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Case study on hypertension, physical exercise and psychophysiological

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African Journal for Physical Activity and Health Sciences (AJPHES), Vol.
22(2:2), June 2016, pp. 514-524.

Case study on hypertension, physical exercise and

psychophysiological coherence biofeedback
STEPHEN D. EDWARDS

Psychology Department, University of Zululand, KwaDlangezwa, South Africa.

E-mail: sdedward@telkomsa.net

(Submitted: 05 May 2016; Revision Accepted: 21 May 2016)

Abstract

Hypertension is a serious stress related disorder, typically requiring pharmacology in

combination with various methods of health promotion including diet, specific lifestyle and
psychophysiological techniques. This case study describes the effective treatment of a
hypertensive crisis in a 63 year old woman with special reference to relevant, optimal, physical
exercise and psychophysiological, heart rhythm variability, biofeedback interventions.
Quantitative findings and client’s experiential descriptions provided convergent support for the
hypothesis that these interventions would be associated with blood pressure reductions. The
single case study is instructive with regard to the typically holistic, multifactorial nature of
aetiology, diagnosis and treatment, especially with regard to such common disorders as essential
hypertension.

Keywords: Introspection, case study, hypertension, blood pressure, physical exercise,

HeartMath, psychophysiological coherence.

How to cite this article:

Edwards, S.D. (2016). Case study on hypertension, physical exercise and psychophysiological
coherence biofeedback. African Journal for Physical Activity and Health Sciences, 22(2:2), 514-524.

Introduction

Hypertension is a serious stress related disorder, which affects at least 1 in 4

adults (Abuldager, 2012; American Heart Association, 2014). It is measured in
terms of systolic blood pressure, when the heart contracts, and diastolic blood
pressure, when the heart relaxes. Diastolic pressure increases up to middle age
and then tends to decline, whereas systolic pressure continues to increase with
age and is an important determinant of elevated blood pressure in middle-aged
and older adults. Hypertension risks increase with systolic readings above 140
mm Hg and diastolic readings above 90 mm Hg, reaching crisis levels when
these readings exceed 180 and/or 110 mm Hg respectively (American Heart
Foundation, 2014). In addition to pharmacology, blood pressure reductions are
reportedly achievable with various health promoting methods, including specific
lifestyle and mind-body techniques, such as optimum physical activity of 150
minutes a week and psychophysiological biofeedback, which are associated with
mean systolic reductions of up to 9 mm Hg and 14 mm Hg respectively (Childre,
 Hypertension, exercise and psychophysiological coherence biofeedback 515

Martin, Rozman & McCraty, 2016; Department of Health, Physical Activity,

Health Improvement and Prevention, 2004; McCraty, Atkinson & Tomasino
2003; Oberg, 2009). These techniques are the focus of the present case study.

Physical exercise may be defined as a subset of physical activities that are

planned and purposeful attempts to improve performance, health and/or
wellness. For example, in addition to vigorous, performance driven, pursuit of
athletic excellence, this includes regular, moderate intensity, exercise
interventions to promote health (Berger, 2001). Biofeedback involves the use of
instrumentation to monitor typically unconscious psychophysiological processes,
which may be brought under voluntary control (Thompson & Thompson, 2004).
This study used a HeartMath, Inner Balance, biofeedback apparatus to monitor
and train psychophysiological coherence, which was characterized by a heart
rhythm pattern of elevated amplitude in low frequency heart rate variability of
around 0.1 Hz, equivalent to about 5-7 breaths per minute, accompanied by heart
focussed breathing and the cultivation of positive emotional states such as
contentment, peace and happiness.

The goal of this study was to promote health in a hypertensive crisis experienced
by a client. In this context, health is viewed as a coherent, dynamic integrity of
various interacting energies, components and contexts (Childre et al., 2016;
Wilber, 2000). The aim was to evaluate physical exercise and
psychophysiological biofeedback interventions. In view of the abovementioned,
reported effectiveness of these techniques, it was hypothesized that they would
be effective in reducing blood pressure levels.

Methodology

The case study, with mixed quantitative and qualitative methodology (Creswell
& Plano-Clark, 2007), consisted of a health promotion intervention, involving
the recording of physical exercise and psychophysiological coherence practice,
and related personal experiences. The study began with a hypertensive crisis and
extended over a period of exactly two months. A contracted minimum number of
30 BP recordings sessions, taken after both physical exercise and HeartMath
practice, was deemed minimal for optimizing and evaluating intervention
effectiveness.

