Biofeedback and Hypertension: A Déjà Vu Experience: Comments on Yucha's “Problems Inherent in Assessing Biofeedback Efficacy Studies”

The author makes several comments and observations on Yucha's recent paper on biofeedback treatment of hypertension (C. B. Yucha, 2001). In particular, he highlights the need for replicability of biofeedback treatment effects to move the field forward.     

Controlled evaluation of thermal biofeedback in treatment of elevated blood pressure in unmedicated mild hypertension

In the first of two studies, 42 unmedicated mild hypertensives completed either 16 sessions of thermal biofeedback (TBF) training for hand (7 sessions) and foot (9 sessions) warming or 8 weeks of monitoring BPs at home. There was a trend (p<.10) for more of those treated (57.1%) to have DBPs lower than 90 mm Hg than for those only monitoring BPs at home (33%). Analyses of clinic BP values from random zero sphygmomanometer measurements, from 24-hour ambulatory BP monitoring, and from home BP measurements made by the patient showed no advantage for treatment versus BP monitoring. Sixteen of the 21 patients in BP monitoring were later treated. Analyses of treatment effects across all treated subjects by gender revealed a significant (p=.02) decrease in DBP for treated female subjects (n=13) but not for males (n=24). In the second study the 22 initial treatment successes, that is, those whose DBP was below 90 mm Hg at posttreatment (59.4% of those who completed treatment), were randomized to an intensive follow-up (monthly visits for 6 months, then visits every two months) emphasizing regular home practice with an electronic TBF device or regular follow-up (visits every 3 months). Twelve of the 22 were still normotensive at 12 months. There were no differences at any point during the follow-up between the two conditions in success rate or BPs despite a numerical advantage in reported frequency of home practice by those in the intensive follow-up condition.This research was supported by a grant from NHLBI, HL-31189.     

Modification of Baroreceptor Cardiac Reflex Function by Biofeedback

Baroreceptor sensitivity (BRS) is considered a powerful prognostic factor in cardiovascular health. This study investigated the possibility of modifying the baroreflex cardiac function through biofeedback. Thirty-two psychology students underwent 3 biofeedback sessions, with four 5-min trials each, in which they had to increase and decrease baroreflex function. BRS was assessed by a system that analyzed baroreflex cardiac function on-line using a noninvasive spontaneous sequence method in the time domain. Baroreceptor parameters were differentiated in terms of blood pressure increases ("up" sequences) or blood pressure decreases ("down" sequences). BRS in the "up" sequences increased during the Increase Condition and decreased during the Decrease Condition. BRS in the "down" sequences decreased during the Decrease Condition but was unchanged during the Increase Condition. The increase in BRS during the Increase Condition was associated with a significant reduction in blood pressure and increase in heart period. The opposite cardiovascular changes were observed during the Decrease Condition. Suggestions for future research were discussed.     

Thiobarbituric acid-reactive substances relate to arterial stiffness and blood pressure in 6 to 8-year-old boys stratified by maternal risk

Early cardiovascular disease (CVD) onset can be inflicted by familial cardiovascular and lifestyle risk factors. We aimed to compare phenotypic characteristics and explore associations between oxidative stress and vascular function in boys stratified by maternal cardiovascular and lifestyle risk. We included 40 Black and 41 White boys (ages 6–8 years), along with the biological mother of each child. The study population was divided into two groups (nonmaternal risk vs. maternal risk) according to maternal risk predetermined by their selfreported cardiovascular and lifestyle risk factors. Pulse wave velocity (PWV) was measured at various sites and blood pressures were recorded. Urine samples were collected for analyses of thiobarbituric acid-reactive substances (TBARS), 8-hydroxy-2-deoxy guanosine (8-OHdG), albumin, and creatinine. Higher levels of urinary albumin to creatinine ratio (uACR) were found in the maternal risk group compared to the nonmaternal risk group (p?=?.038). Multiple regression analysis in the maternal risk group revealed diastolic blood pressure (R²?=?0.159; β?=?0.293; p?=?.050), carotid femoral PWV (R²?=?0.158; β?=?0.297; p?=?.038) and carotid dorsalis pedis PWV (adj R²?=?0.322; β?=?0.505; p?R²?=?0.161; β?=??0.261; p?=?.046) with TBARS was observed. Also, in the maternal risk group, independent associations of DBP (R²?=?0.273; β?=?0.289; p?=?.040) and uACR (R²?=?0.283; β?=?0.268; p?=?.027) with 8-OHdG were indicated. In boys, as young as 6 years of age, oxidative stress related to arterial stiffness and diastolic blood pressure was observed. This association was only evident in boys with linked maternal lifestyle and cardiovascular risk factors, suggesting potential family-related early onset of cardiovascular risk.     

