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The meditative approach of concentration in alternative therapeutic treatments and its impact on health: a critical review 


Berghmans, Claude
PHD, Psychology
43 rue des gramin�es
57100 Thionville - France
T�l : 00.352.621.259 617
Email:  HYPERLINK "mailto:claude.berghmans@wanadoo.fr" claude.berghmans@wanadoo.fr


Abstract�:
Research carried out on meditation in health psychology within the psychotherapeutical context is increasingly important. A great deal of works actually underscore the positive effects of meditation both in terms of physical and psychical health. Within the framework of two important orientations of meditation techniques (concentration and mindfulness), this research is aimed at focusing on the so-called � concentration � meditation by leaving out the other forms of meditation (mindfulness, compassion) which have already led to numerous works. Once the notion defined from a theoretical perspective, we will get down to developing a review of literature using four data base (Medline, PsycINFO, Psyarticles et Science direct) based on 24 articles (randomized, before/after comparison) dealing with this form of practice by focusing especially on the transcendental and mantra meditations as well as other forms only requiring concentration in order to shed light on the therapeutical effects of this approach. However, we will be cautious about the result and avoid rushing to conclusions on the systematical positive effects of these pratices by pointing out the importance of the methodological limitations found all the time in the works. 
Key words�: Meditation, alternative therapy, mantra meditation, transcendental meditation

R�sum�:
Les recherches sur la m�ditation en psychologie de la sant�, dans le cadre psychoth�rapeutique sont de plus en plus importantes. En effet, beaucoup de travaux soulignent les effets b�n�fiques en termes de sant� physique et psychiques de la m�ditation. Dans le cadre de deux grandes orientations des techniques de m�ditation (concentration et pleine conscience), l�objet de cette recherche est de se focaliser sur la m�ditation dite de concentration en ne tenant pas compte des autres formes de m�ditation (pleine conscience, compassionnelle) qui ont donn�es lieux � de nombreux travaux. Apr�s avoir encadr� la notion � un niveau th�orique, et � l�aide des bases de donn�es Medline, PsycINFO, Psyarticles et Science direct, nous d�velopperons une revue de la litt�rature bas�e sur 24 articles (randomis�s, comparaison avant/apr�s) sur cette forme de pratique en ciblant pr�cis�ment la m�ditation transcendante et de mantra ainsi que d�autres formes utilisant uniquement la concentration afin de mettre en lumi�re les effets th�rapeutiques de cette approche. Cependant, nous resterons prudents quant � �mettre des conclusions h�tives sur les effets b�n�fiques syst�matiques de ces pratiques en mettant en lumi�re l�importance des limites m�thodologiques que l�on retrouve dans ces travaux.
Mots cl�s�: M�ditation, th�rapie alternative, mantra m�ditation, m�ditation transcendantale

Introduction

Since the 1970s, psychology and medicine have been interested in the therapeutic and psychotherapeutic approaches which owe their origins to eastern  cultures (Baringa, 2003). A large amount of research has focused on divers themes such as meditation, relaxation, the effects of Chinese medicine and ayruvedic, acupuncture and tai-chi to mention a few. Today, all of these approaches are grouped under the theme of medicine and complementary and alternative therapies (CAM, Complementary and Alternative Medicine), and a large number of prestigious scientific journals are more and more interested in this issue. It is no longer unusual to find articles dealing with these topics in journals such as  Lancet (1996), Psychoneuroendocrinology (1997), The Journal of Complementary and Alternative Medicine (2006). The field of research in this domain has been enlarged and an increasing number of researchers have focused on these issues. Individuals, whether they have psychological problems or not, are seeking new methods of treatment in order to better manage the physical as well as psychological disorders which plague their everyday lives. They are searching for new techniques and approaches which would offer them well-being and stability, and in which they would be the actors in their cure. A quick overview of this increasing interest offers the following information: a study carried out in 2002 by the American government shows that 36% of the population resorts to alternative and/or complementary therapies (Barnes et al., 2004). The number of patients who consult �alternative practitioners� in Canada has more than doubled in ten years (Wayne, 2001). A study estimates that the proportion of consumers of alternative treatments in Europe varies from 20% to 50% depending on the country (Fischer & Ward, 1994). This is estimated to be 48% in Australia (MacLennan et al., 1996) and 65% in Japan (Suzuki, 2004). We have little data on this subject in France. In 1992, the American congress voted to create the National Center for Complementary and Alternative Medicine, a new department of the National Institute of Health, which is entirely devoted to the scientific study of traditional remedies made from plants, of approaches such as meditation, tai-chi, yoga, acupuncture, and even controversial practices such as shamanic healing, laying on hands or reiki (Gordon, 2005).
Thus, alternative therapeutic practices are attracting increasing attention, which is justified when we know that according to the WHO, 80% of the care systems in the world are based on traditional medicine (Barzansky & al., 2000). The WHO defines complementary and alternative therapies as �all of the practices in which the patients are considered in their globality within their ecological context. These therapies insist on the fact that illnesses or the state of poor health are not only caused by an exterior agent or a particular pathological predisposition, but they are above all the consequence of an individual�s instability in relation to his ecological system� (Wetzel et al., 2003). Alternative and complementary therapies then take into consideration physical (the body, movement), emotional (feelings, sensations), intellectual (the brain and its cognitive abilities) and spiritual dimensions (understanding the self, the world and the transcendental aspects of life) of the human being in relation to the environment. And the state of �good health� is defined as a balanced relation between the body, the emotions and the thoughts of the individual. These therapies advocate effective communication between these three aspects of the individual and intelligent relationships between the individual, his fellow men and his environment. Thus, this refers to an integrative, global and holistic approach. From this perspective, our research is focused on the approach of concentration meditation.
First, we will clarify the concept of meditation and define the term concentration meditation. Second, we will analyze some published studies (verified and randomized) which demonstrate the interest and the pertinence of this approach in modern psychology. Our aim is not to show the effectiveness of concentration meditation in a definitive manner, but simply to point out the interest of this treatment in the field of health in order to see if it can offer benefits in terms of physical and psychological health. This introductory work, which aims at clarifying the notion through a review of the question, could then result in a meta-analytical type of investigation whose objective would be to know if concentration meditation could be associated with therapeutic effectiveness.  

Theoretical elements and conceptual framework

The concept of meditation is not easy to define and it is linked to the history of civilizations and Indo-European religions. From the Latin meditari which means �to practice, to reflect�, the term meditation comes from the Indo-European root med which means �to think, to reflect�, as does mederi which means �to heal� and which is at the origin of the word medicine. 
The term meditation has a series of distinct meanings in its general use (Varela et al., 1993): a) a strategy of self-regulation with a focus on attention, b) a state of concentration in which the reflected consciousness is focused on a single object, c) a state of psychologically and medically benefiting relaxation, d) a dissociated state in which the phenomena of trance can be produced, and e) a mystical state in which the highest realities or religious objects are experienced. These different meanings have in common being different or modified states of consciousness. The meditator does something to leave his ordinary state of reality. According to Schnetzler (2000), a current mistake consists in limiting the practice to the conceptual level while it simultaneously concerns the body, the mental state and the mind. If we refer to common language (Mantel, 2000), when one speaks of meditation, one often thinks of a form of steady attention on an object, a sound, a thought with a movement of slowed down thinking when the mind is attentive to something in particular. One of the attractions of meditation is generating positive emotional and mental states such as calm or happiness, or reducing negative emotional states such as fear or anger (Goleman, 1988). According to Shapiro (2005), �meditation refers to a group of techniques which have in common a conscious attempt at focusing the attention in a nonanalytical manner and an attempt at not dwelling on discursive thoughts and rumination�. Although this definition is brief and incomplete, it sheds light on at least four important aspects. The first is the use of the term �conscious� which emphasizes and explicitly introduces the importance of the intention by focalizing attention. The second emphasizes the fact that, unlike approaches with an analytical inspiration, verbalization and discourse are not the focus of this method. It is not verbalizing which is central, but the experience of what is felt which opens new areas of consciousness to the subject. The third concerns the fact that the notion of meditation is defined independently of any religious, spiritual or sectarian context. This is the very condition of its definition as a measurable and assessable scientific object concerning its effects on the psychological state and the quality of life of individuals (in good or ill health) who devote themselves to it. The fourth also emphasizes the notion of attempt which sheds light on the concept of the psychological process as opposed to the result. 

Meditation is seen as a health practice and a spiritual method in many parts of the world, and reference has been made to it for about 5000 years. The practice of meditation has become more and more popular in the west over the past forty years, particularly in relation to the ecological and spiritual movements of the 1960s and 1970s. This practice is found as much in oriental spiritual movements (Buddhism, Hinduism) as in the Judeo-Christian and Sufic spiritual and religious movements since their beginnings (De Smedt M., 1979). For the past thirty years, meditation has been viewed as an additional therapeutic strategy in the movement of alternative and cognitive psychotherapies (Cottraux, 2004). The therapeutic effects of meditation have been studied in the scientific literature since the 1970s, resulting in numerous studies and reports whose main criticism has been the lack of methodological rigor (Smith J. 1975).
Cardoso et al.(2004) include the following operational parameters in their definition of the meditative practice: (1) the use of a specific technique that is clearly defined and practiced regularly, and which must be transmitted and given by an instructor, (2) the involvement of muscular and physiological relaxation in the process, (3) the involvement of mental relaxation which does not attempt to analyze psychophysiological effects, nor to judge mental states, nor to create expectations regarding the process, (4) the fact of having and putting into practice a self-induced state, in other words, a method that the individual can replicate, on his own, without the presence of an instructor and without there being a relation of dependence on the instructor, in other words, an autonomous application of the method, (5) the development of a self-focalization skill (known as an anchor) on the breath, an image or a sound. This definition is quite broad and covers many meditation traditions. 
Consequently, and in spite of the lack of consensus on the definition of meditation in the scientific literature, most researchers agree that meditation involves a form of concentration and mental training which leads to emptying the mind with the goal of developing a detached mental state of observation in which the participants are conscious of their environment without being involved, insofar as possible, in the thought process or the process of developing thoughts. 
Finally, it can be mentioned that meditation can also be described and classified according to certain phenomenological characteristics such as (1) the principal objective of the practice (therapeutic or spiritual), (2) the direction of the attention (mindfulness, concentration), (3) the type of anchor used (sound, word, mantra, breath), (4) the posture used. Regarding this historical state of the research, it can be asserted that meditation can be seen as a complex, interactive and multidimensional therapeutic intervention. It involves a combination of complex and varied characteristics which can be practiced alone or in addition to other therapies. 
These global definitions consider meditation as a unique and systematic process without taking into account the differences which can exist between the different approaches or techniques of meditation. Shapiro (Shapiro 2006) points out that the different types of meditation vary in function of three criteria: (a) the type of attention on which concentration meditation is focused, on an object such as the breath or a sound, while mindfulness meditation aims at a flowing and vigilant attention on several successive objects, (b) the relation to the cognitive process in which some practices consider cognition only as a thought or an image while others modify it deliberately, (c) the goal on which some practices are concentrated; only well-being and mental development, while others are focused on developing specific mental qualities such as emotions like happiness or compassion. 
Berghmans & Tarquinio (2007 submitted) have pointed out the impossibility of defining meditation in a single, systematic and global manner, thereby showing that the different currents in meditative practices require their own definitional approaches. 
Our work is based on the following definition of meditation, that is, a complex psychophysiological, interactive and multidimensional process which, on the one hand (and in a general manner) involves: 
the intentionality and the commitment of the subject to the process,
the use of specific techniques that are clearly defined and regularly practiced, and which must be transmitted by instruction,                   
the activation of a type of attention (focalized or flowing and vigilant) and the development of a skill in focusing on an internal or external object (breath, image, sound), 
the involvement of muscular and physiological relaxation,   
putting into practice a self-induced state, in other words, a method that the subject can replicate alone (without the presence of, or dependency on, an instructor),
corporal involvement in a posture (seated, lying down, ambulatory),
the direct or indirect observation of mental states, 

and, on the other hand (and more specifically), characteristics proper to the type of meditation used such as concentration, mindfulness or contemplation. These characteristics can be:

the involvement of mental relaxation which implies not attempting to analyze nor judge mental states in order to avoid developing a process of rumination and cognitive elaboration,  
the relation to the cognitive process in which some practices see cognition only as a thought or an image while other modify it deliberately, 
the goal of the practices (well-being, mental or emotional development, spiritual overture).

