Preliminary study of Slow Deep Breathing in Mindfulness Exercise Effects on Physical Health Outcome among Hypertensive Patients

Hypertension from major vital organ complications in cardiovascular, cerebrovascular diseases, retinopathy and nephropathy, are major causes of morbidity and mortality.1-3 Most hypertensive patients have uncontrolable hypertension and need support to reach their goal of blood pressure 3,4 which poses a high risk of side effects and drug interaction from long term drugs therapy. Recently nonpharmocological treatment observed that slow breathing in mindfulness has been used to promote an alternative complementary treatment and has managed to lower blood pressure based on scientific data. The definition of consciousness is that the mind recognizes and accepts experience that arrives mentally, it is a form of concentration with a relaxed and clear mind in conjunction with brain processes.5-7 However, its effects on the reduction of physical health outcome is still seen as controversial with BP and HR. For example, D’Silva et al.8 found that there was no significant reduction in BP and HR after deep breathing exercise for patients with hypertension, coronary disease and diabetes mellitus. Meanwhile, other studies revealed that slow breathing was linked to beneficial effects on resting BP and HR in hypertensive patients.9

The Bangkok Medical Journal Vol.14, No.2; September 2018 ISSN 2287-0237 (online)/ 2287-9674 (print) Thus, the purpose of the current study was to see how hypertensive patients could perform slow breathing by observing mindfulness.From the result of the review, we hypothesized that after intervention, hypertensive patients would promote slow deep breathing, and this would lead to better physical health-related outcomes.

Materials and Methods
A quasi-experimental research was conducted with two-group three repeated measures design for this study.The area of study was from two PCU in two districts of Pathumthani province from July 2017 to September 2017.All subjects met the following inclusion criteria: 1. Aged 35 -59 years old 14 2. Stage I hypertension 3 (SBP140-159 mmHg and/or DBP 90-99 mmHg)

Instruments
8][19][20] The physical assessment recorded RR, BP, and HR measured on before (0 week), after (6 th week), and at follow-up (12 th week).All of the measurements were performed by registered nurse practitioners who passed an evaluated training in accordance with standard guidelines. 3,15

Data collection
The protocol and the informed consent were approved by the Research Ethics Committee of the Thammasat University, MTU-EC-ES-2-218/59, with the approval date of 18 January 2017, and all patients received the research objectives and submitted their written informed consents before any study related procedure was undertaken.
3. Taking antihypertensive drugs 4. No underlying complication of hypertension 3,15 5. Understanding Thai Participants who had limit learning processing, organic brain syndrome, or a history of psychiatric problems were excluded from this study.
The sample size was predetermined based on power analysis using G*Power statistics 16 with an effect size at 0.4, statistical power at 0.80, and obtaining a sample at least of 23 participants per group.Approximately 10% were added for drop out, obtaining the final sample of 26 participants per group.However, at the follow up on 12 th week there were 4 participants (experiment group) and 10 participants (control group) who were excluded (Figure 1).
Instructors training: Mindful contemplation training was obtained at Mahidol and Thammasat Universities for nine days and the Willpower Institute for six months.Meanwhile, a systematic review of the principle strategies in mindfulness were summarized.Then, the methods of breathing exercises of test-retest reproducibility were included in similar sample programs by following an expert's advisory.The instructor produced an intervention, comprising the principle observed in slow deep breathing in mindfulness lasting 1.5 hours per session.Weekly group meeting conversations were included.Participants were put into equal groups in morning and afternoon sessions.Six-coherence practices were observed.Feelings were recognized and adapted to everyday life, and daily individual practice continued at home and were recorded throughout until the follow up on the 12 th week.
The control group received hypertension guideline treatment 3 and participants were measured at the physical assessment appointment on the 0, 6 th , and 12 th week.The experiment group received hypertension guideline treatment 3 and participants were measured at the physical assessment appointment on 0, 6 th , and 12 th week.In addition, the six-week program was implemented by adding the six steps of observational breathing exercises to mindfulness skills with a group conversation to create the intention, attention, and attitudes through careful listening, non-judgmentally accepting, and respecting relationships.To beging with, peace in the environment was created, with no noise, and increased relaxation in body and mind.The six steps of breathing are as follows: • Step 1: Induce awareness of breathing, learning a new style with a scientific mechanism which is not only beneficial for the physical body but also for relaxation.The first step consists of a deep exhale (count 1, 2, 3, 5, and 6) followed by a deep inhale (count 1, 2, 3, and 4).

