MEDITATION RESEARCH- HISTORY AND CURRENT STATUS

The positive effects seen in the practitioners of meditation generated scientific

curiosity and the first research paper on meditation was published in 1970 by

Robert Keith Wallace “Physiological Effects of Transcendental Meditation”.

Oxygen consumption, heart rate, skin resistance, and electroencephalograph

measurements were recorded before, during, and after subjects practiced

Transcendental meditation. There were significant changes between the control

period and the meditation period in all measurements. During meditation,

oxygen consumption and heart rate decreased, skin resistance increased, and the

electroencephalogram showed specific changes in certain frequencies. These

results initiated further research on TM and many more papers were published

on substance abuse, self actualization and autonomic stability in the next two

years (Wallace R.K 1972, Seeman W 1972, Nidich S 1973, Orme-Johnson

D.W 1973).

After this nearly 600 studies have been published from 60 countries on TM.

Most of the studies were on Cardiovascular Disease Risk Factors, Depression,

Anxiety and Insomnia, Stress and Substance Abuse.

Transcendental Mediation® (TM) technique started getting acceptance from

the scientific world as a possible means of countering effects of stress with

altered levels of several hormones both during the practice and longitudinally

after regular practice of this technique. In this prospective in 1972 PJ Russel

conducted a random assignment study, to see changes from baseline levels and

acute responses to laboratory stressors.

41

Four hormones, cortisol, growth hormone, thyroid-stimulating hormone and

testosterone, were studied before and after 4 months of either the TM technique

or a stress education control condition. Daily urine excretions of

catecholamines and Vanillyl Mandelic Acid (VMA) were determined in ten

male advanced meditators and ten male long-term meditators who were

subjected four times to slight physical exercise following a period of rest,

meditation or reading. Blood pressure and heart rate were measured

continuously and blood samples were taken for plasma catecholamine levels

immediately before and after the physical exercise and VMA excretions were

greater in the TM group (R. Lang, 1979). Later in 2001 Morning and evening

Catecholamine levels were studied in 19 regular practitioners of TM and

control group and in the TM group it was lower than in the control (Jose Rafael

Infante, 2001).

Lipid peroxidase levels were studied in 41 normal healthy adults who were

long- term practitioners of the technique (Robert H. Schneider 1998) and serum

lipid peroxidase levels were found to be significantly lower when compared to

the control. Robert H. Schneider et al (1995) tested the short-term efficacy and

feasibility of two stress education approaches to the treatment of mild

hypertension in older African Americans. This was a randomized, controlled,

single-blind trial with 3 months of follow-up in a primary care, inner-city health

center on 127 individuals who were aged 55 to 85 years. The reductions in the

Transcendental Meditation group were significantly greater than in the

progressive muscle relaxation group for both systolic blood pressure and

42

diastolic blood pressure. The linear trend analysis also confirmed the reduction.

A preliminary investigation of the acute effects of TM on total peripheral

resistance was conducted and was found to be decreased significantly during

TM (Vernon A. Barnes 1999).

In 2007 Maxwell V. Rainforth conducted an updated systematic review of the

published literature and identified 107 studies on stress reduction and BP in

TM. Seventeen trials with 23 treatment comparisons and 960 participants with

elevated BP met criteria for well-designed randomized controlled trials and

replicated within intervention categories. Meta-analysis was used to calculate

BP changes for biofeedback, relaxation-assisted biofeedback, progressive

muscle relaxation, stress management training, and the Transcendental

Meditation program, results indicated that among stress reduction approaches,

the Transcendental Meditation program is associated with significant

reductions in BP. In 2008 (JW Anderson) full reports of randomized controlled

trials related to Transcendental Meditation and hypertension were meta-

analyzed and the random-effects meta-analysis model for systolic and diastolic

blood pressure, indicated that Transcendental Meditation, compared to control,

was associated with significant lowering of blood pressure. When the efficacy

of transcendental meditation (TM) was evaluated on components of the

metabolic syndrome and Coronary Heart Disease (CHD), use of TM for 16

weeks in CHD patients improved blood pressure and insulin resistance,

components of the metabolic syndrome, as well as cardiac autonomic nervous

43

system tone compared with a control group receiving health education (Maura

Paul-Labrador 2006).

When 10 experienced male meditators and nine matched subjects, uninformed

of the TM procedure, were compared, after 40 minutes of practice, no

significant difference was seen between these 2 groups with respect to

carbohydrate metabolism (plasma glucose, insulin and pancreatic glucagon

concentrations), pituitary hormones (growth hormone and prolactin) or the

'stress' hormones, cortisol and total catecholamines, although meditators tended

to have higher mean catecholamine levels. Plasma free fatty acids were

significantly elevated in meditators (Cooper R 1985)

After TM, Mindfulness meditation stands second in medical research. A

randomized, wait-list controlled study was conducted on cancer patients.

Patients completed the Profile of Mood States and the Symptoms of Stress

Inventory both before and after the intervention. The intervention consisted of a

weekly meditation group lasting 1.5 hours for 7 weeks plus home meditation

practice. After the intervention, patients in the treatment group had significantly

lower scores on Total Mood Disturbance and subscales of depression, anxiety,

anger, and confusion and more vigor than control subjects. The treatment group

also had fewer overall symptoms of stress; fewer cardiopulmonary and

gastrointestinal symptoms; less emotional irritability, depression, and cognitive

disorganization; and fewer habitual patterns of stress (Michael Speca 2000).

44

Studies on Vipasana meditation showed the possible beneficial role of the

technique in sleep–wakefulness behavior in adults (Sulekha S 2006).

Authors claim that yoga practices help to retain slow wave sleep and enhance

the REM sleep state in middle age thus helping one to retain a younger

biological age as far as sleep is concerned.

Brain electrical activity was measured before and immediately after, an 8-week

training program in mindfulness meditation. Twenty-five subjects were tested

in the meditation group. A wait-list control group was tested at the same points

in time as the meditators. At the end of the 8-week period, subjects in both

groups were vaccinated with influenza vaccine. There was significant increase

in left-sided anterior activation, a pattern previously associated with positive

affect, in the meditators compared with the nonmeditators. It was also found

significantly increased in antibody titers to influenza vaccine among subjects in

the meditation compared with those in the wait-list control group (Richard J

Davidson 2003).

