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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE Mr.GURULINGAPPA S. MANTHALE

AND ADDRESS M.Sc. NURSING I ST YEAR,

NOOR COLLEGE OF NURSING


BOOPASANDRA, BANGALORE

2. NAME OF THE INSTITUTION NOOR COLLEGE OF NURSING


BOOPASANDRA BANGALORE

3. COURSE OF STUDY AND M.SC NURSING IST YEAR


SUBJECT MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION TO 1.10.2009


THE COURSE

5. TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECT OF


PROGRESSIVE MUSCLE RELAXATION ON
BIOPHYSILOGICAL PARAMETERS AMONG
PATIENTS WITH HYPERTENSION IN
SELECTED HOSPITALS AT BANGALORE”

6. BRIEF RESUME OF THE INTENTED WORK

1
INTRODUCTION
Hypertension is the most common continuing medical condition and the
biggest single health problem tackled by nurses in the medical surgical and community health
nursing set up.2 It is a worldwide epidemic with an estimated 690 million people having high
BP.1 The number of people who need some sort of treatment for high BP include at least 10%
of any large group of adults, up to 33% of poorer city adults and about 50% of all people over
65 years of age. High blood pressure itself is not a disease but a reversible risk factor and
treatable cause of the serious diseases like coronary heart disease, heart failure, stroke,
bleeding or detachment of the retina and renal failure2.

The word ‘hypertension’ is used in medical jargon with exactly the same meaning as
‘high blood pressure’. The word ‘hypertension’ comes from translating the French phrase
‘tension arterielle’. This originally referred to not the tension in the mind (stress) but to the
tension (stretching) in the walls of the arteries. 2 High BP means the heart is working harder
than normal, putting both the heart and the blood vessels under strain. Systolic blood
pressure is the pressure in the arteries when the heart beats or pumps and the diastolic BP is
the pressure in the arteries when the heart is resting between beats. Blood pressure is
considered elevated when systolic pressure reaches or exceeds 140 mm of Hg and diastolic
pressure reaches or exceeds 90 mm of Hg.1

Primary or essential hypertension is elevated BP without an identified cause and


accounts for 90% to 95% of all cases of hypertension. 4 Secondary hypertension is elevated
BP with a specific cause that often can be identified and corrected. This accounts for 5-10%
of hypertension in adults. Hypertension is more prevalent in men than in women until age
55; after age 55, it is more prevalent in women than men. 8 Hypertension is often called the
‘silent killer’ because people with hypertension are often symptom free.3

It has now been recognized that hypertension is a global problem posing a major
public health challenge to societies in socio-economic and epidemiological trasition. 4
Industrialization, urbanization and related stress have contributed a lot to the increase in the
incidence of this silent killer. In our fast paced and hectic lives where people miss the
opportunity to take a breath and relax really, hypertension has become a way of life
dependent on regular medication and visits to doctors for routine check-ups. This is a great
challenge to the medical world. Hypertension by itself tends to evoke anxiety and concern
about the dreadful consequences when the diagnosis is revealed. 5 Although stress can raise

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BP on a short term basis and has been implicated in the development of hypertension,
controversy exists as to the benefit of stress management in the prevention and treatment of
hypertension.6

The past few years have witnessed an increased interest in non-pharmacological


treatment approaches to essential hypertension. The management of mild elevations of BP
can be achieved by non-pharmacological measures. In traditional or modified form,
relaxation training had been the focus of more clinical and research attention, for a long
period of time. Relaxation strategies have been used for centuries as integral components of
major philosophical theological and therapeutic traditions. Their current use, stems primarily
from the work of Edmund Jacobson.7

In the early 1930s, Jacobson conducted the first psycho physiological study of
relaxation. He found that when subjects deeply relaxed their skeletal muscles, they would not
show a normal startle response to a loud noise. Later Jacobson developed a technique called
‘Progressive Relaxation’ which was designed to bring about a deep state of muscle relaxation.
He believed that such a state could reduce arousal in both the central nervous system and the
autonomic nervous system and as a result could restore or promote psychological and
physical well-being.7

This view was consonant with the then popular James-Lange theory of emotion,
which held that there was a close and interactive relationship between bodily states (eg:
muscle tension) and emotional states (eg: feelings of anxiety). Thus it followed that by
reducing skeletal muscle tension, a person could reduce anxiety and its negative
consequences.7

