Hypertension

Many years ago, when remedies for hypertension were at issue, it would be routine to mention biofeedback among the available remedies. Nowadays, that is less and less the case. What has happened here? Did authorities change their minds over the years? To an extent, the answer is yes. But the earlier truths did not at some point cease to be true. In fact, they have become even more true! Biofeedback is an effective remedy for hypertension.

The earlier methods consisted largely of biofeedback techniques that involved "peripheral" physiology: hand temperature training, skin conductance work, muscle relaxation training, and the learning of abdominal breathing. More recently, we have had significant success with EEG-based biofeedback. This should be no surprise. Regulation, after all, is centrally controlled, even if the measurements are peripheral. Either way, we are talking to the central nervous system - even when matters concern the heart.

A few years ago I inquired with the head of the NIH Heart, Blood, and Lung Institute as to whether the Institute would be interested in a proposal to study of EEG biofeedback for hypertension. She did not see how that would add significantly to the body of literature. It was already clear from the literature that biofeedback was effective for hypertension. That did not have to be proven all over again with a different modality. As for the question why cardiologists were not routinely recommending biofeedback for their patients, that was not in her job description. She turned up her hands as if to say, that's a much bigger issue.

One suspects that cardiologists are just much more comfortable with the new medications that are coming along, and of course these have a lot of marketing pressure behind them. There is also a kind of safety in sticking with what colleagues are doing, so the medical management of hypertension has essentially taken over. Along with that, we have seen an increasing aggressiveness with regard to hypertension. The standard of what is normal keeps being lowered, with the result that a larger and larger percentage of quite functional people are being recommended for aggressive drug treatment.

Whereas it used to be considered that anything under 140mm Hg of systolic pressure and 90mm of diastolic pressure was normal, the new targets are as low as 120mm over 80. It appears that an obvious tendency may be at work here: If low blood pressure is good, then lower must be better. The frustrating data driving this are that a high percentage of cardiac events occur even in the absence of any of the obvious risk factors. So we push even harder on the risk factors we know about.

This ignorance extends to hypertension itself. From the strictly medical perspective, the cause of some 90% of cases of hypertension is unknown. Perhaps a new perspective is needed. And perhaps the fact that biofeedback "works" routinely for hypertension gives us a clue. The clue is that in up to 90% of the cases the cause may not be organic at all, but rather functional, which in turn opens the door to a functional remedy. What do we mean by a functional deficit? Let's just say that the central nervous system has gotten into bad habits. Over time, and under the various stresses of life, it has learned dysfunction.

As soon as we ask the question about how well the control mechanisms governing heart function are actually working, we find that the two numbers we get while the person is lying inactive on a bed at the doctor's office don't really tell us very much. We have to know how the person functions under the stresses of life: that is to say, we must inquire into the "dynamics" of the heart.

The first and most obvious "stressor" or modulator of the heart is our breath. Our heart rate and blood pressure both follow our breath. In a well-regulated system, the heart rate tracks the in- and out-breath fairly closely, and the blood pressure follows with some delay. The resulting fluctuation is referred to as "Heart Rate Variability (HRV)." The concept is well known to cardiologists. In fact, it is already known within cardiology that HRV is the best single predictor of cardiac morbidity! What is not generally appreciated within the field, however, is that HRV is not only a passive measure, but also a pathway toward an active intervention, namely biofeedback.

Here we have yet another "figure of merit" for heart function that we can use for training our physiology. In fact, we are even better off here than in the usual case of biofeedback. Ordinarily, the functions we are training are "autonomic," under our body's control but not directly under our volitional control. Hence the extended biofeedback training process is necessary to "retrain" our autonomic regulation. When it comes to HRV, however, we can intervene voluntarily because the breath can be put under our voluntary control. So the training of heart function begins with the voluntary control of the breath. This is a course that no one can fail. It is unfortunately a course that very few people take.

Simply slowing down our breathing rate does two wonderful things: the first is that it gives heart rate variability greater range. The heart rate swings more widely simply because it has more time to do so. And that exercises the control loops all by itself. The heart will be kept under "healthy stress" with every breath. The second impact is on the CO2 or carbon dioxide level of the blood. By breathing more slowly, we allow our blood chemistry to equilibrate. Fast breathing short-circuits that process, and that causes all kinds of cumulative mischief with our health.

The dictum that most chronic health conditions involve issues of human behavior is particularly relevant to the condition of our hearts. If the cardiologist reaches directly for the prescription pad without also mentioning the importance of the behavioral realm, then his patient is likely not well served. And the behavioral realm now extends beyond the matter of reducing salt intake to how one lives one's life day-to-day, moment-to-moment, breath-to-breath.

Now we cannot be expected to pay attention to our breath during all of our waking moments. But by placing the breath under our voluntary control for even a while, such as we might do in a biofeedback therapy session, we allow our system to acquire new habits that it then takes home.

In this larger perspective, then, the "success" of the medication in reducing blood pressure occurs at a price of foregoing the conversation that should be taking place, and of avoiding the essential remedy of training dynamic heart function. The combination of Heart Rate Variability training and EEG Neurofeedback should be the remedy of choice for "essential" hypertension. Medication can be of help along the way, but it should not be relied upon as the long-term remedy. Medication targets the symptom; biofeedback addresses the actual problem. - Siegfried Othmer, PhD