Journal of Bodywork & Movement Therapies xxx (2017) 1e7

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Cardiac autonomic response after cranial technique of the fourth

ventricle (cv4) compression in systemic hypertensive subjects
Ana Christina Certain Curi a, Alex Souto Maior Alves a, Julio Guilherme Silva b, c, *
a
rio Augusto Motta), Rio de Janeiro, RJ, Brazil
Rehabilitation Science at UNISUAM (Centro Universita
b
rio Augusto Motta), Brazil
Rehabilitation Science at UNISUAM (Centro Universita
c
Department of Physical Therapy - UFRJ [Universidade Federal do Rio de Janeiro], Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study was to compare blood pressure (BP) behavior and heart rate variability
Received 28 July 2017 (HRV) among hypertensive stage I and normotensive individuals who were submitted to the cranial
Received in revised form technique of the 4th ventricle compression (CV4), an osteopathic technique.
18 October 2017
Methods: In this experimental controlled study, thirty men between 40 and 60 years old were evaluated
Accepted 21 November 2017
and divided into two groups: normotensive (NT) and hypertensive (HT). The CV4 maneuver was applied
in both groups and BP was measured at 5 (five) different stages: pre and post-intervention, 5, 10 and
Keywords:
15min after technique. Time-frequency parameters were obtained from measurements of RR intervals.
Hypertension
Musculoskeletal manipulations
Data were analyzed using an ANOVA two-way for analysis of the condition factor (NT and HT) and times
Osteopathic medicine with p-value
.05.
Heart rate variability Results: There was a reduction in the BP of the HT group. A significant intergroup difference (p ¼ .01) was
noticed, with respect to the standard deviation of successive normal R-R intervals (SDNN) values, mainly
between pre-intervention and 15min stages. Concerning root mean square of the mean squared differ-
ences (RNSSD) values, the highlights were differences between pre-intervention and 10min (p ¼ .01)
only in the NT group. There was an increase in high frequencies (HF) values and a low frequencies (LF)
attenuation in both groups at all different stages.
Conclusion: The data showed a BP reduction in the HT group in pre-intervention/15min and an increase
in parasympathetic activity and decreased sympathetic activity in both groups. This suggests a change in
the sympathetic-vagal balance. However, further studies are needed to elucidate the data on BP
reduction mechanisms with CV4.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction responsible for at least 45% of deaths related to cardiac complica-

tions and 51% of all cerebrovascular accidents (strokes) all over the
Systemic hypertension (SH) is a silent disease with rare symp- world.
toms in the early stages, however, it is one of the risk factors for In Brazil, surveys carried out during the last 20 years show that
cardiovascular diseases (Angeli et al., 2013; Bromfield and Muntner, more than 30% of the population is affected by hypertension,
2013; WHO, 2013; Dasgupta et al., 2014). When undiagnosed and reaching 50% over 65 years (Malta et al., 2015). Moreover, the Basic
therefore not treated, this condition can lead to complications in Health Indicators and Data Brazil (IDB) indicate that 25% of the
organs such as the heart, the kidneys, the brain, the eyes and blood population has been diagnosed and confirmed as having hyper-
vessels (Cloutier et al., 2015). According to guidelines established by tension. According to the Ministry of Health, hypertension affects
the World Health Organization (WHO, 2013), hypertension is 24.3% of the adult population, and as per the VII Brazilian Hyper-
tension Guidelines (Malachias et al., 2016), Systemic Arterial Hy-
pertension affects 35.8% of the male population and 30% of the
~ es, 34/ 1o,
* Corresponding author. Rehabilitation Science Program, Praça das Naço female population in Brazil.
Andar, Bonsucesso, Rio de Janeiro, RJ CEP 21041-010, Brazil. Tel.: þ 55 21 3882 Clinical trials indicate that hypertension detection, treatment
9797x2012. and control are critical for a decrease in the number of cardiovas-
E-mail addresses: [email protected], [email protected]
cular events (Angeli et al., 2013; Dasgupta et al., 2014; Girotto et al.,
(J.G. Silva).

https://doi.org/10.1016/j.jbmt.2017.11.013
1360-8592/© 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
2 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7