Biobehavioral treatment of essential hypertension: A group outcome study

In a group outcome and follow-up study of 77 patients with essential hypertension, significant reductions were seen in systolic and diastolic blood pressure (BP) and in hypotensive medication requirement. A multimodality biobehavioral treatment was used which included biofeedback-assisted training techniques aimed at teaching self-regulation of vasodilation in the hands and feet. Of the 54 medicated patients, 58% were able to eliminate hypotensive medication while at the same time reducing BP an average of 15/10 mm Hg. An additional 19 (35%) of the medicated patients were able to cut their medications approximately in half while reducing BP by 18/10 mm Hg. The remaining 4 (7%) medicated patients showed no improvement in either BP or medication requirement. Similar reductions in BP were seen in initially unmedicated patients. Seventy percent of the 23 unmedicated patients achieved average pressures below 140/90 mm Hg, with an additional 22% of these patients making clinically significant reductions in pressure without becoming normotensive, and with 8% unsuccessful at lowering pressures to a clinically significant extent. Follow-up data available on 61 patients over an average of 33 months indicated little regression in these results with 51% of the total patient sample remaining well-controlled off medication, an additional 41% partially controlled, and 8% unsuccessful in lowering either medications and/or blood pressures to a clinically significant extent.This research was partially supported by grant HL-32136. The Authors wish to thank Sarah Bremer for her assistance in preparing this article.     

Role of zinc in regulation of arterial blood pressure and in the etiopathogenesis of arterial hypertension

Increased gastrointestinal absorption and urinary excretion of zinc has been confirmed in experimental and clinical studies on primary arterial hypertension as a result from changes of intracellular and extracellular zinc content. In arterial hypertension, the levels of zinc in serum, lymphocyte, and bone decrease while increasing in heart, erythrocytes, kidney, liver, suprarenal glands and spleen. These changes result in the loss of zinc homeostasis that leads to various degrees of deficiency, not entirely compensated by nutritional factors or increased absorption in the gastrointestinal tract. Loss of zinc homeostasis can be both cause and effect of high blood pressure. In the present review, the role of zinc metabolism changes and its mechanisms in arterial hypertension are discussed.     

Biofeedback treatments of essential hypertension

Fifteen years of research in the self-regulatory treatment of hypertension by the author is summarized. A model relating expectations, task performance, home practice, and biochemical variables to the thermal biofeedback treatment of hypertension is presented.Essentially, all of the research reported herein was supported by various grants from NHLBI: HL-14906, HL-18814, HL-27622, and HL-31189.     

The Raynaud's Treatment Study: Biofeedback Protocols and Acquisition of Temperature Biofeedback Skills

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.     

The physiologic complexity of beat-to-beat blood pressure is associated with age-related alterations in blood pressure regulation

