8
MBSM
AB
BC
PMR
AC
Fig. 3.1.14 Changes of T1 amplitude during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
None of the changes of AST differed from each other in any of
techniques (p>0.05) (Fig. 3.1.15). There were no statistically significant
differences between MBSM and PMR in any change (p>0.05), but a certain
59
tendency was observed: all changes were bigger during PMR than MBSM.
The only one negative change was BC during MBSM, other changes were
positive during both techniques. During MBSM the greatest change was
AB, during PMR the greatest change was AC.
ST amplitude, mkV
10
MBSM
PMR
8
6
4
2
0
-2
-4
AB
BC
AC
Fig. 3.1.15 Changes of ST1 amplitude during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; AB – the change of the indices during performance (B) compared with during
the resting time (A); BC – the change of the indices during performance (B) compared with
during the recovery (C); AC – the change of the indices during recovery (C) compared with
during the resting time (A).
3.2. Correlation of ECG parameters while performing two different
relaxation techniques
In this study we evaluated the correlation between ECG parameters using
the Spearman correlation coefficient (r).
Strong and statistically significant correlation (p<0.05) was found
between DJT and RR indices (Fig.3.2.1), between AR and AST (Fig.3.2.2)
and between AT and AST (Fig.3.2.3) during both relaxation techniques.
Significantly strong correlation was between RR and AR only during
MBSM (Fig.3.2.4).
Interrelations among parameters were changing differently during
MBSM and PMR. Although correlation between DJT and RR (Fig.3.2.1)
was greater during all stages of the MBSM comparing with PMR, during
MBSM it was changing insignificantly (r was 0.88 in the beginning of the
session and 0.84 at the end). Alternation of DJT and RR correlation was
more expressed during PMR: in the beginning of the session r was 0.78,
then in the mid-time of PMR it decreased to 0.66, and at the end of PMR it
increased to 0.81. In the recovery time it was 0.73.
60
0.9
0.85
r (RR; DJT)
0.8
0.75
0.7
0.65
MBSM
0.6
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.2.1 Alternation of correlation between RR and JT intervals
Notice: r – correlation index; MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation.
Correlation between AR and AST (Fig.3.2.2) was changing differently
from DJT and RR. It was greater during all stages of the PMR comparing
with MBSM. During PMR r was changing insignificantly (0.68 in the
beginning of the session and 0.7 at the end). Alternation of AST and AR
interrelations was more expressed during MBSM: in the beginning of the
session r was 0.55, then in the middle of MBSM (B3) it increased to 0.63,
and at the end of MBSM (B4) it decreased to 0.62. In the recovery time it
was 0.6.
0.75
r (AR; AST1)
0.7
0.65
0.6
0.55
0.5
0.45
MBSM
PMR
0.4
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.2.2 Alternation of correlation between R and ST1 amplitudes
Notice: r – correlation index; MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation.
61
r (AT1;AST1)
Correlation between AT and AST (Fig.3.2.3) was greater at the
beginning (r=0.79) and the end (r=0.67) of the session with PMR comparing
with MBSM (r=0.61 and r=0.5). While performing both relaxation
techniques, AST and AT correlation was very similar. It started to differ
only at the last stage of the techniques (B4).
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
0.45
0.4
MBSM
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.2.3 Alternation of correlation between ST1 and T1 amplitudes
Notice: r – correlation index; MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation.
Strong correlation was found between RR and AR only during MBSM
(Fig.3.2.4). In the beginning of the session it was 0.53, at B1 stage it
reached its highest point 0.55, then started to decrease till the mid-time of
MBSM (B3) (0.48), from where it rose until the end of technique (B4)
(0.54). At the recovery time RR and AR correlation was the same as in the
beginning – 0.53.
0.6
r (RR;AR)
0.55
0.5
0.45
0.4
A
B1
B2
B3
B4
MBSM
C
Stages of the session
Fig. 3.2.4 Alternation of correlation between RR interval and R amplitude
during Mindfulness Body Scan Meditation
Notice: r – correlation index; MBSM – Mindfulness Body Scan Meditation.
62
3.3. The alternation of variability of ECG parameters during
two relaxation techniques
VLF of HRV, ms2
We evaluated the variability of ECG parameters (HRV, DJT, DQRS, AR,
AT, and AST) in order to compare the short term effects of MBSM and
PMR. The variability was divided into three frequency bands: very low
frequency band (VLF), low frequency band (LF) and high frequency band
(HF).
There was a significant alternation in the ECG parameters’ variability in
all frequency bands during both relaxation techniques (appendices 6 – 11).
VLF of HRV (Fig. 3.3.1) differed between the techniques: the VLF
values were bigger during the session with PMR than the one with MBSM
(p<0.05).
The alternation of VLF of HRV was more expressed during PMR: VLF
in stages B2, B3, B4 and C was greater during PMR than MBSM (p<0.05).
VLF was increasing from the resting time A (18.19 ± 4.15 ms2 during
MBSM and 21.21 ± 6.22 ms2 during PMR) to the mid-time (B3) of both
performed techniques (21.94 ± 5.1 ms2 during MBSM and 42.01 ± 5.82 ms2
during PMR). From the mid-time in both relaxation techniques VLF started
to decrease. During recovery VLF was higher (20.23 ± 3.41 ms2 after
MBSM and 25.4 ± 4.82 ms2 after PMR) compared with the resting time
before performing the techniques (p<0.05).
46
43
40
37
34
31
28
25
22
19
16
13
●
●
●
*
●
●
A
*
*
*
●
PMR
●
●
MBSM
B1
B2
B3
●
B4
C
Stages of the session
Fig. 3.3.1 Alternation of very low frequency heart rate variability band
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
63
The alternation of LF of HRV (Fig. 3.3.2) was similar during both
relaxation techniques, although a curve during PMR was expressed more.
During the resting time, mid-time and recovery time LF values were higher
during PMR session than during MBSM (p<0.05).
LF was decreasing (p<0.05) during the resting period of both relaxation
techniques (9.92 ± 1.12 ms2 during MBSM and 11.37 ± 3.22 ms2 during
PMR), but started to increase from the start of performing the techniques
(stage B1) (9.1 ± 1.12 ms2 during MBSM and 9.01 ± 3.22 ms2 during PMR).
LF reached its peak in B2 stage of MBSM (10.35 ± 3.07) and in B3 stage of
PMR (12.74 ± 5.12). During recovery LF was lower (8.43 ± 3.41 ms2 after
MBSM and 10.2 ± 4.32 ms2 after PMR) compared with the resting time
before performing the techniques (p<0.05).
14
●
LF of HRV, ms2
13
12
9
PMR
●
11
10
MBSM
●
●
*
*
●
●
●
8
*
●
7
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.3.2 Alternation of low frequency heart rate variability band during
the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
HF of HRV values (Fig. 3.3.3) were bigger during the MBSM session
than the PMR (p<0.05), but after PMR HF was a little bit bigger (p>0.05)
compared to after MBSM.
HF was decreasing (p<0.05) during the resting period of both relaxation
techniques (6.19 ± 1.12 ms2 before MBSM and 5.15 ± 1.22 ms2 before
PMR), but started increasing from the beginning of performance (4.83 ±
1.12 ms2 during MBSM and 4.14 ± 1.22 ms2 during PMR). HF reached its
peak in B2 stage of both relaxation techniques (5.49 ± 2.1 ms2 during
MBSM and 5.93 ± 1.82 ms2 during PMR). After MBSM HF was lower (5.1
± 1.41 ms2) but after PMR – higher (5.54 ± 1.32 ms2) compared with the
resting time before performing the techniques (p<0.05).
64
6.5
●
HF of HRV, ms2
5.5
●
●
●
*
*
4.0
PMR
●
*
5.0
4.5
MBSM
●
6.0
●
●
●
●
3.5
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.3.3 Alternation of high frequency heart rate variability band during
the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
The alternations of the total HRV (Fig. 3.3.4) during both relaxation
techniques are very similar to the VLF alternation (Fig. 3.3.1). Total HRV
differed between the techniques: HRV values were bigger in PMR than in
MBSM both during and after the performance (p<0.05).
Total HRV started to increase from the resting time (34.3 ± 10.15 ms2
during MBSM and 37.73 ± 6.22 ms2 during PMR) to the mid-time of both
performed techniques (35.82 ± 13.1 ms2 during MBSM and 59.28 ± 15.82
ms2 during PMR). From the mid-time in both relaxation techniques total
HRV started to decrease, but changes during MBSM are statistically
insignificant. During recovery after PMR total HRV was higher (41.14 ±
4.82 ms2) compared with the resting time (p<0.05). But after MBSM the
change was statistically insignificant (33.75 ± 3.41 ms2) compared with the
resting time (p>0.05).
65
Total HRV, ms2
65
60
55
50
45
40
35
30
25
●
MBSM
PMR
●
●
●
A
*
*
B1
●
*
*
B2
B3
B4
C
Stages of the session
Fig. 3.3.4 Alternation of total heart rate variability during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
We also evaluated the HRC, the alternation of which was very similar
during MBSM and PMR (Fig.3.3.5). HRC was bigger during the resting
time and during the recovery in the PMR session than in the MBSM
(p<0.05). HRC values did not differ between the relaxation techniques
during the performance (p>0.05).
HRC started growing from the resting time (32.09 ± 12.92 % before
MBSM and 34.98 ± 11.22 % before PMR). There was a small decrease of
HRC after the beginning of PMR (33.13 ± 11.22 %). But during both
relaxation techniques HRC was increasing until the same time of
performance and reached its peak at 10–15 minutes (41.25 ± 5.8 % during
MBSM and 42.87 ± 12.7 % during PMR). HRC was significantly (p<0.05)
greater after relaxation techniques (36.04 ± 5.8 % after MBSM and 39.88 ±
12.7 % after PMR) than before performing them.
66
●
44
42
●
HRC, %
40
●
38
36
●
●
●
30
*
●
34
32
●
*
●
A
MBSM
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.3.5 Alternation of heart rhythm coherence during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session
VLF of DJT variability (Fig. 3.3.6) differed between the techniques:
during all stages of the session the VLF values were bigger during MBSM
than during PMR (p<0.05).
There were different alternations of VLF of DJT variability observed
during two relaxation techniques. VLF was increasing during the resting
time (7.68 ± 4.15 ms2 before MBSM and 3.58 ± 1.22 ms2 before PMR), but
during MBSM this index was decreasing and increasing again. During PMR
the VLF of DJT was increasing from the resting time until the mid-time
(7.01 ± 2.57 ms2). From the mid-time in both relaxation techniques VLF
started to decrease. During recovery VLF was lower (6.41 ± 1.41 ms2 after
MBSM and 2.88 ± 1.82 ms2 after PMR) compared with the resting time. But
the change was statistically significant only after MBSM (p<0.05).
67
VLF of DJT variability, ms2
10
9
8
7
6
5
4
3
2
1
0
●
●
*
*
*
*
●
●
*
●
●
*
●
MBSM
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.3.6 Alternation of very low frequency DJT variability band during the
relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session.
LF of DJT variability, ms2
LF of DJT variability (Fig. 3.3.7) differed between the techniques:
during all stages of the session the LF values were bigger during MBSM
than during PMR (p<0.05).
8
7
6
5
4
3
2
1
0
●
●
*
*
*
*
●
*
●
*
●
MBSM
A
B1
B2
B3
Stages of the session
B4
PMR
C
Fig. 3.3.7 Alternation of low frequency DJT variability band during the
relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
There was a similar alternation of LF of DJT variability observed during
the two relaxation techniques. LF was increasing until the stage B2 during
68
MBSM and until the stage B3 during PMR, and since then it gradually
decreased until the end of the sessions. At recovery time LF was lower (4.54
± 1.41 ms2 after MBSM and 2.15 ± 1.02 ms2 after PMR) than during the
resting time A (5.69 ± 8.30 ms2 before MBSM and 2.71 ± 1.34 ms2 before
PMR). But the change was statistically significant only after MBSM
(p<0.05).
HF of DJT variability (Fig. 3.3.8) differed between the techniques:
during all stages of the session the HF values were bigger during MBSM
than during PMR (p<0.05).
HF of DJT variability was increasing during MBSM till the stage B2,
during PMR – till the stage B3 and since then it was gradually decreasing
till the end of the session. After both relaxation techniques HF was lower
(4.06 ± 1.41 ms2 after MBSM and 2.22 ± 1.02 ms2 after PMR) than during
the resting time (5.65 ± 2.60 ms2 before MBSM and 2.62 ± 1.17 ms2 before
PMR). But the change was statistically significant only after MBSM
(p<0.05).
HF of DJT variability, ms2
7
6
●
5
4
*
*
*
*
●
3
2
●
*
*
●
1
MBSM
0
A
B1
B2
B3
Stages of the session
B4
PMR
C
Fig. 3.3.8 Alternation of high frequency DJT variability band during the
relaxation techniques
Notice:* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of one
session.
The alternation of total DJT variability (Fig. 3.3.9) was similar to
alternation in all frequency bands. During all stages of the session DJT
variability values were bigger during MBSM than during PMR (p<0.05).
During MBSM it was increasing till the stage B2 and during PMR until
the stage B3, and then in both cases it gradually decreased until the end of
the session. At recovery time total DJT variability was lower (15.02 ± 6.96
ms2 after MBSM and 7.70 ± 3.63 ms2 after PMR) than during the resting
time (19.01 ± 9.35 ms2 before MBSM and 8.91 ± 4.36 ms2 before PMR).
But the change was statistically significant only after MBSM (p<0.05).
69
Total DJT variability, ms2
25
●
20
15
*
*
*
*
●
●
*
*
10
●
5
MBSM
0
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.3.9 Alternation of total DJT variability during the relaxation
techniques
Notice:* – p<0.05 comparing the techniques; p<0.05 comparing different stages of one
session
VLF of DQRS variability, ms2
Although the values of VLF of DQRS variability were greater during
MBSM, there was a much greater alternation observed during PMR than
during MBSM (Fig. 3.3.10). During both relaxation techniques VLF was
increasing till the stage B3 and after that it was gradually decreasing until
the end of the sessions. After both relaxation techniques VLF was lower
(2.11 ± 1.50 ms2 after MBSM and 0.92 ± 0.65 ms2 after PMR) than during
the resting time (2.24 ± 1.55 ms2 before MBSM and 1.22 ± 0.96 ms2 before
PMR), but the differences were statistically insignificant (p>0.05).
3
2.5
*
2
1.5
1
*
●
*
*
●
0.5
MBSM
0
A
B1
B2
B3
B4
Stages of the session
PMR
C
Fig. 3.3.10 Alternation of very low frequency band of QRS complex
duration variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
70
LF of DQRS variability, ms2
LF of DQRS variability (Fig. 3.3.11) was greater during all stages of
MBSM comparing with PMR. During MBSM LF was increasing till the stage
B2, during PMR till the stage B3; in both cases it then gradually decreased until
the end of the session. After both relaxation techniques LF was lower (1.57 ±
0.98 ms2 after MBSM and 0.73 ± 0.51 ms2 after PMR) than during the resting
time (1.58 ± 1.03 ms2 before MBSM and 0.97 ± 0.66 ms2 before PMR), but the
differences were statistically insignificant (p>0.05).
2.5
●
●
●
*
*
2
●
1.5
1
0.5
*
*
●
*
*
●
MBSM
0
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.3.11 Alternation of low frequency band of QRS complex duration
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
The alternation of HF of DQRS variability (Fig. 3.3.12) was similar
during both relaxation techniques, but the HF values were greater during all
stages of MBSM comparing with PMR. HF was gradually increasing till the
end of both techniques, then started decreasing. After both relaxation
techniques HF was lower (1.42 ± 0.83 ms2 after MBSM and 0.64 ± 0.45 ms2
after PMR) than during the resting time (1.46 ± 1.02 ms2 before MBSM and
0.75 ± 0.56 ms2 before PMR), but the differences were statistically
insignificant (p>0.05).
71
HF of DQRS variability, ms2
2.5
●
2
1.5
●
1
*
0.5
●
*
●
*
*
*
●
●
*
MBSM
0
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.3.12 Alternation of high frequency band of QRS complex duration
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session
Total DQRS variability, ms2
The values of total DQRS variability (Fig. 3.3.13) were greater during
all stages of MBSM comparing with PMR. The alternation of total
variability was similar to the alternation in all frequency bands. It was
gradually increasing till stage B4 of both techniques, and then gradually
decreased until the end of the session.
8
7
6
5
4
3
2
1
0
●
*
*
*
●
●
*
*
●
●
MBSM
A
B1
B2
B3
B4
*
PMR
C
Stages of the session
Fig. 3.3.13 Alternation of total QRS complex duration variability during the
relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different
stages of one session
At recovery time total DQRS variability was lower (5.11 ± 3.15 ms2 after
MBSM and 2.29 ± 1.47 ms2 after PMR) than during the resting time (5.29 ±
72
VLF of AR variability, ms2
3.27 ms2 before MBSM and 2.94 ± 2.04 ms2 before PMR), but the
differences were statistically insignificant (p>0.05).
Although the values of VLF of AR variability (Fig. 3.3.14) were greater at
the beginning and the end of the session with MBSM (p<0.05), there was a
much greater alternation observed during PMR than during MBSM. VLF in
stage B3 was greater during PMR (28.9 ± 14.41 ms2) than during MBSM
(11.49 ± 6.96 ms2) (p<0.05). VLF changed slightly during MBSM and after the
performance it was insignificantly (p>0.05) higher (13.03 ± 9.13 ms2)
compared with the resting time (12.5 ± 10.94 ms2). VLF changed
insignificantly (p>0.05) after PMR (9.78 ± 5.22 ms2) compared with the resting
time (9.45 ± 3.56 ms2).
31
29
27
25
23
21
19
17
15
13
11
9
7
●
*
●
*
●
●
A
B1
●
*
MBSM
B2
B3
B4
Stages of the session
PMR
C
Fig. 3.3.14 Alternation of very low frequency band of R amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
The alternation of LF of AR variability (Fig. 3.3.15) was similar to
VLF. LF was more expressed during PMR. LF values were different in all
stages between the techniques: during MBSM LF was greater except the
stage B3 where it was opposite. At recovery time LF was lower (7.70 ± 6.23
ms2 after MBSM and 4.93 ± 1.71 ms2 after PMR) than during the resting
time (7.97 ± 6.48 ms2 before MBSM and 5.72 ±1.79 ms2 before PMR), but
the differences were statistically insignificant (p>0.05).
73
LF of AR variability, ms2
13
12
11
10
9
8
7
6
5
4
●
*
*
*
*
*
*
●
A
MBSM
B1
B2
B3
Stages of the session
PMR
B4
C
Fig. 3.3.15 Alternation of low frequency band of R amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session.
HF of ARV, ms2
The values of HF of AR variability (Fig. 3.3.16) were bigger during the
session with MBSM than with PMR. At recovery time HF was lower (8.64
± 5.9 ms2 after MBSM and 7.02 ± 3.98 ms2 after PMR) than during the
resting time (9.11 ± 6.47 ms2 before MBSM and 8.17 ± 4.85 ms2 before
PMR) (p<0.05).
10
9.5
9
8.5
8
7.5
7
6.5
6
●
●
●
*
*
*
●
●
*
●
MBSM
A
B1
B2
B3
Stages of the session
PMR
B4
C
Fig. 3.3.16 Alternation of high frequency band of R amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation;
PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session.
