-
Hindawi Publishing CorporationInternational Journal of
HypertensionVolume 2012, Article ID 578397, 11
pagesdoi:10.1155/2012/578397
Review Article
Current Perspectives on the Use of Meditation toReduce Blood
Pressure
Carly M. Goldstein,1, 2 Richard Josephson,1, 2, 3 Susan Xie,4
and Joel W. Hughes1, 2, 3
1 Kent State University, Kent, OH 44242, USA2 Summa Health
System, Akron, OH 44309, USA3 Harrington Heart & Vascular
Institute, University Hospitals Case Medical Center andDepartment
of Medicine, Case Western Reserve University School of Medicine,
Cleveland, OH 44106, USA
4 Rice University, Houston, TX 77005, USA
Correspondence should be addressed to Joel W. Hughes,
[email protected]
Received 9 August 2011; Revised 17 October 2011; Accepted 24
October 2011
Academic Editor: Tavis S. Campbell
Copyright © 2012 Carly M. Goldstein et al. This is an open
access article distributed under the Creative Commons
AttributionLicense, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is
properlycited.
Meditation techniques are increasingly popular practices that
may be useful in preventing or reducing elevated blood pressure.
Wereviewed landmark studies and recent literature concerning the
use of meditation for reducing blood pressure in
pre-hypertensiveand hypertensive individuals. We sought to
highlight underlying assumptions, identify strengths and weaknesses
of the research,and suggest avenues for further research, reporting
of results, and dissemination of findings. Meditation techniques
appear toproduce small yet meaningful reductions in blood pressure
either as monotherapy or in conjunction with traditional
pharma-cotherapy. Transcendental meditation and mindfulness-based
stress reduction may produce clinically significant reductions
insystolic and diastolic blood pressure. More randomized clinical
trials are necessary before strong recommendations regarding theuse
of meditation for high BP can be made.
1. Introduction: Meditation Techniques asTreatments for Elevated
Blood Pressure
According to worldwide estimates, hypertension affects
ap-proximately 1 billion people, resulting in 7.1 million
attrib-uted deaths per year [1]. In the United States, nearly
halfof all adults have blood pressure (BP), expressed in termsof
systolic (SBP) over diastolic blood pressure (DBP), in
theprehypertensive (SBP of 120–139 or DBP of 80–89) or
hyper-tensive (SBP > 140 or DBP > 90) range [2, 3]. As one
ofthe most widespread, least controlled diseases around theworld,
hypertension poses a threat to adults from all culturesand
lifestyles. Factors such as improved treatment, phar-macologic
interventions, preventative measures, and lifestylechanges have
contributed to a 60% decrease in age-adjusteddeath rates from
stroke and a 50% decrease in age-adjusteddeath rates from coronary
heart disease in the United Statessince 1972. However, despite
these improvements, BP con-trol among American adults still remains
suboptimal. For
example, two-thirds of hypertensive individuals are not
beingcontrolled to recommended BP levels. Furthermore,
approx-imately 30% of American adults are unaware of their
hyper-tension, and over 40% of those with hypertension are
notreceiving treatment [3].
Current treatment guidelines for hypertension
includeantihypertensive medications and health-promoting
lifestylemodifications such as weight reduction, the DASH
eatingplan (increased fruits and vegetables, and low fat dairy
prod-ucts with reduced saturated and total fat), reduced
dietarysodium, increased physical activity, and moderation
ofalcohol consumption. Ideally, antihypertensive medicationsand
lifestyle modifications successfully reduce BP to optimallevels.
However, despite the effectiveness of antihypertensivemedication
[4], adherence to medication regimens is oftenpoor and interferes
with the goal of reducing BP [5, 6]. Inaddition, hypertensive
medications can produce trouble-some side effects such as insomnia,
sedation, dry mouth,drowsiness, impotence, and headaches [4]. Due
to difficulty
-
2 International Journal of Hypertension
adhering, side effects, and prescription drug costs,
hyperten-sive individuals may desire a nonpharmacologic
interventionto avoid or complement their antihypertensive
medicationregimen. Therefore, whereas continued improvement
inpharmacologic treatments is necessary, these advancementsmust be
complemented by nonpharmacological approachesto BP control. Toward
that end, mind-body interventionssuch as relaxation, stress
management, and meditation—whether used alone or in combination
with lifestyle mod-ifications—have been evaluated as potential
treatments forhigh BP (refer to Table 1 for an overview of the
major typesof mind-body interventions). Ample evidence exists
re-garding the effects of relaxation and stress management onBP to
draw some conclusions, which are discussed below.However, less is
known regarding the potential of meditationas an intervention for
hypertension. The purpose of thisfocused paper is to evaluate the
evidence that meditation isan effective intervention for lowering
elevated BP (refer toTable 2 for a summary of studies in the
literature search).
2. Mind-Body Interventions
Relaxation therapies for hypertension have been evaluatedfor
over 30 years with disappointing results. For example,the
Hypertension Intervention Pooling Project found notreatment effect
for SBP and a small effect for DBP [22]. Ina study by Irvine and
Logan, relaxation therapy producedeffects equal to a group that
received support therapy, andthe relaxation group did not produce a
larger decrease in BP[23]. Positive results sometimes observed for
relaxation canoften be explained by methodology [24]; that is,
individualswith higher baseline BPs tend to benefit more than
individ-uals with lower baseline BPs, and repeated monitoring ofBP
appears sufficient to reduce BP levels [24, 25]. Overall,relaxation
techniques, the most common being progressivemuscle relaxation
(PMR), are not considered effective meth-ods for treating
hypertension [26]. Consequently, PMR caneven be used as a control
group for randomized controlledtrials of other mind-body
interventions.
In contrast, stress-management therapies have had somesuccess
reducing BP [27–30]. In a meta-analysis, multicom-ponent stress
management treatments were more effective inreducing BP (13.5 mm Hg
SBP and 3.4 mm Hg DBP) thansham treatments, whereas
single-component therapies (e.g.,relaxation alone) did not produce
significant results [31].Another meta-analysis reported that
multicomponent stress-management therapies were more effective in
reducing BPthan single-component relaxation-based therapies [32].
TheCanadian Coalition for High Blood Pressure Prevention andControl
has recommended multicomponent stress manage-ment be considered for
hypertensive individuals whose stressappears to contribute to their
hypertension [30].
Despite the promise of multicomponent stress-manage-ment
interventions, implementation has not been wide-spread.
Historically, the field of behavioral medicine hastaken a keen
interest in the contribution of stress to eleva-tions in BP.
Naturally, evidence that stress contributes to ele-vated BP and
hypertension was followed by attempts to treatstress in order to
reduce BP. However, stress-management
interventions for high BP are neither widely available
norcommonly practiced. Although we cannot be certain, wespeculate
the association of stress management programswith mental health
treatment may introduce stigma andreduce patient acceptance of
stress-management approaches.The expense of treatment programs and
relative scarcity ofhealthcare professionals qualified to provide
stress manage-ment to patients with high BP may also contribute to
thelimited implementation of multicomponent stress manage-ment
programs as a uniquely behavioral medicine solutionto
hypertension.