This definition is based on a synthesis of earlier research and by taking into account the globalization of meditative practices.
 
Regarding meditative practices, different techniques or approaches to meditation exist in function of the authors. However, based on their report which aimed at synthetically analyzing the research done on meditation by taking into account different practices of meditation (the research design used, the results obtained, the effectiveness of the practices according to different indicators [psychological, physiological, neurological] found in seventeen medical and psychological databases going back as far as September 2005, as well as other sources [contact with experts, interviews, bibliographical research]), Ospina, Bond et al. (2007) have shown five categories of meditation which correspond to an arbitrary choice of categorization. These include (1) the so-called mantra meditation (which includes transcendental meditation or TM, the relaxation response and Clinical Standardized Meditation or CSM), (2) mindfulness meditation (including such approaches as Vipassana, Zen Buddhist, MBSR, MBCT), (3) Yoga, (4) Tai Chi and (5) Qigong.
On the basis of this classification, this research will only focus on mantra meditation which groups transcendental meditation (under its cultural name) and is part of the family of concentration. All other forms of meditation are excluded (mindfulness, walking meditation) and we refer the reader to research orientated in these domains (Ospina et al. 2007).

In a short time, the study of the concept of meditation has gone from an analytical phase of a mystical process of spiritual quest or a search for self-knowledge, to a complementary therapeutic method of creating and maintaining well-being and improving health (Cardoso et al. 2004). Several forms of meditation exist which often vary in function of the spiritual method which offers it. Two important orientations, very much used in Buddhism, delimit the field of meditation (Schnetzler, 1994): that of concentration or Samadhi and that of penetrating vision or Vipassana, which is traditionally known as �mindfulness�. So-called concentration meditation consists in consciously focusing one�s mental activity on an exact point in a progressive, steady, intense and sustained manner. By means of this process, all mental activities, with the exception of the one chosen, are temporarily eliminated, such as sensorial activity, the perception of the outside world, the perception of the body and discursive thinking. Here, any object of the consciousness can be an object of meditation (concentration), such as a word, a sound, a prayer or a mantra. The mind turns round the object, it is brought back by the object when the mind wanders. In all types of concentration meditation, the subject attempts to ignore other stimuli in his environment and focuses his attention completely on the object of his meditation which can be a sound (Carrington, 1998), a word (Benson & Proctor, 1984), a thought, an image or another object. The subject concentrates his attention in a non analytical and unemotional manner in order to directly experience the object of meditation. 
The meditative approach which mainly requires concentration of attention and which has been studied the most for the past few years, is the so-called transcendental meditation, also known as �mantra meditation� in some cases. This is a form of meditation based on focusing thought on a stimulus (sound, mantra, object). It is presented as a technique of profound relaxation and of consciousness development and finds its origin in Advaita Vedanta, one of the six traditional systems of India. The transcendental meditation movement was created in  HYPERLINK "http://fr.wikipedia.org/wiki/1957" \o "1957" 1957 by  HYPERLINK "http://fr.wikipedia.org/wiki/Maharishi_Mahesh_Yogi" \o "Maharishi Mahesh Yogi" Maharishi Mahesh Yogi, a disciple of the Indian thinker,  HYPERLINK "http://fr.wikipedia.org/wiki/Brahmananda_Sarasvati" \o "Brahmananda Sarasvati" Brahmananda Sarasvati. The movement met with a certain international popularity in the 1960s thanks to some celebrities who introduced it in artistic circles. It is a simple technique which requires no beliefs or particular life styles, and allows the consciousness to return to its basic state called �pure consciousness� in which the mind is no longer perturbed by parasitic thoughts or any mental activity. Transcendental meditation involves daily practice of 15 to 20 minute sessions during which the follower mentally repeats a mantra, that is, a word which is theoretically secret and adapted to his personality. However, unlike the MBSR (Mindfulness Based Stress Reduction) developed by Jon Kabat-Zinn, no protocol or standard training exists for transcendental meditation. As a rule, there is an introductory lecture consisting of two one and half hour sessions, followed by interviews with the participants who receive individual instructions which permit the practice of this approach, and then group meetings and follow-up which take place twice a week for the first four weeks, and then once a week  (Labrador, Polk et al., 2006). Different protocols for this practice are also found, thereby raising questions of a methodological order which we will deal with in the last section of this paper. As the session advances, the mantra must fade to leave the mind in a state of �pure� consciousness, without any thought. It is a state of absolute non thinking. A large number of studies (Alexander et al. 1991, Orme-Johnson 1987), which have been done since 1965, have shown that the search for this state results in physical benefits. Transcendental meditation has become at present a serious object of study in psychology in the field of alternative therapeutics.                
However, since this technique began in the west during a period of cultural and social protest and the discovery of other forms of spirituality and a search for a different life style, it was associated in some cases with sectarian religious and anti-establishment movements which largely altered its image. However, the perception of this technique of meditation varies from one culture to another, and the social conditions behind its creation have largely contributed to its positive or negative perception. It must be noted that it became the subject of more serious and rigorous scientific research in the 1980s, which emphasizes the link between this practice and the development of physical and psychological well-being. The main process which is shown in this approach is then the concentration of the attention on a stimulus in order to subsequently create another state of consciousness or a modification of the mental states. Most of the research on transcendental meditation has shown the beneficial effects of this approach without clarifying the process itself and, therefore, the active principle, as is the case of  research on mindfulness meditation. 

Methods

 The studies used here were chosen in the framework of a research group working on the problematic of psychotherapeutic alternatives in the field of health psychology (Berghmans, Tarquinio & Strub, submitted; Tarquinio, 2007). This selection involved two stages:
First stage: An inventory was made of most of the publications which appeared between January 1980 and January 2007 in the databases of Medline, PsycINFO, Psyarticles and Science direct. The statistics gathered from the documentary research of the different databases are synthesized in Table 1. The key words �transcendental meditation� and �mantra meditation� were used in order to obtain only articles dealing with the theme of concentration meditation. However, it must be noted that elements of concentration can be found in other meditative approaches such as mindfulness, but this term did not figure among the key words chosen for referencing. 
Second stage: All of the works were then subjected to an inter-judge evaluation. The choice of the studies was based on four criteria: 1. That the studies were published in journals with a review committee; 2. That the experimental procedure included a before-after comparison (A-B-A) as well as a comparison to a control group (generally with the wait list technique) or another therapeutic procedure, or both; 3. That the authors carried out a longitudinal study; 4) That the repartition of the subjects in the groups was randomized. 

Table 1 � Key words and the results obtained from the documentary research 
Key wordsGlobal number of articles identified in the databases        Articles meeting the fixed criteria    Transcendental meditation, mantra meditation81940Total (after eliminating redundant articles in the databases) 24

Crossing the results obtained with the various databases has shown redundancies regarding the choice of some articles. In all, twenty-four articles were recorded and retained for the final analysis.                                      

Results   

The studies are presented on the basis of seven criteria including the authors� names and the date of publication, the aim of the study, the methods of intervention used and methodological information, the duration of the program, the typology of the evaluations, the measurements taken, the somatic and psychological effects (S.P.). Finally, commentaries are made for each of the studies retained.                                                    
Four articles were also added (Table 3) which were published in literary journals and meta-analyses offering some very interesting clarifications on this practice.                          
Table 2
AuthorsObjectivesMethods of intervention and experimental conditions Length of the program and type of program Principal evaluations and measures Psychologicaland somatic effects CommentariesBarnes et al. (2001)To evaluate the impact of a program of transcendental meditation (TM) on the cardiovascular function of adolescents at rest and in situation of acute stress with high normal blood pressure. 
Measures before/after intervention.TM (n=15)
Control (n=18)Group session of 15 min./day and individual session of 15 min./weekday at home, and 15 min. twice a day on weekends for a 2 month period.
7 sessions on health education of 1 hour/week.SBP and DBP (Blood pressure)
HR (Heart rate)
CO (Cardiac output)
TPR (Total peripheral resistance)
The measures are taken in 3 conditions:
- rest
- car driving simulation (evaluation on a 9-point scale on the perception of participation in the task, level of skill, experience with the game) 
- interview on social stressor (evaluation on a 6-point scale on the perception of participating in the task, change in the affective state) SConcerning the rest condition, the TM group shows a more important decrease in the SBP and DBP measures in comparison to the control group. Higher decreases regarding SBP, HR and CO measures (pre vs. post-intervention) are observed in the TM group in comparison to the increases shown (pre vs. post-intervention) in the control group during the car driving simulation task.
The condition regarding the interview on the social stressor shows a decrease in the SBP measure for the two groups but this is more important for the TM group in comparison to the control group. Barnes et al. (2004)To evaluate the impact of a program of meditation of the concentration type (MED) on the heart rate and ambulatory and resting blood pressure of students.
Measures before/after intervention.MED (n=34)
Control (n=39)1 10 min./day session at school and at home for a 3 month period, plus an average of 4 min./day of direct contact with the instructor.
1 session of 20 min./week (health education).SBP and DBP (Blood pressure)      
HR (Heart rate)
Spielberger Anger Expression Scale (Anger)
Neighborhood Stress Index (Environmental effort)
Self-report of physical activity 
Evaluation of the expected results SpAmong the measures at rest, only the SBP shows a significant difference (pre-test vs. post-test) between the two groups. The changes observed for the measures DBP and HR are not statistically significant in the two groups.  
Concerning the daytime ambulatory measures at school regarding SBP, DBP and HR, the differences between the groups are not significant. For the daytime ambulatory  measures after school, the changes are significant between the MED group and the control group for the SBP (-2.0 vs. 3.6 mm Hg), DBP (0.1 vs. 4.3 mm Hg) and HR (-5.3 vs. 0.3 bpm) measures. 
The nighttime ambulatory measures show a slight change for the two groups. The HR measures in the ambulatory nighttime condition show a reduction in the MED group in comparison to the increase observed in the control group (-0.3 vs. 3.5 bpm).Manocha et al. (2002)To evaluate the effectiveness of an intervention based on Sahaja Yoga meditation (concentration type) in complement with a medical treatment for adult patients suffering from asthma.  
Measures before/after intervention, then at 2 months. Sahaja Yoga (n=21)
Control (n=26)Session of 2h/week for 4 months, then 10-20 min. twice a day.PEF (Peak expiratory flow)
FEV (Forced expiratory volume in 1 second)
AQLQ (Asthma quality of life questionnaire)
POMS (Patient Outcomes Measure Study)
CAS (Clinical Asthma Score, the use of a bronchodilator and PEF)SThe results of the study underline an improvement in the response of the breathing passages to methacoline (AHR) in the Salaja Yoga intervention group vs. the control group. The follow-up done two months after the intervention shows that the difference between the two groups is no longer significant.. 
The results concerning the scale of the quality of life mainly show an effect on mood in the intervention group. The evaluation of the POMS scale indicates better improvements regarding tension and fatigue vs. the control group.Smith et al. (1995)To evaluate the effects of associating a program of meditation and the PHEP (Personal Happiness Enhancement Program)MEDP (n=7): concentration  meditation + instructions on the subjective well-being of Fordyce�s
PHEP (n=12): 
PHEP + instructions on the subjective well-being of Fordyce�s PHEP