74
total AR variability, ms2
Total AR variability (Fig 3.3.17) was greater during the session with
MBSM except the stage B3 where it was the opposite. The alternation of
this index was similar to the alternations VLF and LF. It was more
expressed during PMR: in stage B3 this value was greater during PMR
(49.86 ± 22.8 ms2) than during MBSM (29.84 ± 16.58 ms2) (p<0.05). VLF
changed only slightly during MBSM and after the performance it was not
different (29.37 ± 20.04 ms2) to the resting time (29.58 ± 23.07 ms2). After
PMR total AR variability was lower (21.73 ± 8.71 ms2) compared to the
resting time (23.34 ± 7.62 ms2), but the difference was statistically
insignificant (p>0.05).
55
●
50
45
40
*
35
30
25
20
*
●
A
.
B1
MBSM
PMR
*
B2
B3
Stages of the session
B4
C
Fig. 3.3.17 Alternation of total R amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation; * – p<0.05 comparing the techniques; ● – p<0.05 comparing different
stages of one session.
Although at the beginning of both sessions the values of the VLF of AT
variability (Fig. 3.3.18) were the same, the alternation of this index was more
expressed during PMR: VLF in mid-time was much greater during PMR (19.80
± 5.46 ms2) than during MBSM (14.81 ± 14.13 ms2) (p<0.05). But at the end of
the session VLF was higher after MBSM than PMR (p<0.05). VLF was
insignificantly (p>0.05) higher after MBSM (11.80 ± 4.89 ms2) than at the
resting time (10.28 ± 4.95 ms2). After PMR VLF was insignificantly (p>0.05)
lower (8.67 ± 4.95 ms2) than at the resting time (10.37 ± 4.96 ms2).
75
●
21
VLF of ATV, ms2
19
17
*
15
●
●
●
13
11
●
9
●
*
MBSM
7
A
B1
PMR
B2
B3
Stages of the session
B4
C
Fig. 3.3.18 Alternation of very low frequency band of T wave amplitude
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
Although at the beginning of both sessions the values of LF of AT
variability (Fig. 3.3.19) were the same, in the recovery time LF was lower
after PMR than after MBSM. The alternation of LF of AT variability was
more expressed during PMR: LF in stage B3 was greater during PMR
(11.59 ± 5.14 ms2) than during MBSM (10.08 ± 8.82 ms2) (p<0.05). LF
changed slightly during MBSM and at the recovery time was a little bit
higher (8.79 ± 8.61 ms2) than during the resting time (8.22 ± 3.66 ms2)
(p>0.05). After PMR LF was lower (6.24 ± 4.46 ms2) than during the resting
time (8.46 ± 5.58 ms2) (p<0.05).
LF of AT variability, ms2
12
MBSM
PMR
11
●
10
9
8
●
*
●
●
●
*
●
7
●
6
A
B1
B2
B3
Stages of the session
B4
*
●C
Fig. 3.3.19 Alternation of low frequency band of T wave amplitude
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
76
Just as with VLF and LF, at the beginning of both sessions the values of
HF of AT variability (Fig. 3.3.20) were the same, but during the recovery
time HF was lower after PMR than after MBSM. The alternation of HF of
AT variability was more expressed during PMR: VLF in stage B2 was
greater during PMR (11.54 ± 10.95 ms2) than during MBSM (8.79 ± 7.25
ms2) (p<0.05). HF was changing slightly during MBSM and at the recovery
time was the same (8.62 ± 6.94 ms2) as during the resting time (8.72 ± 3.83
ms2) (p>0.05). After PMR HF was lower (5.98 ± 4.20 ms2) than during the
resting time (8.18 ± 5.22 ms2) (p<0.05).
●
HF of AT variability, ms2
12
MBSM
PMR
11
10
9
8
7
●
●
●
*
*
●
6
*
*
●
●
B4
C
5
A
B1
B2
B3
Stages of the session
Fig. 3.3.20 Alternation of high frequency band of T wave amplitude
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
At the beginning of both sessions the values of total AT variability (Fig.
3.3.21) were the same, but during the recovery time this index was lower
after PMR than after MBSM. The alternation of total AT variability was
similar to the alternations VLF and LF. In stage B3 the value was higher
during PMR (41.08 ± 14.53 ms2) than during MBSM (34.27 ± 28.47 ms2)
(p<0.05). After MBSM it was insignificantly (p>0.05) higher (29.21 ± 13.94
ms2) than during the resting time (27.22 ± 11.65 ms2). After PMR total AT
variability was lower (20.89 ± 12.90 ms2) than during the resting time
(27.01 ± 15.35 ms2) (p<0.05).
77
total AT variability, ms2
44
42
40
38
36
34
32
30
28
26
24
22
20
18
●
●
●
*
●
*
*
●
*
●
*
●
MBSM
A
B1
●
C
PMR
B2
B3
Stages of the session
B4
Fig. 3.3.21 Alternation of total T wave amplitude variability during
the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
VLF of AST variability, ms2
The values of VLF of AST variability (Fig. 3.3.22) were higher in all
stages of MBSM compared to PMR (p<0.05). The highest values were in the
mid-time during both relaxation techniques (13.35 ± 9.99 ms2 during MBSM
and 11.11 ± 5.80 ms2 during PMR) (p<0.05). After both techniques VLF was
insignificantly (p>0.05) lower (11.12 ± 13.35 ms2 after MBSM and 4.96 ± 3.98
ms2 after PMR) compared to during the resting time (11.77 ± 12.15 ms2 before
MBSM and 5.41 ± 2.67 ms2 before PMR).
14
12
●
●
*
10
8
*
*
●
●
*
*
●
●
*
6
4
●
A
MBSM
B1
PMR
B2
B3
Stages of the session
B4
C
Fig. 3.3.22 Alternation of very low frequency band of ST amplitude
variability during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques;
● – p<0.05 comparing different stages of one session.
78
LF of AST variability, ms2
The values of LF of AST variability (Fig. 3.3.23) were higher during the
session with MBSM compared to PMR (p<0.05), except during the midtime when they were equal. The alternation of LF was more expressed
during PMR. LF in the mid-time was highest during PMR (9.50 ± 6.93 ms2)
(p<0.05). LF alternation was changing slightly during MBSM and during
the recovery time (8.59 ± 9.21 ms2) it was the same (p>0.05) than during
rest (7.81 ± 5.14 ms2). After PMR LF was lower (3.48 ± 1.54 ms2) than
during rest (5.00 ± 2.72 ms2) (p<0.05).
11
10
9
8
7
6
5
4
3
2
MBSM
●
●
*
*
●
PMR
●
*
*
●
●
*
●
A
B1
B2
B3
B4
●
C
Stages of the session
Fig. 3.3.23 Alternation of low frequency band of ST amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
The values of HF of AST variability (Fig. 3.3.24) were higher during all
stages of MBSM than in PMR. During both relaxation techniques HF was
increasing till the stage B3, then started decreasing. After MBSM, HF was
insignificantly (p>0.05) higher (7.943 ± 8.7045 ms2) than during rest (6.86 ±
3.8 ms2). After PMR, HF was lower (3.24 ± 1.49 ms2) than during rest (4.66
± 2.54 ms2) (p<0.05).
79
HF of AST variability, ms2
10
9
8
7
6
5
4
3
2
●
●
●
*
*
●
*
*
●
●
*
*
●
PMR ●
MBSM
A
B1
B2
B3
Stages of the session
B4
C
Fig. 3.3.24 Alternation of high frequency band of ST amplitude variability
during the relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
Total AST variability,ms2
The alternation of total AST variability (Fig. 3.3.25) was similar to the
alternations of all frequency bands. The values of this index were higher
during all stages of MBSM than PMR (p<0.05). During both relaxation
techniques total AST variability was increasing till the mid-time, then
started decreasing. After MBSM total AST variability was insignificantly
(p>0.05) higher (27.65 ± 30.79 ms2) than during rest (26.44 ± 20.03 ms2).
After PMR this index was lower (11.68 ± 6.35 ms2) compared to the resting
time (15.07 ± 7.13 ms2) (p<0.05).
36
33
30
27
24
21
18
15
12
9
6
●
●
*
*
*
*
●
*
●
●
●
MBSM
A
B1
B2
B3
Stages of the session
B4
*
●
PMR
C
Fig. 3.3.24 Alternation of total ST amplitude variability during the
relaxation techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
80
3.4. The alternation of heart complexity during the relaxation
techniques
In order to compare the alternation of heart complexity during
different relaxation techniques we evaluated the conjunction of ECG
parameters – RR and JT, JT and DQRS. The discriminant of the RR and JT
conjunction (Fig. 3.4.1) was greater during all stages of the session with
MBSM except B4. There was a mild alternation of this index during
MBSM. It was slowly increasing till the end of PMR and after performance
of the technique started to decrease sharply. At the end of the session with
MBSM the discriminant was smaller than it was in stage A (p<0.05). The
difference in values during PMR was statistically insignificant (p>0.05).
Discriminant (RR;JT)
0.09
0.08
MBSM
●
PMR
0.07
●
0.06
*
0.05
*
*
*
0.04
0.03
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.4.1 Alternation of RR and JT discriminant during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
The curves of the discriminant of the JT and DQRS (Fig. 3.4.2)
conjunction were similar comparing the techniques, but the values of the
discriminant were greater during all stages of the session with MBSM
except in C. This index was increasing from the beginning of MBSM and
stage B2 of PMR till stage B3. From there it slowly decreased until the end
of both techniques and after the session started to increase sharply. At the
end of the session with PMR, the discriminant was higher than during the
resting time (p<0.05) and also higher than that with MBSM (p<0.05). After
the session with MBSM the discriminant was smaller than during the resting
time, but the difference in values was statistically insignificant (p>0.05).
81
Discriminant (JT;DQRS)
0.24
●
●
0.23
0.22
0.21
●
*
*
0.20
0.19
●
MBSM
0.18
A
B1
B2
B3
B4
PMR
C
Stages of the session
Fig. 3.4.2 Alternation of JT and DQRS discriminant during the relaxation
techniques
Notice: MBSM – Mindfulness Body Scan Meditation; PMR – Progressive Muscle
Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05 comparing different stages of
one session.
CoPr
The curve of complexity profile (CoPr) (Fig. 3.4.3) was slowly rising till
the stage B3 during MBSM but decreasing during PMR. Then CoPr was
decreasing until the end of both techniques. From B4 onwards CoPr was
increasing and at the end of both sessions it was higher than during the
resting time (p<0.05). The increase in complexity during the recovery time
was greater after PMR.
0.20
0.19
0.18
0.17
0.16
0.15
0.14
0.13
0.12
MBSM
PMR
●
*
●
●
●
A
B1
B2
B3
Stages of the session
B4
C
Fig. 3.4.3 Alternation of complexity profile during the relaxation techniques
Notice: CoPr – complexity profile; MBSM – Mindfulness Body Scan Meditation; PMR –
Progressive Muscle Relaxation;* – p<0.05 comparing the techniques; ● – p<0.05
comparing different stages of one session.
82
3.5. Alternation of cardiovascular indices in patients with and without
anxiety during the relaxation techniques
HR, b/min, during session with
MBSM
We evaluated the alternation of HR, ABP and HRV in order to determine
the differences in patients with and without anxiety during the two
relaxation techniques.
The alternation of HR was greater for the patients without anxiety during
the session with MBSM (Fig. 3.5.1): for them HR decreased more than for
the ones with anxiety symptoms (p<0.05). There was a tendency of decrease
of HR for the latter, but the differences were statistically insignificant
(p>0.05).
66.5
66
65.5
65
64.5
64
63.5
63
62.5
62
●
*
*
●
●
A1
Without anxiety
With anxiety
A2
C1
Stages of the session
C2
Fig. 3.5.1 Alternation of heart rate during Mindfulness Body Scan
Meditation
Notice: MBSM – Mindfulness Body Scan meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
Heart rate was insignificantly (p>0.05) higher in people with anxiety
during all stages of PMR (Fig. 3.5.2). The increase of HR was more
significant in the patients without anxiety symptoms, but the differences
were statistically insignificant (p>0.05).
83
HR, b/min, during session with
PMR
61
60.5
60
59.5
59
58.5
58
57.5
57
A1
Without anxiety
With anxiety
A2
C1
Stages of the session
C2
Fig. 3.5.2 Alternation of heart rate during Progressive Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
SBP, mmHg, during session
with MBSM
Systolic blood pressure decreased in both groups during MBSM (p<0.05)
(Fig. 3.5.3). The biggest decrease was at the end of MBSM and then SBP
started rising. SBP was higher for the people with anxiety during all stages
of MBSM (p<0.05). For them SBP decreased more than for the people
without anxiety symptoms (p<0.05).
132
130
128
126
124
122
120
118
116
114
●
Without anxiety
*
●
●
*
*
A1
With anxiety
●
A2
C1
Stages of the session
●
C2
Fig. 3.5.3 Alternation of systolic blood pressure during Mindfulness Body
Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
During PMR the alternation of systolic blood pressure was different from
MBSM in both groups (Fig. 3.5.4): it changed less and the decrease was
smaller than during MBSM. The biggest decrease of SBP was after the
resting time and from the beginning of PMR it started to increase again.
84
SBP, mmHg, during session with
PMR
After PMR systolic BP was smaller than during the resting time for the
patients with and without anxiety.
132
130
128
126
124
122
120
118
116
114
●
*
●
●
*
*
*
Without anxiety
A1
A2
C1
Stages of the session
With anxiety
C2
Fig. 3.5.4 Alternation of systolic blood pressure during Progressive Muscle
Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
DBP, mmHg, during session
with MBSM
Diastolic blood pressure was higher in people with anxiety during all
stages of MBSM (p<0.05) (Fig. 3.5.5). There was a decrease of DBP during
MBSM in both patient groups, although for those without anxiety DBP
moderated more. DBP decreased consistently from the beginning until the
end of the session in both groups.
80
Without anxiety
With anxiety
78
76
74
*
*
72
*
●
70
*
●
68
A1
A2
C1
C2
Stages of the session
Fig. 3.5.5 Alternation of diastolic blood pressure during Mindfulness Body
Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
85
DBP, mmHg, during session with
PMR
DBP was higher in people with anxiety during all stages of PMR
(p<0.05) (Fig. 3.5.6). DBP decreased during the resting time, but in the
beginning of PMR started rising and reached its peak at the end of PMR.
DBP increased in both groups after the session with PMR comparing with
the stage, but the differences were statistically insignificant (p>0.05).
80
78
76
74
*
*
*
*
72
70
Without anxiety
68
A1
A2
C1
With anxiety
C2
Stages of the session
Fig. 3.5.6 Alternation of diastolic blood pressure during Progressive
Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
We evaluated the alternation of HRV in all frequency bands and HRC in
patients with and without anxiety during MBSM and PMR (appendices 12
and 13).
The alternation of VLF (Fig. 3.5.7) was sinusoid for both patient groups
during MBSM, but opposite comparing between the groups: VLF was
increasing in the group with anxiety at the stages (B1, B2) where there was
a decrease for the group without anxiety. There was an increase in VLF
during MBSM in both groups (p<0.05).
86
VLF of HRV, ms2, during
MBSM
26
With anxiety
24
22
20
●
●
*
*
●
●
18
●
*
*
16
14
Without anxiety
●
●
●
12
A
B1
B2
B3
B4
Stages of the session
C
Fig. 3.5.7 Alternation of very low frequency band of heart rate variability
during Mindfulness Body Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
VLF of HRV, ms2, during PMR
The alternation of VLF during PMR was similar for both groups (Fig.
3.5.8), although the values of VLF were higher during all stages of the
session for the patients with anxiety (p<0.05). VLF rose from the beginning
of the session and reached its peak in mid-time in both groups. Then it
started decreasing and at the end of the session it was insignificantly
(p>0.05) higher in both groups compared with the resting time.
50
●
45
40
*
35
●
*
30
25
20
15
●
*
*
*
●
A
With anxiety
B1
Without anxiety
B2
B3
B4
Stages of the session
C
Fig. 3.5.8 Alternation of very low frequency band of heart rate variability
during Progressive Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
87
The alternation of LF (Fig. 3.5.9) was similar to VLF: it was sinusoid for
both patients groups during MBSM, but opposite comparing between the
groups: LF increased in the group with anxiety at the stages (B1, B2) where
there was a decrease for the group without anxiety. There was a decrease in
LF during MBSM in both groups, but the difference was statistically
significant (p<0.05) only in the group without anxiety.
LF of HRV, ms2, during
MBSM
12
11
10
9
8
7
6
5
4
With anxiety
●
●
Without anxiety
●
*
*
●
*
●
A
B1
B2
B3
Stages of the session
B4
C
Fig. 3.5.9 Alternation of low frequency band of heart rate variability during
Mindfulness Body Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
The alternation of LF during the session with PMR was almost equal in
both patient groups (Fig. 3.5.10).
LF of HRV, ms2, during PMR
14
13
●
●
●
12
●
11
10
●
●
9
●
8
●
With anxiety
7
A
B1
Without anxiety
B2
B3
Stages of the session
B4
C
Fig. 3.5.10 Alternation of low frequency band of heart rate variability
during Progressive Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
88
HF of HRV, ms2, during MBSM
LF decreased during the resting time, then rose from the beginning of
PMR and reached its peak in mid-time in both groups. Then it decreased
and after the end of performance started rising again. At the end of the
session LF was lower in both groups than it was during the resting time, but
the difference was statistically significant (p<0.05) only in the anxiety
group.
The values of HF in patients without anxiety were higher (p<0.05) than
those of the anxiety group in almost all stages of the session (Fig.3.5.11).
HF was increasing in the group with anxiety in the mid-time of
performance, although there was a decrease in that time for the group
without anxiety. There was a decrease in HF during PMR in the anxiety
group (p<0.05).
7
●
With anxiety
Without anxiety
●
*
6
5
●
*
*
*
4
●
●
3
A
B1
B2
B3
Stages of the session
B4
C
Fig. 3.5.11 Alternation of high frequency band of heart rate variability
during Mindfulness Body Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
The alternation of HF during the session with PMR was similar in both
patient groups (Fig. 3.5.12). During the resting time this index was higher in
the anxiety group. It started to rise from the beginning of PMR and reached
its peak in stage B2 in both groups, where the value was greater in the group
without anxiety. After that HF decreased until the end of B4, and after
performing the technique started rising again. At the end of the session HF
was insignificantly (p>0.05) higher in the anxiety group compared to the
resting time. HF was the same during the recovery time in the non-anxiety
group as it had been during the resting time (p>0.05). During the recovery
time HF was higher in anxiety group compared to non-anxiety group
(p<0.05).
89
HF of HRV, ms2, during PMR
8
With anxiety
●
7
6
●
5
*
4
Without anxiety
*
*
●
●
●
A
B1
●
3
B2
B3
Stages of the session
B4
C
Fig. 3.5.12 Alternation of high frequency band of heart rate variability
during Progressive Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
Total HRV, ms2, during MBSM
The alternation of total HRV during MBSM (Fig. 3.5.13) was similar to
VLF and especially to LF: for both patient groups it was sinusoid but
opposite comparing between the groups: total HRV was increasing in the
group with anxiety at the stages (B1, B2) where there was a decrease for the
group without anxiety. There was an increase in total HRV after MBSM
compared with the resting time in non-anxiety group (p<0.05).
