TY - JOUR
AU1 - Ditto, Blaine
AU2 - Byrne, Nelson
AU3 - Holly, Crystal
AB - Abstract Background Applied tension (AT) is a behavioral technique used to reduce symptoms such as dizziness and fainting in people with blood and injury phobias as well as medical patients undergoing invasive procedures. AT has been found to reduce dizziness and fainting in several studies of blood donors. Purpose The purpose of this study was to examine the psychophysiological effects of AT in the context of blood donation. Methods Ninety-eight young adult blood donors wore ambulatory physiological monitors and were randomly assigned to one of two groups that practiced AT or one that did not. Measures of blood pressure, heart rate, stroke volume, and other physiological parameters were obtained while participants gave blood. Results Donors who did not practice AT were more likely to report symptoms in the donation chair and generally displayed a pattern of physiological activity consistent with risk for a vasovagal reaction. For example, heart rate and total peripheral resistance decreased. The drop in heart rate was probably due at least in part to an increase in vagal parasympathetic nervous system activity, as suggested by an increase in high-frequency heart rate variability. In contrast, donors who practiced AT displayed stable heart rate and high-frequency heart rate variability. Conclusions The results suggest that the physiological effects of AT, particularly the inhibition of vagal activity, interfere with those promoting a vasovagal reaction. There may be a number of useful applications for AT in medical settings. Applied tension, Blood donation, Vasovagal reaction, Ambulatory monitoring Introduction Applied tension (AT) is a well-tested behavioral technique for blood and injury phobias [1–4]. The primary component is repeated isometric muscle tension. It was developed originally to aid exposure therapy for blood and injury phobias since so many people became dizzy or fainted during exposure, interrupting or terminating treatment, but has become an independent treatment. The ability of AT to reduce dizziness is believed to spring at least in part from the impact of muscle tension on blood pressure, maintaining blood pressure and cerebral perfusion during periods in which fear might otherwise trigger vasovagal syncope [3–7]. More recently, the results of a number of studies suggest that AT may be useful in a wider medical context with patients who are not necessarily needle or blood phobic but undergoing invasive procedures. In particular, we have used a variation of AT with non-phobic individuals in a different environment: the blood donation clinic [8–11]. This is an interesting model to study medically related vasovagal reactions and treatments for several reasons. First, despite the fact that blood donors voluntarily present themselves for the experience, many approach with mixed feelings [12–15]. Blood donation is typically viewed as altruistic behavior, but this does not mean that all prospective donors are at ease with the prospect of venipuncture with a relatively large needle and withdrawal of a significant amount of blood. It has been known for many years that pre-donation anxiety is common and is related to symptoms such as dizziness and fainting [15–19]. Second, vasovagal symptoms during blood donation are common. The frequency of symptoms varies considerably depending on the population (much more common in young, inexperienced donors) and the definition [20], but many people experience dizziness, weakness, nausea, visual or hearing disturbances, etc. due to minor vasovagal reactions. For example, validation data for the Blood Donation Reactions Inventory (BDRI), the primary measure of blood donation-related symptoms revealed that 159 out of 364 donors (44%) reported at least a mild experience of at least one symptom [19]. This is an important issue for blood collection agencies. For example, a number of studies have shown that the experience of vasovagal symptoms is a significant disincentive for return blood donation [21–25]. Third, though donation necessarily involves blood loss, blood donation-related vasovagal reactions are due mostly to anxiety. It is understandable to think that vasovagal reactions to blood donation are due to the “physical” stress of blood loss, but if that was true, everyone who gave blood would be at risk and this is clearly not the case. Reactions among experienced donors are very rare. As noted above, they are much more likely among people who are inexperienced donors [16, 17, 20] or have higher ratings of anxiety before donation [16–19]. The maximum amount of blood loss in a typical North American procedure is 450 ml, usually less than 10% of total blood volume, and modest from a hemodynamic point of view in young to middle-aged adults. The main discussion in recent years has been the impact of blood loss on elderly donors [26]. As a result, research on blood donation-related vasovagal reactions and treatments may be generalizable to many medical patients undergoing invasive procedures. However, while AT has well-documented effects on symptoms such as dizziness [1–4, 8–11], relatively little is known about its physiological effects in a clinical context [3–7], though basic physiological research suggests it may be useful. Medically related vasovagal symptoms such as dizziness and fainting are due to a combination of vasodilation and reduced heart rate (HR; traditionally associated with an increase in cardiac parasympathetic, vagal activity), which lead to an abrupt decrease in blood pressure and cerebral perfusion. Isometric muscle tension can increase