Hypertension: A Significant Health Problem

Question:

Discuss About The Effectiveness Harmony Randomized Controlled?

Hypertension or increased blood pressure is a major health problem today resulting in 7.5million deaths worldwide and 57million adjusted life styles (WHO, 2017). It is estimated based on current trends that by 2025, the number of people suffering from hypertension shall increase to 1.56 billion adults (Nejati et al. 2015).

The systolic and diastolic blood pressure of normal adults should be within 90-120 mm Hg and 60-80 mm Hg respectively. Any increase in these respective values shall lead to hypertension and enhance the risks for cardiovascular disease and stroke (Karak et al. 2014). Hypertension can thus lead to morbidity and mortality.

The manifestation of hypertension is not immediate but takes time to show symptoms like head and neck pain, pain in heart and chest region, shortness of breath, palpitation, and dizziness (Thakrar et al. 2016). This leads to late identification of the problem and progression into morbid conditions. Dietary changes, pharmacological therapies, and physical activity are suggested to treat hypertension and reduce blood pressure (Jain, 2016). The physical activity effectively modifies the lifestyle and complemented with medicines, assists the individual to manage blood pressure.

Yoga does not have a universally accepted definition but the concept encircles around tradition of physical activity of engaging into control of breath, different postures withy specific rules and contracts (Blom et al. 2013). The benefits of Yoga are recognised worldwide and it is said to enhance the mental and physical health. Thus, this is suggested as a strategy for reducing blood pressure to normal levels for hypertensive adults.

To critically evaluate the effectiveness of yoga on reduction of blood pressure among hypertensive adults.

• To evaluate the prevalence of hypertension in adults
• To assess prevalence among pre-hypertensive adults
• To evaluate the effect of yoga on hypertension

Several studies have been conducted to suggest that yoga can improve the health and enable hypertensive adults to maintain a healthy lifestyle. There have been several instances of lifestyle modification in adults and aged people worldwide which can be dealt in a cost-effective manner with the help of yoga. This traditional technique which originated in India, 5000years ago can be thus useful for reduction of elevated levels of blood pressure (Wolff, 2016).

Blood pressure is an extended part of the fight or flight response associated with anxiety, fear, stress, anger, excitement and anticipation which leads to activation of the sympathetic nervous system (Sujatha and Judie, 2014). It indicates that yoga can be of help since studies show it can regulate the various hormonal levels responsible for the flight or fight responses. The physical activities which comprise yoga can thus help reduce levels of blood pressure to normal in hypotensive adults.

The Role of Lifestyle Modification in Treating Hypertension

The study is particularly significant since there are several reports on the effect on yoga on the holistic health development. Yoga is known to treat several ailments of body pain, gout, and hormonal imbalance (Fahmi and Sari, 2016) and so on but the effect of yoga on particularly health of individuals affected by hypertension from a systematic perspective has never been conducted.

The study shall be conducted in with the adults, above 18years of age in perspective suffering from hypertension. The effect of yoga on their health and decrease in the level of original blood pressure or elevation would be assessed through this review that aims to critically analyse the impact of this age old tradition to modify the lifestyles of the hypertensive patients and linearize them with the normal lifestyle.

Hypertension is a significant risk factor that contributes to myocardial infarction, heart failure, and stroke and kidney disease. As per American Heart Association (2013), there has been 2.4 million in US in 2009, among which 348,102 died of hypertension (Chu et al. 2016). This incident particularly displays the prevalence which is widespread and is evident from the data. Though several medication and therapies have evolved in past decade, hypertension experts like Wahlstrom et al. (2017), Wolff (2016) and Cramer (2016) suggest through their studies that lifestyle modification and dietary changes may reflect as reduction of cholesterol levels, lowering of blood pressure and control of hormonal levels like thyroid, insulin etc.

Pharmacological intervention to reduce the cases of hypertension and controlling it in case of chronic patients, whose lifestyles have ben drastically altered due to it has been widespread. Research bySantaella et al.  (2014), suggests yoga can be a non-pharmacological intervention that may reduce the instances of morbidity or mortality caused due to hypertension.

