http://dx.doi.org/10.

1590/0103-166X2014000100012

Breathing and relaxation training for patients

with hypertension and stress

Treino de relaxamento e respiração em

pacientes com hipertensão e estresse

Livia de Matos CHICAYBAN1

Lucia Emmanoel Novaes MALAGRIS1

Abstract

This study evaluated the effects of the relaxation and breathing training for hypertensive patients on the index,
levels and symptoms of stress and blood pressure among hypertensive patients suffering from stress. Nineteen
patients from a hypertension and diabetes program in Rio de Janeiro participated in the study that which used, as
instruments, Lipp’s inventory of stress symptoms for adults, the psychological interview for hypertensive patients,
the relaxation and breathing training for hypertensive patients protocol, weekly registration form and blood
pressure monitors. The experimental group received the relaxation and breathing training for hypertensive
patients in 13 sessions of 60 minutes and had blood pressure monitored before and after each session. The
control group had blood pressure monitored weekly. It was observed that the relaxation and breathing training for
hypertensive patients reduced the stress index and symptoms in the experimental group in isolation, except when
compared to the control group. However, it did not reduce the levels of blood pressure in the experimental group
in comparison to the control group. The results report that, besides the relaxation and breathing training for
hypertensive patients, other strategies are necessary to control stress and hypertension.
B

Keywords: Blood pressure; Hypertension; Stress; Relaxation therapy. R

I
N

Resumo
A

Este estudo avaliou os efeitos do treino de relaxamento e respiração para hipertensos no índice, níveis, sintomas de L

stress e pressão arterial de hipertensos estressados. Participaram do estudo 19 pacientes de um programa de hipertensão A

I
O

e diabetes do Rio de Janeiro, utilizando-se como instrumentos o inventário de sintomas de stress para adultos de Lipp, N

entrevista psicológica para hipertensos, protocolo e folha de registro semanal do treino de relaxamento e respiração
F

para hipertensos e esfigmomanômetro. O grupo experimental submeteu-se ao treino de relaxamento e respiração

H

Y
 P

▼▼▼▼▼
I
O

1
Universidade Federal do Rio de Janeiro, Instituto de Psicologia, Programa de Pós-Graduação em Psicologia. Av. Pasteur, 250,
Fundos,
N

2º andar, Praia Vermelha, 22290-902, Rio de Janeiro, RJ, Brasil. Correspondência para/Correspondence to: L.E.N. MALAGRIS E-mail:
N

<lucianovaes@terra.com.br>.
S

Article based on the dissertation of L.M. Chicayban intitled “Stress e Hipertensão: treino de relaxamento e respiração como método de E

intervenção”. Universidade Federal do Rio de Janeiro, 2009.

Support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.
Acknowledgments: Centro Municipal de Saúde Marcolino Candau and the trainees Anna C. Andrade, Carla Telles, Gabriela
Lim
a
and
11
5
Luciana Bento, for their collaboration in the study field work.

Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro - março 2014

para hipertensos em 13 sessões de 60 minutos e teve pressão arterial aferida antes e após cada sessão. O
grupo- -controle compareceu semanalmente para aferir pressão arterial. Verificou-se que o treino de relaxamento
e respiração para hipertensos reduziu índice e sintomas de stress no grupo experimental, isoladamente, exceto
na comparação com o grupo-controle; contudo, não reduziu níveis de pressão arterial do grupo experimental,
comparado ao grupo- -controle. Os resultados indicam que, além do treino de relaxamento e respiração para
hipertensos, outras estratégias parecem necessárias para controle do stress e da hipertensão.
Palavras-chave: Pressão arterial; Hipertensão; Estresse; Terapia de relaxamento.
 (1965) commenced his studies on on Arterial Hypertension (Mion et
stress in the area of health, al., 2007; Sociedade Brasileira de
concluding that it was a matter of a Cardiologia, Sociedade Brasileira
complex, dynamic de Hipertenção e Sociedade
neuropsychophysiological process Brasileira de Nefrologia, 2010),
which takes place over three stages emphasize that Systemic Arterial
(alarm, resistance and exhaustion). Hypertension (SAH), or high arterial
According to the author, stress has Blood Pressure (BP), is a
an adaptive function and when
chronic, it may contribute to the Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro
development of various diseases - março 2014

