Yoga Therapy Studies for Hypertension

 Yoga Therapy Studies for Hypertension

1. Yoga in Arterial Hypertension- 

Background: Yoga seems to exert its effect against arterial hypertension mainly through the associated breathing and meditation techniques, and through yoga postures. The goal of this trial was to compare the blood pressure-lowering effect of yoga interventions with and without yoga postures in patients with arterial hypertension. 

Methods: 75 patients taking medications for arterial hypertension (72% women, mean age 58.7 ± 9.5 years) were randomized into three groups: a yoga intervention group with yoga postures (25 patients, of whom 5 dropped out of the trial before its end), a yoga intervention group without yoga postures (25 patients, 3 dropouts), and a wait list control group (25 patients, one dropout). The interventions consisted of 90 minutes of yoga practice per week for twelve weeks. The data collectors, who were blinded to the intervention received, assessed the primary outcome measures "systolic 24-hour blood pressure" and "diastolic 24-hour blood pressure" before and after the intervention. In this report, we also present the findings on secondary outcome measures, including follow-up data.

Results: After the intervention, the systolic 24-hour blood pressure in the yoga intervention group without yoga postures was significantly lower than in the control group (group difference [Δ]= -3.8 mmHg; [95% confidence interval (CI): (-0.3; -7.4) p = 0.035]); it was also significantly lower than in the yoga intervention group with yoga postures (Δ = -3.2 mmHg; 95% CI: [-6.3; -0.8]; p = 0.045). Diastolic blood pressures did not differ significantly across groups. No serious adverse events were encountered in the course of the trial.

Conclusions: In accordance with the findings of earlier studies, we found that only yoga without yoga postures induced a short-term lowering of ambulatory systolic blood pressure. Yoga is safe and effective in patients taking medications for arterial hypertension and thus can be recommended as an additional treatment option for persons in this category.

2. Role of naturopathy and yoga treatment in the management of hypertension-

Background: The primary aim was to study the effect of naturopathy and yoga interventions in treatment of mild to moderate hypertension.

Methods: The variables of interest were measured at the beginning and end of the intervention using a pre-post design. The study was conducted by INYS medical research society in Jindal NatureCure Institute, Bangalore. A total of 104 subjects, already diagnosed with mild to moderate hypertension and on treatment with antihypertensive medicines, were included in study. The intervention consisted of various inpatient administration of different naturopathy treatments, yoga therapies, low calorie and low sodium diet for 21 days. Antihypertensive medicines were withdrawn for some patients in one week based upon response to the treatment. The outcome measures were values of diastolic and systolic blood pressure and body weight. Subjects were followed for a period of one year after every 3 months.

Results: After starting the non pharmacological approach of naturopathy and yoga, Systolic blood pressure came down from 139.6 to 129.6 whereas it came down from 91.2 to 86.1 for diastolic blood pressure. At the same time favorable effect was also seen in other variables like lipid profile and body weight. At the end of one year out of 57 patients who came for follow-up, 14 cases were found to have blood pressure within normal ranges without any medication over the previous 12 months.

Conclusions: Naturopathy and yoga therapy can be considered as a valuable non pharmacological approach in treatment of hypertension.

3. Effect of Yoga Intervention in the Managing of Hypertension: A Preventive Trial-

Background: Noncommunicable diseases are on the rise in India. Hypertension is one of the major risk factors for cardiovascular diseases and also labeled as a chronic lifestyle disorder. Hence, non-pharmacological interventions leading to lifestyle modifications are of utmost importance to control and prevent hypertension. This trial aims to implement yoga intervention to the experimental group in addition to medicines, advice on diet and physical activity and to compare blood pressure and perceived stress scores with the control group.

Methods: It was an open-label, two-armed, non-randomized controlled trial, conducted at a tertiary care center on 145 patients with hypertension: 73 in the intervention group and 72 in the control group. The intervention group received yoga intervention for a period of 4 months on a weekly basis along with advice on physical activity, diet, and routine medicines. The control group did not receive yoga intervention.

Results: The mean age of the participants was 51.3 ± 9.4, females (58.2%) outnumbered males (41.3%). Following the intervention, perceived stress score and blood pressure showed a significant reduction between two groups (P < 0.001). Also, perceived stress and blood pressure were found to be reduced significantly within both groups (P < 0.001).