In the 1950s, progressive relaxation characterized by an active approach to relaxation,


had emerged as the technique of choice over other passive forms of relaxation. 7 Another
major influence on the development of relaxation techniques was the demand for quicker and
more cost-effective methods of teaching, relaxation. As a result an astonishing array of ‘self
help’ approaches to relaxation emerged, including a large number of self-help manuals and
audio-cassette programs. Progressive relaxation is the most popular relaxation procedure
used, due to the historical developments noted above.7

Clients are much more likely to practice relaxation training and to cooperate with the
therapist because they understand why they are learning the technique and what benefits they

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are likely to experience from its regular use.7 The Progressive Muscle Relaxation of Dr.
Edmund Jacobson (JPMR) is a systematic technique for achieving a deep state of relaxation.
He discovered that a muscle could be relaxed by first tensing it for a few seconds and then
releasing it. JPMR consists of learning to tense and then relax various muscle groups
throughout the body, while at the same time paying very close attention to the feelings
associated with both tension and relaxation. This helps to produce a deep state of relaxation,
which Dr. Jacobson found capable of relieving a variety of conditions, such as high blood
pressure, migraine headaches, ulcerative colitis backaches and insomnia. The regular practice
of JPMR can go a long way towards helping one to better manage one’s anxiety and feel
better all around. It also helps to acquire skills to gain control of one’s life and to take up the
challenges of the ever-changing society.

6.1 NEED FOR THE STUDY

Hypertension is a killer disease of the modern civilized society. High blood pressure
is estimated to cause 7 million deaths annually accounting for 13% of all deaths globally.
Hypertension accounts for one in eight deaths in the world.26 Overall 26.4% (972 million) of
the world adult population was estimated to have hypertension in the year 2000, a figure that
is projected to increase to 29.2% (1.56 billion) by the year 2025.27

Hypertension is the most common risk factor for cardiovascular and cerebrovascular
diseases in the developed and developing countries, resulting in disability and increased
health care system costs.21,22 WHO has estimated that about 62% of cerebrovascular disease
and 49% of ischaemic heart disease burden world wide are attributed to suboptimal BP level
(SBP>115mm Hg).26 In the developing countries like India, high BP is a much more serious
problem than in the developed countries, with very high rates for stroke and corresponding
burdens of care for these populations. Hypertension is directly responsible for 57% of all
stroke deaths and 24% of all coronary heart disease deaths in India. 25 WHO has estimated
that one in every three deaths in India is due to heart disease and hypertension has been
established as the key risk factor for this growing menace.

Pooling of epidemiological studies shows that hypertension is present in 25% urban


and 10% rural population in India. The same study estimated that there were about 66
million hypertensives in India (32 million rural and 34 million urban). 9 About one in every 4
Indian adults over 50 years has high BP. Among all types of hypertension, 90% to 95% is

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essential hypertension.3 A total of 70% of these would be stage I hypertension (systolic BP :
140-159 and/or DBP: 90-99 mm Hg). Recent reports show that this stage hypertension carry
a significant cardio vascular and cerebrovascular risk and there is a need to reduce this BP.
Population based cost-effective hypertension control strategies should be developed.25

Research studies show that at every level of blood pressure, higher BP means a higher
eventual risk of stroke, heart attacks and other circulation problems. 2 Accordingly, helping
patients with high BP to understand all about the problem and to manage their hypertension is
an extremely important function of nurses.5

Currently, non-pharmacological means of managing hypertension is gradually


developing, the most common being relaxation. “R...E…L…A…X!” is an admonition
commonly heard by people with hypertension. Relaxation can adjust the reaction of the
hypothalamus to the parasympathetic nerves, which allows the body to decrease heart beat,
rate, blood pressure, metabolism and respiration rate, as well as reduce oxygen consumption
and muscle tension. This allows the body to maintain a healthier and more balanced state,
while also allowing patients to achieve mental calmness. 10 Jacobson11 also indicated that
relaxation can decrease neural reflex function, which reduces skeleto-muscular neural input
and output activity. Consequently, autonomic nervous activity is reduced. Therefore,
relaxation must be considered in the treatment of patients with hypertension and
cardiovascular diseases.

