|Year : 2015 | Volume
| Issue : 2 | Page : 62-67
Effects of progressive muscle relaxation on postmenopausal stress
Arunima Chaudhuri1, Manjushree Ray2, Daniel Saldanha3, Sajal Kumar Sarkar4
1 Department of Physiology, Burdwan Medical College, Burdwan, West Bengal, India
2 Department of Anaesthesiology, Burdwan Medical College, Burdwan, West Bengal, India
3 Department of Psychiatry, D. Y. Patil Medical College, Pune, Maharashtra, India
4 Department of Surgery, Burdwan Medical College, Burdwan, West Bengal, India
|Date of Web Publication||14-May-2015|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Menopause increases stress level among females and this may be a contributing factor in developing metabolic syndrome. Objectives: The objective of this study is to study the effects of progressive muscle relaxation on cardiorespiratory efficiency and autonomic functions in over weight and obese working stressed postmenopausal females. Materials and Methods: A total of 30 postmenopausal overweight or obese (body mass index [BMI]: 24.97 ± 1.28) females belonging to the age group 50-55 years were included. Stress level in the subjects was assessed according to the presumptive life event stress scale. The perceived stress scale (PSS) of Sheldon Cohen was used for measuring the perception of stress. Fasting blood samples were collected to exclude diabetic subjects and analyze lipid profile. BMI and waist/hip ratio were calculated. Resting pulse rate and blood pressure, respiratory rate were measured. VO 2 max, physical fitness index, breath holding time and 40 mm endurance test time were calculated for estimation of cardiopulmonary efficiency. Autonomic function tests were carried. Subjects were given progressive muscle relaxation training for 3 months and all parameters were reevaluated. Data was analyzed using SPSS version 16 (SPSS Inc., Chicago, USA). Results: PSS in pre-training session was 26.16 ± 1.7 and in post-training session was 14.33 ± 2.01 and the difference was statistically significant. There was a significant decrease in pulse rate, blood pressure, BMI, waist/hip ratio, cholesterol, low-density lipoprotein following preventive medicine residency training. Results of autonomic function tests and cardiopulmonary efficiency test improved significantly following relaxation training. Conclusions: Increased stress levels may increase BMI and waist/hip ratio, dyslipidemia and lead to autonomic dysfunctions and increase incidence of cardiovascular disease in postmenopausal females. Lifestyle modification with relaxation exercises decreases stress levels and improves autonomic functions, cardiopulmonary efficiency, and lipid profile.
Keywords: Autonomic functions, postmenopausal stress, relaxation therapy
|How to cite this article:|
Chaudhuri A, Ray M, Saldanha D, Sarkar SK. Effects of progressive muscle relaxation on postmenopausal stress. J Sci Soc 2015;42:62-7
| Introduction|| |
Menopause increases stress level among females. Menopause is a substantial life event and causes women to reflect on past, think about future, and possibly even come to terms with some issues of their own mortality. Postmenopausal women have increased risk of metabolic syndrome, including dyslipidemia, insulin resistance, hypertension and cardiovascular diseases (CVDs). The pathology may be a direct result of ovarian failure or an indirect result of central fat distribution with estrogen deficiency and higher stress levels. ,,,
Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups in geographic regions. ,,, In an article in 2009 Evolahti et al., have demonstrated a significant association between the psychosocial work environment and women's cardiovascular health at menopause.  Autonomic dysfunction is associated with stress. ,,
Lifestyle approaches for cardiovascular event prevention are recommended for all women. It is now not justifiable to use hormone replacement therapy for cardiac disease prevention, rather the decision to choose hormone replacement therapy should be made by weighing non-coronary benefits and harms as advised by the American Heart Association. ,,
There are numerous techniques available to reduce stress and produce relaxation. One of these, Jacobson's progressive muscle relaxation technique, has shown positive clinical results.  This pilot project was undertaken to study the effects of progressive muscle relaxation on cardiorespiratory efficiency and autonomic functions in over weight and obese working stressed postmenopausal females in an urban population of a developing country.
| Materials and methods|| |
The study was undertaken in a time span of 1 year, from December 2012 to November 2013, in a tertiary care hospital. Institutional Ethics Committee approval and informed consent of the subjects was obtained prior to commencement of this pilot project.
