Journal of Bodywork & Movement Therapies xxx (2017) 1e7

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Cardiac autonomic response after cranial technique of the fourth

ventricle (cv4) compression in systemic hypertensive subjects
Ana Christina Certain Curi a, Alex Souto Maior Alves a, Julio Guilherme Silva b, c, *
a
rio Augusto Motta), Rio de Janeiro, RJ, Brazil
Rehabilitation Science at UNISUAM (Centro Universita
b
rio Augusto Motta), Brazil
Rehabilitation Science at UNISUAM (Centro Universita
c
Department of Physical Therapy - UFRJ [Universidade Federal do Rio de Janeiro], Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study was to compare blood pressure (BP) behavior and heart rate variability
Received 28 July 2017 (HRV) among hypertensive stage I and normotensive individuals who were submitted to the cranial
Received in revised form technique of the 4th ventricle compression (CV4), an osteopathic technique.
18 October 2017
Methods: In this experimental controlled study, thirty men between 40 and 60 years old were evaluated
Accepted 21 November 2017
and divided into two groups: normotensive (NT) and hypertensive (HT). The CV4 maneuver was applied
in both groups and BP was measured at 5 (five) different stages: pre and post-intervention, 5, 10 and
Keywords:
15min after technique. Time-frequency parameters were obtained from measurements of RR intervals.
Hypertension
Musculoskeletal manipulations
Data were analyzed using an ANOVA two-way for analysis of the condition factor (NT and HT) and times
Osteopathic medicine with p-value
.05.
Heart rate variability Results: There was a reduction in the BP of the HT group. A significant intergroup difference (p ¼ .01) was
noticed, with respect to the standard deviation of successive normal R-R intervals (SDNN) values, mainly
between pre-intervention and 15min stages. Concerning root mean square of the mean squared differ-
ences (RNSSD) values, the highlights were differences between pre-intervention and 10min (p ¼ .01)
only in the NT group. There was an increase in high frequencies (HF) values and a low frequencies (LF)
attenuation in both groups at all different stages.
Conclusion: The data showed a BP reduction in the HT group in pre-intervention/15min and an increase
in parasympathetic activity and decreased sympathetic activity in both groups. This suggests a change in
the sympathetic-vagal balance. However, further studies are needed to elucidate the data on BP
reduction mechanisms with CV4.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction responsible for at least 45% of deaths related to cardiac complica-

Systemic hypertension (SH) is a silent disease with rare symp-
toms in the early stages, however, it is one of the risk factors for
cardiovascular diseases (Angeli et al., 2013; Bromfield and Muntner,
2013; WHO, 2013; Dasgupta et al., 2014). When undiagnosed and
therefore not treated, this condition can lead to complications in
organs such as the heart, the kidneys, the brain, the eyes and blood
vessels (Cloutier et al., 2015). According to guidelines established by
the World Health Organization (WHO, 2013), hypertension is
~ es, 34/ 1o,
* Corresponding author. Rehabilitation Science Program, Praça das Naço
Andar, Bonsucesso, Rio de Janeiro, RJ CEP 21041-010, Brazil. Tel.: þ 55 21 3882
9797x2012.
E-mail addresses: jglsilva@yahoo.com.br, julio.guilherme@unisuamdoc.com.br
(J.G. Silva).
tions and 51% of all cerebrovascular accidents (strokes) all over the
world.
In Brazil, surveys carried out during the last 20 years show that
more than 30% of the population is affected by hypertension,
reaching 50% over 65 years (Malta et al., 2015). Moreover, the Basic
Health Indicators and Data Brazil (IDB) indicate that 25% of the
population has been diagnosed and confirmed as having hyper-
tension. According to the Ministry of Health, hypertension affects
24.3% of the adult population, and as per the VII Brazilian Hyper-
tension Guidelines (Malachias et al., 2016), Systemic Arterial Hy-
pertension affects 35.8% of the male population and 30% of the
female population in Brazil.
Clinical trials indicate that hypertension detection, treatment
and control are critical for a decrease in the number of cardiovas-
cular events (Angeli et al., 2013; Dasgupta et al., 2014; Girotto et al.,

