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
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<0.
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com
pare
dto
the
hea
lth
edu
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onco
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oup
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6 International Journal of Hypertension
Ta
ble
2:C
onti
nu
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ings
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dom
ized
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inde
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her
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ts’t
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ult
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dult
sag
ed22
–62
yrs.
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hes
sen
tial
hype
rten
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re)
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oup
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ived
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nin
gov
er5
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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
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AX
plac
ebo
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ph
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nin
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om
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adin
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at1
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terv
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dom
ized
,si
ngl
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ind
Exp
erie
nce
dT
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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
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Tran
scen
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tal
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itat
ion
(TM
)or
prog
ress
ive
mu
scle
rela
xati
on(P
MR
),w
ith
1w
k.in
itia
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stru
ctio
nan
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r.m
onth
lyfo
llow
ups
for
3m
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ive
(lif
esty
lem
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cati
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adin
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er1-
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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.
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