Another mind-body intervention for high BP is medita-tion. It
appears to be a promising option, as meditation isportable and can
be practiced independently of structuredtreatment programs,
although evaluation in clinical trialsobviously requires a clear
treatment protocol. Meditation hasless association with mental
health stigma and may be a moreacceptable intervention than
stress-management treatmentsin many cultures.
The most widespread types of meditation interventionscan be
roughly grouped into mantra meditation, such astranscendental
meditation (TM) and mindfulness medita-tion. Mindfulness meditation
involves an attitude of open-ness, acceptance, and reflection
rather than impulse andjudgment toward the practitioner’s current
experiences, aswell as the observation of thoughts, feelings, and
the externalworld alike through calm, detached sensory awareness
[33].Mantra meditations focus on a word, phrase, or concept.The
mantras often have soft sounds, like “Om,” and thesewords are
thought to produce different vibrations in differentpeople,
producing various effects on the individual [34]. Inthe TM
technique, the mantras, which are used for soundvalue rather than
meaning, become increasingly secondaryin experience and eventually
disappear, while self-awarenessbecomes primary in experience as the
practitioner tran-scends to a state of pure consciousness [35].
Mindfulness—described as a calm awareness of one’sbody, mind,
and environment that embodies an interactionbetween nonjudgmental
acceptance and focuses on the pre-sent moment—has existed for over
2,500 years and canbe found in numerous religions, cultures,
meditation tech-niques, and psychotherapies [36]. Although it is
the 7th stepof the Noble Eightfold Path in Buddhism, there is
noth-ing inherently religious about mindfulness as it is
mostlytaught completely independent from any religious
doctrine.Mindfulness meditation research became formalized in
1979when Dr. Jon Kabat-Zinn founded the MBSR program atUniversity
of Massachusetts-Amherst to treat the chronicallyill [37]. Other
practices and interventions that utilize theconcept of mindfulness
include yoga [38], acceptance andcommitment therapy [39],
dialectical behavior therapy [40],Tai Chi [41], and Qigong
[42].
2.1. Transcendental Meditation. TM has been extensivelystudied
as a meditation therapy for high BP. In one study,the feasibility
and efficacy of TM and progressive musclerelaxation (PMR) were
tested via a subgroup analysis by sexand level of hypertension risk
in older African Americans[17]. Compared to control subjects who
underwent lifestyle
-
International Journal of Hypertension 3
Ta
ble
1:M
ajor
type
sof
min
d-bo
dyin
terv
enti
ons.
Maj
orty
pes
ofm
ind-
body
inte
rven
tion
sSu
btyp
esD
escr
ipti
onSe
ttin
gC
erti
fica
tion
toad
min
iste
rD
ose
Stan
dard
izat
ion
Rel
axat
ion
ther
apy
Pro
gres
sive
mu
scle
rela
xati
on(P
MR
),bi
ofee
dbac
k,re
laxa
tion
-ass
iste
dbi
ofee
dbac
k,au
toge
nic
trai
nin
g
Use
sre
laxa
tion
tech
niq
ues
toac
hie
veph
ysic
alan
dm
enta
lre
laxa
tion
,oft
enco
upl
edw
ith
brea
thin
gex
erci
ses
orm
enta
lim
ager
y
Gro
up
orin
divi
dual
Var
ies
(hea
lth
prof
essi
onal
s,ps
ych
olog
ists
,th
erap
ists
,etc
.)
Var
ies
(e.g
.,w
eekl
yse
ssio
ns
wit
hh
omew
ork
assi
gnm
ents
)N
otst
anda
rdiz
ed
Stre
ss-m
anag
emen
tth
erap
yN
/A
Adj
ust
sbe
hav
iora
lan
dps
ych
olog
ical
resp
onse
sto
stre
ssth
rou
ghco
gnit
ive
beh
avio
ral
inte
rven
tion
s
Gro
up
orin
divi
dual
Var
ies
Var
ies
Not
stan
dard
ized
Zen
med
itat
ion
N/A
Focu
ses
atte
nti
onon
cou
nti
ng
deep
brea
ths
orko
ans
(rid
dles
irre
solv
able
bylo
gic)
tocu
ltiv
ate
awar
enes
s
Mos
tly
indi
vidu
alZ
enpr
acti
tion
erV
arie
sN
otst
anda
rdiz
ed
Tran
scen
den
talm
edit
atio
n(T
M)
N/A
Take
sat
ten
tion
beyo
nd
nor
mal
thin
kin
gpr
oces
ses
un
tilt
hou
ght
istr
ansc
ende
dan
da
stat
eof
pure
con
scio
usn
ess
isac
hie
ved,
begi
nn
ing
wit
hre
peti
tion
ofa
man
tra
Mos
tly
indi
vidu
al
Cer
tifi
edin
stru
ctor
thro
ugh
the
Mah
aris
hiV
edic
Edu
cati
onFo
un
dati
on
Tech
niq
ue
lear
ned
ina
7-st
epco
urs
eor
thro
ugh
pers
onal
inst
ruct
ion
,pr
acti
ced
15–2
0m
intw
ice/
day
Stan
dard
ized
Min
dfu
lnes
s-ba
sed
stre
ssre
duct
ion
(MB
SR)
N/A
Use
sm
edit
atio
nan
dst
ress
-man
agem
entt
ech
niq
ues
,in
clu
din
gm
indf
uln
ess
skill
s,su
chas
copi
ng,
sitt
ing
med
itat
ion
,an
dyo
ga,t
oim
prov
eph
ysic
alan
dem
otio
nal
wel
l-be
ing
Gro
up
sess
ion
sw
ith
indi
vidu
alpr
acti
ceV
arie
s
8w
eekl
y2.
5h
r.se
ssio
ns,
wit
hat
leas
t45
min
.of
daily
prac
tice
6da
ys/w
eek,
con
clu
din
gw
ith
an8
hr.
min
dfu
lnes
sre
trea
tw
ith
ath
erap
ist
Stan
dard
ized
-
4 International Journal of Hypertension
Ta
ble
2:L
iter
atu
rese
arch
over
view
.
Med
itat
ion
stu
dyov
ervi
ewSa
mpl
esi
ze,
popu
lati
onIn
terv
enti
on/d
ose
Con
trol
Len
gth
ofba
selin
e,n
o.of
BP
read
ings
Ran
dom
ized
,bl
inde
dT
her
apis
ts’t
rain
ing
Res
ult
sF/
U
Min
dfu
lnes
s[7
]
70(n
orm
oten
sive
,fe
mal
epo
sttr
eatm
ent
can
cer
pati
ents
,age
≥18)
8w
k.M
BSR
Pass
ive
(wai
tlis
t)3
read
ings
take
nat
3-m
in.i
nte
rval
sN
otra
ndo
miz
ed,
NR
ifbl
inde
d
Clin
ical
psyc
hol
ogis
tw
ith
over
10yr
s.of
expe
rien
ce
No
sign
ifica
ntd
iffer
ence
inB
Pbe
twee
nM
BSR
grou
pan
dco
ntr
ol;w
hen
pati
ents
wer
ean
alyz
edby
“hig
her
BP
”an
d“l
ower
BP
”gr
oups
base
don
BP
read
ings
atw
eek
1,“h
igh
erB
P”
MB
SRpa
rtic
ipan
tsh
adlo
wer
SBP
com
pare
dto
con
trol
sat
wee
k8
Non
e
Min
dfu
lnes
s[8
]
121
(Afr
ican
Am
eric
ann
inth
grad
ers,
rest
ing
SBP
betw
een
50th
and
95th
perc
enti
les)
Lif
esk
ills
trai
nin
g,h
ealt
hed
uca
tion
,or
Bre
ath
ing
Aw
aren
ess
Med
itat
ion
(BA
M),
wit
h10
-min
.in
-sch
oola
nd
at-h
ome
sess
ion
sev
ery
day
for
3m
os.