According to Mayer-Berger (2017), Yoga is defined as a non-pharmacological, lifestyle intervention which encompasses breathing & meditation, that can be used as an effective tool to control blood pressure levels.

Yoga originated in India, thousands of years back and has recently come into limelight through diligent promotion and due to its diverse health benefits. It is reported by Singh et al. (2016) that yoga is the natural remedy for different diseases. It reduces stress and activates the autonomic function by suppression of sympathetic activity. Studies by Das et al. (2015), Roche and Hesse (2014) evaluate the effect and yoga on hypertension and suggest that the consistent practice for long durations of time leads to lowering of blood pressure levels. The study was conducted for 6 months.

Yoga as a Strategy to Reduce Blood Pressure

Meta-analysis by Wolff et al. (2013) shows the effects of yoga on reducing blood pressure levels in patients with hypertension and pre-hypertension. The study uses 17 control and 17 experimental, who undertook rigorous yoga in a systematic manner by a registered practitioner and this study led to the demonstration of an 8mm Hg reduction in systolic blood pressure and 6mm Hg reduction in diastolic blood pressure.

In case of pre-hypertensive adults, incorporation of pranayama in their yoga routine can be of benefit and efficiently assist them to control their blood pressure levels to normal. This may overall eliminate the chances of progression in stage I hypertension or delay the progression considerably (Hagins et al. 2014).

Studies by Tyagi and Cohen (2014) indicated acute and long term effects of hatha yoga on regulation of blood pressure. This study opted for a methodology based on practice of hatha yoga by following an instructional yoga video by participants. The study resulted in an immediate acute increase in blood pressure because of the increase in heart rate due to physical activity. The cardiac output is increased due to the intensive breathing and movement related activity like Pranayama, Vajrasana, Dhanurasana, Ustrasana so on and so forth.

The prehypertension and stage1 hypertension is increasing despite the introduction of several pharmacological interventions. Iyengar Yoga has been reported to be beneficial is reducing blood pressure by several researchers like Cramer (2014), Yadav (2016) and Posadzki (2014). But the trial leading to establishment of the fact that it can improve systolic and diastolic blood pressure levels and align it with the normal level came out of the randomised trial conducted by Wolff et al. (2013). 12 weeks of Iyengar Yoga could substantially reduce the blood pressure levels as compared to enhanced usual care (EUC). The EUC group was subjected to dietary controls and they showed decrease in levels of blood pressure as well. In case of Iyengar yoga however, there was no concomitant alteration in catecholamine or cortisol levels. Thus, the mechanism by which yoga helps the patients suffering from hypertension and prone to it is unknown but the effect is established by clinically significant data. The reduction shows up after constant yoga training for 12 weeks and not initially whereas the EUC results showed the blood pressure reduced gradually but to much lower extents, 3 mm Hg as compared to 6mm Hg at maxima.

Yogic relaxation and techniques involving bio-feedback were used for treatment of 20 hypertensive patients in the study conducted by Tyagi and Cohen (2014). It showed that antihypertensive therapy can be drastically reduced to 33-60% as in the case of 7 patients or stopped in 5 patents. Some patients could not respond to the therapy but other responded and the overall results were positive. Among the 5 patients who completely stopped ant hypertension therapy, one derived certain indirect benefits as it led to relief of migraine and depression.

Studies Showing the Effect of Yoga on Hypertension

Another study by Das et al. (2015) showed that using Shavasana can reduce the extent of hypertensive drug administration. The study involved 25 patients of essential hypertension. 20 patients of these were not subjected to any antihypertensive drug treatment whereas 5 were administered antihypertensive drugs before inclusion into the study. They were subjected to Shavasana and trained to perform it correctly. The training and administration of yoga continued for 6 months. Statistically significant decrease in the mean systolic and diastolic blood pressure was observed in both groups. Thus, the study concluded that the inherent requirement of antihypertensive drugs can be completely eliminated by practicing Shavasana for therapeutic purposes. It may otherwise be used as an adjunct in hypertension treatment for patients who suffer from chronic hypertension.