Participant

The client, code name W, was a female, 63 year old, retired, pre-primary school
teacher, with a Bachelor’s degree in Psychology and Education. A well-known,
active member of her local community, W was happily married, with two
children and two grandchildren, practised yoga, played tennis twice a week and
walked briskly for approximately 6 kilometres a day. This was her second
516 Edwards

hypertensive crisis. Following the initial episode, she was previously maintained
on the beta blocker, Bisoprolal fumerate (Cardicor), 2.5 mg by her medical
practitioner for the past four years. This second episode followed a period of
three weeks of fluctuating blood pressure, anxiety and stress related to a crisis
involving a close relative. Additional medication, angiotensin receptor
antagonist, Adco-Zetomax 5 mg, was prescribed. However acute symptoms of
dizziness, headache, loss of balance and left sided sensations of tingling and
numbness eventually led to emergency hospitalization. CT and MRA scans were
not clinically significant. Aware of the possible iatrogenic effects of medication,
as well as negative concomitants of anxiety and stress related activities, W
committed to focus on minimizing negative stresses, and optimizing health
promoting physical exercise and psychophysiological coherence interventions, to
complement existing medical hypertension prevention measures.

Ethics

Ethical approval for community projects involving health and/or sport promotion
was granted by the University to which the author, a clinical, sport psychologist
and certified HeartMath coach, is attached. In addition to providing written
informed consent, W was thoroughly informed on stress reduction with special
reference to optimal amounts of physical exercise as well as HeartMath research
and practice.

Instruments

A clinically validated, portable, battery operated, Dis-Chem Medic Upper Arm

Blood Pressure Monitor, Model KD558, was used to measure hypertension
levels. The cuff, which has a circumference of 22-30 cm, is inflated by an
automatic electric pump. The LCD display, and metric oscillations measuring
method, provides automated readings of date, time, systolic and diastolic blood
pressure, and pulse rate. The instrument, which has diastolic and systolic ranges
of 40-199 and 60-260 mm Hg respectively, can record pulse rates of 40-180,
with a pressure accuracy of approximately 3mm Hg and a pulse accuracy of
approximately 5%.

Heart Rate Variability (HRV) is well established as a diagnostic, training and

performance monitoring tool for promoting health, physical activity, exercise
and sport (Aubert, Seps & Beckers, 2003; Makivic, Nicik & Willis, 2013). Heart
Rate Variability Biofeedback (HRVB) equipment typically utilizes Fast Fourier
techniques for mathematical transformation of HRV into power spectral density
(Lehrer & Gevirtz, 2014; Shaffer, McCraty & Zerr, 2014). The HeartMath
biofeedback tool, Inner Balance, gives readings of psychophysiological
coherence practice with regard to date, time, session duration, heart rate
variability, average heart rate, achievement score, coherence score, challenge
 Hypertension, exercise and psychophysiological coherence biofeedback 517

level; which ranges from 1 to 4, coherence ratio, in terms of percentage of time

spent in low, medium or high coherence, time elapsed, and graphic display of
practice activity spent in a demarcated, coherent, zone of optimal, autonomic
nervous system functioning. Biofeedback consists of red, blue and green
coloured bars, with percentage indications and accompanying tones for low,
medium and high coherence levels respectively, as well as coherence points
accumulated. Session measurements are continuously monitored and recorded on
a Heart Cloud.

Physical exercise was simply measured in terms of its duration in minutes, and
intensity, using the Borg 10 point Category scales with Ratio properties (CR10)
of perceived exertion as a rough guide (Borg & Kaijser, 2005).

Data collection

Data collection simply took the form of recording 5 baseline or pre-test measures
and 30 blood pressure readings after both some form of physical exercise and
HeartMath practice sessions. W typically practised approximately one minute of
relaxation after each activity before recording BP in a sitting position in the same
chair. As indicated in the following experiential description, this brief relaxation
time was an additional source of improved resilience, insight and self-efficacy.

Data analysis

Data analysis took place after W had recorded 30 blood pressure readings
following some form of physical exercise or HeartMath practice. Quantitative
data were analysed with the Statistical Package for the Social Science (SPSS)
non parametric programmes for Kruskal Wallis, Mann Whitney, Wilcoxon and
Chi Square statistics.

Results

Quantitative findings.