https://doi.org/10.1016/j.jbmt.2017.11.013
1360-8592/© 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
2 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7
2013). The main recommendation for patients with high blood
pressure is a change of lifestyle, that is, an improvement in eating
habits reducing sodium, fat and sugar consumption; the practice of
regular physical activity, to avoid alcoholic beverages and to reduce
the level of stress (WHO, 2013; Girotto et al., 2013; Campbell et al.,
2014). These guidelines are aimed at keeping Systemic Arterial
Hypertension under control, and even reversing the problem,
especially in patients with stage I hypertension. With regards to the
treatment of hypertension, there is plenty of information about
drug-free methods of intervention and/or actions that support
alternative approaches. They range from diets and the practice of
physical exercise to alternative techniques, such as the manual
therapies for cases of stage I hypertension (Taylor, 2014; Frishman
et al., 2005).
Within this scope, manual therapy techniques have been getting
special attention in the literature of this area for promoting sys-
temic changes that can contribute to the treatment of some sys-
temic diseases. Even though there is not a robust number of
findings, investigations such as the one by Shi et al. (2011); Miana
et al. (2013) and Nelson et al. (2006) started discussions about
the results of the physiological effects caused by the CV4, especially
with regard to hypertension, Frishman et al. (2005). In light of this,
we can call attention to the Osteopathic Manipulative Treatment
(OMT) and its various forms of intervention which work as a tool in
the control of hypertension.
Therefore, the OMT can be an important ally when associated
with changes to lifestyle and drug therapy. Among the various OMT
approaches, one specific technique calls attention to its systemic
effects: the 4th ventricle compression technique (CV4) and oste-
opathy treatment (Sutherland, 1962; Frishman et al., 2005;
Cerritelli et al., 2011; Shi et al., 2011, Miana et al., 2013). However,
there is a lack of research on the CV4 technique and its possible
systemic changes, mainly in hypertensive individuals. Thus, the
objective of this study is to analyze pressure behavior and auto-
nomic modulation, pre- and post-intervention with the use of the
CV4 osteopathic maneuver, in normotensive and hypertensive
individuals.
2. Method
2.1. Sample
In this experimental study, the sample was composed of hy-
pertensive and normotensive men aged between 40 and 60 years
old. Hypertensive individuals were recruited in the Osteopathy
Clinic of Hospital Municipal de Reabilitaça ~o Pedro II [Pedro II Reha-
bilitation City Hospital]. Normotensive individuals were recruited
by convenience. The research was based on CONSORT e Consoli-
dated Standards of Reporting Trials. This work was approved by the
Ethics Committee of Centro Universita
rio Augusto Motta (UNISUAM)
under number CAAE 47106115.0.0000.5235.
Regarding the eligibility criteria, the individuals who took part
in this work had a confirmed diagnosis of stage I hypertension
according to the 7th Brazilian Guidelines of Hypertension and the
ESH/ESC Guidelines for the management of arterial hypertension
2016, who had never heard of and/or undergone the osteopathic
manipulative CV4 cranial technique. Individuals under antihyper-
tensive drugs, with blood pressure (BP) under control, and/or under
psychotropic medication in general, painkillers, muscle relaxants or
any other medication that may alter the BP were excluded from the
study. Also excluded were individuals with chronic renal problems,
diabetes mellitus, previous or current cardiovascular diseases, si-
nus, pulmonary diseases, and those with cognitive deficits that