Hypertension by itself tends to evoke anxiety and concern about the dreadful
consequences when the diagnosis is revealed.5 Stress is a modifiable risk factor for
hypertension.23 Teaching patients stress management techniques effectively reduce stress and
therefore blood pressure.24

There are many ways of achieving relaxation. Jacobson’s Progressive Muscle


Relaxation (JMPR) is a simple and easily learned technique for relaxation and has resulted in
the greatest effects on behavioral and self report measures of relaxation.

Many empirical studies have used JPMR in various populations with beneficial
physiologic effects. For example, PMR effectively reduces heart rate, pulse rate, 12,13 systolic
BP12,13,14,15,17 and diastolic BP12,13,14,15,17 in hypertensive patients.

A study was conducted to examine the effect of PMR on blood pressure and
psychosocial status for clients with essential hypertension in Taiwan. PMR training had an

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immediate effect, reducing pulse rate 2.35 beats/min, systolic BP 5.44 mm Hg and diastolic
BP 3.48 mm Hg. PMR significantly lowered patients’ perception of stress and it enhanced
their perception of health.12

PMR also reduces respiratory rate,16 headache, pain and seizure frequency (in epilepsy
patients) and improve lung parameters.17 PMR was also found to be effective for the
maintenance of natural killer cells.13 In hypertensive patients it can eliminate the need for
second hypertension medication and decrease adrenalin concentration and oxygen
consumption.15

Even small reduction in BP can have large clinical effects. A decline in population
diastolic BP of 5 mm Hg and in systolic BP of 9 mm of Hg would reduce strokes by one-third
and coronary events by approximately one-fifth. Reduction in diastolic BP of 5-6 mm Hg
resulted in 42% reduction in stroke, 14% decrease in heart disease and 21% reduction in
vascular mortality in drug trials. Mean reduction of only 2 mm Hg lowers stroke risk by 15%
and heart disease risk by 6%. This would have major impact on public health and explains
the increasing interest in non-pharmacological method of BP control.18

Stress is a state of tension. Relaxation is a state opposite to stress. So progressive


relaxation using Jacobson’s technique is one of the most effective methods of dealing with
stress. The secret of JPMR is in the relation between negative emotions and muscle tension.
Negative emotions like fear, anxiety, uneasiness, panic and irritation can always cause
muscular tension. This relation of stress and muscular stress, is so strong that if one learns to
get rid of the excessive muscular tension, he will know how to reduce the intensity of
stressful emotions.

Many empirical studies found beneficial psychological effects of PMR in various


populations. In hypertensive patients, PMR reduces the patients’ perception of stress and it
enhances perception of health.12 It decreases the symptoms of stress,13 anxiety,16 and improves
generic quality of life in cancer patients 16. PMR significantly reduces anger level 17 and
enhances psychological health16 and health-related quality of life.17

The researcher during her clinical experience has noticed that the anti-hypertensive
therapy which is costly, demands careful monitoring and frequent adjustment and produces
troublesome side effects for a high proportion of the population and for the remainder of their
lives. The major side effects are renal dysfunction, GI upsets, fluid and electrolyte

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imbalances, sexual dysfunction, menstrual irregularities, hypotension (orthostatic),
bronchospasm and cardiac arrythmias.1 Side effects and adverse effects of antihypertensive
drugs may be so severe or undesirable that the patient does not comply with the therapy. 1
High cost of anti hypertensive is yet another reason for poor compliance with the prescribed
treatment plan.

Behavioral interventions like PMR may decrease or eliminate the need for drug
therapy in hypertensive patients. PMR being a cost-effective intervention, requiring
minimum training and no elaborate equipment can be easily offered to the patients for daily
home-practice. So the investigator was interested and motivated to undertake the present
study.

The researcher believes that she could evaluate the effectiveness of the BP control
strategy like JPMR in reducing BP and health related stress, of hypertensive patients

6.2 REVIEW OF LITERATURE

A literature review is a compilation of resources that provides the ground work for the
study. It helps with the conceptualization of research problems and the determination of
specific methodology to be used for further exploration of the problems.

Thus, review of literature is an essential step in the development of a research project.


It helps the researcher to design the proposed study in a scientific manner so as to achieve the
desired result. It helps to determine the gaps, consistencies and inconsistencies in the
available literature about a particular subject under the study.