Women with history of amenorrhea for consecutive 12 months or more were considered to be menopausal. Postmenopausal overweight or obese working females belonging to the age group 50-55 years were included. Overweight and obese subjects were classified as per Asian standards as their body composition differs from Caucasians (underweight <18.5; normal range: 18.5-22.9; overweight >23; obese I: 25-29.9; obese II >30). 
Subjects suffering from any illness, acute or chronic, affecting cardiorespiratory efficiency; individuals taking any type of medication; past history of prolonged medication or prolonged hospitalization, major surgery, any chronic illness of cardiovascular system, respiratory system, neuromuscular or any other systemic illness was enquired about, and subjects who indicated a disease state were excluded. Alcohol, drug, tobacco addicts and smokers were excluded. Subjects undertaking any yoga or meditation practices, regular exercise programs were not included. Morbidly obese subjects were excluded. Subjects on hormone replacement therapy or taking any drug that may alter autonomic function tests were not included.
Study was conducted on 30 healthy postmenopausal (body mass index [BMI]: 24.97 ± 1.28) working females who were not engaged in any type of regular physical exercise or yoga. The subjects were appointed in different government organization and had to work for 5 days in a week from 10 am to 5 pm. The work did not involve much physical labor. They had no shift duties and could avail leave on emergency requirements.
Sampling was carried out using multistage random sampling technique. The height and weight were recorded as per standard procedures. BMI and waist/hip ratio were calculated. A total of 105 subjects who met the inclusion and exclusion criteria and were willing to join the exercise program were chosen. On the first appointment, histories of the subjects were carefully recorded. Subjects were asked to tally a list of 43 life events based on a relative score [Table 1]. Stress level in the subjects was assessed according to the presumptive life event stress scale (PSLES).  Accordingly they were categorized into no stress, less/moderate stress and severe stress. Score stress up to 40: No stress; 41-200 less/moderate stress; more than 200 severe stress. Finally, 46 females with scores above 200 were chosen for the study, as they had higher risk of developing illness. 
The perceived stress scale (PSS) of Sheldon Cohen, the most widely used psychological instrument for measuring the perception of stress, was used to measure perceived stress in these 46 females who had stress scores above 200 according to PSLES. It is a measure of the degree to which situations in one's life are appraised to be stressful. Items were designed to find 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 questions in the PSS ask about feelings and thoughts during the last month. It comprises of 10 items, four of which are reverse-scored, measured on a 5-point scale from 0 to 4. PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items. Total score ranges from 0 to 40. 
After clinical examinations were conducted, and pre-test instructions were given to avoid consumption of any drugs that may alter the autonomic function 48 h prior to the test, the subjects were advised to have a good restful sleep.
On the day of the test, no cigarette, nicotine, coffee, or drugs was permitted. Fasting blood samples were collected to exclude diabetic subjects and analyze lipid profile. Two subjects were found to be diabetic, and they were excluded.
Resting pulse rate and blood pressure, respiratory rate were measured. Electrocardiogram (ECG) was done to exclude pathological wave forms. 12 subjects had ischemic heart diseases, as seen after doing ECG, so they were excluded. So the sample size came down to 32. VO 2 max, physical fitness index (PFI), breath holding time and 40 mm endurance test time were calculated for estimation of cardiopulmonary efficiency. Autonomic function tests were carried using polyrite-D.
VO 2 max by modified harvard step test
Duration of the test was set at 4 min. The subject was closely watched for any signs of discomfort or any of the indications to stop the test. Immediately after finishing the test, the subject's pulse rate was counted using radial artery for full 1 min, i.e., from 0 to 1 min for VO 2 max estimation by Astrand-Ryhming nomogram. Two subjects complained of chest pain and respiratory distress during the test. Hence the procedure was immediately stopped, and they were re-examined and excluded from the study.
After recording the pulse (0-1 min) for VO 2 max estimation, the radial pulse was again counted at intervals of 1-1½, 2-2½ and 3-3½½ min of completing the test to evaluate the PFI. The PFI was evaluated by using the formula:
Breath holding time
The subject was asked to inhale maximally then hold her breath until breaking point was reached, i.e., the point when the subject could no longer hold his breath. The time was noted in seconds.
The 40 mm endurance test
The subject was asked to take in a full breath and blow in the tube of the sphygmomanometer so that the mercury level rises up to 40 mm. The subject was instructed to maintain the level as long as possible.
