Running head: YOGA STYLE AND BLOOD PRESSURE
The short-term effect of Hatha, Power, and Eischens Yoga on blood pressure
by
Shannon Mikrut
M.A., Concordia University, Nebraska 2014
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master in Public Health
Concordia University, Nebraska
December, 2014
YOGA STYLE AND BLOOD PRESSURE
Abstract
Background: Yoga is a physical and meditative practice that has long been used to
improve health and emotional well-being. Throughout the years, different styles of yoga
have emerged, each offering its own unique approach to connecting the mind and body to
influence positive health outcomes.
Aim: The aim of this study was to measure the blood pressure (BP) of participants before
and after 60-minute classes of three different types of yoga: Hatha, Power, and Eischens,
to determine if one style of yoga reduces BP more than another.
Methods: The BP of 76 participants was measured before and after scheduled Hatha,
Power, and Eischens Yoga classes in Chaska, Minnesota. A Likert-type survey measuring
general fitness, as well as basic demographic information was also collected. Data was
analyzed using t-test, mean, ANOVA, ANCOVA, and Bonferroni’s corrected t-test.
Results: The results of this study showed that there was a mean reduction in BP among
all styles (p = 0.000), but no observable difference was found when comparing the
difference between the styles of Hatha, Power, and EischensYoga (SBP: p = 0.49; DBP:
p = 0.61).
Conclusion: Yoga was found to effectively lower BP among participants; however, when
comparing the differences between styles, no style of yoga decreased BP to a notable
degree more than another after a 60-minute class. These findings are of great importance
because a growing number of Americans continue to be diagnosed with high BP. The
data suggests that yoga can aid hypertension patients in reducing or maintaining a healthy
BP, regardless of which type of yoga they practice.
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YOGA STYLE AND BLOOD PRESSURE
Table of Contents
List of Tables .................................................................................................................... vi
List of Figures .................................................................................................................. vii
Chapter 1: Introduction ....................................................................................................1
Overview of Hypertension and Yoga ............................................................................1
Thesis Statement ............................................................................................................5
Purpose of the Study ......................................................................................................5
Research Questions ........................................................................................................5
Theoretical Base.............................................................................................................6
Definition of Terms........................................................................................................7
Assumptions...................................................................................................................9
Limitations .....................................................................................................................9
Delimitations ................................................................................................................10
Significance of the Study .............................................................................................11
Summary and Transition ..............................................................................................11
Chapter 2: Literature Review .........................................................................................13
Introduction ..................................................................................................................13
Literature Search ..........................................................................................................14
History and Primary Treatment Methods for Hypertension ........................................14
The Use of LSMs and CAMs for Lowering BP ..........................................................27
Yoga’s Effects on Preventing, Reducing, and Managing High BP .............................37
Summary ......................................................................................................................47
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YOGA STYLE AND BLOOD PRESSURE
Chapter 3: Research Method ..........................................................................................49
Introduction ..................................................................................................................49
Setting .........................................................................................................................50
Sample .........................................................................................................................51
Research Design and Approach ...................................................................................52
Measurement Instruments and Materials .....................................................................52
Procedures ....................................................................................................................54
Data Measures and Statistical Analysis .......................................................................55
Protection of Human Participants ................................................................................56
Chapter 4: Results............................................................................................................58
Introduction ..................................................................................................................58
Data Analysis ...............................................................................................................59
Quantitative Data .........................................................................................................61
Chapter 5: Discussion, Conclusion, and Recommendations ........................................67
Introduction ..................................................................................................................67
Discussion ....................................................................................................................68
Limitations ...................................................................................................................73
Recommendations for Future Studies ..........................................................................75
Recommendations for Action ......................................................................................75
Conclusion ...................................................................................................................77
References .........................................................................................................................79
Appendix A: Study Form ................................................................................................91
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YOGA STYLE AND BLOOD PRESSURE
Appendix B: Blood Pressure Form Handout ................................................................92
Appendix C: Blood Pressure Form Handout ...............................................................93
Appendix D: Informed Consent Form ...........................................................................94
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YOGA STYLE AND BLOOD PRESSURE
List of Tables
Table 1. Baseline characteristics for participants who completed the study ……..….….60
Table 2. Mean pre- and post-test measurements for all study participants……..….....…62
Table 3. Mean difference of pre- and post-test SBP ……...…………………………….63
Table 4. Mean difference of pre- and post-test DBP …………………………………....64
Table 5. Mean difference of pre- and post-test HR ……………………………………..65
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YOGA STYLE AND BLOOD PRESSURE
List of Figures
Figure 1. Mean difference between pre-and post-test HR .................................................65
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1
Chapter 1: Introduction
Overview of Hypertension and Yoga
Hypertension is a chronic health condition that affects more than 67 million
Americans (Centers for Disease Control and Prevention [CDC], 2014). Also called high
blood pressure (BP), this serious public health problem greatly increases one’s risk of
cardiovascular disease (CVD) and stroke, both of which are among the top three leading
causes of death in the United States (CDC, 2014). It was estimated in 2010, that high BP
cost the United States $93.5 billion dollars in healthcare services, medication, and lost
productivity in the workplace (Heidenreich et al., 2011). As the costs of medical care and
antihypertensive drugs continue to rise, health professionals and citizens alike have raised
concern that alternative approaches to preventing, delaying, and managing BP are
needed. This growing demand sparked the increase in research to explore alternative
medicines for managing BP, as well as for other chronic health conditions (Grossman,
Grossman, Schein, Zimlichman, & Gavish, 2001).