The fluctuations in resting-state beat-to-beat blood pressure (BP) are physiologically complex, and the degree of such BP complexity is believed to reflect the multiscale regulation of this critical physiologic process. Hypertension (HTN), one common age-related condition, is associated with altered BP regulation and diminished system responsiveness to perturbations such as orthostatic change. We thus aimed to characterize the impact of HTN on resting-state BP complexity, as well as the relationship between BP complexity and both adaptive capacity and underlying vascular characteristics. We recruited 392 participants (age: 60–91 years), including 144 that were normotensive and 248 with HTN (140 controlled- and 108 uncontrolled-HTN). Participants completed a 10-min continuous finger BP recording during supine rest, then underwent measures of lying-to-standing BP change, arterial stiffness (i.e., brachial-ankle pulse wave velocity), and endothelial function (i.e., flow-mediated vasodilation). The complexity of supine beat-to-beat systolic (SBP) and diastolic (DBP) BP was quantified using multiscale entropy. Thirty participants with HTN (16 controlled-HTN and 14 uncontrolled-HTN) exhibited orthostatic hypotension. SBP and DBP complexity was greatest in normotensive participants, lower in those with controlled-HTN, and lowest in those in uncontrolled-HTN (p < 0.0005). Lower SBP and DBP complexity correlated with greater lying-to-standing decrease in SBP and DBP level (β = −0.33 to −0.19, p < 0.01), greater arterial stiffness (β = −0.35 to −0.18, p < 0.01), and worse endothelial function (β = 0.17–0.22, p < 0.01), both across all participants and within the control- and uncontrolled-HTN groups. These results suggest that in older adults, BP complexity may capture the integrity of multiple interacting physiologic mechanisms that regulate BP and are important to cardiovascular health.     

A Biofeedback System of Baroreceptor Cardiac Reflex Sensitivity

The evidence presently available suggests that the parasympathetic nervous system and sympathetic-parasympathetic interactions could play a role in the pathophysiology of cardiovascular disorders and, specifically, in hypertension. A loss of sensitivity of the baroreceptor reflex is one of the fundamental mechanisms underlying the deficits found in parasympathetic cardiac control. The baroreceptor reflex is a basic mechanism for the regulation of blood pressure, a powerful source of vagal afferent input to the central nervous system, and one of the most important physiological mechanisms affecting efferent cardiac vagal activity. This paper describes a computerized system for the on-line analysis of the baroreceptor cardiac reflex function using the noninvasive spontaneous sequence method in the time domain. The system provides feedback of the baroreceptor reflex sensitivity (the change in heart period per unit change in systolic blood pressure) differentially both when the systolic blood pressure is increasing and when it is decreasing. The accuracy of the described system has been tested against the conventional off-line procedure. None of the parameters supplied by the analysis show a significant difference between the on-line and off-line methods. These results confirm the accuracy of the on-line system to analyze baroreceptor cardiac reflex function.     

Interactions of several lipid-related gene polymorphisms and cigarette smoking on blood pressure levels

The interactions of single nucleotide polymorphisms (SNPs) and cigarette smoking on blood pressure levels are limited. The present study was undertaken to detect nine lipid-related SNPs and their interactions with cigarette smoking on blood pressure levels. Genotyping of ATP-binding cassette transporter A1 (ABCA-1) V825I, acyl-CoA:cholesterol acyltransferase-1 (ACAT-1) rs1044925, low density lipoprotein receptor (LDL-R) AvaⅡ, hepatic lipase gene (LIPC) -250G>A, endothelial lipase gene (LIPG) 584C>T, methylenetetrahydrofolate reductase (MTHFR) 677C>T, proprotein convertase subtilisin-like kexin type 9 (PCSK9) E670G, peroxisome proliferator-activated receptor delta (PPARD) +294T>C, and Scavenger receptor class B type 1 (SCARB1) rs5888 was performed in 935 nonsmokers and 845 smokers. The interactions were detected by factorial regression analysis. The frequencies of genotypes (ACAT-1 and LIPG), alleles (ABCA-1), and both genotypes and alleles (LDL-R, LIPC, PPARD and SCARB1) were different between nonsmokers and smokers (P < 0.05-0.001). The levels of pulse pressure (PP, ABCA-1), and systolic, diastolic blood pressure (SBP, DBP) and PP (LIPC) in nonsmokers were different among the genotypes (P < 0.01-0.001). The levels of SBP (ABCA-1, ACAT-1, LIPG and PCSK9), DBP (ACAT-1, LDL-R, LIPC, PCSK9 and PPARD), and PP (LIPC, LIPG, MTHFR and PCSK9) in smokers were different among the genotypes (P < 0.01-0.001). The SNPs of ABCA-1, ACAT-1 and PCSK9; ACAT-1, LDL-R, MTHFR and PCSK9; and ABCA-1, LIPC, PCSK9 and PPARD were shown interactions with cigarette smoking to influence SBP, DBP and PP levels (P < 0.05-0.001); respectively. The differences in blood pressure levels between the nonsmokers and smokers might partly result from different interactions of several SNPs and cigarette smoking.     

