INTRODUCTION:

An emotion that involves tense feelings, nervous ideas, and physical disturbances, including elevated blood pressure, is how the American Psychological Association (APA) defines anxiety¹.

When a person has severe distress and their ability to perform is impaired, normal anxiety turns into a pathological condition². According to extensive population-based surveys carried out in the twenty-first century, Anxiety problems affect up to 33.7% of individuals at certain points in their entire lives.

Most mental disorders are caused by anxiety disorders. Anxiety problems affect one in three people at some point in their lives, according to epidemiological study. The midlife stage is when they are most common³. The pathophysiology of anxiety is significantly influenced by neurotransmitters such as glutamate, GABA, dopamine, and serotonin⁴. Panic disorder, social anxiety, generalized anxiety disorder, and particular phobias are the four main types of anxiety. Post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) are two additional conditions that are frequently linked to anxiety disorders⁵.

The two most prevalent phobias, agoraphobia and simple phobia, both have significant prevalence rates. The lifetime prevalence of social anxiety disorder (2%–16%), generalized anxiety disorder (3%–30%), and obsessive-compulsive disorder (2%–4%) is lower⁶. Genetic and environmental factors can both contribute to anxiety⁷. Anxiety disorders occur more common in women while compare with men³. Physical symptoms of anxiety that often indicate autonomic arousal include dyspnea, shaking, vomiting, chest tightness, fast heartbeat, tingling or numbness, and dizziness. A wide range of emotional feelings, including fear and panic, trepidation, and nervousness, can be brought on by anxiety. Two cognitive symptoms of anxiety are worry, anxiety, negative thoughts about potential risks, and difficulty focusing. Behavioral anxiety symptoms such as evasion, running away, and seeking safety are often an attempt to avert or lessen a perceived threat or suffering. Anxiety's behavioral and cognitive symptoms frequently lead to ineffective functioning at work, home, or in social situations⁸. The GAD-7 and the Hamilton Anxiety Rating Scale are used to diagnose anxiety disorders^9,10. Research on the prevalence of anxiety indicates that almost half of those who experience it have difficulty falling asleep, especially with insomnia, and that anxiety can be exacerbated or even be the result of sleep loss¹¹. A healthy body and mind are reflected in a person's sound sleep¹². Good sleep quality is a strong predictor of overall vitality, mental and physical health¹³. Sleep issues are linked to early death, poor mental health, chronic illness, and diminished cognitive function. Sleep disruptions are more common in those with higher levels of chronic life stress, which includes tension at work, financial hardships, and general tension¹⁴.

Teachers are regarded as the most important social change agents. The teacher must become aware of his strengths and weaknesses in order to educate to the best of his ability and in accordance with national values in order to be able to carry out such a great responsibility¹⁵. Over the past few decades, technology's influence on education and teachers' professional development has expanded substantially. Furthermore, a number of factors, such as a lack of training or pressure to use the technology, have had an impact on people's brains. Over time, the issue of teacher stress and anxiety caused by educational technology has gotten worse¹⁶. Job satisfaction was affected by many reasons such assalary and perks, employment stability, relationships with superiors and students, workload and working conditions, interpersonal relationships among coworkers, opportunities for career advancement, and government regulations pertaining to the teaching profession¹⁷.

Teachers' personal lives are negatively impacted by the responsibilities they face, and they have less time for their families or themselves. Consequently, there has been a rise in symptoms associated with sleep, such as fatigue, insomnia, and inadequate sleep. A study of complaints regarding mental health in the state of Bahia found that instructors reported feeling sleepy in 14.1% of cases and drowsy in 22.6% of cases¹⁸. Pharmacological management for anxiety includes benzodiazepines, tricyclic antidepressants, SSRI, and additional drugs like hydroxyzine, mirtazapine, and nefazodone. Both patients and physicians need to be aware of the side effects of medications. All of these medications have the potential to cause constipation, headaches, dry mouth, weight gain, and sexual dysfunction^19,20. Add just "no" When it comes to treating anxiety problems, cognitive behavioral therapy is the most popular type of psychotherapy. It has been demonstrated that cognitive-behavioral therapy is a more successful approach to treating anxiety problems overall. The two most common first-line therapies for anxiety disorders are psychopharmacotherapy and cognitive behavioral therapy. Additional techniques for treating anxiety include mindfulness-based practices, acceptance and commitment therapy (ACT), metacognitive therapy, non-invasive stimulation techniques including transcranial magnetic stimulation or transcranial direct current stimulation, and aerobic exercise^21,22.