This chapter attempts to present a review of studies done, methodology adopted and
conclusions assured by earlier investigators, which help to study the problem in depth. The
sources to obtain more information on the selected topic were internet search, textbooks,
published journals, editorials, conference proceedings and published and unpublished thesis

A study was conducted in Jaipur to determine the changing trends in the prevalence of
hypertension and mean blood pressure levels in India and to study the urban and rural
differences. A meta- analysis of all available epidemiological studies was performed. Trend
analysis of comparable studies among urban areas (N=10) showed a significant increase in
the prevalence of hypertension (P=0.014). The studies in rural areas (N=14) also showed an
increase in the prevalence of hypertension although the rise was not as steep as that in urban

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populations (p=0.097). The meta-analysis concluded that, in India, hypertension is emerging
as a major health problem and is more in urban subjects than in rural subjects.

An analysis of worldwide data to asses the global burden of hypertension was done by
the department of Epidemiology, Tulane University school of public Health, USA. Data was
pooled from different regions of the world to estimate the overall prevalence and absolute
burden of hypertension in 2000, and to estimate the global burden in 2025. They searched the
published literature from Jan 1, 1980, to Dec 31, 2002, using MEDLINE supplemented by a
manual search of bibliographies of retrieved articles. All data were obtained independently by
two investigators with a standardized protocol and data collection form. The results showed
overall, 26.4% of the adult population (26.6% men and 26.1% women) in 2000 had
hypertension, 29.2% (29% men and 29.5% women) were projected to have this condition by
2025. The study interpreted that hypertension was an important public health challenge world
wide. Prevention, detection, treatment and control of this condition should receive high
priority.

A study was conducted in India by searching the MEDLINE, EMBASE, and INDMED
databases from 1940-2005 to obtain prevalence studies on hypertension in Indian population.
In a study done by Gopinath and Chadha et al, in 1987, the prevalence of hypertension in
Delhi (criteria 160/90) was found to be 11% among males and 12% among females in
urban areas and 4% and 3% respectively in rural areas.36 In the ICMR study in 1994 involving
5537 individuals (3050 urban residents and 2487 rural residents) demonstrated 25% and 29%
prevalence of hypertension (criteria 140/90 mm Hg) among males and females respectively
in urban Delhi and 13% and 10% in rural Haryana. A study by Gupta R from Jaipur, through
3 serial epidemiological studies (Criteria:>=140/90 mm of Hg) carried out during 1994,2001,
and 2003 demonstrated rising prevalence of hypertension (30%, 36%, and 51% respectively
among males and 34%, 38% and 51% among females). A study conducted in the urban areas
of Chennai during 2000 (age group 40yrs) reported a higher prevalence of hypertension
(54%) among low income group (monthly income <Rs. 30,000/annum) and 40% prevalence
among high income group (monthly income >Rs. 60,000/ annum).

A study was conducted in Jaipur to assess the trends in hypertension epidemiology in


India. The results showed that cardiovascular diseases caused 2.3 millions deaths in India
during the year 1990 ; this is projected to double by the year 2020. Hypertension is directly
responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in

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India.25 Recent studies using revised WHO criteria (BP 140 and / or 90 mm Hg) have shown
a high prevalence of hypertension among urban adults: men 44%, women 45% in Mumbai ;
men 31%, women 36% in Thiruvananthapuram; 14% in Chennai ; and men 36%, women
37% in Jaipur. Among the rural populations, hypertension prevalence in men 24%, women
17% in Rajasthan. Pooling of epidemiological studies show that hypertension is present in
25% of urban 10% of rural subjects in India.25

A study was conducted in Dekalb to evaluate the effects of PMR on blood pressure of
hypertensive clients. After collection of baseline data, 22 clients received group relaxation
training followed by individual monitoring sessions over a 6 week period, while 22 persons
in the control group did not receive relaxation training. The group instructed in relaxation had
a lower mean systolic BP (p<0.05) than the non-trained group at 4 months follow-up. While
the relaxation trained group showed a significant decrease (p<0.02) in diastolic pressure
from baseline to follow-up, the difference between trained and non-trained groups at follow-
up was not significant (p=NS). Relaxation taught initially in group with individual follow-up
visits, resulted in continued practice of relaxation and subsequent lowering of blood pressure
in subjects with essential, uncomplicated hypertension.