When the study was conducted on the effectiveness of Mindfulness-based

stress reduction (MBSR) program, it was found to be associated with increase

in mindfulness and spirituality. There were significant improvements in state

and trait mindfulness, psychological distress, and reported medical symptoms.

(Carmody 2008).

45

BRAIN CHANGES DURING MEDITATION

ACTIVATION OF THE PREFRONTAL AND CINGULATE CORTEX

Since meditation requires intense focus of attention, it seems appropriate that a

model for meditation begin with activation of the Pre Frontal Cortex (PFC),

particularly in the right hemisphere, as well as the cingulate gyrus.

THALAMIC ACTIVATION

Several animal studies have shown that the PFC, when activated, innervates the

reticular nucleus of the thalamus (Cornwall J 1988), particularly as part of a

more global attention network (Portas C M 1988). When excited, the reticular

nucleus secretes the inhibitory neurotransmitter GABA onto the lateral

geniculate nuclei, cutting off input to the PSPL and visual centers in proportion

to the reticular activation (Destexhe A 1998). Several studies have

hypothesized an increase in serum GABA during meditation (Elias A. N 1998).

PSPL DEAFFERENTATION

When deafferentation of the PSPL via the reticular nucleus’s GABA ergic

occurs, an individual may begin to lose his or her usual ability to spatially

define the self and help to orient the self.

46

HIPPOCAMPAL AND AMYGDALAR ACTIVATION

In addition to the complex corticothalamic activity, meditation might also be

expected to alter activity in the limbic system, especially since stimulation of

limbic structures is associated with experiences similar to those described

during meditation (Fish D R 1993, Saver J L 1997).

HYPOTHALAMIC AND AUTONOMIC NERVOUS SYSTEM CHANGES

The hypothalamus is extensively interconnected with the limbic system.

Stimulation of the right lateral amygdala has been shown to result in

stimulation of the ventromedial portion of the hypothalamus with a subsequent

stimulation of the peripheral parasympathetic system (Joseph R 1996).

Increased parasympathetic activity is associated with the subjective sensation

first of relaxation and, of a more profound quiescence (Newberg 2003).

Activation of the parasympathetic system would also cause a reduction in heart

rate and respiratory rate. All of these physiological responses have been

observed during meditation (Davis M 1992). When an individual’s breathing

and heart rate slow down, the para gigantocellular nucleus of the medulla

ceases to innervate the locus ceruleus (LC) of the pons. The paraventricular

nucleus of the hypothalamus typically secretes corticotropin-releasing hormone

47

(CRH) in response to innervation by NE from the locus ceruleus (Jevning R

1992, Walton K G 1995). This CRH stimulates the anterior pituitary to release

adreno-corticotropic hormone (ACTH) (Livesey J. H 2000). ACTH, in turn,

stimulates the adrenal cortex to produce cortisol, one of the body’s stress

hormones (Davies E 1985). Decreasing NE from the locus ceruleus during

meditation would likely decrease the production of CRH by the paraventricular

nucleus, which would ultimately decrease cortisol levels. Most studies have

found that urine and plasma cortisol levels are decreased during meditation

(Sudsuang R 1991, Jevning R 1978, Renaud L P 1996). The drop in blood

pressure associated with para-sympathetic activity during meditation practices

would be expected to relax the arterial baroreceptors leading the caudal ventral

medulla to decrease its GABAergic inhibition of the supraoptic nucleus of the

hypothalamus.

48

CHANGES DURING MEDITATION

      

Sustained attention, Focussing                            

PFC   Cingulate gyrus

              

 

 

Decrease stimulation of LC 

Decrease ACTH 

Reticular nucleus of thalamus

PSPL 

Hippocampus, amygdala 

Decrease gluconeogenesis 

 

Stimulate PSN 

Decrease HR, RR 

Hypothalamus

 

Decrease Cortisol 

Decrease CRH, ↓ Symp.NS-

49

CRITICISMS AND LACUNAE IN MEDITATION RESEARCH

The University of Alberta Evidence-based Practice Center (UAEPC) reviewed

and synthesized the published literature on the state of the research of

meditation practices for health.

State of Research on the Therapeutic Use of Meditation Practices in

Healthcare

Eight hundred and thirteen studies provided evidence regarding the state of

research on the therapeutic use of meditation practices. Half of the studies on

meditation were published after 1994. Most of the studies were published as

journal articles. Studies were conducted mainly in North America (61 percent).

Of the 813 studies included, 67 percent were intervention studies (286 RCTs,

114 NRCTs and 147 before-and-after studies), and 33 percent were

observational analytical studies (149 cohort and 117 cross-sectional studies).

Control groups in these studies: The number of control groups used in the 668

controlled studies ranged from one to four. The majority of the studies utilized

an active, concurrent control.

Study population: The majority of studies on meditation practices have been

conducted in healthy populations.

Outcome measures: Physiological functions, particularly cardiovascular

outcomes, were the most frequently reported outcome of interest in meditation

research. Psychosocial outcomes, outcomes related to clinical events and health

50

status, cognitive and neuropsychological functions, and healthcare utilization

outcomes have also been evaluated in studies of meditation practices.

Results of the analysis: A few studies of overall poor methodological quality

were available for each comparison in the meta-analysis, most of which

reported no significant results.

The physiological and neuropsychological effects of meditation practices were

evaluated in 311 studies. The majority of studies were conducted in healthy

participants. Meta-analysis revealed that the most consistent and strongest

physiological effects of meditation practices in healthy populations occur in the

reduction of heart rate, blood pressure, and cholesterol. The strongest

neuropsychological effect is in the increase of verbal creativity. There is also

some evidence from before and after studies to support the hypothesis that

certain meditation practices decrease visual reaction time, intraocular pressure,

and increase breath holding time. The overall low methodological quality of

the studies indicated that most of the studies suffered from methodological

problems that may result in overestimations of the treatment effects or

compromise the generalizability of the study results. Particularly, the lack

of a concurrent control group in the before and after studies, results in an

inability to control for temporal trends, regression to the mean, and

sensitivity to methodological features.