could compromise the understanding of instructions. Finally, those
who had drunk anything containing caffeine or alcohol and, also,
Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
those who had smoked tobacco within 30 min prior to the study,
and those who had practiced intense exercises 60e90 min before
the experiment was carried out were excluded as well (Geleilete
et al., 2009; Arterial Hypertension Program 2015). As far as the
definition of sample loss is concerned, individuals who described a
feeling headache, migraine, dizziness and/or nausea during CV-4
with occipital and/or cervical pain were not considered. If they
experienced any symptoms or side effects during an application of
the technique, the treatment would cease immediately. During the
study, there were no complaints from the subjects and sample loss.
2.2. study design
In this study, the participants were divided into two groups:
normotensive (NT) and hypertensive (HT). Therefore, this is the
flowchart with the study design (see Fig. 1).
2.3. Procedure
First, participants answered a triage questionnaire (anamnesis)
through which the following information was gathered: drugs
being taken, level of physical activity, an indication of being under
physical therapy. Next, in the osteopathy clinic at Pedro II Reha-
bilitation City Hospital, in an adequate and climatized environ-
ment, individuals had their BP and heart rate variability (HRV)
monitored by two devices: an ambulatory BP monitoring equip-
ment and a cardiac monitor. Both pieces of equipment were
dependable and had been tested (Gamelin et al., 2006; ESH/ESC
Guidelines for the management of arterial hypertension, 2013). In
reference to the CV4 osteopathic maneuver, it was used in both
groups by an Osteopath D.O with 12 years of clinical experience.
The performance of the intervention is carried out with the indi-
vidual in a dorsal decubitus position and lower limbs straight. The
technique, by Sutherland (1962), consists of a light compression
carried out with the practitioner's thenar eminence in the supra-
occipital region, precisely on the patient's squama of the occipital
bone with compression beginning with the exhalation phase of the
primary respiratory mechanism [PRM] and maintaining the
compression for 5 min (see Fig. 2), according to the proposal by
J€
akel and Hauenschild (2011).
2.4. Hemodynamic measurements
Before commencement of the osteopathic manipulative CV4
cranial technique, subjects rested quietly in a supine position for
5 min before the initial measurement of the resting BP. After
applying the osteopathic manipulative CV4 cranial technique, BP
was immediately measured and remeasured every 5min resulting
in a total of 5 readings (5min, 10min, and 15min after the inter-
vention). Before and after each session, subjects were fitted with
ambulatory BP monitoring equipment (PM50 Monitor; Contec
Medical, Beijing, China), and this equipment was used for all pre-
and post-intervention BP measurements. The ambulatory BP
equipment was auto-calibrated before each use to ensure accuracy.
Interpositions readings, because of factors such as interference,
were automatically edited by the software. During BP pre- and
post-monitoring, subjects remained in a supine position in a
temperature-controlled quiet room (21  C).
Assessment of Heart Rate Variability (HRV)
HRV analysis within the established time and frequency were
obtained based on the measurements of RR intervals taken during
five continuous minutes, in five different stages (pre- and post-
intervention periods, and the next 5, 10 and 15min). RR intervals
measurements were obtained through a cardiac monitor (Polar
RS800, EUA), with a sampling rate of 1 kHz, A/D resolution of 12 bits
 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7 3

