image73

Full Case Study on Hypertension

  

Abstract


Background: Heart disease is the number one killer in the United States and other developed countries. The World Health Organization’s (WHO) 2012 report states that hypertension, which is a precursor to heart failure, is on the rise. Relaxation massage studies and reflexology studies have been done to evaluate their effect on lowering blood pressure (BP) in hypertensive people. 


Objective: To study the combined effect of full body relaxation massage and foot reflexology on the blood pressure of an unmedicated person with hypertension. 


Method: The subject received 10, 60-minute sessions once a week. Each session included 30 minutes of full body relaxation massage and 30 minutes of foot reflexology. The same routine for massage and reflexology was used for every session. The subject’s BP was taken with a stethoscope and sphygmomanometer before and after each session. 


Results: The systolic pressure decreased throughout the study in both pre- and post- session readings. The diastolic pressure, conversely, showed some increase in the pre-session readings but no significant change in either direction in the post-session readings. 


Conclusions: The combination of full body relaxation massage and foot reflexology lowered the BP in this case of hypertension. 


Key words: Lowering Blood Pressure; Complementary Therapy; Therapeutic Massage; Reflexology Benefits; Hypertension


Introduction 


Heart disease is a growing health concern as it is the leading cause of death in the United States. The Center for Disease Control reports that heart disease accounts for 599,413 deaths in the U.S. followed by cancer at 567,628 (1). The risks of high BP can lead to hypertension. Hypertension ultimately can lead to heart failure and the increased possibility of a myocardial infarction, commonly known as a heart attack. Furthermore, high BP may lead to arteries bursting or clogging more easily which can increase the likelihood of having a cerebral vascular accident, referred to as a stroke (2). High BP also has a correlation with other serious health conditions such as obesity and diabetes, although it is not a causative factor of these conditions (3). 


Hypertension is a dangerous and symptomless disease aside from the actual elevated BP. According to the American Heart Association’s 2012 annual report, approximately 80% of hypertensive adults are aware of their condition. Of this group, 71% are using antihypertensive medication of some kind but only 48% of those are aware of whether or not their condition is in a controlled state (2). It is important for everyone to know what is considered a healthy BP and proactive ways to achieve or maintain that level.


There is some debate over the most effective drug therapy to achieve a healthy BP level in patients with hypertension. A systematic review of studies that considered commonly used medications, including beta-blockers and calcium-channel blockers, revealed that most medications required a combination of drugs in order to reduce BP to the targeted level (4). If a single medication truly does not achieve the desired BP on its own, then complimentary therapies may assist in a successful hypertension treatment plan.


A growing number of people today are looking to alternative and complimentary care to prevent and/or treat their medical conditions such as hypertension (5). Statistically significant reduction in BP has been found in hypertensive patients who made lifestyle changes. Some of these changes include diet, exercise, and fish oil supplements (6). Stress reduction therapies may also contribute to lowering BP. Stress hormones are released into the body when the sympathetic nervous system stimulates the hypothalamus, pituitary, and adrenal glands. The continually elevated stress response can raise blood pressure over time. The stimulation of the parasympathetic nervous system, “rest and digest”, returns the body to a dynamic homeostatic state where the BP can be brought back to a healthy level. The goal of both massage therapy and reflexology are to produce physiological changes to the vascular, muscular, and nervous systems of the body to return the body to homeostasis (5, 7). Studies have shown that both relaxation massage therapy and reflexology have been used effectively for stress reduction and have been proven to lower BP (7, 8, 9 10, 11, 12, 13). These natural methods can supplement traditional western practices for healthy living. 


We know that some patients with hypertension seek complementary and alternative medicine (CAM) to help control BP (14). Despite the studies cited above, limited research has been done to demonstrate the effectiveness of these modalities’ ability to assist with lowering BP (5). This gives us cause to investigate these two modalities in conjunction with one another. Separately each therapy has been proven to lower BP. It is our hypothesis that the combination of full body relaxation massage and foot reflexology will lower blood pressure in a woman with hypertension.


Methods


Profile of the Client:


The client (CL) is a 54-year-old female who was diagnosed with stage 2 hypertension and type 2 diabetes by her medical doctor in September of 2011. Initially, the M.D. placed the CL on lisinopril, metformin hydrochoridid, and a daily aspirin. After one month, the CL lost more than half of her hair and stopped taking these medications. The CL has not taken other medications since October 2011 but did begin a B complex at that time and started Iodine Plus 2 (niacin free) in September 2012. The CL also does meditation, acupuncture, and energy work periodically for stress relief. The CL had a few seizures from ages 5-9, and was put on dilanten, diagnosed by a neurologist to have had epilepsy with no further medication necessary by age 15. 5 years ago, the CL was diagnosed by a M.D. with anemia and sleep apnea. She currently takes iodine and iron for the anemia. The sleep apnea has not been treated successfully. A naturopathic doctor used biofeedback to determine that the CL is oxygen deficient and prescribed Oxygen Pus. The CL has seen a chiropractor consistently for years but has only received massage for a personal injury case and car accident over 4 years ago. The CL’s desired outcome was to lower blood pressure without the use of medications through using natural methods including massage and reflexology.