blood pressure without the vasodilation that often accompanies dynamic, aerobic exercise. As well, basic research on the autonomic effects of isometric exercise shows that the increase in heart rate is due primarily to a decrease in vagal activity [27–29]. Thus, AT has the potential to directly counteract the increase in vagal activity that is a key part of the vasovagal reaction. As noted above, studies of the physiological effects of AT have indicated that, when practiced in the absence of anxiety-provoking stimuli, it can increase blood pressure and heart rate [7], and when practiced in the presence of anxiety-provoking stimuli, it can maintain blood pressure and heart rate [6]. Using a more physical stressor, Krediet et al. [30] have observed that isometric muscle tension similar to AT is useful in reducing vasovagal symptoms induced by passive head-up tilt and argue that this is due solely to an enhancement of cardiac output (CO) [31]. The present study was conducted to examine the psychophysiological correlates of AT in a real-life medical setting commonly associated with fear-related vasovagal reactions. It was hypothesized that donors who practiced AT would display more stable heart rate, blood pressure, and high-frequency heart rate variability (HF HRV; an index of vagal activity) than people who underwent the typical blood donation procedure. Methods Participants and Experimental Conditions As a follow-up to a randomized controlled trial of different components of AT [11], ambulatory physiological data were obtained from 98 additional participants. All were young adults attending mobile blood clinics held in Montreal-area universities and colleges. In the larger study, six groups of approximately 200 randomly assigned donors practiced different aspects of AT such as repeatedly tensing just the arm with the needle in it, repeatedly tensing both arms, tensing only the lower body, etc. Based on preliminary analyses of symptoms and the more complex procedure of data acquisition with the physiological measures, it was decided to collect physiological data from participants in only three groups—people randomly assigned to a donation as usual (no treatment) group (N = 31), donors who were instructed to practice full body AT while they were in the donation chair (N = 33), and donors who were told that they would be learning AT, but this was described and depicted in the video only as repeated muscle tension in the lower body—the legs and abdomen (N = 34). Consistent with the random assignment, there were no significant differences between participants in the three groups in sex (55% female), body mass index (22.8 ± 2.7 kg/m2), age (X = 20.9 ± 2.4 years), or number of previous blood donations (X = 1.9 ± 2.2). Apparatus Repeated measurements of systolic and diastolic blood pressure (SBP and DBP, in millimeters of mercury) were obtained at 5-min intervals using a Suntech Instruments (www.suntechmed.com) Accutracker DX ambulatory auscultatory blood pressure monitor. A number of other physiological measures were obtained using a Bio-Impedance Technology (www.microtronics-bit.com) ambulatory impedance monitor (AIM) model 8F. To assess cardiac stroke volume (SV, in milliliters), the AIM uses a tetrapolar combination of spot and band electrodes. One spot current electrode is placed behind the right ear over the base of the mastoid process. The other spot current electrode is placed over the lower right rib cage below the lower recording band electrode, which encircles the thorax over the tip of the xiphoid process. The other recording band electrode encircles the base of the neck. A third spot electrode is placed over the lower left rib cage. This electrode, along with the two other spot electrodes, is also used to obtain the ECG signal for the AIM and HR (in beats per minute). CO (in liters per minute) is calculated as stroke volume × heart rate and total peripheral resistance (TPR, in dyne s/cm5) is calculated as (mean arterial blood pressure/CO) × 80. Impedance-based measures were based on values that were ensemble-averaged over 55-s intervals. Post hoc editing was done using the Copworks program. In addition to these volume-related variables, the AIM also measures cardiac pre-ejection period (PEP). PEP is the cardiac time interval during which the left ventricle contracts while the aortic and mitral valves are closed, measured by the time between the ventricular depolarization in the ECG and the upswing in the impedance signal, indicating the release of blood into the aorta. PEP is perhaps the best noninvasive measure of cardiac sympathetic activity [32, 33]. Procedure After recruitment, participants completed a brief pre-donation questionnaire requesting demographic information and an abbreviated version of the Spielberger State Anxiety Scale [34]. They were assigned to a condition and accompanied by a same-sex experimenter to a nearby washroom where the two ambulatory physiological monitors were attached. Both monitors are light, non-invasive, and were largely concealed by the donor's clothes. The blood pressure cuff and electrodes were attached by cords routed underneath their clothes to two small battery-powered recorders placed in a fanny pack worn around the waist. After programming, the monitors obtained continuous data until they were disconnected after donation. People in the full-body AT condition then watched a video depicting repeated 5-s on, 5-s off cycles of whole body isometric tension while maintaining steady breathing. People in the lower body AT condition watched a similar video, though only repeated tension in the legs, hips, and abdomen was depicted. Participants