Astuti et al.

BMC Nursing 2019, 18(Suppl 1):36

https://doi.org/10.1186/s12912-019-0357-8

RESEARCH Open Access

Decreased blood pressure among

community dwelling older adults
following progressive muscle
relaxation and music therapy (RESIK)
*
Niken Fitri Astuti, Etty Rekawati and Dwi Nurviyandari Kusuma Wati
From The 6th Biennial International Nursing Conference
Depok, Indonesia. 2-4 October 2017

Abstract
Background: Hypertension is a major risk factor related to leading causes of death among older adults.
Numerous efforts have been done but they still remain sub-optimal. This condition encourages
development of a non-pharmacological therapy to complement pharmacological therapy, such as
progressive muscle relaxation and music therapy (RESIK). The purpose of this study was to determine
the effect of RESIK on blood pressure among older adults with hypertension in Depok Indonesia.
Methods: This study used quasi experimental design with pre and post test with control group approach.
One-hundred older adults with hypertension were divided into two groups using stratified random
sampling and purposive sampling.
Result: After 11 sessions of RESIK therapy in 6 days, the paired t-test showed a decrease in systolic
blood pressure to 29.2 mmHg and a decrease in diastolic blood pressure to 16.2 mmHg.
Conclusion: In conclusion, RESIK decreased systolic blood pressure p < 0,001, but it did not
significantly decrease diastolic blood pressure p > 0.167. It is recommended that RESIK be used
regularly for an older adult population with hypertension.
Keywords: Blood pressure, Hypertension, Music therapy, Older adults, Progressive muscle relaxation

Background The Indonesian government has undertaken efforts to

Hypertension is one of the leading causes of death, surveillance of Non-Communicable Diseases (NCDs)
worldwide. As many as 9.4 million people die every year based Posbindu and pharmacological therapy [5]. How-
due to hypertension, and more than 1 billion people live ever, both efforts did not have optimal impact, a study
with high blood pressure, 40% of which are over the age explained the evaluation of surveillance of NCDs risk
of 25 [1]. It was estimated 25.8% of Indonesia’s popula- factors based on the Posbindu NCDs resulted the
tion at 2013 suffered from hypertension [2]. Worldwide, surveillance personnel, facilities, and financing were in
hypertension is a major factor in the cause of death among accordance with the guidelines, data collection was con-
older adults due to conditions, such as ischemic heart ducted but the data processing, data analysis, data inter-
disease and stroke [3]. Moreover, the high preva-lence of pretation and dissemination of information was not
this disease can affect a country’s economy [4]. conducted during surveillance, the coverage of examin-
ation at Posbindu and Puskesmas level was less than cut
* Correspondence: [email protected]
off point [6]. Other studies also explained that the treat-
Faculty of Nursing, Universitas Indonesia, Jalan. Prof.Dr.Bahder ment of hypertensive patients had not been effective
Djohan,Kampus UI, Depok, West Java 16424, Indonesia

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Astuti et al. BMC Nursing 2019, 18(Suppl 1):36 Page 2 of 5