12 sessions of 1.5 h for a period of 6 weeks.HM (Frequency & intensity of happiness)
PHI (Happiness)
STAI (State Trait Anxiety Scale)
BDI (Beck Depression Inventory)
SPThe results of this study suggest that a program intended to increase happiness and to diminish negative moods can be significantly  improved by the addition of a simple type of concentration meditation.Tloczynskiet al. (1998)Comparing the meditative practice of concentration �Zen Breath� with relaxation on stressors in the context of the student life of women. 
Initial measures, at 3 weeks and at 6 weeks. �Zen breath� Meditation (n=21)
Relaxation (n=20)
Control (n=21)Practice of at least 20 min./day.CAS (9 psychological criteria proper to a student population)
TMAS (Taylor Manifest Anxiety Scale)PMeditation and relaxation seem to be effective strategies for students, particularly regarding anxiety and depression. The two techniques have positive effects regarding the reduction in anxiety and stress, but meditation gives slightly better short-term results. Moreover, it has proven to be very effective in reducing interpersonal problems, which is not the case for relaxation
Meditation includes, of course, a �relaxation� component but it offers a supplementary dimension regarding concentration which would explain the better results. 
The two techniques would then be effective and credible but differently in function of the aim of the treatment and the type of individual. Jayadevappa. (2007)
To evaluate the effects of a program of reducing stress through transcendental meditation on the functional capacity and the quality of life of Afro-Americans suffering from congestive heart failure and comparison with a program of cardiac education. 
n = 23
TM group (n = 13)
HE group (n = 10) Measures taken at the beginning and the end of a 6 month period. TM�group: transcendental meditation
Practice 15 to 20 min. twice a day + 7 classes given in the form of meetings lasting 1.5 hours for 7 consecutive days + review sessions and biweekly follow-ups during the first 3 months, then 3 monthly follow-ups.
 
HE group: health education
Educational sessions based on the same time schedule as that of the TM. 
Listening to music or reading 20 min. twice a day.

Keeping a daily diary for the two groups 
6 monthsFunctional capacity: Test �walk for 6 minutes� (functional capacity).    

SF-36 (quality of life)
LHFQ (quality of life linked to heart failure)
QWB-SA (well-being)
CES-D (depression)
PSS (perceived stress) 
Blood tests at the beginning, at 3 months and at 6 months to analyze BNP (biochemical marker) 
SPThe results obtained by the bias of transcendental meditation show improvements on all of the scales measured. The physiological parameters remain unchanged.. This program could then be a useful tool in the prevention and the treatment of congestive heart failure. However, because of the small size of the sample and a too short follow-up period in relation to more long-term effects, its validation would require other studies.  
Wenneberg S.G., et al. (1997)To evaluate the effects of reducing stress though transcendental meditation on cardiovascular reactivity and ambulatory blood pressure. 
Measures at the beginning and after 16 weeks.
n = 64

Experimental group TM 
(n = 32 at the beginning, n = 21 at the end)

Control group SEC 
(n = 32 at the beginning, n = 18 at the end).

Each group is divided into 2 subgroups:
High conformity (practice twice a day)
Low conformity (practice once a day or less)
TM Group�
Practice 15 to 20 min twice a day + individual introductory classes given by a qualified instructor + 3 follow-up group meetings of 1-2 h  the following 3 days. 

SEC Group
Classes given by a psychologist + practice at home consisting of keeping a diary 15 min. twice a week.

14 to 16 weeksLaboratory session 
Measures of blood pressure and heart beat every 4 minutes at the beginning, then exposure to a stressor every 20 minutes.  (arithmetic, psychomotor, physical).

Branching the subjects to an ABP monitor, then measures every min. for the first 3 min. of an initial 5 min. period and giving instructions. Measures every min. during the 3 min. of preparation   for the discourse and the 3 min. of discourse strictly speaking. Reprogramming the monitor in view of measures every 15 min. for 9 h. SThe results obtained do not show significant differences with the exception of the subgroup of high conformity. It can be deducted that the reduction in blood pressure or tension generated by transcendental meditation cannot be attributed to a mechanism of reactivity to stress. Hence, for the moment, reactivity cannot be considered as a factor in hypertension, but rather it should be assimilated as a sign of illness. It would be interesting to replicate this study by taking into account the effects of transcendental meditation on the mean ambulatory blood pressure among the normotensive.
This study can thus have an important role in the basic prevention of hypertension and the cardiovascular diseases which result from it.  

Manikonda
(2007)Effects of contemplative meditation combined with breathing techniques on the reduction of ambulatory blood pressure and hypertension generated by stress. 
Measures at the beginning and the end of 8 weeks (at the same time of day). n = 52

CMBT group
Control group Experimental group (CMBT):
Contemplative meditation + breathing techniques
2 sessions of 40 min., one early in the morning and the other in the evening, divided into a 1st phase of 10 min. focusing on breathing exercises and another 30 min. devoted to meditation exercises based on Christian tradition. 

Control group:
No intervention

8 weeksMeasures of blood pressure 4 times every 5 min. after 10 min. of rest, then calculation of the mean of the last 3 measures.
Recording the blood pressure for 24h with specification day/night. 
KLT (concentration power) + measures of heart beat and blood pressure 20 min. before the test, every 5 min during (30 min.) and 20 min. after.SThe results show that CMBT can reduce blood pressure in conditions of rest or mental stress in primary phase of hypertension in an effective manner and without danger, but the anti-hypertensive effects which result from it remain substantial and the same as those of pharmaco-therapeutic tests. The experiment meets some limits (the impossibility to study the effects of meditation and breathing separately, risk of a placebo effect) but the results remain encouraging and justify more extensive studies focusing on the long-term effects of CMBT on blood pressure as a treatment in itself or in complement with a pharmacological therapy. 



Brazier (2005)


To evaluate the effects of yogic breathing of concentration and a meditative intervention (concentration) among seropositive individuals for 15 days.
5 series of measures: at the time of recruiting, several days before the beginning of the in residence program, 1 week after the end of the program, 6 weeks after the end of the program, 12 weeks after the end of the program. n = 62 at the beginning, n = 42 at the end

Intervention group (n = 30 at the beginning, n = 20 at the end)
Control group (n = 32 at the beginning, n = 27 at the end)Intervention group (Quebec):  
In residence program for 15 days (breathing techniques, meditation, movement and group process) including 12 weekly follow-up sessions, then daily exercises at home and follow-up sessions in  Vancouver.

Control group:
Classical care in Vancouver
MHI (mental health index), MOS-HIV (health survey), DSI (daily stress inventory)PThe quantitative and qualitative results show the positive impact of the program on the patients� well-being while showing the complexity with which they perceive these effects and their duration. If the sample was sufficient for uniquely observing significant effects at the outcome of the in residence program, a larger number of participants would have, however, made it possible to detect significant changes during the follow-up, the effects being likely to diminish over time. This study also shows the necessity to combine different analytical methods and to compare the results so that the interpretation is optimal. 







Curiati (2005)To evaluate the effects of concentration meditation on the reduction of the sympathetic activation and an improvement in the quality of life of elderly patients suffering from congestive heart failure.
Measures before and after 14 weeks ( 1 week.n = 19

M Group (meditation)
n = 10 at the beginning, n = 8 at the end
C Group (control)
n = 9 at the beginning, n = 7 at the end
M Group:
Listening to a tape for 30 min. at home twice a day + weekly meetings. 

C Group:
Weekly meetings only .  

12 weeks (after 2 months of carvedilol treatment) Measures of NE (noradrenaline blood levels), MLWHFQ (Minnesota Living with Heart Failure Questionnaire), VE/VCO2 slopes
(rate of increase in ventilation/unit of increase in the production of CO2),  consumption of O2 measured by CPT (cardiopulmonary exercise testing) LVEF (left ventricular ejection fraction), LVDDi (left ventricular end-diastolic volume index) measured by echocardiogram.SThe results show improvements in noradrenaline blood levels, of the quality of life and the VE/VCO2 slopes; the other parameters remain unchanged. Although it is encouraging, this study remains limited because it does not include data on the prognosis and does not make it possible to define the precise action mechanism of meditation on the sympathetic system. However, it makes it possible to consider meditation as a new hope in the treatment of congestive heart failure and to justify new studies, for example on the effects of meditation on other diseases leading to CHF by activating an influence of the sympathetic system. It should also be noted that the advantage of this therapy lies in the simplicity of its application, its low cost and its non-invasive character.
Mehling (2005)

Effects of therapy based on breath (concentration) compared to physical therapy in patients suffering from chronic back pain.
Measures at the beginning, between 6 and 8 weeks and at 6 months.n = 36 at the beginning, 
n = 26 at the end


Respiration Therapy Group� (RT)
n = 18 at the beginning, 
n = 14 at the end


Physical Therapy Group  � (PT)
n = 18 at the beginning, 
n = 12 at the end

Introductory evaluation session (60 min.) and 12 individual therapeutic sessions of the same length (45 min.) for 6 to 8 weeks for the two groups (longer sessions for the PT group).
Daily exercises at home (20 to 30 min.).
Keeping a diary during the 6 to 8 weeks of intervention (thoughts related to the therapy and the therapist, different thoughts concerning one�s body, one�s back, one�s pain and one�s life in general).

RT Group:
Verbal intervention and targeted touch by the therapist in order to guide the patient�s consciousness towards subtle physical sensations of respiratory movements in his back.

PT Group:
Individualized strategies including mobilizing limp tissues, mobilizing the articulations, exercises for postural correction, flexibility, pain relief, stabilization, reinforcement, execution of functional tasks and physical therapy for the back.
VAS (pain), SF 36 (bodily pain subscale).