Autonomic function tests
Tests reflecting cardiac parasympathetic damage
Heart rate response to postural change (30:15 ratio) (normal ≥1.04), heart rate variation during deep breathing (normal ≥15), heart rate response to Valsalva maneuver (normal ≥1.21).
Tests reflecting sympathetic damage
Blood pressure response to postural change (the fall in systolic pressure was used as the result of orthostatic tolerance test; abnormal: 30 mmHg or more), to sustained (isometric) hand-grip (the rise in diastolic blood pressure was calculated and taken as the result of an institute of human genetics test. abnormal: 10 mmHg or less).
The resting time given to subjects in between two tests was 5-10 min.
All subjects were given a training of Progressive muscle relaxation (PMR). Training involved tensing the specific muscle groups for 7-10 s, followed by releasing them (relaxing) for 15-20 s as per Jacobson's  protocol. They were asked to practice this technique at home for 20 min every day for 3 months and come for follow-up. Subjects were followed-up at regular intervals during this period. Two subjects did not come for follow-up. So they had to be excluded and the ultimate sample size came down to 30.
After 3 months, the lipid profile and vital parameters were rechecked and subjects were asked to repeat the same exercise. After exercise, the vitals were recorded in a similar fashion.
Data obtained was analyzed using SPSS software version 16 (SPSS Inc., Chicago, USA). t-test was used to analyze the data. The data were considered as significant and highly significant if the analyzed probability values (P values) were < 0.05* and < 0.01**, respectively.
| Results|| |
The present study was carried on 30 overweight or obese postmenopausal subjects under stress. The average age of the subjects was 55.23 ± 2.32 and fasting blood sugar before practicing PMR was 107.25 ± 6.98 and 94.5 ± 4.43 after practicing PMR, and the difference was significant with P = 0.026. PSS in pre-training session was 26.16 ± 1.7 and in post-training session was 14.33 ± 2.01 and the difference was statistically significant [Table 2]. There was significant decrease in pulse rate, blood pressure, BMI, waist/hip ratio, cholesterol, low-density lipoprotein following PMR training. Pre-training values of BMI were 24.97 ± 1.28 and post-training values were 22.5 ± 1.36; Pre-training values of waist/hip ratio were 0.984 ± 0.08 and post-training values were 0.91 ± 0.03; No significant changes were seen following PMR in triglyceride and high-density lipoprotein values. Results of autonomic function tests improved significantly except values of Valsalva ratio [Table 3]. Pre-training values of VO 2 max were 29.97 ± 2.41 and post-training values were 33.77 ± 2.67; Pre-training values of PFI were 77.6 ± 3.49 and post-training values were 82.6 ± 2.98; Pre-training values of Breath holding time (BHT) were 30.4 ± 1.49 and post-training values were 34.4 ± 1.52; Pre-training values of 40 mm endurance test were 26.5 ± 2.23 and post-training values were 27.9 ± 1.78. The parameters reflecting cardiopulmonary efficiency were significantly improved following PMR training [Table 4].
|Table 2: The average values of pulse rate, BP, BMI, waist/hip ratio, total cholesterol, TGL, HDL and LDL of postmenopausal women on PMR and before PMR training|
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|Table 3: The average values of Valsalva ratio, deep breath test, 30:15 R-R interval ratios, IHG test, OTT of|
postmenopausal women on PMR and before PMR training
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|Table 4: Comparison cardiopulmonary effi ciency tests of subjects before PMR and a er PMR training|
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| Discussion|| |
Sixty million women in India are above the age of 65 years. Average lifespan for Indian women is 65 years while in developed countries it is 80 years, so women of our country deserve special attention.
At the time of menopause, a woman must re-adjust her life from one that has been physiologically stimulated by estrogen and progesterone production to one devoid of these hormones. Withdrawal of these hormones increases stress levels and autonomic dysfunctions in postmenopausal women. ,, Hormones have a direct link in production and management of neurotransmitters in brain. When these chemicals are altered during menopause it can lead to mental stress. Stress influences health and disease and this might be of special relevance for ageing, age-associated changes of the hypothalamic-pituitary-adrenal axis and influence of rising stress hormone levels for the ageing brain. ,,,,
Estrogen is a known sympatholytic and vagotonic hormone and a metabolite of progesterone is known to have sympatholytic effects. There is a decrease in heart rate variability in postmenopausal females, and these factors increases an incidence of myocardial infarction. Estrogens have a significant plasma cholesterol lowering action and produce rapid vasodilatation by increasing the local production of nitric oxide. These actions inhibit atherogenesis and contribute to the low incidence of myocardial infarction and other complications of atherosclerotic vascular disease in premenopausal women. ,,,
The prevalence of CVD is reported to be 2-3 times higher in the urban population when compared to the rural. Coronary heart disease is expected to be the single most important cause of morbidity and mortality in India by the year 2015. So this study was conducted in postmenopausal females to find a lifestyle modification that may improve the quality of life and decrease deaths from CVDs.