Fig. 1. Study Design: division of the groups.

NN50 (number of interval differences of successive NN intervals

greater than 50 ms); pNN50 (percentage of normal R-R intervals
greater than 50 ms) and RMSSD (root mean square of the mean
squared differences) of successive R-R intervals (Chung et al., 2011;
Nooijen et al., 2015; Saunders et al., 2015).
For frequency-domain analysis, R-R intervals time series were
re-sampled to equal intervals by spline cubic interpolation method
at 2 Hz, and mean value and linear trend were removed. Fast
Fourier transformation was used for calculating the power spec-
trum (Welch's periodogram was employed to assess the 1024-point
spectra with a Hanning window and 50% overlap). Spectral power
was obtained by integrating the power spectrum density function
in the very low-frequency (VLF: 0.0033 and 0.04 Hz), the low-
frequency (LF: 0.04e0.15 Hz), and the high-frequency (HF:
0.15e0.40 Hz) bands. The spectral power was also computed in
normalized units for the HF [HFnu ¼ HF/(total power - VLF) X 100]
and LF [LFnu ¼ LF/(total power - VLF) X 100], and the autonomic
balance evaluated by the LF/HF (Chung et al., 2011; Saunders et al.,
2015).

2.5. Statistical analysis

Firstly, the Kolmogorov-Smirnov test was applied to verify

Fig. 2. CV4 maneuver.
and additional digital filtering, with frequency band between 0.5
and 40 Hz (3 dB) (high-pass filter in 0.5 Hz and low-pass filter in
40 Hz). The recording occurred under spontaneous voluntary
ventilation at rest (all groups showed an average breathing rate of
about 12 breaths per min). All readings were manually checked to
eliminate possible ectopic beats and artefacts originated from
electrical interference. However, the frequency of the edition reg-
isters always lower than 1% of all detected RR intervals.
The following time domain of HRV variables were analyzed: R-R
(mean of all normal R-R intervals) during the 10-min recording;
SDNN (standard deviation of successive normal R-R intervals);
sample distribution. After the confirmation of its normality, data
relating to sample characterization was treated based on descrip-
tive statistics, with the description of central (mean and median),
and dispersion tendency (standard deviation). In reference to
dependent variable data (BP), an ANOVA two-way was carried out
for the different stages (pre- and post-intervention, 5min, 10min
and 15min). The level of significance was 95% (p
.05). The pro-
gram used for the statistical analysis was SPSS version 20.0 IBM.
3. Results
Demographic data of the sample are in Table 1. About BMI, both
groups were overweight according to the BMI weight classification

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
4 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7