(cardiovascular, renal, arthritis, multifactorial disease which

hypertension, ulcers and cancer). represents an independent,
Based on her field research, Lipp significant risk factor in the
(2000) concluded that the stress occurrence of cardiovascular
process occurs in four phases (alert,diseases and stroke Cerebral
resistance, near-exhaustion and Vascular Accident (CVA), giving rise
exhaustion) which, when it reaches to a high level of hospitalization
the advanced phases, involves a resulting from the complications of
significant degree of impairment of these diseases and posing a high
the organism (Lipp & Malagris, medical and socioeconomic cost.
2011). Accordingly, a close link has been
suggested between emotional
As far as Lipp (Lipp & Malagris,
stress and high BP. Amongst the
2001, p.477) is concerned, stress risk factors for the development,
can be defined as “the organism’s maintenance and aggravation of
reaction to psychological and hypertension, such as age
physical components, caused by (Daugherty et al., 2011), gender
psychophysiological alterations (Sandberg & Ji, 2012), family history
which occur when an individual is (Souza et al., 2009), race (Carson
confronted with a situation which in et al., 2011), obesity, sedentary
some way irritates, scares, excites lifestyle, use of alcohol, tobacco,
L

. or confuses him or even makes him birth control drugs and food rich in
C

H
immensely happy”. It is already sodium and fats (Forman, Stampfer,
I
C known that thoughts and mental & Curhan, 2009), emotional stress
processes play a clear role in stress is prominent (Lipp & Rocha, 1994,
A

(Lazarus & Folkman, 1984). As for 2008; Malagris et al., 2009). For this
B

N
reason, the 6th Brazilian Guidelines
the emotions, they sustain stress,
&
on Arterial Hypertension (Sociedade
activating physiological alterations
Brasileira de Cardiolo gia - SBC et
L

which comprise the stress response

.

.
al., 2010) emphasize the need for
and negative emotions contribute
N

.
stress management programs as a
M
significantly to the psychological
A fundamental, non pharmacological
L

A
and physical effects of stress (Lipp, step in the treatment of
G
Malagris, & Novais, 2007, Straub, hypertension.
R

I
2005), which include, amongst
Aspects such as the cost of
S

others, the development of high

continuous treatment with
blood pressure (Davis, Eshelman &
antihypertensive drugs, the potential
116 McKay, 2000).
lack of transparency with regard to
It was in the early 1930s that Selye The 5th and 6th Brazilian Guidelines the doctor patient relationship, the
multiple medications sometimes that hypertensive individuals tend to multinational company. These
prescribed and the collateral effects present with superficial breathing authors emphasize that deep,
of these drugs (Pimenta, Calhoun, &and, as a result, the level of carbon diaphragmatic breathing and muscle
Oparil, 2007), have served to dioxide in the blood rises, prompting relaxation, when applied in
explain and encourage the quest for respiratory acidosis. According to conjunction, are shown to be useful
non pharmacological approaches to these authors, correct breathing strategies for controlling excessive
controlling arterial pressure, such as occurs through a spacious stress. In Lipp’s stress control
complementary treatment. Studies inhalation that is deep, slow and
program, a reduction was found in
have found that the use of a uses both nostrils. It should be
the levels of stress and BP. In the
multidisciplinary approach, emphasized that exhaling should be
SCP developed by Lucini et al.
comprising clinical, pharmacological slower, via the mouth and should
(2008), a reduction in the level of
treatment and a program of take twice as long as it takes to
stress, a reversal in the deregulation
intervention to control the risk inhale. Slow, regular breathing
factors, is more effective in reducing produces beneficial effects in the of the Autonomous Nervous System
the rate of cardiovascular mortality cardiovascular reflex control through physiological parameters
and morbidity than treatment which system, including an increase in and a reduction in SBP were all
is exclusively drug-based (Khan et cardiorespiratory endurance and observed.
al., 2007; Pugliese et al., 2007; baroreflex sensitivity, reduction in The aims of the present study were
Sociedade Bra sileira de BP (Thalenberg, 2006; Thalenberg to: (a) compare the index, level
Cardiologia et al., 2010). et al., 2008; C.H.J. Pinheiro, (phase) and number of stress
One of these approaches, which Medeiros, Pinheiro, & Marinho
symptoms, identified using
complements the use of drugs, has 2007) and an increase in oxygen
Inventário de Sintomas de Stress
been the technique of relaxation, saturation in acute myocardial
para Adultos de Lipp (ISSL, Lipp’s
capable of making the body infarction (E. Grossman, Grossman,
Adult Stress Symptoms Inventory),
maintain a calmer, more balanced Shein, & Zimlichman, 2001).
after practicing Relaxation and
state, having an effect also on Pinheiro et al. (2007), carrying out
Breathing Training for Hypertensive
mental relaxation. Various types of treatment with a slow breathing
technique with hypertensive Patients (RBTHP) in the
relaxation techniques exist,
patients, obtained important results Experimental Group (EG), in
including Progressive Muscular
in respect of the cardiovascular relation to the passage of time, with
Relaxation (PMR) developed by
system: the modification in the the Control Group (CG); (b)
Jacobson in 1929 (Jacobson, 1938,
respiratory pattern improved compare the levels of basal blood
1993) which has proved to be
cardiovascular control in pressure (SBP and DBP) in
effective, non-invasive, simple, easy hypertension, through the reduction
stressed, hypertensive patients after
to learn and capable of bringing a in Systolic Blood Pressure (SBP),
practicing RBTHP in the EG,
reduction in BP in hypertensive Diastolic Blood Pressure (DBP), compared to the CG.
individuals (Sheu, Irvin, Lin, & Mar, reduction in respiratory frequency
2003). Jacobson’s initial argument as well as other hemodynamic
was that, given anxiogenic thoughts parameters evaluated in the study.
or events, the body reacts with The benefits for BP of relaxation
muscular tension and that and slow, deep breathing have been
progressive muscular relaxation, observed in hypertensive
through a reduction of tension from individuals using stress control
region to region of the body, leads programs such as Lipp’s Stress
to overall relaxation. Control Training (Lipp, 1991, 2007)
Another non-pharmacological and the stress control program
approach to the treatment of developed and administered by
hypertension is breathing training. Lucini, Riva, Pizzinelli and Pagani
Lipp and Rocha (1994) point out (2008) on employees in an Italian
 varied according to specific O