38
36
34
32
30
●
●
●
●
●
*
●
*
*
●
28
●
●
26
With anxiety
24
A
B1
Without anxiety
B2
B3
B4
Stages of the session
C
Fig. 3.5.13 Alternation of total heart rate variability during Mindfulness
Body Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
90
Total HRV, ms2, during PMR
The alternation of total HRV during the session with PMR (Fig. 3.5.14)
was similar to LF and the dynamic was very similar comparing the two
groups. The values of total HRV were higher in the anxiety group during the
resting time, mid-time and the recovery time compared with the non-anxiety
group (p<0.05). This index decreased in the anxiety group during the rest,
but started rising from the resting time in the non-anxiety group. In both
groups HRV rose from the beginning of PMR and reached its peak in the
mid-time. Then it decreased until the end of the session. During recovery
time total HRV was higher in both groups compared to the resting time, but
the change was statistically significant only in the anxiety group (p<0.05).
●
65
60
*
●
55
●
50
45
●
●
40
35
30
*
*
●
A
With anxiety
B1
B2
B3
Without anxiety
B4
C
Stages of the session
Fig. 3.5.14 Alternation of total heart rate variability during Progressive
Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
The values of HRC (Fig. 3.5.15) were greater in the anxiety group than in
the non-anxiety group during all stages of the session with MBSM except
during the resting time. But the alternation of HRC was similar in the two
groups. In both groups HRC rose from the beginning of the session and
reached its peak in the mid-time. Then it slowly decreased until the end of
the session, where it was higher in both groups than it had been during the
resting time (p<0.05).
91
HRC, %, during MBSM
50
●
45
*
40
●
35
30
●
*
●
*
●
●
With anxiety
25
A
B1
B2
B3
Without anxiety
B4
C
Stages of the session
Fig. 3.5.15 Alternation of heart rhythm coherence during Mindfulness Body
Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
The HRC alternation during the session with PMR (Fig. 3.5.16) was
similar in the two groups, although the values of HRC were higher in the
anxiety group during PMR.
HRC, %, during PMR
50
With anxiety
●
45
40
35
Without anxiety
●
●
●
●
●
*
30
●
25
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.5.16 Alternation of heart rhythm coherence during Progressive
Muscle Relaxation
Notice: PMR – Progressive Muscle Relaxation; * – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
During the resting and recovery time the values of HRC of the anxiety
group were lower than in the non-anxiety group. This index decreased in the
non-anxiety group from the resting time to the mid-time, but did not change
92
during those stages in the anxiety group. In both groups HRC rose during
the mid-time of performance. Then it slowly decreased until the end of PMR
and at the recovery time it was higher than during the rest (p<0.05). In the
non-anxiety group HRC started rising after B4 and during the recovery time
it was higher than during the rest (p<0.05).
In order to compare the alternation of heart complexity in patients with
and without anxiety we evaluated the conjunction of ECG parameters – RR
and JT, JT and DQRS. The results of our study showed that JT and DQRS
conjunction of the parameters was characteristic of a greater complexity
than the RR and JT conjunction during both sessions. The discriminants of
the JT and QRS conjunction were greater than that of RR and JT.
The discriminant of the RR and JT conjunction during MBSM (Fig.
3.5.17) was higher in patients without anxiety. This index decreased in the
non-anxiety group until the end of the session. There was a mild alternation
observed in the values of the anxiety group. At the end of the session the
discriminant of the RR and JT conjunction was lower than during the resting
time, but the difference was statistically significant (p<0.05) only in the
non-anxiety group.
DSC (RR;JT) during MBSM
0.10
0.09
with anxiety
●
without anxiety
0.08
0.07
*
●
*
*
0.06
0.05
0.04
A
B1
B2
B3
Stages of the session
B4
C
Fig. 3.5.17 Alternation of RR and JT discriminant during Mindfulness Body
Scan Meditation
Notice: DSC – discriminant; MBSM – Mindfulness Body Scan Meditation; * – p<0.05
comparing the techniques; ● – p<0.05 comparing different stages of one session.
The alternation of the RR and JT conjunction discriminant during PMR
(Fig. 3.5.18) differed from that of MBSM in both groups. In the anxiety
group this index rose from the beginning until the mid-time, and then slowly
decreased until the end of the session. The alternation of the discriminant
was more expressed in patients without anxiety: there was a steep rise from
stage B2 till B4, and after the technique there was a steep decrease. At the
93
DSC (RR;DJT) during PMR
end of the session the discriminant of the RR and JT conjunction was less
than during the resting time, but the differences were statistically
insignificant in both groups (p>0.05).
0.08
●
●
0.07
*
0.06
0.05
0.04
●
with anxiety
0.03
A
B1
B2
B3
Stages of the session
without anxiety
B4
C
Fig. 3.5.18 Alternation of RR and JT discriminant during Progressive
Muscle Relaxation
Notice: DSC – discriminant; PMR – Progressive Muscle Relaxation; * – p<0.05 comparing
the techniques; ● – p<0.05 comparing different stages of one session.
DSC (JT;DQRS) during
MBSM
The alternation of the JT and DQRS conjunction discriminant during the
session with MBSM (3.5.19) was similar between the groups, although the
values of this index were greater in patients without anxiety in all stages of
the session. The alternation of this discriminant was minimal: the values
almost did not change during the session in both groups (p>0.05).
0.27
0.26
0.25
0.24
0.23
0.22
0.21
0.20
0.19
0.18
0.17
*
*
*
*
with anxiety
A
B1
B2
B3
Stages of the session
*
*
without anxiety
B4
C
Fig. 3.5.19 Alternation of JT and DQRS discriminant during Mindfulness
Body Scan Meditation
Notice: DSC – discriminant; MBSM – Mindfulness Body Scan Meditation; * – p<0.05
comparing the techniques; ● – p<0.05 comparing different stages of one session.
94
DSC (JT;DQRS) during PMR
The alternation of the JT and DQRS conjunction discriminant during the
session with PMR (Fig. 3.5.20) was similar between the groups, although
this index was bigger in patients without anxiety in all stages of the session.
The alternation of this discriminant was slight, but at the end of the session
the values were higher than during resting time (p<0.05).
0.27
0.26
0.25
0.24
0.23
0.22
0.21
0.20
0.19
0.18
0.17
0.16
0.15
with anxiety
without anxiety
●
●
*
●
*
*
*
*
*
●
B4
C
●
●
A
B1
B2
B3
Stages of the session
Fig. 3.5.20 Alternation of JT and DQRS discriminant during Progressive
Muscle Relaxation
Notice: DSC – discriminant; PMR – Progressive Muscle Relaxation;* – p<0.05 comparing
the techniques; ● – p<0.05 comparing different stages of one session.
The values of complexity profile (CoPr) were higher in patients without
anxiety in all stages of the session with MBSM (Fig. 3.5.21). The curves of
CoPr were similar in the two studied groups except there was a greater decrease
in stage B4 in the anxiety group. CoPr was consequently increasing in patients
without anxiety. In the anxiety group CoPr was decreasing from stage B3 but
after the technique finished it started to increase sharply. After the session CoPr
was higher in both groups than it had been during the resting time, but the
difference was statistically significant (p<0.05) only in the non-anxiety group.
95
CoPr during MBSM
0.20
0.19
0.18
0.17
0.16
0.15
0.14
0.13
0.12
●
●
*
*
*
A
*
*
B1
with anxiety
without anxiety
B2
B4
B3
C
Stages of the session
Fig. 3.5.21 Alternation of the complexity profile during Mindfulness Body
Scan Meditation
Notice: MBSM – Mindfulness Body Scan Meditation; * – p<0.05 comparing the
techniques; ● – p<0.05 comparing different stages of one session.
The values of CoPr were greater in patients without anxiety in all stages
of the session with PMR (Fig. 3.5.22). The curves of CoPr were similar in
both studied groups except there was a decrease in stage B2 in the anxiety
group. From stage B3 onwards CoPr decreased but after the technique
finished, it increased sharply. After the session CoPr was higher in both
groups than it had been during the resting time (p<0.05).
0.24
with anxiety
without anxiety
CoPr during PMR
0.22
0.20
0.18
●
*
●
0.16
0.14
*
0.12
●
*
*
●
*
*
0.10
A
B1
B2
B3
B4
C
Stages of the session
Fig. 3.5.22 Alternation of the complexity profile during Progressive Muscle
Relaxation (PMR)
Notice: PMR – Progressive Muscle Relaxation;* – p<0.05 comparing the techniques; ● –
p<0.05 comparing different stages of one session.
96
4. DISCUSSION
Many functions of the human body slow down during relaxation [19,
105]. Studies have shown that the relaxation response, which is the
physiological opposite of the fight or flight response to stress, is elicited
through a variety of techniques in addition to meditation such as imagery,
hypnosis, autogenic training, and progressive muscle relaxation [144, 133].
Benson et al [21] concluded that the relaxation response may act through
thalamic and subthalamic activity to reduce anxiety and other negative
psychological reactions due to stress. The physiological changes of the
relaxation response are consistent with decreased sympathetic nervous
system activity including decreased oxygen consumption and increased
carbon dioxide elimination, as well as changes in heart rate, respiratory rate,
blood pressure, minute ventilation, muscle tones, arterial blood lactate, skin
resistance, and alpha brain activity. These changes contrast with the
physiological manifestations of sitting quietly or sleeping [144]. But most of
the studies have been done with long-term relaxation programs. There is
very little information on the short-term effects of different relaxation
techniques [69].
The present study was made to evaluate the alternation of the functional
state of the CVS in post-MI-men during Mindfulness Body Scan Meditation
(MBSM) and progressive muscular relaxation (PMR). Both methods are
simple, well-tolerated, and economical procedures that can be used without
problems in clinical routine procedures. According to many authors PMR
and MBSM effectively reduce physiological indices [64, 69, 25, 250]. But
the relaxation mechanisms of these methods are different. During the PMR
technique the relaxation is directly pointed into the physiological processes
of the system i.e. muscles are contracted and relaxed. By effecting
physiological processes mental changes are expected too. During MBSM
the relaxation mechanism is primarily associated with mental processes and
only afterwards with physiological ones.
Physical activity is important for a dynamic of the physiological and
psychological state in post-MI patients [36] but it was not a focus in our
study. Long-term effects were not assessed in this study either. It would be
of interest to estimate the long-term effects of these relaxation techniques.
But after discharge from the hospital, patients will start to exercise at
different levels and will be pharmacologically treated by different family
physicians, which may make meaningful comparisons very difficult. During
the hospital stay of the patient the influence of physiological perturbations
97
and of various drug regimens can widely be controlled, thus allowing for the
best possible comparison among the groups.
For investigating the received data we used a model of integral
evaluation developed by the Institute of Cardiology at Kaunas University of
Medicine [237], which has become popular among Lithuanian researchers
[208, 179, 177, 118, 257, 24, 164]. Unfortunately we were able to examine
only two elements of the model: (1) the regulatory system, involving the
central nervous system, autonomic regulation and (2) the supplying system
(cardiovascular), which manages the central hemodynamic. Due to
specificity of our investigation, we could not accurately assess a third one,
the executive system, which is reflected by activated muscle groups.
The heart is an organ with continuous activity, which must satisfy the
demands of an organism given various conditions. Therefore, heart activity
is modulated at many levels, including intrinsic regulatory mechanisms,
humoral factors and the autonomic nervous system. The regulation of heart
activity by the sympathetic and parasympathetic nervous systems is well
known [132]. The parasympathetic and sympathetic parts of the autonomic
nervous system affect the heart generally contrariwise. At rest the
parasympathetic nervous system dominates, regulating heart activity. It
inhibits the HR and reduces the force of myocardial contraction. When the
effect of the parasympathetic nervous system weakens, HR becomes more
frequent. This is the result of the sympathetic nervous system effect, which
is particularly activated by physical and emotional stress [195].
An existing control mechanism from sub-cellular to systemic levels
ensures that information is constantly exchanged across all levels of
organization, even at rest, and enables the body to adjust to an everchanging environment. Dynamic processes are evident in the complex
fluctuations of physiological output signals (heart rate, blood pressure and
others). The output of physiological systems under neural regulation
exhibits a high degree of variability, special and temporal fractal
organization which remains invariant at different scales of observation, as
well as complex nonlinear properties [51].
An investigation of the HR shows that changes in its wave structure are
related to the functional state of the heart and cardiovascular system.
Different mechanisms are formatting separate structural elements. Stankus
et al. concluded that monitoring of the HR makes it easier to assess the
influence of the central nervous system, especially during a relaxation
procedure [213].
There were no big HR alternations in our studied patients during both
relaxation techniques, but HR was higher during the whole session of
MBSM than during PMR. The mean HR of our studied patients was higher
98
already before the sessions with MBSM compared with PMR. This may be
due to two reasons. Firstly, the sessions were done on different days after
the operation and the results might be influenced by the recovery. Secondly,
MBSM was performed previously, therefore it is possible that the person
may have experienced a reaction to the researcher, causing a short increase
of sympathetic nervous system activity which decreased after some time.
ABP remained within the norms during both sessions. SBP decreased
during MBSM and during PMR (p<0.05). Although DBP did not differ
before the sessions, the relaxation techniques had a different effect on this
index. There was a reduction tendency in DBP during MBSM and an
increase during PMR (p>0.05). The differences were during recovery time
after performing the techniques: DBP was lower after MBSM than after
PMR (p<0.05). A reduction of the parameters during MBSM reflects a
calmer situation in the heart – a decrease of sympathetic and
parasympathetic activity. Decreased SBP is associated with vascular
dilatation, therefore lower ABP shows better arterial elasticity. A decrease
of DBP shows a decreasing tonus of the arteriole and an improvement in
their dilatative characteristic.
Our results show no statistically significant short-term effect of PMR on
the systemic indices (HR and ABP). There have been no studies done using
these techniques with hospitalized post-MI men, but the study with PMR on
essential hypertension [207] showed different results to ours. According to
other authors, PMR had an immediate effect, reducing pulse rate 2.35 beats
(per minute), SBP 5.44 mm Hg and DBP 3.48 mm Hg.
Electrical activity of the heart is not only associated with its physiology.
The electrocardiogram parameters may also reveal the relationship of CVS
with other body systems. Scientists worldwide as well as in Lithuania have
investigated at length the dynamics of the main ECG parameters, mainly
during physical activity [164]. We compared the means of ECG parameters
(RR, DJT, DQRS, AR, AT, AST) and their alternation during MBSM and
PMR in order to evaluate the short-term effects of relaxation on these
indices. The values of the ECG parameters differed between MBSM and
PMR insignificantly (p>0.05) during almost every stage of the session, but
nevertheless there have been certain tendencies noticed.
We evaluated the alternation of electrocardiogram RR interval as the
function of the regulatory system, with reference to the model of integral
health evaluation [236]. The results of the study showed that the duration of
RR interval increases from the beginning of PMR, but decreases from the
beginning of MBSM. After the session with PMR, RR interval was longer
than before performing it (p<0.05). This index increased during PMR due to
the activation of the parasympathetic nervous system, and a decrease in
99
activity of the sympathetic nervous system. Longer RR interval probably
shows reduced stress in the system. RR interval did not increase during
MBSM because, as was mentioned above, this relaxation technique was
performed first, so the results might have been influenced by the different
recovery time and also the person may have had a reaction to the researcher.
This caused a short increase of sympathetic nervous system activity which
decreased after some time.
Enhanced cardiac parasympathetic tone may explain an important
mechanism underlying the beneficial effect of the relaxation response [194].
One of the ways the parasympathetic system activates is by triggering it
with arterial baroreflex stimulation. Sometimes the terms baroreceptor and
baroreflex are used to refer only to the high pressure sensor-response loop,
but we will use the broader meaning of baroreflex (baro means "pressure" or
"heavy" in Greek) to refer to either the high or low pressure reflex loops.
One short-term neural baroreflex feedback loop response, adapted from
Batzel [16], is shown together with the model of integral evaluation in Fig.
6.1. We represented these two models in one scheme in order to understand
the baroreflex feedback loop response in the context of the model of integral
evaluation.
100
Regulatory
System
Central
Nervous
System
Carotid-arterial
Cardiopulmonary
Baroreceptor
Heart Rate
Mindfulness
Body Scan
Meditation
Sympathetic
Activity
Parasympathetic
Activity
Progressive
Muscle
Relaxation
Systemic
vascular
Resistant
Executive
System
Venous Tone
Contractility
Right Atrial
Pressure
Stroke
Volume
Arterial
Pressure
Supplying
System
Cardiac
Output
Hypotension
after physical
load
Fig. 6.1 Baroreceptor control loops in the context of the model of integral
evaluation
The regulation of vascular tonus, as with many other mechanisms,
functions according to the principal of negative feedback. This means that
when ABP and vascular tonus increases, the impulsation from medulla
oblongata vasomotor centers to vascular smooth muscles decreases. And
vice versa, when ABP and vascular tonus decreases, impulsation increases.
Due to these mechanisms there is often a wave-like fluctuation of ABP and
vascular tonus.
When there is an increase in arterial systemic blood pressure,
sympathetic activity is reduced and parasympathetic activity increases.
Increased parasympathetic activity quickly slows down HR and lowers
101
ABP. Reduced sympathetic activity also reduces HR, contractility, and
systemic resistance, all of which act to lower ABP. There may also be a
reduction in venous tone, which raises the unstressed volume. When there is
a reduction in ABP, there is a reduction in baroreceptor activity and an
opposite set of responses is generated. The partition of the response into
changes in HR, contractility, systemic resistance, and unstressed volume can
be highly individual. The evoked control response depends on the cause of
that perturbation of ABP. For example, during an acute drop in blood
volume, the venous return and the right atrial pressure are reduced, followed
by a drop in cardiac output and hence ABP. Baroreflex stimulation will
increase HR, contractility and systemic resistance to various degrees, with
any increase in cardiac output bounded by the baroreflex target pressure
[16]. Fig. 6.1 shows a schematic of the possible control responses. During
generalized exercise, on the other hand, there is an initial net drop in
systemic resistance due to a reduction of local resistance to increased local
blood flow. Pressure will be stabilized primarily by changes in HR and
contractility, with contributions also from increases in systemic resistance in
the cutaneous and splanchnic circulations [16].
It must be kept in mind that certain feedback responses (based on the
type of stress induced) may include possible changes in vascular tone, with
or without influencing HR, and certain elements of the individual
cardiopulmonary and arterial reflexes may involve counteracting or
inhibiting influences with regard to other elements [16].
Approaching the described mechanisms according to the model of
integral evaluation, the mentioned processes reflect three holistic systems:
the regulatory system (CNS, HR, baroreceptors), the supplying system
(contractility, stroke volume, cardiac output) and the executive system
(systemic vascular resistance, venous tone, right atrial pressure, arterial
pressure). The relaxation techniques that we studied affected physiological
changes through different paths: MBSM made an impact on the regulatory
system (CNS), and PMR on the regulatory system (CNS) and on the
executive system (ABP).
A good blood supply to the heart is an important performance indicator
of its work. Organ blood supply is determined by the intensity of its
metabolic rate. Cardiac metabolic changes are associated with JT interval
[237]. ECG JT interval corresponds with the cardiac electric systole and its
changes are associated with the intensity of myocardial metabolism.