Table 1 in the HT group in the 5min post-intervention when compared to

Demographic Data of the sample. rest (see Fig. 4D).
Demographic Data NT (Mean/SD) HT (Mean/SD) Test T (p value) Fig. 5 shows resting and post-cranial technique of the 4th
Age (years) 50 ± 6.67 54.07 ± 7.11 p ¼ .689
ventricle compression mean values of SDNN and RMSSD for both
Weight (Kg) 84.47 ± 9.56 85.46 ± 9.05 p ¼ .895 groups (HT/NT). At 10 min post intervention, HT group exhibited
Height (m) 1.78 ± 0.07 1.73 ± 0.07 p ¼ .643 lower SDNN than NT group (P < .001) (see Fig. 5A). HT group
BMI (kg/m2) 26.92 ± 3.15 28.56 ± 2.72 p ¼ .680 showed decrease significant of SDNN in 10 min post intervention
NT ¼ Normotensive Group; HT¼ Hypertensive Group. when compared to rest and immediately post-intervention (see
Fig. 5A). As to RMSSD values, only significant differences were
found between the pre- and 10min intervention stages (p < .001) in
as per the WHO (2013). All individuals in the HT group were under the HT group (see Fig. 5B).
medical treatment. The sample used in both groups was formed by
individuals with a sedentary lifestyle according to their own 4. Discussion
anamnesis record file.
Fig. 3 showed significant differences in the systolic blood pres- The main objective of this work was to analyze blood pressure
sure (SBP) and diastolic blood pressure (DBP) at rest, immediately (BP) and heart rate (HR) behavior in hypertensive and normoten-
post-intervention, and 5 min, 10 min, 15 min Post-cranial technique sive individuals after the use of the CV4 technique.
of the 4th ventricle compression. Outcomes showed a significant Our data showed a decrease in the BP of the HT group, especially
decreasing SBP immediately post-intervention, and 5 min, 10 min, when comparing pre and 15min stage interventions. There was a
15 min in HT (see Fig. 3A). HT group showed a significant decrease significant decrease in the average values of systolic and diastolic
of the DBP only 5 min (85.3 ± 9.72 mmHg) and 15 min BP in the HT group, between pre and 15min stage interventions.
(84.6 ± 9.5 mmHg) post-cranial technique of the 4th ventricle This may be r elated to the relationship of the stimulus caused by
compression in relation to rest (89.2 ± 9.13 mmHg) (p < .005) (see the maneuver and the anatomic region. According to Sutherland
Fig. 3B). (1962), the CV4 technique activates the structures of the brain-
Fig. 4 shows the R-R interval, LF power, HF power, and LF/HF stem, cranial region of the parasympathetic nervous system (Brasil,
ratio to HT group versus NT group. In statistic between the groups 2017). In this manner, our data suggests that there is a relationship
no significant difference was observed, but R-R interval increases between the CV4 technique and the parasympathetic activation
significantly in 10 min and 15 min post-intervention to HT group and, consequently, a BP decrease. Therefore, results seem to agree
(p ¼ .001) (see Fig. 4A). Fig. 4B showed significant lower LF power with what is stated by Sutherland (1962) on the possibility of the
visually detected for the HT group in 10 min post-intervention CV4 technique promoting physiological changes by vagal nerve
versus at rest (p < .01). On the other hand, LF/HF ratio was lower stimulation.
In relation to HRV, which is the measurement of heart rate
frequency variation between each two beatings of the heart at a
certain time interval (R-R interval), this study intended to discuss
the distinct stages of time and frequency scopes. According to
studies by Sant'anna et al. (2015), Lopes et al. (2013), Júnior et al.
(2004) hypertensive individuals present a sympathetic hyperac-
tivity and, for this reason, a reduced HRV if compared to normo-
tensive individuals. Such information was confirmed by our results,
where the NT group showed a higher HRV, observed during the
power spectrum analysis of the RR interval variability.
Additionally, results of the HRV analysis that considered the
different times of intervention, which was performed based on
consecutive RR intervals, indicated that there was an increase in
SDNN behavior (standard deviation of all RR normal intervals) in
the NT group after the performance of the CV4 technique, between
pre- and 15min stage interventions. The SDNN variable is influ-
enced by the sympathetic-vagal tone. Still considering time, RMSSD
data (the square root of the squared mean of the differences be-
tween consecutive RR intervals) provides the quantification of
abrupt variations in variability, and reflect the changes in vagal
tone, showing a significant difference between pre and 10min
stages of intervention in the HT group. Such behavior may be
explained by the prevalence of parasympathetic activity and sug-
gests the existence of a predisposition to a BP drop and HR change,
after the CV4 technique.
As to frequency, the coefficient between LF and HF (LF/HF ratio)
is used to express the autonomic modulation. Our results presented
an increase in the HF/LF ratio mainly due to the increase of the
parasympathetic activity (HF) and the decrease of the sympathetic
activity (LF). This data resembles the discoveries of the work of Shi
Fig. 3. Hemodynamic response at rest, immediately post intervention, and 5min, et al. Geleilete et al., 2009 who demonstrated in the study carried
10min, and 15min after the intervention for normotensive versus hypertensive. Data
are presented as mean ± SD.
out with 21 healthy individuals (8 women and 13 men), that the
*p < .005eSignificant difference between the groups (HT/NT). CV4 technique may promote a sympathovagal modulation, after
#p < .005 - Significant difference within the groups (Rest and Post intervention). the HRV analysis. Milnes and Moran (2007), on the other hand, with