Studies by Mayer-Berger (2017) shows that yoga can successfully regulate the variables of hypertension. The patients of hypertension aged between 35-61 years of age were trained in yoga for 1 hour every day for 11 weeks and their levels or parameters like body weight, pulse rate and blood pressure were examined after the therapy. The control group here comprised on adults in that age group who took regular medication directed at lowering of hypertension. Results tested with ANCOVA showed that treatment stimulus, drugs and yoga can be effective for controlling the variables associated with hypertension.

According to studies conducted by Wahlstrom et al. (2017), psychophysical relaxation can be attained through yoga but the effects are not retained if the practice is terminated. 20 patients were subjected to yoga for 12 months and age, sex matched controls were monitored along with them. Those undertaking yoga as a part of their lifestyle showed reduction or control over their blood pressure however those who were in the control group showed irregularities more often. Significant reduction in blood pressure was observed in the yoga group but absent in control. This further validates the point that yoga can be beneficial especially for patients suffering from hypertension.

The studies considered for this review were selected based on their relevance to the subject topic. Those that presented a scattered inconclusive form were not considered. For the ease of understanding, studies conducted and published in English were only considered. The data that showed statistical relevance were given priority and data presenting the prevalence in recent times conducted on patients exposed to the modern day environment were considered. The modern day environment has several factors that affect the epigenetic factors and the lifestyle of the patient thus recent studies conducted of them are more relevant.

Conclusion

Non-randomised and preventive trials were excluded from the study. Furthermore, the studies based on normotensive and abstract articles in unrecognised journals and unreliable web sources were also excluded to conserve and enrich the value of systematic review.

The study is based systematic review of literature encircling the efficacy of yoga as a therapy in hypertension. The secondary archived literature sources mentioned in relevant and reliable papers, journals and websites. The conceptual clarity of the project has been retained by review of qualitative and quantitative secondary research. The project was conducted by examining the methodological quality and appropriate considerations with stringency were imposed to remove bias of any sort in the review systems. The JBI critical appraisal tool was used and data extraction was conducted with the sole aim of establishing the relationship between yoga and hypertension conclusively. The impact of the same shall be evaluated by critical appraisal methods by extracting data from PUBMED, CINHAL, SCOPUS and Cochrane database of systematic Reviews that enables the comprehension to develop. The basis or mechanism of yoga affecting the sympathetic nervous system is explored through a combination of studies that indicate the results of yoga could be enhancement of levels initially or reduction gradually in certain weeks. The project is thus designed in a methodical manner to critically analyse the merits and demerits of yoga and particularly emphasise on its effect on hypertensive adults.

To maintain the quality of the review, JBI critical appraisal tool was used. It enables the examination of methodological quality of any study and determines the bias in the study. The tool further enables the reprisal of bias in method of analysis which improves the quality of the study strategically.

Data extraction was done through detailed analysis of renowned journals and articles that are credible and reliable in terms of medical concepts so that the data is relevant. The relevant data was then extracted and represented on word and referenced through the Harvard referencing technique.

The proposed timeframe was abided by and proposal was composed in 2 weeks which required fundamental data extraction to formulate the strategy of research. Further expanded studies were conducted to find papers which were relevant and statistically significant enough to be considered to incorporation and examination under the current research. This study took 1 week time to evaluate and ascertain the quality appraisal. The further data extraction and review formulation as well as data synthesis subsequently took 2 weeks and construction of final report consumed a week for the complication of the wide range of the data so obtained for the current systematic review.

The search strategy was implemented by using databases that confer assistance of finding the clinically relevant data on randomised trials directed at hypertension. The databases PUBMED, SCOPUS, CINHAL and Cochrane database of systematic Reviews were consulted with key words, hypertension, yoga and effectiveness to find and extract the data recently updated in these fields for the incorporation and inference extraction from the review. The systematic review has been strategically composed in accordance with the structure of report and specialised keywords like randomised trial, yoga postures for reduction of hypertension and impacts of yoga on hypertensive adults were used for extraction and search efficiency elevation. The strategic findings were then reviewed.