W’s records lasted exactly two months. Her 30 physical exercise sessions
consisted of 16 walks, 5 individual sessions of tennis, 3 of yoga, 3 shopping and
3 of house cleaning. The records indicated a mean duration of 56.8 minutes, with
a standard deviation (SD) of 35.0, at an intensity level of 4.8 (SD = 1.4) spent on
physical exercise. Thus her physical exercise was typical of regular, moderate
intensity, interventions, known to promote health (Berger, 2001). Her 30
HeartMath sessions, recorded at the basic or beginner challenge level, averaged
11.1 minutes (SD = 4.3), with a mean Achievement level of 358.4 (SD = 171.6)
points accrued at a mean coherence level of 2.7 (SD = 0.6). The HeartMath
Institute recommends a minimum of 300 points a session. The Coherence Score
518 Edwards

Guide has the following categories: 0.5 = basic – good beginner level; 1 = good;
2 = very good; 3+ = excellent. (Most regular practitioner scores fall in the 3 to
6.5 range (R. McCraty, personal communication, 31 May, 2015). Thus, W’s
HeartMath practise satisfied minimum session achievement recommendations
and fell into the very good category of coherence. Her blood pressure, physical
exercise and HeartMath practice findings follow in Table 1.

Table 1: Means, Standard Deviations (SD), in parenthesis, and Kruskal Wallis analysis of
Baseline, Exercise (E) and HeartMath (H) conditions for Systolic Blood Pressure (SPB),
Diastolic Blood Pressure (DBP) and Pulse readings
Measure Baseline Exercise (E) HeartMath (H) Statistic
SPB 175.8 (5.0) 128.2 (9.7) 133.3 (6.5) X2 = 12.52**
DBP 88.6 (6.7) 73.4 (4.8) 75.3 (3.7) X2 = 12.26**
Pulse 72.0 (10.0) 58.9 (4.8) 58.2 (5.9) X2 = 9.0 **

Table 1 refers to Means, Standard Deviations (SD), in parenthesis, and Kruskal

Wallis, Chi Square (X2) comparisons between Baseline, Exercise (E) and
HeartMath (H) conditions for Systolic Blood Pressure (SPB), Diastolic Blood
Pressure (DBP) and Pulse readings respectively. As observed, there were
significant differences for comparisons between baseline, Exercise and
HeartMath interventions for: Systolic Blood Pressure (SPB), X2 = 12.52, p = .00;
Diastolic Blood Pressure (DBP), X2 = 12.26, p = .00; and Pulse recordings, X2 =
9.0, p = .00 respectively. Individual Mann-Whitney U comparisons indicated that
both interventions, separately, were significantly different from baseline. The
Baseline versus Exercise comparison indicated significant differences at the 1 %
significance levels for: SPB, Z = 3.5, p = .00; DBP, Z = 3.5, p = .00 and Pulse Z
= 3.0, p = .00 recordings respectively. The Baseline versus HeartMath
comparison indicated significant differences at the 1 % significance levels for:
SPB, Z = 3.5, p = .00; DBP, Z = 3.5, p = .00 and Pulse Z = 2.9, p = .00
recordings respectively. When individual comparisons were made between the
two interventions, results were as follows for: SPB, Z = 2.1, p = .03; DBP, Z =
1.7, p = .09 and Pulse Z = 0.5, p = .64 recordings respectively.

Thus in summary, the quantitative findings provide support for the hypothesis
that both Exercise and HeartMath interventions would be associated with
improvements in blood pressure. As can be observed from Table 1, although the
Exercise intervention appeared to be slightly more effective than the HeartMath
intervention, significance was only reached in the case of SPB. This difference
could be related to the relatively greater duration of time spent on physical
exercise, the basic, beginner level of HeartMath practise and/or various less
obvious factors.
 Hypertension, exercise and psychophysiological coherence biofeedback 519

Qualitative findings

W’s verbatim experiential description of the physical exercise and HeartMath

interventions was as follows:

“I am a health conscious and active person, who enjoys exercise and being
outdoors, however at times I tend to drive myself and overdo things. My husband
describes me as being: “Ever ready.” I also do not handle stressful situations
very well and tend to internalise them.