individual needs. Four participants, H

2 from the Experimental Group (EG)

Y

and 2 from the Control R

Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro I

O

- março 2014 N

117

Method

Participants

A total of 19 patients with

hypertension in stage 1 (mild
hypertension) and stage 2
(moderate hypertension) took part in B

the study, all of whom were treated

E

in the Hypertension and Diabetes

T

Program at the Centro Municipal de N

Saúde Marcolino Candau (CMSMC, A

Marcolino Candau Municipal Health N

Center), which is a part of the R

Sistema Único de Saúde (SUS,

E

Brazilian National Health System). X

The patients were monitored by a T

Program doctor, making use of

O

anti-hypertensive medication which F

 I
S (WRS-RBTHP), handed out every
week to the participants for them to
fill in each day at home with the
118 days of the week on which the
Group (CG), were excluded from relaxation and breathing exercises
the sample as they only showed up were carried out and returned to the
for one session. So the initial team at the time of the next session,
sample, comprising 23 participants, when the participant would receive
was reduced to 19, 9 in the EG and a new WRS-RBTHP and finally, a
calibrated analog pressure device,
10 in the CG, including,
or sphygmomanometer, certified
respectively, 5 women and 4 men
and approved by Instituto Nascional
(EG) and 9 women and 1 man (CG).
de Meterologia, Qualidade e
As far as age range is concerned,
Tecnologia (InMetro, Brazil’s
the participants had an average age
National Institute of Metrology,
of 54.26 ± 8.97. Quality and Technology).
The inclusion/exclusion criteria for
participation in the study were as
follows: being stressed from the Procedures
Resistance phase, as per the ISS L;
This research was part of a wider
being aged between 30 and 65;
study which aimed to compare
undergoing medical treatment for
Lipp’s full SCT with the use of
hypertension; not using
psychotropic drugs; not being
diabetic; not having suffered an Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro
- março 2014
Acute Myocardial Infarction (AMI); relaxation and breathing techniques
not having suffered a stroke (CVA); created on one of the SCT pillars,
not suffering from chronic renal already approved by the Municipal
disease, ischemic myocardiopathy Health Department’s Commission of
or known serious mental disorders; Ethics in Research on Human
being literate; not undergoing Beings. The procedure for the study
psychotherapy and not being an expounded here is based on the
expectant mother. application of the RBTHP protocol,
in 13 weekly sessions each lasting
60 minutes.
Instruments
L

.
After signing the ICF, the patients
were submitted to Psychological
M

. The following materials and

C

instruments were used: Informed Interview for Hypertensive Patients

H

I
C Consent Form (ICF); ISSL (Lipp, and to the ISSL. In the EG,
A

Y 2000, 2005) for an evaluation of the evaluations were carried out both
B

A
presence, phase and symptoms of before and after the RBTHP while in
N

stress; psychological interview for the CG, before and after the period
&

hypertensive patients, relaxation of time proportional to that used for

L

.
and breathing training protocol for the RBTHP (13 weeks). The groups
E

.
N hypertensive patients (Lipp & were composed according to order
.