In the present study autonomic functions, cardiopulmonary efficiency, dyslipidemia were significantly decreased following PMR training as PSS decreased in these females. There was also a decrease in BMI and waist/hip ratio. In previously conducted studies to see an influence of diet, obesity on autonomic functions in postmenopausal women negative correlation of autonomic functions, obesity and high-fat diet has been observed. , Dyslipidemia was found to be a major cause for development of autonomic dysfunctions in these females. ,,
Recent studies have shown that women experience an acceleration of cognitive problems after menopause and that estrogen treatment can improve cognitive functioning in postmenopausal women. However, some studies have shown that the negative emotional effects of psychosocial stress are magnified in normal postmenopausal women after estrogen treatment. These data suggest that the relationship between estrogen administration and cognitive/behavioral performance in postmenopausal women may be more complex than appreciated. The benefits of hormones in treatment of psychosocial stress remain controversial. ,,,
Chronic stress in postmenopausal women can lead to serious physical complications such as increased blood pressure, heart rate, which can increase the risk of a heart attack. Women often exercise less after they enter menopause, which can lead to weight gain. To further complicate matters, the metabolism is also decreased. As the metabolism drops, many women do not adjust their calories accordingly, which often leads to weight gain. ,,,,, Stress is an important risk factor for the emergence of metabolic syndrome. ,
Progressive muscle relaxation technique has shown positive clinical results and may be of help in reducing stress induced obesity. , Night eating syndrome (NES) is characterized by a lack of appetite in the morning, consumption of 50% or more of daily food intake after 6:00 p.m., and difficulty in falling and/or staying asleep. It is associated with stress and with poor results at attempts to lose weight. A study was conducted in 2003 to see if relaxation intervention (progressive muscle relaxation therapy) would benefit an NES population. 20 adults with NES were randomly assigned to either relaxation training or a control (quietly sitting for the same amount of time) group, and all subjects attended two laboratory sessions 1 week apart. Pre-and post-session indices of stress, anxiety, relaxation, and salivary cortisol were obtained. The results indicated that 20 min of a muscle relaxation exercise significantly reduced stress, anxiety, and salivary cortisol. After practicing these exercises daily for 1 week, subjects exhibited lowered stress, anxiety, fatigue, anger and NES. 
Menopausal women need to begin a good health program, including lifestyle changes in diet, exercise, including yoga and limiting smoking as well as alcohol. Hormone replacement therapy should be considered only after considering the risk factors in comparison to its benefit. Exercise and physical activity are effective stress relief techniques that are often disregarded. Any type of exercise helps relieve stress by producing endorphins, neurotransmitters that boost mood. Exercise can also help lower blood pressure and reduce cholesterol. ,, The goal of yoga is to combine physical and mental disciplines in an effort to achieve peacefulness and balance. In addition to releasing stress, yoga can also help with weight management. Yoga may also help combat insomnia, fatigue, depression, and anxiety. Yoga can also reduce blood pressure, lower heart rate, and improve mood. Women who practice yoga regularly may experience improved balance, greater flexibility and increased strength. 
Strengths and limitations
Subjects in the present study were followed-up regularly for 3 months. In similar studies on postmenopausal females the follow-up time was less compared with the present study. We were not able to analyze cortisol levels and did not have a control group, and this adds to the limitations of our study. As cortisol levels have a circadian rhythm, so samples need to be collected in different times to come to a definite conclusion, so cortisol level was not analyzed in the present study.
| Conclusions|| |
Increased stress levels may increase BMI and waist/hip ratio, dyslipidemia and lead to autonomic dysfunctions and increase incidence of CVD in postmenopausal females. Lifestyle modification with relaxation exercises decreases stress levels and improves autonomic functions, cardiopulmonary efficiency and lipid profile. These factors help to decrease morbidity and mortality improving the quality of life, so they need to be popularized to the population at a large.
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[Table 1], [Table 2], [Table 3], [Table 4]
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