Accumulating evidence shows that lifestyle modifications (LSMs), including
maintaining a healthy weight, regular physical activity, eating a healthy diet low in
sodium, complementary and alternative medicines (CAMs), managing stress, being
tobacco free, and limiting alcohol can help lower BP and aid in preventing, delaying, and
managing hypertension (CDC, 2014). A major focus of this research has been on the
benefits of regular physical activity for improving BP; yoga is one form of physical
activity that has become increasingly popular in the United States (Ross & Thomas,
2010). A comprehensive literature review performed by Ross and Thomas (2010)
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examined the impact of yoga on BP and on a variety of other health conditions versus
traditional forms of physical activity. Their research found that yoga was as effective, if
not more effective as other forms of physical activity in lowering not only BP, but also in
reducing the risk of other chronic health conditions, blood glucose, and cancer (Ross &
Thomas, 2010). Mind-Body Therapies (MBTs) such as yoga, meditation, and
biofeedback are a class of alternative medicine recognized by the U.S. National Center
for Complementary and Alternative Medicine [NCCAM] that have also received growing
recognition for reducing BP, and maintaining one’s physical and mental health
(NCCAM, 2014; Grossman et al., 2001). It is believed that yoga and other MBTs may be
more effective in reducing BP, stress, and risk factors for chronic health conditions when
compared to physical activity because MBTs integrate focus on the mental and emotional
body, as well as the physical body (Ross & Thomas, 2010). MBTs philosophize that the
state of the physical and psychological body affect the whole person. In other words,
everything is connected; the mind, body, spirit, and one’s behavior can affect emotions,
thoughts, and attitudes, which in turn have a reciprocal effect on the body (Ives &
Sosnoff, 2000).
Yoga is an ancient tradition that is, first and foremost a practice, philosophy, and
lifestyle. Yoga originated in the Eastern world and can be traced back to the early
civilizations within the regions of central Asia (Jayasinghe, 2004). Traditions of yoga
were originally passed orally from generation to generation; the earliest written word,
Yoga Sutras, is estimated to be only around two-thousand years old (Cohen & Townsend,
2007). Patanjali, a yoga teacher and philosopher, wrote the famous comprehensive text
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documenting the principles and practice of yoga, of which is still used throughout the
world today (Jayasinghe, 2004).
By definition, yoga, from the Sanskrit root yuj, means union or to yolk (Iyengar,
2002). The original intention of yoga was not that of physical activity, but rather a way of
life, a means for connecting the body with the mind, to surrender and let go of control, as
a path to enlightenment, and ultimately, to find balance within one’s self and the universe
(Baptiste, 2002). Through combining pranayama (controlled breathing); asanas (physical
postures); mindfulness; mantras; and meditation, yoga brings together the mental,
physical, emotional, and spiritual elements of the individual (Ross & Thomas, 2010). The
yogic breathing technique pranayama, is, in essence, one’s vital life source. Pranayama is
an intentional, slow, rhythmic, and diaphragmatic breath that brings awareness to the
mind and body, while also creating heat and energy through increased oxygen and blood
flow (Jayasinghe, 2004). Asanas are physical poses that are intended to open energy
channels (Chakras), increase flexibility, strengthen bones, rid the body of toxins, and
activate the immune and circulatory system (Brisbon & Lowery, 2009; WebMD, 2014).
Savasana, or corpse pose, is often the last asana in modern yoga classes. Savasana is a
neutral pose that is performed for several minutes by lying down on one’s back with eyes
closed. The intention of this pose is to release the physical and mental body; to meditate
in the present moment; and to find harmony between the physical, mental, and universal
self.
Yoga was brought to the West in the late nineteenth and early twentieth centuries
through the work of Swami Vivekanada, a native Indian monk (Jayasinghe, 2004). Yoga
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immediately took hold in America, and has since become a popular form of exercise and
relaxation (Cowen & Adams, 2007). It is estimated that more than 15.8 million
Americans practice yoga, and as the population of practitioners have grown, so have the
variations of yoga practice styles (Hagins, States, Selfe, & Innes, 2013).