Measure of postural stability at the beginning and directly after therapy with SOT (Sacrooccipital technique, balance), NeuroCom Smart Balance Master, Neurocom and platform of static force.The results show comparable improvement in the two groups. If the small size of the sample does not allow one to explain this fact, it could be possible, however, that the personalized adaptation of the physical therapy interventions (diaphragmatic respiration and use of mental imaging techniques) had a role. Moreover, the positive impact of the therapy is directly linked to its duration. 
However, this study presents limits because it does not make it possible to evaluate separately psychosocial, musculoskeletal, biomechanical and neuromotor factors linked to the rate of relapse as well as the reactivity to the treatment. It will be necessary to envisage additional studies in order to determine if the responses to the two therapies are specifically associated to psychological, cultural or functional characteristics of the patient. Moreover, it�s difficult to establish any association between the objective measures of postural control and the clinical course of back pain, undoubtedly due to the fact that these measures were not accurate enough. 
This is the first study which made it possible to prove the beneficial effects of respiratory therapy on chronic back pain. The qualitative data suggest that it could improve treatment and shed now light on the effects of stress in relation to the illness.
A new study should make it possible to determine if an approach combining the two therapies would prove to be more beneficial.
Bormann J.E. et al. (2006)Effects of mantric spiritual repetition on seropositive individuals. 
Measures in week 1 (pre-intervention), week 5 (middle intervention), week 10 (post-intervention) and week 22 (follow-up) for psychosocial factors, measures at the beginning and during follow-up for clinical factors. n = 93

Mantra group M (n = 46 at the beginning, n = 32 at the end)

Attention control group AC (n = 47 in the beginning, n = 34 at the end)

5 consecutive weekly sessions (90 min./week) for the 2 groups + 4
automatic weekly telephone calls (to encourage the practice of the mantra for the M group  and data concerning the study for the CA group) + final session in week 10.

M group: 
Weekly reading of mantric handbook, distribution of a textbook of courses with exercises and a list of recommended mantras representing divers spiritual traditions. 
Each class is divided as follows: 
questions/answers on the material presented, report concerning homework and sharing strategies, practical exercises, 5 min. of  mantric writing or silent repetition of mantras in group, instructions for homework.

AC group:
Viewing videos about subjects related to seropositivity then group discussions. 

10 weeksMeasures of psychosocial factors:
Revised intrusion subscale/
Horowitz�s Impact of events scale (intrusive thoughts)
PSS (stress), STAI (anxiety), short form of the STAI (anger), CES-D (depression), Q-LES-Q (quality of life), FACIT-SpEx version 4 (existential spiritual well-being)

Daily evaluation of the mantric practice by means of counters and follow-up forms from week 2 to week 10 (8 weeks in all)
 
Blood samples for CD4 and HIV-RNA evaluations at the beginning and during the follow-up (health condition) by using the CD4 count and the HAART (highly active anti-retroviral therapy) PSThe results show that mantric repetition can significantly contribute to decreasing psychological distress linked to anger and to increase the spiritual faith associated with the quality of life among seropositive individuals. Important improvements have been observed concerning results during face to face meetings, but maintaining them requires a 3 month follow-up and encouraging practice. It is also important to point out that certain benefits were felt only at the end of 5 weeks while other types of interventions of stress management required longer durations. These results justify implementing more extensive research on mantic repetition in order to improve the understanding of its mode of functioning since this study is found to be limited due to the single geographical origin of the sample, the number of abandons and a lack of objectivity on the part of the guides.
Williams  A.L. et al. (2005)Effects of concentration meditation and massages on the quality of life of individuals in an advanced stage of AIDS. 
Measures at the beginning and as long as 8 weeks. n = 58 at the beginning, 
n = 41 at the end

Meditation group ME 
(n = 13)

Massage group MA 
(n = 16)

Meditation group + massage MM (n = 13)

Control group C (n =16)ME Group:
Introductory group courses on Metta meditation of 90 min. + distribution of a 15 min. cassette on Metta meditation (�loving-kindness� and forgiveness meditation) to listen to at least once a day, short meeting with the instructor at the end of week 1.

MA Group: 
30 min. massage 5 days/week.

MM Group  :
Interventions ME group + MA group 

C Group:
Leeway�s classical care 

1 monthMVQOLI (Missoula-Vitas quality of life index) at the beginning, at the end of weeks 2 and 4, and 1 month after the end of intervention, then every 3 months as long as 68 weeks (only if their condition permitted it.)PThis study shows significant improvements regarding the spiritual as well as the general quality of life among patients having received the combined intervention meditation + massage. However, the interpretation of the results would have been optimized by tabulating the real number of interventions/responses in spite of the anticipation of a high number of defections compensated by an over-recruitment of patients. It would be interesting in future studies to carry out a rigorous investigation of the synergic relation between meditation and massage, such as objective measures of physiological responses and a qualitative evaluation of what the participants experienced. 
Oman D et al. (2006)Effects of passage meditation (concentration) on perceived stress among health care professionals. 
Initial measures, final and during the follow-up at 8 to 19 weeks. 
n = 61 at the beginning, 
n = 58 at the end

Intervention group 
(n = 30 at the beginning, n = 27 at the end)

Wait list (n = 31)Training in the spiritual aptitudes of EPP, weekly sessions of 2h.

8 weeks Cohen and Williamson�s scale  (perceived stress), MOS subscales (mental health and vitality), MBI subscales (burnout) Diener�s scale (life satisfaction), 7-point scale (life satisfaction).PThis study shows the positive effects of meditation on perceived stress and mental health, making it convincing for applying it to stress management or other therapeutic applications. 
It is an important basis for carrying out other studies focusing on the way in which such practices can be used in treatment by drawing inspiration from spiritual or religious resources. 
However, one must remain cautious regarding the interpretation of the results because the study has several limits (lack of an active comparison group capable of more radically excluding contradictory explanations regarding the reported effects, absence of demonstrating the relation between cause and effect, a small sample, insufficiency of detailed measures on eventual past meditative experience). It would be interesting to study in future research the replicability and the generalizability to more diversified groups, the use of longer follow-ups and the implications on physiological stress and the markers of illnesses as well as to carry out qualitative and structured interviews and to study other potential and moderating variables such as the type of personality. 
Schneider R.H., Castillo-Richmond A. et al. (2001)Effects of transcendental meditation on Afro-Americans suffering from hypertensive diseases. 
Measures at the beginning and at 6 months. 
n = 170

Transcendental meditation group TM

Control group C (conventional treatment, program for preventing risk factors)TM group:
Classes in the form of meetings of 1.5h for 5 consecutive days + follow-up meetings at 1 week, every 2 weeks for 2 months, then monthly for 3 months.

C group:
90 min. meeting once a week during the first 5 weeks, then a session every 2 weeks for 2 months, then once a month during the last 3 months. 

6 monthsMeasures of blood pressure at the beginning, every month for 3 months then at 6 months.
Measures of all the other physiological parameters and psychological variables at the beginning and at 6 months of intervention.

Physiological measures:
Blood pressure (ambulatory BP monitoring system, echocardiogram to measure left ventricular mass and doppler to evaluate functional ventricular structures), echography of the carotid, test of cardiovascular reactivity. 
Urinary sodium excretion due to its relation to the left ventricular mass among individuals with high normal blood pressure at the beginning and the end of the treatment period. 
Psychological measures:
SF-36 (general perception of health), MHI (anxiety, depression and positive affect), AES (anger), SIS (stress impact), PSS (perceived stress) 
to determine psychosocial functioning + CSES (self-esteem), PES (personal efficacy) and SHSC (somatization).

Evaluation of risk factors:
JNC VI (treatment of high BP), TOMHS procedures (study of low hypertension) at the beginning and at 6 months and TOHP procedure (trials for hypertension prevention), hygienic and nutritional recommendations. 
SPThe results of this study will be given in future articles. If they are significant, they will corroborate the use of TM as an effective behavioral technique in the treatment given to Afro-Americans suffering from hypertensive diseases. 
. Stigsby B. & Rodenberg J.C. (1980)Effects of mantra meditation on electroencephalographic results.n = 27

Group A: meditation then sleep (n=14)
Group B: sleep then meditation (n=13)Being comfortably seated on a chair in a room with subdued lighting during meditation and the period of vigilance with the eyes closed, then lying on the back during the phases of drowsiness and sleep.

20 min. Records of EEG during meditation, the period of vigilance with the eyes closed,
the phase of drowsiness, the phase of obvious sleep and the sleep phase of 8 subjects.
5 min. before meditation, 20 min. during meditation and up to 5 min., after as well as during a period of up to 1h when the subjects attempt to fall asleep or sleep (n = 8).
Questionnaire related to the subjective experiences of the patients during meditation and the experimental conditions.SThe results show that the experienced meditators are found on a quantitative level of consciousness situated between the state of vigilance and drowsiness. The EEG is incredibly stable during the 20 min. of meditation; it can then be deduced that they are capable of putting themselves in a state characterized from an encephalographic perspective as an intermediary state between vigilance and drowsiness, and this in spite of the experimental situation. It will be necessary to carry out other studies because these results differ from those already obtained, by comparing, for example, the results of experienced meditators with those of inexperienced meditators, by using a type of EEG analysis which makes it possible to establish increased coherence between the cerebral hemispheres during meditation without neglecting the parameter of falling asleep during the session of meditation.
It is difficult for scientists to establish a relation of cause and effect between the short-term physiological changes and the long-term psychological benefits claimed by meditators. Nevertheless, after comparison between the physiological state of meditation and the sleep phases known for the respective well-being that they provide, we can not exclude that practicing meditation for 20 min. twice a day has an appreciable importance even if it will be necessary to carry out many other studies to establish the objective value of meditation. 
Schneider R.H., Staggers F. et al. (1995)Effects of different approaches (TM, relaxation) compared to educational programs for changing life styles on reducing stress among older Afro-Americans suffering from low hypertension. 
3 monthsn = 127 at the beginning
n = 111 at the end

TM group (n = 36)
PMR group (progressive muscle relaxation) (n = 37)
EC group (educational control in function of modifications in life styles) (n = 38)Active intervention groups (TM and PMR):
1.5h meetings for giving instructions during 1 week (introductory presentation and discussion, brief personal meeting, meeting for individual instructions and 3 follow-up workshops in small groups).
Practicing their respective technique for 20 min. twice a day (morning and evening, comfortably seated, the eyes closed) + prohibition to reveal details of the program to individuals not belonging to their treatment group. 

EC group: 
Distribution of a set of educational instructions and material (specific instructions for reducing alimentary sodium and calorie intake + aerobic exercises).
Monthly meetings of one half to 1h (individual or in small groups) during the treatment phase, indication of the possibility of lowering BP by adopting these changes in life style).

Measures of BP at home twice a day for 1 week at the end of the base period and the phases of intervention. 
Filling out a monthly evaluation questionnaire on the frequency of practicing the technique of stress reduction during the treatment phase.
Filling out a questionnaire on the effectiveness of the treatments during the final session of tests. 
Monthly collection of data for 3 months.                  

Physiological data:
Automatic stationary BP monitor (clinical BP measures)
Semi-automatic auscultating device (BP measures at home)

Psychological and behavioral data:
NSBA (Personal efficacy, impact on stress, social support)
STPI (anxiety and anger)
MHLCS (Multidimensional Health  Locus of Control)
Self-esteem   
Well-being
NHP (profile of stress in function of the quality of life, distress)
GOE (disposition to optimism)
Expectation of results of these specific treatments. Questionnaire on alimentary habits and physical activity.    
Evaluation questionnaire on the frequency of practicing the stress reduction technique (conformity with the active interventions).  
Questionnaire on the effectiveness of the treatments.                        


