Members of the research team reflect on the results of their recent review of stress management and relaxation interventions for hypertension and pre-hypertension. You can access the full review here: https://doi.org/10.1136/bmjmed-2024-001098.
Despite the long-standing availability of effective medication, hypertension is still a leading cause of death and poor health worldwide. Current management typically involves a range of interventions, including advice on appropriate exercise, diet and smoking cessation, usually alongside blood pressure lowering medication. However, some people have difficulty adhering to medications and may struggle with side effects. Additionally, lifestyle changes, including different relaxation therapies, may confer further benefits when implemented alongside medication. Ideally, we need a variety of evidence-based options to ensure that treatment can be individualized and optimized for each person.
Our work gives a state-of-the-art review of the potential for relaxation therapies to contribute to management of hypertension. We reviewed systematically all randomized controlled trials that considered the use of relaxation or stress management techniques for people with hypertension or pre-hypertension. In the short term (up to three months), many different relaxation techniques appear to result in reductions in blood pressure.
These techniques may not suit everyone. However, a reduction in blood pressure was seen with almost all relaxation methods, indicating that people could select the technique that most suited their needs. The availability of online relaxation classes, or self-guided practice, means that these interventions may be relatively cheap and flexible treatment options (although evidence for cost-effectiveness was lacking). There may also be more holistic health benefits from the adoption of relaxation techniques, such as improvements in mental health and wellbeing. Delivery of these techniques to groups rather than individuals may add further benefits and improve feasibility and costs, although more evidence is needed in this area.
As is often the case with complementary and alternative therapies, the evidence base is not sufficiently robust to inform practice. Indeed, the National Institute for Health and Care Excellence (NICE), removed a recommendation for relaxation therapies from their hypertension guidelines for just this reason. All of the trials included in our analysis had at least some concerns regarding their risk of bias – often due to unclear or poor trial methodology, and high participant drop-out. By neglecting to study these techniques in a robust and reproducible manner we are potentially missing out on a valuable tool to help manage hypertension.
We need well conducted studies, that continue to follow-up participants for a year or more, to confirm the efficacy and acceptability of relaxation techniques in the longer term. It is likely that relaxation practice must be maintained to see continued effects on blood pressure, much as drug benefits require continued adherence, therefore understanding whether people persevere with these techniques over time is important. Longer-term studies will also enable the collection of important safety data, as well as information on major cardiovascular events, which were poorly reported or not assessed in the existing studies.
We hope that this work will encourage patients, clinicians, guideline authors and researchers to look again at relaxation therapies for individuals with raised blood pressure, considering whether they may be a valuable addition to current treatment regimens. Given the promising effects of relaxation therapies in the short term, we advocate for further studies to assess the longer-term impact of these techniques, and explore the most efficient means of delivery.