because of recurrence andlong term side effects [7] . Ex- group and Cisalak Pasar for control group, next the re-
ample, the older adults consumed angiotensin-converting searcher used purposive sampling to choose community
enzyme (ACE) at risk of new-onset osteoporotic fracture groups which were used as research place. The inclusion
(NOF) [8]. These conditions encouraged the development criteria were: older adults with systolic blood pressure ≥
of non-pharmacologic therapies to complement pharma- 140 mmHg and diastolic ≥90 mmHg, with no hearing and
cological therapeutics, thereby enhancing treatment out- vision impairment, no mobilisation impairment or
comes [7]. cognitive disorder, with a mini-mental state exam
Non-pharmacologic therapy, such as progressive (MMSE) score ranging from 18 to 23 and who had or had
muscle relaxation and music therapy (RESIK), is a type of not undergone standard anti-hypertension therapy. The
nursing intervention used to decrease blood pressure [9]. exclu-sion criterion was older adults with critical
Many studies have explained the effect of progressive hypertension, characteris ed. by systolic blood pressure ≥
muscle relaxation on blood pressure, but this type of 180 mmHg or diastolic blood pressure ≥ 120
therapy would be better if it is done simultaneously with mmHg.Sampling procedure can be seen in Fig. 1.
other types of relaxation therapy, such as music therapy.
In fact, breathing exercises, progressive muscle relaxation Procedure
and music therapy have been found to decrease blood The study was conducted as many as 11 sessions in 6
pres-sure, especially in older adults [10]. days in the morning and evening with 3 practice ses-sions.
This research used music therapy in conjunction with The exercise schedule took one week to get max-imum
progressive muscle relaxation. Music therapy was a ther-apy result [13–15]. Six day interventions with a duration of 15
that could help in the healing process. Music that could be min significantly reduced systolic blood pressure in
used in this therapy was a consistent and stable rhythm, primary hypertension [16]. The data analysis used paired
dynamic, fun harmonious, regular rhythm with-out any t-test and independent t-test.
sudden change [11]. The instrumental music of Peter The present study has received ethical clearance and
Sterling’s “The Angels Gift” was one of the instru-mental was approved by the Faculty of Nursing Ethical Commit-
music of the harp, flute, violin and soft orchestral strings that tee of the Universitas Indonesia on 17 April 2017. The
could stabilize blood pressure after being given for 25 min intervention caused no harmful side effects for the re-
[12]. In the current studies, there had been no study that spondent if the respondent did in accordance with the
combined progressive muscle relaxation and music therapy procedure, but if the respondent did not follow the pro-
(RESIK). Therefore, the researcher was motivated to explore cedure accordingly, blood pressure would increase. If the
the effect of progressive muscle relax-ation and music respondents’ blood pressure increased during therapy,
therapy (RESIK) to decreased blood pres-sure among older they were encouraged to rest while breathing regularly for
adults with hypertension. So this therapy could be one of 5 min until they felt relaxed.
alternatives that could be given to the older adults with
hypertension. Result
The mean age of the respondents in the intervention group
Method was 66.54 (standard deviation [SD] = 5.665). In the
Study design and sample control group, the mean age of the respondents was 67.48
This study used quasi experimental design with pre and (SD = 5.388) with a homogeneity score of 0.397. All the
post test with control group approach. In the present characteristic variables were tested for homogen-eity
study, the sample consisted of 100 older adults with using a chi-square test for the categorical data and an
hypertension in Depok, Indonesia. The participants were independent t-test for the numerical data. The results
divided into an intervention group and a control group. showed that the respondents characteristics in the inter-
The sample size in the study was determined using dif- vention and control groups were homogeneous. Other
ferent formula 2 mean dependent group that had con- respondent characteristics are presented in Table 1.
sidered the drop out sample and the design effect.
Sampling method used stratified random sampling. Re- Discussion
searcher conducted two times drawing, the first drawing Participating in progresive muscle relaxation until feeling
was to determine the research area, from 11 districts in relaxed, calm and while fully concentrating for 30 min can
Depok City, researcher got Cimanggis as a place for re- decrease a person’s corticotrophin releasing hormone (CRH)
search, followed by the second drawing which aimed to and adrenocorticotropic hormone (ACTH) levels in the
determine the district used as the intervention group as hypothalamus [17]. This process decreases sympa-thetic
well as the control group. Results from the second draw- nerve activity, so adrenaline and non-adrenaline levels can
ing, from 6 Sub-districts in Cimanggis, Harjamukti Sub- also decrease. This resulted in a decreased heart rate,
district was obtained as research area for intervention widening of the blood vessels, decreased blood vessel
Astuti et al. BMC Nursing 2019, 18(Suppl 1):36 Page 3 of 5

Fig. 1 Sampling procedure

resistance and decreased exertion of cardiac muscles, combination between progressive muscle relaxation and
thus, decreasing cardiac arterial blood pressure [17]. music therapy.
This study showed that blood pressure decreased as The research suggested that music could inhibit and
many as 29.2 mmHg (systolic) and 16.2 mmHg (dia- balance brain waves, capable to activate limbic system
stolic), the detailed results are scribed in Table 2. An- related with emotion. When the limbic system was acti-
other research showed a progressive muscle relaxation vated, the individual would feel relaxed. The music could
which have been done by 40 respondents aged 40–70 affect sympathoadrenergic activities that had a role in
years for 8 sessions in 4 days with duration 20 min in the plasma catecholamine concentrations and also affected
morning and afternoon could only decrease blood pres- the release of stress-released hormones and stimulated the
sure as many as 6.42 mmHg (systolic) and 0.8 mmHg body to produce nitric oxide (NO) molecules that
(diastolic) [18]. That condition was due to the
Table 2 Differences of blood pressure before and after
Table 1 Respondent characteristic intervention in the intervention and control group
Characteristic Intervention Control P Variable Mean SD** Mean P
(n = 50) (n = 50)
f (%) f (%)
different
Gender, Female (%) 30 (60) 32 (64) 0.680
Pre Post Pre Post
Education level, Senior high school (%) 27 (54) 17 (34) 0.252
BMI, Normal (%) 26 (52) 24 (48) 0.100 Systolic 0.001*
Family History, No (%) 26 (52) 35 (70) 0.065 •Intervention 152.8 123.6 11.61 14.81 29.2
Smoking History, No (%) 41 (82) 40 (80) 0.799 •Control 156.2 142.2 11.76 15.82 14.0
Anti-Hypertensive Medication,Yes (%) 34 (68) 37 (74) 0.509
Diastolic 0.001*
Note: The characteristic of respondents were the highest precentage. All
variables were homogeneous and had been tested with chi square test. •Intervention 96.40 80.20 7.217 11.16 16.2
BMI Body Mass Index
•Control 96.60 83.20 7.453 10.39 13.4
*statistically significant on on α < 0.05**deviation standard
Showed the changes of blood pressure before and after intervention in
both group (p < 0.05), with the highest change in the intervention group
which systolic was 29.2 mmHg and diastolic was 16.2 mmHg
Astuti et al. BMC Nursing 2019, 18(Suppl 1):36 Page 4 of 5