So the current study was designed on a new meditation technique named

Integrated Amrita Meditation technique designed and presented to the world by

Her Holiness Mata Amritanandamayi Devi.

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MATA AMRITANANDAMAYI MATH (MAM)

The Mata Amritanandamayi Math was established in 1982 at Mata

Amritanandamayi devi’s (Amma’s) birthplace, Parayakadavu, a small fishing

village on the Arabian Sea, 13 kms from Karunagappally, Kollam district,

Kerala. The ashram is run by Amma’s monastic disciples and regularly holds

spiritual discourses and classes. The devotees enjoy participating in the

devotional singing meditation and chanting that take place daily. The Math has

over 30 branches all over India and 60 branches across the world. Through

these branches, the Math conducts various humanitarian activities such as

medical camps, feeding the poor, distributing pensions, building free homes for

the homeless and more.

INTEGRATED AMRITA MEDITATION TECHNIQUE

From ancient times up to the present day, an unbroken succession of Self-

realized Masters has taken birth in India to lead seekers of Truth to the ultimate

reality. Mata Amritanandamayi is known variously as a Humanitarian, Mother,

52

Friend, Guru, and God by the people. She is popularly known as Amma. She

has offered herself to the world. In reality, She is beyond all such roles, her true

nature is to be the true nature of all of us the blissful divine consciousness that

pervades this universe. But out of her infinite compassion, Amma comes down

to the level of whoever is standing before her the poor, the lonely, the seeker in

order to give what is desired, what is needed.

IAM - Integrated Amrita Meditation Technique® is a powerful meditation

technique created by Amma to help people find fulfillment in spiritual as well

as materialistic life. It can be comfortably performed by anyone in just 23

minutes per day. The IAM - Integrated Amrita Meditation Technique® is

protected under a registered trade mark in order to preserve the original form of

this meditation designed and developed by Amma and to prevent misuse by

unauthorized and unqualified teachers. Therefore, at the beginning of the

course each participant is requested to sign an agreement that he or she shall

keep the course, including all written materials received as part of the course,

strictly confidential. This meditation course is meant only for a person of sound

mental health.

Amma’s disciples teach the technique in all parts of the world. IAM

Technique® is not only taught to Amma’s devotees, but also to organizations

throughout the world, including corporations, education institutions and

correctional facilities. Students of various Universities and the Indian Army

have also been introduced to this technique.

53

RESEARCH HYPOTHESIS & OBJECTIVES

SAMPLE SIZE CALCULATION

STUDY DESIGN

MATERIALS ND METHODS

54

RESEARCH HYPOTHESIS AND OBJECTIVES

Introduction to methodology: Previous studies on meditation indicates that,

not all techniques have the same effects and in most of the studies, small

sample size, suboptimal control groups, lack of long-term follow up, and

problems of adherence among participants were the factors criticized. So we

designed the current study with an aim to understand the effect of Integrated

Amrita meditation technique on physiological and psychological stress using

two control groups and of the four phases of intervention, i.e., baseline, 48

hours, 2 months, and 8 months.

Hypothesis: Our hypothesis is that IAM Meditation would reduce stress in

normal young adults and this will be reflected as changes in physiological and

psychological stress indicators.

Research question that needs to be answered through the study: Does IAM

Meditation bring any change in the response to stress?

Objective of the study:

The objective of the study is to study the changes in the immediate (48 hours),

short term and long term stress responses after IAM meditation technique

through culturally adapted psychological questionnaires, short and long term

stress coping pathways (cortisol, adrenaline) and physiological parameters like

blood pressure, heart rate, respiratory rate, GABA and IGA levels.

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SAMPLE SIZE CALCULATION

The sample size was calculated from the available information from published

papers. Since no study was reported earlier using IAM Technique the minimum

sample size was computed based on the results reported for Buddhist

meditation technique. The sample size was estimated with 95% confidence and

80% power. Details of the sample size estimation are given in the Table.

(Sudsuang et al1991)

Before

(mean ± SD) After

(mean ± SD) Difference

(mean ± SD) Sample

size Cortisol (M) 12.33 ± 2.82 9.31 ± 1.79 3.02 ± 3.34 Cortisol (C) 11.39 ± 1.64 11.43 ± 1.39 -0.04 ± 2.12

7 ~ 10

Systolic BP (M) 111.33 ± 8.33 104.66 ± 10.06 6.67 ± 13.06 Systolic BP (C) 115.11 ± 12.14 116.83 ± 7.93 1.72 ± 14.5

21~ 25

Diastolic BP (M) 73.33 ± 6.17 64.33 ± 6.39 9 ± 8.88 Diastolic BP (C) 75.66 ± 7.73 76.33 ± 6.68 0.67 ± 10.22

7.67~8

Heart rate (M) 83.69 ± 11.29 74.8 ± 9.15 8.89 ± 14.53 Heart rate (C) 80.26 ± 5.24 80.73 ± 7.72 0.47 ± 9.33

13.5~14

Adrenaline (M) 136.6 ± 13 119.7 ± 10.8 16.9 ± 16.9 Adrenaline (C) 236.8 ± 21 175 ± 17.4 61.8 ± 27.27

2

n = (sd12 + sd2

2) (Z 1-α+ Z 1-β)2 /d2

(d= mean 1- mean 2)

It may be noted that maximum sample size among the various parameters was

estimated for Systolic Blood Pressure which was a sample size of 25. Hence the

minimum sample size was fixed as 25 for the present study for each of the three

groups to obtain a characteristical difference for all the parameters which were

planned to be measured.

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STUDY DESIGN

The study received Institutional Ethics Committee clearance and Scientific

Advisory committee clearance before the commencement.