Minimum duration of JT interval is about 160 ms, maximum is about 360
ms. The changes of DJT are influenced by the regulatory nervous system.
Metabolic changes in the organism are closely associated with
repolarization changes. Derivations, where JT interval is shorter, show that
102
in those myocardium areas the repolarization happens earlier, and metabolic
changes are faster. Longer DJT shows slower repolarization and slower
metabolic reactions [164].
There is a well-known parabolic relationship between the HR and JT
interval - when HR rises, JT interval shortens, and vice versa. This JT
interval shortening shows the accelerating metabolism of the heart [164]. In
our study the DJT lengthened from the beginning of both sessions. After
both relaxation techniques DJT was elongated (p<0.05). The DJT while
performing MBSM was longer during the all session time than while
performing PMR, although the differences were statistically insignificant
(p>0.05). Elongated DJT shows that there was less metabolic activity
needed for performing this technique and the myocardium worked more
economically.
We evaluated the JT and RR relation remembering Bazett’s (1920)
square linear dependence, between these parameters. Although the
difference between techniques was insignificant, the tendencies of our
results show a reverse dependence – during PMR, DJT is shorter but RR
interval is longer than during MBSM. There are two explanations possible
for shorter JT interval during PMR: (1) stress and greater parasympathetic
(longer RR) and sympathetic (shorter JT) tonuses in the body, and (2) more
intense ischemic processes during PMR. Although examined ST changes
cannot confirm the second version, there is a first version left – stress in the
system during PMR.
QRS complex is a part of the regulatory system of the heart, which
reflects a spreading of ventricle depolarization. The wider QRS complex
shows a slower conduction in the heart ventricle [164]. DQRS can range in
normal conditions from 80 to 120 ms. This index is sensitive to tonus
changes of the sympathetic and parasympathetic nervous systems. The
results of our study showed insignificantly (p<0.05) longer DQRS after both
relaxation techniques.
We evaluated the alternation of ECG R amplitude as a function of the
regulatory system, with reference to the model of integral health evaluation.
The alternation of AR reflects the function of the respiratory system (RS).
The results of our study showed that AR increased during both relaxation
techniques (p<0.05). The rising curve shows a bigger blood supply to the
lungs and smaller airiness [164]. A decrease of AR is associated with an
increase of airiness and resistance in the lungs, also with a bigger voltage
drop, which is characterized by stress. The results of our study show that
MBSM and PMR have an indirect positive effect on respiratory function.
Clearly the cardiovascular and respiratory systems are interconnected,
both acting to satisfy the requirements of stable metabolism [100]. The
103
traditional approach was to study these two systems as though they were
essentially independent. According to this view, in normal rest conditions,
ventilation and pulmonary blood flow coordination require only indirect
coordination through the interplay of the individual negative feedback
controls of the CVS and RS, responding to metabolic demand and particular
control constraints such as stable blood pressure. Important to this interplay
is the fact that blood so quickly, efficiently, and completely loads and
unloads blood gases in the alveoli, that blood gas transport is essentially
limited only by the pulmonary perfusion rate [100]. However, beyond this
interplay and loose coordination of independent system elements, it is clear
that there are a number of key links between the two systems that require an
integrative view of what can be referred to as the cardiovascular-respiratory
system. Even in the normal rest state, a degree of active coupling between
ventilation and blood flow likely exists, as for example, in respiratory sinus
arrhythmia, which may aid pulmonary gas exchange by influencing
ventilation-perfusion coupling and via cardiopulmonary and pulmonary
sensors signaling changes in cardiac output, which may influence minute
ventilation. The lung inflation reflex attenuates vagal influence of HR when
ventilation increases as during hypoxia. During the normal but more
extreme situation of exercise (which can be viewed as a form of stress), the
need to match the activity of the two systems is more critical, and the
systems respond in a more coordinated fashion, requiring additional modes
of control. CVS and RS coordination and interaction are also complicated
by stresses imposed by extreme but abnormal conditions such as asphyxia,
hemorrhage, apnea-induced hypoxia, and many other clinical conditions,
which distort the usual functional relations. The nature and degree of
interaction of related CVS and RS controls often depend on the type and
degree of the stimulus. For example, hypoxia induced during apnea results
in systemic vasoconstriction, while hypoxia occurring during spontaneous
breathing results in systemic vasodilation [100].
Both parameters DQRS and AR have shown roughly the same behavior.
This leads to a question: what changes of regulatory system activity could
evoke the alternation of these parameters? One hypothesis could be – a drop
in parasympathetic system activity can increase DQRS and can slow down
hemodynamic in the lungs by increasing blood in them, which causes
smaller impedance and an increase in the amplitude of R wave.
T wave and ST-segment show the repolarization of the heart ventricle.
The normal amplitude of T wave is from 0.25 to 0.6 mV, duration 0.12–0.16
s. The results of our study showed that AT was higher after MBSM than
during the resting time (p<0.05), but there was no significant increase after
104
PMR. The alternation of AT did not differ comparing the two techniques
(p>0.05).
Cardiac activity is more essential than the activity of other organs even in
rest conditions, and myocardial need for oxygen must be met given any
level of metabolism [237]. If coronary blood vessels supply an inadequate
amount of blood, it changes the metabolic balance and action potentials in
the myocytes, while in the electrocardiogram the changes in ST-segment
amplitude are registered. ST-segment amplitude deviation from the norm
both at rest and during physical activity shall be considered as an indication
of typical heart failure, hemodynamic, and possible functional ischemia.
The results of our study showed that AST had a mild alternation and this
index increased after both relaxation techniques (p<0.05). The values of
AST while performing PMR were (p<0.05) greater than while performing
MBSM. Comparing the alternation of AR, AT and AST during both
sessions we can see significant differences between them. This was
observed despite the fact that these are amplitude parameters and their
alternation can be influenced in the same way by respiratory function. This
fact is apparently hiding certain unexplained features of the interaction
between the human heart and body.
Since there were no differences observed in the alternation of ECG
parameters (except AST) between the two techniques, we evaluated the
changes of the indices compared with the total time of performance (total
B). There were no statistically significant differences between MBSM and
PMR in any changes of ECG parameters (p>0.05), but certain tendencies
were observed. During the sessions we expected that by setting into action
the impact (change AB) and stopping it (change BC) we would observe
their reverse changes, i.e. if AB is positive, then BC would be negative and
of similar size. Therefore we would have minimal AC, or it would be close
to zero. However, AC in most parameters was big enough. This fact shows
that both relaxation techniques had an effect on the body, apparently taking
the system into a more optimal state energetically (HR was slowing, JT and
AST were lengthening).
We assessed the correlation in order to see if the same alternation was
repeating itself among the parameters. We expected to see a similar pattern
in other indices (the durational parameters in one way, the amplitude
parameters differently), but it was not the case. This means that every
assessed parameter reflects only specific physiological information in
different fractal levels of the body. In this study we evaluated the correlation
between ECG parameters using the Spearman correlation coefficient (r).
Strong and statistically significant correlation (p<0.05) was found
between DJT and RR indices, between AST and AR and between AST and
105
AT during both relaxation techniques. Significantly strong correlation was
between RR and AR only during MBSM. Interrelations among parameters
were changing differently during MBSM and PMR. Although correlation
between DJT and RR was greater during all stages of the MBSM compared
with PMR, during MBSM it changed insignificantly. Alternation of DJT
and RR correlation was more expressed during PMR.
Correlation between AST and AR alternated differently from DJT and
RR. It was higher during all stages of the PMR compared with MBSM.
During PMR r changed insignificantly. Alternation of AST and AR
interrelations was more expressed during MBSM.
Correlation between AST and AT was greater at the beginning and the
end of session with PMR compared with MBSM. While performing both
relaxation techniques, AST and AT correlation was very similar. It started to
differ only at the last stage of the technique (B4).
Strong correlation was found between RR and AR only during MBSM.
At the recovery time RR and AR correlation was the same as it had been in
the beginning.
The alternation of variability of ECG parameters during the two
relaxation techniques
The evaluation of the parameters’ complexity, particularly the RR
interval, has aroused much interest in studies of different human states [103,
51, 15]. However the nonlinear functioning of other ECG parameters such
as the JT interval, QRS complex, R, T and ST amplitudes during relaxation
as well as their interaction remains unclear. We evaluated the variability of
ECG parameters (RR, DJT, DQRS, AR, AT, AST) in order to compare the
short term effects of MBSM and PMR. The variability was divided into
three frequency bands: very low frequency band (VLF), low frequency band
(LF) and high frequency band (HF). The variability of the registered signals
accompanied by changes provides all the requirements for the creation of a
new stable state through fluctuations [239].
The idea to study cardiac electrical instability in terms of morphologic
variability in the surface ECG was first suggested by Prasad et al. [181].
They developed a method that exploits the morphologic variability of timealigned beats in the standard 12-lead ECG. Large variability was found in
patients with ischemic heart disease, whereas normal subjects had small
variability [181].
The assessment of HRV-indices has potential in the prediction of
arrhythmias, non-arrhythmic cardiac events, and autonomic neuropathy [2].
Reduced HRV is a powerful and independent predictor of an adverse
prognosis in patients with heart disease and in the general population [65].
106
Post-MI patients with low HRV are at particular risk of sudden cardiac
death [2]. Relaxation techniques have an effect on neuro-autonomic function
including modulation of HRV [229]. The scientists found that short-term
HRV increases during relaxation in healthy adults and in patients with
hypertension [229].
Several methods of HRV have been used to describe the complex
regulatory system between heart rate and the autonomic nervous system.
The conventional methods based on statistical methods of variance and
power spectral analysis of HRV are most often used. The physiological
background of these measurements is well understood. The high frequency
(from 0.18 to 0.4 Hz) fluctuations of heart rate (and blood pressure) are
determined by respiration. These oscillations represent autonomic neural
fluctuations and central blood volume changes. These high frequency
fluctuations are modified by the phenomenon called respiratory gating,
whose magnitude depends on the level of stimulation of autonomic motor
neurons. When the level of the stimulation is low (low vagal activity at low
arterial pressure), respiratory oscillations of vagal activity are also low. The
low frequency (from 0.03 to 0.15 Hz) fluctuations of heart rate have been
proposed to be derived from arterial pressure Mayer waves, whose major
determinant is considered to be sympathetic vasomotor activity. The very
low frequency fluctuations (below 0.03 Hz) have been attributed to the
renin-angiotensin system, other humoral factors and thermoregulation. The
conventional measures of HRV have been shown to provide prognostic
information in several patient populations) [103]. Meanwhile, it is known
that cardiac surgery leads to an early depression of autonomic function, and
that there is potential for recovery after a certain time frame [189].
The variability of all ECG parameters changed in all frequency bands
during both relaxation techniques: the values of variability (in ms2 and %)
of all evaluated ECG parameters after MBSM and PMR were significantly
different from the resting values.
The alternation of VLF band of HRV was more expressed during PMR
than MBSM (p<0.05). This index increased after both relaxation techniques.
The alternation of LF of HRV was similar during both relaxation
techniques, although a curve during PMR was expressed more. LF
decreased (p<0.05) after both relaxation techniques. HF decreased after
MBSM (stage C) but increased after PMR (p<0.05). The increased highfrequency amplitude without changes in the respiratory parameters indicates
enhanced cardiac parasympathetic tone [194].
The alternation of the total HRV during both relaxation techniques was
very similar to the VLF alternation. Total HRV increased after PMR
(p<0.05). From HRV we can state that there was an activation of the
107
sympathetic nervous system which to judge by maximal changes was more
expressed in stage B3 during PMR. It is likely that sympathetic activation
has a big influence on other time parameters: DJT and DQRS.
VLF band was less expressed during MBSM. Sympathetic activation was
greater during PMR: in B3 stage all time parameters had the highest value.
During both sessions there was a wave-like alternation in VLF, LF and
FH bands of HRV possibly due to an inter-coordination of regulatory
processes in the heart. This alternation was more pronounced during PMR
than during MBSM.
The study of the relaxation with controlled frequency of respiration has
shown that this method had an effect on HRV: the HF and LF components
of HRV increased. This influence was higher for healthy subjects,
comparing to IHD. Relaxation procedure with controlled frequency of
respiration may activate baroreflex control of the heart rate by means of
readjustment of the blood between pulmonary and systemic circulation
[215].
We also evaluated the heart rhythm coherence (HRC). The alternation
of HRC was very similar during MBSM and PMR. The results show that
both relaxation techniques significantly (p<0.05) increased the HRC. The
higher heart-rhythm coherence (HRC) is associated with a better, calmer
functioning of the heart [147]. There was a significant improvement in heart
function during both our studied relaxation techniques. Despite the small
changes of the Furje spectrum in all frequency bands, HRC revealed more
clearly the positive effect of these impact methods.
Coherence is a very beneficial mode which leads to a resetting of
baroreceptor sensitivity; increased vagal afferent
 traffic; increased cardiac
output in conjunction with increased efficiency in fluid exchange, filtration,
and absorption between the capillaries and tissues; increased ability of the
cardiovascular system to adapt to circulatory requirements; and increased
temporal synchronization of cells throughout the body. This results in
increased system-wide energy efficiency and metabolic energy savings
[147]. HLC may be especially useful in follow-up HRC studies because of
its high reproducibility.
The spectrum of JT interval variability alternated similarly to RR
variability in all frequency bands during both sessions. However if an
increase in the RR spectrum during a relaxation is accepted to be evaluated
positively, then here, the decrease of DJT variability can be associated with
the better state of the system (more stable metabolism during the
relaxation). DJT variability shows that MBSM is even superior to PMR.
Variability of DJT decreased in all frequency bands during both relaxation
techniques, but the change was statistically significant only after MBSM
108
(p<0.05). DJT variability differed between the techniques: during all stages
of the session the variability spectrum was greater during MBSM than
during PMR (p<0.05).
Increased beat-to-beat DQRS variability has been suggested as a
possible marker for myocardial ischemia and infarction [181]. It is believed
that the subtle variations may reflect islets of ischemic tissue, variations in
sympathetic tone, coronary flow, or myocardial contraction pattern [211].
Connective tissue among myocardial fibers can also possibly influence the
electrical activation path from beat to beat. Ben-Haim and co-workers
investigated morphologic beat-to-beat variability in patients with healed
myocardial infarction, using an orthogonal lead configuration [17]. It was
found that patients with healed myocardial infarction had an increased
DQRS variability compared with the control subjects. In our study DQRS
variability spectrum decreased insignificantly after both relaxation
techniques. DQRS variability was also greater in all frequency bands during
all stages of MBSM compared with during PMR. The variability of DJT and
DQRS in all frequency bands was greater during MBSM, most likely due to
stress when the patient is confronted with an unknown situation. Probably
on the second day the studied were calmer psychologically and the
variability of the mentioned parameters was smaller.
After performing the techniques there was a tendency of decrease in
variability of DJT and DQRS in all frequency bands. The short-term effect
reached during the first technique continued to the next day. During PMR it
decreased even more. The same tendency is observed in all components of
both parameters. It was the opposite with HRV – there was an increase in
VLF, which shows the function of the blood-vessels, and in total HRV.
Total HRV increased due to a rise in VLF. There is a totally different
reorganization in the heart (reflects DJT and DQRS) than in the systemic
level of human organism (reflects HRV).
There was an interesting pattern of R amplitude variability. During
PMR, while isometrically contracting the muscle groups, there is an obvious
intensification of the respiration that is seen in VLF and LF bands in stage
B3. In the area of these frequency bands there is a respiratory rate (approx.
6–20 t/min or 0,1–0,3 Hz). It was not apparent during MBSM. The
influence of this frequency is seen in almost all parameters in stage B3
during PMR. Although correlation showed a weak or no relation between
AR and other parameters, analysis of variability showed the significant
influence of the alternation of respiration (AR), especially in stage B3
during PMR (RR; DJT; DQRS; AT and AST). During supine rest AR
variability was higher in all frequency bands before performing MBSM than
before PMR. The alternation was greater during PMR, but at the end of
109
MBSM it was higher again compared to during PMR (p<0.05). Only the HF
band of AR variability decreased significantly after both relaxation
techniques.
The resting AT variability was the same before both techniques, but
there was a big increase and then decrease during PMR. LF, HF and total
AT variability were lower after PMR compared to the resting time. After
MBSM the changes of AT variability in all frequency bands were
insignificant.
The variability of AST was greater in all frequency bands during
MBSM compared to during PMR (p<0.05). VLF was insignificantly lower
after both techniques. LF, HF and total AST variability decreased after PMR
(p<0.05), but did not change after MBSM.
All frequency bands of AR and AST had lower values in the beginning
stage of PMR than in MBSM, similar to DJT and DQRS.
The alternation of heart complexity during the relaxation techniques
The heart is not a periodic oscillator under normal physiological
conditions and standard linear measures may not be able to detect subtle, but
important changes in heart signals’ time series. Therefore we used the
physiological model-based analysis of the human body’s functional state
combined with an application of the mathematical method based on matrix
theory for the ECG signals analysis. In the present study a co-integration
method (second-order matrix analysis) was applied, which highlights the
body's internal processes and their variations more than the widely used
correlation method [163]. We calculated the discriminant, the value of
which indicates the value of complexity. The greater the complexity, the
lower the conjunction between parameters. Conversely, when a complexity
decreases, the conjunction between the parameters increases, decreasing
their individual informativeness, and the parameters become more
interdependent.
Physiological impairments may accumulate over time as a consequence
of clinical and subclinical diseases, adverse exposures (e.g., health habits,
environment), genetic factors, and the ill-defined aging process.
Accumulation of physiological impairments may result in deterioration of
complex, dynamic interactions across multiple regulatory systems that finetune homeostatic adaptive responses to stressors. Conceptually,
deterioration of this complex network of interacting physiological signals,
which can be thought of as a reduction in “physiological complexity,” may
compromise the capacity to mount compensatory physiological adaptations
in response to stressors and lead to greater clinical vulnerability — or frailty
state—in older adults, but empirical data characterizing the direct
110
relationship between “physiological complexity” and frailty state in older
adults remain scarce. Recent advances in frailty measurement and the
development of measures that, albeit indirectly, may be used to quantify
“physiological complexity” now offer an opportunity to examine such a
relationship [52].
In the present study new methods of analysis broaden the assessment
possibilities of the human functional state. In order to compare the
alternation of heart complexity during different relaxation techniques we
evaluated the conjunction of ECG parameters – RR and JT, JT and DQRS.
The conjunction of inter-parametric variables of a complex system causes an
integration considering their time and space characteristic into an organized
whole [239]. There have already been presented some studies investigating
the conjunction of ECG parameters by applying algebraic methods of data
co-integration [163, 24, 239].
Considering the body’s general functional state and its adaptability, a
complex model allows the evaluation of its integrity and reflects the main
functional interactions. Cardiovascular signals are largely analyzed using
traditional time and frequency domain measures, but these measures fail to
indicate the dynamics of inter-parametric conjunction which is related to
multiscale organization and nonequilibrium dynamics [239]. Consequently
the collection and analysis of ECG data in the present research provides
additional insights regarding the performance of the body as a complex
system during relaxation sessions, and also enables analysis of interparametric conjunction.
The human body is a complex system described as an alternating,
independent system, which comprises many elements. The nonlinear
interaction of these elements in the different hierarchical levels as well as
between them represents the whole functioning system. Interactions
between these subsystems determine the function of the whole system [156].