working on blood vessel tone and could decrease blood direct and indirect exposure to cigarettes could increase a
pressure [19–21]. person’s heart rate by as much as 34% and diastolic blood
Changes in blood pressure are related to the adminis- pressure by as much as 17% [24]. This study was in line with
tration of anti-hypertensive drugs, which are routinely the results of this study, that blood pressure did not decrease
used by older adults. Research has shown that captopril in 5 of the 9 respondents in the interven-tion group who had
can decrease systolic blood pressure and diastolic blood a smoking history, so it could be concluded that many factors
pressure by as much as 29.16/11.83 mmHg and amlodi- could affect diastolic blood pressure. The above conditions
pine can decrease systolic blood pressure and diastolic could be minimised by modifying a person’s lifestyle
blood pressure by as much as 32.94/16.38 mmHg [22]. (lifestyle modification in JNC VII), such as losing weight,
Based on those findings, the decrease in blood pressure in adopting a healthy diet, restrict-ing daily salt intake,
the present study was caused by both the RESIK ther-apy increasing physical activity, restricting alcohol consumption
and the anti-hypertensive drugs taken by the respon-dents. and stopping smoking [25].
If the effect of taking anti-hypertension drugs for most of In the present study, blood pressure was sometimes
the respondents (68%) had a minimum effect on blood increased after treatment. This outcome occurred in 5
pressure (as much as 29.16/11.83 mmHg com-pared with respondents because 4 of them did not follow the proto-
the blood pressure final result, which was as much as col, such as exhaling through the mouth, and they
29.2/16.2 mmHg), it could be concluded that RESIK remained tense when the researchers instructed them to
therapy could be combined with pharmacological therapy relax their muscles and 1 respondent felt worried about
to help ensure a maximum decrease in blood pressure. her blood pressure. The intervention protocol indicates
that while respondents are attempting to relax, nurses or
(Table 3) shows none significant differencein diastolic researchers must consider how to relax the muscle group
blood pressure after RESIK therapy for 11 sessions. Dia- a respondent is tensing. If respondents do not achieve a
stolic hypertension is often associated with a decrease in relaxed state, CRH is secreted and ACTH levels in the
cardiac muscle function, the ability of the heart to pump hypothalamus are not optimal, so the para-sympathetic
and stiffness of the heart muscle [16]. A person’s age also nervous system releases the neurotransmit-ter
physiologically affects cardiac function. When car- acetylcholine to inhibit the sympathetic nerves by
diovascular function decreases, the ability of the heart to reducing the contractile heart muscle; moreover, vaso-
pump and stiffness in the heart muscle causes diastolic dilation of the anterior and vein was also not optimal so
blood pressure to decrease, but not significantly. In con- the blood pressure could not significantly decrease [26].
trast, in systolic hypertension cardiovascular function can RESIK therapy has to be done regularly to maintain
progressively change due to changes in the elasticity of blood pressure within normal limits. RESIK in this study
the blood vessels, so systolic blood pressure can change was a coping mechanism regulator that could affect
more rapidly than diastolic blood pressure. physiological function, self concept, role function and
Other factors that may affect diastolic blood pressure interdependensi elderly. These effects would provide both
include tea drinking habits, triglyceride levels, lipopro- adaptive and ineffective responses [16]. Roy’s theory
teins, blood glucose and Body Mass Index (BMI) [23]. explained that an individual could improve his health by
This finding is in line with the results of this study, which maintaining behavior adaptively and being able to change
found that 29% of the respondents had a BMI with behavior maladaptif. The constant interaction between
overweight categories. Another study reported that humans and the environment would have an impact on
internal and external changes, so did treat-ment of
Table 3 The differences of blood pressure before and adaptive behavior continously in the elderly with high
after intervention in the intervention and control group blood pressure caould be formed [27].
Variable Mean SD** P Evidently, the mean of systolic and diastolic blood
Systolic pressure in the intervention group included in the pre-
hypertension category. That was different with control
•Intervention 123.6 14.81 0.001*
group. The mean of blood pressure in the control group
•Control 142.2 15.82 was in category 1 hypertension. While diastolic blood
Diastolic pressure was no difference significantly with the control
•Intervention 80.20 11.16 0.167 group, this therapy could help maximizing the treatment
•Control 83.20 10.39
that has been performed such as drug administration as
previously explained that the decrease in blood pressure
*meaningful on α < 0.05 ** deviation standard
Illustrated that there was a significant difference of systolic blood in the intervention group was higher than the control
pressure between intervention and control group (p < 0.05), but there group who had the habit of taking medicine as many as
was no differences of diastolic blood pressure between intervention
and control group (p > 0.05)
74%.
Astuti et al. BMC Nursing 2019, 18(Suppl 1):36
 Page 5 of 5

Conclusion
In the present study, RESIK therapy significantly de-
creased blood pressure, dropping it from category 1
hypertension to pre-hypertension. RESIK therapy should
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designed the study, supervised the data collection, and contributed Terhadap Perubahan Ansietas, Depresi, Kemampuan Relaksasi dan
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Availability of data and materials 2013;5(2):171–6 https://doi.org/10.5958/j.0974-9357.5.2.089.
A confidentiality agreement with respondents prevent us from
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