A COMPARATIVE STUDY ON THE EFFECTIVENESS OF

RELAXATION TECHNIQUES ON HYPERTENSION BY USING

BOX TECHNIQUE AND GIUDED IMAGINARY
INTRODUCTION
Globally more than 1.3 billion people are hypertension globally, 82% live in low- and
middle-income countries, and India alone is estimated to have 220 million adults with
hypertension according to World Health Organization
Hypertension (high blood pressure) is when the pressure in the blood vessels is too high
(140/90 mmHg or higher). The high blood pressure eventually leads to heart failure,
strokes, heart attacks, blindness, kidney failure, loss of libido and poor circulation of
blood in the legs.
There are various mechanisms described for the development of hypertension which includes
the increased salt absorption resulting in volume expansion,an impaired response of the
renin-angiotensin-aldosterone system (RAAS),increased activation of the sympathetic
nervous system. These changes lead to the development of increased total peripheral
resistance and increased afterload which in turn leads to the development of hypertension

Risk factors of hypertension is broadly classified into Modifiable risk factors like unhealthy
diets like excessive salt consumption, a diet high in saturated fat and trans fats, low intake
of fruits and vegetables); physical inactivity, consumption of tobacco and alcohol; being
overweight or obese. The Non-modifiable risk factors includes a family history of
hypertension; age over 65 years; co-existing diseases like diabetes or kidney disease
As well as psychosocial factors such as depression, anxiety, lack of social support and
hostility, acute and chronic stress factors also increase the risk of developing hypertension.
To lower blood pressure, antihypertensive drugs are available, as well as various non-drug
treatment options involving a change in individual behavioural patterns persist.
Box breathing exercises stimulates the parasympathetic nervous system and suppress the
sympathetic nervous system, sending messages to and fro along the vagus nerve leading to
relaxation response.
Guided imagery is a mind-body therapy that involves the visualisation of various mental
images to facilitate relaxation and reduction in blood pressure. This involves instructional
guidance that invokes sensory experiences and behavioural and physiological responses.

AIM AND NEED FOR THE STUDY

The aim of the study is to compare the effectiveness of relaxation technique on hypertensive
patients by using box breathing technique or guided imaginary.

NEED OF THE STUDY:

This study is essential as most of the population suffer from this problem. It also helps the
physiotherapist to enhance their knowledge in recent concepts to treat condition like
hypertension as little evidence exists to indicate the effectiveness of physiotherapeutic
interventions

REVIEW OF LITERATURE
1. Mori H.,et al (2005)
The effect of deep breathing on blood pressure and pulse rate. Journal of human hypertension
Research.
2. AlShukeili et al: (2008)
A Control and Management of Hypertension at a University Health Centre in Oman. Sultan
Qaboos University Medical Journal.
3.Mungreiphy NK et al:(2011).
Association between BMI, Blood Pressure, and Age: Study among Tangkhul Naga Tribal
Males of Northeast India. Journal of Anthropology.
4Sattari,et al: 2012.
GI RCTs often focus on medically associated pain and stress management. Several of these
studies have found GI effective. In comparison to controls, GI has decreased intensity,
frequency, and duration of chronic tensiontype headaches .

5. Carretero OA et al:(2013).
Prevalence and risk factors for resistant hypertension among hypertensive patients from a
developing country. BMC Research Notes
6. Heitkemper Dirksen, et al:(2013).
Medical surgical Nursing: Assessment and Management of clinical problems. Maureen
Barry, Sandra Goldsworthy, Donna Goodridge editors. 4th ed. Canada. Elsevier publication.
7. Dorairaj Prabhakaran.et al:(2014)
Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and
control of hypertension. Journal of Hypertension.
8. Dr. Amel Gomaa et at:(2014)
Effect of slow deep breathing exercise on blood pressure and heart rate among newly
diagnosed patients with essential hypertension. Journal of Education and Practice
9.National Center for Complementary and Integrative Health, 2016 et al:
Guided imagery (GI) is a relaxation technique that relies on descriptive language to facilitate
listener visualization of detailed, calming images, with the goal of achieving a relaxation
response
10. Patricia LG.et al:(2017)
Sudarsan kriya yogic breathing in the treatment of stress, anxiety and depression: Part I
Neurophysiologic model. The journal of alternative and complementary medicine.