Conclusions: Yoga proves to be an effective, safe, and less expensive adjunct therapy for hypertension management. Yoga was also found to be effective in reducing the level of stress. Diet modification and physical activity have an important role to play in the control and prevention of hypertension.

4. Impact of yoga on blood pressure and quality of life in patients with hypertension - a controlled trial in primary care, matched for systolic blood pressure-

Background: Medical treatment of hypertension is not always sufficient to achieve blood pressure control. Despite this, previous studies on supplementary therapies, such as yoga, are relatively few. We investigated the effects of two yoga interventions on blood pressure and quality of life in patients in primary health care diagnosed with hypertension.

Methods: Adult patients (age 20-80 years) with diagnosed hypertension were identified by an electronic chart search at a primary health care center in southern Sweden. In total, 83 subjects with blood pressure values of 120-179/≤109 mmHg at baseline were enrolled. At baseline, the patients underwent standardized blood pressure measurement at the health care center and they completed a questionnaire on self-rated quality of life (WHOQOL-BREF). There were three groups: 1) yoga class with a yoga instructor (n = 28); 2) yoga at home (n = 28); and 3) a control group (n = 27). The participants were matched at the group level for systolic blood pressure. After 12 weeks of intervention, the assessments were performed again. At baseline a majority of the patients (92%) were on antihypertensive medication, and the patients were requested not to change their medication during the study.

Results: The yoga class group showed no improvement in blood pressure or self-rated quality of life, while in the yoga at home group there was a decline in diastolic blood pressure of 4.4 mmHg (p < 0.05) compared to the control group. Moreover, the yoga at home group showed significant improvement in self-rated quality of life compared to the control group (p < 0.05).

Conclusions: A short yoga program for the patient to practice at home seems to have an antihypertensive effect, as well as a positive effect on self-rated quality of life compared to controls. This implies that simple yoga exercises may be useful as a supplementary blood pressure therapy in addition to medical treatment when prescribed by primary care physicians.

5. The Role of Integrated Approach to Yoga Therapy-Based Yoga Module in Improving Cardiovascular Functions and Lipid Profile in Hypertensive Patients: A Randomized Controlled Trial-

Background: Hypertension is a growing public health problem and its optimal management is imperative. Integration of lifestyle modification and yoga with antihypertensive drugs leads to its successful management. Yoga has been shown to modulate blood pressure (BP) and lipid metabolism in individuals with hypertension. The current study is a preliminary effort to ascertain the underlying mechanisms behind it.

Methods: Hundred patients were screened, among which 65 who met the inclusion criteria were recruited. After baseline assessments, they were randomly allocated (1:1) to an intervention group (IG) who practiced an integrated approach to yoga therapy (IAYT)-based yoga module for 6 days a week, for 3 months and a control group (CG) who received no intervention. BP, heart rate variability, and lipid profile were assessed before and after the intervention. Data acquired from 60 cases were analyzed by post-hoc analysis for multiple comparisons between the mean values.

Results: At the end of 3 months, within-group comparison showed significant changes (P < 0.05) in IG in all variables except triglycerides, high-density lipoprotein (HDL), and very low-density lipoprotein (LDL) while similar changes were not present in the control group. Significant differences were seen between the groups in the TC (P = 0.005), HDL (P = 0.047), non-HDL (P = 0.013), LDL (P < 0.001), LDL/HDL Ratio (P = 0.031), CHOL/HDL Ratio (P = 0.043), DBP (P < 0.001), SBP (P < 0.001), and all indices of HRV (P < 0.001).

Conclusion: These findings suggest that IAYT-based yoga module was effective in improving cardiovascular performance and lipid metabolism, thereby mitigating coronary artery disease risk.

6. Effectiveness of Yoga for Hypertension: Systematic Review and Meta-Analysis-

Objectives: To systematically review and meta-analyze the effectiveness of yoga for reducing blood pressure in adults with hypertension and to assess the modifying influences of type and length of yoga intervention and type of comparison group. 

Methods: Academic Search Premier, AltHealthWatch, BIOSIS/Biological Abstracts, CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, PsycARTICLES, Natural Standard, and Web of Science databases were screened for controlled studies from 1966 to March 2013. Two authors independently assessed risk of bias using the Cochrane Risk of Bias Tool. 