Two months ago, after a stressful time related to a crisis involving a close
relative, I experienced extreme dizziness and an overwhelming feeling of anxiety
while playing tennis. I visited my Doctor and my blood pressure was very high
and medication was prescribed. As the weeks passed I continued to feel unwell,
with headaches, dizziness, a feeling of being uncoordinated and off balance. I
also experienced the sensation of numbness and tingling in my limbs and face. I
was no longer sufficiently confident to do many of my routine activities like play
tennis or drive a car. This lead to increased anxiety on my part. I was admitted to
hospital for tests and, besides my potassium being below the normal reading,
nothing abnormal was found. I visited my Doctor for a follow up consultation
and my blood pressure was still moderately elevated and he again increased my
blood pressure medication. I was unhappy that my symptoms were being treated
without a cause being found. The medication was causing detrimental side
effects and I did not feel I wanted to take these blood pressure medications long
term. On doing some intensive research I discovered that many of my symptoms
correlated with a magnesium deficiency. I started taking a magnesium
supplement and began to sleep much more peacefully.

Although I had practiced HeartMath prior to this episode I was not very
proficient, nor did I do it regularly. In consultation with my psychologist I agreed
to do HeartMath, recording at least 1000 points a day. I also did moderate
exercise daily according to how severe my symptoms were at the time. I
purchased a home Blood Pressure machine to monitor my BP and began
reducing the blood pressure medication. I relaxed and monitored my blood
pressure in the same chair after either exercise or HeartMath. With the above
interventions my symptoms began to improve. I feel I have taken control of my
life again. I am now only on my original medication cardicor. My blood pressure
is back to what it was before this episode. I am becoming more proficient in
HeartMath and my coherence is improving all the time. I am able to get into the
zone quicker and centre positive feelings towards my heart. I have learnt to relax,
control my breathing and distance myself from stressful situations. I try to live in
the moment and let go of situations I can’t control. I am now able to participate
in all my sporting activities again and am back to driving a car.
520 Edwards

I believe this holistic treatment which includes HeartMath, moderate exercise

and the correct balance of magnesium, calcium and potassium have restored my
health and wellbeing. For this I have an enormous sense of gratitude and I will
continue with the above programme as a way of life.”

Discussion

W’s qualitative, experiential description supports and extends the

abovementioned brief summary and quantitative data. Clearly, she has
experienced emotional insight and change with regard to hypertension, anxiety,
stress management and general lifestyle. In addition to her blood pressure
reduction, she reports increased confidence, self-efficacy, health and well-being.
She attributes her transformation to “holistic treatment which includes
HeartMath, moderate exercise and the correct balance of magnesium, calcium
and potassium”. As effective treatment is typically multifactorial, it should be
noted that healing could also include many other, specific and non-specific, bio-
psycho-social-spiritual variables, as, for example, support of family and friends,
the relaxation response and biofeedback function of the blood pressure monitor.
To complete the scientific rigour of randomized controlled trials with large
samples of participants, single case study methodology adds this advantage of
readily elucidating the typically holistic, multifactorial nature of aetiology,
diagnosis and treatment.

The case study is based on and supportive of many research studies,

demonstrating the effectiveness of optimal physical exercise in preventing stress,
anxiety and depression (Biddle, Fox & Boutcher, 2000; Weinberg & Gould,
2016). Regular, moderate intensity exercise interventions seem particularly
valuable in promoting health and well-being, where the type, intensity and
duration of the exercise programmes are tailored to suit the particular exercisers
(Berger, 2001). Studying desirable changes in mood and meaning in exercise
programmes, researchers have emphasized non-competitive movement,
involving rhythmic, abdominal breathing of 20 to 30 minutes duration in
comfortable, predictable contexts as in Tai Chi, Pilates, Yoga, dance, aerobic
exercise and resistance training, which is performed in a slow, controlled way.
Various qualitative, quantitative, mixed and integrative methodologies have been
used to both describe the experience/meaning and measure such changes
(Berger, 2001; Edwards, 2006). Public health interventions attempting to
improve quality of life through increased exercise adherence clearly need to take
such personal meanings into account, as well as the learning principle that people
will repeat behaviours that are intrinsically rewarding.