2013). The main recommendation for patients with high blood those who had smoked tobacco within 30 min prior to the study,
pressure is a change of lifestyle, that is, an improvement in eating and those who had practiced intense exercises 60e90 min before
habits reducing sodium, fat and sugar consumption; the practice of the experiment was carried out were excluded as well (Geleilete
regular physical activity, to avoid alcoholic beverages and to reduce et al., 2009; Arterial Hypertension Program 2015). As far as the
the level of stress (WHO, 2013; Girotto et al., 2013; Campbell et al., definition of sample loss is concerned, individuals who described a
2014). These guidelines are aimed at keeping Systemic Arterial feeling headache, migraine, dizziness and/or nausea during CV-4
Hypertension under control, and even reversing the problem, with occipital and/or cervical pain were not considered. If they
especially in patients with stage I hypertension. With regards to the experienced any symptoms or side effects during an application of
treatment of hypertension, there is plenty of information about the technique, the treatment would cease immediately. During the
drug-free methods of intervention and/or actions that support study, there were no complaints from the subjects and sample loss.
alternative approaches. They range from diets and the practice of
physical exercise to alternative techniques, such as the manual 2.2. study design
therapies for cases of stage I hypertension (Taylor, 2014; Frishman
et al., 2005). In this study, the participants were divided into two groups:
Within this scope, manual therapy techniques have been getting normotensive (NT) and hypertensive (HT). Therefore, this is the
special attention in the literature of this area for promoting sys- flowchart with the study design (see Fig. 1).
temic changes that can contribute to the treatment of some sys-
temic diseases. Even though there is not a robust number of 2.3. Procedure
findings, investigations such as the one by Shi et al. (2011); Miana
et al. (2013) and Nelson et al. (2006) started discussions about First, participants answered a triage questionnaire (anamnesis)
the results of the physiological effects caused by the CV4, especially through which the following information was gathered: drugs
with regard to hypertension, Frishman et al. (2005). In light of this, being taken, level of physical activity, an indication of being under
we can call attention to the Osteopathic Manipulative Treatment physical therapy. Next, in the osteopathy clinic at Pedro II Reha-
(OMT) and its various forms of intervention which work as a tool in bilitation City Hospital, in an adequate and climatized environ-
the control of hypertension. ment, individuals had their BP and heart rate variability (HRV)
Therefore, the OMT can be an important ally when associated monitored by two devices: an ambulatory BP monitoring equip-
with changes to lifestyle and drug therapy. Among the various OMT ment and a cardiac monitor. Both pieces of equipment were
approaches, one specific technique calls attention to its systemic dependable and had been tested (Gamelin et al., 2006; ESH/ESC
effects: the 4th ventricle compression technique (CV4) and oste- Guidelines for the management of arterial hypertension, 2013). In
opathy treatment (Sutherland, 1962; Frishman et al., 2005; reference to the CV4 osteopathic maneuver, it was used in both
Cerritelli et al., 2011; Shi et al., 2011, Miana et al., 2013). However, groups by an Osteopath D.O with 12 years of clinical experience.
there is a lack of research on the CV4 technique and its possible The performance of the intervention is carried out with the indi-
systemic changes, mainly in hypertensive individuals. Thus, the vidual in a dorsal decubitus position and lower limbs straight. The
objective of this study is to analyze pressure behavior and auto- technique, by Sutherland (1962), consists of a light compression
nomic modulation, pre- and post-intervention with the use of the carried out with the practitioner's thenar eminence in the supra-
CV4 osteopathic maneuver, in normotensive and hypertensive occipital region, precisely on the patient's squama of the occipital
individuals. bone with compression beginning with the exhalation phase of the
primary respiratory mechanism [PRM] and maintaining the
2. Method compression for 5 min (see Fig. 2), according to the proposal by
J€
akel and Hauenschild (2011).
2.1. Sample
2.4. Hemodynamic measurements
In this experimental study, the sample was composed of hy-
pertensive and normotensive men aged between 40 and 60 years Before commencement of the osteopathic manipulative CV4
old. Hypertensive individuals were recruited in the Osteopathy cranial technique, subjects rested quietly in a supine position for
Clinic of Hospital Municipal de Reabilitaça ~o Pedro II [Pedro II Reha- 5 min before the initial measurement of the resting BP. After
bilitation City Hospital]. Normotensive individuals were recruited applying the osteopathic manipulative CV4 cranial technique, BP
by convenience. The research was based on CONSORT e Consoli- was immediately measured and remeasured every 5min resulting
dated Standards of Reporting Trials. This work was approved by the in a total of 5 readings (5min, 10min, and 15min after the inter-
Ethics Committee of Centro Universita
rio Augusto Motta (UNISUAM) vention). Before and after each session, subjects were fitted with
under number CAAE 47106115.0.0000.5235. ambulatory BP monitoring equipment (PM50 Monitor; Contec
Regarding the eligibility criteria, the individuals who took part Medical, Beijing, China), and this equipment was used for all pre-
in this work had a confirmed diagnosis of stage I hypertension and post-intervention BP measurements. The ambulatory BP
according to the 7th Brazilian Guidelines of Hypertension and the equipment was auto-calibrated before each use to ensure accuracy.
ESH/ESC Guidelines for the management of arterial hypertension Interpositions readings, because of factors such as interference,
2016, who had never heard of and/or undergone the osteopathic were automatically edited by the software. During BP pre- and
manipulative CV4 cranial technique. Individuals under antihyper- post-monitoring, subjects remained in a supine position in a
tensive drugs, with blood pressure (BP) under control, and/or under temperature-controlled quiet room (21  C).
psychotropic medication in general, painkillers, muscle relaxants or Assessment of Heart Rate Variability (HRV)
any other medication that may alter the BP were excluded from the HRV analysis within the established time and frequency were
study. Also excluded were individuals with chronic renal problems, obtained based on the measurements of RR intervals taken during
diabetes mellitus, previous or current cardiovascular diseases, si- five continuous minutes, in five different stages (pre- and post-
nus, pulmonary diseases, and those with cognitive deficits that intervention periods, and the next 5, 10 and 15min). RR intervals
could compromise the understanding of instructions. Finally, those measurements were obtained through a cardiac monitor (Polar
who had drunk anything containing caffeine or alcohol and, also, RS800, EUA), with a sampling rate of 1 kHz, A/D resolution of 12 bits