Results: All 17 studies included in the review had unclear or high risk of bias. Yoga had a modest but significant effect on systolic blood pressure (SBP) (−4.17 [−6.35, −1.99], P = 0.0002) and diastolic blood pressure (DBP) (−3.62 [−4.92, −1.60], P = 0.0001). Subgroup analyses demonstrated significant reductions in blood pressure for (1) interventions incorporating 3 basic elements of yoga practice (postures, meditation, and breathing) (SBP: −8.17 mmHg [−12.45, −3.89]; DBP: −6.14 mmHg [−9.39, −2.89]) but not for more limited yoga interventions; (2) yoga compared to no treatment (SBP: −7.96 mmHg [−10.65, −5.27]) but not for exercise. 

Conclusion: Yoga can be preliminarily recommended as an effective intervention for reducing blood pressure.

7. Content, Structure, and Delivery Characteristics of Yoga Interventions for Managing Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials-

Objectives: This systematic review aimed to synthesize the content, structure, and delivery characteristics of effective yoga interventions used for managing hypertension and to compare these characteristics with ineffective interventions.

Method: The JBI and the PRISMA guidelines were followed in this systematic review. RCTs conducted among hypertensive adults were included. RCTs reporting at least one of the major components of yoga (i.e., asana, pranayama, and dhyana and relaxation practices) and comparing them with no intervention or any intervention were eligible. Sixteen databases were searched for published and unpublished studies without any date and language restrictions till March 15, 2021.

Results: The literature search yielded 13,130 records. 34 RCTs (evaluating 38 yoga interventions) met the inclusion criteria. Overall, included studies had low methodological quality mostly due to inadequate reporting. Yoga reduced SBP and DBP compared to a control intervention (MD -6.49 and -2.78; 95CI% -8.94- -4.04 and -4.11- -1.45, respectively). Eighteen, 14 and 20 interventions were effective in improving SBP, DBP, or either, respectively. 13 out of 20 effective interventions incorporated all the 3 major components of yoga and allocated similar durations to each component whereas ineffective interventions were more focused on the asana and duration of asana practice was longer. The most common duration and frequency of effective interventions were 45 min/session (in 5 interventions), 7 days/week (in 5 interventions), and 12 weeks (in 11 interventions) whereas the most common session frequency was 2 days a week (in 7 interventions) in ineffective interventions. Effective interventions were mostly center-based (in 15 interventions) and supervised (in 16 interventions) and this was similar with ineffective interventions.

Conclusion: Findings suggest yoga interventions may effectively manage hypertension. Effective yoga interventions mostly incorporated asana, pranayama, and dhyana and relaxation practices and they had a balance between these three components and included regular practice. They were mostly delivered in a center and under supervision. 

8. Antihypertensive effects of yoga in a general patient population: real-world evidence from electronic health records, a retrospective case-control study-

Background: Despite decades of research and established treatment strategies, hypertension remains a prevalent and intractable problem at the population level. Yoga, a lifestyle-based practice, has demonstrated antihypertensive effects in clinical trial settings, but little is known about its effectiveness in the real world. Here, we use electronic health records to investigate the antihypertensive effects of yoga as used by patients in their daily lives.

Methods: A retrospective, observational case-control study of 1815 records among 1355 yoga exposed patients and 40,326 records among 8682 yoga non-exposed patients collected between 2006 and 2016 from a regional academic health system. Linear mixed-effects models were used to estimate the average treatment effect of yoga on systolic and diastolic blood pressures. Mixed effects logistic regression models were used to calculate odds ratios for yoga use and four blood pressure categories: normal, elevated, stage I, and stage II hypertension. Yoga notes were manually annotated and associated patient encounters were only included if the patient had a regular yoga practice, defined here as at least one yoga session per week, at the time of the clinical encounter (e.g., “goes to yoga class on Saturdays”, “exercise: yoga 3x per week”, “does yoga daily at home”). Yoga patient encounters were excluded if the note indicated yoga was used less frequently than one time per week (e.g., “yoga 2-3x a month”) or if there was no indication of frequency (e.g., “exercise: walking, yoga”). Otherwise, notes were annotated by the number of times a patient reported using yoga each week.

