RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the candidate
And Address /
MANIYAR PURVESH JAYESHBHAI
SRINIVASCOLLEGE OF PHYSIOTHERAPY,
PANDESHWAR,
MANGALORE-575001.
2 /

Name of the Institute

/ SRINIVASCOLLEGE OF PHYSIOTHERAPY, MANGALORE.
3 /

Course of study and

Subject / Master of Physiotherapy (MPT)
2 years Degree Course.
“Physiotherapy in Cardio Respiratory Disorders and Intensive Care.”
4 /

Date of Admission

To course / 15/05/2008
5 /

Title of the Topic

/ ‘‘A STUDY TO EXAMINE THE EFFECT OF SLOW BREATHING TECHNIQUE ON EXERCISE CAPACITY IN PATIENTS WITH ESSENTIAL HYPERTENSION.”
Brief resume of the intended work:
6.1 Need for the study:
Hypertension is a leading cardiovascular disease in the industrialized nations of the world. The study on a prevalence of hypertension on urban community in India revealed the systolic hypertension(140mm of Hg) is 40.9% and diastolic hypertension(90mm of Hg) is 29.3% among study population.1
Hypertension is diagnosed when the diastolic blood pressure is equals or exceed than 90mm of Hg and systolic blood pressure is consistently higher than 140mm of Hg. Approximately, 90-95% of individuals with hypertension have no specific cause for their disease and are said to have Primary or Essential hypertension.2
If hypertension is not controlled then there will be future cardio-vascular complication like Atherosclerotic Heart disease,congestive heart failure, cerebrovascular accidents, aneurysm, peripheral vascular disease and renal failure.2
Hypertension is known as silent killer because is not diagnosed in most of the people until there is an end organ damaged. So, the early screening of hypertension is needed to prevent the future cardio vascular complications.
Primary prevention of hypertension can be done by pharmacological or non-pharmacological(change in life style, weight loss, alcohol and dietary salt restriction and moderate intensity exercises) which reduces morbidity and mortality associates with hypertension3.
Autonomic imbalance has a major role in etiology of hypertension which is characterized by increase in sympathetic activity.4 One of the mechanism associates with autonomic
imbalance is reduced baroreflex sensitivity which in turn fails to reduce sympathetic over-activity.5 In hypertension, chemoreflex activation can also be an additional mechanism responsible for increase in sympathetic activity.6
Studies prove that slow breathing technique can reduce the sympathetic over-activity and increase parasympathetic activity in hypertensive patients by improving the baroreflex sensitivity and reducing chemoreflex activation.7
Studies also prove that there will be decreased maximal VO28 and elevated total peripheral resistance9 in subjects with hypertension.
A study reveals that exercise tolerance is decreased as much as 30% in hypertensive patients compared to normotensives.10
So, the aim of my study is to know the effect of slow breathing technique on exercise capacity in patients with essential hypertension.
6.2Review of Literature:
  1. Carlos Hermano da Justa Pinheiro et al(2007)
Did a study to know the effect of slow breathing technique on cardio-respiratory system modulation of patients with essential hypertension and found that respiratory retraining using slow breathing technique can improve autonomic balance, respiratory control and lowering the blood pressure in essential hypertension.11
2. . Chacko N. Joseph et al (2005)
Studied to assess whether the slow breathing(6breaths/min) technique reduces blood pressure in hypertensive and normal subjects and concluded that slow breathing technique can acutely reduce blood pressure and improves baroreflex sensitivity in hypertensive patients.12
3. Luciano Bernardi et al (2002)
Investigated that whether arterial baroreflex can be enhanced by slow breathing rate (6breaths/min) in healthy subjects and in patients with chronic heart failure and found that slow breathing can increase baroreflex sensitivity and vagal activity and also reduces sympathetic over-activity in patients with heart failure as well as in healthy subjects.13
4. Bernardi L. et al (2001)
Investigated whether slow breathing can modify chemoreflex and baroreflex sensitivity and found that increase in tidal volume due to slow breathing rates activate the hering breuer reflex which in turn reduces chemoreflex sensitivity and thus might enhance baroreflex sensitivity.7
5. Brook RD et al (2000)