SPThis study shows the feasibility and the short-term effectiveness of approaches to stress reduction. 
TM and PMR significantly reduce systolic and diastolic BP in comparison to the control group. TM shows reductions roughly twice as important as PMR, as well as for the effects obtained regarding mental and behavioral health. 
Thus, these results reinforce the heterogeneity of the approaches of stress reduction, in other words, that different techniques lead to different results. However, the confirmation of these results will require doing other studies for longer periods of intervention, on larger groups (in order to compare the anti-hypertensive responses of groups taking medication or not), on a measure of BP at home using an ambulatory monitor and varied technical samples in order to generalize the results to other populations. 
Labrador  M.P., Polk D. et al. (2006)28Effect of transcendental meditation on the components of metabolic syndrome among patients suffering from coronary heart diseases. n= 103, n= 84 at the end TM Group n=52 (end=45)
HE Group n= 51 (end=39)16 weeks of TM:

2 introductory lectures lasting 1.5 h each, an individual interview of 10 to 15 min., individual instruction lasting 1 to 1.5 h, 3 group meetings of 1.5 h each, follow-up meetings of 1.5 h twice a week for the first 4 weeks and then weekly meetings for the remaining 12 weeks.

16 weeks of HE:
The same number, duration and frequency of group meetings as in TM. 

The meetings and discussions include risk factors (CHD), the impact of stress, diet and exercises for CHD. Daily exercises at home for the TM group. 
Level of total plasmatic cholesterol, triglycerides & high density lipoprotein cholesterol
Dosage of the concentration of insulin & glucose in plasma
Estimation of the level of insulin-resistance
Measure of endothelium-dependent vasomotor response, of the endothelium-dependent vasodilatation 
Measures of parameters of blood pressure by using a Holder

Questionnaire on anger
CES-D (measure of depression)
STAI (anxiety)
Life Stress Instrument Questionnaire
SpThe TM group shows significant variations concerning the following indicators:
Blood pressure (systolic outflow and mean), improvement in the levels of glucose and insulin. 

Before the protocol, the HE group showed a much higher level of depression and anger than the TM group, and the authors observe no change at the end of the protocol.

Moreover, the authors observe an improvement in the nervous-vegetative system. The results suggest that TM can modulate the physiological response to stress via a neurohumoral activation rather than the stress itself.
 
The authors note the limits of the study due to the size of the sample and its duration. 
Walton K.G., Fields J.Z. et al. (2004)Effect of transcendental meditation on cardio-vascular risk among post-menopausal women. N=30 (mean age 75)
TM: n= 16 (23 years of practice)
GC: n=14Standard TM 
(2 introductory lectures of 1.5h, individual interviews of 10 to 15 min., individual instructions of 1.5h, 3 group sessions of 1.5h, 2 follow-up meetings of 1.5h for the first 4 weeks, then once a week).
Level of cortisol in the urine and the saliva 
Blood pressure    SThe long-term practice of transcendental meditation reduces the response of the HPA axis
 (hypothalamic-pituitary-adrenocortical) in function of a stressor. A significant decrease in cortisol is observed. This study suggests a significant effect of TM in this disorder. 
Schneider R.H., Staggers F. et al. (2005)Effect of transcendental meditation via progressive relaxation and health education on the reduction of stress among Afro-Americans suffering from hypertension.TM=54
PMR=52
HE=44Standard TM (20 min /day)
(2 introductory lectures of 1.5h, individual interviews of 10 to 15min., individual instructions of 1.5h, 3 group session of 1.5h, 2 follow-up meetings of 1.5h/week  during the first 4 weeks, then once a week)

Progressive muscle relaxation (PMR)
Health education (HE)Blood pressure     
Heart rate        
SA significant decrease (and more pertinent than in the other 2 groups) in blood pressure appeared in these results. TM can be useful in terms of additional treatment for hypertension. 
Puente A.E. (1981)Psychophysiological effects (of 2 manipulations) of transcendental meditation compared to Benson�s relaxation response (BRR) and a control group without treatment. Manipulation 1:

N=47
TM, n=16
BRR, n=16
CG, n=15

Manipulation 2:

N=30
TM, n=10
BRR, n=10
CG, n=10
Manipulation1 and 2:

Standard TM 
BRR (Benson�s technique of progressive relaxation)Respiratory frequency 
Heart rate 
EMG
EEG
Level of skin electricitySThe first experimentation does not show significant physiological differences in the 2 practices used and the CG.
There were no significant results in the second experimentation and the subjects with 5 years of experience in TM did not show a difference from the subjects who have been practicing it for only 1.5 years. 
Gaylord C. et al. (1989)


Effects of transcendental meditation and progressive relaxation on EEG coherence, stress and mental health over one year.  N=83
TM, n=25
PR, n=25
CBS, n=24 (cognitive behavioral strategy) Standard TM
BRR (Benson�s technique of progressive relaxation)
CBSEEG
SP (electric potential of the skin)
TSCEP
SSTAISPThe results for the TM and PR groups are significant regarding mental factors and anxiety. 
The TM group show a significant increase in the coherence of the theta and alpha waves, unlike the other two groups which did not show convincing differences. The coherence of the brain waves during the TM phase is more marked in the right hemisphere.
However, the regularity of the patients� practice is not measured, which largely limits these results. 
Zuroff D.C. & Schwartz J.C. (1978)Evaluation of the effects of transcendental meditation and muscle relaxation on anxiety, maladjustment, LOC (locus of control) and the consumption of alcohol and marijuana. 

Measures before/after, in the middle of the treatment period and at the end of 9 weeks of treatment. TM=19
MR=20
Control=21TM: 2 group classes of 1h each, 1h of individual instruction about the technique, 3 additional group meetings of 1h. 
MR: the training procedure is identical as possible to that of the TM. Exercises at home: 20 min. twice a day.
Control: no practice, nor a request to modify one�s life style. Rotter�s LOC 
Social Desirability Scale by Crowne & Marlowe
Demographical questionnaire (previous and current drug and alcohol consumption, and prior experiences with TM and MR). 
The question of expectations (possible benefits)
Measure of the pulse
Rotter�s Incomplete Sentences Test (general psychological maladjustment)
ACL (anxiety) by Zuckerman
S-R Inventory of Anxiousness (reactions to anxiety)
BAM (anxiety) by Rehm & Marston.PThe authors indicate that out of the three measures used to evaluate anxiety, only the S-RI shows a real decrease in anxiety. The authors do not observe any significant difference for all the other evaluations (LOC and the consumption of drugs and alcohol). 


Table 3


AuthorsMeta-analysis and review of literature: ObjectivesMethods of intervention and experimental conditionsDuration and type of program Principal evaluations and measures Psychological/somatic effects CommentariesArias (2006)Demonstration of the effectiveness and the innocuousness of meditative techniques in the treatment of illness in 20 randomized studies.
n = 958

Experimental group (n = 397)
Control group (n = 561)Relaxation response (Benson), Tibetan yoga, PCLE yoga, SKY meditation, mindfulness meditation, 
Hatha yoga, Shavasana yoga, Sahaja yoga, Transcendental Meditation, Yoga, Kundalini yoga, MBSRExercises related to each practice  The results mainly reinforce the potential effectiveness of the techniques of meditation in the treatment of illnesses originating from non-psychotic mood disorders and anxiety as well those in which mental distress plays an important role. However, their validation will require more advanced research, and some questions related to the significance of the differences in the results obtained depending on the techniques of meditation, the contribution of mental activities in relation to physical activities or even other parameters (tolerability, generalizability, effectiveness and cost in the framework of a generalized application) still remain in suspension. The techniques of meditation can prove to be more effective if their role is limited to that of a complement to conventional therapies. Nevertheless, they do not present any danger for the patients and the potential benefit of their integration justify more research.
 Schneider/Kenneth (2006)Review of the literature on evaluating the effects of transcendental meditation and treatment based on Maharishi consciousness on the prevention of cardiovascular diseases and promoting health. Synthesis of different studies Practice of classical yoga exercises 15 to 20 min. twice a day, taking plant based preparations (MAK), MRT, MVVT, following a specific food diet, TMMeasure of the systolic and diastolic blood pressure, measures of total cholesterol and lipidic peroxides in the serum, meta-analyses of several indicators of autonomic activity and measures of markers, IMT (intima-media thickness), National Death Index, analysis of quantitative dataThe results show that the treatments based on Maharishi consciousness have a positive impact on the risk factors of cardiovascular diseases, including a reduction in blood pressure, on the risk factor associating cholesterol/lipids oxides/tobacco, on patho-physiological mechanisms, on morbidity and on the costs linked to treatments and chronic diseases that is so spectacular that it would largely justify more advanced studies. 
Thus, they could make it possible to partly attain the national objectives fixed by health professionals, in particular because of their preventive and holistic nature, as well as improving the quality of life without secondary effects.  
Canter P.H. & Ernst E. (2004)Positive effects or not of transcendental meditation on lowering blood pressure in comparison to other approaches: comparing the results based on six randomized clinical trials.
1. Alexander et al
n = 73
TM group
MF group
MR group
NT group

2. Schneider et al
n = 127
analysis at 3 months on n = 111
 to
TM group
PMR group
LME group

3. Wenneberg et al
n = 66 at the beginning, n = 26 at the end

TM group
High-conformity subgroup (n = 8)
Low-conformity subgroup 

CS group
High-conformity subgroup (n =5)
Low-conformity subgroup    

4. Barnes et al. 1
n = 35

TM group
LME group

5. Barnes et al 2.
n = 156

TM group
LME group

Analysis of variance  on n = 100

6. Kondwani
n = 34

TM group
DE group1. TM (transcendental meditation) or MF (mindfulness training) or MR (mental relaxation) or NT (no treatment)
3 months

2. TM or PMR (progressive muscle relaxation) or LME (preparation for a change in life style)
3 months
Measures of blood pressure on average 4 visits every 1 to 2 weeks at the beginning, and measures at the end of the preparatory period based on 3 measures taken during each of the last two preparatory visits. 
Monthly follow-up of blood pressure measures. 

3. TM or CS (control of cognitive stress)
4 months
Measures of ambulatory blood pressure after 9h

4. TM or LME
2 months
Measures of blood pressure after 10, 12 and 14 minutes taken lying down on the back once during the initial test and once during the final test 

5. TM or LME
4 months
Measures of the ambulatory blood pressure after 24h during the initial test, at 2 and 4 months during the final test and at 4 months of the follow-up 

6. TM or DE (diet and physical exercise program)
1 year
Measures of blood pressure (diastolic and systolic)        SAll of the clinical trials reported at present show important methodological weaknesses and perhaps are not objective due to the authors� involvement in the TM organization. It will then be important for future studies to be carried out by researchers who are entirely independent. At present, the results do not make it possible to affirm that TM has a positive cumulative effect on lowering blood pressure. 
Canter P.H. & Ernst E. (2003)Cumulative effects of transcendental meditation on the cognitive function: comparing the results of ten randomized clinical trials.
1. Miskiman
n = 120

TM group (n = 60)
R group (resting with eyes closed) (n = 60)

2. Pelletier
n = 40

TM group (n = 20)
S group (calmly seated) (n = 20)

3. Reddy
n = 30

TM group (n = 15)
R group (resting with eyes closed or lying on the back) (n = 15)

4. Sereda

n = 127
TM group
SY group (Savasana Yoga) 
PM group (pseudo meditation) 
NT group (control) (n = 25)

5. Yuille
n = 136

TM group (n = 37)
SY group (n = 38)
PM group (n = 36)
NT group (n = 25)

6. Kember
n = 16

TM group (n = 10)
NT group (n = 6)

7. Hall
n = 30

TM group (n =10)
VBR group (visual motor behavioral repetition) (n =10)
NT group (n = 10)

8. So
n = 114

TM group (n = 56)
N group (nap) (n = 58)

9. Mengel
n = 27

TM group
MA group (listening to music week 1 to 6) + RR (relaxation response week 7 to 12)

10. Alexander
n = 73


TM group (n = 20)
MT group (mindfulness) (n = 21)
R group (relaxation) (n = 21)
NT group (n = 11)

1. Training and practice of TM or resting with the eyes closed. 
40 days

2. TM or resting calmly seated 
3 months

3. Training and practice of meditation twice a day for six weeks or spending the same amount of time lying on the back with the eyes closed 
 6 weeks

4. TM or SY (body posture)  or PM (technique of self-instructed produced relaxation  �Ananda� Yoga)
3 months

5. TM or SY or PM
3 months

6. TM
6 months

7. Shooting practice 3 times a week 
 6 weeks

8. Training and practice of TM or taking a nap  
6 months

9. Instruction and practice of TM for 12 weeks or listening to music for 6 weeks followed by practicing Benson�s relaxation response. 
12 weeks

10. TM or MF (creative and structured mental activities) or MR (sitting with the eyes closed and repeating a chosen syllable
3 months1. Recalling lists of words after a session of arithmetic./Evaluation of the capacity to organize words in a conceptual manner (index of grouping) before and after treatment. 

