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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 1 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). 2 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 3 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). 4 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 5 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 6 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 7 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, 8 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. 9 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. 10 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 11 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 12 (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]. 15 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. 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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 139 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 141 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 142 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. 146 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 147 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. 148 Appendix 5.1 149 Appendix 5.2 150 Appendix 6 151 Appendix 7 152 Appendix 8 153 Appendix 9 154 Appendix 10 155 Appendix 11 156 Appendix 12 157 Appendix 13 158