Non
e
4re
adin
gsta
ken
wit
hin
10m
in.
(firs
tre
adin
gdi
scar
ded)
over
3co
nse
cuti
veda
ys
Ran
dom
ized
,si
ngl
e-bl
ind
Hea
lth
/phy
sica
led
uca
tion
teac
her
str
ain
edan
dce
rtifi
edby
prog
ram
inst
ruct
ors
On
lyth
eB
AM
grou
psh
owed
sign
ifica
ntd
ecre
ases
in24
-hou
rSB
P3
mos
.
Min
dfu
lnes
s[9
]
166
(Afr
ican
Am
eric
ann
inth
grad
ers,
rest
ing
SBP
betw
een
50th
and
95th
perc
enti
les)
Bot
vin
Lif
eSki
llsTr
ain
ing
orB
AM
,w
ith
10-m
in.
in-s
choo
lan
dat
-hom
ese
ssio
ns
ever
yda
yfo
r3
mos
.
Act
ive
(hea
lth
edu
cati
on)
3re
adin
gsta
ken
wit
hin
10m
in.
(firs
tre
adin
gdi
scar
ded)
over
3co
nse
cuti
veda
ys
Ran
dom
ized
,NR
ifbl
inde
d
Hea
lth
edu
cati
onte
ach
ers
trai
ned
bypr
ogra
min
stru
ctor
s
BA
Mgr
oup
show
edgr
eate
stde
crea
ses
inSB
P,ch
ange
sin
over
nig
ht
SBP,
DB
P,an
dh
eart
rate
(sig
nifi
can
tgro
up
diff
eren
ces)
Non
e
Min
dfu
lnes
s[1
0]
56(a
dult
sag
ed30
–60
yrs.
,91%
Cau
casi
an,
BP
inth
epr
ehyp
erte
nsi
vera
nge
,120
–139
mm
Hg
SBP,
or80
–89
mm
Hg
DB
P,u
nm
edic
ated
)
MB
SRfo
r8
wks
.A
ctiv
e(P
MR
trai
nin
g)
3re
adin
gsta
ken
at5-
min
.in
terv
als,
follo
wed
by2
addi
tion
alm
easu
rem
ents
wit
hin
2w
ks.
Ran
dom
ized
,si
ngl
e-bl
ind
MB
SRan
dP
MR
ther
apis
ts
MB
SRpr
odu
ced
sign
ifica
nt
decr
ease
sin
clin
icSB
P(b
y4.
9m
mH
g)an
dD
BP
(by
1.9
mm
Hg)
Non
e
-
International Journal of Hypertension 5
Ta
ble
2:C
onti
nu
ed.
Med
itat
ion
stu
dyov
ervi
ewSa
mpl
esi
ze,
popu
lati
onIn
terv
enti
on/d
ose
Con
trol
Len
gth
ofba
selin
e,n
o.of
BP
read
ings
Ran
dom
ized
,bl
inde
dT
her
apis
ts’t
rain
ing
Res
ult
sF/
U
TM
[11]
35(a
dole
scen
tsw
ith
hig
hn
orm
alB
Pag
ed15
–18
yrs.
,34
Afr
ican
Am
.,1
Cau
casi
anA
m.,
rest
ing
SBP
≥85t
han
d≤9
5th
perc
enti
le)
TM
,wit
h15
min
med
itat
ion
sess
ion
stw
ice/
day
for
2m
os.
Act
ive
(hea
lth
edu
cati
on)
3co
nse
cuti
veoc
casi
ons,
len
gth
ofba
selin
eN
R
Ran
dom
ized
,NR
ifbl
inde
dN
RT
Mgr
oup
show
edgr
eate
rde
crea
ses
inre
stin
gSB
Pan
din
SBP
duri
ng
acu
test
ress
orN
one
TM
[12]
60(A
fric
anA
mer
ican
adu
lts,
aged
>20
year
s;w
ith
hig
hn
orm
alB
Pof
130–
139/
80-8
5,st
age
1hy
pert
ensi
onB
Pof
140–
159/
90–9
9,or
stag
eII
hype
rten
sion
BP
of16
0–17
9/10
0–10
9)
TM
for
6–9
mos
.(a
vera
gein
terv
enti
onpe
riod
of6.
8±
1.3
mos
.)
Act
ive
(CV
Dri
skfa
ctor
prev
enti
oned
uca
tion
prog
ram
)
3re
adin
gsta
ken
atea
chof
3co
nse
cuti
vevi
sits
(las
t2vi
sits
wer
eav
erag
ed)
Ran
dom
ized
,si
ngl
e-bl
ind
Cer
tifi
edin
stru
ctor
sfr
omth
eA
fric
anA
mer
ican
com
mu
nit
y
Bot
hgr
oups
had
sign
ifica
nt
decr
ease
sin
BP
(TM
grou
pby
7.77±
10.3
4m
mH
gSB
Pan
d3.
5±
7.6
mm
Hg
DB
P,co
ntr
olgr
oup
by6.
74±
12.8
SBP
and
5.9±
8.6
DB
P),
but
only
the
BP
decr
ease
inT
Mgr
oup
was
asso
ciat
edw
ith
corr
espo
ndi
ng
decr
ease
inca
roti
din
tim
a-m
edia
thic
knes
s)
Non
e
TM
[13]
39(n
orm
oten
sive
Cau
casi
anA
m.m
ale
adu
lts,
mea
nag
eof
24.6
yrs.
)
TM
for
4m
os.
Act
ive
(cog
nit
ive-
base
dst
ress
edu
cati
on)
BP
mea
sure
dev
ery
4m
in.f
or20
min
.R
ando
miz
ed,
sin
gle-
blin
dQ
ual
ified
TM
inst
ruct
or
TM
decr
ease
dam
bula
tory
DB
Pby
4.8±
2.4
mm
Hg
(8.8±
3.0
mm
Hg
inh
igh
-com
plia
nce
subg
rou
p)
Non
e
TM
[14]
298
(un
iver
sity
stu
den
ts,B
P<
140/
90an
d>
90/6
0m
mH
g,w
ith
159
ina
hype
rten
sion
risk
subg
rou
pfo
rh
avin
gSB
P>
130
mm
Hg,
DB
P>
85m
mH
g,or
oth
erri
skfa
ctor
s)
TM
for
3m
os.
