1. The Effect of Biofeedback Relaxation on Blood Pressure and Skin Surface Temperature in Hurricane Survivors Kyungeh An, PhD, RN, Nancy Jallo, PhD, FNP-BC, WHNP-BC, Victoria Menzies, PhD, RN Virginia Commonwealth University

2. Background (Photo by NASA 2008) Hurricane Ike hit Galveston and south east Texas in 2008 Heavy landfall & storm surge followed by flooding Caused an extensive damage in this community.

3. Background More than 140,000 people in the Texas Gulf Coast area had failed to evacuate Over 940 were rescued from rising waters Nearly 2,000 rescued afterward

4. Survivors of the Hurricane Witnessed demolishing of their homes and neighborhood, Cleaning debris and recovering homes with a huge demand & limited resources Faced loss of their loved ones Massive & prolonged unemployment Photos taken by An, 2008

5. Aftermath Stress

6. Previous Studies After hurricane Katrina, incidence of coronary heart disease (CHD) was increased by three fold at two years and three years after Hurricane (Gautam, 2009; Giao, 2012). Six months after Hurricane Ike, a survey with 401 respondents reported that over 60% (n=242) had elevated stress levels, of 393 that completed depression assessments, 34.6% (n=137) showed elevated levels of depression (Bishop et al., 2010).

7. Significance Survivors from hurricane often suffer long lasting symptoms associated with stress such as apprehension, elevated blood pressure, and poor peripheral circulation. Biofeedback relaxation may alleviate these symptoms associated with hyper arousal of sympathetic nervous system, yet, there is scanty of data that support scientific evidence of the effectiveness of this technique.

8. Specific Aims The objective of the study was to examine the effects of biofeedback relaxation for 4 weeks on the psychological and hemodynamic variables among hurricane survivors. Specific aims of the study were to: (1)examine whether there is a significant difference in perceived stress, depression and anxiety score before and after the 4 weeks of biofeedback relaxation training; (2)examine whether there is a significant changes in SBP, DBP, HR, and skin surface temperature before and after 4 weeks of biofeedback relaxation training

9. Methods: Setting 16 Participants were individuals who had remained in Galveston, Texas during Hurricane Ike in 2008 Those who visited the St. Vincent Free clinic in Galveston island and appeared high level of stress after the event. Level of stress was measured by the Perceived Stress Scale ( ) No previous history of hypertension or circulatory disorder, any fever last two weeks.

10. Methods: training A certified nurse provided the 20 minute biofeedback relaxation intervention twice a week for 4 weeks, accounting for a total of 8 sessions. Physiologic measures were obtained after a 20 minute rest period prior to and immediately after each intervention session. Daily 20 minute home practice was encouraged.

11. Methods: measurements Blood pressure and heart rate were measured by the continuous BP monitor Skin surface temperature were measured by the galvanometer Analysis : Changes in systolic/diastolic blood pressure and skin temperature in each session as well as the changes over 4 weeks were analyzed using repeated measure ANOVA.

12. Procedures

13. Characteristics of the Sample Count (%) AgeUnder 403 (18.8) 40 or older13(81.3) SexMen1(6.3) Women15(93.8) Marital status Single11(73.3) Married2(13.3) Separated2(13.3) Ethnic group Hispanic2(12.5) White5(31.3) Black9(56.3) Other0(.0) Have Insurance/ No8(61.5) Yes5(38.5) SmokingNo2(12.5) Yes14(87.5)

14. Psychological Strains Descriptive Statistics (N=16) MinMax Norm Perceived Stress 1 17.0038.00 Depression 2 2.0028.00 Anxiety 3 2.0022.00 PTSD 4 5.0035.00 1.Cohen, S., Kamarck, T., and Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386-396. 2. & 3. Brief form of Symptom check list SCL-90-R(Derogatis & Melisaratos, 1983) 4. Trauma Screening Questionnaire (TSQ)(Coffey, et al.,1998)

15. Severity of PTSD

16. Changes in Blood Pressure

17. Results Sixteen participants complete the study. Both systolic and diastolic blood pressure significantly decreased over time (F df=7 =4.562, p<0.001 for SBP and F df=7 = 5.362, p<0.001 for DBP). Skin surface temperature significantly increased over time (F df=7 =6.002, p<0.001). The increment of the temperature elevated by the biofeedback training consistently increased over time, indicating training effects (p<0.001).

18. Conclusion Biofeedback relaxation is an effective intervention for attenuating high blood pressure that may develop during the stressful life event such as Hurricane. Results also demonstrated relaxation effects on peripheral vasodilation as demonstrated by the skin surface temperature elevation.