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7 3

Fig. 1. Study Design: division of the groups.

NN50 (number of interval differences of successive NN intervals

greater than 50 ms); pNN50 (percentage of normal R-R intervals
greater than 50 ms) and RMSSD (root mean square of the mean
squared differences) of successive R-R intervals (Chung et al., 2011;
Nooijen et al., 2015; Saunders et al., 2015).
For frequency-domain analysis, R-R intervals time series were
re-sampled to equal intervals by spline cubic interpolation method
at 2 Hz, and mean value and linear trend were removed. Fast
Fourier transformation was used for calculating the power spec-
trum (Welch's periodogram was employed to assess the 1024-point
spectra with a Hanning window and 50% overlap). Spectral power
was obtained by integrating the power spectrum density function
in the very low-frequency (VLF: 0.0033 and 0.04 Hz), the low-
frequency (LF: 0.04e0.15 Hz), and the high-frequency (HF:
0.15e0.40 Hz) bands. The spectral power was also computed in
normalized units for the HF [HFnu ¼ HF/(total power - VLF) X 100]
and LF [LFnu ¼ LF/(total power - VLF) X 100], and the autonomic
balance evaluated by the LF/HF (Chung et al., 2011; Saunders et al.,
2015).

2.5. Statistical analysis

Firstly, the Kolmogorov-Smirnov test was applied to verify

Fig. 2. CV4 maneuver.
sample distribution. After the confirmation of its normality, data
relating to sample characterization was treated based on descrip-
and additional digital filtering, with frequency band between 0.5 tive statistics, with the description of central (mean and median),
and 40 Hz (3 dB) (high-pass filter in 0.5 Hz and low-pass filter in and dispersion tendency (standard deviation). In reference to
40 Hz). The recording occurred under spontaneous voluntary dependent variable data (BP), an ANOVA two-way was carried out
ventilation at rest (all groups showed an average breathing rate of for the different stages (pre- and post-intervention, 5min, 10min
about 12 breaths per min). All readings were manually checked to and 15min). The level of significance was 95% (p
.05). The pro-
eliminate possible ectopic beats and artefacts originated from gram used for the statistical analysis was SPSS version 20.0 IBM.
electrical interference. However, the frequency of the edition reg-
isters always lower than 1% of all detected RR intervals. 3. Results
The following time domain of HRV variables were analyzed: R-R
(mean of all normal R-R intervals) during the 10-min recording; Demographic data of the sample are in Table 1. About BMI, both
SDNN (standard deviation of successive normal R-R intervals); groups were overweight according to the BMI weight classification