Pass
ive
3re
adin
gsta
ken
at1-
min
.in
terv
als
(las
t2re
adin
gsw
ere
aver
aged
)
Ran
dom
ized
,si
ngl
e-bl
ind
Res
earc
hst
affan
dT
Min
stru
ctio
nal
staff
Inth
ehy
pert
ensi
onri
sksu
bgro
up,
TM
sign
ifica
ntl
yre
duce
dSB
Pby
5.0
mm
Hg
and
DB
Pby
2.8
mm
Hg;
redu
ctio
ns
inov
eral
lsam
ple
wer
en
otsi
gnifi
can
t.T
Mpr
odu
ced
sign
ifica
nti
mpr
ovem
ents
into
talp
sych
olog
ical
dist
ress
,an
xiet
y,de
pres
sion
,an
ger/
hos
tilit
y,an
dco
pin
g.
Non
e
TM
[15]
100
(Afr
ican
Am
eric
anad
oles
cen
tsag
ed16.2±
1.3
yrs.
,w
ith
hig
hn
orm
alSB
P)
TM
for
4m
os.
Act
ive
(hea
lth
edu
cati
onco
ntr
olw
ith
lifes
tyle
edu
cati
onse
ssio
ns)
Rea
din
gsta
ken
from
6AM
–11P
Mev
ery
20m
in.
(day
tim
e)an
d11
PM
-6A
Mev
ery
30m
in.
(nig
htt
ime)
over
24h
rs.
Ran
dom
ized
,NR
ifbl
inde
dN
R
TM
grou
psh
owed
grea
ter
decl
ines
inda
ytim
eSB
P(P
<0.
04)
and
DB
P(P
<0.
06)
com
pare
dto
the
hea
lth
edu
cati
onco
ntr
olgr
oup
4m
os.
-
6 International Journal of Hypertension
Ta
ble
2:C
onti
nu
ed.
Med
itat
ion
stu
dyov
ervi
ewSa
mpl
esi
ze,
popu
lati
onIn
terv
enti
on/d
ose
Con
trol
Len
gth
ofba
selin
e,n
o.of
BP
read
ings
Ran
dom
ized
,bl
inde
dT
her
apis
ts’t
rain
ing
Res
ult
sF/
U
TM
-bas
ed[1
6]
41(a
dult
sag
ed22
–62
yrs.
,wit
hes
sen
tial
hype
rten
sion
,u
nm
edic
ated
,≥1
00m
mH
gar
teri
alpr
essu
re)
SRE
LA
Xgr
oup
rece
ived
trai
nin
gov
er5
wkl
y.se
ssio
ns
base
don
TM
(in
clu
din
gm
antr
a),
wit
h15
–20
min
med
itat
ion
sess
ion
stw
ice/
day
Bot
hpa
ssiv
ean
dac
tive
(NSR
EL
AX
plac
ebo
grou
ph
adsa
me
trai
nin
g,n
om
antr
a)
5re
adin
gsta
ken
at1
min
.in
terv
als
Ran
dom
ized
,si
ngl
e-bl
ind
Exp
erie
nce
dT
Min
stru
ctor
Bot
hSR
EL
AX
and
NSR
EL
AX
mod
estl
yde
crea
sed
BP,
wit
hsi
gnifi
can
tdec
reas
eon
lyin
DB
P
3m
os.
TM
orre
laxa
tion
[17]
127
(hyp
erte
nsi
veA
fric
anA
m.a
dult
sag
ed55
–85
yrs.
,SB
P≤1
79m
mH
g,D
BP
90–1
04m
mH
g)
Tran
scen
den
tal
Med
itat
ion
(TM
)or
prog
ress
ive
mu
scle
rela
xati
on(P
MR
),w
ith
1w
k.in
itia
lin
stru
ctio
nan
d1.
5h
r.m
onth
lyfo
llow
ups
for
3m
os.
Act
ive
(lif
esty
lem
odifi
cati
on)
4re
adin
gsov
er1-
2m
os.
Ran
dom
ized
,si
ngl
e-bl
ind
NR
TM
sign
ifica
ntl
yde
crea
sed
BP
inbo
thw
omen
(SB
Pby
10.4
mm
Hg,
DB
Pby
5.9
mm
Hg)
and
men
(SB
Pby
12.7
,D
BP
by8.
1);P
MR
only
decr
ease
dD
BP
sign
ifica
ntl
yin
men
(by
6.2)
3m
os.
TM
orre
laxa
tion
[18]
127
(Afr
ican
Am
.ad
ult
sag
ed55
–85
yrs.
,wit
hm
ildhy
pert
ensi
on,S
BP
≤189
mm
Hg,
DB
P90
–109
mm
Hg,
fin
alba
selin
eB
P≤1
79/1
04m
mH
g)
TM
orP
MR
,wit
h1
wk.
init
ial
inst
ruct
ion
and
1.5-
hr.
mon
thly
follo
wu
psfo
r3
mos
.
Act
ive
(lif
esty
lem
odifi
cati
on)
3re
adin
gsta
ken
aton
evi
sit
Ran
dom
ized
,si
ngl
e-bl
ind
Afr
ica
Am
.in
stru
ctor
squ
alifi
edto
teac
hei
ther
TM
orP
MR
TM
decr
ease
dSB
Pby
10.7
mm
Hg,
DB
Pby
6.4
mm
Hg
(bot
hsi
gnifi
can
tly
grea
ter
decr
ease
sth
anth
ose
inP
MR
)
3m
os.
TM
orre
laxa
tion
[19,
20]
150
(Afr
ican
Am
.ad
ult
s,m
ean
age
of49±
10yr
s.,S
BP
140
to17
9m
mH
g,D
BP
90–1
09m
mH
g)
TM
orP
MR
Act
ive
(con
ven
tion
alh
ealt
hed
uca
tion
)
3re
adin
gsta
ken
wit
hin
1h
r.at
each
of5
sess
ion
sov
er1
mo.
Ran
dom
ized
,si
ngl
e-bl
ind
NR
TM
decr
ease
dSB
Pby
3.1
mm
Hg,
DB
Pby
5.7
mm
Hg
(gre
ates
tde
crea
seof
all
grou
ps);
TM
decr
ease
du
seof
anti
hype
rten
sive
med
icat
ion
(rel
ativ
eto
incr
ease
sin
oth
ergr
oups
)
1yr
.
TM
,min
dfu
lnes
s,or
rela
xati
on[2
1]
72(e
lder
lyre
tire
men
t-ag
ead
ult
s,m
ean
age
of81
yrs.
)
TM
,min
dfu
lnes
str
ain
ing
(MF)
,or
men
talr
elax
atio
nPa
ssiv
e
3re
adin
gsta
ken
at2-
min
.in
terv
als
(on
lySB
Pre
port
ed)
Ran
dom
ized
,si
ngl
e-bl
ind
21tr
ain
edin
stru
ctor
s(p
rofe
ssio
nal
s,gr
adu
ate
stu
den
ts,
and
colle
gese
nio
rs)
TM
decr
ease
dSB
Pby
12.4
mm
Hg
(gre
ates
tde
crea
seof
all
grou
ps),
and
surv
ival
rate
was
100%
(com
pare
dto
the
seco
nd
hig
hes
t,87
.5%
inM
F)af
ter
3yr
s.