One of the goals of the complex systems study is to analyze and apply the
theory that explains the interaction of the structure and functioning of the
higher level with the components of the lower level [183]. Complexity
profiles provide a possibility to observe the peculiarities of complex system
as well as the scales of fractal level [248]. Having chosen the QRS complex
parameter of the lowest scale (approximately 100 ms), the JT interval
parameter of a higher scale (approximately 300 ms) and the RR interval
parameter as the highest (approximately 1000 ms), we designed the
complexity profiles comparing the JT and QRS, and the JT and RR
conjunction of the parameters that reflected the different fractal levels. The
RR and JT showed systemic changes, while the JT and QRS showed
subsystem changes occurring in the heart [23, 239].
111
The results of our study showed that JT and QRS conjunction of the
parameters was characteristic of a greater complexity than the RR and JT
conjunction during both sessions. The discriminants of the JT and QRS
conjunction were greater than those of RR and JT. The value of complexity
profile analogous to heart rhythm coherence also showed rising complexity
of heart function i.e. the better functional state at the end of both relaxation
techniques.
Alternation of Cardiovascular Indices in patients with and without
anxiety during the two relaxation techniques
Psychosocial factors such as stress, anger, anxiety are associated with an
increased activity of the sympathetic nervous system, and decreased activity
of the parasympathetic nervous system, with an imbalance of autonomous
heart regulation [100]. We evaluated the alternation of HR, ABP and HRV
in order to determine the differences of MBSM and PMR for patients with
and without anxiety.
HR was higher for the people with anxiety symptoms during the session
with MBSM, although the starting HR was the same in both groups. After
MBSM, HR significantly decreased only for the patients without anxiety
(p<0.05). Before the session with PMR, HR was higher in the anxiety
group, while during PMR the values did not differ between the groups.
There was a tendency of increase after PMR for the patients without
anxiety.
SBP and DBP was higher for the people with anxiety during all stages of
the sessions with MBSM and PMR (p<0.05). SBP decreased in both groups
after MBSM and in the anxiety group after PMR (p<0.05). The alternation
of DBP was different during the two sessions. In both groups DBP was
decreasing consistently from the beginning until the end of the session with
MBSM, but there was a decrease and then a rise during PMR. After MBSM,
DBP decreased in both patient groups, although more for the non-anxiety
group (p<0.05). After PMR, it increased insignificantly in both patient
groups.
We evaluated the alternation of HRV in all frequency bands and HRC in
patients with and without anxiety during MBSM and PMR. VLF increased
during MBSM in both groups (p<0.05).
VLF was higher during all the stages of the session with PMR for the
anxiety group (p<0.05). After PMR it increased insignificantly in the nonanxiety group. LF decreased significantly after MBSM in non-anxiety
group, and decreased after PMR in anxiety group. HF decreased for the
anxiety group after MBSM, but did not change after PMR in either group.
Total HRV increased in the non-anxiety group after MBSM and in the
112
anxiety group after PMR. HRC increased in both patient groups after both
relaxation techniques. It is interesting to note that HRC was higher in the
anxiety group.
In summary the patients with anxiety had higher HR, SBP and DBP.
MBSM had a stable reducing effect on these indices, whereas PMR
decreased SBP insignificantly and did not have any effect on HR and DBP.
HRV differed significantly between two groups during both MBSM and
PMR. Especially during PMR session persons with anxiety were
characterized by a bigger Furje spectrum than persons without anxiety.
Comparing the HRC between the groups did not reveal any new
information. After both sessions this index had risen, and this can be
associated with a better functional state after the relaxation techniques.
The alternation of heart complexity in patients with and without
anxiety during the two relaxation techniques
In order to compare the alternation of heart complexity in patients with
and without anxiety we evaluated the conjunction of ECG parameters – RR
and JT, JT and DQRS. The results of our study showed that JT and DQRS
conjunction was characteristic of a greater complexity than the RR and JT
conjunction during both sessions. The discriminants of the JT and QRS
conjunction were greater than that of RR and JT. The discriminant of the
RR and JT conjunction during MBSM was greater in patients without
anxiety. Our results demonstrate that the interactions of the functional
elements and the regulatory mechanisms of the CVS corresponded to the
principles of the theory of complex dynamic systems – when the
conjunction decreased, the complexity increased [248].
The conjunction between DJT and DQRS showed a lower level of
complexity in the anxiety group during both MBSM and PMR. The CoPr of
these conjunctions showed that for the persons without anxiety both
relaxation techniques served equally well (complexity grew at the last
recovery stage). For the patients without anxiety PMR had a better effect.
So this evaluation makes possible a more specific application of the studied
relaxation techniques.
The study determined that the alternation of CVS functional state during
the relaxation techniques depended significantly on the anxiety symptoms.
It was shown that there was a significant difference not only in the change
of distinct CVS functional parameters but also in their conjunction in
persons with anxiety. The study determined that the conjunction of the ECG
parameters reveals new and clinicaly important information, which is not
accessible by analysing the initial ECG signals in the traditional way.
113
Summarizing we can state that classical methods of research provide the
possibility to record the dynamics of physiological parameters. However,
the volume of obtained information and its value significantly depend on the
methods of data analysis. The new methods of data analysis as well as the
new methodology used in this study broaden the possibilities of
physiologists to disclose unrevealed peculiarities of bodily function. We
conclude that the evaluation of the data is difficult due to a lack of similar
studies. However, the results demonstrate that the methods we used are
viable and suitable for revealing new synergic peculiarities of complexity of
body function.
114
CONCLUSIONS
1. The cardiovascular system functional state of the participants improved
during both relaxation techniques:
1.1. Systolic arterial blood pressure decreased after the relaxation
techniques.
1.2. ECG time-parameters (RR, JT intervals and QRS complex duration)
increased.
1.3. ECG amplitude-parameters (amplitudes of R wave, T wave and ST
interval) increased.
2. The two relaxation techniques had a different short-term effect on the
variability of ECG parameters and complexity parameters:
2.1. There was a greater alternation and increase of heart rate variability
(high and very low frequency bands) during Progressive Muscle Relaxation
than during Mindfulness Body Scan Meditation, which indicates enhanced
autonomic nervous system tone. Heart rhythm coherence increased during
both relaxation techniques, which shows an improvement in heart function.
2.2. The greater decrease of DJT variability after Mindfulness Body Scan
Meditation than after Progressive Muscle Relaxation shows the better
functional state of cardiovascular system. Greater AR variability during
Progressive Muscle Relaxation indicates the intensification of the
respiration, which influenced the variability of other parameters. A
decrease in T wave and ST amplitude variability after Progressive Muscle
Relaxation shows the better functional state of the cardiovascular system.
2.3. The alternation of conjunctions of ECG parameters (RR;JT and
JT;QRS) depended on which relaxation technique was performed: the
decreasing conjunctions during Mindfulness Body Scan Meditation revealed
greater complexity and thus better functional state of the cardiovascular
system than during Progressive Muscle Relaxation.
3. The effect of both relaxation techniques on the cardiovascular system
functional parameters and complexity measures depended on anxiety
symptoms:
3.1. In patients with anxiety systolic arterial blood pressure decreased
during both relaxation techniques. In patients without anxiety this index
decreased only during Mindfulness Body Scan Meditation. Diastolic arterial
blood pressure decreased only during Mindfulness Body Scan Meditation
(in both patient groups).
115
3.2. The increase of heart rate variability was greater in patients without
anxiety during Mindfulness Body Scan Meditation. In patients with anxiety
this index was greater during Progressive Muscle Relaxation.
3.3. The presence of anxiety has a significant impact on the conjunctions of
ECG parameters (RR;JT and JT;QRS): decreasing conjunctions during the
relaxation in people without anxiety reveal greater complexity, and thus
better functional state of the cardiovascular system. In the patients with
anxiety the conjunctions during the relaxation were higher, the complexity
was lower and thus the functional state of the cardiovascular system was
worse.
116
PRACTICAL RECOMMENDATIONS AND GUIDELINES
FOR FUTURE STUDIES
For post-MI men with anxiety symptoms it would be advisable to
practise PMR. For post-MI men without anxiety symptoms it would be
advisable to practise MBSM.
In clinical uses, medical personnel should provide careful instruction in
the specific steps of the relaxation techniques, and evaluate sensory and
affective responses to the intervention immediately after its use. As with all
interventions, specialists should be aware of the need to tailor or change
treatment plans based on individual patient response. Medical personnel
would be better equipped to help their patients if they had research evidence
about specific relaxation interventions which are effective for specific
patients.
Although the patients can use the audio-recording by themselves, the
MBSM should be guided only by a trained person.
Studies have shown that stress management might reduce future cardiac
events in patients with cardiovascular disease. Unfortunately, the influence
of psychosocial risk factors on cardiovascular disease remains underrecognized compared with traditional cardiac risk factors. Physicians and
their associates should screen for psychosocial stressors and recognize
potential symptoms. Consideration should be given to developing improved
liaison relationships with psychological or behavioral specialists to facilitate
more specialized interventions when appropriate [79].
Although the international scientific literature examines quite extensively
the significance of stress, anxiety and relaxation on cardiovascular patients'
health status and quality of life, there have been only a few studies made in
Lithuania in this area. We hope that the results of this study will encourage
Lithuanian health care professionals to focus more on the importance of
stress prevention and management for cardiovascular patients.
Further studies are needed to research the long-term effects of the
relaxation techniques. Research with larger sample size would be also
beneficial.
117
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Abbey S, Stewart DE. Gender and psychosomatic aspects of ischemic
heart disease. J Psychosom Res 2000;48:417–23.
Abildstrom SZ, Jensen BT, Agner E, Torp-Pedersen C, Nyvad O, et al.
Heart rate versus heart rate variability in risk prediction after
myocardial infarction. J Cardiovasc Electrophysiol 2003; 14(2):168–
173.
Allison TG, Williams DE, Miller TD et al. Medical and economic
costs of psychologic distress in patients with coronary artery disease.
Mayo Clin Proc 1995;70(8):734–742.
Alonzo AA. Acute myocardial infarction and posttraumatic stress
disorder: the consequences of cumulative adversity. J Cardiovasc Nurs
1999;13:33–45.
American Heart Association. Heart and Stroke Statistical Update.
Dallas, TX: American Heart Association; 2002.
Anda R, Williamson D, Jones D, Macera C, Eaker E, et al. Depressed
affect, hopelessness, and the risk of ischemic heart disease in a cohort
of US adults. Epidemiology 1993;4:285–294.
Aubert AE, Vandeput S, Beckers F et al. Complexity of cardiovascular
regulation in small animals Phil. Trans. R. Soc. A 2009; 367:1239–
1250.
Ay F, Alpar SE. Approaches taken by nurses in treating postoperative
pain. Agri 2010; 22(1):21–9.
Barefoot JC, Helms MJ, Mark DB, Blumenthal JA, Califf RM, Haney
TL et al. Depression and long-term mortality risk in patients with
coronary artery disease. Am J Cardiol 1996;78: 613–7.
Barlow DH. Anxiety and Its Disorders. New York: The Guilford
Press; 1988.
Barnes VA, Treiber FA, Davis H. Impact of Transcendental
Meditation on cardiovascular function at rest and during acute stress in
adolescents with high normal blood pressure. J Psychosom Res
2001;51:597–605.
Barnes VA, Treiber FA, Johnson MH: Impact of transcendental
meditation on ambulatory blood pressure in African-American
adolescents. AJH 2004:17:366–369.
Barton K.A., Blanchard E.B. The Failure of Intensive Self-Regulatory
Treatment With Chronic Daily Headache: A Prospective Study. AAPB
2001;26(4):311–318.
118
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Bastani F, Hidarnia A, Kazemnejad A, Vafaei M, Kashanian M. A
randomized controlled trial of the effects of applied relaxation training
on reducing anxiety and perceived stress in pregnant women. J
Midwifery Womens Health 2005; 50:36–40.
Batzel J, Baselli G, Mukkamala R, Chon KH. Modelling and
disentangling physiological mechanisms: line ar and nonlinear
identification techniques for analysis of cardiovascular regulation.
Phil. Trans. R. Soc. A 2009;367:1377–1391.
Batzel JJ, Kappel F., Schneditz D., Tran H.T. Cardiovascular and
Respiratory Systems Modeling, Analysis, and Control. Philadelphia:
Society for Industrial and Applied Mathematics; 2007. p. 105–119.
Ben-Haim SA, Becker B, Edoute Y, et al. Beat-to-beat
electrocardiographic morphology variation in healed myocardial
infarction. Am J Cardiol 1991;68:725.
Bennett P, Owen RL, Koutsakis S, et al. Personality, social context
and cognitive predictors of posttraumatic stress disorder in myocardial
infarction patients. Psychology Health 2002;17:489–500.
Benson H & Klipper MZ. The relaxation response: Updated and
expanded. New York: Harper Collins; 2000.
Benson H, Frankel FH, Apfel R, et al. Treatment of anxiety: a
comparison of the usefulness of self-hypnosis and a meditational
relaxation technique. Another view. Psychother Psychosom
1978;30:229–42.
Benson H. The Relaxation Response. New York: William Morrow;
1975.
Bernardi L, Sleight P, Bandinelli G, et al. Effect of rosary prayer and
yoga mantras on autonomic cardiovascular rhythms: Comparative
study. BMJ 2001;323:1446–1449.
Berškienė K, Lukoševičius A, Jaruševičius G, Jurkonis V, Navickas Z,
Vainoras A, Daunoravičienė A. Anglysis of dynamical interrelations
of electrocardiogram parameters. Electronics and Electrical
Engineering 2009; 7(95):95–98.
Berškienė K. The analysis of dynamic interrelationships of
electrocardiografic signal parameters. Doctoral Dissertation; Kaunas
2010.
Berskiene K., Lukosevicius A., Navickas Z., Vainoras A.. Modeling of
Long Lasting Functional State of Healthiness Dynamics. Electronics
and Electronical Engineering 2006;7(71):73–76.
Bieliauskaite I, Jarasiunaite G. Physiological changes during
progressive muscle and biofeedback relaxation methods (Pilot
119
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
research) International Journal of Psychology: a Biopsychosocial
Approach 2009; 4:119–134.
Bieliauskaite I, Perminas A., Jasulaitis M., Neverauskas J.
Psichofiziologinių pokyčių, taikant biogrįžtamojo ryšio relaksacijos
užsiėmimus, įvertinimas. Biologine psichiatrija ir psichofarmakologija
2009;11(2):73–78.
Bieliauskas LA. Stress and its relationship to health and illness.
Boulder: Westview Press, 1982:65–79.
Bishop SR. What do we really know about mindfulness-based stress
reduction? Psychosom Med. 2002;64:71–83.
Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the
Hospital Anxiety and Depression Scale. An updated literature review.
J Psychosom Res 2003; 52:69–77.
Blanchard EB, McCoy GC, Wittrock D, Musso A, Gerardi RJ,
Pangburn L. A controlled comparison of thermal biofeedback and
relaxation training in the treatment of essential hypertension: II.
Effects on cardiovascular reactivity. Health Psychol 1988;7:19–33.
Blumenthal J, Sherwood A, Babyak M, et al. Effects of exercise and
stress management training on markers of cardiovascular risk in
patients with ischemic heart disease: a randomized controlled trial.
JAMA 2005;293:1626–34.
Blumenthal JA, Jiang W, Reese J, Frid DJ, Waugh R, et al. Mental
stress-induced ischemia in the laboratory and ambulatory ischemia
during daily life: association and hemodynamic features.
Circulation1995;92:2102–2108.
Boguzienė J. Links between emotional state and stress coping
strategies among patients with cardiovascular diseases with and
without surgery interventions: Master work of psychology. The
University of Vytautas the Great. Faculty of social sciences.
Department of theoretical psychology. – Kaunas, 2008 [Manuscript].
Bradt J, Dileo C. Music for stress and anxiety reduction in coronary
heart
disease
patients.
Cochrane
Database
Syst
Rev.
2009;15;(2):CD006577.
Brožaitienė J., Juškėnas J., Abelkienė I. Psichoemocinės būklės įtaka
miokardo infarktą patyrusių ligonių fizinių treniruočių poveikio
prognozei.
Biologinė
psichiatrija
ir
psichofarmakologija
2008;10(1):17–20.
Bunevičius R, Žilėnienė S. Palyginamasis MMPI ir HAD skalių
įvertinimas. Lietuvos aukštųjų mokyklų mokslo darbai: Psichologija
1991;1:41–45.
120
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Buselli EF, Stuart EM. Influence of Psychosocial Factors and
Biopsychosocial Interventions on Outcomes after Myocardial
Infarction. The Journal of Cardiovascular Nursing 1999;13(3):60–72.
Būta A, Stankus A, Žukauskas A.. Širdies ritmo variabilumas
relaksacijos su valdomu kvėpavimu metu. Lietuvos medicina 1996;
46–57.
Būta A. Psichologinis sessionavimas ir reabilitacija. Sveikata 2002;
9:32–33.
Calderon KS, Thompson WW. Biofeedback relaxation training: A
rediscovered Mind-Body tool in Public Health. AJHS 2004;
19(4):185–194.
Campbell N, Grimshaw J, Rawles J, Ritchie L: Cardiac rehabilitation
in Scotland: is current provision satisfactory? J Public Health Med
1996;18:478–480.
Campbell N, Grimshaw J, Ritchie L, Rawles J: Outpatient cardiac
rehabilitation: are the potential benefits being realised? JR Coll
Physicians Lond 1996;30:514–519.
Carlson CR, Hoyle RH. Efficacy of Abbreviated Progressive Muscle
Relaxation. a quantitative review of behavioral medicine research. J
Consult Clin Psychol 1993, 61(6):1059–1067.
Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress
reduction in relation to quality of life, mood, symptoms of stress, and
immune parameters in breast and prostate cancer outpatients.
Psychosom Med 2003;65:571–81.
Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress
reduction in relation to quality of life, mood, symptoms of stress and
levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and
melatonin
in
breast
and
prostate
cancer
outpatients.
Psychoneuroendocrinology 2004;29:448–474.
Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of
a mindfulness meditation-based stress reduction program on mood and
symptoms of stress in cancer outpatients: 6-month follow-up. Support
Care Cancer 2001; 9(2):112–23.
Carney RM, Rich MW, Freedland KE, Saini J. Major depressive
disorders predicts cardiac events in patients with coronary artery
disease. Psychosom Med 1988;50:627–633.
Carney RM, Saunders RD, Freedland KE, Stein P, Rich MW, Jaffe
AS. ().Association of depression with reduced heart rate variability in
coronary artery disease. AJC 1995;76(8):562–564.
Castillo-Richmond A, Schneider RH, Alexander CN, Cook R, Myers
H, Nidich S et al. Effects of Stress Reduction on Carotid
121
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
Atherosclerosis in Hypertensive African Americans. Stroke 2000;
31(3):568–73.
Cerutti S, Hoyer D, Voss A. Multiscale, multiorgan and multivariate
complexity analyses of cardiovascular regulation. Phil. Trans. R. Soc.
A 2009;367:1337–1358.
Chaves PH, Varadhan R, Lipsitz LA, Stein PK, Windham BG, Tian J,
et al. Physiological Complexity Underlying Heart Rate Dynamics and
Frailty State in Community-Dwelling Older Women J Am Geriatr Soc
2008; 56(9):1698–703.