Two pilot studies were conducted on a working adult population. The subject

information sheet and informed consent were given to people working at

AIMS. In the first pilot, 20 employees of AIMS were recruited and randomized

into three groups (IAM, PMR, control). But out of the seven recruited for the

IAM only one person came for the first visit. When the subjects were contacted

further, it was learned that they were not comfortable with randomization and

were not sure whether they would be able to continue for eight months in the

study. In the second pilot anticipating the heavy drop out, 60 subjects were

recruited and randomized but again there was a heavy dropout and the study

could not be conducted. On further discussion with the drop out subjects of the

pilot it was found that due to work constraints they could not find time for the

practice and those who had dropped out of the control group felt that they

would not benefit from learning a relaxation technique and so were no longer

interested in the study. Finally it was decided to take college students for the

study as they are a captive audience. (Follow up was easier as we could go to

them rather than having them come to us) Ensuring compliance was also

expected to be easier as the students could be contacted at regular intervals in

their classes or hostels.

57

The original study was conducted in two campuses under the Amrita

Viswavidyapeetham. The purpose of the study and the methodology was

clearly explained through slides to the students of age group 18-21.

Any student who had practiced any relaxation technique at anytime was asked

not to participate in the study.

The volunteers were selected through a screening questionnaire i.e., Life styles

questionnaire. The exclusion criteria were alcoholics, chronic smokers and

psychiatric patients. There was only one student who had reported that she was

taking psychiatric medicine and was excluded. Subjects signed informed

consent forms prior to participation in the study.

Since we anticipated a heavy dropout of subjects after randomization, double

the required sample size was selected for the first visit. Thus one hundred and

fifty college students were randomly assigned three groups by the lottery

method. Subjects were numbered and tokens were prepared with these numbers

written on it. From this the tokens were drawn and assigned to three different

groups. The first group was trained to practice the meditation technique called

Integrated Amrita Meditation (IAM) Technique. The subjects randomized to

the second group were given training on Progressive Muscle Relaxation (PMR)

technique. The subjects randomized to the third group served as controls and

did not practice any meditation technique or do any relaxation exercises.

IAM technique was taught to the IAM group by trained instructor from the MA

Math. PMR technique was taught by a trained physiotherapist. The control

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group was not given any special training. All the psychological, physiological

and biochemical parameters were collected after 48 hours to study the

immediate changes and again after two months of continuous practice to see the

short term effect and after eight months of regular IAM or PMR practice to

study the long term effects.

A self-maintained diary assessed compliance in both the groups. All the subjects

in the IAM and PMR groups continued regular practice of these techniques

throughout the eight month period. Apart from assessing the diaries, compliance

was also assured by frequently visiting the students at their college and hostel.

Baseline values for all the parameters were collected at 0 hours, i.e. before any

training was given to the IAM & PMR groups. (Through out the entire study all

data were collected in the morning by 8 am). Blood was collected for all the

visits and plasma was separated and stored at minus 20 degree Celsius in the

deep freezer. The tests were conducted for all the parameters in AIMS.

The data was entered in SPPSS statistical package. All subjects were followed

up for a total duration of eight months. Regular refresher courses were arranged

for IAM and PMR groups.

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MATERIALS AND METHODS

IAM TECHNIQUE

Like any other form of meditation, IAM has its roots in the Indian Tantric

practices. It is a method for experiencing the energy of the macrocosm within

the microcosm through mastering a technique of energy movement called Prana

Sanchara. It consists of energizing exercises (yogic postures) for up to 8

minutes, a brief period of relaxation for 2 minutes and 13 minutes of

meditation. At the end of the technique the subjects are asked to remain in

silence for 5 minutes.

The components of the technique are:

Relaxation exercises/yogic postures: These exercises progressively relax the

muscles and joints and so the mind too. It also has an energizing, holistic effect.

Breathing exercises (focused breathing): These breathing exercises draw

attention to the way one breathes, prompts a more complete breathing.

Awareness: Throughout the process awareness is the main component. One is

encouraged to be aware of all the subtleties of each of the steps. One part in

particular focuses on the flow of breath.

Visualization: This is a key component of this technique as mind is focused on

an internal point, rather than on a physical object outside.

Only the first class is guided. The later practice is without the help of any

external means.

Criteria for successful practice: Belief in a spiritual master and chanting the

mantra given by the master is recommended.

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The relaxation of the mind by this technique is expected to reduce stress and

expand thinking in general, making the subject more creative on his work or

studies.

This is the first study on the IAM Technique

PROGRESSIVE MUSCLE RALAXATION TECHNIQUE Progressive

Muscle Relaxation (or PMR) is a technique for reducing anxiety by alternately

tensing and relaxing the muscles. It was developed by American physician

Edmund in the early 1920s (Jacobson, E. 1924). Jacobson argued that since

muscular tension accompanies anxiety, one can reduce anxiety by learning how

to reduce the muscular tension. PMR has a physical and mental component.

The physical component involves the tensing and relaxing of muscle groups

over the arms, legs, face, abdomen and chest. With the eyes closed and in a

sequential pattern, a tension in a given muscle group is purposefully done for

approximately 10 seconds and then released for 20 seconds before continuing

with the next muscle group.

The mental component focuses on the difference between the feelings of the

tension and relaxation. Jacobson found that the relaxation procedure is effective

against ulcers, insomnia, and hypertension. The technique has also proven

effective in reducing acute anxiety in people with Schizophrenia. (Chen WC

2009). Jacobson's Progressive Relaxation has remained popular with modern

physiotherapists. This is a standardized relaxation technique. We have taken

this as one of the control group because IAM technique is a combination of few

61

relaxation exercises and deep meditation and we wanted to see if the effects of

the mediation are due to the muscle relaxation part of the technique or due to

the deep meditation.

PSYCHOLOGICAL INSTRUMENTS

A. Life changes stress scale

In 1967, psychiatrists Thomas Holmes and Richard Rahe examined the medical

records of over 5,000 medical patients as a way to determine whether stressful

events might cause illnesses. Patients were asked to tally a list of 43 life events

based on a relative score (Holmes TH 1967). A positive correlation of 0.118

was found between their life events and their illnesses. Their results were

published as the Social Readjustment Rating Scale (SRRS) known commonly

as the Holmes and Rahe Stress Scale. M A Miller and Rahe Recent life changes

questionnaire in scaling for the 1990 containing 73 items which is a modified

version of Holmes and Rahe scale was used in the study.