16周有氧运动对中老年baPWV及ABI的影响

目的：探讨16周有氧运动锻炼对中老年动脉硬化的干预作用及相关机制。方法：以27名中老年人为研究对象,平均年龄（62.70 ±3.26）岁,采用每次60 min、每周6次,共16周的广场舞/太极拳进行锻炼,分别测试锻炼前和锻炼8周末、16周末受试者收缩压（SBP）、舒张压（DBP）、左肱踝动脉脉搏波传导速度（L-baPWV）、右肱踝动脉脉搏波传导速度（R-baPWV）、左踝臂血压指数（L-ABI）和右踝臂血压指数（R-ABI）的变化,并检测血清甘油三酯（TG）、总胆固醇（TC）、高密度脂蛋白胆固醇（HDL-c）、低密度脂蛋白胆固醇（LDL-c）、超氧化物歧化酶（SOD）、丙二醛（MDA）和谷胱甘肽过氧化物酶（GSH-Px）等相关指标的变化。结果：①与运动前相比,有氧运动锻炼8周末R-baPWV、R-ABI下降,16周末则L-baPWV、R-baPWV、R-ABI、L-ABI均呈显著性下降（P<0.01）;②与运动前比,8周末SBP和DBP显著下降（P<0.05）,16周末SBP、DBP和脉压差则显著降低（P<0.01,P<0.05）;③与运动前相比,在8周末、16周末受试者TC、LDL-c均显著降低（P<0.01）,HDL-c、TG在8周末和16周末的变化则无统计学意义;④与试验前相比,8周末血清SOD、GSH-Px、MDA无明显变化,16周末血清SOD、GSH-Px活性呈显著性升高、而血清MDA含量则呈显著性下降（P<0.01）。结论：通过16周有氧运动,可明显降低中老年人baPWV和ABI水平,调节血压、血脂及过氧化脂质水平,进而可能对动脉硬化程度起到一定的改善作用。     

Biofeedback in the treatment of headache and other childhood pain

Since the first biofeedback (BFB) studies on pediatric pain were published in the early 1980s, most of the studies have focused on the treatment of pediatric migraine. More recently, BFB has also been evaluated in the treatment of tension headache in children. Not surprisingly, most of what we know about the efficacy and mechanisms of BFB in the treatment of children's pain problems concerns the treatment of childhood headache (HA). In this review, we provide a detailed summary of studies that have evaluated BFB in the treatment of childhood HAs with an emphasis on treatment outcome and maintenance of treatment success. Moreover, findings and hypotheses with regard to the mechanisms that may mediate the treatment effects of BFB are addressed. Finally, we discuss specific issues relating to the treatment of pain in children with BFB and outline future directions of research.     

Effects of elements in human blood pressure control

This review enumerates and discusses the elements involved in the control of human blood pressure via a historical evolutionary form. The older and most recent element literature presentations were researched using MEDLINE and a manual review of documents cited. Independent data extraction and cross-referencing was performed. Of the 28 known elements that can influence blood pressure, 15 were found to be involved in human blood pressure regulation. The elements were divided into four groups: electrolyte, composed of sodium, potassium, calcium, and magnesium; metal, which included zinc, copper, and iron; toxic, made up of lead, mercury, cadmium, barium, thallium, arsenic; miscellaneous (lithium and selenium). Evolutionary historical data, possible mechanisms of actions, and interactions between elements that have been shown to influence blood pressure are discussed. Controversy exists over the therapeutic use of elements to alter blood pressure but is absent in the case of the toxic group where preventive control is a proven public health matter. The significance of these 15 elements in the regulation of human blood pressure has been established and ongoing studies will continue to reinforce their influence and importance.     