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7
Fig. 4. Frequency-domain of HRV at rest, immediately post intervention, and 5min, 10min, and 15min after the intervention for normotensive versus hypertensive. Data are
presented as mean ± SD.
#p < .001 - Significant difference within the groups (Rest and Post-intervention).
Fig. 5. Time-domain of HRV at rest, immediately post intervention, and 5min, 10min,
and 15min after the intervention for normotensive versus hypertensive. Data are
presented as mean ± SD.
*p < .001eSignificant difference between the groups (HT/NT).
#p < .001 - Significant difference within the groups (Rest and Post-intervention).
Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
5
10 asymptomatic individuals (4 men and 6 women), observed that
after the CV4 technique the parasympathetic activity increased in
only 3 individuals.
Despite the lack of studies, investigations such as the one by Shi
et al. (2011); Miana et al. (2013) and Nelson et al. (2006). Started
discussions about the effects of the physiological effects caused by
the CV4. Miana et al. (2013) showed alterations to cortical activity,
especially in the alpha band, in healthy individuals submitted to the
CV4 technique. This specific technique caused a significant increase
of alpha absolute power and, the higher the energy in the elec-
trodes of the central parietal region, the lower the activation.
Therefore, this justified the state of relaxation observed in the in-
dividuals after the CV4 technique was performed. However, this
state of relaxation maybe related to the effects of a decrease in BP
seen in this work, however, our data does not provide us with much
theoretical support in this sense.
Shi et al. (2011) analyzed, in healthy individuals, through
infrared spectroscopy, the saturation of tissue oxygen (SCTO2) and
cardiac autonomic modulation, with the ECG, using osteopathic
manipulative cranial techniques, such as the CV4. Results showed a
cerebral hemodynamic reduction after the decrease in the
oxygenation of brain tissue in right and left prefrontal cortex re-
gions during the time the CV4 technique was performed. They also
observed a decrease in cardiac sympathetic modulation and the
increase in vagal activity, detected in the variation of RR interval
spectral power. Despite the use of various cranial techniques, the
findings of Shi et al. (2011) confirm the data found in this investi-
gation which has identified an increase of parasympathetic activity.
This was confirmed by the values found in the frequency scope. In
this context, the CV4 technique seems to be able to promote
physiological changes and obtain improvements in some clinical
manifestations.
6 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7
Nelson et al. (2006) showed an alteration in the T-H (Traube-
Hering) frequency component due to a change in the speed of blood
flow after the CV4. In a previous study it was shown, through a
laser-Doppler flowmetry, that THM (Traube - Hering - Mayer) os-
cillations coincide with the primary respiratory mechanism (PRM)
or cranial rhythmic impulse - CRI (Nelson et al., 2001). Tissue
perfusion, circulatory homeostasis, and body temperature are
considered a result of THM oscillation. Therefore, blood pressure
and flow speed are also a consequence of the THM frequency and
suffer autonomic nervous system (ANS) interference as well
(Machado and Haerthel, 2013; Nelson et al., 2001). ANS acts on the
regulation of the cardiac frequency which will, consequently,
impact BP and the blood flow propelled to the tissues. Conse-
quently, one can imply that the CV4 technique influences BP and
cardiac flow, as per the results of this study.
Due to the lack of literature on similar experiments, the compar-
ison was restricted. However, Cerritelli et al. (2011) in a similar study,
investigated the effects of an osteopathic manipulative treatment
(OMT) in individuals with hypertension and vascular alterations. The
osteopathic program consisted of maneuvers according to the
detection of somatic dysfunctions, in accordance with OMT precepts,
during a year of follow up. For this purpose, 63 individuals were
included, divided into two groups, (31 nonrandomized to the OMT
group and 32 in the control groups). All participants had their basal
rates recorded (BP, CR in rest, tunica intima average widths and BMI)
at a pre and post OMT stage. Nonetheless, the variables that involve
changes to lifestyle, such as a low salt diet, physical exercises and
stress level were not mentioned. The sessions were carried out every
15 days. The results of the Cerritelli et al. (2011) indicated an
improvement in BP and tunica intima average width, associated with
OMT, at the end of the monitoring period.
5. Study limitations
There is a restriction as to the number of comparisons available
and therefore a restriction in the number of comparisons
mentioned in our results. Another important aspect that limited
part of this investigation was the absence of a placebo group. Had
these two groups been included, our observations could have been
expanded and a more critical look at the HRV behavior would have
been allowed. Another limiting aspect was the possibility that
respiratory frequency may have interfered with the HRV. It would
have been interesting to have controlled this variable. Finally, the
HRV monitoring period (25min) may not have been enough to state
that the values measured would have been maintained.
6. Conclusion
This study showed a decrease in BP among the HT group be-
tween pre and 15min stage interventions with the CV4 technique.
An HRV analysis indicated an increase in parasympathetic activity
and a sympathetic decrease in both groups, and this suggests an
alteration in autonomic modulation balance. Both when consid-
ering time and frequency. New investigations on this topic are
necessary, especially involving clinical trials, to better clarify the
physiological mechanisms involved in the performance of the CV4
technique and their autonomous answers.
Declaration of interest
The authors report no CONFLICT of interest.
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Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013