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Biofeedback For Hypertension

This disorder is one of the most common and vexing medical disorders in the Western world. Untreated hypertension (HT) is a contributing factor in premature death from stroke, kidney disease, and heart attack; elevated blood pressure affects some 50 million people in this country (Burt, Cutler, Higgins, Horan, Labarthe, Whelton, et al., 1995). Increased blood pressure (BP) risk factors include increasing age, diabetes, obesity, alcohol use, lack of exercise, high sodium diet, and chronic psychological stress (McGrady & Linden, 2003). There are significant gender and ethnic differences as well: Men have higher BP than women, and African-Americans have higher BP than Caucasians.

The explanation of the physiology of BP can be found in the book Biofeedback (Schwartz & Andraskik, 2003, p. 383 ff); it is too complex to review here. Briefly stated, barorecptors (BR), located in the heart and its arterial walls, are senstive to stretching which is a major factor in elevated BP. These receptors send messages to the medulla of the brain (which itself is a feedback loop). This is an important system, since the BR can influence hypertension within 5-10 seconds (see Schwartz & Andraskik, 2003, p. 383). What this means in terms of biofeedback is that by training the person's behavior, and including the brain in such training, HT can be positively influenced.

The Joint National Committee (JNC, 2004) meets every few years to classify the levels of HT as follows (for systolic BP):  Less than 120 is normal.  From 120-139 is prehypertension; over 140 is hypertension (HT), with the following categorizations: 140-159 is Stage 1; 160-179 is Stage 2; and Stage 3 is greater than 180. Over a decade ago, the 130 level would have been considered normal, but nowaday the level of over 130 warrants attention because of the prospect of future disease (JNC, 1997).

Although biofeedback has been known to be effective in lowering blood pressure (BP) for several decades, it seems to play a minor role in the medical treatment of cardiovascular disorders.  Several meta-analytic studies have shown the effectiveness of biofeedback and other behavioral treatments.  The review by Yucha and her colleagues (Yucha, Clark, Smith, Uris, Lafleur & Duval, 2001) revealed that both biofeedback and other active behavioral interventions resulted in lower systolic blood pressure (SBP) and/or diastolic blood pressure (DBP), with all treatments equally effective compared to no-treatment controls.  The average reduction was modest but meaningful (6.7 mmHg for SBP, and 4.8mmHg for DBP; Yucha et al, 2001).  Another meta-analysis by Nakao  and his colleagues (2003) supported this conclusion reviewing 22 randomized controlled studies in which they found that biofeedback reduced DBP by 7.3 mmHg and DBP by 5.8 mmHg.  Again, these results were equal to other behavioral treatments.

Lifestyle modification is commonly included in most biofeedback treatment, and a good example of this is the treatment of HT.  The JNC (2004) recommends the following for such patients:

  • Lose weight if overweight

  • Adopt the DASH eating plan

  • Limit alcohol to one drink per day (8 oz wine, 24 oz beer, or 2 oz liquor)

  • Exercise aerobically on a regular basis

  • Reduce sodium intake to less than 100 millimol per day (<6 grams of salt)

  • Do not smoke

  • Reduce dietary saturated fat and cholesterol intake

  • Maintain adequate dietary potassium, calcium and magnesium intake

Explaining the rationale for each component of a lifestyle change can be helpful in gaining cooperation of the patient.  For example, it could be explained that increased sodium causes retention of water and thereby increases BP because of the increased fluid in the body.  Aggressive treatment of high BP decreases the incidence of morbidity and mortality from cardiovascular events (McGrady & Linden, 2003).  The above lifestyle recommendations are often considered an integral part of the office practice of biofeedback, and the ones noted for hypertension could apply to many disorders.

Biofeedback is considered one component of many possible biobehavioral interventions.  Early studies reported the effectiveness of biofeedback alone or combined with other relaxation treatments in lowering BP in those with hypertension (Patel, 1973; Benson, Shapiro, Tulsky, & Schwartz, 1971; McGrady, Yonker, Tan, Fine, & Woerner, 1981).  What predicts whether a patient will be successful with biofeedback treatment for hypertension?  Higher neurogenic tone (Cottier, Shapiro, & Julius, 1984), higher anxiety, forehead muscle tension and cortisol levels have been reported (McGrady, Utz, Woerner, Bernal, & Higgins, 1986).

An important issue in hypertension treatment research is how high the BP is when treatment is started.  For example, subjects who enter a hypertension study with very high BP can be expected to show a more dramatic drop in blood pressure with treatment, thereby distorting the percentage of success rates in the study.  Still, biofeedback has been found to be helpful at all levels of hypertension (Linden & Chambers, 1994).





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Benson H., Shapiro,D.,  Tulsky, B, & Schwartz, G.E. (1971). Decreased systolic blood pressure through operant conditioning techniques in patients with essential hypertension. Science, 173, 740-741.

Burt, V., Cutler, J., Higgins, M., Horan, M., Labarthe, D., Whelton, P., et al. (1995). Trends in the prevalence, awareness, treatment, and control of hypertension in he adult US population.  Hypertension, 26, 60-69.

Cottier, C., Shapiro, K., & Julius, S. (1984).  Treatment of mild hypertension and emerging treat considerations. Archives of Internal Medicine, 144, 1954-1958.

Linden, W., & Chambers, L. (1994). Clinical effectiveness of non-drug therapies for hypertension: A meta-analysis.  Annals of Behavioral Medicine, 16, 35-45.

McGrady, A., Utz, S., Woerner, M., Bernal, G., & Higgins, J. (1986).  Predictors of success in hypertensives treated with biofeedback-assisted relaxation.  Biofeedback and Self-Regulation, 11 (23), 95-103.

McGrady A., & Linden, W. (2003). Biobehavioral treatment of essential hypertension. In M. Schwartz, & F. Andrasik (Eds.)  Biofeedback. NY: Guilford, pp. 382-407.

Nakao, M., Yano E., Nomura, S., & Kuboki, T. (2003). Blood pressure-lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertension Research, 26 (1), 37-46.

Patel, C. (1973). Yoga and biofeedback in the management of hypertension. Lancet, ii,1053-1055.

McGrady, A., Yonker, R., Tan, S., Fine, T., & Woerner, M, (1981).  The effect of biofeedback-assisted relaxation training on blood pressure and selected biochemical parameters in patients with essential hypertension.  Biofeedback and Self-Regulation, 6 (3), 343-353.

Schwartz, M., & Andrasik, F. (Eds.) (2003). Biofeedback A practitioner’s guide (3rd Ed.).NY: Guilford.

Yucha, C., Clark, L., Smith, M. Uris, P., Lafleur, B, & Duval, S. (2001). The effect of biofeedback in hypertension. Applied Nursing research, 14 (10), 29-35.

Goebel, M., Viol, G., & Orebaugh, C. (1993). An incremental model to isolate specific effects of behavioral treatments in essential hypertension.  Biofeedback and Self-Regulation, 18 (4), 255-280.

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