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
4 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7

Table 1 in the HT group in the 5min post-intervention when compared to

Demographic Data of the sample. rest (see Fig. 4D).
Demographic Data NT (Mean/SD) HT (Mean/SD) Test T (p value) Fig. 5 shows resting and post-cranial technique of the 4th
Age (years) 50 ± 6.67 54.07 ± 7.11 p ¼ .689
ventricle compression mean values of SDNN and RMSSD for both
Weight (Kg) 84.47 ± 9.56 85.46 ± 9.05 p ¼ .895 groups (HT/NT). At 10 min post intervention, HT group exhibited
Height (m) 1.78 ± 0.07 1.73 ± 0.07 p ¼ .643 lower SDNN than NT group (P < .001) (see Fig. 5A). HT group
BMI (kg/m2) 26.92 ± 3.15 28.56 ± 2.72 p ¼ .680 showed decrease significant of SDNN in 10 min post intervention
NT ¼ Normotensive Group; HT¼ Hypertensive Group. when compared to rest and immediately post-intervention (see
Fig. 5A). As to RMSSD values, only significant differences were
found between the pre- and 10min intervention stages (p < .001) in
as per the WHO (2013). All individuals in the HT group were under the HT group (see Fig. 5B).
medical treatment. The sample used in both groups was formed by
individuals with a sedentary lifestyle according to their own 4. Discussion
anamnesis record file.
Fig. 3 showed significant differences in the systolic blood pres- The main objective of this work was to analyze blood pressure
sure (SBP) and diastolic blood pressure (DBP) at rest, immediately (BP) and heart rate (HR) behavior in hypertensive and normoten-
post-intervention, and 5 min, 10 min, 15 min Post-cranial technique sive individuals after the use of the CV4 technique.
of the 4th ventricle compression. Outcomes showed a significant Our data showed a decrease in the BP of the HT group, especially
decreasing SBP immediately post-intervention, and 5 min, 10 min, when comparing pre and 15min stage interventions. There was a
15 min in HT (see Fig. 3A). HT group showed a significant decrease significant decrease in the average values of systolic and diastolic
of the DBP only 5 min (85.3 ± 9.72 mmHg) and 15 min BP in the HT group, between pre and 15min stage interventions.
(84.6 ± 9.5 mmHg) post-cranial technique of the 4th ventricle This may be r elated to the relationship of the stimulus caused by
compression in relation to rest (89.2 ± 9.13 mmHg) (p < .005) (see the maneuver and the anatomic region. According to Sutherland
Fig. 3B). (1962), the CV4 technique activates the structures of the brain-
Fig. 4 shows the R-R interval, LF power, HF power, and LF/HF stem, cranial region of the parasympathetic nervous system (Brasil,
ratio to HT group versus NT group. In statistic between the groups 2017). In this manner, our data suggests that there is a relationship
no significant difference was observed, but R-R interval increases between the CV4 technique and the parasympathetic activation
significantly in 10 min and 15 min post-intervention to HT group and, consequently, a BP decrease. Therefore, results seem to agree
(p ¼ .001) (see Fig. 4A). Fig. 4B showed significant lower LF power with what is stated by Sutherland (1962) on the possibility of the
visually detected for the HT group in 10 min post-intervention CV4 technique promoting physiological changes by vagal nerve
versus at rest (p < .01). On the other hand, LF/HF ratio was lower stimulation.
In relation to HRV, which is the measurement of heart rate
frequency variation between each two beatings of the heart at a
certain time interval (R-R interval), this study intended to discuss
the distinct stages of time and frequency scopes. According to
studies by Sant'anna et al. (2015), Lopes et al. (2013), Júnior et al.
(2004) hypertensive individuals present a sympathetic hyperac-
tivity and, for this reason, a reduced HRV if compared to normo-
tensive individuals. Such information was confirmed by our results,
where the NT group showed a higher HRV, observed during the
power spectrum analysis of the RR interval variability.
Additionally, results of the HRV analysis that considered the
different times of intervention, which was performed based on
consecutive RR intervals, indicated that there was an increase in
SDNN behavior (standard deviation of all RR normal intervals) in
the NT group after the performance of the CV4 technique, between
pre- and 15min stage interventions. The SDNN variable is influ-
enced by the sympathetic-vagal tone. Still considering time, RMSSD
data (the square root of the squared mean of the differences be-
tween consecutive RR intervals) provides the quantification of
abrupt variations in variability, and reflect the changes in vagal
tone, showing a significant difference between pre and 10min
stages of intervention in the HT group. Such behavior may be
explained by the prevalence of parasympathetic activity and sug-
gests the existence of a predisposition to a BP drop and HR change,
after the CV4 technique.
As to frequency, the coefficient between LF and HF (LF/HF ratio)
is used to express the autonomic modulation. Our results presented
an increase in the HF/LF ratio mainly due to the increase of the
parasympathetic activity (HF) and the decrease of the sympathetic
activity (LF). This data resembles the discoveries of the work of Shi
Fig. 3. Hemodynamic response at rest, immediately post intervention, and 5min, et al. Geleilete et al., 2009 who demonstrated in the study carried
10min, and 15min after the intervention for normotensive versus hypertensive. Data
are presented as mean ± SD.
out with 21 healthy individuals (8 women and 13 men), that the
*p < .005eSignificant difference between the groups (HT/NT). CV4 technique may promote a sympathovagal modulation, after
#p < .005 - Significant difference within the groups (Rest and Post intervention). the HRV analysis. Milnes and Moran (2007), on the other hand, with