Did a study to find out the changes occurring in autonomic balance in hypertension and found that autonomic imbalance has a major role in etiology of hypertension which is characterized by an increase in sympathetic activity and reduce parasympathetic acitivity.4
6. Goodman JM et al (1992)
Studied to identify the limiting factors of exercise performance in subjects with hypertension associated with left ventricular hypertrophy and to establish the relationship between the peripheral factors and exercise capacity and they concluded that the failure to reduce elevated total peripheral resistance in subjects with hypertension during exercise limits the exercise performance despite maintenance of left ventricular hypertrophy.9
7. Missault L et al (1992)
Studied to investigate changes in VO2 and rate pressure product in patients with hypertension compared to normo-tensives. They included 22 patients with mild essential hypertension(systolic BP=162+/-22mm of Hg and diastolic BP=95+/-8mm of Hg) and 36 normotensive as control group and performed an arm ergometry test till exhaustion and concluded that hypertensive patients had a lower maximal VO2 and lower maximal rate pressure product than the normotensive subjects.8
8. Somers VK et al(1991)
Studied to examine the effect of baroreflex activation on sympathetic response to stimulation of chemoreceptors in humans and found that changes in sympathetic activity and baroreflex sensitivity are interrelated.15
6.3 Objectives of the study:
  • To find the changes in exercise capacity of patients with essential hypertension, after giving the slow breathing techniques.
  • To examine the lowering of blood pressure after giving slow breathing technique, in patients with essential hypertension.
6.4 Hypothesis:
Experimental hypothesis:
There will be significant changes in exercise capacity after giving a Slow breathing technique in patients with essential hypertension.
Null hypothesis:
There will be no significant changes in exercise capacity after giving a Slow breathing technique in patients with essential hypertension.
Material and Methods:
7.1 Source of data:
WENLOCK Govt. hospital, Mangalore and other hospitals in Mangalore.
7.2 Method of collection of data:
This study will consist of 40 subjects diagnosed as Essential hypertension. After obtaining the informed consent forms from all subjects the blood pressure will be measured in 3 different points of time and their clinical and pharmacological history will be asked, to screen for inclusion and exclusion criteria. If subjects fulfill the criteria for our study then all subjects will be divided into 2 groups: Experimental group (n=20) and Control group (n=20).
The subjects in both groups will continue with their pharmacological treatment but the experimental group will only be treated with Slow breathing technique, additionally.
Then, the blood pressure, heart rate and exercise capacity of all subjects in both groups will be measured by using one mile track walk testand the VO2 (oxygen consumption) can be calculated by using equation.14
A training protocol for breathing control will be applied using, Diaphragmatic, Inter-costal, and Upper chest breathing patterns to make the patient aware of his respiratory movements. Patients will be asked to lie supine, with knees flexed and feet flat on the floor, and raise their hands to the area of the chest related to each breathing pattern: Diaphragm, Inter-costal muscles and Clavicular region. At each breathing pattern patients will be instructed to feel and identify the rib cage motion and its amplitude. Then, they will also be instructed to decrease their respiratory rates gradually while increasing respiratory amplitude. This procedure then will also be performed in sitting position, in same manner as performed in supine position.
Each breathing pattern will be performed 10 times in both positions. This Slow breathing technique will be followed twice a week for a one month.
After the treatment protocol, again the blood pressure, heart rates and exercise capacity will be measured by performing the one mile track walk test and VO2 can be calculated using equation.
Sampling:
Purposive sampling
7.4 Materials to be used:
  1. Sphygmomanometer
  2. Stop watch
  3. Digital heart rate instrument
  4. Measure tape
  5. Stethoscope
  6. Weighing machine
INCLUSION CRITERIA:
  • Patients who are having Systolic blood pressure between 140-160mm of Hg and Diastolic blood pressure between 90-100mm of Hg, according to JNC-VII criteria.