M A Miller and Rahe Recent life changes questionnaire was initially given to

the adults and college students in Kochi in South India where the study was

conducted. As the subjects reported that many items given in the scale were

irrelevant for the Indian population and many stress precipitating factors were

missing, the questionnaire was modified. The new questionnaire contained 74

items.

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Standardization

Standardization of the new questionnaire was then done.

As a part of standardization 12 items were deleted. The Health item ‘Major

change in your usual type or amount of recreation’ was not found to be a

significant stress factor for the local population. Home and family items like

‘Parent’s divorce’, ‘A parent remarries’; personal like ‘Beginning or ending of

school’, ‘Change in political beliefs’, ‘Change in religious belief’, ‘New close

personal relationship’ and finance factors like ‘Moderate purchase’ ,

‘Foreclosure on mortgage or loan’ were insignificant stress factors for the

Indian population and were deleted. Thirteen items which were more important

in inducing stress were added like ‘An examination’ (Work), ‘Menopause’, ‘Not

having children’, ‘Not having a son’, ‘Unmarried daughter dowry problems’,

‘Unemployed child/spouse’, ‘Problems with room mate’, ‘Property dispute’

(Home and family); ‘Event that brought shame to the family or caused

humiliation’, ‘ Family member getting addicted to alcohol or drugs’ (Personal

and social) and ‘Major loss of income’, ‘Self or other family member trapped in

a financial problem’, ‘Being in a traffic accident’, ‘Being involved in a natural

or man made disaster’(Financial and other). Five items were merged into two

items (‘Child leaves home to attend college or for marriage’ & ‘Child leaves

home’, ‘Death of a child’, ‘Death of parent’ & ‘Death of a brother or sister’).

The new questionnaire (Table11 a) was given to 101 subjects (the local

population /college students) and they were asked to rate each item or to give

stress score to each item imagining how stressful each event would be if it

63

occurred in his/her life. This was analyzed for split half reliability and was

found to be have correlation coefficient 0.96. Life change units for the Indian

college students were found.

B. PERCEIVED STRESS SCALE - Sheldon Cohen

The Perceived Stress Scale (PSS) is the most widely used psychological

instrument for measuring the perception of stress. It is a measure of the degree

to which situations in one’s life are appraised as stressful. Items were designed

to tap how unpredictable, uncontrollable, and overloaded respondents find their

lives. The scale also includes a number of direct queries about current levels of

experienced stress. The PSS was designed for use in community samples with

at least a junior high school education. The items are easy to understand, and

the response alternatives are simple to grasp.

The questions in the PSS ask about feelings and thoughts during the last month.

C. BECK DEPRESSION INVENTORY

Historically, depression was described in psychodynamic terms as "inverted

hostility against the self (Beck 2009). By contrast, the BDI was developed in a

novel way for its time; by collating patients' verbatim descriptions of their

symptoms and using these to structure a scale which could reflect the intensity

or severity of a given symptom (Beck 2006).

Throughout his work, Beck drew attention to the importance of "negative

cognitions": sustained, inaccurate, and often intrusive negative thoughts about

64

the self (Allen JP2004). In his view, it was the case that these cognitions

caused depression, rather than being generated by depression. Beck developed

a triad of negative cognitions about the world, the future, and the self, which

play a major role in depression. The original BDI, first published in 1961 (Beck

1961), consisted of twenty-one questions about how the subject has been

feeling in the last week. Each question has a set of at least four possible answer

choices, ranging in intensity.

The BDI-II was a 1996 revision of the BDI (Beck 1996) developed in response

to the American Psychiatric Association's publication of the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, which changed many of

the diagnostic criteria for Major Depressive Disorder.

METHODS

Life Changes Questionnaire: These standardized questionnaires were given

without scores to the subjects who were randomized into the 3 groups and they

were asked to rate how stressful each event would be if it occurs in their life.

All the questionnaires were collected at baseline (before any intervention), and

again 48 hours later to assess the stress response of the subjects to each

stressful event before and after the practice of the techniques. Subsequently the

questionnaires were collected two months and eight months after

randomization. BDI & PSS were also collected at baseline (before any

intervention), and again 48 hours later and then collected 2 months and eight

months after randomization.

65

BIOCHEMICAL TESTS

A. ADRENALINE ANALYSIS

Plasma Adrenaline analysis was done by ELISA (Adrenaline EIA).

Adrenaline was extracted using a cis-diol specific affinity gel. It was then

acylated to N - acyladrenaline and converted enzymatically to N-

acylmetanephrine. Acylated Adrenaline from the sample and solid phase of

the micro titer plate compete for antiserum binding sites. The antibody bound

to solid phase was detected by an anti rabbit IgG peroxidase conjugate using a

suitable substrate. The reaction was monitored at 450 nm.

B. CORTISOL ASSAY

Cortisol was estimated by Chemiluminescent micro particle immuno assay

method. The sample and anti Cortisol coated paramagnetic micro particles are

combined to create a reaction mixture. Cortisol present in the sample binds to

the anti Cortisol coated micro particles. After incubation Cortisol acrinidium

labeled conjugate is added to the reaction mixture and trigger solutions are

added to the reaction mixture. The resulting chemiluminescent reaction is

measured as Relative Light Units (RLU).

C. IGA

IgA was analysed by turbidimetry method. IgA represents about 10 to 15 % of

the serum immunoglobulins. The most important form of IgA is the secretory

66

IgA, found in tears, sweat, saliva, milk, colostrums and gastrointestinal and

bronchial secretions.

We analyzed the plasma IgA levels. Anti-human IgA antibodies form

insoluble complexes when mixed with samples. As the scattering light of the

immunocomplexes depends of the IgA concentration in the subjects sample,

the values were quantified by comparison from a calibrator of known IgA

concentration.

D. GABA

GABA was analyzed by HPLC. GABA present in the supernatant or in a

standard solution of GABA of convenient concentration was derivatized to

phenylthiocarbamyl-GABA (PTC-GABA) following the indications of

Gunawan et al. A 100-/zl aliquot of supernatant (or of standard solution of

GABA) was dried under vacuum. The residue was dissolved in 20 /microlitre

of ethanol-watertriethylamine (2:2:1) and evaporated to dryness under

vacuum. A 30-/ microlitre volume of ethanol-watertriethylamine- PITC (7:1 :

1 : 1) was added to the residue and allowed to react for 20 min at room

temperature to form PTC-GABA. Excess reagent was then removed under

vacuum. The standard curve for GABA was determined by applying the same

procedure to four standard solutions of GABA (0.125, 0.25, 0.50 and 0.75

mM GABA).