The methodological quality was ensured by inclusion of data from reliable sources and acknowledged journals and articles published in the aforementioned databases. The quality of the study was further evaluated by the reviewer based on the structure and methods that led to the conclusion. The relative intensity of research and statically relevance of the data was taken in to consideration while incorporation of the extracted data in to the current study.

The overall outcome of this study was focussed on Yoga and it respective impact on hypertensive adults. Several randomised trials and qualitative data were taken in consideration for this. The reason for the strategic incorporation of the positivist theory and inclusion of reliable literature that discusses the fundamental effect of increases in variables of blood pressure is to constrict the study to these dependant variable, hypertension and independent variable, yoga. The systematic review has brought into light several insights that developed gradually as more pieces of studies were evaluated and compiled to produce the ultimate constructive review of the non-pharmacologic intervention of yoga on the lifestyle and medical requirements of the hypertensive adults, above the age of 18 who have developed the condition because of several causative reasons such as stress, anxiety and so on. The measures of the outcome were derived from both qualitative and quantitative achieved data.

Yoga is an ancient form of exercise that helps the hypertensive adults to control their condition. Yoga has a holistic effect on the body and mind of the patients and in a yet undiscovered manner assists in lowering the systolic and diastolic blood pressure levels to normal. The requirement for medication and pharmacologic intervention can be completely eliminated by practising yoga according to some studies (Fahmi and Sari, 2016). However, other studies indicate that for chronic patients yoga can act as a supplementary method that helps them to keep the levels under control and reduce the systems and risk associated with morbidity (Wahlstrom et al. 2017).

Hypertension is a part of the flight or fight response and thus rigorous physical activities can elevate the levels of blood pressure. Bothe the levels can substantially managed by employment of yoga according to Cramer (2016) but the study indicates there is subsequent effect on the catecholamine and cortisol levels that may be reflected as a lowering. However, yoga may induce changes in hormonal levels such as adrenaline involved in the fight or flight response thus leading to reduction of blood pressure and heart rate (Chu et al. 2016).

Another contracting fact that deviates from the ideology that yoga affects the hormonal levels to regulate the blood pressure is that, initially the blood pressure rises and the heart rate is also substantially higher than usual but with proper asana like Shavasana, Iyengar yoga and Hastha asana the long term benefits of yoga are observed (Karak et al. 2014). The effects of yoga appear late as compared to diet induced control of hypertension. The resultant 6mmHg reduction in systolic and diastolic pressure occurs only after 11-12 weeks and not gradually as in EUC where initial lowering of 2mm Hg is observed and with increase in duration 3mm Hg is achieved (Santaella et al. 2014). The lowering is thus subjective. The mechanisms by which yoga benefits the hypertension patients are yet unknown but the effect is evident form this study.

Several studies further indicate that the mortality and morbidity rates due to hypertension is relatively high in countries where obesity is prevent like US and thus Yoga’s effect on loss of weight concomitant with lowering of blood pressure may corroboratively contribute to the higher rate of reduction (Jain, 2016). Diet induced and pharmaceutical drug induced reduction of blood pressure is limited but the regulation can be achieved in a far more cost-effective manner with the use of yoga as an additional non-pharmacologic additive to the daily life of these individuals (Wolff, 2016). As for the pre-hypertensive individuals who are on the verge of adapting to a solely medicine based treatment of hypertension can adopt this strategy of performing yoga daily for hour to reduce the chances.

Hypertension is seen to associate with heart attack, stroke, cardiac arrest, blockage and several other ailments that affect the lifestyle of the adults drastically. Yoga can help in the betterment of the lifestyle but the initial elevation of blood pressure levels on beginning the therapy must induce some problems if the patient is already suffering from a chronic heart condition (Das et al. 2015). Thus, the type of yoga must be administered with diligent care and not simply followed through any available tutorial. The hypertensive adults must specifically undertake Shavasana, Iyengar yoga and Hastha asana for controlling their blood pressure levels. These asana also render certain additional benefits in form of alleviation of migraine in certain individuals thus the practice should be widespread and suggested by physicians (Mayer-berger et al. 2017). The yogic practices that originally evolved in India today has spread into the world because of it wide applicability and health benefits that are impossible to ignore. The advantages are enormous and specific asana can help alleviate the specific problems of every individual (Wang et al. 2013).