In Hong-Kong, an empirical work examined, the effects of three relaxation therapies


for the reduction of high blood pressure in nine Chinese subjects. Subjects were randomly
assigned to three groups: (a) Progressive muscle relaxation (b) Stretch Release Relaxation(c)
Cognitive imagery relaxation. Systolic and diastolic blood pressure and heart rate were
assessed in a baseline session, the 8 th post – treatment session and a 30-days follow-up
session. Data were analyzed using ANOVA and paired sample t-test. Results revealed that in
the context of the study all relaxation therapies can reduce blood pressure in Chinese
subjects, but stretch release relaxation and PMR therapies appeared to be more effective in
lowering blood pressure compared to cognitive imagery relaxation.

A study was conducted in Korea to assess the effectiveness of the thermal biofeedback
training combined with the progressive muscle relaxation therapy in the treatment of patients
with essential hypertension. Blood pressure decline was measured on the treatment group
who had the combined thermal biofeedback and progressive muscle relaxation training
(N=11) and on the control group who had only progressive muscle relaxation training (N=8).
Baseline blood pressure was measured four times for two weeks on both groups. For the
treatment group, blood pressure was measured twice before and after each of eight sessions

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of thermal biofeedback training for four weeks. For the control group, BP was measured
before and after the PMR self-training, during the visits to a clinic. A significant decline of
the systolic BP by 20.6 mm Hg and of the diastolic BP by 14.4 mm Hg was observed in the
treatment group (p<0.05).

A study was conducted in Bavaria to examine the efficacy of PMR on change in blood
pressure, lung parameters and heart rate in female adolescent asthmatics. In this prospective,
randomized, double – blind, controlled study the subjects (N=31) were tested to find out how
the systolic BP (SBP), forced expiratory volume in the first second (FEV 1), peak expiratory
flow (PEF) and heart rate change after PMR. The control group (N=30) received a placebo
intervention. The results of the study revealed that a significant reduction in SBP (p<0.01)
and a significant increase in the FEV1 (p<0.05) and PEF (p<0.01) were observed after PMR.
In the PMR group, mean SBP reduced from 125.39.4 to 110.67.8 and in the control group
mean SBP reduced from 126.98.8 to 124.39.3. Hence it can be concluded that PMR is
effective in the improvement of blood pressure, lung parameters and heart rate in adolescent
female asthmatics.

In Hong Kong (united Xian Hospital) a study was done to evaluate and
compare two different behavioral rehabilitation programs in improving the quality of life in
cardiac patients. Convenience sampling with referral from the cardiac specialty was used in
the study. A total of 65 subjects aged 42-76 years, were alternatively allocated to the 2
groups. The first group of patients were given instructions and practiced on PMR. The second
group of patients underwent training in ‘qigong’. A total of 8 sessions were conducted and
each session lasted for 20 minutes. The findings show that 59 subjects (44 men and 15
women) completed all eight rehabilitation sessions in the study. Patients allocated to the
treatment groups had comparable baseline characteristics. Progressive relaxation was more
effective in reducing blood pressures compared to qigong. In the PMR group SBP reduced
from 124.8117.45 to 113.0315.47 (p=0.000) and DBP from 64.1011.53 to 59.239.48
(p=0.024). Relaxation appeared to be particularly beneficial in somatic domains. Qigong
group demonstrated greater improvement in psychologic measures in addition to reduction in
SBP. PMR also reduced state and trait anxiety (p<0.05). Hence, it can be concluded that the
progressive relaxation and qigong exercise improved the quality of life for cardiac patients

6.3 STATEMENT OF THE PROBLEM

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“A study to assess the effectiveness of progressive muscle relaxation on
biophysilogical parameters among patients with hypertension in selected hospitals at
bangalore”

6.4 OBJECTIVES

1. Assess the bio-physiological parameters among patients with hypertension.


2. Determine the effectiveness of progressive muscle relaxation on the bio-physiological
parameters among patients with hypertension.

6.5 OPERATIONAL DEFINITIONS

Effectiveness

Impact of progressive muscle relaxation on the bio-physiological parameters

Progressive Muscle Relaxation

It is a systematic technique for achieving a deep state of relaxation in which one will
alternatively tense and relax the specific group of muscles

Bio-physiological parameters

`It includes pulse rate, respiratory rate, blood pressure, head ache and
discomfort.