HPLC SEPARATION AND EVALUATION OF GABA

The dry residue containing PTC-GABA was dissolved in 100/ microlitre of

the mobile phase, consisting of a mixture of 80% solution A (aqueous

67

solution of 8.205 g sodium acetate, 0.5 ml triethylamine, 0.7 ml acetic acid

and 5.0 ml acetonitrile in 1000 ml) and 20% solution B [acetonitrile-water

(60:40)], adjusted to pH 5.8. Isocratic HPLC separations were performed on a

Shimadza (Japan) apparatus. HPLC system consists of Shimadza LC – 10

ATVP Pump, a manual injector, a diode array detector SPD – M10 AVP, a

column oven CTO – 10 CTO – 10 ASVP and system controller SCL –

10AVP. Luna c – 18column was used. The mobile phase for isocratic elution

was pumped at 0.6 ml/min, at room temperature; detection was at 254 nm.

PHYSIOLOGICAL MEASUREMENTS

RECORDING OF BLOOD PRESSURE, HEART RATE,

RESPIRATORY RATE

A. Blood Pressure- The mercury sphygmomanometer method which is

considered generally as the gold standard for recording BP (Dougherty L

2008) was used in the study to record BP. The subject was allowed to relax

and BP was recorded in the upper arm in the sitting posture. For the same

subject BP was recorded twice each time and the average of the two

recordings was taken as the reading. The measurements were taken by the

same qualified nurses during all visits to minimize inter observer variability.

B. Heart Rate- HR was recorded with the elbow and forearm resting

comfortably on a table and the palm of the hand turned upward and the radial

pulse was felt and counted for 1 minute exactly.

68

C. Respiratory Rate - Examiner's fingers were placed on the subject’s

abdomen and the number of breaths or respirations in one minute was recorded.

Effort was taken to prevent people from becoming aware that their breathing

was being checked.

STATISTICAL ANALYSIS

The reliability of the LCQ stress scale was studied by computing split half

reliability coefficient. The data was analyzed using SPSS - Version 11 (SPSS

Inc, Rostock, IL) statistical package.

The within group comparison for all the parameters was done by paired t test.

The difference in the mean values of all variables between groups was done by

applying ANCOVA (repeated measures) taking four levels of observation

(visits 1, 2, 3, 4).

Note: When the analysis is done with all the time points (within group)

together only the minimum number of cases observed at a particular point will

be considered at all points reducing the sample size at each point to very

small. Also replacement of the missing values by imputation method

especially when there are many missing values may not be very valid as

imputation method itself has a lot of criticism. Hence the within group

comparison has been done for the groups separately for time points 1&2,

1&3, 1&4 so that the maximum number of cases available can be considered

for the analysis.

69

Compliance: All subjects were followed up for a total duration of eight

months. A self-maintained diary assessed compliance in both the groups. All

the subjects in the IAM and PMR groups continued regular practice of these

techniques throughout the eight months period. Practicing the technique

minimum four times a week was taken as the standard of compliance. The

compliance was found to be 85.7% in IAM and 84.4% in PMR group.

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RESULTS & DISCUSSION

8.1 PSYCHOLOGICAL QUESTIONNAIRES

LCQ

PSS

BDI

8.2 BIOCHEMICAL VARIABLES

CORTISOL

ADRENALINE

IgA

GABA

8.3 PHYSIOLOGICAL VARIABLES

BP

HR

RR

71

COMPARABILITY OF THE GROUPS

The comparability of the groups was analyzed on basis of age, sex, education,

diet, stress, appetite and sleep. There was no significant difference between the

male female ratio in the groups. The percentage of females was 81.8 in IAM,

79.5 in PMR and 81.5 in control. Vegetarian vs Nonvegetarian diet, extremely

stressed vs relaxed, good appetite vs poor appetite and sleep less than 5 hours vs

greater than 5 hours, also did not show any statistical difference between groups

on comparison at the baseline visit (Table1).

Table 1. Comparabilty between groups in terms of sociodemographic variables.

Variable IAM % PMR % Control % p -value

Male 18.2 20.5 16.7 Sex

Female 81.8 79.5 81.5

0.908

18-19 77.3 77.3 72.2 Age group

(Yrs.) 20 and above

22.7 22.7 27.8

0.837

12th Std 13.6 15.9 22.5

Degree 65.9 63.6 63.9

Education

PG 20.5 20.5 13.9

0.823

Veg 31.8 36.4 30.6 Diet

Non Veg 68.2 63.6 69.4

0.840

Extremely stressed

22.7 20.9 27.8 Stress

Relaxed 77.3 79.1 72.2

0.764

Good 61.4 61 75 Appetite

Poor 38.6 38.6 25.0

0.350

<5 Hours 7 16.3 11.1 Sleep

>5 Hours 93 83.7 88.5

0.399

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LIFE CHANGES QUESTIONNAIRE

The analysis of the changes within IAM group showed a significant change (p=

0.004) from the second visit i.e. after 48 hours (Mean score - Visit 1 -

60.15±17.7, Visit 2 -53.13±19) which was maintained in the third i.e. after 2

months (p = 0.003 Mean score - Visit 3- 49.98 ± 20.80) and fourth visits i.e. after

8 months (p = 0.001 Mean score Visit 4 – 34.94 ± 21.80). Within the PMR group

there was a significant drop (P = 0.006) in the third visit and fourth visits (Mean

score - Visit 1- 60.53±16.57, Visit 2- 57.65±19.74, Visit 3- 49.41±21.83, Visit 4-

45.00±21.83). No significant change was seen within the control group in any of

the visits (Mean score – Visit 1- 56.77±12.70, Visit 2- 56.96±14.56, Visit 3-

55.52±16.23, Visit 4- 52.46±19.65).