However, caution must be exercised by patients of hypertension while practicing other forms of yoga that require rigorous activity or indulging in uncomfortable postures since they may induce an increase in the heart rate. Hence, practicing yoga is a subjective concept that is rapidly evolving to display the specific asana as that benefits the specific health conditions like hypertension.

Yoga asana involves a plethora of postures and breathing techniques hence the specific yoga for hypertension, viz. Shavasana, Iyengar yoga and Hastha asana must be practiced by hypertensive adults and other asana must be practiced for additional ailments (Wang et al. 2013) with evident feedback from community or medical practitioners suggestion as they may be harmful for the hypertensive patients and lead to elevation of the levels which might have further repercussions on the health of the individual.

Thus, the study conclusively states through a descriptive review based on the research articles that performed primary studies on hypertensive individuals, that yoga has an overall positive impact on the health of hypertensive patients if they are practising the right asana or postures. The correct postures practised for long terms like 11-12 weeks can lead to improvement of their condition and overall disabled lifestyle (Fahmi and Sari, 2016).

Hypertension may perturb the normal lifestyle of patients suffering from it; reduce their life span by coercing them towards heart diseases and disorders that lead to attacks, stroke and cardiac arrests (Das et al. 2015). The pharmaceutical based intervention has proven to be effective but the cost-efficiency can be increased and the dosage of medicine can be substantially lowered by using yoga as an additive to the treatment of theses hypertensive adults (Wang et al. 2013).

The modern day stress and work pressure as well as work-life imbalance and other environmental factors has affected the mental and physical health which is reflected as the increased number of hypertensive patients and the increased cases of morbidity or mortality because of hypertension (Mayer-berger et al. 2017). These hypertensive and the pre-hypertensive patients can thus be substantially assisted by using yoga as a lifestyle choice which consumes simply 1 hour a day for leading a healthier life.

Conclusion

The study aimed to illustrate and combine the varied studies conducted on yoga as an effective means of reducing blood pressure that describe the cumulative effects of diverse yoga postures on the health of hypertensive adults.

For the purpose, a qualitative and quantitative secondary approach has been adopted where through constructive critical analysis and stringent inclusion and exclusion criteria implementation, certain articles and papers that concentrate their findings on the correlation of yoga and hypertension has been reviewed systematically for extraction of indispensible information to conclusively suggest the impact of yoga on hypertensive adults.

Hypertensive adults can benefit drastically and the completely eliminate the usage of medication for controlling blood pressure from their lives by practising proper yoga postures like Shavasana, Iyengar yoga and Hastha asana that have recognised benefits in case of hypertension. The practice of yoga for long spans of time like 11-12 weeks can help in controlling blood pressure a lead to lowering of dosage in chronic hypertension patients. Those on the verge of developing it, pre-hypertensive patients may also be benefited by the practice of yoga and their case may arrest at that stage itself, further progression into hypertension can be prevented completely. However, certain studies have shown there is an increase in heart rate and blood pressure initially, thus the yoga postures must be practised with caution by hypertensive patients so that the therapy does not affect their wellbeing in any way and doesn’t effectively lead to ailments like heart diseases and fatigue.

The study has been mainly limited by the time and resources. There were several more studies that require paid access and thus could not be availed for the current study, furthermore the study has also been limited by the relevant sources of literature and exclusion criteria set by the researcher. Since, many articles have been discarded due to publishing in unrecognised journals and web sources for enhancing the quality of the current study. The study is thus primarily limited by time and secondarily by the databases comprised of research papers which lacked in terms of insightful reviews on the impact of yoga and more postures that could be employed for reduction of blood pressure.

• Incorporation of yoga therapy as an adjunct to medicine based therapy for chronic hypertension patients shall be beneficial
• Guidance from medicinal practitioners based on the asana of yoga that may be of significant benefit to hypertensive and pre-hypertensive individuals must be provided after diagnosis.
• Hypertensive and the pre-hypertensive patients should be aware of using yoga as a lifestyle choice which consumes simply 1 hour a day for leading a healthier life.

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