Rocha, 2008); weekly record sheet of arrival at the interviews. The first
M

A
of relaxation and breathing training members of the sample were
L

A
for Hypertensive Patients assigned to the EG, until the
G

R
appropriate number of participants
was arrived at for the performance the participants, an experimental the exercises. As for the participants
of the RBTHP, while the others were session was conducted, so in fact in the CG, they were asked to turn
assigned to the CG. there were 13 sessions in total. The up at the CMSMC every week for 13
The Relaxation and Breathing participants’ BP was checked at the weeks to check their BP.
Training for Hypertensive Patients beginning and at the end of the At the end of the intervention period,
was forecast to be carried out in 12 RBTHP sessions, following the the participants in both groups were
weekly sessions of 60 minutes each patient preparation and pressure reassessed using the ISSL in the
(30 minutes relaxation and measurement procedures last RBTHP session, and in the CG
th
breathing exercises and 30 minutes recommended by the 5 Brazilian after 13 weeks, in order to check for
preparation of the participants and Guidelines on Hypertension (Mion changes in the stress diagnosis,
measurement of blood pressure), Jr. et al., 2007). In each session, the level of stress and levels of basal
based on Lipp’s SCT (Lipp, 1991). patients in the EG received the BP. The criteria for checking the
In order to teach the relaxation and WRS-RBTHP to fill in at home every effectiveness of the RBTHP were
slow, deep breathing technique to day, in which they were to mark the the reduction in SBP and DBP, as
days of the week they performed
well as a reduction in the level of stress and the a significant difference (p=0.029) in the EG,
number of physical and/or psychological taking into account the pre- and
symptoms of stress. post-intervention, in terms of the stress index,
indicating that there was a reduction in the
number of stressed individuals in the group. In
Results the CG, on the other hand, this was not the
case (p=1) (Tables 1 and 2). Comparing the EG
The data obtained were input to
and CG in terms of the stress index after the
Microsoft→ Office Excel 2003 spreadsheets,
RBTHP, a marginally insignificant difference
enabling the calculation of means and standard
was found (p=0.057). Therefore there was no
deviations for each variable. To analyze the
significant reduction in the index of stressed
results, the programs SPSS 13.0 for Windows
individuals in the EG after the RBTHP,
and SAS System for Windows, version 8.02
compared to the CG.
were used. In all the tests applied, a level of
significance of 5% (p<0.05) was used. In Table 3, the patients in each group are
characterized as to the diagnosis and
Analyzing the EG separately, the
symptomology of stress found in the ISSL in the
reevaluation indicated that, after the RBTHP, 5 initial assessment, and again at the end of the
(55.6%) patients no longer presented with study, in the reassessment. As for stress levels,
stress and 4 (44.4%) continued to experience it was found that in the EG, prior to intervention,
stress. As for the CG, after the period of 13 6 participants (67.0%) were in the Resistance
weeks, only 1 (10.0%) patient ceased to phase, while 3 (33.0%) were in the
present with stress, as opposed to the 9 Near-Exhaustion phase. In the CG, on the other
remaining patients (90.0%), who continued to hand, 7 patients (70.0%) were identified in the
be stressed. Analyzing each group separately, Resistance phase, while 3 (30.0%) received a
there was diagnosis of Near-Exhaustion. A similar
distribution was observed, therefore, between
the
Table 1

Stress index in the groups before and after the intervention. Rio de Janeiro (RJ),

2008 Presence
 of stress
A

Timing CG (n=10) Frequence % Frequence % p value

EG (n=9) No Total
Frequence % Intergroup
Frequence % CG (n=10)
B

EG (n=9) Frequence % R

Yes
Total Frequence %
E

Pre 99 100.0 10 10 100.0 19 19 100.0 09 100.0 0 100.0 0 100.0 AN

Total Post 4 9 10 1 19 6
D

044.4 9 090.0 13 19 068.4 59 055.6 010.0 031.6 p=0.057 R

Total 100.0 047.4 10 052.6 100.0 100.0 0 10 19

047.4 052.6 100.0
TH E

0
IN

100.0 0 G
LA

X
*
*
Note: p>0.05. Not analyzed, as all the participants were suffering from stress.
A