• Step 2:
To observe the differences in feeling when the breath is blown through the throat, chest, and abdomen.
The awareness feeling is found during the breath as it blows in and out.(i.e., know how the breath is blowing: short, long, deep or shallow).

• Step 3:
To discover the natural physical and mental symptoms from breathing observation (i.e., a feeling of relaxation or feeling uncomfortable) , with no breath counting and holding.

• Step 4:
To discover the transience of negative or positive emotions in cognitive feeling that comes back and goes out while breathing.

• Step 5:
To discover deep breathing with prolong inhaleexhale and how it induce a consistently slowed breathing rhythm which leads to relaxation in body and mind.• Step 6: Induce the emotional feeling reflected during the mindful group conversation.
Data collection and how each intervention was implemented is shown in Figure 2.

Statistical analysis
We used SPSS (version 22 for windows) with Chi-square test at the baseline of demographic data.The physical health data was tested by a normal probability plot and handling missing data, we used an intention-to-treat analyse on before (0 week), after (6 th week), at follow-up (12 th week) via a Generalized Linear Model (GLM) for repeated measures in order to estimate effect.The comparison and adjustment to the means score, and standard error, resulted in a 95% CI between the groups.

Results
There is a similarity in frequency distribution in demographic data between control and experiment group.Table 1 shows that both have high number of female participants (76.9-80.0%),age range (52.5-54.2years),duration of hypertension history (5.9-7.2 years).For the educational level, there was a high number of participants with primary school education in the control group, whereas this level was lower in the experiment group.
When comparing each group post intervention, a physical on the 6 th week outcome was statistically significant different with a decrease in RR 4.7 breaths/min (p = 0.007), DBP 6.7 mmHg (p = 0.008), HR 7.1 beats/min (p = 0.018), meanwhile, there was no statistical difference in systolic blood pressure (SBP) 1.0 (p = 0.783).At the follow up on the 12 th week, there was a statistically significant in RR 9.0 (p < 0.001), and DBP 5.6 (p = 0.002), meanwhile, there was no statistically significant difference in SBP 1.9 (p = 0.600), and HR 0.2 (p = 0.959) respectively, as show in Table 2 and Figure 3.

Discussion
There is a statistical significance at baseline in the physical outcome in DBP and HR but no significant difference in SBP between groups.However, the adjusted mean for this effect by GLM for repeated measure was used and the result found was that the observed breathing in mindfulness had been directly induced for a normal reduction of RR (19.4 ± 1.2, 13.6 ± 1.2, and 11.0 ± 1.3 breaths/min respectively).This mechanism began with 15 minutes going up to 30 minutes per day and had enhanced inner self-efficacy empowerment.2] Although the non intensive training for follow up at 3 weeks may be affecting minimal increase in DBP there was no detemination of HR.This study showed that the principal of slow and deep breathing with a natural breath flow approach had been created by individual intention, attention and attitude.The opened-heart in group conversation about mind and body symptoms also helped.][7] When there was a feeling of any thoughts, which come back and go out through the mind, the participants were able to understand and to see more clearly and come back to the new breathing.This breathing is based on true physical and affective states.An opened-heart discussion in a group process allows for an individual self-reflection progress that ultimately increased the basic performance levels of concentration. 7