in both AT conditions were asked to practice the technique they learned while in the donation chair. Afterwards, all participants proceeded through the standard blood donation procedure. During blood donation, a research assistant recorded various characteristics such as whether the participant practiced AT (if applicable) or showed signs of a vasovagal reaction. That is, they recorded whether or not the participant fainted, whether their chair was reclined to treat a reaction, and whether they spontaneously reported any symptoms and their nature. Donors were not questioned about vasovagal symptoms while in the donation chair to minimize interference with the collection process and the possibility of inadvertently increasing the chance of a reaction. However, after donation, the participant completed a longer questionnaire including another Spielberger State Anxiety Scale and the BDRI [19]. The BDRI is a well-validated self-report index of vasovagal symptoms such as dizziness, nausea, and lightheadedness. Data Reduction and Analysis To provide further information about the effects of blood donation and AT on autonomic activity, analyses of heart rate variability were conducted using the sequential cardiac interbeat interval data obtained by the AIM and the program HRV Analysis (Biomedical Signal Analysis Group, Department of Applied Physics, University of Kuopio, Finland). This program uses standard Fourier transform algorithms [35] to calculate HF HRV (in milliseconds squared) in the 0.15–0.40 Hz band and low-frequency heart rate variability (in milliseconds squared) in the 0.04–0.15 Hz band. When interpreted cautiously, HF HRV is a good non-invasive index of cardiac parasympathetic, vagal activity [36]. The autonomic origins of low-frequency heart rate variability are more ambiguous and thus were not examined in detail. However, the heart rate variability data were also used to assess respiration rate, which is not measured directly by the AIM. Estimates of respiration rate were obtained using the central frequency of the respiratory band in the autoregressive spectrum of heart rate variability [37]. Estimates of these features of heart rate variability within 5-min blocks were calculated using sitting on the donation chair as the index event. Participants who were asked to practice AT began to do so at that point. Mean values of the other physiological measures—SBP, DBP, HR, SV, CO, TPR, and PEP—were also obtained for each 5-min block. In turn, two change scores for each measure were calculated to reflect the donor's response to the first 5 min of blood donation and the second 5 min. It was decided to stop the analyses 10 min after the participant sat on the donation chair since the blood draw was often complete at that point. After this time, the physiological data are more difficult to interpret since some donors were still in the chair while others began moving to the refreshment/recovery area. Based on similar considerations, change was assessed from the period 10–5 min before the participant got on the donation chair. This block was viewed as the best baseline period, since the participant was sitting with a nurse in the pre-donation screening area at that point. Afterwards, just before they got on the donation chair, they had to move from the screening area to the chair. In sum, the physiological change scores reflect the impact of going from sitting quietly in the pre-donation screening area to sitting on the donation chair with legs extended. Change scores were converted to percent change scores to simplify interpretation of the results and address a problem inherent to impedance cardiography. That is, while non-invasive measurements of variables such as stroke volume are highly correlated with those obtained using traditional medical techniques, the validity of absolute values in units such as milliliters is questionable even in controlled conditions. As a result, it is often recommended to use an alternative to absolute units such as percent change [38, 39]. As discussed in a previous paper based on the larger sample [11], the behavioral effects of the “full” AT procedure and those of the lower body tension procedure were virtually identical. Thus, it was not surprising that preliminary analyses revealed very similar patterns of physiological response to the full and lower body tension procedures. To simplify analyses, data from the two AT groups were considered together. As a result, the primary analyses were 2 condition (no treatment vs. AT) × 2 time (5-min time block) repeated measures analyses of variance (ANOVAs) of change scores. To further sharpen the focus of the analyses on blood donation-related change in each measure, the participant's baseline value was included as a covariate in the analyses presented (results were identical for raw and covariate-adjusted ANOVAs). Results Symptoms There were no significant group differences in pre- or post-donation anxiety scores. However, in general, pre-donation anxiety was considerably elevated in relation to post-donation anxiety, t(95) = 6.04, p <0.001. This supports the view discussed above that, despite their volunteer status, blood donation was an anxiety-provoking activity for many donors who for various reasons (e.g., altruism, a sense of family debt, and friendly persuasion) became medical patients for an hour or so. While the impact of AT on blood donation-related symptoms in this group was less pronounced than in the larger sample [11] and the overall rate of fainting was low, people assigned to practice AT were significantly less likely to faint than people assigned to the donation as usual group, 0% vs. 