I
O

EG: Experimental Group; EC: Control Group; Pre: Before intervention; Post: After intervention.
N

Table 2
E

Index of intragroup stress in the CG, EG and the total sample, before and after the intervention. Rio de Janeiro (RJ), 2008
I
O

Total sampe Frequence % p Frequence % p

S

Timing CG
Frequence % p
T

N
R

EG D E

Pre 19 13 100.0 068.4 **

94 100.0 044.4 **
10 9 100.0 090.0
0.019 0.029 1.000
* * *
Post SS

Note: *Not analyzed, as all the participants were suffering from stress; **p<0.05.
119
EG: Experimental Group; EC: Control Group; Pre: Before; Post: After.

Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro - março 2014

groups prior to the intervention, there being no
statistically significant difference via the Fisher’s
Exact Test (p=1). After the intervention, in the
EG, there were 5 (55.6%) participants without
stress and 4 (44.4%) in the Resistance phase.
As for the CG, there was only 1 (10.0%) patient
with no stress,
8 (80.0%) in the Resistance phase and 1
(10.0%) in the Exhaustion phase. No patients
were found to be in the alert or near-exhaustion
phases in the reassessment, in either group.
The statistical analysis, via the Fisher’s exact
test, showed that there was no significant
difference between the groups

Table 3

Stress before and after the period of intervention, by group. Rio de Janeiro (RJ), 2008
 Patient 1E Post 2 2
Resistance 19
Pre No Stress 3 3 19
2E Post Resistance 0 3 13
Pre No Stress 5 1 10
3E Post Resistance 0 0 11
Pre No Stress 4 2 6
4E Post 0 0
Near-Exhaustion 14
Pre Resistance 7 1 5
5E Post 3 0
Near-Exhaustion 24
Pre Resistance 8 3 14
6E Post 5 2
Near-Exhaustion 31
Pre No Stress 7 3 29
7E Post 0 4
Resistance 29
Pre No Stress 6 3 8
8E
Post Resistance 0 0 16
Pre No Stress 2 2 2
9E
Post Resistance 0 0 14
Pre Resistance 4 3 6
1C
Post Near-Exhaustion 4 0 15
Pre Resistance 5 1 15
2C
Post Resistance 4 2 18
Pre Resistance 5 5 17
3C
Post Resistance 4 3 22

4C
Pre Resistance 3 4 22
Post Resistance 4 3 15

5C Pre Resistance 3 2 11
Post Near-Exhaustion 6 2 16
6C Pre Resistance 5 3 20
L
Post Resistance 4 3 28
.

M
7C Pre Resistance 1 5 21
.
Post Resistance 2 3 10
CH

Pre Resistance 4 4
IC

AY 8C 13
BA
N
Post Near-Exhaustion 1 3 21
&
9C Pre Exhaustion 6 5 11
L

.
Post Physical symptoms 7 4 40
E

10C in the phase Psychological

.
Phase 5 35
N
symptoms in the
.
Period 9
phase
M
Resistance Total number of
A

Pre Resistance symptoms

LA
2
G

Post Resistance 2 14
R
3
IS

Pre Resistance 6 10

120
Note: E: Patient Experimental Group; C: Patient Control Group; Pre: Before intervention; Post: After intervention. Estudos

de Psicologia I Campinas I 31(1) I 115-126 I janeiro - março 2014

(p=0.084). Consequently, a reduction in the symptoms in the EG, in the pre-intervention

level (phase) of stress was not observed in the period, revealed a mean of 19.0+7.3, with a
EG after the RBTHP, when compared with the variance of between 11 and 31 symptoms, while
CG. in the CG the corresponding numbers noted a
The analysis of the number of stress mean of 19.9+8.7, varying between 10 and 40
symptoms. The Mann Whitney test revealed
there was no statistically significant difference
between the groups in terms of stress
symptoms in the pre-intervention period
(p=0.78). After intervention, the EG obtained a
mean of 11.4+8.3 symptoms, with a minimum of
2 symptoms and a maximum of 29. The CG
obtained a mean of 17.1+8.1 symptoms, with a
minimum of 6 and maximum of 35 symptoms.
As the initial mean (pre-intervention) of
symptoms in the EG was equal to 19 and the
ending mean (post-intervention) was equal to
11.4, the total mean variation of symptoms
(difference between the ending and starting
mean number of symptoms), in this group,
corresponded to 7.6. In the CG, the starting
mean of symptoms
Table 4
was equal to 19.9 and the ending mean (after
13 weeks), was equal to 17.1, so the mean of
the total variance of symptoms in this group
equates to 2.8. Comparing the groups in terms
of the total number of post-intervention
symptoms, the Mann-Whitney test revealed
there was no statistically significant difference
(p=0.065). Although the mean of the total
variance of symptoms intragroup was 7.6 in the
EG and 2.8 in the CG, what can be seen is that,
comparing the groups in terms of the total
number of symptoms, using the Mann-Whitney
test, no statistically significant difference was
found (p=0.133).
The results shown separately by group
revealed that, in the EG, the symptoms of 8
participants were reduced, no participants
demonstrated an increase while just 1
participant continued to have the same number
of symptoms. The Wilcoxon test found
intragroup statistical significance for the EG
(p=0.012). On the other hand, in the CG, 6
participants had reduced symptoms over time,
2 showed an increase while 2 continued to
have the same number of symptoms.