  • Patients who are diagnosed as Essential or Primary hypertension with the age group between 35–60 years.
EXCLUSION CRITERIA:
  • Patients with secondary hypertension due to Liver/Heart/Renal failure.
  • Recent cardiovascular events
  • Pulmonary diseases
  • Diabetes mellitus
  • Neuropathies
  • Autoimmune diseases
  • Cardiac arrhythmias
  • Cigarette smoking
  • Alcohol consumption
  • Use of oral contraceptives
  • Use of neuroleptics/Anti-arrhythmic and Lithium
SATISTICAL ANALYSIS :
STUDY DESIGN : Quasi experimental design
TEST: Paired and Unpaired t- test
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
YES
I intend to assess the effect of slow breathing technique on exercise capacity in patients with Essential hypertension.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Consent has been taken from the college.
LIST OF REFERENCES :
  1. Shyamal Kumar Das, Kalyan Sanyal, Arindam Basu; Study of urban community survey in India: growing trend of high prevalence of hypertension in a developing country; Int J Med Sci. 2005; 2:70-78.
  2. Ellen A. Hillegass, H. Steven Sadowsky; Essential of Cardiopulmonary Physical Therapy. ; 2nd Edition.
  3. Suzuki S, Ohta T; Non-pharmacological treatment of hypertension in the elderly. Nippon Rinhso. 2005; 63 (6): 1010-5.
  4. Brook RD, Julius S; Autonomic imbalance, hypertension and cardiovascular risk. ; Am J Hypertens. 2000; 13: 112S-122S.
  1. Radaelli A, Bernardi L, Valle F, Leuzzi S, Salvucci F, Pedrotti L, Marchesi E, Finardi G, Sleight P.; Cardiovascular autonomic modulation in essential hypertension: effect of tilting.; Hypertension. 1994; 24: 556-563.
  2. Somers VK, Mark AL, Abboud FM.; Potentiation of sympathetic nerve responses to hypoxia in borderline hypertensive subjects.; Hypertension. 1988; 11: 608-612.
  3. Bernardi L, Gabutti A, Porta C, Spicuzza L.; slow breathing reduces chemoreflex to hypoxia and hypercapnia, and increases baroreflex sensitivity.; J Hypertens. 2001; 19 (12): 2221-9.
  4. Missault L, Duprez D, de Buyzere M, de Backer G, Clement D.; Decrease exercise capacity in mild essential hypertension: non-invasive indicator of limiting factors. ;J Hum Hypertens.1992;6 (2): 151-5.
  5. Goodman JM, McLaughlin PR, Plyley MJ, Holloway RM, Fell D, Logan AG, Liu PP.; Impaired cardiopulmonary response to exercise in moderate hypertension.; Can J Cardiol. 1992; 8 (4): 363-71.
  6. Pitt O. Lim, Robert J. MacFadyen, Peter B.M. Clarkson,Thomas M. MacDonald,; Impaired exercise tolerance in hypertensive patients.; Annals of Internal medicine. 1996; 124 (1): 41-55.
  7. Carlos Hermano da Justa Pinheiro; Renato Antonio Ribeiro Medeiros; Denise Goncalves Moura Pinheiro; Maria de Jesus Ferreira Marinho.; Spontaneous respiratory modulation improves cardiovascular control in essential hypertension.; Arq. Bras. Cardiol. 2007; 88 (6).
  8. Chacko N. Joseph, Cesare Porta, Gaia Casucci, nadia Casiraghi, Mara Maffeis, Marco Rossi, Luciano Bernardi.; Slow breathing improves arterial baroreflex sensitivity and decreases blood pressure in essential hypertension.; Hypertension. 2005; 46: 714-718.
  9. Luciano Bernardi, Cesare Porta, Lucia Spicuzza, Jerzy Bellwon, Giammario Spadacini, Axel W. Frey, Leata Y.C. Yeung, John E. Sanderson, Roberto Pedretti, Roberto Tramarin,; Slow breathing increases arterial baroreflex sensitivity in patients with chronic heart failure.; Circulation. 105; 143-145.
  10. Kline G. et al; Estimation of VO2max from a one-mile track walk, gender, age and body weight. ; Med. Sci. Sports Exerc. 1987; 19: 253.
  11. Viren K. Somers, Allyn L. Mark and Farcois M. Abboud; Interaction of Baroreceptor and Chemoreceptor reflex control on Sympathetic nerve activity in normal humans.; The Journal of Clinical Investigation. 1991; 87: 1953-1957.

9 /
Signature of the candidate
10 /
Remarks of the guide
11 / 11.1 Guide’ name
Designation of the Guide
11.2 Signature
/
DR. V. NARAYANAN
Assistant Professor in Physiotherapy
11.3 Co-Guide (If Any)
Designation of co-guide
11.4 Signature /
DR. VARGHESE JOHN
Assistant Professor in Physiotherapy
11.5 Head of the Department
Designation

11.6 Signature

/
DR.T.JOSELEY SUNDERRAJ PANDIAN
Associate Professor in Physiotherapy
And P.G. Coordinator
12 /
12.1 Remarks of Chairman and Principal
12.2 Signature /
DR. RAMPRASAD M.
Principal and Associate Professor in Physiotherapy.

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