Cherrington CC, Moser DK, Lennie TA. The physiological response
in patients with acute myocardial infarction to the administration of
psychological instruments. Biol Res Nurs 2002;4(2):85–91.
Cheung UL, Molassiotis A, Chang AM. The effect of progressive
muscular relaxation on anxiety and quality of life after stoma surgery
in colorectal cancer patients. Psychooncology 2003;12:254–66.
Cole PA, Pomerleau CS, Harris JK. The effects of noncurrent and
concurrent relaxation training on cardiovascular reactivity to a
psychological stressor. J Behav Med 1992;15:407–14.
Collins JA, Rice V.H. Effects of relaxation intervention in phase II
cardiac rehabilitation: replication and extension. Heart Lung
1997;26:31–44.
Cooper S, Oborne J, Newton S, et al. Effect of two breathing exercises
(Buteyko and pranayama) in asthma: a randomised controlled trial.
Thorax 2003;58(8):674–9.
Coryell W, Noyes R, and Clancy J. Excess mortality in panic disorder.
Arch. Gen. Psychiatry 1982;39:701–703.
Curtis BM, O’Keefe JH. Autonomic Tone as a Cardiovascular Risk
Factor: The Dangers of Chronic Fight or Flight. Mayo Clin Proc
2002;77:45–54.
Cusumano, J.A., Robinson, S.E. The Short-term Psychophysiological
Effects of Hatha Yoga and Progressive Relaxation on Female Japanese
Students. Applied Psychology 1993; 42(1):77–90.
Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D,
Santorelli S.F, et al. Changes in brain and immune function produced
by mindfulness meditation. Psychosom Med 2003; 65(4):564–570.
Davison GC, Williams ME, Nezami E, Bice TL, DeQuattro VL.
Relaxation, reduction in angry articulated thoughts, and improvements
in borderline hypertension and heart rate. J Behav Med 1991;14:453–
66.
Deaton C, Namasivayam S. Nursing Outcomes in Coronary Heart
Disease. Journal of Cardiovascular Nursing 2004; 19(5):308–31.
122
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
Dehdari T, Heidarnia A,
Ramezankhani A, Sadeghian S,
Ghofranipour F. Effects of progressive muscular relaxation training on
quality of life in anxious patients after coronary artery bypass graft
surgery. Indian J Med Res 2009;129:603–608.
Dekker JM, Schouten EG, Klootwijk P, et al.. Heart rate variability
from short electrocardiograph recordings predicts mortality from all
causes in middle-aged and elderly men. The Zutphen study. Am J
Epidemiol 1997;145:899–908.
Dimsdale J, Mills P. An unanticipated effect of meditation on
cardiovascular pharmacology and physiology. Am J Cardiol
2002;90:908–9.
Dimsdale JE, Hackett TP. Effect of denial on cardiac health and
psychological assessment. Am J Psychiatry 1982;139:1477–80.
Dimsdale JE. Psychological Stress and Cardiovascular Disease. J Am
Coll Cardiol 2008; 51(13):1237–1246.
Ditto B, Eclache M, Goldman N. Short-Term Autonomic and
Cardiovascular Effects of Mindfulness Body Scan Meditation. Ann
Behav Med. 2006; 32(3):227–34.
Dixhoorn JV, White A. Relaxation therapy for rehabilitation and
prevention in ischemic heart disease: a systematic review and metaanalysis. Eur J Cardiovasc Prev Rehabil 2005;12:193–202.
Dixhoorn VJ, Duivenvoorden HJ, Pool J, Verhage F. Psychic effects
of physical training and relaxation therapy after myocardial infarction.
Journal of psychosomatic research 1990; 34(3):327–37.
Dixhoorn VJ, Duivenvoorden HJ, Staal JA. et al. Cardiac events after
myocardial infarction: Possible effect of relaxation therapy. Eur Heart
J 1987;8(11):1210–1214.
Dixhoorn VJ. Implementation of relaxation therapy within a cardiac
rehabilitation setting. In: Kenny DT, Carlson JG, editors. Stress and
health: Research and Clinical Application. Amsterdam Harwood
Academic, 2000; 355–73.
Dossey BM, Keegan L, Guzzetta CE, Kolkmeirer LG. Holistic
Nursing: A Hand-book for Practice. 2nd ed. Gaithersburg, MD: Aspen
Publishers; 1995.
Dossey BM. Core Curriculum for Holistic Nursing. Gaithersburg,
MD: Aspen Publishers; 1997.
Drory Y, Shapira I, Fisman EZ, Pines A. (). Myocardial ischemia
during sexual activity in patients with coronary artery disease. AJC
1995;75(12):835–837.
Effat MA. Pathophysiology of ischemic heart disease: an overview.
AACN Clin Issues 1995; 6(3):369–74.
123
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
Fahrion SL. Thermal biofeedback and self-regulation of blood
pressure. In: Craig KD, Weiss SM, eds. Health enhancement, disease
prevention, and early intervention: biobehavioral perspectives. New
York: Springer; 1990. p. 147–67.
Figueredo VM. The time has come for physicians to take notice: the
impact of psychosocial stressors on the heart. Am J Med
2009;122(8):704–12.
Fillingham RB, Blumenthal JA. The use of aerobic exercise as a
method of stress management. In: Lehrer PM, Woolfolk RL, eds.
Principles and practice of stress management. 2nd ed. New York:
Guilford Press; 1993. p. 443–462.
Frasure-Smith N, Lesperance F, Juneau M, Talajic M, Bourassa MG.
Gender, depression, and one-year prognosis after myocardial
infarction. Psychosom Med 1999;61(1):26–37.
Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month
prognosis after myocardial infarction. Circulation 1995;91:999–1005.
Frasure-Smith N, Lesperance F, Talajic M. Depression following
myocardial infarction: impact on 6-month survival. JAMA
1993;270:1819–1825.
Frasure-Smith N, Lesperance F, Talajic M. The impact of negative
emotions on prognosis following myocardial infarction: Is it more than
just depression? Health Psychology 1995; 14(5):388–398.
Frasure-Smith N. In-hospital symptoms of psychological stress as
predictors of long-term outcome after acute myocardial infarction in
men. Am J Cardiol 1991;67:121–7.
Fredrickson BL. Positive emotions. In: Snyder CR, Lopez SJ, eds.
Handbook of Positive Psychology. New York: Oxford University
Press; 2002. p. 120–134.
Gabbay FH, Krantz DS, Kop WJ, Hedges SM, Klein J, et al. Triggers
of myocardial ischemia during daily life in patients with coronary
artery disease: physical and mental activities, anger, and smoking.
JACC 1996;27(3):585–592.
Gelzinienė V, Duonelienė I, Alonderis A. Depresijos įtaka sergančiųjų
koronarine širdies liga širdies ritmo variabilumui. Biologine
psichiatrija ir psichofarmakologija 2007; 9(2):47–50.
Ginzburg K, Solomon Z, Koifman B, et al. Trajectories of
posttraumatic stress disorder following myocardial infarction: a
prospective study. J Clin Psychiatry 2003;64:1217–1223.
Glassman AH, Shapiro PA. Depression and the course of coronary
artery disease. AJP 1998; 155:4–11.
124
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
Goštautas A, Gustainienė L, Perminas A, ir kt. Kraujospūdžio kitimai
taikant ankstyvosios psichologinės reabilitacijos priemones stacionaro
sąlygomis. Medicinos teorija ir praktika 2002; 31( 3):188–192.
Gottdiener JS, Krantz DS, Howell RH, Hecht GM, Klein J, et al.
Induction of myocardial ischemia with mental stress testing:
relationship to the triggers of ischemia during daily life activities and
to ischemic functional severity. JACC 1994;24:1645–1651.
Gross CR, Kreitzer MJ, Russas V, Treesak C, Frazier PA, Hertz MI.
Mindfulness meditation to reduce symptoms after organ transplant: a
pilot study. Adv Mind Body Med 2004;20:20–9.
Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness based
stress reduction and health benefits: a meta-analysis. J Psychosom Res
2004; 57:35–43.
Gullette EC, Blumenthal JA, Babyak M, Jiang W, Waugh RA, et al.
Effects of mental stress on myocardial ischemia during daily life.
JAMA 1997; 277(19):1521–1526.
Gustainienė L. Gyvenimo stilius ir psichologinių-pedagoginių metodų
efektyvumas padidėjusiam kraujo spaudimui mažinti gyventojų
grupėse. Daktaro disertacijos santraukos tezės, Kauno Technologijos
universitetas, 1995. Kaunas.
Guyton AC. Textbook of medical physiology. Philadelphia: W.B.
Saunders Company; 1991.
Halm M.A. Relaxation: A Self-Care Healing Modality Reduces
Harmful Effects of Anxiety. Am J Crit Care 2009;18(2):169–172.
Hanssena TA, Nordrehaugb JE, Eidea GE. et al. Anxiety and
depression after acute myocardial infarction: an 18-month follow-up
study with repeated measures and comparison with a reference
population. Eur J Cardiovasc Prev Rehabil 2009;16:651–659.
Harris KF, Matthews KA. Interactions between autonomic nervous
system activity and endothelial function: a model for the development
of cardiovascular disease. Psychosom Med 2004;66:153–164.
Hawkins SR, Hart DA. The Use of Thermal Biofeedback in the
Treatment of Pain Associated With Endometriosis: Preliminary
Findings. AAPB 2003; 28(4):279–289.
Health of the Lithuanian Population and Activity of Health Care
Institutions, 2008. Lithuanian Health Information Centre, Vilnius
2009. The publication is issued in Lithuanian. Available at:
http://www.lsic.lt/html/en/hlpahci.htm
Huikuri H, Perkiomaki JS, Maestro R, Pinna GD. Clinical impact of
evaluation of cardiovascular control by novel methods of heart rate
dynamics. Phil. Trans. R. Soc. A 2009;367:1223–1238.
125
104. Isen AM. Positive affect. In: Dalgleish T, Power M, eds. Handbook of
Cognition and Emotion. New York: John Wiley & Sons; 1999. p. 522–
539.
105. Jacobs GD. The physiology of mind-body interactions: The stress
response and the relaxation response. Journal of Alternative &
Complementary Medicine 2001;7(1):583–592.
106. Jacobson E. Progressive Relaxation: A Physiological and Clinical
Investigation of Muscular States and Their Significance in Psychology
and Medical Practice, 3rd ed. University of Chicago Press; 1974.
107. Jain S, Shapiro SL, Swanick S, et al. A randomized controlled trial of
mindfulness meditation versus relaxation training: effects on distress,
positive states of mind, rumination, and distraction. Annals Behav
Med. 2007; 33:11–21.
108. Januzzi JL, Stern TA, Pasternak RC, Desanctis RW. The influence of
anxiety and depression on outcomes of patients with coronary artery
disease. Arch Intern Med 2000;160:1913–21.
109. Jevning R, Wallace RK, Beidebach M. The physiology of meditation:
A review. A wakeful hypometabolic integrated response. Neurosci
Biobehav Rev 1992;16:415–424.
110. Jiang W, Babyak M, Krantz DS, Waugh RA, Coleman RE, et al.
Mental stress induced myocardial ischemia and cardiac events. JAMA
1996; 275(21):1651–1656.
111. Jolliffe J, Rees K, Taylor R, Thompson D, Oldridge N, Ebrahim S.
Exercise-based rehabilitation for coronary heart disease (Cochrane
review). In: Cochrane Library, issue 4. Oxford: Update software;
2000.
112. Kabat-Zinn J, Lipworth L, Burney R, Sellers W. Four year follow-up
of a meditation-based program for the self-regulation of chronic pain:
treatment outcomes and compliance. Clin J Pain 1987;2:159–73.
113. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness
meditation for the self-regulation of chronic pain. J Behav Med
1985;8(2):163–190.
114. Kabat-Zinn J, Massion AO, Kristeller J, Peterson L.G., Fletcher K.E.,
Pbert L., et al. Effectiveness of a meditation-based stress reduction
program in the treatment of anxiety disorders. Am J Psychiatry 1992;
149(7):936–43.
115. Kabat-Zinn J, Massion AO, Kristeller J, Peterson LJ, Fletcher KE,
Pbert L, et al. Effectiveness of a meditation-based stress reduction
program in the treatment of anxiety disorders. Am J Psychiatr 1992;
149: 936–943.
126
116. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your
Body and Mind to Face Stress, Pain, and Illness. New York:
Delacourt; 1990.
117. Kabat-Zinn J. Mindfulness-based interventions in context: past,
present, and future. Clin Psychol Sci Pract 2003; 10:144–56.
118. Kajėnienė A. Krepšininkų ir futbolininkų atsigavimo po dozuoto fizinio krūvio vertinimas naudojant integralųjį modelį. Daktaro disertacija. Kaunas: KMU, 2008.
119. Kamarck T, Jennings JR. Biobehavioral factors in sudden death.
Psychol Bull 1999; 109:42–75.
120. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a
meditation-based stress reduction program on fibromyalgia. Gen Hosp
Psychiatry 1993; 15(5):284–89.
121. Kappes BM. Sequence effects of relaxation training, EMG and
temperature biofeedback on anxiety symptom report, and self-concept.
Journal of Clinical Psychology 1983;39(2):203–208.
122. Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, et al.
Prospective study of phobic anxiety and risk of coronary heart disease
in men. Circulation1994;89:1992–1997.
123. Kawachi I, Sparrow D, Vokonas PS, Weiss St. Symptoms of anxiety
and risk of coronary artery disease: The normative aging study.
Circulation 1994; 90:2225–2229.
124. Khanna A, Paul M, Sandhu JS. Efficacy of two relaxation techniques
in reducing pulse rate among highly stressed females. Calicut Medical
Journal 2007; 5(2):23–25.
125. Kop WJ, Ader DN. Assessment and treatment of depression in
coronary artery disease patients. Italian Heart Journal 2001;2(12):890–
894.
126. Kop WJ. Chronic and acute psychological risk factors for clinical
manifestations of coronary artery disease. Psychosom Med 1999;
62:476–487.
127. Krantz DS, Kop WJ, Santiago HT, Gottdiener JS. Mental stress as a
trigger of myocardial ischemia and infarction. Cardiology Clinics
1996;14(2):271–286.
128. Kreitzer MJ, Gross CR, Ye X, Russas V, Treesak C. Longitudinal
impact of mindfulness meditation on illness burden in solid-organ
transplant recipients. Prog Transplant 2005;15:166–72.
129. Kristeller JL. Mindfulness Meditation In P. Lehrer, R.L. Woolfolk &
W.E. Sime. Principles and Practice of Stress Management. 3rd
Edition. New York: Guilford Press; 2007. p. 393–427.
127
130. Kroger WS. Clinical and experimental hypnosis. In: Levy JK.
Standard and Alternative Adjunctive Treatments in Cardiac
Rehabilitation; 2nd ed. Philadelphia: JB Lippincott; 1977. p. 191–211.
131. Kubota Y, Sato W, Toichi M, Okada T, Hayashi A et al. Frontal
midline theta rhythm is correlated with cardiac autonomic activities
during the performance of an attention demanding meditation
procedure. Cogn Brain Res 2001;11:281–287.
132. Kukanova B, Mravec B. Complex intracardiac nervous system. Bratisl
Lek Listy 2006;107(3):45–51.
133. Kwekkeboom K L, Gretarsdottir E. Systematic Review of Relaxation
Interventions for Pain. J of Nurs Scolar 2006;38:3:269–277.
134. Lazar SW, Bush G, Gollub RL, Fricchione GL, Khalsa G, Benson H.
Functional brain mapping of the relaxation response and meditation.
NeuroReport 2000; 11(7):1581–1585.
135. Lee MS, Kim BG, Huh HJ, et al. Effect of Qi-training on blood
pressure, heart rate and respiration rate. Clinical Physiology
2000;20:173–176.
136. Lehrer P, Sasaki Y, Saito Y. Zazen and cardiac variability. Psychosom
Med 1999;61:812–821.
137. Lehrer PM, Vaschillo E, Vaschillo B, Lu SE, Eckberg DL., Edelberg
R., et al. Heart rate variability biofeedback increases baroreflex gain
and peak expiratory flow. Psychosom Med 2003;65(5):796–805.
138. Leonaite A., Vainoras A. Heart rate variability during three relaxation
techniques: a pilot study. Sporto mokslas. 2010, 2.
139. Linden W, Moseley JV. The efficacy of behavioral treatments for
hypertension. Appl Psychophysiol Biofeedback 2006;31:51–63.
140. Linden W, Stossel C, Maurice J. Psychosocial Interventions for
Patients With Coronary Artery Disease. A Meta-analysis. Arch Intern
Med 1996;156(7):745–752.
141. Lohaus A, Klein-Heßling J. Relaxation in Children: Effects of
Extenden and Intensified Training. Psychology and Health 2003;18(
2):237–249.
142. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA
2008;300:1350–1352.
143. Ma SH, Teasdale J.D. Mindfulness-based cognitive therapy for
depression: replication and exploration of differential relapse
prevention effects. J Consult Clin Psychol 2004;72(1):31–40.
144. Mandle CL, Jacobs SC, Arcari PM, Domar AD. The efficacy of
relaxation response interventions with adult patients: a review of the
literature. J Cardiovasc Nurs 1996; 10(3):4–26.
128
145. McCaffery M, Pasero C. Pain: Clinical manual for nursing practice
(2nd ed.). St. Louis, MO: Mosby; 1999.
146. McComb RJJ, Tacon A, Randolph P, Caldera Y. A pilot study to
examine the effects of a mindfulness-based stress-reduction and
relaxation program on levels of stress hormones, physical functioning,
and submaximal exercise responses. J Alternative Compl Med 2004;
10:819–827.
147. McCraty R, Atkinson M, Tomasino D, Bradley RT. The Coherent
Heart. Heart–Brain Interactions, Psychophysiological Coherence, and
the Emergence of System-Wide Order. HeartMath Research Center,
Institute of HeartMath; 2006. p. 3–10.
148. McCubbin JA, Wilson JF, Bruehl JF, Ibarra S, Carlson P, et al.
Relaxation Training and Opioid Inhibition of Blood Pressure Response
to Stress. JCCP 1996;64(3):593– 601.
149. McEwen BS. Protective and damaging effects of stress mediators.
NEJM 1998;338:171–179.
150. McGrady A, Davies TC, Wickramasekera I., editors. Handbook of
Mind-Body Medicine for Primary Care. London: Thousand Oaks;
2003. p. 44–47.
151. McGrady A. Effects of group relaxation training and thermal
biofeedback on blood pressure and related physiological and
psychological variables in essential hypertension. Biofeedback Self
Regul 1994;19(1):51–66.
152. Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized,
controlled trial of breath therapy for patients with chronic low-back
pain. Altern Ther Health Med 2005;11(4):44–52.
153. Mendes de Leon CF, Dilillo V, Czajkowski S, Norten J, Schaefer J,
Catellier D, et al. Psychosocial characteristics after acute myocardial
infarction: the ENRICHD pilot study. Enhancing Recovery in
Coronary Heart Disease. J Cardiopulm Rehabil 2001; 21(6):353–62.
154. Miller J, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical
implications of a mindfulness-based stress reduction intervention in
the treatment of anxiety disorders. Gen Hosp Psychiatry 1995;17:192–
200.
155. Mills N, Allen J. Mindfulness of movement as a coping strategy in
multiple sclerosis: a pilot study. Gen Hosp Psychiatry 2000;22:425–
31.
