2. Yoga as a non pharmacological alternative or complementary therapy for hypertension Manoj Sharma, MBBS, Ph.D. Session 3083; Board 1; Monday, October 31, 2011; 10:30 am

3. Introduction Hypertension is an important risk factor for heart disease and stroke. Treatment of hypertension reduces this risk. The Healthy People 2020 objective is to increase the proportion of adults with high blood pressure whose blood pressure is under control.

4. Prevalence of Hypertension Prevalence of hypertension in the United States based on the data from NHANES 2007-2008 indicate 29% people have hypertension (95% CI: 27.6% - 30.5%) defined as systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg. Blood pressure was controlled in approximately 50.1% (95% CI 46.8% - 53.5%) of all patients with hypertension based on NHANES 2007-2008 data. Not all patients accept pharmacological therapy.

5. Characteristics of yoga users 2002 National Health Interview Survey (NHIS) found about 5.1% of US population or over 14 million people were yoga users 85% Caucasians 76% females Means age of 39.5 years Hypertension was associated with lower use (OR 0.78; 95% CI: 0.64-0.95)

6. Stages of Ashtangayoga Yama: Techniques for successful living in society Niyama: Techniques for managing and purifying self Asaana: Postures for physical homeostasis & mental balance Pranayama: Breathing techniques for physical homeostasis & mental balance Pratihara: Techniques for developing dispassion toward senses for mental balance and equanimity Dharana: Concentration techniques for mental balance and equanimity Dhyana: Meditation techniques for mental balance and equanimity Samadhi: Universal consciousness

7. Purpose The purpose of this study was to examine whether yoga is beneficial as a non pharmacological alternative or complementary therapy for hypertension.

8. Methods The method used in this study was a systematic qualitative review of interventions obtained from MEDLINE, CINAHL, & ERIC databases. The criteria for including studies were: publication in English language, publication between 1975 and 2010, studies that measured blood pressure as an outcome, and studies that used yoga (from any school) as an intervention.

9. Results A total of 16 articles met the criteria with one study reporting two interventions. Eight interventions were from India, five from United Kingdom, three from United States, and one from Thailand. Only five interventions used randomized controlled trials. All the interventions demonstrated statistically significant beneficial effects of yoga on hypertension.

10. Studies 1, 2 (with 2 studies): 1975 DesignnDurationApproachRes.Country Age and sex matched control design 4012 months Relaxation, yoga & biofeedback +U.K. (a) Same (b) Same 40 32 6 weeks Yoga & Biofeedback ++++ U.K.

11. Studies 3, 4, 5: 1975, 1976, 1979 DesignnDurationApproachRes.Country RCT346 weeksYoga & Biofeedback +U.K. Time series 76 monthsTranscendental meditation +USA Pre-test Post test 444 weeksAsana + Pranayama +India

12. Studies 6, 7, 8: 1984, 1988, 1989 DesignnDurationApproachRes.Country Pre-test Post test 256 monthsShava asana+India Quasi exp. 604 weeksShava asana+India Case study 16 monthsYoga & relaxation +USA

13. Studies 9, 10: 1998, 2000 DesignnDurationApproachRes.Country Two group pre-test post test 203 weeksAsanas incl. shava asana +India RCT3311 weeksAsanas incl. shava asana +India

14. Studies 11, 12, 13: 2002, 2005, 2007 DesignnDurationApproachRes.Country Pre-test Post test 203 monthsAsana + pranayama +India Quasi exp. 618 weeksAsana + pranayama +Thailand Pre-test Post test 4287 daysAsana + pranayama +U.K.

15. Studies 14, 15, 16: all 2009 DesignnDurationApproachRes.Country RCT5712 weeksIyengar yoga +USA RCT603 monthsBreathing exercises +India RCT1138 weeksAsana + pranayama +India

16. Discussion…1 Almost all studies used shava asana (relaxation) which can be considered as the common denominator for effectiveness of yoga interventions for hypertension. Only five studies used randomized controlled trial (RCT) as the design. Future studies must use the robust RCT or group randomized controlled designs.

17. Discussion…2 Most studies had small sample sizes (< 50). Such small sizes limit generalizability and do not allow for subgroup analyses. Future studies need to use larger sample sizes. The duration of interventions ranged from 7 days to 12 months. This implies that duration is not associated with effectiveness. However, most interventions were between 6-8 weeks long and that seems to be most practical.

18. Discussion…3 It can be concluded that yoga is beneficial for management of hypertension and must be used more as a non pharmacological complimentary and alternative treatment of hypertension