3yr
s.
-
International Journal of Hypertension 7
modification education only, TM produced significant de-clines
in BP after 3 months for both men (by 12.7 mm HgSBP and 8.1 mm Hg
DBP) and women (by 10.4 mm Hg SBPand 5.9 mm Hg DBP). In contrast,
women practicing PMRfailed to show significant declines, while men
practicingPMR experienced significant declines solely in DBP (by6.2
mm Hg) [17]. An earlier randomized controlled trial ofTM by the
same authors reported that 20 elderly patientswho were treated with
TM exhibited a 12.4 mm Hg drop inSBP, compared to a 2.4 mm Hg
reduction for patients in thecontrol group [21].
The short-term efficacy of TM and PMR in treating
mildhypertension was also evaluated in 127 African Americanmen and
women aged 55 to 85 years, compared with a life-style modification
education control program [18]. TM re-duced SBP (10.7 mm Hg) and
DBP (4.7 mm Hg), whichwas significantly greater than those observed
for relaxation(4.7 mm Hg SBP and 3.3 mm Hg DBP). Between the
twostress-reducing approaches, TM was about twice as effectiveas
PMR. Later, Schneider and colleagues [19] conductedanother study
following African American hypertensive indi-viduals over one year
while they underwent TM, PMR, orconventional health education
classes as a control. The TMgroup experienced greater decreases in
SBP and DBP thanthe PMR or control groups, as well as reduced use
of anti-hypertensive medication, relative to increases for PMR
andthe control group. Consequently, the TM program may
beparticularly useful in the long-term treatment of hyperten-sion
in African Americans, for whom many of these effectshave been
demonstrated. Schneider and colleagues also con-ducted a recent
meta-analysis, which revealed that, comparedwith combined controls,
the TM group showed substantialdecreases in all-cause mortality,
cardiovascular mortality,and cancer-related mortality [20].
In another study [16], unmedicated patients with hyper-tension
underwent TM-based training (treatment group),TM-based training
without a mantra (placebo controlgroup), or no training
(no-treatment control group). Com-pared with the no-treatment
controls, modest BP declineswere observed in both the treatment and
placebo controlgroups, with DBP percentage showing a significant
decrease[16]. The similarity in effectiveness of TM training and
TMtraining without a mantra could be attributed to the fact
thatboth were in effect “meditation” groups or that changes inBP
were due to another factor. A meta-analysis that onlyincluded
high-quality assessments—as determined by 11factors, which included
participant selection, randomization,blinding, full description of
the therapeutic intervention, andappropriate measurements of
BP—found TM, compared tocontrols, associated with clinically
meaningful reductions of4.7 and 3.2 mm Hg in SBP and DBP,
respectively [43]. TMhas also appeared to reduce carotid
arteriosclerosis in AfricanAmericans [12] and a 4.8 mm Hg drop in
ambulatory DBPamong white males treated with TM [13].
A study assessing the effects of TM on BP,
psychologicaldistress, and coping among university students was
alsothe first randomized clinical trial to demonstrate that
TMsignificantly increased coping and reduced BP in associationwith
lessened psychological distress in a hypertension risk
subgroup. The TM program may decrease the risk for devel-oping
hypertension in young adults [14]. TM also reducedresting BP among
adolescent African Americans with highnormal BP (with a resting SBP
≥85th and ≤95th percentile)over two months, with larger declines
than those in a healtheducation control group, demonstrated during
both at restand during acute laboratory stressors [11]. In another
studyon African American adolescents with high normal systolicBP,
the 4-month TM group showed greater declines indaytime SBP (P <
0.04) and DBP (P < 0.06) comparedto the health education control
group, further exhibiting abeneficial impact of TM in youth at risk
for hypertension.This study is of particular interest due to its
utilization ofambulatory 24-hour BP monitoring, which not only
tendsto be relatively free of placebo effects and to be
highlyreproducible but also records BP regularly over a
prolongedtime period in the participants’ natural environments,
thusincreasing sensitivity to changes in average BP and providinga
more reliable measure of overall BP [15]. Ambulatorystudies like
the one produced here by Barnes and colleaguesare valuable because
they generate the potential to measuretreatment effects out of the
laboratory and in day-to-day life,which may allow generalization of
treatment effects.
2.2. MBSR. Mindfulness-based stress reduction (MBSR), asubset of
mindfulness meditation that has been standardizedand manualized, is
said to treat depression and anxiety, lowerstress, and treat health
conditions like hypertension. MBSRis a program that utilizes
meditation and stress managementtechniques. Originally founded by
Dr. Jon Kabat-Zinn, TheCenter for Mindfulness in Medicine, Health
Care, and Socie-ty at the University of Massachusetts Medical
School (http://www.umassmed.edu/cfm/) has treated over 19,000
patientswith MBSR.
MBSR was originally developed and used in a behavioralmedicine
setting for individuals with chronic pain [44] andtypically
consists of eight 2.5-hour weekly group sessions.These sessions
contain instruction and practice in mindful-ness meditation, as
well as conversations of stress, coping,and homework assignments.
Students learn a range ofmindfulness skills including body scan
exercises, sitting med-itation, and yoga exercises. Homework
consists of practicingthese skills for at least 45 minutes per day,
6 days per week,in addition to practicing mindfulness skills during
groupmeetings. The program concludes with an 8-hour
intensivemindfulness retreat with a therapist. During and after
theprogram, students are encouraged to pay mindful, non-judgmental
attention to daily activities like walking, eating,and talking. One
goal is for participants to see that mostsensations, emotions, and
thoughts are short-lived and donot require immediate
suppression.
Recent studies have evaluated the effectiveness of MBSRfor
reducing BP, as well as breathing awareness meditation(BAM), a
primary exercise in MBSR, in producing declinesin BP among
differing populations. In one study, 121 AfricanAmerican ninth
graders (with a resting SBP >50th percentileand
-
8 International Journal of Hypertension
in 24-hour SBP. Another study also conducted among 166African
American ninth graders at increased risk for essentialhypertension
compared the treatment effects of BAM, theBotvin LifeSkills
Training, or a health education control [9].Significant group
differences emerged, with the BAM groupexhibiting the greatest
decreases in SBP, DBP, and heart rate.
MBSR has also shown some potential for lowering BPin individuals
with elevated BP. A recent study comparingthe effects of MBSR
versus PMR on prehypertensive adultsfound that MBSR produced
significant reductions in SBPand DBP. A 4.9 mm Hg reduction in
clinic SBP was observedin the MBSR group compared to 0.7 mm Hg in
the PMRgroup, and MBSR produced a 1.9 mm Hg reduction in
DBPcompared to a 1.2 mm Hg increase for PMR [10]. Theresults were
qualitatively similar to reductions in BP reportedin a
meta-analysis of TM [45], as well as the reductionobserved in the
PREMIER trial of comprehensive lifestylemodification for high BP
[46]. In another study, adult femaleposttreatment cancer patients
who underwent MBSR didnot experience significant differences in BP
compared tothe waitlist control group [7]. However, when patients
wereanalyzed by “higher BP” and “lower BP” groups through amedian
split based on BP readings during the first week oftreatment,
“higher BP” MBSR participants had lower SBPcompared to controls at
the end of the MBSR program.Given the normotensive sample and
preliminary results dueto methodological limitations of the study
(e.g., results mayhave been an effect of regression to the mean),
more well-designed trials are needed to evaluate the utility of
MBSR inreducing clinically elevated BP [7].