Symptoms of stress by patient, before and after the period of intervention, by group. Rio de Janeiro (RJ), 2008
Symptoms p value - Symptoms Average Variance of p value - Variance in
Patient Before After Intragroup Symptoms Symptoms - Intergroup
Group
FO

3C 15 17 22 11 20 21 R

4C 13 11 35 H

5C
Y

6C ER
TE

EG 7.6 2.8 N

7C S

IO

* 8C
Note: p<0.05. *
N

1E 9C p=0.012 p=0.08
AND

2E 10C STR
E

14 19 13 11
3E SS

14 24 31 29 16 p=0.133
4E
BR

5E 14 15 18 22 15 16
EA
TH
IN

6E 28 10 21 40 G

7E 10 19 10 6 AN
D

CG 8E 5
R

9E 14 29 8 E

LA

1C 2 XA
T

IO

2C 6 N

121
EG: Experimental Group; EC: Control Group; E: Patient Experimental Group; C: Patient Experimental Group.

Using the Wilcoxon test, there was found to be
a difference in the CG after 13 weeks (p=0.08).
Consequently, evaluating just the EG, a
difference was found in the total number of
symptoms post intervention, but when
compared to the CG, no statistical difference
was found using the Mann Whitney test
(p=0.065). The difference between the EG and
the CG can be seen separately, by patient, in
Table 4.
With regard to the levels of basal blood
pressure, initially, the SBP of the EG and the
CG were compared, measured before the
sessions (SBP pre), the EG obtained a mean of
124.5+12.7, with a minimum of 102.0mmHg
and maximum of 142.2 mmHg. The CG
obtained a mean of 123.4+9.6, with a minimum
of 110.8mmHg and maximum of 143.3mmHg.
As for the mean DBP measured before the
sessions (DBP-pre), in the EG, a mean of
82.3+11 was identified, with a minimum of
62.8mmHg and maximum of 97.1mmHg. The
CG exhibited a mean of 81.3+5.2, with a
minimum of 74.2mmHg and maximum of
89.3mmHg. Subsequently, a comparative
analysis was conducted using the Anova test
for repeated SBP and DBP measurements
between the EG and the CG before
intervention, at the beginning of each session,
revealing no difference (SBP: p=0.73; DBP:
p=0.838). The same test was performed
comparing the groups, with the pre-session
values at the end of the intervention and again
no difference was found between the groups
(SBP: p=0.312; DBP: p=0.19). There was,
therefore, no significant SBP-pre or DBP-pre
variance between the EG and the CG neither
before nor after the intervention. Similarly, with
session SBP and comparing 2 C
H
DBP, the Anova L
analysis was M
1
performed for 4 5
3 I
repeated EG and CG, which difference between
the groups (SBP:
did not reveal a
measurements significant p=0.329; DBP:
. C
Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro - março 2014
regard to the post
each RBTHP session and then the mean
pressure variance was calculated for the 13
sessions. As far as the SBP is concerned, a
mean of 2.8+5.96 was found, lying between a
minimum value of -4.4 and a maximum of 15.6.
The t-test, applied to this variable in the EG,
obtained a result of p=0.196, a statistically
insignificant outcome. The DBP, on the other
hand, had a mean variance of 3.14+3.9, with
minimum and maximum values of -2.7 and 8.2,
respectively. For the mean DBP variance, in the
EG, the t-test showed p=0.041, demonstrating
the presence of statistical significance for this
variable. The result shows that, for SBP, there
was no significant variance before and after the
sessions, in the EG, based on the mean
variance in each session. As for the DBP, a
statistically significant variance was found,
denoting an increase in the levels. Table 5
displays the results relating to the CG (which
was not subjected to intervention): mean of the
SBP-pre and DBP-pre means each week and
the means of the “pre” means for every week
during the period of study.
Discussion
The most significant results observed in
this study relate to the physical and
psychological symptoms associated with stress
in the EG. It is
Table 5
Mean SBP pre and DBP pre in the CG each week and over the
total period
Weeks SBP Mean SBP Pre DBP Mean DBP Pre
A
Y p=0.212).
B
Accordingly, no
 significant post SBP the CG, neither EG, an analysis was
A
each session. To
or 6 before nor after the L
this end, the 13
intervention.
A