DESIGN AND METHODOLOGY

RESEARCH DESIGN:
This study is experimental research design.
The Study was experimental in nature . Thirty subjects were selected using simple random
sampling method and were divided into two equal groups.
1. Experimental group I
2. Experimental group II
Pre test measurements were done for pain with the help of Visual analogue scale
(VAS).
After the pretest assessment the experimental group I received box breathing
for a period of 3 weeks and experimental group II received guided imagery for a period for
3 weeks . Post test measurements were done on 3th week in a similar fashion as that of
pretest measurement.

EXPERIMENTAL GROUP- I
Day 1 21th day
Box breathing technique

Pre-test Post-test

EXPERIMENTAL GROUP -II

Day 1 21th day

Guided imagery technique

Pre-test Post-test

CRITERIA FOR SELECTION

 Subjects both male and females are included.

 Subjects with age group between 45-55 years are included.

 Subjects with only primary hypertension were included.

 Subjects who were psychologically fit were only included.

 Subjects with other associated problems were excluded.

POPULATION
Subjects who fulfilled the selection criteria were considered as the population.

SAMPLE SIZE AND METHOD OF SELECTION

Thirty samples were selected from the population using simple random sampling method.

VARIABLES
INDEPENDENT VARIABLE
Box breathing technique
Guided imagery

DEPENDENT VARIABLE
Hypertension

VALIDITY AND RELIABILITY OF THE TOOL USED

Sphygmomanometer.

SETTING
The study was conducted in the Department of Physiotherapy , Vinayaka Mission’s kirupananda
variyar Medical College and Hospital , Salem .

METHODOLOGY
Thirty samples were selected from the population by simple random sampling method.

The pretest measurement was taken with sphygmomanometer on measuring blood

pressure were recorded.

Post test measurements were taken on 3th week in the similar manner as the pretest
measurement and were recorded .

MEASUREMENT:

A sphygmomanometer is an instrument used to measure blood pressure. It typically consists of an

inflatable cuff, a pressure gauge, and a bulb for inflating the cuff
The cuff is wrapped around the upper arm and inflated using the bulb. This inflates the cuff to a
pressure that temporarily occludes the blood flow in the artery.
As the cuff deflates, the gauge measures the pressure in the cuff. This pressure is used to determine
the systolic and diastolic blood pressure.
Systolic Pressure:This is the higher number and represents the pressure in the arteries when the heart
beats. It is identified by the first sound heard through a stethoscope placed over the artery as the cuff
deflates.
Diastolic Pressure: This is the lower number and represents the pressure in the arteries when the heart
rests between beats. It is identified by the last sound heard through the stethoscope before it
disappears as the cuff continues to deflate.
TREATMENT PROCEDURE :
EXPERIMENTAL GROUP -1
(box breathing technique)
The experimental group 1 were given box breathing technique.
The patient is asked to sit or lie down comfortably and patient is instructed to close their eyes
and asked to place the hands on the stomach to notice the rise and fall of the abdomen and
then the patient is asked to inhale for 4 seconds and to hold the breath for 4 sec and then
asked to exhale for 4 seconds.
This procedure is followed for the period of 5- 7 mins for two sessions in the morning and in
the evening after the exercise the bp is again measured. This procedure is followed for a
period of 3weeks.
EXPERIMENTAL GROUP - II

(Guided Imagery)
• Step One: Sit or lie down comfortably. Ideally, the space will have minimal distractions.
• Step Two: Visualize a relaxing environment by either recalling one from memory or created
one through imagination (e.g., a day at the beach). Elicit elements of the environment using
each of the five senses using the following prompts:
1. What do you see? (e.g., deep, blue color of the water)
2. What do you hear? (e.g., waves crashing along the shore)
3. What do you smell? (e.g., fruity aromas from sunscreen)
4. What do you taste? (e.g., salty sea air)
5. What do you feel? (e.g., warmth of the sun)
• Step Three: Sustain the visualization as long as needed or able, focusing on taking slow,
deep breaths throughout the exercise. Focus on the feelings of calm associated with being in a
relaxing environment.