Vagus nerve stimulation (VNS), a strong anticonvulsant, has been found to have antidepressant effects when used to treat chronic depression that is not responding to medicine. The transmission of information from the vagus nerve to brain regions such the insula, hippocampus, locus coeruleus, and orbitofrontal cortex may impact the perception or incidence of numerous physical and cognitive symptoms that are particular to anxiety disorders. These areas play a crucial role in managing anxiety²³. The devices for transcutaneous vagus nerve stimulation (t-VNS) were initially suggested by Ventureyra. Since then, research has shown that these devices not only offer the benefits of portability, low cost, non-invasiveness, and less side effects, but they can also attain an equivalent degree of effectiveness as implantable devices. Auricular and cervical approaches (taVNS and tcVNS, respectively) are the two categories into which transcutaneous devices are separated.

The superficial branch, also known as the auricular branch, of the vagus nerve arises from the upper cervical ganglia and finishes in the ear concha chamber and outer auditory canal. This is the anatomic backdrop of trans-auricular devices. Modern transcutaneous devices with improved technology have shown promise in the treatment of post-stroke rehabilitation, severe depressive disorders, elderly patients, and resistant epilepsy. A few VNS patients reported feeling happier, having less fatigue during the day, and having higher quality sleep and life²⁴. To lessen the severity of anxiety and sleep disturbances, progressive muscle relaxation can be used as a cost-effective adjunct therapy to conventional medical treatment^25,26. Add only no Depression, anxiety, and tension can be effectively reduced using Jacobson relaxation²⁷. Although there are certain adverse effects associated with anxiety and depression medications, it is also possible for symptoms to return in the event that the dosage is lowered. There is an extended tradition of employing music as a treatment tool. In ancient Egypt, Greece, China, India, and Rome, music was considered to be a healer with a soothing influence that reduced anxiety and encouraged relaxation. Reducing anxiety with music therapy is an easy, secure, and cheap method²⁸. The objective of this study is to ascertain the degree to which teaching professionals' anxiety and sleep quality are influenced by technological advanced transcutaneous auricular vagal nerve stimulation (taVNS).

MATERIALS AND METHODS:

Subjects:

A nine-month study was carried out from April 2023 to March 2023. Teachers who arrived at a tertiary suburban hospital in the southern region of India with different concerns were also recruited, as were the teaching professionals from Saveetha University for this study. Participants aged between 20 and 35 years with a GAD-7 (Generalized Anxiety Disorder-7) value more than 14 and a SQS (Sleep Quality Scale) value greater than 40 who had ceased taking medications that affected their sleep one month prior to the start of the intervention, both male and female participants who willingly gave their consent, recognized the information on the scale, consented to participate in therapy, and agreed to follow, were included. Participants with neurological illnesses, recent injuries, heart disease, and participants with no interested in taking part in the study were eliminated, as were participants receiving essential therapy that could have an impact on the study's conclusion.

Ethical clearance:

01/020/2023/ISRB/PGSR/SCPT

Procedure:

