Yoga and Hypertension

Complementary and alternative medical therapies for treatment and prevention of hypertension are increasingly popular with the lay population. Mind-body therapies (MBTs), in particular, the Transcendental Meditation and yoga, have raised interest because they represent an alternative to medication and may contribute to an increased feeling of empowerment for patients in preventing and treating their hypertension. The Canadian Hypertension Society has even recognized the role of multicomponent stress management techniques in managing hypertension.1 The thinking is that stress plays a role in the pathophysiology of hypertension and that MBTs represent an alternative to traditional lifestyle modification. Traditional lifestyle recommendations include weight loss, diet modifications, and increased physical activity, which can reduce systolic blood pressure (BP) by 3 to 10 mm Hg. Yoga, a movement-based MBT, is an intriguing therapy in the management of elevated BP because of its wide appeal to Westerners and its combination of gentle physical activity, slowed regulated breathing, and meditation. This makes yoga especially attractive to older patients and those with musculoskeletal conditions who may not be able to engage in more rigorous aerobic physical activity.2 Yoga is based on 1 of 6 systems of Indian philosophy that have been transmitted orally through generations. Patanjali, the father of Ayurvedic medicine, wrote a treatise called the Yoga Sutras in which he formalized this discipline. The word yoga originates from the Sanskrit for union and aims to harmonize mind, body, and spirit. Traditional yoga incorporates the 8 limbs as set out by Patanjali: yamas and niyamas (moral and ethical restraints), asanas (postures), pranayama (regulation of breathing), pratyahara (internalization of the senses), dharana (concentration), dhyana (meditation), and samadhi (self-realization).3 Iyengar yoga, developed and popularized by B. K. S. Iyengar, emphasizes the precise use of alignment in a wide variety of asanas to derive therapeutic benefit. There are 200 different asanas used for a variety of medical conditions ranging from musculoskeletal complaints to internal organ disturbances such as hypertension, diabetes, and heart disease.4 Iyengar is primarily responsible for the Westernization of yoga and the use of yoga as medical therapy. Several reports attest to the effects of various yoga programs on BP.5–8 Most of these reports have been uncontrolled case reports or small cohort studies with significant methodologic limitations. There have been only 2 randomized controlled trials of yoga for hypertension.9,10 In the most recent study, done in India, 33 hypertensive adults were randomly assigned to 3 groups (yoga, medications only, or no therapy) and were followed for 11 weeks.9 Yoga was performed at home for 6 hours per week and included a combination of asanas, pranayamas, and mantras. At the end of the study, the systolic BP was reduced by an impressive 33 mm Hg compared with 4 mm Hg in the control group and 24 mm Hg in the poorly described drug therapy group. The differences were significant compared with both control and drug treatment. In the other older randomized controlled trial, in England, 43 known hypertensives, most of whom were already medically treated, were randomized to yoga + biofeedback or usual care.10 Treatment reduced systolic BP by 26 mm Hg vs 9 mm Hg in the control (P < .005) group. This study used a mixed intervention that included biofeedback in addition to yoga, however, which was more like Transcendental Meditation and did not include any movement. We have recently completed a pilot study at the University of Pennsylvania assessing the effects of Iyengar yoga vs enhanced dietary intervention on BP showing comparable BP reductions in prehypertensive and stage 1 hypertensive patients (D.L.C and R.R.T., unpublished data, 2007). Given the general acceptance of yoga therapies and their high tolerability, we hope to see more randomized studies to elucidate how well the antihypertensive effects of yoga can be generalized to patients with stage 1 hypertension and, in particular, to those with prehypertension, for whom therapeutic goals are mostly rooted in lifestyle interventions.

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