156. Mitchell M, Newman M. Complex systems theory and evolution.
Encyclopedia of Evolution. New York: Oxford University press;2002.
157. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, et
al. Triggering of acute myocardial infarction by heavy exertion:
129
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
protection against triggering by regular exercise. NEJM
1993;329:1677–1683.
Monginaite L. Psychology introduction. Educational book of Vilnius
Gediminas Technical University Department of Philosophy and
Political Science. Vilnius: "Technika"; 2004.
Moser DK, Riegel B, McKinley S, Doering LV, An K, Sheahan S.
Impact of Anxiety and Perceived Control on In-Hospital
Complications After Acute Myocardial Infarction. Psychosom Med
2007; 69(1):10–16.
Muldoon MF, Herbert TB, Patterson SM, Kameneva M, Raible R,
Manuck SB. Effects of acute psychological stress on serum lipid
levels, hemoconcentration, and blood viscosity. Arch Intern Med
1995;155:615–620.
Muller JE, Abela GS, Nesto RW, Tofler GH. Triggers, acute risk
factors, and vulnerable plaques: the lexicon for a new frontier. JACC
1994; 23:809–813.
Muller JE, Tofler GH, Stone PH. Circadian variation and triggers of
onset of acute cardiovascular disease. Circulation 1989;79:733–743.
Muntianaitė-Dulkinienė I, Poškaitis V, Vainoras A, Jurevičius J,
Bikulčienė L, Navickas Z. Cointegration of Different ECG Parametres
for Various Physical Tasks. Electronics and Electrical Engineering
2009; 6(94):77–80.
Muntianaitė-Dulkinienė I. The evaluation of the complexity of
cardiovascular system parameters when performing physical tasks.
Doctoral Dissertation, Kaunas, 2010.
Myers R, Dewar HA. Circumstances surrounding sudden death from
coronary artery disease with coroner’s necropsies. Br Heart J 1975;
37:1133–1143.
Orth-Gomer K, Ahlbom A. Impact of psychological stress on ischemic
heart disease when controlling for conventional risk indicators. J
Human Stress 1980;6(1):7–15
Pagani M, Mazzuero G, Ferrari A, Liberati D, Cerutti S.
Sympathovagal interaction during mental stress. A study using
spectral analysis of heart rate variability in healthy control subjects
and
patients
with
a
prior
myocardial
infarction.
Circulation1991;83:43–45.
Patel C, Marmot MG, Terry DJ, Carruthers M, Hunt B, Patel M. Trial
of relaxation in reducing coronary risk: four year follow up. Br Med J
(Clin Res Ed) 1985;290(6475):1103–6.
Patterson SM, Krantz DS, Gottdiener JS, Hecht G, Vargot S, et al.
Prothrombic effects of mental and cold pressor stress: changes in
130
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
platelet function, blood viscosity, and plasma volume. Psychosom
Med 1995;57:592–599.
Pawlow LA, Jones GE. The Impact of Abbreviated Progressive
Muscle Relaxation on Salivary Cortisol and Salivary Immunoglobulin
A (sIgA). AAPB 2005;30(4):375–387.
Pedersen SS, Middel B, Larsen ML. Posttraumatic stress disorder in
first-time myocardial infarction patients. Heart Lung 2003;32:300–
307.
Pedersen SS, van Domburg RT, Larsen ML. The effect of low social
support on short-term prognosis in patients following a first
myocardial infarction. Scand J Psychol 2004;45:313–8.
Peng CK, Henry IC, Mietus JE, et al. Heart rate dynamics during three
forms of meditation. Int J Cardiol 2004;95:19–27.
Peng CK, Mietus JE, Liu Y, Khalsa G, Douglas PS, Benson H,
Goldberger AL. Exaggerated heart rate oscillations during two
meditation techniques. Int J Cardiol 1999;70(2):101–7.
Perez-De-Albeniz A, Holmes J. Meditation: concepts, effects and uses
in therapy. Int J Psych 2000;(1):49–59.
Petrie A, Sabin C. Medical Statistics at a Glance. Second Edition.
Blackwell Publishing; 2005. P.96–98.
Poderys J. Ištvermę ir greitumą lavinančių sportininkų raumenų kraujotaka ir širdies-kraujagyslių sistemos greitosios ir lėtosios adaptacijos
savybės atliekant fizinius pratimus. Habilitacinis darbas. Kaunas:
KMU, 2000.
Porta A, Rienzo MD, Wessel N, Kurths J. Addressing the complexity
of cardiovascular regulation. Phil. Trans. R. Soc. A 2009;367:1215–
1218.
Poškaitis V. Raumenų, širdies ir kraujagyslių sistemų sinergija fizinių
krūvių metu. Daktaro disertacija. Kaunas: KMU, 2008.
Pradhan EK, Baumgarten M, Langenberg P et al. Effect of
Mindfulness-Based Stress Reduction in Rheumatoid Arthritis Patients
Arthritis & Rheumatism. Arthritis Care Res 2007;57(7):1134–1142.
Prasad K, Gupta MM. Phase-invariant signature algorithm. A
noninvasive technique for early detection and quantification of
ouabain-induced cardiac disorders. Angiology 1979;30:721.
Pratt LA, Ford DE, Crum RM, Armernian HK, Gallo JJ, Eaton WW.
Depression, psychotropic medication, and risk of myocardial
infarction: prospective data from the Baltimore ECA follow-up.
Circulation 1996;94:3123–3129.
Quarteroni A, Fornaggia L, Veneziani A. Complex Systems in
Biomedicine. Springer; 2006.
131
184. Que CL, Kenyon CM, Olivenstein R, Macklem PT, Maksym GN:
Homeokinesis and short-term variability of human airway caliber. J
Appl Physiol 2001;91:1131–1141.
185. Rainforth MV, Schneider RH, Nidich SI, Gaylord-King C, Salerno
JW, Anderson JW. Stress reduction programs in patients with elevated
blood pressure: a systematic review and meta-analysis. Curr Hypertens
Rep 2007; 9(6):520–8.
186. Rausch SM, Gramling SE, Auerbach SM. Effects of a Single Session
of Large-Group Meditation and Progressive Muscle Relaxation
Training on Stress Reduction, Reactivity, and Recovery. IJSM
2006;13(3):273–290.
187. Rees K, Bennett P, West R, Davey Smith G, Ebrahim S. Psychological
interventions for coronary heart disease. Cochrane Database Syst Rev
2004;2.
188. Reibel DK, Greeson JM, Brainard GC, Rosenzweig S. Mindfulnessbased stress reduction and health-related quality of life in a
heterogeneous patient population. Gen Hosp Psychiatry 2001;23:183–
92.
189. Retzlaff B, Bauernschmitt R, Malberg H et al. Depression of
cardiovascular autonomic function is more pronounced after mitral
valve surgery: evidence for direct trauma. Phil. Trans. R. Soc. A
2009;367:1251–1263.
190. Robinson FP, Mathews HL, Witek-Janusek L: Psycho-endocrineimmune response to mindfulness-based stress reductionin individuals
infected
with
the
human immunodeficiency virus: A
quasiexperimental study. J Alternative Compl Med 2003;9:683–694.
191. Rozanski A, Berman DS. Silent myocardial ischemia:
Pathophysiology, frequency of occurrence, and approaches toward
detection. AHJ 1987;114:615–638.
192. Rozanski A, Blumenthal JA, Davidson KW et al. The epidemiology,
pathophysiology and management of psychosocial risk factors in
cardiac practice: the emerging field of behavioral cardiology. J Am
Coll Cardiol 2005;45:637–651.
193. Rozanski A, Blumenthal JA, Kaplan J. Impact of Psychological
Factors on the Pathogenesis of Cardiovascular Disease and
Implications for Therapy. Circulation 1999;99:2192–2217.
194. Sakakibara M, Takeuchi S, Hayano J. Effect of relaxation training on
cardiac parasympathetic tone. Psychophysiology 1994;31(3):223–8.
195. Schmidt RF, Thews G. Human physiology. London;1996.
196. Schmidt T, Wijga A, Von Zur Muhlen A, Brabant G, Wagner TO.
Changes in cardiovascular risk factors and hormones during a
132
197.
198.
199.
200.
201.
202.
203.
204.
205.
206.
207.
208.
comprehensive residential three month kriya yoga training and
vegetarian nutrition. Acta Physiol Scand 1997;640:158–162.
Schneider RH, Alexander CN, Staggers F et al. A randomized
controlled trial of stress reduction in African Americans treated for
hypertension for over one year. Am J Hypertens 2005;18:88–98.
Schneider RH, Alexander CN, Staggers F et al. Long-term effects of
stress reduction on mortality in persons >/=55 years of age with
systemic hypertension. Am J Cardiol 2005;95(9):1060–64.
Seely AJ, Christou NV: Multiple organ dysfunction syndrome:
exploring the paradigm of complex nonlinear systems. Crit Care Med
2000;28:2193–2200.
Seely AJE, Macklem PT. Complex systems and the technology of
variability analysis. Crit Care Med 2004;8:367–384.
Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. Effects
of music therapy on physiological and psychological outcomes for
patients undergoing cardiac surgery. J Cardiovasc Nurs 2006;21:194–
200.
Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based
stress reduction for health care professionals: results from a
randomized trial. Int J Stress Manag 2005;12:164–176.
Shapiro SL, Bootzin RR, Figueredo AJ, Lopez AM, Schwartz GE. The
efficacy of mindfulness-based stress reduction in the treatment of sleep
disturbance in women with breast cancer: an exploratory study. J
Psychosom Res 2003;54:85–91.
Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness based
stress reduction on medical and premedical students. J Behav Med
1998;21:581–599.
Shemesh E, Yehuda R, Milo O, et al. Posttraumatic stress,
nonadherence, and adverse outcome in survivors of a myocardial
infarction. Psychosom Med 2004;66:521–6.
Sheps DS, McMahon RP, Becker L, Carney RM, Freedland KE et al.
Mental stress-induced ischemia and all-cause mortality in patients with
coronary heart disease: results from the Psychophysiological
Investigations of Myocardial Ischemia study. Circulation
2002;105(15):1780–1784.
Sheu S, Irvin BL, Lin HS, Mar CL. Effects of progressive muscle
relaxation on blood pressure and psychosocial state for clients with
essential hypertension in Taiwan. Holist Nurs Pract 2003; 17(1):41–
47.
Šilanskienė A. Žmogaus organizmo funkcinės būklės kitimo ilgalaikių
treniruočių metu vertinimas. Daktaro disertacija. Kaunas: KMU; 2003.
133
209. Šliupaitė A, Navickas Z, Vainoras A. Evaluation of Complexity of
ECG Parameters Using Sample Entropy and Hankel Matrix 09.
Electronics and Electrical Engineering;4(92):107–110.
210. Smith PJ, Blumenthal JA, Babyak MA, Georgiades A, Sherwood A,
Sketch MH Jr et al.Ventricular ectopy: impact of self-reported stress
after myocardial infarction. Am Heart J 2007;153(1):133–139.
211. Sornmo L, Wohlfart B, Berg J, Pahlm O. Beat-to-Beat QRS
Variability in the 12-Lead ECG and the Detection of Coronary Artery
Disease. J Electrocardiol 1998;31(4):336–44.
212. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list
controlled clinical trial: the effect of a mindfulness meditation-based
stress reduction program on mood and symptoms of stress in cancer
outpatients. Psychosom Med 2000;62:613–22.
213. Stankus A, Būta A, Meižienė R, Alonderis A. Multichannel
registration of the heart rate during relaxation training. Heart rate
variability. 2001.
214. Stankus A, Būta A, Meižienė R, Žukauskas A. Relaksacijos su
valdomu kvėpavimu poveikis sergančių išemine širdies liga širdies
ritmo variabiliškumui. Medicina 1995;31(2):161–167.
215. Stankus A, Būta A. An influence of relaxation procedure with
controlled frequency of respiration on heart rate variability. Heart rate
variability, 2001.
216. Stefanovska A. Complex but Not Complicated Cardiovascular and
Brain Interactions. IEEE Eng Med Biol Mag 2007;26:25–29.
217. Stenlund T, Lindström B, Granlund M, Burell G. Cardiac
rehabilitation for the elderly: Qi Gong and group discussions. Eur J
Cardiovasc Prev Rehabil 2005;12(1):5–11.
218. Stetter F, Kupper S. Autogenic training: a meta-analysis of clinical
outcome studies. APPB 2002;27(1):45–98.
219. Stone PH, Krantz DS, McMahon RP. Relationship among mental
stress-induced ischemia and ischemia during daily life and during
exercise: the Psychophysiologic Investigations of Myocardial
Ischemia (PIMI) study. J Am Coll Cardiol 1999;33(6):1476–84.
220. Sturgis LM, Coe WC. Physiological responsiveness during hypnosis.
Int J Clin Exp Hypn 1990;38:196–207.
221. Sundin O, Lisspers J, Hofman Bang C, Nygren L, Ohmen A.
Comparing multifactorial lifestyle interventions and stress
management in coronary risk reduction. Int J Cardiol 2003;10:191–
204.
134
222. Sutherland G, Andersen MB, Morris T. Relaxation and health related
quality of life in multiple sclerosis: the example of autogenic training.
J Behav Med 2005;28:249–56.
223. Tacon AM, McComb J, Caldera Y, Randolph P. Mindfulness
meditation, anxiety reduction, and heart disease: a pilot study. Fam
Commun Health 2003;26:25–33.
224. Takahashi T, Murata T, Hamada T, et al. Changes in EEG and
autonomic nervous activity during meditation and their association
with personality traits. Int J Psychophysiol 2005; 55:199–207.
225. Talbert RL. Ischemic heart disease. In Pharmacotherapy: DiPiro J,
Talbert R, Yee G, Matzke GA. Pathophysiologic Approach. 2008.
p.261–297
226. Tamosiunaite M, Urbonaviciene G, Vainoras A, Gargasas L,
Kaminskienė S, Bluzaite I, Rickli H. Influence of Deep Breathing on
Heart Rate Variability in Patients with Ischemic Heart Disease.
Electronics and Electrical Engineering 2005;3(59):33–36.
227. Taylor-Piliae RE. Tai Chi as an adjunct to cardiac rehabilitation
exercise training. J Cardiopulm Rehabil 2003;23(2):90–96.
228. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM,
Lau MA. Prevention of relapse/recurrence in major depression by
mindfulness-based cognitive therapy. J Consult Clin Psychol
2000;68:615–23.
229. Terathongkum S, Pickler RH. Relationships among heart rate
variability, hypertension, and relaxation techniques. J Vasc Nurs
2004;22(3):78–82.
230. Thompson D, Bowman G, Kitson A, de Bono D, Hopkins A. Cardiac
rehabilitation services in England and Wales: a national survey. Int J
Cardiol 1997;59:299–304.
231. Thompson DR, Lewin RJP. Management of the post-myocardial
infarction patient: rehabilitation and cardiac neurosis. Heart
2000;84:101–105.
232. Todd IC, Wosornu D, Stewart I, Wild T. Cardiac rehabilitation
following myocardial infarction. A practical approach. Sports Med
1992;14:243–59.
233. Travis F, Olson T, Egenes T, Gupta HK. Physiological patterns during
practice of the Transcendental Meditation technique compared with
patterns while reading Sanskrit and a modern language. Int J Neurosci
2001;109:71–80.
234. Tsai SL. Audio-visual relaxation training for anxiety, sleep, and
relaxation among Chinese adults with cardiac disease. Issues Ment
Health Nurs 2004;27:458–68.
135
235. Urbonavičienė G, Gargasas L, Aržanauskiene R, Bertašiene Z,
Tamošiūnaitė M, Blužaitė I. Usefulness of Signal-averaged ECG,
Short-term Heart Rate Variability, QT Interval and T Loop Criteria in
Predicting 2 Years Lethal Outcome after Myocardial Infarction.
Electronics and Electrical Engineering 2006;6(70):29–32.
236. Vainoras A, Daunoravičienė A, Šiupšinskas L, Zaveckas V, Poderys J,
Mauricienė V ir kt. Kineziologija. Kaunas: Vitae Litera; 2005.
237. Vainoras A. Kardiovaskulinė sistema ir sportinė veikla. Kardiovaskulinė sistema ir sportinė veikla. Vilnius; 1996. p. 3–8.
238. Venkatesh S, Raju TR, Shivani Y, Tompkins G, Meti BL. (1997) A
study of structure of phenomenology of consciousness in meditative
and non-meditative states. Indian J Physiol Pharmacol
1997;41(2):149–53.
239. Venskaityte E, Poderys J, Balagué N, Bikulciene L. Assessment of
Dynamics of Conjunction of the parameters during Exercise Sessions.
Electronics and Electrical Engineering 2009;6(94):89–92.
240. Verrier RL, Mittleman MA. Life-threatening consequences of anger in
patients with coronary heart disease. Cardiology Clinics
1996;14(2):289–307.
241. Wainstein C, Amed M. Creative visualization and relaxation
techniques in the treatment of patients with HIV. Int Conf AIDS. 1996
Jul 7–12; 11: 203.
242. Weiner DA, Ryan TJ, McCabe CH, Chaitamn BR, Sheffield FT, et al.
Prognostic importance of a clinical profile and exercise session in
medically treated patients with coronary artery disease. JACC
1984;53:772–779.
243. Weissbecker I, Salmon P, Studts JL, Floyd AR, Dedert EA, Sephton
SE. Mindfulness-based stress reduction and sense of coherence among
women with fibromyalgia. J Clin Psychol Med Settings 2002;9:297–
307.
244. Wenger NK. In-hospital exercise rehabilitation after myocardial
infarction and myocardial revascularization: physiologic basis,
methodology, and results. In: Wenger NK, Hellerstein HK, editors.
Rehabilitation of the coronary patient. 3rd ed. New York: Churchill
Livingstone; 1992. p. 351–65.
245. Weydert JA, Shapiro DE, Acra SA et al. Evaluation of guided imagery
as treatment for recurrent abdominal pain in children: a randomized
controlled trial. BMC Pediatrics 2006;6(29): 127–136.
246. Whitehead DL, Perkins-Porras L, Strike PC et al. Post-traumatic stress
disorder in patients with cardiac disease: predicting vulnerability from
136
247.
248.
249.
250.
251.
252.
253.
254.
255.
256.
257.
emotional responses during admission for acute coronary syndromes.
Heart 2006;92:1225–1229.
Yamamoto Y, Hughson RL. Coarse-graining spectral-analysis-new
method for studying heart-rate-variability. J Appl Physiol
1991;71:1143–1150.
Yaneer BY. Complexity rising: from human beings to human
civilization, a complexity profile. NESCI research projects 2003.
Available at: http://nesci.net/projects/yaneer/Civilization.html
Yildirim YK, Fadiloglu C. The effect of progressive muscular
relaxation on anxiety levels and quality of life in dialysis patients.
Edtna Erca 2006;32:86–8.
Yu D, Lee D, Woo J. Effects of relaxation therapy on psychologic
distress and symptom state in older Chinese patients with heart failure.
J Psychosom Res 2006;62(4):427–437.
Yusuf S, Reddy S, Ounpuu S et al. Global burden of cardiovascular
diseases, I: general considerations, the epidemiologic transition, risk
factors, and impact of urbanization. Circulation 2001;104:2746–2753.