2. Autokinetic test (following the movement of a point of light through a tube and representation of it) + embedded figures test (capacity to distinguish a simple figure embedded in a more complex one) + rod and frame test (capacity to position a rod within a tilted frame so that it is either vertical or horizontal, in a dark room). These 3 tests were conceived to put the subjects in the continuum field independence/dependence (ego-closeness/ ego-distance) 

Division of each group into 2�groups:
Group A: test before and after field independence treatment Group B: test after treatment only

3. Athletic performances, test of reaction time and coordination, intelligence test (Bathias) before and after treatment 

4. Measures of intelligence (Ravens progressive matrices), reading comprehension (Nelson-Denny), numerical estimation, memory for paragraphs and memory span for  numbers

5. Tests of short-term and long-term memory, perceptual aptitude, reading ability (Nelson-Denny) and intelligence (Raven) before and after the period of treatment 

6. Comparing the results of the examination (9 before treatment and 12 after)

7. Classical shooting tests before and after treatment 

8. Tests of field independence, speed of information processing and creativity. Test of entangled figures, the time for inspection, creative thinking - drawing  production, IQ 

9. Reading ability after 6 and 12 months of treatment.

10. DST (dementia) and SCWIT (measure of the degree to which incongruous stimuli delay a response) before and after treatment, repetitive mental task only after treatment.
The results do not allow one to prove that transcendental meditation has specific positive and cumulative effects on the cognitive function other than those which are nourished by practical effects or an effect of expectation/motivation. 
-------
The study done by Barnes et al. (2001) evaluates the impact of a transcendental meditation (TM) program on the cardiovascular function at rest and in situation of acute stress of adolescents showing a higher than normal level of blood pressure. It stresses research of a contemplative state of meditation by highlighting the interest in a different state of consciousness based on an overture to more spiritual dimensions. In this study, the TM group, in comparison to the control group, shows a more important decrease in the measures taken of systolic and diastolic blood pressure (SBP, DBP) during a session of driving simulation, as well as higher decreases in the measures of heart rate (HR) and cardiac output (CO). At the end of the interview, a decrease in the level of blood pressure (SBP) is observed in the two groups, with a higher decrease for the meditation group. The author concludes in the effectiveness of this technique for reducing stress and points out the interest of an initial randomized study comparing a control group for this technique of meditation. This form of meditation has been little studied over the last thirty years and would require more in-depth research as well as comparisons with other forms of meditation. 
In another study, Barnes et al. (2004) also show the benefits of the technique of concentration meditation on the heart rate and the ambulatory and resting blood pressure of female students. Here it should be recalled that concentration meditation is also part of a heritage of oriental traditions and emphasizes focusing attention on an idea, a thought, a sound, the breath or an object. On average, it is practiced 10 to 15 minutes per day. In terms of results, among the measures taken at rest, only SBP shows a significant difference (pre-test vs. post-test) between the two groups. The changes observed for the DBP and HR measures between the two groups are not statistically significant.
The differences between the groups are not significant regarding the daytime ambulatory measures at school of SBP, DBP and HR levels. Regarding the daytime ambulatory measures after school, the changes between the MED group and the control group are significant for SBP (-2.0 vs. 3.6 mm Hg), DBP (0.1 vs. 4.3 mm Hg) and HR (-5.3 vs. 0.3 bpm) levels.
 The nighttime ambulatory measures show a slight change in both groups. The HR measures in the nighttime ambulatory condition show a decrease in the MED group in comparison to the increase observed in the control group (-0.3 vs. 3.5 bpm). This technique of meditation shows a reduction in physical tension and in stress in general. However, more in-depth research is necessary to better understand these action mechanisms and to generalize the results obtained. Moreover, reference is not made to a strict and regular protocol of concentration meditation which could be analyzed and compared. This observation is found in a large number of studies dealing with concentration meditation, and will be developed in the discussion section of this paper.   
From the perspective of studies on concentration meditation, Smith et al. (1995) have studied the effects of associating a program of concentration meditation and PHEP (program for improving happiness) which is carried out in twelve one and a half hour sessions for a duration of six weeks. The results of this study suggest that a program intended to improve happiness and to reduce negative moods can be significantly improved by the addition of a simple form of concentration meditation.
Manocha et al. (2002) have evaluated the effectiveness of an intervention based on Sahaja Yoga meditation in addition to a medical treatment among adult patients suffering from asthma. This is a form of traditional meditation based on yogic principles which are used in a therapeutic approach based on concentration. While it uses exercises of focalizing attention, overture and contemplation, it emphasizes a �mental silence� in which the meditator is alert and conscious but disturbed by a mental activity. Meditation sessions of two hours per week for four months are given by an experienced instructor who suggests to the participants that they continue their practice after the formal sessions. The results of the study emphasize an improvement in the response of the air passages to methacholine (AHR) in the Sahaja Yoga intervention group compared to the control group. At the follow-up two months after the intervention, the difference between the two groups is no longer significant. The results show a positive effect on the quality of life in the Sahaja Yoga group. The evaluation of the POMS scale indicates improvements regarding tension and fatigue in the meditation group. This study shows the pertinence of this form of meditation as a supplementary therapy for the problems of asthma. Based on breath practices stemming from yoga and oriental traditions which lead subjects to states of psychological relaxation and rest, additional research would make it possible to better understand these action mechanisms in order to develop a more systematic form of therapy which could help patients interested in associated non medicinal therapies. 

Tloczynski & Tantriella (1998) have compared the practice of �Zen breath� meditation with relaxation on stressors in the context of student life. This form of meditation, which originates from the oriental Zen tradition, emphasizes the breathing process as the focal point of attention. If the meditator�s attention is perturbed by annoying or distracting thoughts, he can refocus on his breathing. Here, the effort of concentrating on the breath is primordial. It must be noted that this form of meditation based on the breath is only one of the techniques used in the Zen approach. Its interest lies in the fact that it can be applied quickly to non specialist subjects. This approach is found in a large number of techniques of meditation such as MBSR which uses it as one of the exercises of its protocol (Kabat-Zinn, 1990). Relaxation is defined more as a passive somatic technique of relaxation (Gilbert, Parker & Claiborn, 1978) which, unlike meditation, does not involve intention. Meditation, of course, can result in states of relaxation although this is not its main objective. The results of this study show that meditation and relaxation seem to be efficient strategies for students because they permit a reduction in anxiety, depression and stress. It must be noted that meditation offers slightly better short-term results. Moreover, it proves to be very efficient in reducing interpersonal problems, which is not the case with relaxation. Meditation certainly includes a �relaxation� component but it has a supplementary dimension regarding concentration, which would explain the better results. The two techniques would then be efficient and credible, but differently in function of the goal of the treatment and the type of individual. Future comparative research would be interesting and would make it possible to isolate the effects of the relaxation component in the meditative approaches. 
Manikonda (2007) has studied the effects of contemplative meditation combined with breathing techniques on lowering blood pressure and hypertension generated by stress. Stress is a risk factor and a mediating factor in hypertension (Chobanian & al. 2003).  Research on the reduction of stress has aimed at showing if these techniques can lower hypertension in a significant manner. This study shows that CMBT can effectively and without danger lower blood pressure in conditions of rest or mental stress in the first stage of hypertension, but the anti-hypertensive effects which result from it are not as convincing. Effectively, the experiment has some limits (impossibility to study separately the effects of meditation and breathing, risk of a placebo effect), but the results remain encouraging and justify more extensive studies dealing with the long-term effects of CMBT on blood pressure as a treatment in itself, or as a complement to pharmacological therapy. 
From the same perspective, Brazier (2005) has carried out research on the effectiveness of a program called the �Art of Living with HIV� which includes yogic breathing (concentration on the breath), a meditative practice of concentration, physical movements and a group process with seropositive patients over a fifteen day period. The quantitative and qualitative results show a positive impact of the program on the well-being of the patients while demonstrating the complexity, depending on how they perceive these effects and their duration. From a qualitative perspective, the patients report well-being after the experiment, giving them the possibility to better manage their lives in relation to their health problems, by offering them tools and more pertinent ways to face their everyday life. They have developed a greater consciousness of themselves, have learned to live in the present moment, have developed a greater sense of acceptance as well as a better understanding of the connection mind-body.  If the sample was sufficient for only observing the significant effects of the outcome of the in residence program, a larger number of participants would have, however, made it possible to detect significant changes during the follow-up, the effects being likely to diminish over time. This study also shows the necessity of combining different methods of analysis and confirming the results to obtain an optimal result. Moreover, with the exception of the concentative aspect, it was not possible to isolate the other factors acting in the framework of meditation from the group process which also has an important role in terms of group effect in the constitution of the well-being felt. It is difficult to say explicitly that the effect of concentration meditation has an exact therapeutic impact. Additional research on this method proves to be indispensable. 
Curiati (2005) has evaluated the effects of concentration meditation on reducing the sympathetic activity and improving the quality of life among older patients suffering from heart failure. This technique of meditation is partly based on listening to a 30 minute cassette containing instructions on breathing control twice a day. This breathing control is accompanied by concentrating on different parts of the body as well as a body scan. In addition, this technique includes mental repetitions of the word �peace� with the goal of hindering other thoughts from perturbing the mental state. Finally, concentration in terms of visualizing the heart in good health is added to these practices. It is the addition of these practices which make up this meditative approach based on concentration. The results of this research show improvements regarding noradrenaline blood levels, the quality of life and the VE/VCO2 slope, while the other parameters remain unchanged. Although it is encouraging, this study remains limited because it fails to include data on the prognosis and does not make it possible to define the exact action mechanisms of meditation on the sympathetic system. However, it allows one to consider meditation as a new hope in the treatment of congestive heart failure and justifies new studies, for example the effects of meditation on other diseases resulting in CHF and activating an influence on the sympathetic system. It must also be noted that the advantage of this therapy lies in the simplicity of its application, its low cost and noninvasive character. However, this meditative approach involves several techniques (body scan, breathing control, mental repetition, visualization), making it difficult to separate the components in order to know which one is effective. This constitutes an important bias in this approach which we will deal with later. 

