Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11814 Effect of Gamelan and progressive muscle relaxation on blood pressure in hypertensive patients Ira Rahmawati,1 Firda Ayu Magfiroh,2 Budiono Budiono,1 Sulastyawati Sulastyawati1 1Department of Nursing, Politeknik Kesehatan Kemenkes Malang, Malang, Indonesia; 2Prima Husada Hospital, Malang, Indonesia Abstract Chronically elevated blood pressure was a prominent risk fac- tor for cardiovascular diseases. The management of hypertension, especially in community settings, should combine pharmacologi- cal and non-pharmacological interventions. This study aimed to evaluate whether music-assisted progressive muscle relaxation (PMR) using Gamelan, Javanese classical music, could reduce blood pressure more effectively in hypertensive elderly individu- als in Malang, Indonesia, than PMR alone. This study employed a pre-test and post-test study design with a control group. Fifty- eight respondents were randomly assigned to the intervention group (n=31) and the control group (n=27). Three respondents in the control group did not complete the study; thus, they were excluded from the analysis. The intervention group was trained and guided to perform PMR while listening to Gamelan. Meanwhile, the control group only received PMR. The interven- tion was conducted twice a week for 20 minutes for eight weeks. Dependent variables in this study were systolic and diastolic blood pressure, which were measured using an aneroid sphygmo- manometer. Data were analyzed using descriptive statistics, paired t-tests, independent t-tests, and Mann-Whitney test. We found a significant decrease in systolic and diastolic blood pressure in both groups. A Mann-Whitney test showed that there was a signif- icant difference in the reduction of systolic blood pressure in the intervention group compared to the control group (p=0.000). Meanwhile, the independent t-test showed that the diastolic blood pressure in the intervention group reduced more significantly than that in the control group. The efficacy of Gamelan-assisted PMR in significantly reducing both systolic and diastolic blood pressure showcases the potential of such combined interventions in manag- ing hypertension. We recommend Gamelan-assisted PMR as a complementary therapy for the elderly with primary hypertension. Introduction Elevated blood pressure is a significant risk factor for critical diseases, including heart, kidney, and cerebral diseases, as well as many other serious conditions.1 The incidence of hypertension is consistent with trends related to increasing age span and life expectancy.2 Recent studies have found that hypertension increas- es the risk of poor outcomes in patients with COVID-19. Globally, hypertension affects 1.13 billion people, with two-thirds of them residing in underdeveloped and developing countries.3 Globally, hypertension affects 1.13 billion people, with two-thirds of them residing in underdeveloped and developing countries.4 In 2018, approximately 34.1% of Indonesians aged over 18 years had hypertension, and only 54.4% of them had adequately controlled blood pressure.5 Although hypertension is commonly asymp- tomatic, it can cause complications that account for about eight million deaths each year, 88% of which occur in underdeveloped and developing countries.6 Hypertension is generally asymptomat- ic and goes unnoticed, but sometimes patients report dizziness, headaches, nosebleeds, chest pain, and palpitations.7 Behavioral risk factors for hypertension are well-studied. These factors include physical inactivity, regular alcohol con- sumption, tobacco use, caffeine intake, and stress.8–11 In older peo- ple, physiological changes in the blood vessels increase the risk of primary hypertension, especially in individuals who lack physical activity.7 The management of hypertension, especially in commu- Correspondence: Ira Rahmawati, Department of Nursing, Politeknik Kesehatan Kemenkes Malang, Malang, Indonesia. E-mail: irarahmawati.polkesma@gmail.com Key word: progressive muscle relaxation; javanese classical music; gamelan; hypertension; music-assisted PMR. Contributions: IR, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; FA, conceptualization, investigation, and writing – original draft, review and editing; BD, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; SL, methodology, visualization, writing – review & editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Research Ethics Commission, Politeknik Kesehatan Kementerian Kesehatan Malang (State Polytechnic of Health) Malang based on ethical certificate Number 546/KEPK-POLKESMA. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non- maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 15 September 2023. Accepted: 22 November 2023. Early access: 14 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11814 doi:10.4081/hls.2023.11814 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11814] [page 41] Non -co mmerc ial us e o nly nity settings, should encompass both pharmacological and non- pharmacological interventions.12 In general, hypertension treat- ment involves the use of a class of drugs that block the angiotensin-converting enzyme, calcium channel blockers, diuret- ics, beta-blockers, alpha-blockers, and angiotensin II receptor antagonists.13 It has been proven that non-pharmacological inter- ventions can effectively control blood pressure, so these interven- tions should be considered a complement to pharmacological ther- apies.14 In addition, the use of antihypertensive drugs to manage hypertension has not proven to be efficacious due to the long-term side effects of these drugs. A study has revealed that the use of Angiotensin-converting enzyme (ACE) inhibitors, which are com- monly prescribed antihypertensive drugs for the elderly with hypertension, can significantly increase the risk of new-onset osteoporotic fractures (NOF)15. Studies have also found that the incidence of new-onset osteoporotic fractures (NOF) and osteo- porosis had increased in patients with hypertension and chronic heart failure (CHF) who used loop diuretics.16,17 Due to the various adverse effects of drugs and the presence of drug-resistant hypertensive patients, non-pharmacological thera- pies should be widely implemented as adjuvants to classical thera- pies. Progressive muscle relaxation (PMR) is one of the oldest non-pharmacological interventions for reducing blood pressure in hypertensive patients. However, this exercise has not been routine- ly implemented in community health care as part of the manage- ment of patients with hypertension. PMR decreases muscle ten- sion, blood pressure, and anxiety in both patients and healthy indi- viduals by reducing sympathetic nervous system activity. Studies have suggested that a combination of two or more non-pharmaco- logical methods is more effective in achieving goals than individ- ual therapy.18,19 Studies have found that music can have beneficial effects on blood pressure.20–22 However, most studies included a broad range of ages and exclusively used Mozart classical music.23 Only a few studies have been conducted to analyze the effect of music on blood pressure in the pre-elderly and elderly population, especially in Indonesian settings. Therefore, research is needed to understand music preferences among pre-elderly and elderly indi- viduals in Indonesia and whether it could help control blood pres- sure among hypertensive elderly patients. Gamelan is one of Indonesia’s traditional music forms that is famous and appreciated, especially among Javanese older people. In this study, we aim to investigate whether a combination of PMR and Gamelan music has more positive effects on blood pressure and therapy adherence in hypertensive elderly patients compared to PMR alone. Materials and Methods This experimental study employed a pre-test and post-test study design and was conducted in Krajan Village, Malang District, from July to November 2022. Elderly individuals with primary hypertension who met the inclusion criteria and willingly participated in this research were recruited. All the respondents were regular members of The Integrated Development Post Program, known as posbindu in Indonesia, a facility that provides community health services for the elderly in Krajan Village. The inclusion criteria in this study include people aged above 45 years old, diagnosed with primary hypertension, fully conscious, and able to communicate. Elderly individuals with significant health problems such as heart diseases and chronic kidney diseases were excluded from this study. Initially, a total of 58 respondents partic- ipated in this study and were randomly assigned to the intervention and control groups. The intervention group comprised 31 respon- dents were initially assigned to the intervention and control groups, with the intervention group comprising 31 individuals who received a combination of progressive muscle relaxation and Gamelan Javanese music, while 27 in the control group received only progressive muscle relaxation therapy. Three respondents in the control group did not complete the intervention, so they were excluded from the statistical analysis. The control group received only progressive muscle relaxation therapy. The instruments used in this study included MP3 Players and headphones for listening to Gamelan music, an aneroid sphygmomanometer and stethoscope for measuring blood pressure, and scoring sheets for recording blood pressure measurements. Each respondent in the intervention group was trained and guided to perform progressive muscle relax- ation while listening to Gamelan, Javanese classical music, twice a week for 20 minutes over eight weeks. Meanwhile, the control group was trained and guided with the same technique but without Gamelan music. Each intervention session lasted about 30 min- utes. In addition, respondents were instructed to independently perform PMR and musical therapy every day for eight weeks on their own. The independent variables in