Zeidan F, Gordon NS, Merchant J, Goolkasian P. The Effects of Brief
Mindfulness Meditation Training on Experimentally Induced Pain.
The Journal of Pain 2010;11(3):199–209.
Žemaitytė D. Širdies ritmo autonominis reguliavimas: mechanizmai,
vertinimas, klinikinė reikšmė. – Kaunas: KMA, 1997.
Ziegelstein RC. Depression in patients recovering from a myocardial
infarction. JAMA 2001; 286:1621–7.
Zigmond AS, Snaith RP.The hospital anxiety and depression scale.
Acta Psychiatr Scand 1983; 67(6):361–370.
Zipes DP, Wyse DG, Friedman PL, Epstein AE, Hallstrom AP, et al.
A comparison of antiarrhythmic-drug therapy with implantable
defibrillators in patients rescusitated from near-fatal ventricular
arrhythmias. NEJM 1997;337(22):1576–1583.
Žumbakytė R. Krepšininkų ir futbolininkų ypatybių vertinimas veloergometrinio mėginio metu. Daktaro disertacija. Kaunas: KMU; 2006.
137
Published work on the subject of dissertation
1. A. Leonaite, A. Vainoras. Heart Rate Variability during two
Relaxation Techniques in Post-MI Men // Electronics and Electrical
Engineering. – Kaunas: Technologija, 2010. – No. 5(101). – P. 107–110.
Available at http://www.ee.ktu.lt/journal/2010/5/24.
2. Leonaite A., Vainoras A. Heart rate variability during three relaxation
techniques: a pilot study. Sporto mokslas, 2010. – No. 3(61).
Reports at conferences on the subject of dissertation
1. Leonaitė, Aura; Vainoras, Alfonsas. A review of the method for
evaluating the distinctive cardiovascular effects of different relaxation
techniques / A. Leonaitė, A. Vainoras // Biomedical engineering :
Proceedings of International Conference : 29, 30 October 2009, Kaunas
/ Kaunas University of Technology. Kaunas : Technologija. ISSN 2029–
3380. 2009, p. 41–44 : pav. [0,500].;
2. Leonaitė, Aura; Vainoras, Alfonsas. Pecularities of ECG Parameters
Variability during Two relaxation techniques in Men After Myocardial
Infarction // International Congress on Electrocardiology: 3–5 June,
2010, Lund, Sweden.
Articles from other published work:
1. Leonaitė, Aura. Vaikų agresyvumas ir širdies bei kraujagyslių
sistemos reakcija // Lietuvos bendrosios praktikos gydytojas. (Paskaita).
ISSN 1392–3218. 2006, t. 10, Nr. 11, p. 744–746. [1,000].;
2. Leonaitė, Aura. 11–12 metų vaikų širdies ir kraujagyslių sistemos
funkcinių rodiklių ryšys su riebaline mase // Biomedicininė inžinerija :
Tarptautinės konferencijos pranešimų medžiaga = Biomedical
engineering : Proceedings of International Conference / Kauno
technologijos universitetas. Kaunas : Technologija, 2006. (Section II).
ISBN 9955251514. p. 35–39. [1,000].;
138
APPENDICES
Appendix 1.1
Protocol of the study
PART I (1st day)
Code _____________
Date_______________
Date of birth _________/_____/_____
Height ________________m
Body mass_____________kg
Additional
diseases
_____________________________________________________________
Questions to ask before the session:
Does the patient smoke? If yes, for how long?
□ No
□ Yes ……………years
How does the patient evaluate his level of physical activity in his daily
life?
□ Very high □ high
□ average
□ low
□ very low
How is the patient subjectively feeling at the hospital right now?
□ Relaxed
□ Stressed
□ Indifferent
□ He does not know
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Appendix 1.2
Heart rate and arterial blood pressure measurement during the session with
MBSM:
Indices
1st min
5th min
1st min
5th min
of supine rest of supine rest of recovery
of recovery
time
time
HR, b/min
Systolic
ABP,
mmHg
Diastolic
ABP,
mmHg
Questions to ask after the session:
Did the patient fell asleep during the session with MBSM?
□ Yes
□ No
Has the patient ever done MBSM before?
□ No
□ Yes, once
□ Yes, more than once
Did the patient like doing MBSM?
□ Yes
□ No
Would the patient like to practice MBSM in the future?
□ Yes
□ No
140
Appendix 1.3
PART II (2nd day)
Heart rate and arterial blood pressure measurement during the session with
PMR:
Indices
1st min
5th min
1st min
5th min
of supine rest of supine rest of recovery
of recovery
time
time
HR, b/min
Systolic
ABP,
mmHg
Diastolic
ABP,
mmHg
Questions to ask after the session:
Did the patient fell asleep during the session with PMR?
□ Yes
□ No
Has the patient ever done PMR before?
□ No
□ Yes, once
□ Yes, more than once
Did the patient like doing PMR?
□ Yes
□ No
Would the patient like to practice PMR in the future?
□ Yes
□ No
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Appendix 2
Hospital Anxiety and Depression Scale (HADS)
Read each item and place a firm tick in the box opposite the reply, which
comes closest to how you have been feeling in the past week. Don’t take too long
over your replies; your immediate reaction to each item will probably be more
accurate than a long thought-out response. Tick one box only in each section.
1 I feel tense or wound up:
Most of the time
A lot of the time
Time to time, occasionally
Not at all
2 I still enjoy the things I used to enjoy:
Definitely as much
Not quite so much
Only a little
Hardly at all
3 I get a sort of frightened feeling as if
something awful is about to happen:
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn’t worry me
Not at all
4 I can laugh and see the funny side of
things:
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
5 Worrying thoughts go through my
mind:
A great deal of the time
A lot of the time
From time to time bur not too often
Only occasionally
6 I feel cheerful
Not at all
Not often
Sometimes
Most of the time
7 I can sit at ease and feel relaxed:
Definitely
Usually
Not often
Not at all
8 I feel as if I am slowed down:
Nearly all the time
Very often
Sometimes
Not at all
9 I get a sort of frightened feeling like
“butterflies” in the stomach:
Not at all
Occasionally
Quite often
Very often
10 I have lost interest in my
appearance:
Definitely
I don’t take so much care as I should
I may not take quite as much care
I take just as much care as ever
11 I feel restless as if I have to be on
the move:
Very much indeed
Quite a lot
Not very much
Not at all
12 I look forward with enjoyment to
things:
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
13 I get sudden feelings of panic:
Very often indeed
Quite often
Not very often
Not at all
14 I can enjoy a good book or radio
or TV program:
Often
Sometimes
Not often
Very seldom
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Appendix 3
Mindfulness Body Scan Meditation (MBSM)
Welcome to this body scan meditation. Make yourself comfortable. For
the next 20 minutes form the intention to simply be present with yourself,
with this moment as it is. Choosing to take some time away from the busy
schedule of the day and simply to be where you are.
Lying here you can become aware of this sensation of the floor pressing
up on the body, the body pressing down into the floor at the certain points of
contact. And there are other parts of the body which are barely touching or
not touching the floor at all. Just notice the sensation of those points of
contact.
And in this lying here you may become aware of the sensation of
breathing, the flow of the air, cooler as it moves through the nostrils and
down into the chest; the rise and fall of the belly as the air moves in and
moves back out. And the slightly warmer, moister air exiting the nostrils
and mouth on the exhale and then the process continues. Recognizing that it
is not about breathing in any particular way but simply being aware of the
process of breathing itself.
Allowing attention to rest on the body as a whole. Recognizing that along
the way we may feel somewhat relaxed on occasion but that may not be
necessarily the point of being present in this body scan. And it might not be
that relaxing at times, just simply noticing what it is. If we are anxious, if
we are uncomfortable, if we are wanting it to be different, if we are excited
in some way, noticing that as well. And if relaxation is here noticing the
relaxation. What that feels like in a body.
So, moving the attention, narrowing it from a floodlight down to a beam
of light that moves very deliberately down the body. Down your left leg
until the left foot and toes, so we are resting in an awareness of the left toes
of the left foot. Almost to the exclusion of anything else we may be aware
of. Just noticing the sensations in the toes, it may be warm, be cool, it may
be numbness, it can be any tensions or feelings. Simply allowing whatever
sensation or lack of sensation to be here. Allowing the attention to spread to
the entire left foot, the ball of the foot, the arch, the heel, the sides, the top of
the foot, the muscles and tendons inside the foot. Just taking in everything
as it is at this moment. We may find along the way that our attention drifts,
that we find ourselves thinking of other things, other times, having
memories, desires, emotions, anything at all. And simply when we notice
this, bringing the attention back, resting it firmly, at this point on the left
foot. Allowing the attention to focus on the left ankle – a part of the body
143
which we rarely pay any attention to unless it gives us some difficulty. See
if we can simply be aware of it as it is. To the exclusion of the foot below
and the leg above. Simply aware of the left ankle. And the left lower leg, the
calf resting against the floor or the mat, the sides of the shin, the sensations
on a surface perhaps of clothing touching this part of the body. Or
sensations inside the muscles, bone, and tissues. Bringing the attention back
to the left lower leg. Each time that we notice the attention has wandered,
bringing it back to the left lower leg.
And now the left knee. Once again seeing if we can only feel the left
knee, in isolation from the rest of the body.
Aware of the left thigh, an area where we hold tension sometimes. And if
what we encounter here is tension we can certainly choose to let go of that
tension, or simply notice it. Just notice where you feel it and what it feels
like: is it warm, is it tingling, is it numb, is it tight, is it loose, just taking
stock, taking it in, aware of tissues and muscles along the leg and inside it.
Allowing the attention to shift across the hips and down the right leg,
down to the right foot and to the toes of the right foot. Simply noticing the
toes, perhaps aware of how they are different from the toes of the left foot,
but not necessarily having them to be any particular way. Moving the
attention to the rest of the right foot, the outside and the inside, the sole and
the top, the left side and the right side. Aware perhaps of how complex this
part of the body is and how amazing it is that it moves us around. Aware of
the right ankle, only the right ankle, as it is now, not straining to notice
anything special, not trying to have any particular experience, but allowing
ourselves to be aware, to tune in to this particular small radio station as if
you were the frequency of the right ankle, seeing what’s there. Sometimes it
is useful to adopt an attitude of what we could call playful curiosity about
the body. What will we find here? Exploring this body in the same way that
we explore any new thing that we encounter, even though it is not new at
all.
The right lower leg, the calf, the shin, noticing any sensations that are
here, coolness and warmth, the sensation of clothing touching this part of
the body. Awareness of the right knee, possibly feeling some of the twist of
the right leg, the right foot falling outward.
The right thigh. Finding our attention perhaps wandering, associating
with thoughts about other things, other times, other places. Each time that
we are aware that the mind is wandering simply bringing it back, urging it
back to the place of the body where we are, in this case, to the right thigh.
Allowing the attention to rest here for whatever period of time we are able
144
and the next time we find the attention wandering, simply bringing it back
once again, patiently, calmly, but firmly.
Allowing the attention to move to the pelvic area, the buttocks, genitals,
the pelvic organs. Tuning in to awareness of this part of the body as it is at
the moment, and if what we encounter is no sensation that’s fine also. So we
move the attention to the lower back, an area where some people have
discomfort and you may be one of those people, or you may know some
particular discomfort most of the time. And it does not really matter, what
we are interested in here is what is right here right now. See if we can be
fully present with the sensation of what we are aware of in a lower back in
this moment. And if we find ourselves labeling it as pain, seeing if we can
be more specific, can we be more aware of the sensation the pain takes in
the lower back at this particular moment or whatever other sensation is here.
Not stopping at a label.
Bringing attention to the front of the lower part of the torso: the
abdomen, the muscles, the skin of the abdomen, the organs inside. Feeling
here, perhaps more directly, the movement of the breath, the effects of the
process of breathing, the rise and the fall of the diaphragm, the rise and fall
of the belly. Tuning in to what is here.
Moving up the torso into the ribcage, the lungs, the heart, the upper back.
Aware perhaps of the work of the lungs and the heart, breathing and
moving oxygen in the entire body; the expansion and contraction of the ribs,
the sensations in the upper back from this process of breathing, awareness of
the shoulders, the effects of the rocking motion of breathing on the
shoulders.
Transferring the attention of that narrow beam of light over to the left
shoulder, down the left arm all the way down to the tips of the fingers.
Slowly making the journey up the left arm, aware of the fingers of the left
hand, the hand itself, the palm, the back of the hand, and all of the muscles
and tissues inside. Perhaps the sensation of the floor or the mat or the bed,
wherever the hand may be touching it, aware of the wrist, the forearm, the
elbow, the upper arm. Experiencing just the left arm, the left arm as a whole.
Can we stay present with it for this moment as it is, regardless of how it is?
Allowing the attention to move from the left arm over the chest to the right
shoulder, moving down the right arm down to the right hand, to the fingers
of the right hand. Tuning in to what we find here in the fingers of the right
hand and to the right hand itself including the back of the hand, the bones
and the muscles inside, the palm of the hand. Aware of any subtle
temperature difference between the palm of the hand and the back of the
hand.
145
Aware of the wrist. The forearm. Bringing awareness, just pure
awareness, to the right elbow and the right upper arm, opening that beam of
attention to include the right arm as a whole from the tips of the fingers all
the way up to the shoulder.
Bringing attention now to the neck, this very complex part of the body
with all the muscles and bones and tissues and nerves and blood vessels
passing through this area. Aware of the breath moving through. The neck is
an area where we may hold some discomfort, we may be aware of tension,
of warmth, of tightness, of discomfort in a variety of forms. And seeing if
even in this moment we can simply be aware of it without the need to do
anything, without the need to change it in any way, just allowing it to be
here, because it is.
Moving the attention up into the head, into the jaw, the chin, the teeth,
the tongue, the roof of the mouth, the lips. Tuning in to the sensations of the
face, the cheeks, the nose, the upper lip, the areas around the eyes, the eyes
themselves, the eyebrows, the forehead. We may encounter tightness or
tension in the eyebrows, or clenching of the teeth. We can choose to let go
of that tension but for the purpose of this body scan it is enough simply
noticing that it is there. Once again not needing it to be any different than it
is. Aware of the sides of the head, the ears, the back of the head, perhaps
noticing the sensation of the back of the head resting on a pillow or cushion
or mattress. Being aware, to whatever degree we are able, of the brain inside
the head and the top of the head.
Very slowly but deliberately broadening the beam back to the floodlight,
to encompass the body as a whole, from the top of the head all the way
down to the tips of the fingers, and all the way down the body to the tips of
the toes.
Aware of this amazing vehicle in which we live. This whole body
breathing in this moment, functioning in this moment, thinking, feeling,
imagining, remembering. But still present, still here. Breathing.
In the last few moments taking the time to feel some gratitude for
yourself for having taken this time to simply be present with your
experience as it is without a need to make it any different, without a need to
do anything except to be aware, to be present for the only moments that we
actually have – these moments.
So, in a few moments, as it feels comfortable for you, begin to wriggle
your fingers and toes, gently bringing yourself back to the place where you
are and to the activities of your day, recognizing that this feeling of
presence, of focus, if that is what you are experiencing, is as close as the
next moment, as close as the next breath.
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Appendix 4
Progressive Muscle Relaxation (PMR)
Lie comfortably on your back.
Close your eyes and breathe deeply, calmly, gradually: inhale – exhale.
Focus on your right hand and right forearm. Clench your right fist and
feel the tension in the muscles of the right hand. Tighten the muscles even
more and keep them tense. Then let go. Let all the tension disappear.
Unclench your hand, let it fully relax and fall on the ground. Now try to feel
how any strain disappears from this hand. Then direct your attention to your
left hand and left forearm. Clench your left fist and tense your forearm
together. Tighten the forearm muscles and hold the tension. Then let go.
Unclench your fist, completely relax your palm and let the left hand to fall
on the ground. Now try to feel the tension disappearing, and enjoy the
pleasant sense of release.
Now focus again on the right hand, right forearm and right upper arm.
Again clench the right fist and tighten the forearm and the upper arm. The
right-hand muscles are now very hard. Keep them tense. Then let go. Let all
the tension disappear and let the hand fall to the ground. ¶Feel a pleasant
sense of relaxation, which now covers all of your right hand.
Now tense the left arm. Clench the left fist and tighten the arm muscles,
that they become hard and hold the tension. Let all the tension disappear
from your left hand. Enjoy the pleasant feeling of relaxation, which is now
gradually spreading through both hands. Hands are now lying on the
ground, tired and heavy.
Focus on your face. Tighten all the muscles of the face, contract your
forehead, squint, and pull back the corners of your lips. Clench your teeth
and hold the tensed muscles. Then relax all the facial muscles. Facial
muscles will now again be smooth and relaxed, loose. The teeth are
unclenched; the tongue is flabby and relaxed. Feel the relaxation spread all
over your face. Re-tighten the facial musculature. Knit your brow, severely
squint, pull back the corners of your lips and clench your teeth. Tighten the
muscles even more and feel the tension. Then let the facial muscles go. Let
all of them relax completely. The teeth are unclenched; the tongue is relaxed
and flabby. Enjoy the feeling of relaxation spreading across your face.
Focus now on the neck and back muscles. Contract the shoulder-blades,
incline your head forward and press the whole body to the ground. Tighten
more and keep tense. Then let go. Let all the tension disappears from your
neck and back muscles. And now enjoy the feeling of relaxation. Re-tighten
the neck and back muscles. Again contract the shoulder-blades, incline the
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head forward and press the entire body to the ground. Tense more and keep
the tension. Then let go of the neck and back muscles. Let all the tension
disappears. Feel how your neck and back muscles are flabby and relaxed.
Enjoy the pleasant feeling of relaxation, which increasingly embraces your
whole back.
Now, breathe in deeply, then deeper and hold the breath. Then exhale –
let all the air be expelled from the lungs. Once again, breathe in deeply –
deeper, deeper – and again hold your breath. Then exhale. Your breathing
becomes calm again, and smooth, very quiet and smooth.
Now focus on your right leg and right foot. Extend your right leg and
stretch all the muscles so that they become hard. Tighten them a little more
and keep the tension. Then relax the leg. Feel the tension disappear from
your right leg and right foot. Enjoy the feeling of relaxation. Compare your
right leg with the left leg. Once again tense your right leg. The muscles
again will become hard. Keep it tight. Then let go. Let all the tension
disappear from your right leg. Now, through the whole right leg you will
feel a pleasant sense of relaxation and gravity. Compare the relaxed right leg
to your left leg.
Focus now on the left leg and left foot. Extend your left leg and stretch
all the muscles so that they become hard. Tighten them a little more and
keep the tension. Then relax the left leg. Let all the tension disappear from
the entire left leg. Enjoy the pleasant feeling of relaxation. Once again,
tighten the left leg. Extend the leg and stretch all the muscles so that they
become hard. Stretch further and hold the tension. Now let the tension
disappear. You will feel how both legs are tired and relaxed now, totally
relaxed and tired. Enjoy the pleasant feeling of relaxation.
Double-check all the other muscle groups and get rid of the rest of the
tension. Now you will be lying completely relaxed and heavy.
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Appendix 5.1
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Appendix 5.2
150
Appendix 6
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Appendix 7
152
Appendix 8
153
Appendix 9
154
Appendix 10
155
Appendix 11
156
Appendix 12
157
Appendix 13
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