Treatment Plan:


Each Monday morning at 7:30am, the CL arrived without having had any breakfast. 10 minutes before the session began, while seated, the BP was measured 3 times. The CL then disrobed and lay supine. 15 minutes of relaxation massage to the head, anterior neck, shoulders, arms, and legs was applied first. The relaxation massage included basic relaxation strokes toward the heart including longitudinal stroking, kneading, horizontal short strokes, and cross fiber longitudinal stroking. This style was used to increase blood flow and oxygen to the muscles (15).


Remaining supine, a 30-minute reflexology routine was performed on each foot. This routine included a 7-minute warm up using relaxation techniques and the alternating pressure, called finger walking (FW), over the entire foot. An 8-minute targeted session on each foot included FW of the reflex areas of the endocrine and cardiovascular systems reflex areas including the heart and lungs. Specific pressure, called pinpointing, was held over the 12 thoracic spinal nerves, the vagus nerve, kidneys, adrenal glands, and solar plexus reflex areas. The heart and lung reflexes were chosen because they support the cardiovascular system. The 12 thoracic nerve reflexes were stimulated to support nerve supply to the cardiovascular organs. The vagus nerve reflex was selected due its control of heart rate and breathing. The kidney and adrenal gland reflexes were stimulated because of their integral endocrine support of the cardiovascular system. Finally, the solar plexus reflex was chosen for relaxation (16, 17, 18, 19). 

The session concluded with the CL prone for 15 minutes for relaxation massage to the back, gluteal muscles, and posterior legs. The same stroke styles were used on the posterior body as the anterior body for the final 15 minutes of the massage. 10 minutes after the session was complete, the BP was taken 3 more times with the CL clothed and seated. The method was not changed at all over the 10-week period of the study.


Statistical Analysis:


Statistical significance of the data was determined by using Student’s t-test. Results were considered statistically significant if p < 0.10. 


Results


The systolic pressure consistently decreased throughout the study with the most decrease in the first 7 sessions. This was seen in the pre- and post- session BP measurements. The systolic pressure level before each session was significantly lower when compared to the first pre-session reading. All but one post-session systolic pressure readings were significantly lower when compared to the first post-session systolic pressure. On average, the overall pre-session systolic pressure was reduced by 43 points between the first and last session while, in the post-session measurements, the systolic pressure decreased by 30 points. These results can be seen in Figures 1, 2, and 3.


The pre-session diastolic pressure showed significant change only in 4 of the sessions when compared to the first session. For these sessions, the average diastolic pressure was higher than the average for the first session. In the post-session, there was no significant change to the diastolic pressure readings. On average, the overall diastolic pressure change between the first and last session was 0 points pre-session and reduced 11.33 points in the post session. These results can also be seen in Figures 1, 2, and 3.


Overall there was no significant change to the BP when the pre-session BP was compared to the post-session BP. There are two exceptions that are marked in Figure 3. In session 10, the systolic pressure significantly increased from pre- to post reading but there was no significant change in the diastolic pressure. In session 9, the diastolic pressure significantly decreased from pre- to post-measurement whereas there was no significant change in the systolic pressure.



Figure 1) Pre-session BP measurements plotted as a function of session number. The average pressure is denoted by a cross (x) and the standard deviation is denoted by open circles (o). Pressure measurements that were statistically significant when compared to the first session are denoted by an asterisk (*) (p<0.10). 


Figure 2) Post-session BP measurements plotted as a function of session number. The average pressure is denoted by a cross (x) and the standard deviation is denoted by open circles (o). Pressure measurements that were statistically significant when compared to the first session are denoted by an asterisk (*) (p<0.10)


Figure 3) BP is plotted as a function of session number. The average pressure is denoted by a cross (x) and the standard deviation is denoted by the open circles (o). Measurements between pre- and post-session that were considered statistical significant are denoted by a plus symbol (+)(p<0.10).


Discussion 


The study aimed to combine the essential aspects of relaxation massage and foot reflexology, which separately have been shown in previous studies to successfully reduce BP (5, 7, 8, 9, 10, 11, 12, 13). In this study the systolic BP was significantly lowered in 17 out of the 18 pre- and post-session averages when compared to the respective measurements of the first session. On the other hand, the overall diastolic BP did not significantly change. This is a question to examine in future studies. The diastolic pressure may have lowered significantly more had we chosen to take the post-session BP in a reclining position as was done in some studies (5, 9). However, sitting is the standard posture for BP reading, and hence the sitting position was chosen when we took the pre- and post-session readings to be as consistent as possible. There was a significant increase in systolic pressure in the 10th session when the pre-session reading is compared to the post-session and a significant decrease in diastolic pressure in the 9th session when the pre-session reading is compared to the post-session reading. While these results are important to note, it appears that these changes were anomalies in each of the two instances. The overall significant decline of the systolic BP throughout the 10-week study demonstrated that the combination of full body relaxation massage and foot reflexology successfully lowered BP in a woman with stage 2 hypertension.