3. Methodological Considerations
A report on meditation techniques conducted by the UnitedStates
Agency for Healthcare Research and Quality (AHRQ)evaluated the
methodological quality of 286 randomizedcontrolled trials employing
meditation practices in a varietyof populations [33]. Studies were
evaluated using the Jadadscores, as the Jadad scale is the most
commonly used assess-ment scale of methodological quality of
randomized con-trolled trials in health care research [47]. Scores
(on a scaleof 1–5, from lowest to highest methodological
quality)are based on reported method of randomization,
double-blinding, and description of withdrawals and dropouts,
withlow scores indicating a higher risk of bias [48]. The quality
ofmeditation trials was evaluated to be poor overall, with only14%
being rated high quality (i.e., Jadad scores ≥3 points);the studies
reviewed were found to have too many qualitativeor observational
reports, limited descriptions of participantcharacteristics
(including if the inclusion criteria required anofficial diagnosis
of prehypertension or hypertension), smallsample sizes,
inadequately described blinding proceduresand randomization, lack
of control groups, insufficient fol-lowup periods, limited
reporting of intention-to-treat statis-tical analyses, and
inadequately described losses to followup[33]. Furthermore, much of
the research published on spe-cific forms of meditation has been
conducted by the orga-nizations that create or disseminate those
specific forms of
meditation. Although the methodological quality of this
re-search is improving, meditation techniques should be testedby
independent research teams who have no association
withorganizations promoting a particular approach to medita-tion.
Recent additions to the literature have increasinglyadhered to the
CONSORT recommendations (ConsolidatedStandards of Reporting Trials;
49). There are many method-ological improvements that can be made.
For example,conflict of interest and researcher bias can be
minimized bycollaborative efforts with outside institutions having
inde-pendent oversight of data collection and analysis,
indepen-dent replication, rigorous blinding, allocation
concealment,randomization, and selection of a suitable control
condition.
4. Future Directions and Studies
Future research targeting meditation interventions must be-gin
by adequately defining the role of mindfulness or otherconcepts and
components in meditation and delineatingintentions for applications
to the study population. Med-itation treatments should be
standardized and manualizedas much as possible to ensure maximal
external validity.Additionally, similarities and differences
between kinds ofmeditation interventions should be highlighted
within pub-lications. The role of mindfulness and meditation in a
givenintervention should be explained. Furthermore, assessmentsthat
target measurements of the construct, mindfulness, andthe process
through which mindfulness is achieved, medi-tation, should be
refined and psychometrically validated inmedical populations and
healthy controls.
Future studies should clearly outline their inclusion
andexclusion criteria, with efforts to extend meditation
interven-tions to hypertensive individuals who otherwise belong
tounderstudied populations. Including a variety of populationsmakes
the examination of potential moderators such asethnicity possible.
Aims should include using larger samplesizes and continuing with
the disease-specific approach tointerventions, implying the use of
strict inclusion criteriarequiring participants must be diagnosed
with either prehy-pertension or hypertension to participate. There
may needto be a better selection of control protocols, with
preferencegiven to similar interventions that have been validated
tonot produce the results experimenters expect to find (ornot) in
the experimental condition. In addition, studiesdefining dose
response would be substantially beneficial inhelping not only to
confirm the correlation-effect link, butalso to determine how much
of an intervention producesboth statistically and clinically
significant effects. This wouldfacilitate wider dissemination and
scalability.
Procedural and statistical methodology must be
explicitlyoutlined so the studies can be critiqued and replicated
andso articles published from the studies can be included inreviews
and meta-analyses. With improved adoption of theCONSORT guidelines
[49], better systematic comparisons ofeffects of different
mindfulness interventions can be estab-lished. Hopefully, as the
methodology and reporting of thesestudies is strengthened and
clarified, scientists will be able toadopt more experimental
designs, ultimately optimizing theability to make causal
inferences.
-
International Journal of Hypertension 9
Meditation is an intervention for hypertension and
pre-hypertension that is perhaps best characterized as being inits
adolescence. There is clearly considerable promise, with avariety
of studies demonstrating efficacy in the short-termreduction of BP
similar to that achieved with single-agentdrug therapy. On the
other hand, many of these studiesare potentially biased due to lack
of blinding, inadequatebaseline measurements of BP, and limited
followup. All med-itation techniques are not created equal, and few
studies havedirectly compared one technique to another. More
impor-tantly, there has been essentially no evaluation to
determinewhat may be the essential components of a putatively
suc-cessful methodology or if an entire “standard” approach
isrequired. This has major implications for scalability,
partic-ularly in resource-limited settings where both clinical
stafftime and patient meditation environment and time maybe
constrained. Hypothesis-driven mechanistic studies arerare and, if
well conceived and executed, could dramat-ically advance the field.
Potential mechanisms of actioninclude alterations in the autonomic
nervous system, withchanges in the sympathovagal balance favoring
the latter.Perhaps meditation affects mood in hypertensives; in
othersettings depression has been associated with physical
inac-tivity and altered eating patterns, both of which may
affectBP.
Hypertension is paradigmatic of a chronic disease, withclinical
sequelae typically developing after years of elevatedBP. Long-term
followup, after the acute intervention is com-plete but, while the
patient is still employing meditative tech-niques, is essential.
Perhaps “booster doses” of instructionwill be required. While prima
facie meditation would appearto be free of side effects, few
studies have systematicallyevaluated their presence and
consequences. It is possible thatthe most significant side effect
may be procedural, wheremeditation is simplistically viewed only as
an alternative orsubstitute for antihypertensive drugs.
Pharmacotherapy ofhypertension frequently involves multiple drugs,
particularlyin those with substantially elevated baseline pressure.
It isunlikely that meditation will be effective as monotherapy
inall (and perhaps most of) patients with established
hyper-tension. A therapeutic approach of multimodality
treatment,wherein meditation is truly viewed as complementary
todrug treatment, is an important underexplored area, withthe
potential to expand the number of individuals whocould both benefit
from meditative techniques and achieveimproved BP control.
Perhaps the greatest potential benefits of meditationtechniques
in the treatment of individuals with hypertensionare in developing
countries. Many of these countries areexperiencing large population
growth and with the increas-ing penetration of a Western lifestyle
come both increasedcaloric and sodium intake and decreased physical
activity.In these circumstances, cardiovascular diseases,
particularlyhypertension, are assuming increased prevalence.
Meditationtechniques, if they can be delivered efficiently and
effectively,may prove to be valuable tools to treat the growing
epidemicof hypertension, particularly if they eliminate the
inconve-niences of laboratory monitoring or prescription refills
andindeed have few and rare side effects.