7%, X2(1) = 4.37, p = 0.033. Among the less dramatic manifestations of vasovagal reactions, there was no significant group difference in whether or not the donor's chair was reclined to treat a reaction or BDRI scores. However, individuals assigned to practice AT were significantly less likely to verbally express some form of discomfort (the most common specific symptoms were dizziness and nausea) during donation than people assigned to the donation as usual group, 14% vs. 39%, X2(1) = 6.54, p = 0.011. Physiological Results There were no significant group differences in baseline physiological measures or anything that approached significance (all p > 0.15). The ANOVA of heart rate responses revealed a significant effect of condition, F(1, 67) = 11.48, p = 0.001. As can be seen in Fig. 1, participants who practiced AT maintained and even slightly increased their heart rates, while participants who did not practice AT experienced heart rate deceleration during donation (corresponding to an average decrease of 5 bpm toward the end). Fig. 1 Open in new tabDownload slide Heart rate change after getting on the donation chair and beginning AT or sitting quietly To examine the autonomic origins of this pattern, similar ANOVAs were conducted on PEP (reflecting cardiac sympathetic activity) and HF HRV (reflecting cardiac parasympathetic activity) responses. Similar to heart rate, the PEP ANOVA produced only a significant effect of condition, F(1, 67) = 4.74, p = 0.033. As can be seen in Fig. 2, practicing AT led to significant reduction in PEP, consistent with an increase in sympathetic activity. In contrast, the HF HRV ANOVA revealed an effect of condition, F(1, 63) = 4.13, p = 0.046, in the opposite direction (Fig. 3). That is, donors who did not practice AT displayed a significant increase in HF HRV, suggesting an increase in vagal parasympathetic activity, while those who did AT had stable values. In sum, AT appears to have led to an increase in cardiac sympathetic activity and avoidance of the typical increase in vagal parasympathetic activity during blood donation. This allowed donors who practiced AT to maintain their heart rates, while those who did not practice AT experienced heart rate deceleration. Fig. 2 Open in new tabDownload slide Pre-ejection period change after getting on the donation chair and beginning AT or sitting quietly Fig. 3 Open in new tabDownload slide High-frequency heart rate variability change after getting on the donation chair and beginning AT or sitting quietly There were no significant effects of condition or time in the ANOVA of stroke volume change scores, although in general, stroke volume increased upon sitting on the donation chair (X = 20%) probably due to enhancement of venous return by sitting with the legs extended. The pattern of heart rate and stroke volume responses explains the significant interaction in the ANOVA of CO, F(1, 67) = 4.51, p = 0.037 (Fig. 4). That is, among donors who did not practice AT, CO began to fall during the procedure due to dropping heart rate values. As a group, CO remained elevated during donation for most people who did not practice AT, consistent with the fact that severe symptoms were rare. However, both the behavioral results and physiological profile of the no-treatment participants suggest greater risk for vasovagal symptoms. Fig. 4 Open in new tabDownload slide Cardiac output change after getting on the donation chair and beginning AT or sitting quietly The main effect of condition in the ANOVA of diastolic blood pressure was significant, F(1, 63) = 6.71, p = 0.012, due to increased DBP among people who practiced AT (Fig. 5). The effect of condition in the ANOVA of SBP approached significance, F(1, 64) = 2.83, p = 0.098. Fig. 5 Open in new tabDownload slide Diastolic blood pressure change after getting on the donation chair and beginning AT or sitting quietly The ANOVA of TPR revealed an interesting time × condition interaction, F(1, 58) = 5.13, p = 0.027 (Fig. 6). In general, consistent with the “vaso” part of a vasovagal response, TPR decreased significantly when people sat on the donation chair and presented themselves for blood donation. There was a trend for this to be more pronounced among people who did not practice AT, although direct pairwise comparisons were not significant in part due to a great deal of missing data for TPR. TPR is a computed measure that required complete data from both the AIM and the blood pressure monitor. Missing data from either monitor was due to various factors including equipment malfunction and, for blood pressure, clinical reasons. That is, after arriving at the donation chair, the phlebotomist occasionally decided that the arm without the blood pressure cuff was unsuitable for venipuncture. Rather than delay the donation process by re-attaching the cuff to the other arm, blood pressure measurement was discontinued in these cases. Fig. 6 Open in new tabDownload slide Total peripheral resistance change after getting on the donation chair and beginning AT or sitting quietly There were no significant effects in the ANOVA of respiration rate. Discussion At first glance, the patterns of physiological activity displayed by no treatment and AT participants may appear complex. However, when considered separately, a fairly clear picture emerges that is consistent with previous research. The Typical Response to Blood Donation Although few participants fainted, many in the no-treatment control condition experienced at least mild symptoms. More reported symptoms such as dizziness and nausea while in the donation chair compared to participants in the AT condition (39% vs. 14%). In fact, the