Using simple randomization blind fold method, the 28 teaching professionals were split into two groups, A and B. Each group consists of 14 participants. This was a randomized feasibility study. A pre-test, such as the GAD-7 questionnaire and the Sleep Quality Scale (SQS), was administered before the intervention. During a period of four weeks, Group A underwent technological advanced transcutaneous auricular vagal nerve stimulation (taVNS) with Jacobson relaxation exercises. Each week, there were four sessions, and each session lasted 60 minutes.30 minutes for taVNS and 30 minutes for Jacobson relaxation exercise. The electrodes were positioned over the left ear's cymba concha. A sinusoidal waveform with a 0.2ms pulse width, 20 Hz frequency, 1 milliamperes amplitude, and stimulation intensity set to the highest level the patient could tolerate was chosen as the stimulation setting. Participants in the Jacobson relaxation exercise was told to close their eyes and find a comfortable seat. Contract the muscle and maintain it for slower counts of five seconds during this training cycle. Then, rapidly and totally relax the muscle for ten seconds. After every step, to help you calm down, take three deep breaths, in via your nose and out through your mouth. Group B received music therapy with Jacobson relaxation exercises for a four-week period, with four sessions each week and each session lasted 60 minutes. 30 minutes for music therapy and 30 minutes for Jacobson relaxation exercise. Music therapy at 432 Hz with a slow tempo, repetitive rhythm, gentle contours, and strings using headphones. Participants in the Jacobson relaxation exercise was told to close their eyes and find a comfortable seat. Contract the muscle and maintain it for slower counts of five seconds during this training cycle. Then, rapidly and totally relax the muscle for ten seconds. After every step, to help you calm down, take three deep breaths, in via your nose and out through your mouth. GAD-7 questionnaire and the SQS post-tests were evaluated four weeks following the intervention.

Outcome measure:

GAD-7 (Generalized Anxiety Disorder-7) questionnaire:

The level of anxiety over the previous two weeks are measured with this seven-item self-report anxiety test. A score of 0 to 21 represents the total. The patient is asked to what extent it affects them to be anxious, tense, or on edge; to have excessive concerns about different things; to find it hard to relax; to become angry quickly; and tofeel as though anything might happen. As a result, a person's anxiety level is categorized as low if it lies between 0 and 4, mild if it falls between 5 and 9, moderate if it lies between 10 and 14, and severe if it falls above 15. Its sensitivity is 89%, and its specificity is 82% for generalized anxiety disorder.

Sleep Quality Scale (SQS):

Six components of sleep quality are evaluated by the 28-item Sleep Quality Scale (SQS): daily symptoms, post-sleep wellness, difficulties falling asleep and staying asleep, difficulties waking up, and enjoyment of sleep. The total value ranges from 0-84, with more points denoting more severe sleep issues. There is 0.92 internal consistency and 0.81 test-retest reliability.

Statistical analysis:

The assessment involved conducting pre-tests on Groups A and B using the GAD-7 questionnaire and the SQS before the intervention. Following a 4-week intervention, both groups underwent post-tests, including the GAD-7 questionnaire and the SQS. The Wilcoxon Signed Rank Test was employed to contrast the pre- and post-test results for GAD-7 between the two groups, while the Mann-Whitney Rank Sum Test was utilized to assess the post-test variations for GAD-7 in both groups. Additionally, the Wilcoxon signed rank test was applied to evaluate the variation in SQS scores across both groups based on pre- and post-test results. Finally, the Mann-Whitney Rank Sum Test was used to determine the difference in post-test scores on the sleep quality scale (SQS) between the two groups.

RESULT:

In the statistical evaluation of the collected data for GAD-7, values before and after for both Groups A and B were evaluated with the Wilcoxon Signed Rank Test. In the pre-test of group A, 17.000 was the median value, 15.750 was 25% of the value, and 19.000 was 75% of the value. In the post-test, 11.000 was the median value, 9.000 was 25% of the value, and 11.250 was 75% of the value. A difference that was statistically significant was discovered (P = <0.001). In the pre-test of group B, 17.000 was the median value, 16.000 was 25% of the value, and 18.250 was 75% of the value. In the post-test, 14.000 was the median value, 14.000 was 25% of the value, and 15.250 was 75% of the value. A difference that was statistically significant was discovered (P = <0.001). The Mann-Whitney Rank Sum Test was used to examine the post-test results for Generalized Anxiety Disorder-7 (GAD-7) between groups A and B. In Group A, 11.000 was the median value, 9.000 was 25% of the value, and 11.250 was 75% of the value. In group B, 14.000 was the median value, 14.000 was 25% of the value, and 15.250 was 75% of the value. The two groups' median values differ beyond what would be assumed by chance; a difference that was statistically significant was discovered (P = <0.001). There was a statistically significant variance between groups A and B post-test. The P-value was < 0.001 in the Generalized Anxiety Disorder-7 (GAD-7) post-test. The Sleep Quality Scale (SQS) pre- and post-values for groups A and B were compared using the Wilcoxon Signed Rank Test. In the Group A pre-test, 55.500 was the median value, 47.500 was 25% of the value, and 63.500 was 75% of the value. In the post-test, 38.000 was the median value, 30.500 was 25% of the value, and 45.500 was 75% of the value. A difference that was statistically significant was discovered (P = <0.001). In the pre-test of group B, 53.500 was the median value, 47.000 was 25% of the value, and 61.000 was 75% of the value. In the post-test, 49.500 was the median value, 44.000 was 25% of the value, and 56.250 was 75% of the value. A difference that was statistically significant was discovered (P = <0.001). The Sleep Quality Scale (SQS) post-test results between groups A and B were examined using the Mann-Whitney Rank Sum Test. In Group A, 38.000 was the median value, 30.500 was 25% of the value, and 45.500 was 75% of the value. In Group B, 49.500 was the median value, 44.000 was 25% of the value, and 56.250 was 75% of the value. The two groups' median values differ beyond what would be predicted by chance. A difference that was statistically significant was discovered (P = <0.001). There was a statistically significant variance between groups A and B post-test results. The P-value was < 0.001 in the Sleep Quality Scale (SQS) post-test.

Table 1.1: Pre and Post-test values of Group A and Group B obtained using GAD indicate a reduction in the level of anxiety by physiotherapy intervention.

Groups	Test	Median	25%	75%	W value	Z value	P value
Group A	Pre-test	17.000	15.750	19.000	-105.000	-3.354	<0.001
Group A	Post-test	11.000	9.000	11.250	-105.000	-3.354	<0.001
Group B	Pre-test	17.000	16.000	18.250	-105.000	-3.397	<0.001
Group B	Post-test	14.000	14.000	15.250	-105.000	-3.397	<0.001

Table 1.2: post-test of group A and group B obtained using GAD.

Test

Median

25%

75%

T value

P value

Pre-test

11.000

9.000

11.250

106.500

<0.001

Post-test

14.000

15.250

Table 1.3: Pre and Post-test measurements of Group A and Group B were obtained using Sleep Quality Scale (SQS), indicating improvement of sleep quality.

GROUPS	Test	Median	25%	75%	W value	Z value	P value
GROUP A	Pre-test	55.500	47.500	63.500	-105.000	-3.320	<0.001
GROUP A	Post-test	38.000	30.500	45.500	-105.000	-3.320	<0.001
GROUP B	Pre-test	53.500	47.000	61.000	-105.000	-3.341	<0.001
GROUP B	Post-Test	49.500	44.000	56.250	-105.000	-3.341	<0.001

Table1.4: Post-test measurements of both Groups A and B were obtained using Sleep Quality Scale (SQS).

TEST

MEDIAN

25%

75%

T value

P value

PRE-TEST

38.000

30.500

45.500

131.000

<0.001

POST-TEST

49.500

44.000

56.250

DISCUSSION:

Our study was designed to identify the previously unrecognized anxiety that exists among teaching professionals. This study set out to determine how teaching professionals' anxiety and sleep quality were affected by transcutaneous auricular vagal nerve stimulation in conjunction with the Jacobson relaxation technique. Teachers need to adjust fast to changing norms and practices in education due to the rapid growth of technology. It's possible that this rate of change will make people more anxious²⁹. Women in the teaching profession have also reported struggling to strike a balance between their personal and professional lives³⁰. Teaching anxiety may have a major impact on instructors' classroom behavior and professional efficacy. Teachers who experience teaching anxiety may be less inspired to create engaging lesson plans, less motivated to use cutting-edge teaching strategies, and less willing to try new things³¹. Sleep difficulties are a common indicator of anxiety^32,33. Regular disruptions in sleep, drowsiness during the day, falling asleep too slowly, an entire night of tossed and turned are the quality of poor sleep³⁴. Anxiety can be reduced with a variety of treatments. Modern transcutaneous auricular vagal nerve stimulation is one such therapy that can improve the quality of sleep and reduce anxiety. It is a less-invasive method that involves applying an electrical current through surface electrodes at specific sites. Usually, it impacts either the cervical branch or the vagal nerves auricular branch, which is located in the neck. The two types of technological advancedtVNS treatments are auricular and cervical. Because both afferent and efferent fibers exist in the cervical position, it is difficult to selectively transcutaneously activate the vagus nerve fibers. In contrast, the vagus nerve's auricular branch innervates a section of the outer ear skin and is only an afferent, sensory nerve. Therefore, only the sensory arm of the vagus nerve is stimulated by trans-auricular vagus nerve stimulation (taVNS)³⁵. Transcutaneous auricular vagal nerve stimulation was previously studied by Yating Wu et al. in individuals with primary insomnia for a month, twice a day for 20 minutes each time. They came to the conclusion that safely, transcutaneous auricular vagal nerve stimulation at 20 Hz enhanced their sleep quality and decreased their anxiety and depression²⁴. Srinivasan Vignesh etal.,previously done a study on anxiety and sleep, he concluded that vagal nerve stimulation is effective in addressing anxiety and sleep disturbances³⁶. Yue Jiao et al., conducted an experimental study in which they discovered that, after four weeks, taVNS stimulation decreased anxiety, reduced sleepiness, and decreased depression³⁷. Srinivasan Vignesh et al., conducted an experimental study in which the vagal nerve stimulation reduced anxiety in retired teachers³⁸. The findings also support the use of taVNS stimulation, which offers a solid foundation for the current study's applicability in the treatment of anxiety in teaching professionals. There exist supplementary methods to reduce anxiety. The Jacobson relaxation technique is one of the therapies available. Progressive muscle relaxation needs neither a set location nor a set time, nor any specialized tools or technology²⁵. Akbari Ali et al., conducted an experimental study in which they concluded that relaxation techniques such as Jacobson and Benson are effective in reducing anxiety, depression, and stress in multiple sclerosis patients²⁷. One simple and inexpensive intervention for reducing anxiety is music therapy. Madineh Jasemi et al., conducted an experimental study to identify the impact of musical intervention on lowering anxiety in patients with cancer. After the intervention of 3 days for 20 minutes per day, they concluded that there was a reduction in anxiety and depression levels²⁸.

The statistical analysis of this study reveals that both interventions lower anxiety levels and improve the quality of sleep for teaching professionals, but when the two interventions were contrasted, technological advanced transcutaneous auricular vagal nerve stimulation combined with the Jacobson relaxation technique proved to be more effective at lowering anxiety levels and improving sleep. It offers a non-invasive, affordable treatment, which is one of its strong points.

CONCLUSION:

The current study shows that technological advanced taVNS stimulation is a safer and more efficient method for teaching professionals to reduce anxiety and improve sleep quality.

CONFLICT OF INTEREST:

Nil.

ACKNOWLEDGEMENT:

We are grateful to the individuals that developed the Generalized Anxiety Disorder-7 and the Sleep Quality Scale. The authors are appreciative of the important assistance provided by the suburban hospitals in southern India for the sample collection. We deeply appreciate the contributions from all of the participants, including the writers of the articles that were cited and referenced in this study.

REFERENCE:

1. Hart, J. Mind–Body therapies for treating anxiety. Alternative and Complementary Therapies. 2013; 19(6): 306-9. https://doi.org/10.1089/act.2013.19602

2. Khandagale C. An Exploratory Study to assess Social Anxiety among Adolescents Studying in Higher Secondary Schools of Pune City. Asian Journal of Nursing Education and Research. 2015; 5(2): 262-9. doi: 10.5958/2349-2996.2015.00052.X

3. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues in clinical neuroscience. 2022; 17(3): 327-335.https://doi.org/10.31887/DCNS.2015.17.3/bbandelow

4. Raju V, Bell JJ, Merlin NJ, Dharan SS. Anxiety disorders-a review. Asian Journal of Pharmaceutical Research. 2017; 7(4): 217-21. doi: 10.5958/2231-5691.2017.00033.8

5. Sarkar, D. A review of behavioral tests to evaluate different types of anxiety and anti-anxiety effects. Clinical Psychopharmacology and Neuroscience. 2020, 18(3): 341. doi: 10.9758/cpn.2020.18.3.341