OBSERVATION AND ANALYSIS

The collected data were subjected to paired “t” test

EXPERIMENTAL GROUP-I
Table - 1.1
Box breathing technique (Paired ‘t’ test)
Variable “t”-cal value “t”-tab value
Blood pressure 5.67 2.145
The ‘t’ calculated value of paired ‘t’ test was matched with ‘t’ table values.
The ‘t’ calculated values were found to be greater than ‘t’ table values in both groups. Hence
there is a significant difference between the pre and post treatment assessment for the blood
pressure.

EXPERIMENTAL GROUP-I I
Table - 1.2
Guided imagery (Paired ‘t’ test)

Variable “t”-cal value “t”-tab value

Blood pressure 5.67 2.145

The ‘t’ calculated value of paired ‘t’ test was matched with ‘t’ table values.
The ‘t’ calculated values were found to be greater than ‘t’ table values in both groups. Hence
there is a significant difference between the pre and post treatment assessment for the blood
pressure.
INDEPENDENT ‘t’ TEST
After the paired ‘t’ test the data were subjected to independent ‘t’ test to analyze any
significant difference in improvement between Group I and Group II.

Table - 1.3
Independent ‘t’ test
Variable “t”-cal value “t”-tab value
Blood pressure 10.76 2.050

The ‘t’ calculated value of paired ‘t’ test was matched with ‘t’ table values.
The ‘t’ calculated values were found to be greater than ‘t’ table values in both groups.
Hence there is a significant difference between the pre and post treatment assessment for the
pain.

RESULTS AND DISCUSSION

RESULT
The data was subjected to statistical analysis and the following results were obtained.
Box breathing technique is significantly effective in reducing blood pressure on patients with
hypertension.
Guided imagery is also significantly effective in reducing blood pressure on patients with
hypertension.
Guided imagery is significantly more effective in reducing blood pressure on patients with
hypertension than box breathing

DISCUSSION
The primary aim of this study was to determine if performing guided imagery than breathing
exercise resulted in recducing hypertension. The group 1 subjects were allowed to perform
box breathing and group 2 performed guided imagery . At the end of 3 weeks of guided
imagery program, post test of sphygmomanometer scores were measured for the both
groups.
Guided imagery will produce endorphins. Endorphins are neurohormones associated with
pleasurable sensations.
Theses endorphins tend to have a relaxing effect, which helps relieve nervous tension from
experiencing excessive and strong pressure. Guided Imagery based on Spiritual Care makes
relaxation and positive imagination decrease sympathetic activity so that it relaxes blood
vessels and smooth muscles and causes a decrease in blood pressure.
Hypertension patients will also benefit from guided imagery . This will affect the mind,
relaxation response, comfort, and tranquility. In a safe and calm atmosphere, a person will
experience the opposite anxiety and stress responses so that feelings of discomfort, tension,
blood pressure, oxygen use, and so on will decrease.
guided imagery can stimulate the reward center so that it creates a feeling of calm.
Diet and exercise are basic elements to maintain blood pressure.
Although many alternative therapies are promoted for the management of hypertension, few
are truly therapeutic.
The present analysis examined the effect of guided imagery intervention on the reduction of
blood pressure among hypertensive patients.
Numbers of studies related to the effects of breathing exercise in reduction of blood pressure
undertaken and which proven the positive effect.

RECOMMENDATION FOR FURTHER STUDY

The study can be done including the secondary hypertension patients to reduce the side
effects of pharmacological treatment
The study can be done along with the other device assisted techniques to regularise the
breathing pattern
The study can be done including the patient with higher range of more than 160/100mm Hg.
The study can be made to find the effectiveness of yoga therapy is helps in reducing
hypertension.

CONCULSION
The result of this study makes concludes that guided imagery technique was found to be
significantly more effective method in reducing blood pressure in hypertension patient than
box breathing technique.

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 APPENDIX – 1

NAME :
AGE :
SEX :
OCCUPATION :
CHIEF COMPLAINTS :
SIDE AFFECTED :
TREATMENT GROUP :