In the same vein, Mehling (2005) has analyzed the effects of a therapy based on breathing (concentration) compared to physical therapy among patients suffering from chronic back pain. This technique based on breathing is accompanied by concentration on different parts of the body, body scan and relaxation movements. Developed in Germany in the 1920s, it is different from physical therapies in that the patient concentrates on physical sensations by developing greater corporal consciousness. The techniques of liaison and relation mind-body such as tai-chi, meditation, yoga, relaxation and therapies based on corporal consciousness were studied and were used for dealing with the problems of back aches and back pain by giving the patients greater awareness of corporal consciousness. Mehling (2001) suggests that therapy based on breathing increases both corporal consciousness and postural control which should improve this pathology. It has proven to be useful in the problems of back pain. 
The results show comparable improvements in the two groups. Therapy based on breathing shows results which are no better than physical therapy. If the small size of the sample does not make it possible to explain this fact, it could be, however, that the personalized adaptation of the interventions of physical therapy (diaphragmatic respiration and the use of techniques of mental imagery) have a role. Moreover, the positive impact of the therapy is directly linked to its duration.
However, this study does have limits because it does not allow one to evaluate separately the psychosocial, musculoskeletal, biomechanical and neuromotor factors linked to the rate of relapse as well as the reactivity to treatment. Additional studies must be envisaged in order to determine if the responses to the two therapies are specifically associated with the psychological, cultural or functional characteristics of the patient. This was the first study which made it possible to prove the beneficial effects of breathing therapy on chronic back pain. The qualitative data suggest that it could improve the treatment and shed new light on the effects of stress in relation to the illness. A new study should make it possible to determine if an approach combining the two therapies could prove to be more beneficial. 

Similarly, Williams et al. (2005) have studied the effects of concentration meditation (metta) and massages on the quality of life of patients in an advanced stage of AIDS. �Metta� meditation groups exercises of meditation linked to forgiveness and compassion, and are given by means of audio-cassettes to be listened to regularly, and oral instructions given by an instructor for a duration of eight weeks. This form of meditation leads to a questioning of a spiritual level regarding the relation to others and compassion. The massages consist of 30 minute interventions for five days. The results show significant improvements regarding both the quality of spiritual life and the overall life of patients who followed the combined meditation and massage intervention, as opposed to the massage or meditation interventions only. However, the interpretation of the results would have been optimized by tabulating the real number of interventions/responses despite the anticipation of the high number of defections compensated by an over-demand of patients. It would be interesting in future research to focus on a rigorous investigation of the synergic relation between meditation and massage, such as objective measures of physiological responses and a qualitative evaluation of the real experiences of the participants. A methodological improvement regarding the indicators of measures proves to be essential here. Additional research of this type of comparison would be very pertinent. 
Oman et al. (2006) have shown the positive effects of passage meditation on perceived stress, burnout, satisfaction with life and mental health. Passage meditation, also known EPP (Eight Point Program) consists of a succession of several exercises and advice to follow which are (1) repetition in silence and concentration on mantras (words or formulas) of a spiritual nature (not necessarily religious) for 15 minutes upon awakening, (2) repetition and concentration on words or a mantra of a spiritual nature at different times of the day, (3) advice for reducing pressure in daily activities, particularly in interpersonal conflicts, (4) training to focalize the attention on precise themes and objects, (5) learning to find pleasure in what is beneficial for the subject and learning to decondition oneself from certain harmful habits, (6) putting the interests of others first and developing compassion, (7) gaining awareness of spiritual themes through discussions with others, and (8) developing one�s inspiration through readings of a spiritual and religious nature. This program is strongly linked to spiritual development (Bandura, 2003). 
The results of this research show the positive effects of meditation on perceived stress and mental health, making it credible for applying it to stress management or other therapeutic applications. It constitutes an important base for carrying out other studies focusing on the way in which such practices can heal by drawing on spiritual or religious resources. However, one must cautious regarding the interpretation of the results because the study has some limits (lack of an active comparison group capable of more radically excluding contradictory explanations regarding the reported effects, absence of demonstrating the relation between cause and effect, small size of the sample, insufficiency of detailed measures concerning eventual past meditative experience). It would be interesting to study in future research the replicability and the generalizability to more diversified groups. It must also be pointed out that in this program, the subject does not only activate processes of concentration, but is led to questioning of a spiritual and religious nature which allows him to question or to relativize his existence. It would be judicious if the active elements in the globality of this program could be more clearly identified. This would be judicious in future research.  
Bormann et al. (2006) have studied the influence of mantric repetition meditation, in other words, concentration on a mantra (a word or a phrase) in the management of stress, anxiety, depression, the quality of life and on physiological indicators among seropositive patients. This type of practice of Indian origin is similar to the programs of transcendental meditation that we will develop more in a forthcoming paper. It emphasizes concentration of the mind on a word or a sound (mantra) that the subject repeats in silence or in a sonorous and slow manner. This program lasts ten weeks and consists of five weekly sessions of 90 minutes, and includes four weekly follow-up telephone calls. From a theoretical perspective, by referring to the broad model made by Kaplan et al. (1994), stressing events in life give rise to automatic responses, and intrusive and perturbing thoughts which can lead to divers symptoms of psychological dysfunction. The hypothesis of this model is based on the fact that concentration and mental repetition interrupt the development of negative and perturbing thoughts, and consequently increase psychological well-being in general. This model, of course, must be tested, operationalized and lead to more in-depth research. We mention it here for information only, our aim is not to go into the details of the psychological processes which underlie meditative activities, which would result in additional research. 
The results show that mantric repetition can contribute to significantly reducing psychological distress linked to anger and to increase spiritual faith associated with the quality of life among seropositive individuals. Important improvements have been observed regarding the results during face to face meetings, but maintaining them requires a follow-up contact at three months and encouraging practice. It is also important to note that some improvements are only felt after five weeks while other types of interventions on stress management require longer periods. These results justify carrying out more exhaustive research on mantric repetition in order to improve the understanding of its mode of functioning, because this study is found to be limited due to the unique geographical origin of its sample, the number of dropouts and the lack of objectivity of the guides. The underlying psychological processes of an eventual effectiveness must be investigated in an in-depth manner, particularly the cognitive and neurological activities associated with mental repetition and concentration. As shown by the research of Seeman et al. (2003) and Ironson et al. (2002), the variables of a spiritual nature must also be taken into account in this study since they can affect the patients� health.
Stigsby & Rodenberg (1980) have also studied the effects of mantra meditation on heart rate and the electrogalvanic response by using EEG measures.�The results show that experienced meditators are found to be in a state between vigilance and drowsiness on a quantitative level of consciousness. The EEG is incredibly stable during the 20 minutes of meditation; it can then be deduced that they are capable of putting themselves in a state which is characterized from an encephalographic point of view as an intermediary state between vigilance and drowsiness, and this in spite of the experimental situation. However, it will be necessary to carry out other studies because these results differ from those already obtained, by comparing, for example, the results of experienced and inexperienced meditators, by using a type of EEG analysis which makes it possible to establish more coherency between the cerebral hemispheres during meditation, without neglecting the parameter of falling asleep during the session of meditation.
It is difficult for scientists to establish a relation of cause and effect between the short-term physiological changes and the long-term beneficial psychological effects claimed by the meditators. However, after comparing the physiological state of meditation and the periods of sleep known for the respective well-being that they offer, we cannot exclude that practicing meditation for 20 minutes twice a day is not without significance, even if it would be necessary to carry out other studies to assess the objective value of meditation.  
We will now discuss in a general manner the results of the research on transcendental meditation which emphasizes concentration of the mind on specific tasks such as the repetition of a mantra or a sound as seen earlier. 

The first controlled studies on this subject date from the 1980s with Zuroff et al. (1978) who studied the effects of transcendental meditation and muscle relaxation on anxiety, the incapacity to adapt to one�s environment, LOC (Locus of Control) and the consumption of alcohol and marijuana. The authors have shown that among the three measures for evaluating anxiety, only the S-RI shows a real reduction in anxiety. Regarding the effects of meditation, the authors did not observe any significant difference (LOC and consumption of drugs and alcohol) for the other evaluations. These early research studies are marked by methodological lacunae. 

Puente (1981) has compared the psychophysiological effects (in two manipulations) of transcendental meditation with Benson�s relaxation response (BRR) and a control group without treatment. The first experimentation does not show significant physiological differences in the two practices used and the control group. There are no significant results in the second experimentation, and differences are not observed between the subjects with five years of experience in meditation and the subjects who have been practicing for one and a half years. In 1989, Gaylord et al. (1989) studied the effects of transcendental meditation and progressive relaxation on EEG coherence, stress and mental health for one year. The results for the TM and PR groups are significant regarding mental factors and anxiety. The TM group shows a significant increase in the coherence of the theta and alpha waves, unlike the two other groups which do not show convincing differences. The coherence of the brain waves during the TM phase is more marked in the right hemisphere. However, the regularity of the patients� practice is not measured, which largely limits these results. 
Schneider and Staggers (1995, 2005), and Schneider and Castillo (2001) have shown the effects of different approaches (TM, relaxation) compared to educational programs for changing life styles in reducing stress among older Afro-Americans suffering from low hypertension for a duration of three months. The results show the feasibility and the short-term effectiveness of this approach on reducing stress. TM and PMR significantly lower systolic and diastolic BP in comparison to the control group. The reductions with TM are about twice as important as those with PMR, as well as for the effects obtained regarding mental and behavioral health. However, confirming these results will require carrying out other studies on longer periods of intervention, larger groups (in order to compare the anti-hypertensive responses of groups taking medication or not), measuring BP at home by using ambulatory equipment and various technical samples in order to generalize the results to other populations. More precise additional studies on larger samples with a standardized protocol of meditation should give a definitive response to the effectiveness of practicing TM, particularly on lowering blood pressure. 
In a similar vein, Wenneberg et al. (1997) have evaluated the effects of reducing stress on cardiovascular reactivity and ambulatory blood pressure through transcendental meditation for 16 weeks. They do not observe significant differences, with the exception of the subgroup of high conformity. It can be deduced that the reduction in blood pressure or tension generated by transcendental meditation cannot be attributed to a mechanism of reactivity to stress. For the moment, reactivity then cannot be considered as a factor in hypertension but it should be assimilated as a sign of disease. It would be interesting to replicate this study by taking into account the effects of transcendental meditation on the mean ambulatory blood pressure among normotensive individuals. Thus, this study can also play an important role in the basic prevention of hypertension and the cardiovascular diseases which result from it. Complementary data are necessary. 

Three studies on transcendental meditation and cardio-vascular diseases have attracted our attention. First, the works of Walton & Fields (2004) who have explained the effects of transcendental meditation on cardio-vascular risks among postmenopausal women. By measuring the level of cortisol in the urine and the saliva, as well as blood pressure, the authors show the fact that a long-term practice of transcendental meditation reduces the response of the HPA axis (hypothalamic-pituitary-adrenocortical axis) in function of a metabolic stressor. A significant decrease in cortisol is also observed. This study suggests a significant effect of TM in this disorder and points to the preventive aspect of TM in coronary diseases.
Labrador and Polk (2006) have made similar conclusions in their study on the effects of TM on the components of metabolic syndrome among subjects with coronary heart diseases.  By using different measures of a physiological and psychological nature, the TM group shows significant variations concerning the following indicators: blood pressure (systolic outflow and mean), improvements in the levels of glucose and insulin. Moreover, an improvement regarding the vegetative nervous system is observed. The results suggest that TM can modulate the physiological response to stress by means of a neuro-humoral activation rather than to the stress itself. The authors show the limits of the study due to the size of the sample and its length. Further studies on larger samples prove to be necessary. Finally, Jayadevapp (2007) has evaluated the effects of a program for reducing stress by means of transcendental meditation on the functional capacity and the quality of life of Afro-Americans suffering from congestive heart failure and comparison with an educational cardiac program. The results obtained by means of transcendental meditation show improvements on all the scales measured. The physiological parameters remain unchanged. This program could then prove to be a valuable tool in the prevention and treatment of congestive heart failure. However, because of the small size of the sample and an overly short follow-up regarding more long-term effects, their validation will require other studies. 