On applying ANCOVA (Repeated measures) taking four levels of observation

(visits 1, 2, 3, 4) it was seen that the difference in the mean values of LCQ among

the 3 groups was significant (p value <0.05).The IAM group showed a

statistically significant drop (P = 0.002) in the fourth visit (eight months) when

compared to the control group. PMR group did not show any difference when

compared to the control group in any of the four visits (Table 5).

When the items in the questionnaire were analyzed separately, IAM showed a

significant difference in the fourth visit in all the items compared to the Control

group. In the items health, work and finance there was a significant drop in the

third visit too (p = 0.016, 0.007, and 0.039 respectively). The PMR group showed

a significant drop in the health item alone in the fourth visit in comparison with

73

the control. No significant difference was seen between the IAM and PMR

groups in any of the visits (Table 5).

Table 2. LCQ – Changes in LCQ scores from basal to various follow-up periods

(LCQ1, LCQ2, LCQ3, LCQ4) in the IAM group

Variable IAM (n) Mean ± SD p value

LCQ1 38 60.15 ± 17.7

LCQ2 38 53.13 ± 19.0 0.004

LCQ1 28 57.25 ± 18.3

LCQ3 28 45.98 ± 20.80 :

0.003

LCQ1 33 58.58 ± 18.6

LCQ 4 33 34.94 ± 21.80 0.001

Table 3. LCQ – Changes in LCQ –items from basal to various follow-up periods in the PMR group

Variable PMR (n) Mean ± SD p value

LCQ1 30 60.53 ± 16.57

LCQ2 30 57.65 ± 19.74 0.375

LCQ1 28 62.77 ± 15.20

LCQ3 28 49.41 ± 21.83 0.006

LCQ1 30 61.86 ± 13.86

LCQ 4 30 45.00 ± 22.31 0.001

74

Table 4. LCQ – Changes in LCQ – items from basal to various follow-up periods in the control group

Variable Control (n) Mean ± SD p value

LCQ1 32 56.77 ± 12.70

LCQ2 32 56.96 ± 14.56 0.266

LCQ1 26 55.96 ± 12.1

LCQ3 26 55.52 ±16.23 0.859

LCQ1 31 56.40 ± 13.17

LCQ4 31 52.46 ±19.65 0.248

Table 2a1. LCQ – Changes in LCQ – Health items from basal to various follow-up periods in the IAM group

Variable IAM (n) Mean ± SD p value

Health1 38 46.76 ± 21.08

Health2 38 44.11 ±17.98 0.322

Health1 28 41.08 ± 18.70

Health3 28 36.57 ± 17.98 0.186

Health1 31 46.21 ± 20.10

Health 4 31 31.08 ± 19.96 0.007

75

Table 2- a2. LCQ – Changes in LCQ – Home items from basal to various follow-up periods in the IAM group

Variable IAM (n) Mean ± SD p value

Home1 38 64.13 ± 21.00

Home2 38 59.08 ± 20.27 0.052

Home 1 28 63.90 ± 21.00

Home3 28 55.30 ± 20.52 0.128

Home 1 31 62.34 ± 18.76

Home4 31 39.36 ± 23.32 0.001

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Table 2.a3. LCQ – Changes in LCQ –Personal items from basal to various follow-up periods in the IAM group

Variable IAM (n) Mean ± SD p value

Personal1 38 59.13 ± 17.98

Personal2 38 52.35 ± 20.54 0.010

Personal 1 28 56.87 ± 19.20

Personal3 28 52.16 ± 24.36 0.212

Personal 1 29 58.15 ± 18.74

Personal4 29 38.35 ± 19.68 0.001

Table 2.a4 LCQ – Changes in LCQ –Finance items from basal to various follow-up periods in the IAM group

Variable IAM (n) Mean ± SD p value

Finance1 38 56.27 ± 21.27

Finance2 38 49.55 ± 21.74 0.004

Finance1 28 55.1 ± 20.10

Finance3 28 44.52 ± 20.69 0.014

Finance1 29 53.2 ± 20.20

Finance4 29 39.31 ± 20.69 0.002

77

Table 2.a5. LCQ – Changes in LCQ –Work items from basal to various follow-up periods in the IAM group

Variable IAM (n) Mean ± SD p value

Work1 38 54.98 ± 19.00

Work2 38 48.28 ± 18.47 0.001

Work1 28 54.98 ± 19.10

Work3 28 42.10 ± 17.47 0.003

Work1 32 53.2 ± 21.10

Work4 32 34.79 ± 20.98 0.001

Table 3a1. LCQ – Changes in LCQ – Health items from basal to various follow-up periods in the PMR group

Health1 36 47.16 ± 21.10

Health2 30 45.64 ±14 0.554

Health1 30 47.52 ± 22.36

Health3 30 39.52 ±23.88 0.010

Health1 46.78 ± 21.80

Health4 30 33.97 ± 21.57 0.009

78

Table 3- a2. LCQ – Changes in LCQ – Home items from basal to various follow-up periods in the PMR group

Variable PMR (n) Mean ± SD p value

Home1 36 68.43 ±18.02

Home2 29 69.33 ±18.18 0.820

Home1 29 67.96± 20.11

Home3 29 61.20 ±20.74 0.050

Home1 30 68.80 ± 17.60

Home4 30 49.48 ±22.83 0.001

Table 3.a3 LCQ – Changes in LCQ –Personal items from basal to various follow-up periods in the PMR group

Variable PMR (n) Mean ± SD p value

Personal1 36 58.06 ±18.99

Personal2 30 55.91 ±21.34 0.611

Personal1 28 59.54 ± 18.18

Personal3 28 57.98 ±25.27 0.548

Personal1 30 57.98 ± 25.27

Personal4 30 42.13 ± 23.85 0.001

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Table 3.a4. LCQ – Changes in LCQ –Finance items from basal to various follow-up periods in the PMR group

Variable PMR (n) Mean ± SD p value

Finance1 36 56.24 ± 18.73

Finance2 29 54.64 ±17.53 0.611

Finance1 28 56.42 ± 21.34

Finance3 28 47.33 ±22.07 0.548

Finance1 30 57.30 ± 19.96

Finance4 30 43.35 ± 24.34 0.001

Table 3.a5. LCQ – Changes in LCQ –Work items from basal to various follow-up periods in the PMR group