It is our hope that this overview of meditation techniqueshas
highlighted prior successes, outlined the limitations exis-tent in
the field today and provided inspiration and guidanceto move the
field forward with mechanistic, specificallydetailed, and long-term
studies in the future.
Considering the current healthcare system in the UnitedStates,
it is possible for mindfulness interventions to beimplemented as
both prevention and treatment programs(pending confirmation of
their effectiveness). Most mindful-ness interventions can be taught
in a group format, whichreduces the cost on participants and the
burden on clinicians.As more treatments are standardized and their
efficacy canbe demonstrated in clinical trials, insurance companies
maybe more inclined to fund mindfulness training.
Longitudinalstudies must also be executed to determine if
mindfulnesscan act as a protective factor against an array of
psychosocialand medical ailments. Positive results may indicate
thatmindfulness interventions could produce a clinically
signifi-cant resiliency or protection against problems requiring
carefrom mental health and medical professionals. As a promis-ing
construct in complementary and alternative medicines,there is a
strong possibility that mindfulness could becomea component of
effective interventions designed to preventhypertension and lower
suboptimal BP.
References
[1] World Health Organization, The World Health Report 2002,vol.
58, World Health Organization, Geneva, Switzerland,2002.
[2] American Heart Association, Heart Disease and Stroke
Statis-tics—2005 Update, American Heart Association, Dallas,
Tex,USA, 2005.
[3] A. V. Chobanian, G. L. Bakris, H. R. Black et al., “The
sev-enth report of the joint national committee on
prevention,detection, evaluation, and treatment of high blood
pressure:the JNC 7 report,” Journal of the American Medical
Association,vol. 289, no. 19, pp. 2560–2572, 2003.
[4] C. V. S. Ram, “Antihypertensive drugs: an overview,”
AmericanJournal of Cardiovascular Drugs, vol. 2, no. 2, pp. 77–89,
2002.
[5] J. Dunbar-Jacob, K. Dwyer, and E. J. Dunning,
“Compliancewith antihypertensive regimen: a review of the research
in the1980s,” Annals of Behavioral Medicine, vol. 13, no. 1, pp.
31–39,1991.
[6] L. E. Burke, J. M. Dunbar-Jacob, and M. N. Hill,
“Compliancewith cardiovascular disease prevention strategies: a
review ofthe research,” Annals of Behavioral Medicine, vol. 19, no.
3, pp.239–263, 1997.
[7] T. S. Campbell, L. E. Labelle, S. L. Bacon, P. Faris, and
L.E. Carlson, “Impact of mindfulness-based stress reduction(MBSR)
on attention, rumination and resting blood pressurein women with
cancer: a waitlist-controlled study,” Journal ofBehavioral
Medicine. In press.
[8] L. B. Wright, M. J. Gregoski, M. S. Tingen, V. A. Barnes,
andF. A. Treiber, “Impact of stress reduction interventions
onhostility and ambulatory systolic blood pressure in
AfricanAmerican adolescents,” Journal of Black Psychology, vol. 37,
no.2, pp. 210–233, 2011.
[9] M. J. Gregoski, V. A. Barnes, M. S. Tingen, G. A.
Harshfield,and F. A. Treiber, “Breathing awareness meditation and
life-skills training programs influence upon ambulatory blood
-
10 International Journal of Hypertension
pressure and sodium excretion among African
Americanadolescents,” Journal of Adolescent Health, vol. 48, no. 1,
pp.59–64, 2011.
[10] J. W. Hughes, D. M. Fresco, M. van Dulmen, L. E. Carlson,R.
Josephson, and R. Myerscough, “Mindfulness-based stressreduction
for prehypertension,” Psychosomatic Medicine, vol.71, no. 3, p. 23,
2010.
[11] V. A. Barnes, F. A. Treiber, and H. Davis, “Impact of
tran-scendental meditation on cardiovascular function at rest
andduring acute stress in adolescents with high normal
bloodpressure,” Journal of Psychosomatic Research, vol. 51, no. 4,
pp.597–605, 2001.
[12] A. Castillo-Richmond, R. H. Schneider, C. N. Alexander
etal., “Effects of stress reduction on carotid atherosclerosis
inhypertensive African Americans,” Stroke, vol. 31, no. 3,
pp.568–573, 2000.
[13] S. R. Wenneberg, R. H. Schneider, K. G. Walton et al.,
“Acontrolled study of the effects of the transcendental
meditationprogram on cardiovascular reactivity and ambulatory
bloodpressure,” International Journal of Neuroscience, vol. 89, no.
1-2, pp. 15–28, 1997.
[14] S. I. Nidich, J. Z. Fields, M. V. Rainforth et al., “A
randomizedcontrolled trial of the effects of transcendental
meditationon quality of life in older breast cancer patients,”
IntegrativeCancer Therapies, vol. 8, no. 3, pp. 228–234, 2009.
[15] V. A. Barnes, F. A. Treiber, and M. H. Johnson, “Impact
oftranscendental meditation on ambulatory blood pressure
inAfrican-American adolescents,” American Journal of Hyperten-sion,
vol. 17, no. 4, pp. 366–369, 2004.
[16] P. Seer and J. M. Raeburn, “Meditation training and
essentialhypertension: a methodological study,” Journal of
BehavioralMedicine, vol. 3, no. 1, pp. 59–71, 1980.
[17] C. N. Alexander, R. H. Schneider, F. Staggers et al.,
“Trial ofstress reduction for hypertension in older African
Americans:II. Sex and risk subgroup analysis,” Hypertension, vol.
28, no.2, pp. 228–237, 1996.
[18] R. H. Schneider, F. Staggers, C. N. Alexander et al., “A
ran-domized controlled trial of stress reduction for hypertensionin
older African Americans,” Hypertension, vol. 26, no. 5, pp.820–827,
1995.
[19] R. H. Schneider, C. N. Alexander, F. Staggers et al., “A
random-ized controlled trial of stress reduction in African
Americanstreated for hypertension for over one year,” American
Journalof Hypertension, vol. 18, no. 1, pp. 88–98, 2005.
[20] R. H. Schneider, C. N. Alexander, F. Staggers et al.,
“Long-term effects of stress reduction on mortality in persons
≥55years of age with systemic hypertension,” American Journal
ofCardiology, vol. 95, no. 9, pp. 1060–1064, 2005.
[21] C. N. Alexander, E. J. Langer, R. I. Newman, H. M.
Chandler,and J. L. Davies, “Transcendental meditation,
mindfulness,and longevity: an experimental study with the elderly,”
Journalof Personality and Social Psychology, vol. 57, no. 6, pp.
950–964,1989.
[22] P. G. Kaufmann, R. G. Jacob, C. K. Ewart et al.,
“Hypertensionintervention pooling project,” Health Psychology, vol.
7, pp.209–224, 1988.
[23] M. J. Irvine and A. G. Logan, “Relaxation behavior
therapyas sole treatment for mild hypertension,”
PsychosomaticMedicine, vol. 53, no. 6, pp. 587–597, 1991.