6. Martin, P. The epidemiology of anxiety disorders: a review. Dialogues in Clinical Neuroscience. 2022, 5(3):281-298. https://doi.org/10.31887/DCNS.2003.5.3/pmartin

7. Michael T, Zetsche U, et al. Epidemiology of anxiety disorders. Psychiatry. 2007; 6(4): 136-42. https://doi.org/10.1016/j.mppsy.2007.01.007

8. Baker A, Simon N, et al. Anxiety Symptoms Questionnaire (ASQ): development and validation. General Psychiatry. 2019; 32(6): e100144. doi: 10.1136/gpsych-2019-100144

9. Thompson E. Hamilton rating scale for anxiety (HAM-A). Occupational Medicine. 2015; 65(7): 601. https://doi.org/10.1093/occmed/kqv054

10. Williams N. The GAD-7 questionnaire. Occupational Medicine. 2014; 64(3): 224. https://doi.org/10.1093/occmed/kqt161

11. Johnson EO, Roth T, et al. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. Journal of psychiatric research. 2006; 40(8): 700-8. https://doi.org/10.1016/j.jpsychires.2006.07.008

12. Adil H, Koser AA, Gupta A. Importance of Sleep for Medical and General Wellness. Research Journal of Pharmacy and Technology. 2019; 12(12): 5827-30. doi: 10.5958/0974-360X.2019.01009.6

13. Ohayon M, Wickwire EM, et al. National Sleep Foundation's sleep quality recommendations: first report. Sleep Health. 2017; 3(1): 6-19. https://doi.org/10.1016/j.sleh.2016.11.006

14. Steptoe A, O'Donnell K, et al. Positive affect, psychological well-being, and good sleep. Journal of Psychosomatic Research. 2008, 64(4):409-15. https://doi.org/10.1016/j.jpsychores.2007.11.008

15. Yoganandan G, Vetriselvan V. Personality traits of (in) effective teachers as identified by Indian MBA students: A qualitative study. Asian Journal of Management. 2017; 8(3): 403-6. http://dx.doi.org/10.5958/2321-5763.2017.00064.6

16. Fernández-Batanero JM, Román-Graván P, et al. Impact of educational technology on teacher stress and anxiety: A literature review. International Journal of Environmental Research and Public Health. 2021; 18(2): 548. https://doi.org/10.3390/ijerph18020548

17. Ruchika M. A study of job satisfaction amongst government and private school teachers in Delhi. Asian Journal of Management. 2017; 8(1): 30-6. doi: 10.5958/2321-5763.2017.00006.3

18. Souza JC, Sousa IC, et al. Sleep habits, daytime sleepiness and sleep quality of high school teachers. Psychology and Neuroscience. 2012; 5(2): 257-63. https://doi.org/10.3922/j.psns.2012.2.17

19. Garakani A, Murrough JW, et al. Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in Psychiatry. 2020; Dec 23; 11: 595584. https://doi.org/10.3389/fpsyt.2020.595584

20. Akhtar U, Wankhade AM, Dhokane YP, Akhtar S. Approaches towards anxiety due to post traumatic stress disorder: A review. doi: 10.52711/2231-5659.2023.00053

21. Ströhle A, Gensichen J, et al. The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International. 2018; 115(37): 611-620. doi: 10.3238/arztebl.2018.0611

22. Panthri K. A study to assess the Effectiveness of Aerobic Exercises on Anxiety among Substance Abuse Patients at Selected Psychiatric Rehabilitation Centre, Dehradun. International Journal of Nursing Education and Research. 2017; 5(1): 77-82. doi: 10.5958/2454-2660.2017.00017.5

23. George MS, Ward Jr HE, et al. A pilot study of vagus nerve stimulation (VNS) for treatment-resistant anxiety disorders. Brain Stimulation. 2008; 1(2): 112-21. https://doi.org/10.1016/j.brs.2008.02.001

24. Wu Y, Song L, et al. Transcutaneous vagus nerve stimulation could improve the effective rate on the quality of sleep in the treatment of primary insomnia: a randomized control trial. Brain Sciences. 2022; 12(10): 1296. https://doi.org/10.3390/brainsci12101296