Variable PMR (n) Mean ± SD p value

Work1 36 56.33 ±14.33

Work2 30 52.18 ±16.20 0.05

Work1 56.73 ± 16.57

Work3 30 48.60 ±20.95 0.06

Work1 56.27 ± 15.22

Work4 30 45.31 ±25.96 0.018

80

Table 4- a2. LCQ – Changes in LCQ – Home items from basal to various follow-up periods in the control group

Variable control (n) Mean ± SD p value

Table 4.a3 LCQ – Changes in LCQ –Personal items from basal to various follow-up periods in the control group

Variable control (n) Mean ± SD p value

Personal1 35 55.91 ±16.09

Personal2 32 55.91 ±16.09 0.454

Personal1 26 54.80 ± 16.23

Personal3 26 59.38 ±19.47 0.144

Personal1 Personal4 30 50.66 ±18.51

Personal1 35 55.91 ±16.09 0.491

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Table 4.a4. LCQ – Changes in LCQ –Finance items from basal to various follow-up periods in the control group

Variable control (n) Mean ± SD p value

Finance1 35 53.70 ±14.77

Finance2 32 53.81 ± 15.93 0.221

Finance1 26 53.81 ± 15.93

Finance3 26 54.56 ± 16.35 0.083

Finance1 29 54.10 ± 14.57

Finance4 29 55.50 ±28.19 0.754

Table 4.a5. LCQ – Changes in LCQ –Work items from basal to various follow-up periods in the control group

Variable control (n) Mean ± SD p value

Work1 36 56.33 ±14.33

Work2 30 52.18 ±16.20 0.05

Work1

Work3 30 48.60 ±20.95 0.06

Work1

Work4 30 45.31 ±25.96 0.018

82

Table 4.a1 LCQ – Changes in LCQ – Health items from basal to various follow-up periods in the control group

Variable control (n) Mean ± SD p value

Health1 35 39.34 ±17.04

Health2 32 41.05 ± 18.93 0.501

Health1 27 39.41 ± 18.42

Health3 27 46.25 ±15.93 0.066

Health1 29 40.74 ± 20.12

Health4 29 44.82 ±18.23 0.166

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Figure. 1.a. Changes in LCQ –items from basal to various follow-up periods between groups after 48 hours

LCQ

0

10

20

30

40

50

60

70

0 20 40 60

hours

LCQ

IAMPMRControl

Figure 1. b. Changes in LCQ –items from basal to various follow-up periods between groups after 2 months, 8 months

LCQ

0

10

20

30

40

50

60

70

-100 0 100 200 300

Days

LCQ

Sco

res

IAMPMRControl

84

Table.5. Changes in LCQ –items from basal to various follow-up periods between

groups

IAM-Control IAM-PMR PMR- control

LCQ1 0.255 0.965 0.229

LCQ2 0.502 0.264 0.627

LCQ3 0.06 0.436 0.446

LCQ4 0.002 0.096 0.184

85

PERCEIVED STRESS SCALE AND BECK DEPRESSION INVENTORY

IAM group showed statistically significant drop in the PSS values from the third

visit i.e. after 2 months. This drop continued in the fourth visit (8 months). PMR

group showed statistically significant drop in the PSS values from the third visit

which was seen even in the last visit. Control group showed no significant change

in PSS in any of the visits. On applying ANCOVA (Repeated measures) taking

four levels of observation (visits 1, 2, 3, 4) it was seen that the difference in the

mean values of PSS among the 3 groups was not significant (p value > 0.05).

On within group analysis BDI scores were found to be decreased from the second

visit (48 hours) in all the three groups i.e. IAM, PMR and control. It was found to

be decreased significantly even in the third visit in all the three groups. But in the

last visit i.e. after 8 months, significant difference was seen in the IAM and PMR

groups.

The control group did not show any significant change in the last visit.

On applying ANCOVA (Repeated measures) taking four levels of observation

(visits 1, 2, 3, 4) it was seen that the difference in the mean values of BDI among

the 3 groups was not significant (p value < 0.05).

86

Table 6. a. Mean and SD of PSS at different time points

GROUP IAM PMR CONTROL

Variable Mean SD Variable Mean SD Variable Mean SD

PSS1 16.80(41 ) 4.9 PSS1

17.45(40 )

5.1 PSS1 16.11(26 )

4.3

PSS2 15.83( 37) 5.5 PSS2

16.45( 37)

4.6 PSS2 15.1( 20)

5.5

PSS3 13.71( 35) 5.5 PSS3

15.03( 28)

4.5 PSS3 15.1( 22)

4.2

PSS4 12.08( 35) 6.2 PSS4

14.42( 28)

6.7 PSS4 15.3( 23)

3.7

Figures in brackets indicates the corresponding sample size Table 6.b. Results on the statistical significance of PSS scores comparison. Visit 1 to IAM PMR Control IAM-

PMR IAM control PMR-

control

Visit 2 0.146 0.311 0.597 Visit 3 0.003 0.067 0.412 Visit 4 0.001 0.019 0.485

Repeated ANCOVA P value- 0.123

Table 7.a. Mean and SD of BDI at different time points

GROUP IAM PMR CONTROL

Variable Mean SD Variable Mean SD Variable Mean SD

BDI1 0.68(36 ) 0.417 BDI1 0.79(30) 0.432 BDI1 0.63(32) 0.38

BDI2 0.48(36 ) 0.375 BDI2 0.64(30) 0.389 BDI2 0.47(32) 0.39

BDI3 0.32(30) 0.291 BDI3 0.47(29) 0.388 BDI3 0.43(28) 0.36

BDI4 0.27(31) 0.386 BDI4 0.34(32) 0.312 BDI4 0.54(26) 0.40

87

Table 7.b. Results on the statistical significance of BDI scores comparison

Visit 1 to IAM PMR Control IAM- PMR

IAM control

PMR-control

Visit 2 0.0001 0.004

0.0016

Visit 3 0.0001 0.0001 0.0002

Visit 4 0.0001 0.0001 0.0964

Repeated ANCOVA P value- < 0.05

88