There have been promising studies that show that both foot reflexology and relaxation massage may help decrease BP in persons with hypertension. (5, 7, 8, 9, 10, 11, 12, 13). None of these studies surveyed combined elements from both modalities to produce a greater reduction of BP. All of the massage studies included essential aspects of relaxation massage but each varied in frequency, length of the massage session, and the areas of the body that were worked on (5, 8, 9, 10, 12). The foot reflexology studies varied in the type of reflexology methods used and usually included the stimulation of the entire foot with no specific target organs mentioned (7, 11, 13). To the best of the author’s knowledge, our study is the first to incorporate both a full body relaxation massage and a focused foot reflexology routine that targeted specific organs while addressing the entire body through the reflex zones and areas. This case study was designed to optimize the relaxation aspects of each modality while providing the therapeutic value to lower BP. Our results proved more effective than other studies have been, possibly because of this modality combination. Other factors that may have contributed to our results is the consistency of our sessions in all possible aspects including the method used, time of day, duration of sessions, and the length of time between sessions, which remained the same throughout the study.


The Moeini study provided 10-15 minute Swedish massages to the upper body, 3 times a week over 3 1/2 weeks, to women who were prehypertensive for 10 sessions. The study included a control group who laid down a bed, eyes closed, for the 10- minute sessions also 3 times a week for 3 1/2 weeks. Both the systolic and diastolic BP were significantly lowered in the test group but not significantly lowered in the control group. The systolic BP test group average was reduced from 128 to 116 while the diastolic average was reduced to 71 from 82 (12). Similar to our study, the sessions included relaxation massage for 10 sessions with a significant reduction in systolic BP. Our study did not see a significant reduction in the diastolic BP but a much greater reduction in systolic BP. The 43 point drop of our average systolic BP, opposed to their 12 BP points, may be due to the length of time our study was conducted (10 weeks compared to 3 ½ weeks), the length of our sessions (60-minute compared to 10-15 minute), and/or our combination of the full body relaxation massage and foot reflexology. 

The Hernandez-Reif study, conversely, did not see a statistically significant reduction in BP. In this case, the participants reported being highly compliant with the antihypertensive medication(s) they were prescribed throughout the length of the study. The massage method included 30-minute full body relaxation massages, twice a week for 5 weeks. While the BP was reduced a few points for each systolic and diastolic, there was not significant change (9).

Similar to our study, both of these previous studies included 10 relaxation massage sessions given over a time period of several consecutive weeks. It may have been the length of time over which the studies were conducted that made the difference in the results. The Moeini study and the Hernandez-Reif study included several massages in a single week whereas our study spread the 10 sessions over 10 full weeks. Another factor that may have contributed is that while the physiological effects of relaxation massage are often present in the body right away, reflexology is intended to take place over a long period of time (15, 16, 17, 18). Thus the addition of reflexology may have contributed to the greater, long-term results in our case study. 


The L foot reflexology study showed a significant reduction in systolic and diastolic BP, 30 min and 60 min, after the foot reflexology was completed (Lu). This study demonstrates that it is possible that reflexology is most effective 30-60 minutes after the session has been completed. Since we measured BP only 25 minutes after the reflexology portion of the session was completed, this may have effected our results. The method intent was to induce the body into a relaxed mode by starting with 15 minutes of anterior full body relaxation massage before beginning the 30-minute reflexology routine. Concluding with a 15-minute posterior full body relaxation massage that was meant to complete a sense of full body relaxation. Since the BP was taken just 10 minutes after the completion of the session, it did not allow for the reflexology to have its possible full effect, 30-60 minutes after the reflexology is complete. In future studies, it is recommended to wait to measure the BP until at least 30 minutes has passed since the completion of the reflexology routine as in the Lu study. 


Our objective, to lower BP through a combination of relaxation massage and foot reflexology, was fulfilled in this case study. The results are compelling and deserve to be investigated in future research studies. It is recommended to continue this study by examining four groups: a group who only receives full body relaxation massage, a group who only receives foot reflexology, a group who receives a combination of massage and foot reflexology, and a control group who lie on a massage table and rest for the session length. The control group would allow for a comparison to determine whether the combination of full body relaxation massage and foot reflexology reduces the BP significantly more than either modality on its own. 