N
. 128.25 123.15 127.65
N

122.00 122.25 124.00

123.32 120.54 124.00
124.40 119.85 120.75
124.60
123.4
80.71 80.40 83.35 82.70
80.45 80.00 76.35 82.23
7 83.85 83.33 83.00 80.00
12
post DBP variance 9
I
S
81.00
was found between .
11
G 81.3
the EG and
M

&
performed of the
L
variance in pressure
between the
R

8 10
In addition, in the
.

start and end of

attributable to stress. The intragroup the study, acting to sustain the
outcome in the EG also levels of stress. According to the
corroborates the studies performed theories of Selye (1965) and Lipp
by Lipp (1991, 2007) and Lucini et (2003), in the second phase of
al. (2008), in which deep, stress, the individual’s capacity to
diaphragm breathing and muscular resist is considerably higher in order
122 relaxation, applied in combination to regain the equilibrium lost in the
pressure variance (difference and together with other resources, first phase (Alert). The organism
between starting and ending blood have been shown to be useful continues trying to maintain
pressure) was initially calculated in strategies for controlling excessive homeostasis and, if the stressor
stress. In the case of the present ceases or the individual succeeds in
Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro study, it is speculated that a sample benefiting from coping strategies,
- março 2014
with a larger number of participants the stress process may be
Note: SBP: Systolic Blood Pressure; DBP: Diastolic
Blood Pressure; Pre: Before intervention. would permit statistical significance interrupted in this phase. In the
possible that the reduction in the to be obtained in intergroup sample researched, basically
rate of stress symptoms found in thecomparisons. composed of participants coming
EG can be attributed to the RBTHP Evaluating the EG by itself, an from the more deprived
to which it was subjected, as it was improvement was seen in the stress communities close to the location of
only this group that saw an index, i.e. in the overall number of the study (CMSMC), it was possible
improvement in the stress index stressed individuals, but when to find that the participants were
when comparing pre- and compared to the CG, there was no exposed to social stressors such as
post-intervention. This outcome improvement in stress levels for unemployment, lack of adequate
supports the findings of Sheu et al. those who continued to be stressed. housing conditions, violence in the
(2003), who emphasized that the One hypothesis to explain this fact community, family problems arising
relaxation response may contribute is that the external and internal from unfavorable financial
to a reduction in anxiety and other sources of stress in some patients situations, amongst others. Social
negative, psychological reactions have persisted during the period of stressors like
these, already studied in some temperatures which, unfortunately,
depth by Gandarillas, Câmara, and were not possible to control. The
Scarparo (2005), are capable of second hypothesis relates to the
acting as external sources of stress, variances which occur differently in
precipitating it or simply maintaining SBP and DBP in hypertensive
the clinical condition. patients and is supported by the
Another possible explanation to study of Lipp, Frare, and Santos
enable an understanding of the (2007) which concluded that one
reason for which the level of stress might change while the other
in the EG, compared with the CG, remained unaltered. The variances
did not decrease, is that perhaps in SBP and DBP, according to these
the techniques of relaxation and authors, are linked to the specific,
breathing are not sufficient to exert experimental situation and to the
an effect on these stressors; i.e. it is patient’s psychological
possible that the technique is characteristics. The authors noted
effective in reducing the index and that unassertive individuals, who
the symptoms of stress through have difficulty in asserting their own
psycho-physiological alterations, but rights and expressing their thoughts,
not in acting on psychosocial and feelings and beliefs in a direct, clear,
internal stressors so as to eliminate sincere and context-relevant
stressors objectively and restructure manner,
erroneous evaluations of events and
distorted cognitions which could be Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro
- março 2014
at the core of the clinical stress
condition (R.S. Lazarus & D.N.
Lazarus, 1994; Lipp, 2001; Lipp &
Malagris, 2011; Malagris, 2004;
Lipp, Malagris, & Novais, 2007).
Possibly a sample with a higher
number of participants could clarify B