Gender
-male -female Age (yrs.)-mean±SD Educational level -primary -secondary and over Duration of hypertension history (yrs.)Focused breathing may produce a flexibility of cognitive ability and self management in breathing behavior.The inner awareness and acceptance was opened from experienceinducing compassion for others as the mind. 6,7The conscious mechanism was to observe slow breathing with induced diaphragm movement rather than the chest breathing pattern. 21,22Thus, this linked to the system of the body, the effect of chemical central nervous system 23 and the autonomic nervous system 24 such as baroreceptors, the parasympathetic nervous system, and many other factors including improved endothelium-dependent vasodilatation, enhancement of baroreceptor sensitivity, and arterial compliance which may also be involved. 23,24e American Heart Association group showed the device-guided slow breathing at a standard level Class IIA, and the level of evidence B which is recommended for BPlowering efficacy. 25According to previous studies, the benefits researched were BP and HR reduction in normal people as well as in hypertensive patients. 26,27From the six studies researched in meta-analysis from 1974 -2016, it was revealed that 269 cardiovascular patients involved hypertensive patients, who had decreased BP and HR by slow breathing training. 28 consistant aspect in the study showed the importance of the addition of relaxation, mindfulness-based stress reduction, and meditation in hypertensive patients. 29The report showed that 10 minutes of focused attention on breathing movement at the lower abdomen is associated with significanly increased pressure levels of oxygenated haemoglobin as measured by near infrared spectroscopy.These was a significant increase in serotonin levels at 5 minutes and 30 minutes after attention was paid to conciousness through attentive breathing. 30The consistant research shows that breathing less than 10 times than the usual rate of 16.6 ± 2.8 times/minute involved deep exhaling at regular intervals of at least 15 minutes a day which led to reduced BP levels. 26,30,31The findings of breathing awareness meditation research measured office-BP measuring and this was more wildly statistically significant than Ambulatory Blood Pressure Measuring (ABPM).Indeed, the participants might be uncomfortable with ABPM measuring in a 24 hour period. 32,33n this study, the DBP on the 12 th week increased more than the 6 th week.Perhaps this was because after the 6th week the participants had non-continuous and intensive practice intervention at PCU.Furthermore, the SBP on 6th, 12 th week and HR on 12 th week were reduced but this was not statistically significant.This variety of factors might influence the physical health outcomes such as exercise or sodium consumption and medication compliance: these should be investigated in an intensive or randomized control trial for further study.Furthermore, there were some special qualitative data during the group conversation meeting: in daily life, the consciousness of body symptoms observation is useful for physical feeling (i.e., headache, chest pain, cardiac arrhythmias, dizziness).The psychological feeling (i.e., angry, distraction) is also important.In addition, there were an extended data in the final 12 th week follow up.They showed that physicians had stopped medication for 2 persons.Moreover they had reduced antihypertensive medication for 2 persons.Thus, these events possibly prevented polypharmacy and side effect of drugs.

Study limitations
The number of samples who missed the follow up was found more in the control group than in the experiment group.Thus, a normality plot was tested and we used the intention-totreat analysis comparing the adjusted means score, standard error, at 95 % CI between groups in order to handle missing data.The allocation was not a truly experimental design according to the limitations of suburban PCU areas.

Conclusions
Slow deep breathing in mindfulness has a positive effect on HR and DBP in physical health outcome as an intervention in lifestyle modification should complement treatment for stage I hypertensive patients.Furthermore, patients can benefit from group processing to raise awareness and to ease acceptance of physical and psychological effects of hypertension.Moreover, the mindfulness-group conversation experience in breathing should be based in the context of the participating PCU.

Figure 1 :
Figure 1: Sample flow through the study.

Figure 2 :
Figure 2: Data collection and intervention process.

Figure 3 :
Figure 3: Charts A, B, C, and D presented the effects of slow deep breathing in mindfulness for an improved physical health outcome.Data are presented as means and SE for experiment and control group.

Table 1 :
The general demographic data between control and experiment group *p from Chi-square test for two group and independent t-test for age and duration of hypertension history *Estimated mean adjusted from GLM for repeated measure *p < 0.05, **p < 0.01, ***p < 0.001.

Table 2 :
Adjusted means and standard error of physical health outcomes between control and experimental group