Results: Yoga patients are predominantly white (88.0%) and female (87.8%) with median age 46 years (IQR 32-57) who use yoga one time per week (62.3%). Yoga is associated with lower systolic (- 2.8 mmHg, standard error 0.6; p < .001) and diastolic (- 1.5 mmHg, standard error 0.5; p = 0.001) blood pressures. Patients using yoga have 85% increased odds (OR 1.85, 95% CI 1.39-2.46) of having normal blood pressure relative to yoga non-exposed patients. Patients aged 40-59 years have 67% decreased odds (0.33, 95% CI 0.14-0.75) of having stage II hypertension. All effect sizes are age-dependent.

Conclusions: Yoga, as used by patients in their daily lives, may be an effective strategy for blood pressure control and the prevention of hypertension at the population level.

9. A Randomized Controlled Trial Comparing the Effects of Yoga With an Active Control on Ambulatory Blood Pressure in Individuals With Prehypertension and Stage 1 Hypertension-

Background: This study was to compare the effects of yoga with an active control (anaerobic exercise) in individuals with prehypertension and stage 1 hypertension.

Method: A randomized clinical trial was performed using two arms: (1) yoga and (2) active control. Primary outcomes were 24‐hour day and night ambulatory systolic and diastolic blood pressures. Within‐group and between‐group analyses were performed using paired t tests and repeated‐measures analysis of variance (time × group), respectively. Eighty‐four participants enrolled, with 68 participants completing the trial. Participants in both groups were asked to attend two 55‐minute classes per week for 12 weeks and to perform 3 sessions of home practice for 20 minutes each week.

Results: Within‐group analyses found 24‐hour diastolic, night diastolic, and mean arterial pressure all significantly reduced in the yoga group (−3.93, −4.7, −4.23 mm Hg, respectively). Direct comparisons of the yoga intervention with the control group found a single blood pressure variable (diastolic night) to be significantly different (P=.038).

Conclusions: This study has demonstrated that a yoga intervention can lower blood pressure in patients with mild hypertension.

10. Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomized controlled multicentre trial in the primary care setting-

Background: Hypertension control remains a major challenge globally. A recent systematic review suggested that yoga has beneficial effects on reducing blood pressure. However, the role of yoga in hypertension management in primary health care has received little attention, and no studies have evaluated the impact of a yoga program fully delivered by health care staff on hypertension. This study, therefore, assessed the effects of a health worker-led yoga intervention on blood pressure reduction among hypertensives patients in the primary care setting.

Methods: This was a multicentric, two-arm, randomized trial conducted among hypertensive patients in seven Ayurveda Health Centres in Nepal between March 2017 and June 2018. One hundred and twenty-one participants who were on or without medications were randomized to intervention (n = 61) and wait-list control (n = 60) groups using stratified block randomisation. Participants in the intervention arm received an intervention consisting of an initial five-day structured yoga training at the centers and then a further home-based practice of yoga for five days a week for the following 90 days. Both intervention and control groups also participated in a 2-h health education session. The primary outcome of this trial was systolic blood pressure at 90-day follow-up. Data were analyzed on an intention-to-treat basis using linear mixed-effects regression models. The intervention group participants were encouraged to practice yoga at home for 30 min per day on five days a week, for the following 90 days from the last day of the training. The yoga program consisted of postures, breathing exercise and meditation structured for 30 min of practice (Additional file 2). Stretching exercise, lateral arc pose and twist pose were included in the initial 9 min of the session. This was followed by breathing exercises for the next 9 min. The remaining 12 min were allocated for meditation and relaxation activities. The combination of posture, breathing exercise and relaxation/meditation has a greater effect when combined.. 

Results: We included all 121 study participants (intervention/control = 61/60) in the primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The difference in systolic blood pressure between the intervention group and the control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse events were reported by the participants.

Conclusions: A yoga program for hypertensive patients consisting of a five-day training in health centers and 90 days of practice at home is effective for reducing blood pressure. Significant benefits for hypertensive patients could be expected if such programmes would become a part of the standard treatment practice.