the results in order to provide a E

better explanation.
T

As far as the BP variable is

N

concerned, a statistical analysis A

found that the groups were D

comparable at the start of the study. R

Contrary to the hypothesis L

postulated, that there would be a

X

reduction in BP, it was found that, in

T

I
O

fact, there was no reduction in SBP. N

There was also no increase in DBP F

over time. The explanation for this R

fact may lie in two hypotheses. The Y

first relates to the environmental E

conditions, often unfavorable to the T

performance of the sessions, such

N

as noise and unsuitable

I
O

N
A
A

N
reduction of 2mmHg in the DBP in
association with
N

D &

S L non-pharmacological interventions,
.
T

E
E

.
using relaxation. It can be seen that
N

S
. the outcome of the present study, as
far as the SBP is concerned, is
M

A
similar to other interventions carried
123
G

R
out. On the other hand, with regard
I
S to DBP, the results found here
depart somewhat from these other
interventions. Nevertheless, it must
124 be borne in mind that, in the survey
so as not to violate the rights of of interventions performed using the
other individuals, and/or alexithymic relaxation technique described
individuals, who have difficulty in above, the reduction observed in
articulating emotions and describing DBP was small and insignificant.
feelings and bodily sensations,
While on the subject of the BP
exhibited a larger variance in DBP
variable, another issue to be
when asked to express themselves
highlighted concerns the
in terms of their feelings, as well as
performance of muscle contraction
a larger variance in SBP when
exercises which are part of the
asked to inhibit their feelings in
Progressive Muscular Relaxation
situations of interpersonal stress
technique. This technique has
and to control themselves
hemodynamic repercussions and
emotionally so as not to express
may cause an increase in arterial
their emotions. In the present study,
pressure if the contraction is kept
the participants received stimuli to
up. In other words, sustained
express their opinions and feelings
muscular contraction for a long
about the training, their existing
period acts like a tourniquet,
difficulties and applications in
preventing the blood from reaching
day-to-day situations of stress. The
the muscle, thereby increasing the
increase in DBP in the EG may be
pressure (Mota, Barreto, Bin,
explained by them being
Simões, & Campbell, 2008). In
encouraged to express feelings and
ideas, examined in the participants
Estudos de Psicologia I Campinas I 31(1) I 115-126 I janeiro
at the end of each session. - março 2014
this regard, it was noted that a
In addition to these explanations,
number of patients had difficulty in
the literature points to the
carrying out specific muscle group
discoveries made by the
exercises although they were
Hypertension Intervention Pooling
frequently instructed on how to carry
Project (Kaufmann et al., 1988).
out the movements correctly, these
which conducted a survey with 12
patients became distracted and
intervention studies involving the
maintained a different rhythm from
L

relationship between the PMR

.

the others, the muscles contracting

technique and BP. This survey
.

for longer than the defined period of

C

H
demonstrated that no significant
time. It is speculated that the
I

change in SBP was found, merely a

C

Y
maintenance of isometric muscle
B
contraction observed in some effective non-pharmacological carentes. Psicologia: Reflexão e Crítica,
patients could, together with the treatment of the illness should 18(1), 62-71.

expression of emotions, have
caused the rise in the DBP, found
uniquely in the EG.
In conclusion, the present study
involve other strategies that
complement relaxation and
breathing, such as changes in
lifestyle and the learning of
Grossman, E., Grossman, A., Shein, M.
H., & Zimlichman, R. (2001).
Breathing-control lowers blood
pressure. Journal of Human
Hypertension, 15(4), 263-269.

found that the RBTHP promoted a behavioral and cognitive techniques Jacobson, E. (1938). Progressive
to relaxation. Chicago: University of
reduction in the stress index of the
Chicago Press.
EG participants and also in the full control stress. These results may
Jacobson, E. (1993). Relax: como
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Khan, N. A., Hemmelgarn, B., Padwal,
periods. The effect of the RBTHP, to support the treatment of SAH, so R., Larochelle, P., Mahon, J. L.,
moreover, had repercussions on the that increasingly effective Lewanczuk, R. Z., et al. (2007). The
number of stress symptoms. These treatments may be developed. 2007 Canadian hypertension education
program recommendations for the
results corroborate earlier studies management of hypertension: Part 2 -
which recommend the use of therapy. Canadian Journal of
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