this study were PMR and Gamelan music, while the dependent variable was blood pressure. Blood pressure was measured before and after the interventions by a registered nurse using an aneroid sphygmomanometer and a stethoscope. Ethical approvals were obtained from Politeknik Kesehatan Kementerian Kesehatan Malang (State Polytechnic of Health) in Malang with ethical certificate Number 546/KEPK- POLKESMA. All participants signed a consent form to participate in this study. Data were analyzed using IBM SPSS Statistics 25. Demographic data were analyzed descriptively. A paired-sample t- test was conducted to compare systolic and diastolic blood pres- sure before and after interventions in each group. A Mann-Whitney test was used to compare the reduction in systolic blood pressure between the intervention group and the control group. Meanwhile, an independent t-test was performed to determine whether the reduction in diastolic blood pressure in the two groups was statis- tically significant (p<0.05; Figure 1). Results Characteristics of the respondents The majority of the respondents in the intervention group were female (77%), aged above 55 years old (74.2%), and had a family history of hypertension (83.9%), but only 19.4% of the respon- dents were active smokers. Similar to the intervention group, most of the respondents in the control group were female (79.1%), aged above 55 years old (83.3%), had a family history of hypertension (79.1%), and were non-smokers (83.3%). All of the respondents in the intervention group completed the interventions for eight weeks with zero dropout rates. Meanwhile, three respondents in the con- trol group did not complete the study for eight weeks, resulting in an 11% dropout rate. The demographic data of the respondents are shown in Table 1. Table 2 reveals a noteworthy reduction in both systolic and diastolic blood pressures within the intervention group, registering substantial declines of 18.87 and 14.44, respectively, following an eight-week intervention period. In contrast, the control group exhibited more modest decreases, with systolic and diastolic blood pressures diminishing by 6.56 and 4.06, respectively, over the Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 42] [Healthcare in Low-resource Settings 2024;12:11814] Non -co mmerc ial us e o nly same eight-week treatment period. A comprehensive overview of these findings is presented in Table 3 for clarity and comparison. Mann-Whitney test was conducted to compare the difference in the reduction of systolic blood pressure between the intervention and control groups. The results of this test are presented in Table 3. The difference in the reduction of diastolic blood pressure between the intervention and control groups was tested with the independent t-test. The results of this test are presented in Table 4. Asymp. Sig. (2-tailed) of 0.000<0.05 indicates a significant differ- ence in diastolic blood pressure reduction between the intervention and control groups (p<0.05). Discussion This study showed that blood pressure reduced by 18.871 mmHg (systolic) and 14.452 mmHg (diastolic) among respondents who received PMR while listening to Gamelan music. Meanwhile, in the group who only received PMR, the systolic blood pressure dropped by 6.583 mmHg, and diastolic blood pressure dropped by 5. mmHg. Similar studies have revealed that progressive muscle relaxation reduced blood pressure in hypertensive respondents by 5.1 mmHg (systolic) and 3.6 mmHg (diastolic) after a four-week intervention of daily 30 minutes PMR18,24 and 24.54 mmHg (sys- tolic) and 16.54 mmHg (diastolic) after seven days of daily PMR25. In the latter, the respondents were also taking daily antihyperten- sive drugs. Progressive muscle relaxation is a well-known non- pharmacological intervention for reducing stress, anxiety, and excessive tension in the body. Progressive muscle relaxation is total relaxation that achieved by contracting and relaxing various muscles in the body.26 These activities may lower blood pressure Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of the respondents. Characteristics Intervention group Control group (n = 31) (n=24) No % No % Sex Male 7 22.6 5 20.8 Female 24 77.4 19 79.1 Age 45-55 8 25.8 4 16.6 56-60 13 41.9 9 37.5 61-65 10 32.3 11 45.8 Currently Smoking Yes 6 19.4 4 16.6 No 25 80.6 20 83.3 Family history of hypertension Yes 26 83.9 19 79.1 No 5 16.1 5 20.8 Table 2. Comparison of mean blood pressure before and after interventions in the intervention and control groups. Groups Variables Pre-intervention Post intervention Mean Sig Mean SD Mean SD difference (2- tailed) Intervention group Systolic blood pressure 163.71 12.039 144.84 10.605 18.871 0 Diastolic blood pressure 96.71 5.599 82.26 6.434 14.452 0 Control group Systolic blood pressure 151.25 6.456 144.67 7.631 6.583 0.001 Diastolic blood pressure 92.21 4.818 86.71 4.506 5.500 0.004 Figure 1. Flow of the intervention. [Healthcare in Low-resource Settings 2024;12:11814] [page 43] Non -co mmerc ial