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7 5

Fig. 4. Frequency-domain of HRV at rest, immediately post intervention, and 5min, 10min, and 15min after the intervention for normotensive versus hypertensive. Data are
presented as mean ± SD.
#p < .001 - Significant difference within the groups (Rest and Post-intervention).

10 asymptomatic individuals (4 men and 6 women), observed that

after the CV4 technique the parasympathetic activity increased in
only 3 individuals.
Despite the lack of studies, investigations such as the one by Shi
et al. (2011); Miana et al. (2013) and Nelson et al. (2006). Started
discussions about the effects of the physiological effects caused by
the CV4. Miana et al. (2013) showed alterations to cortical activity,
especially in the alpha band, in healthy individuals submitted to the
CV4 technique. This specific technique caused a significant increase
of alpha absolute power and, the higher the energy in the elec-
trodes of the central parietal region, the lower the activation.
Therefore, this justified the state of relaxation observed in the in-
dividuals after the CV4 technique was performed. However, this
state of relaxation maybe related to the effects of a decrease in BP
seen in this work, however, our data does not provide us with much
theoretical support in this sense.
Shi et al. (2011) analyzed, in healthy individuals, through
infrared spectroscopy, the saturation of tissue oxygen (SCTO2) and
cardiac autonomic modulation, with the ECG, using osteopathic
manipulative cranial techniques, such as the CV4. Results showed a
cerebral hemodynamic reduction after the decrease in the
oxygenation of brain tissue in right and left prefrontal cortex re-
gions during the time the CV4 technique was performed. They also
observed a decrease in cardiac sympathetic modulation and the
increase in vagal activity, detected in the variation of RR interval
spectral power. Despite the use of various cranial techniques, the
findings of Shi et al. (2011) confirm the data found in this investi-
gation which has identified an increase of parasympathetic activity.
Fig. 5. Time-domain of HRV at rest, immediately post intervention, and 5min, 10min, This was confirmed by the values found in the frequency scope. In
and 15min after the intervention for normotensive versus hypertensive. Data are
presented as mean ± SD.
this context, the CV4 technique seems to be able to promote
*p < .001eSignificant difference between the groups (HT/NT). physiological changes and obtain improvements in some clinical
#p < .001 - Significant difference within the groups (Rest and Post-intervention). manifestations.

Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013
6 A.C.C. Curi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e7

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Arterial Hypertention Program - ProHArt. The Arterial Hypertension Program,
Declaration of interest associated to the HUCFF Clinic- http://www.prohart.hucff.ufrj.br/index.php/
esclareça-suas-duvidas/31-qual-a-tecnica-correta-de-aferiç~ ao-da-pressa ~o-
The authors report no CONFLICT of interest. arterial [Accessed 10January 2015].
Sant'anna Jr., M., Carneiro, J., Carvalhal, R., Tores, D., Cruz, G., Quaresma, J.C., et al.,
2015. Cardiovascular autonomic dysfunction in patients with morbid obesity.
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Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
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Please cite this article in press as: Curi, A.C.C., et al., Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression
in systemic hypertensive subjects, Journal of Bodywork & Movement Therapies (2017), https://doi.org/10.1016/j.jbmt.2017.11.013