After having briefly commented on the different studies chosen in this research, we will discuss the literary journals that we have also selected and which largely contribute to shedding light on this problematic. The works of Canter and Ernst (2003, 2004) on the possible positive effects of transcendental meditation on cognitive functions and on lowering blood pressure in comparison to other approaches, are based on six clinical studies (2004) for blood pressure and ten studies for cognitive activities, and show insufficient results to conclude in the effectiveness of TM. 
A number of researchers (Calderon, Schneider et al. 1999; King, Carr et al, 2002) have shown the therapeutic effects of transcendental meditation on blood pressure among patients with abnormal levels of blood pressure and among those showing signs of hypertension. In fact, all the clinical trials reported at present show important methodological weaknesses and may be lacking in objectivity because of the authors� involvement in the �transcendental meditation� organization. Without taking part of the polemic that we are unaware of, due to the novelty of the subject, it would undoubtedly be pertinent, as pointed out by Canter and Ernst (2004), for all future studies to be carried out by entirely independent researchers. From this point of view, the results do not make it possible to affirm at present that TM has a cumulative positive effect in lowering blood pressure. This study particularly highlights important methodological biases which will be developed in the discussion section and which stress the limits of the current approach to TM, not in terms of questioning the interest of TM, but by suggesting that researchers use much stricter and more controlled experimental protocols on larger samples, with stricter criteria of inclusion and more controlled physiological and psychological measures. This has recently been proposed in a meta-analysis by Anderson, Liu & al. (2008) which clearly shows positive effects in lowering blood pressure through regular practice of transcendental meditation. Hence, this practice is clearly to be considered as curative and preventive in this scenario.

Schneider and Kenneth (2006) have made a review of the literature concerning the evaluation of the effects of transcendental meditation and treatment based on Maharishi consciousness (MT) in the prevention of cardiovascular diseases and health promotion. The results show that treatments based on Maharishi consciousness have a positive impact on the risk factors of cardiovascular diseases, including a reduction in blood pressure, in the risk factor associating cholesterol/lipids oxides/tobacco, in patho-physiological mechanisms, in morbidity and in a reduction of the costs linked to care and chronic diseases which is so spectacular that it would largely justify more advanced studies. They could also help to partly attain the national objectives fixed by health professionals, in particular because of their preventive and holistic nature, as well as an improvement in the quality of life without secondary effects.   

The synthetic study by Arias (2006), which is not only based on transcendental meditation but also shows the interest in meditation in the treatment and prevention of physical and psychological disorders in twenty randomized studies, deserves attention. The results particularly reinforce the potential effectiveness of meditation techniques in treating illnesses stemming from non-psychotic humor disorders and anxiety, as well as those in which mental distress play an important role. However, their validation will require more extensive research, and certain questions related to the significance of the differences in the results obtained depending on the techniques of meditation, the contribution of mental activities in relation to physical activities or even other parameters (tolerability, generalizability, effectiveness and cost in the framework of a generalized application) still remain in suspension. The techniques of meditation can prove to be more effective if their role is limited to that of a complement to conventional therapies. In any case, they do not present any danger for the patients and the potential benefit of their integration justifies more research. 
Finally, we refer to the report by Ospina, Bond et al. (2007) on meditative practices in general and, more specifically, on mantra meditation including TM, with a review of 337 studies (randomized, non randomized, before/after and others) from 1972 to 2005 which, after calculating the size effect (in the context of meta-analyses), shows the following results:  
compared to no treatment, transcendental meditation does not produce highly significant results regarding the regulation of blood pressure (systolic and diastolic). However, these research studies show significant improvements regarding low density lipoprotein cholesterol (LDL-C) and verbal creativity. By making a comparison with a wait listed group and a before/after comparison, a significant reduction in blood pressure is observed (systolic and diastolic). However, additional studies are necessary (Anderson & Liu, 2008) in order to better control the methodological biases which can alter the results and show contradictory data from one study to another. This point will be developed below and constitutes a key remark in our work.

Discussion� 

This review of twenty-four clinical studies and four literary journals leads us to conclude that the results found on concentration meditation (mainly transcendental and mantra, as we have categorized them by choice) are contradictory regarding the effectiveness of the practice and suffer from methodological shortcomings. However, they highlight an important interest in terms of research and encourage more precise studies. The most convincing results that we have just commented on are encouraging and refer to pathologies linked to hypertension and cardiovascular diseases, management of stress and anxiety, and to physical and psychological well-being in general. All of these meditative practices, which mainly refer to focalizing the attention on a stimulus, show physical and psychological modifications concerning improvements in health. However, reservations of a methodological nature remain which are found in the study of the different practices of meditation and should be pointed out. We will emphasize these factors which can explain the variations in the results of the research with several remarks. If meditative practices aim to be useful in the field of health psychology and alternative therapeutics, and this in a preventive or curative manner, the methodological quality of the research must be the most pertinent as possible. 
First, the earlier works on concentration meditation (MT), which are not included in our research and which date from the period between 1970 and 1985, have suffered from important methodological lacunae (no randomized samples, no before/after control, little control on the definition of the method in terms of training). At a certain period, controlled studies were carried out to meet this limitation already pointed out by Smith (1975) when research was beginning in this domain. The size of the samples is often small in current studies and would require control studies on larger samples, thereby permitting a control of the results. 
Second, it is very difficult to have exact information concerning the content of the protocols of concentration meditation. Very little reference is made to the educational background followed in training in the context of transcendental meditation in the research studies. Mention is made of training in MT or mantra meditation, but it is difficult to make an effective comparison of different techniques without a common and recognized methodological protocol, as is the case with mindfulness meditation for which a common protocol was defined by J. Kabat-Zinn (1990), and later reworked by Segal & al. (2005) to give rise to the MBCT approach which results from the transformation of the original MBSR technique. Access to a strict protocol does not exist in the current research studies mentioned, but it is reported in the training of TM diffused by its instructors whose educational and therapeutic skills are unknown. Our interest is not to denigrate these training courses, nor to question the competence of the instructors, but to emphasize the importance of having a common approach which can be verified in order to be able to compare a similar object across different studies. It can be observed that certain aspects of this subject remain unclear. Third, in the approaches of concentration meditation (very often grouping transcendental meditation and mantra meditation, as well as techniques based on breath), several exercises are found such as body scans, exercises based on breathing, the repetitions of sounds and physical exercises. It would be interesting to isolate these different factors in order to determine which one acts the most in terms of results, and to know if it is the combination of all these practices which results in a benefit for the patient, or the repetition of a more specific technique. Shapiro (2006) refers to meta-cognitive and multifactorial processes in mindfulness meditation. In the context of mindfulness meditation, the subject activates a process of focusing the attention which would be worthwhile to study in a more in-depth manner. This observation is also valid for other forms of meditation. Fourth, the content, the diffusion and the evaluation of training courses given in the context of mindfulness meditation, in other words, the diffusion and the evaluation of the therapy, raise questions. Unlike other alternative therapeutics such as EMDR, which has a strict framework for training and diffusion based on precise criteria of selection for its practitioners, as well as for training and regular cycles of supervision, the practices of TM and concentration do not have a standardized framework of this type. Each therapist diffuses the method to his patients individually or in a group based on training which is not necessarily recognized and diffused by different organizations. Conditions for training instructors do not exist, nor for validating the competence required for diffusing this therapeutic practice. This is explained by the newness of this method, its link with the spiritual movements of the 1960s and the importance of its appropriation by the therapist. Differences can then be expected in the diffusion of the practice in function of its appropriation and its personalization. This leads us to ask the question of difference in terms of therapeutic impact. The lines of key exercises are used as points of reference, but the explanation and the transfer of the method can be done differently and, consequently, differences in terms of therapeutic effects are likely to appear.  Similarly, and unlike other therapies, the therapist can or cannot be a practitioner of his method. A therapist who has regularly practiced meditation for a number of years will necessarily have a perception of the meditative experience which differs from that of the therapist who chooses to diffuse it without regularly appropriating it. It is possible that this difference has consequences on the therapeutic results. Comparative studies should make it possible to provide answers. The fifth remark is linked to the distinction between a group practice and an individual practice in diffusing the method. The effect of group can constitute a therapeutic element in itself and should not be ignored. Here too, it would be pertinent to compare subjects trained individually with subjects trained in groups, and to see if the effect of group plays a role regarding therapeutic impact. Finally, a sixth remark concerns the question of therapeutic observance. The subjects who follow this type of practice are encouraged to practice this form of meditation several times a week for a determined period.  Subsequently, the practice is essential. Here the subject has an important active role in terms of involvement, insofar as he takes part in a personal method of practice which can suggest that he change his life habits. The role of the patient is also important in other forms of therapy but here, the therapist remains the organizer of the therapy which structures it with an indisputable dimension of power. In meditation, once the practice is diffused, it is the subject who is the fundamental actor of his well-being under construction and it is through this daily practice that he will be able to adopt a method for a different life. He remains alone, confronted with himself, and the choice to no longer practice for various reasons can be tempting and more or less emphasized in function of the different pathologies. Research on the factors of involvement and following meditative practices in general would be fruitful.

In conclusion, this review of the literature made it possible to shed light on different works on concentration meditation, particularly that of transcendental meditation which highlights a certain therapeutic interest. Although TM continues to have a poor image and its scientific validity is questioned, one notes that it is a domain in expansion which still suffers from important methodological lacunae in the operationalization of its approach. Results regarding effectiveness are seen particularly regarding hypertension, cardiovascular diseases and stress management, and are based on studies which are more and more rigorous. However, it is best to remain prudent and additional studies prove to be necessary to include this practice in a broader and more controlled field of research allowing more solid conclusions. We have emphasized the factor of concentrating or focusing the attention characteristic of these approaches which, at present, would require more in-depth development by using medical techniques and more sophisticated measurements. Health psychology would win by uniting with medicine in order to better understand the neurological mechanisms at issue. It is imperative to stress the active principles of these approaches by basing judgment on controlled experimentations of common and transmissible protocols. The link with the spiritual dimension is also marked in transcendental meditation and it is a rich domain which is beginning to draw the attention of researchers (Seeman, Dubin, 2003). Finally, it must be pointed out that meditation remains a new field of research in health psychology and that, while different orientations of meditation exist (mindfulness, concentration, contemplative � Shapiro, 2006), it is difficult to take a position on a single orientation even if it is more marked in one approach than in another. Meditation remains a subjective and personal activity which is part of a precise cultural framework. A medical approach is pertinent, thereby making it possible to diffuse this practice to a large population which is not part of a specific tradition. But the impact of the spiritual dimension that meditation stimulates in the psychological changes which can appear among individuals must not be underestimated. 



























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