Elemental analysis of blood of nigerian hypertensive subjects

Proton-induced X-ray emission (PIXE) has been used to obtain the concentrations of 11 elements (P, S, Cl, K, Ca, Fe, Cu, Zn, Br, Rb, and Cd) in whole-blood samples of 16 hypertensive subjects (mean age: 52.5 ± 0.5 yr) and 18 age-matched controls (mean age: 51.5 ± 0.5 yr) in a Nigerian population. The results of the study indicate that the hypertensive subjects have significantly higher mean concentration of Cl, Cd, Cu, and Zn when compared with the controls, and the mean concentration of P, K, and Ca was found to be significantly lower in the hypertensive group in comparison to the controls. Furthermore, the Zn : Cd ratio was found to be significantly higher in the controls than in the hypertensives, and the Cu : Zn ratio was significantly higher in the hypertensives.     

葛根素对冷激诱导的高血压小鼠的影响

目的：检测葛根素灌胃对冷激诱导的高血压小鼠的血压血脂及肾脏结构的影响。方法：小鼠分为正常对照组、冷激对照组、冷激葛根素饲喂组（2,5,10ms／kg bw3组）（n=12）。以寒冷刺激（4±2℃）建立小鼠高血压模型,每天定时灌胃葛根素治疗,对照组给予聚乙烯吡咯烷酮溶液。连续饲喂18d．检测各组小鼠血压、血脂含量,石蜡切片观察肾脏结构。结果：冷激对照组小鼠血压显著高于正常对照组（P〈0．01）,葛根素饲喂组血压显著低于冷激对照组（P〈0．05）。冷激对照组TG含量显著高于正常对照组（P〈0．01）,而冷激饲喂组TG含量明显降低（P〈0．05）;冷激饲喂组TC含量与冷激对照组相比有所降低但无统计学意义;2mg／kg BW葛根素组LDL-C显著低于冷激对照组（P〈0．01）,各组间HDL-C含量比较无统计学意义,但葛根素饲喂组HDL-C／LDL-C值显著高于冷激对照组。冷激对照组肾小管上皮细胞水肿,内腔极度缩小,肾小球明显胀大,肾小囊腔显著变窄,葛根素饲喂组肾小管水肿基本消失,内腔明显增大,肾小球、肾小囊结构趋于正常。结论：葛根素灌服具有降血压、降血脂、改善病变肾脏结构的作用。     

Rhythmic clock gene expression in heart, kidney and some brain nuclei involved in blood pressure control in hypertensive TGR(mREN-2)27 rats

Hypertensive TGR(mREN-2)27 rats exerting inverted blood pressure (BP) profile were used to study clock gene expression in structures responsible for BP control. TGR and control Sprague Dawley male rats were synchronized to the light:dark cycle 12:12 with food and water ad libitum. Daily rhythm in per2, bmal1, clock and dbp expression in the suprachiasmatic nucleus (SCN), rostral ventrolateral medulla (RVLM), nucleus of the solitary tract (NTS), heart and kidney was determined in both groups. Sampling occurred in regular 4 h intervals when rats of both strains were 11-weeks-old. Blood pressure and relative heart weight were significantly elevated in TGR rats in comparison with control. Expression of bmal1 and clock was up regulated in SCN of TGR rats but daily rhythm in per2 and dbp expression was similar in both groups. Mesor of per2 expression in RVLM was significantly higher in TGR than in control rats. In NTS of TGR rats expression of per2 was phase delayed by 3.5 h in comparison with control and bmal1 did not exert rhythmic pattern. Our study provided the first evidence about modified function of central and peripheral circadian oscillators in TGR rats at the level of clock gene expression. Expression of clock genes exerted up regulation in SCN and RVLM and down regulation in NTS. Circadian oscillators in selected brain structures were influenced more than oscillators in the heart and kidney by additional renin gene. Interactions of RAS and circadian system probably contribute to the development of inverted BP profile in TGR rats.