us e o nly by reducing sympathetic nervous activity in response to a decrease in the secretion of corticotropin-releasing hormone (CRH) and adrenocorticotrophic hormone (ACTH) by the hypothalamus. This results in a reduced heart rate, vasodilated blood vessels, decreased respiration and metabolic rate, and lower blood pressure.24,27,28 Systolic and diastolic blood pressure significantly reduce when progressive muscle relaxation is combined with another relaxation technique, such as musical therapies. A study that combined the effects of PMR and musical therapy using a piece of instrumental music, showed that systolic blood pressure reduced by as much as 29.2 mmHg, and diastolic blood pressure was lowered by 16.2 mmHg.18 However, in this study, the dropout rate was high (20.6%). In our study, we combined PMR with Gamelan, which is one of the famous traditional music forms in Indonesia. The dropout rate in our study was zero, which could be influenced by the type of music we chose. All the respondents in this study were Javanese older adults, who might be more familiar with and prefer Gamelan over other types of relaxing music. Listening to their pre- ferred musical instrument brings greater benefits to the respon- dents and improves their hemodynamic status.29,30 Studies have shown that music therapy has beneficial effects on patients’ physical and psychological outcomes in various clini- cal settings.22,31,32 However, not all types of music can effectively improve the hemodynamic and psychological status of the respon- dents.33 Several studies have shown no statistical difference in the reduction of blood pressure between respondents who receive music therapy and those who only rest.33,34 Music that might posi- tively affect cardiovascular parameters includes classical music because it is associated with calm and relaxation. Musical pieces chosen by or more familiar to respondents are often more effective and can lead to positive hemodynamic changes.35,36 To produce positive changes, music therapy should be played in a quiet envi- ronment for a minimum of 20-25 minutes for at least four weeks.37 Listening to music activates the hypothalamus and nucleus accum- bens (NAc), which are two of the main brain areas involved in pro- cessing rewarding and pleasure-evoking stimuli, resulting in increased pleasure response and changes in heart rate and respira- tion rate.38 Music therapy might also decrease the activity of the sympathetic nervous system and stimulate endorphin release.39 Furthermore, a study investigating the effect of music on blood pressure found that exposure to classical music increased serum calcium levels and brain dopamine synthesis, which reduced blood pressure.40,41 Indeed, music therapy is one of the non-pharmacolog- ical interventions that can be used to help reduce blood pressure with low cost and minimal side effects.42 Our study found a statistical difference in the reduction of sys- tolic and diastolic blood pressure between the respondents who received a combination of PMR with musical therapy using Gamelan compared to the control group who only received PMR (Tables 3 and 4). Several studies have suggested that combining PMR with other non-pharmacological therapies has better effects on the respondents’ outcomes, such as decreasing stress, enhancing academic performance, reducing chronic pain and fatigue, and improving coping styles.19,43,44 This study shows that Gamelan- assisted PMR can effectively reduce the blood pressure of hyper- tensive elderly individuals. This result is similar to that of another study which combines PMR with classical music therapy.18 Music- assisted PMR should be regularly provided to the respondents to help maintain their blood pressure within the normal range. Additionally, the choice of instrumental music used should be relaxing and familiar to the respondents. This study has several limitations. We employed a relatively small sample size, which may limit the generalizability of the study. Further studies with a large sample size and multi locations are needed to ensure the quality of the study. Conclusions This study was the first to investigate the effect of music- assisted progressive muscle relaxation using Javanese classical music to reduce the blood pressure of Javanese elderly individuals. We discovered that respondents receiving Gamelan-assisted PMR had better outcomes in blood pressure than those only receiving PMR. Based on the result of this study, it is recommended that health workers or other medical personnel can apply music Gamelan therapy regularly as adjuvant therapy in managing hyper- tensive older patients, especially in community settings. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 3. Difference of systolic blood pressure reduction between the two groups. Statistics testa Systolic blood pressure Mann-Whitney U 65.500 Wilcoxon W 561.500 Z -5.209 Asymp. Sig. (2-tailed) 0 aGrouping Variable: Group. Asymp. Sig. 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