Although the quantitative research evidence base for the benefits of physical
exercise interventions in health promotion programmes has become well
established internationally (Weinberg & Gould, 2016), there has been a relative
 Hypertension, exercise and psychophysiological coherence biofeedback 521

dearth of qualitative research on therapeutic movement interventions (Edwards,

2006). Health professionals need to explore carefully the meaning of physical
activity and movement in their clients before, during and after health and
physical exercise investigations and interventions. From a phenomenological
perspective, the lived body is mediator and anchor in the world. In dialogue with
the world, it is the source of pre-reflective intentionality, meaning and goal
directed behaviour. Building on positive past experiences that have been bodily
re-experienced as anchors is also an experientially grounded, theoretical basis for
such healing methods as Yoga, Tai Chi, remedial breathing, progressive
relaxation, systematic desensitization, visualization, imagery, multicultural
counselling and various forms of psychotherapy (Edwards, 2006; Ivey, Ivey &
Simek-Morgan, 1997; Weinberg & Gould, 2016). In W’s case, HeartMath
practise had been sporadic and, although physical exercise was well established,
it was occasionally excessive.

Inclusive of and similar to such techniques as transcendental meditation, zen and

yoga, research has indicated that the relaxation response (Benson, 1997, 2000) is
associated with significant reductions in blood pressure in hypertensive persons.
By its very nature, HeartMath practice is a concentrated and/or focussed form of
relaxation, associated with positive emotions, psychophysiological coherence,
enhanced resilience, insight, intuition, sense of coherence and/or self-efficacy
(Childre & Martin, 1999; Childre et al., 2016). In clinical, health and sport
contexts, HRV analysis serves as a non-invasive test of neuro-cardiac integrity
and autonomic balance, which is valuable in detecting and managing many
illnesses. For example, in addition to particular patterns associated with
particular conditions, stress, overtraining, ageing, illness and disorders such as
diabetes, hypertension, depression, anxiety and anger all also typically present
with lowered HRV. In addition to its great value in optimizing HRV, the Inner
Balance trainer includes a power spectrum display indicating a zone of optimal
sympathetic and parasympathetic functioning, for heart rhythm biofeedback
training towards effecting a perfect synchrony of zero degree phase relationship
between respiration and heart rate assisted by cultivation of positive emotions
and rhythmically stimulated paced breathing at a frequency of about 0.1 Hz, or
10 second rhythm and/or 5-7 breaths per minute (Edwards, 2015).

HeartMath research views emotions as energetic happenings generated

immediately from the occurrence of discontinuities or novel patterns that do not
match familiar, ongoing and recurring inputs (McCraty & Shaffer, 2015). Stress
related negative emotions, such as anxiety, are associated with amygdala
generated fight/flight/freeze responses. HeartMath theory postulates that
HeartMath techniques facilitate an immediate re-patterning effect via the natural
emergence of the physiological coherence mode. It is hypothesized that this
operates at physiological, emotional and cognitive levels, through changes in the
pattern of afferent cardiac signals sent to the brain, a positive feeling pattern
522 Edwards

match and associated cortical electrophysiological activity respectively.

Rigorous research has provided empirical support for these hypotheses in health
and physical activity contexts. (Edwards, 2015; McCraty, Atkinson, Tomasino,
& Bradley, 2009). After appropriate practice, their great value is to transform the
energy of negative emotions into polar opposites, e.g., anger into assertiveness,
feelings of overwhelming panic into centred motivation, overexcitement into
relaxed release, sadness into contentment, hatred into love, negative into
positively perceived stress. Physiologically, changes in afferent information that
occurs with HeartMath self-regulation techniques integrate a “bottom up”
process as well as a “top-down” cognitive approach. Firstly, energy expenditure
is required to better self-regulate, as techniques are practised and anchored.
Adherence is facilitated by mentoring. Secondly, the process become less
effortful, more automatic and intuitive. Thirdly, continued practice improves
resilience, lifts consciousness and brings more consistent, intuitive alignment
with the moment to moment intuitive guidance of the deeper Self (McCraty &
Zayas, 2014).

Conclusion

The case study satisfied the objective of health promotion for hypertension with
special reference to evaluation of physical exercise and psychophysiological
biofeedback interventions. Quantitative and qualitative, evidential and
experiential descriptions converged in support of the research hypothesis as to
reduction in blood pressure levels and related experiential phenomena. In view of
the typically holistic and multifactorial nature of successful treatment, therapy
and/or healing, it is probable that many other specific and non-specific, bio-
psycho-social-spiritual variables, were related to the aetiology and effectiveness
of these interventions. Further case studies as well as randomized controlled
trials using classic experimental designs, double blind methodologies and large
samples of participants will complement and extend evidence and knowledge on
the collective and exclusive usage of these and related hypertension
interventions.

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