Patients

In the present study ‘patients with hypertension’ refers to those patients in the
age group of 40-70 years, who are diagnosed to have hypertension and are admitted in
the selected hospital for the treatment of high blood pressure

Hypertension

It refers to systolic pressure greater than 130 mm of hg and diastolic greater


than 90 mm of hg

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6.6 Hypothesis

There is a significant change in bio physiological parameters among patients


with hypertension who receives progressive muscle relaxation

6.7 Assumptions

 Progressive muscle relaxation is a cost-effective technique of stress management and

blood pressure control.

 Progressive muscle relaxation may have impact on bio physiological parameters

6.8 Delimitations

 The study is delimited to hypertensive patients

 The study is delimited to 4-6 weeks

7.0 RESEARCH METHODOLOGY

Source of data

Patients with hypertension in selected private hospitals at Bangalore.

Research Approach

Evaluative research approach.

Research Design

Pre experimental one group pre and post test research design

Research Setting

The study will be conducted in selected private hospitals at Bangalore

Population

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The investigator had identified the target population included both male and female
patients who were diagnosed to have hypertension in selected private hospitals at Bangalore

Sample

Patients with hypertension admitted in private hospitals.

Sample size

A total of 30 patients, both males and females

Sampling technique

For the present study the patients were selected using convenience sampling technique.

Criteria for Sample Selection

Inclusion criteria

a. Patients with hypertension.


b. Male and female in the age group of 30- 70 years.

c. Who are willing to participate

d. Patients who can speak, read, write kannada or English

Exclusion criteria

a. Patients who had difficulty in hearing.


b. Patient who were not willing to participate.

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Description of the tool

The tool of the study has two sections

Section A Demographic variables

Section B Tools used to measured bio-physiological parameters.

Section A

Consists of questionnaire to collect the demographic data which includes age, sex,
habitance, educational status, occupation, marital status, religion, income, family history of
cancer, number of children, type of family.

Section B

Consists of an observational check list on the bio-physiological parameters. pulse,


respiration and blood pressure were checked at 30 and 45 minutes after initiating
chemotherapy with the standardized instruments. Discomfort measured using seven point
discomfort scale.

Data collection procedure

The formal permission will be obtained from the hospital authority. The method and
purpose of the study will be explained to the study participants. A total of 30 samples will be
selected by convenience sampling technique. Progressive muscle relaxation technique will be
thought to study samples. Pre test will be done on physiological parameters followed by
pretest progressive muscle relaxation will be given as intervention for the study samples. Post
test will be conducted after the intervention.

Statistical Analysis

The data obtained will be analyzed in terms of objectives of the study, using
descriptive and inferential statistics.

7.3 Does the study require any investigation or intervention on patients or other
humans/ animals? If so please describe briefly

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Yes. Progressive muscle relaxation will be given as intervention for the patients who are
diagnosed to have hypertension.

7.4 Ethical consideration towards sample related to study

Permission will be obtained from the concerned authority in the hospital. A


written consent will be obtained from the participants for their willingness to
participate in the study.

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Population. Indian Heart Journal 2006; 58: 21-27.

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GK et al. Prevalence, Correlates, awareness, treatment and control of Hypertension

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psychiatry and medicine. Medical Clinicals of North America. 1977;61(4):929-938.

7. Jacobson E. Progressive Relaxation. New York McGram – Hill : 1938.

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Blood pressure and Psychosocial status for Clients with essential Hypertension in

Taiwan. Holistic Nursing Practice, January 2003 ; 17(1): 41-47.

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Muscle Relaxation Predictive value of Indexes of sympathetic tone. Available from

URL:http://www.archinte ama – assn org/cgi/content.

12. Cheung YL, Molassiotiz A, Chang A.M. The effect of progressive muscle relaxation

training on anxiety and quality of life after stoma surgery in colorectal cancer

patients. European Journal of cancer care. Oct 2001; 10(2): 102-112.

13. Nickel C, Lahmann C, Muehlbacher M, Gil FP, Kaplan P, Buschmann W et al.

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controlled prospective trial. Psychotherapy and psychosomatics. 2006; 75(4) :

237-243.

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Electronic Source:

 www.pubmed.gov

 www.medline.com

 www.yahoo.com

 www.google.com

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9. Signature of the Candidate

10. Remarks of the Guide

11. Name and Designation

11.1 Guide

11.2 Signature

11.3 Co-Guide

11.4 Signature

11.5 Head of the Department

11.6 Signature

12. 12.1 Remarks of the Chairman and


Principal

12.2 Signature

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