Summary: My conclusions based on my review and synopsis of all the literature examined suggest there may be benefits attributed to yoga practice for blood pressure management. The beneficial effects of yoga on hypertension appear to occur by altering markers of sympathetic and parasympathetic activity. Effective yoga interventions mostly incorporated asana, pranayama, nidra, meditation and relaxation practices and they had a balance between these components included in regular practice. Physiological research on the effects of yoga on the body indicates that yoga is associated with a decrease in sympathetic nervous system tone and an increase in parasympathetic (vagal) activity, both of which are related to a reduction in stress-related responses. It has also been proposed that yoga has a beneficial effect on age-related arterial stiffness and encourages improvements in functional capacity as well as improving cardiovascular performance and lipid metabolism. The positive effects of yoga on stress reduction and functional capacity, which are closely related to hypertension, can make yoga an effective approach in hypertension management.

Reference List:

1. Cramer H, Sellin C, Schumann D, Dobos G. Yoga in Arterial Hypertension. Dtsch Arztebl Int. 2018 Dec 14;115(50):833-839. doi: 10.3238/arztebl.2018.0833. PMID: 30722837; PMCID: PMC6375068.

2. S.N. Murthy, N.S.N. Rao, Babina Nandkumar, Avinash Kadam, Role of naturopathy and yoga treatment in the management of hypertension, Complementary Therapies in Clinical Practice, Volume 17, Issue 1, 2011, Pages 9-12, ISSN 1744-3881, https://doi.org/10.1016/j.ctcp.2010.08.005. (https://www.sciencedirect.com/science/article/pii/S1744388110000605)

3. Hadaye RS, Shastri S, Salagre S. Effect of Yoga Intervention in the Management of Hypertension: A Preventive Trial. Int J Prev Med. 2021 May 27;12:55. doi: 10.4103/ijpvm.IJPVM_378_19. PMID: 34447497; PMCID: PMC8356946.

4. Wolff M, Sundquist K, Larsson Lönn S, Midlöv P. Impact of yoga on blood pressure and quality of life in patients with hypertension - a controlled trial in primary care, matched for systolic blood pressure. BMC Cardiovasc Disord. 2013 Dec 7;13:111. doi: 10.1186/1471-2261-13-111. PMID: 24314119; PMCID: PMC4029555.

5. Shetty S, Nandeesh NS, Shetty P. The Role of Integrated Approach to Yoga Therapy-Based Yoga Module in Improving Cardiovascular Functions and Lipid Profile in Hypertensive Patients: A Randomized Controlled Trial. Int J Yoga. 2022 Sep-Dec;15(3):215-221. doi: 10.4103/ijoy.ijoy_107_22. Epub 2023 Jan 16. PMID: 36949834; PMCID: PMC10026340.

6. Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: systematic review and meta-analysis. Evid Based Complement Alternat Med. 2013;2013:649836. doi: 10.1155/2013/649836. Epub 2013 May 28. PMID: 23781266; PMCID: PMC3679769.

7. Nalbant G, Hassanein ZM, Lewis S, Chattopadhyay K. Content, Structure, and Delivery Characteristics of Yoga Interventions for Managing Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Public Health. 2022 Mar 28;10:846231. doi: 10.3389/fpubh.2022.846231. PMID: 35419342; PMCID: PMC8995771.

8. Penrod NM, Moore JH. Antihypertensive effects of yoga in a general patient population: real-world evidence from electronic health records, a retrospective case-control study. BMC Public Health. 2022 Jan 27;22(1):186. doi: 10.1186/s12889-022-12569-3. PMID: 35086500; PMCID: PMC8796468.

9. Hagins M, Rundle A, Consedine NS, Khalsa SB. A randomized controlled trial comparing the effects of yoga with an active control on ambulatory blood pressure in individuals with prehypertension and stage 1 hypertension. J Clin Hypertens (Greenwich). 2014 Jan;16(1):54-62. doi: 10.1111/jch.12244. Epub 2014 Jan 4. PMID: 24387700; PMCID: PMC3948002.

10.  Dhungana RR, Pedisic Z, Joshi S, Khanal MK, Kalauni OP, Shakya A, Bhurtel V, Panthi S, Ramesh Kumar KC, Ghimire B, Pandey AR, Bista B, Khatiwoda SR, McLachlan CS, Neupane D, de Courten M. Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomised controlled multicentre trial in the primary care setting. BMC Public Health. 2021 Mar 20;21(1):550. doi: 10.1186/s12889-021-10528-y. PMID: 33743622; PMCID: PMC7981931.