25. Harorani M, Davodabady F, et al. The effect of progressive muscle relaxation on anxiety and sleep quality in burn patients: A Randomized clinical trial. Burns. 2020; 46(5): 1107-13. https://doi.org/10.1016/j.burns.2019.11.021

26. Gomathy G, Gracy GS. Effectiveness of Progressive muscle relaxation technique among clients with anxiety undergoing alcohol de-addiction in selected rehabilitation centers-Madurai, Tamilnadu. International Journal of Nursing Education and Research. 2021; 9(2): 207-12.

27. Akbari A, Ahmadi F, et al. The effect of relaxation technique (Jacobsen and Benson) on depression, anxiety, and stress in patients with multiple sclerosis. Current Psychiatry Research and Reviews Formerly: Current Psychiatry Reviews. 2020; 16(3): 213-9. https://doi.org/10.2174/2666082216999200819105928

28. Jasemi M, Aazami S, et al. The effects of music therapy on anxiety and depression of cancer patients. Indian Journal of Palliative Care. 2016; 22(4): 455. doi: 10.4103/0973-1075.191823

29. Henderson J, Corry M. Teacher anxiety and technology change: A review of the literature. Technology, Pedagogy and Education. 2021; 30(4): 573-87. https://doi.org/10.1080/1475939X.2021.1931426

30. John K, Paul M. Work and life Balance among Schools Teachers. Asian Journal of Management. 2018; 9(1): 565-8. doi: 10.5958/2321-5763.2018.00089.6

31. Yuruk N. The predictors of pre-service elementary teachers’ anxiety about teaching science. Journal of Baltic Science Education. 2011; 10(1): 17-26. [Book]

32. Trill MD. Anxiety and sleep disorders in cancer patients. European Journal of Cancer Supplements. 2013; 11(2): 216-24. https://doi.org/10.1016/j.ejcsup.2013.07.009

33. Srinivasan V, Abathsagayam K, Suganthirababu P, Alagesan J, Vishnuram S, Vasanthi RK. Anxiety’s correlation with sleepiness and memory among security officers during Covid-19 pandemic. Work. 2023; Dec 22: 1-7. DOI: 10.3233/WOR-230144

34. Cherian VE. Sleep Hygiene. International Journal of Nursing Education and Research. 2019; 7(2): 291-2. DOI: 10.5958/2454-2660.2019.00067.X

35. Rangon CM, Krantic S, et al. The Vagal autonomic pathway of COVID-19 at the crossroad of Alzheimer’s disease and aging: a review of knowledge. Journal of Alzheimer's Disease Reports. 2020; 4(1): 537-51. Doi : 10.3233/ADR-200273

36. Srinivasan V, Abathsagayam K, Suganthirababu P, Alagesan J, Vishnuram S, Vasanthi RK. Effect of vagus nerve stimulation (taVNS) on anxiety and sleep disturbances among elderly health care workers in post Covid19 pandemic. Work. 2023; Dec 22: 1-8. DOI: 10.3233/WOR-231362

37. Jiao Y, Guo X, et al. Effect of transcutaneous vagus nerve stimulation at auricular concha for insomnia: a randomized clinical trial. Evidence-Based Complementary and Alternative Medicine. 2020; Aug 7: 2020. https://doi.org/10.1155/2020/6049891

38. Srinivasan V, Ruthuvalan V, Raja S, Jayaraj V, Sridhar S, Kothandaraman M, Suganthirababu P, Abathsagayam K, Vishnuram S, Alagesan J, Vasanthi RK. Efficacy of Vagal nerve stimulation on anxiety among elderly retired teachers during COVID-19 pandemic. Work. 2024 Mar 15(Preprint): 1-8. DOI: 10.3233/WOR-230356

Received on 28.03.2024 Revised on 08.05.2024

Accepted on 12.06.2024 Published on 20.01.2025

Available online from January 27, 2025

Research J. Pharmacy and Technology. 2025;18(1):333-338.

DOI: 10.52711/0974-360X.2025.00052

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.