This case study was able to demonstrate an average reduction of 42 points in systolic BP in a woman with hypertension by combining full body relaxation massage and foot reflexology. These significant results help to lay the groundwork for future studies that combine these two modalities. Whether used as a preventative measure or in conjunction with proven hypertension treatments, the combination of full body relaxation massage and foot reflexology could become an integral part of maintaining or achieving a healthy BP.


References


1. CDC.gov [Internet]. Center for Disease Control, Leading Causes of Death. [cited 2012 Dec 13]. Available from: http://www.cdc.gov/nchs/fastats/lcod.htm

2. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et. al. AHA Statistical Update, Heart Disease and Stoke Statistics - 2012 Update. Circulation. 2012. 125, 2-220. 

3. Breslin DJ, Gifford RW, Fairbairn JF. Essential hypertension: a twenty-year follow-up study. Circulation. 1966; 33:87-97.

4. Bradley HA, Wiysonge CS, Volmink JA, Mayosi BM, Opie LH. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis. Journal of Hypertension. 2006. 24:2131-2141. 

5. Moraska A, Pollini RA, Boulanger K, Brooks MZ, Teitlebaum L. Physiological Adjustments to Stress Measures Following Massage Therapy: A Review of Literature. Evidenced-Based Complementary and Alternative Medicine. 2010: vol.7 (no.4) pp.409-418

6. Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trails. Journal of Hypertension. 2006. 24:215-233. 

7. Frankel, BSM. The effect of reflexology on baroreceptor reflex sensitivity, blood pressure and sinus arrhythmia. Complementary Therapies in Medicine. 1997. 5, 80-84. 

8. Basler AJ. Pilot study investigating the effects of Ayrurvedic Abhyanga massage on subjective stress experience. Journal of Complement and Alternative Medicine. 2011. 17(5): 435-40. 

9. Hernandez-Reif M, Field T, Krasnegor J, Theakston H, Hossain Z, Burman I. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork and Movement Therapies. 2000. 4(1), 31-38. 

10. Jefferson LL. Exploring effects of therapeutic massage and patient teaching in the practice of diaphragmatic breathing on blood pressure, stress, and anxiety in hypertensive African-American women: an intervention study. Journal National Black Nurses Association. 2010. 21(1): 17-24.

11. Lu W, Chen G, Kuo C. Foot Reflexology Can Increase Vagal Modulation, Decrease Sympathetic Modulation, and Lower Blood Pressure in Healthy Subjects and Patients With Coronary Artery Disease. Alternative Therapies. 2011: vol.17 (no.4) pp. 8-15.

12. Moeini M, Givi M, Ghasempour Z, Sadeghi M. The effect of massage therapy on blood pressure of women with pre-hypertension. Iranian Journal of Nursing and Midwifery Research. 2011. 16(1): 61-70. 

13. Park HS, Cho GY. Effects of foot reflexology on essential hypertension patients. Taehan Kanho Hakhoe Chi. 2004. 34(5): 739-50. 

14. Gohar F, Greenfield S, Beevers DG, Lip GYH, Jolly K. Self care and adherence to medication: a survey in the hypertension outpatient clinic. BMC Complementary and Alternative Medicine. 2008. 8:4.

15. Braun MB, Simonson JS. Introduction to Massage Therapy. 2nd ed. Howard DC, contributor. Baltimore (MD): Lippincott Williams & Wilkins; 2008. p. 395

16. Kunz K, Kunz B. The Complete Guide to Foot Reflexology (Revised). United States: RRP Press; 1993.

17. Norman L. Feet First, A Guide to Foot Reflexology. Cowan T contributor. New York: Fireside; 1988. 

18. Stone, PS. Therapeutic Reflexology. New Jersey; Pearson Education Inc.; 2011. 

19. Tortora, GJ, Derrickson B. Introduction to the Human Body, the Essentials of Anatomy and Physiology. 8th ed. United States. John Wiley and Sons Inc.; 2012.


  

Acknowledgments


Adrienne C. Caldwell, BA, BS, NCRT, LCMT, COMT

Reflexology Instructor, Northwestern Health Sciences University

Faculty Advisor


Stephen D. McIntyre, Ph.D. Candidate, School of Mathematics,

University of Minnesota

Data Analysis 


Case Study Client

Reduction of Blood Pressure in Hypertension by Means of Relaxation Massage & Reflexology

This case study was done by Amy Sirivie in 2012 as part of the Massage Therapy Foundation student case study contest. 


Its inspiration came from how, surprisingly, impressed Amy was with the many applications of Foot Reflexology in her hospital massage therapy work. Amy spent months researching the potential impact, if any, of both massage and Reflexology on hypertension. She then designed a set protocol to combine these modalities within an hour session. For 10 weeks, 10 1 hour sessions were administered at 8am every Monday morning to see whether the heart rate would change over the course of those several months. 


The short answer is yes. :)