majority of participants in the no treatment condition (61%) indicated at least one mild symptom on the post-donation BDRI. The physiological results are consistent with the experience of at least a mild vasovagal response. After sitting in the donation chair to await venipuncture and blood donation, participants in the no treatment condition experienced decreases in TPR (indicating vasodilation) and heart rate. The decrease in heart rate appears to have been at least partly driven by an increase in vagal parasympathetic nervous system activity as indicated by the increase in HF HRV (Fig. 3). In addition to an increase in vagal parasympathetic activity, participants in the no treatment control group also probably experienced a decrease in at least some aspects of sympathetic nervous system activity as indicated by the drop in TPR (Fig. 6). Despite the implication of a predominant role of parasympathetic activity in the traditional term, vasovagal response, the importance of sympathetic withdrawal has been acknowledged for many years and is related to common use of the alternative term, vasodepressor response [40–43]. In a recent laboratory study of blood phobics’ responses to a film depicting surgery, Sarlo et al. [44] observed a pattern of results somewhat similar to those of the present study. That is, the phobics had an increase in CO during the surgery film but a decrease in TPR, which may be a primary reason for their susceptibility to fainting in such circumstances. In the present case, the vasodilation and decrease in heart rate in the no-treatment control group might suggest widespread symptoms and fainting, but the blood-pressure-reducing effects of these responses appear to have been offset to some degree by increased stroke volume. While increased stroke volume can occur as a result of higher sympathetic activity, the most likely explanation in this case was the simple act of extending the legs during donation, facilitating venous return to the heart. It is interesting to note that standard clinical treatment for vasovagal reactions utilizes the same process. That is, medical patients who are experiencing vasovagal symptoms are typically asked to lower their head and chest and/or raise their legs, e.g., the “crash position.” The importance of venous return is also indicated by the ability of passive head-up tilt to induce vasovagal symptoms and the reduction of symptoms by leg muscle tension during the procedure [30]. Krediet et al. [31] studied cardiovascular responses to several physical maneuvers believed to reduce vasovagal responses, including the crash position, and concluded that they work by facilitating venous return and CO rather than increasing TPR. In sum, sitting with legs extended may have been sufficient to get most no-treatment participants through the procedure, though it is interesting to note that posturally induced changes in cardiovascular activity are not usually long lasting. The increased risk for adverse events such as fainting among no-treatment participants seems to have been reflected in the physiological measures. Reactions to Blood Donation Among Applied Tension Participants The main difference in physiological activity between those in the no-treatment and AT conditions was in heart rate. Donors who practiced AT maintained steady heart rate during the procedure. This probably contributed to the modest increase in blood pressure displayed by these individuals. In contrast to those in the no-treatment control group, the increase in stroke volume was not offset by a decrease in heart rate. Basic research on the autonomic effects of isometric exercise indicates that its impact on the heart is mediated primarily by a reduction of parasympathetic activity with a secondary contribution of an increase in sympathetic activity [27–29]. The present results are consistent with this conclusion. That is, although HF HRV did not decrease during donation, participants in the AT group did not display the increase in HF HRV that people in the no-treatment control group experienced during this period. Practicing AT was also associated with a significant decrease in PEP, suggesting an increase in cardiac sympathetic activity. Thus, the autonomic effects of exercise appear to have interacted with those of blood donation in a manner that allowed heart rate to remain stable during this experience. This probably contributed to the reduction in symptoms, such as dizziness and fainting, especially since, like no-treatment participants, TPR dropped for people practicing AT. A decrease in TPR may “set the stage” for symptoms, though this can be offset by a complementary increase in CO such as observed in the AT group. As a result, the findings are consistent with the suggestion that the key feature of these kinds of interventions is facilitation of CO [31]. Probably the most fascinating aspect of fear-related vasovagal reactions is the fact that many physiological measures associated with “arousal” move in an opposite direction when people are confronted with stimuli suggesting injury or blood loss. For example, heart rate often decreases and the blood vessels relax. A number of explanations have been proposed for this phenomenon [45–48]. 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TI - Physiological Correlates of Applied Tension May Contribute to Reduced Fainting During Medical Procedures
JF - Annals of Behavioral Medicine
DO - 10.1007/s12160-009-9114-7
DA - 2009-06-01
UR - https://www.deepdyve.com/lp/oxford-university-press/physiological-correlates-of-applied-tension-may-contribute-to-reduced-tRFcz9DjwC
SP - 306
EP - 314
VL - 37
IS - 3
DP - DeepDyve
ER -