[24] R. G. Jacob, M. A. Chesney, D. M. Williams, Y. Ding, and A.
P.Shapiro, “Relaxation therapy for hypertension: design effectsand
treatment effects,” Annals of Behavioral Medicine, vol. 13,no. 1,
pp. 5–17, 1991.
[25] L. L. Yen, W. K. Patrick, and W. C. Chie, “Comparison
ofrelaxation techniques, routine blood pressure measurements,and
self-learning packages in hypertension control,”
PreventiveMedicine, vol. 25, no. 3, pp. 339–345, 1996.
[26] C. Cottier, K. Shapiro, and S. Julius, “Treatment of
mildhypertension with progressive muscle relaxation.
Predictivevalue of indexes of sympathetic tone,” Archives of
InternalMedicine, vol. 144, no. 10, pp. 1954–1958, 1984.
[27] W. Linden, J. W. Lenz, and A. H. Con, “Individualized
stressmanagement for primary hypertension: a randomized
trial,”Archives of Internal Medicine, vol. 161, no. 8, pp.
1071–1080,2001.
[28] C. Patel, M. G. Marmot, D. J. Terry, M. Carruthers, B.
Hunt,and M. Patel, “Trial of relaxation in reducing coronary
risk:four year follow up,” British Medical Journal, vol. 290, no.
6475,pp. 1103–1106, 1985.
[29] C. Patel, M. G. Marmot, and D. J. Terry, “Controlled
trialof biofeedback-aided behavioural methods in reducing
mildhypertension,” British Medical Journal, vol. 282, no. 6281,
pp.2005–2008, 1981.
[30] J. D. Spence, P. A. Barnett, W. Linden, V. Ramsden, andP.
Taenzer, “Lifestyle modifications to prevent and
controlhypertension. 7. Recommendations on stress
management.Canadian Hypertension Society, Canadian Coalition for
HighBlood Pressure Prevention and Control, Laboratory Centrefor
Disease Control at Health Canada, Heart and StrokeFoundation of
Canada,” Canadian Medical Association Journal,vol. 160, no. 9, pp.
S46–S50, 1999.
[31] D. M. Eisenberg, T. L. Delbanco, C. S. Berkey et al.,
“Cognitivebehavioral techniques for hypertension: are they
effective?”Annals of Internal Medicine, vol. 118, no. 12, pp.
964–972,1993.
[32] W. Linden and L. Chambers, “Clinical effectiveness of
non-drug treatment for hypertension: a meta- analysis,” Annals
ofBehavioral Medicine, vol. 16, no. 1, pp. 35–45, 1994.
[33] M. B. Ospina, K. Bond, M. Karkhaneh et al.,
“Meditationpractices for health: state of the research,” Evidence
Report/Technology Assessment, no. 155, pp. 1–263, 2007.
[34] L. Bernardi, P. Sleight, G. Bandinelli et al., “Effect of
rosaryprayer and yoga mantras on autonomic cardiovascularrhythms:
comparative study,” British Medical Journal, vol. 323,no. 7327, pp.
1446–1449, 2001.
[35] F. Travis, “Comparison of coherence, amplitude, andeLORETA
patterns during transcendental meditation andTM-Sidhi practice,”
International Journal of Psychophysiology,vol. 81, no. 3, pp.
198–202, 2011.
[36] K. W. Brown and R. M. Ryan, “The benefits of being
present:mindfulness and its role in psychological well-being,”
Journalof Personality and Social Psychology, vol. 84, no. 4, pp.
822–848,2003.
[37] J. Kabat-Zinn, Full Catastrophe Living: Using the Wisdom
ofYour Body and Mind to Face Stress, Pain, and Illness, Delta,
NewYork, NY, USA, 1st edition, 1990.
[38] A. E. Beddoe, C. P. P. Yang, H. P. Kennedy, S. J. Weiss,
and K. A.Lee, “The effects of mindfulness-based yoga during
pregnancyon maternal psychological and physical distress,” Journal
ofObstetric, Gynecologic, and Neonatal Nursing, vol. 38, no. 3,
pp.310–319, 2009.
[39] S. C. Hayes, J. B. Luoma, F. W. Bond, A. Masuda, and J.
Lillis,“Acceptance and commitment therapy: model, processes
andoutcomes,” Behaviour Research and Therapy, vol. 44, no. 1,
pp.1–25, 2006.
-
International Journal of Hypertension 11
[40] M. M. Linehan, Cognitive-Behavioral Treatment of
BorderlinePersonality Disorder, Guilford Press, New York, NY, USA,
1stedition, 1993.
[41] G. Y. Yeh, M. J. Wood, B. H. Lorell et al., “Effects of
TaiChi mind-body movement therapy on functional status andexercise
capacity in patients with chronic heart failure: arandomized
controlled trial,” American Journal of Medicine,vol. 117, no. 8,
pp. 541–548, 2004.
[42] M. B. Schure, J. Christopher, and S. Christopher,
“Mind-bodymedicine and the art of self-care: teaching mindfulness
tocounseling students through yoga, meditation, and qigong,”Journal
of Counseling and Development, vol. 86, no. 1, pp. 47–56, 2008.
[43] J. W. Anderson, C. Liu, and R. J. Kryscio, “Blood pres-sure
response to transcendental meditation: a meta-analysis,”American
Journal of Hypertension, vol. 21, no. 3, pp. 310–316,2008.
[44] J. Kabat-Zinn, “An outpatient program in behavioral
medicinefor chronic pain patients based on the practice of
mindful-ness meditation: theoretical considerations and
preliminaryresults,” General Hospital Psychiatry, vol. 4, no. 1,
pp. 33–47,1982.
[45] M. V. Rainforth, R. H. Schneider, S. I. Nidich, C.
Gaylord-King, J. W. Salerno, and J. W. Anderson, “Stress reduction
pro-grams in patients with elevated blood pressure: a
systematicreview and meta-analysis,” Current Hypertension Reports,
vol.9, no. 6, pp. 520–528, 2007.
[46] L. J. Appel, C. M. Champagne, D. W. Harsha et al.,
“Effectsof comprehensive lifestyle modification on blood
pressurecontrol: main results of the PREMIER clinical trial,”
Journal ofthe American Medical Association, vol. 289, no. 16, pp.
2083–2093, 2003.
[47] S. A. Olivo, L. G. Macedo, I. C. Gadotti, J. Fuentes, T.
Stanton,and D. J. Magee, “Scales to assess the quality of
randomizedcontrolled trials: a systematic review,” Physical
Therapy, vol.88, no. 2, pp. 156–175, 2008.
[48] A. R. Jadad, R. A. Moore, D. Carroll et al., “Assessing the
qual-ity of reports of randomized clinical trials: is
blindingnecessary?” Controlled Clinical Trials, vol. 17, no. 1, pp.
1–12,1996.
[49] D. Moher, K. F. Schulz, D. G. Altman, and L. Lepage,
“TheCONSORT statement: revised recommendations for improv-ing the
quality of reports of parallel-group randomized trials,”Annals of
Internal Medicine, vol. 134, no. 8, pp. 657–662, 2001.
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