As differing styles of yoga have emerged throughout yoga’s history, each style
follows a slightly different lineage and each offers a unique approach to the level of
intensity, asana sequencing, breath work, and inclusion of meditation implemented
throughout the practice (Jnaneshvara Bharati, n.d.). Despite their differences, all continue
to stem and uphold elements of ancient yoga traditions. Given the various styles of yoga
practice, the health benefits are likely to be different depending on the style.
A major focus of research pertaining to yoga has been on the physiological and
psychological changes that occur from yoga; heart rate (HR), BP, and stress relief have
been among the leading areas of study (Hagins et al., 2013). Research also has found
positive health benefits from practicing yoga in regards to improved cholesterol, levels of
salivary cortisol, blood glucose, cardiac health, pain management, and immune system
functioning, among others (Ross & Thomas, 2010). An increasing body of research
supports empirical evidence that long-term yoga practice can lower BP, as well as benefit
one’s overall health and well-being (Blank, 2006). However, many of the studies
performed were uncontrolled case studies, had methodological limitations, and had small
sample sizes (Cohen & Townsend, 2007). At this time, little has been studied about the
immediate benefits yoga has on lowering BP, and no studies have compared different
styles of yoga practice to see if one lowers BP more than another. This suggests the need
5
for research on BP outcomes associated with different styles of yoga practice. This study
measured the BP of 76 yoga students before and after three different styles of yoga
classes (Hatha, Power, and Eischens) to determine if there was a short-term change in BP
following a 60-minute class, and whether one style of yoga created a greater difference in
BP than the others. This study filled a gap in the literature and was the first of its kind.
Thesis Statement
It is known that yoga lowers BP; as there is a variety of different yoga styles, it
will be valuable to know whether one type of yoga lowers BP more than another, as this
could help guide treatment options and self-care measures for pre- and hypertension
patients.
Purpose of the Study
The purpose of this study was to 1) confirm that yoga does lower BP after 60minute yoga classes, 2) determine if some yoga styles lower BP more than another, and
3) determine which yoga style among Hatha, Power, and Eischens Yoga lowers BP more
among practitioners. An increasing amount of research confirms that yoga does lower
BP, however, no studies have examined if different styles of yoga lower BP more than
another. Hatha, Power, and Eischens Yoga were specifically chosen because all
incorporate physical yoga asanas, breath work, mind-body connection, and meditation.
However, these three styles of yoga differ in physical intensity, pace of movements, and
breath-to-posture flow.
Research Questions
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Research Question 1. Does blood pressure decrease after a 60-minute yoga
class?
Hypothesis1: Sixty-minute yoga classes significantly lower blood pressure among
practitioners.
Null Hypothesis1: Sixty-minute yoga classes do not significantly lower blood
pressure among practitioners.
Research Question 2. Do different styles of yoga alter blood pressure to a greater
or lesser degree than others?
Hypothesis2: Certain styles of yoga do significantly alter blood pressure more
than other styles.
Null Hypothesis2: Different styles of yoga do not significantly alter blood
pressure to a greater or lesser degree than others.
Research Question 3. Among the styles of Hatha, Power, and Eischens Yoga,
which style lowers blood pressure more?
Hypothesis3: Among the styles of Hatha, Power, and Eischens Yoga, one style
significantly lowers blood pressure more than the other styles after a 60-minute yoga
class.
Null Hypothesis3: There is no significant difference in blood pressures after a 60minute yoga class among the styles of Hatha, Power, and Eischens Yoga.
Theoretical Base
This study is based in quantitative analyses on the adverse health impacts of
hypertension, and yoga as an alternative method for lowering BP. Quantitative and
7
qualitative peer-reviewed descriptive studies were used to provide a theoretical base for
existing findings on the impacts of yoga on BP. This study is quantitative in nature based
on its elements and ability to perform deductive reasoning, test theories, make
generalizations to the larger population, and test hypotheses in relation to the effects
yoga, and different styles of yoga, have on lowering BP.
Definition of Terms
Blood Pressure (BP): The force of blood in the arteries as it circulates through the
body (CDC, 2014).
Cardiovascular Disease (CVD): Diseases of the heart that consists of blocked or
narrowed blood vessels (Mayo Clinic, 2014f).
Complementary and Alternative Medicine (CAM): A non-mainstream approach to
treating health conditions used either in accordance with conventional medicine, or in
place of conventional medicine (NCCAM, 2014).
Diastolic Blood Pressure (DBP): A measure of the force of blood against the
artery walls between heartbeats (American Heart Association [AHA], 2014b; CDC,
2014).
Eischens Yoga: A style of yoga committed to transformational work through
asanas, pranayama, awareness, micro-movements, resistance, and partner feedback
(Tomashik, 2014).
Electrocardiogram (ECG): A test that documents the electrical activity of the
heart (National Heart, Lung, and Blood Institute [NHLBI], 2010).
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Electromyography (EMG): A procedure used to analyze the health of muscles and
neurons.
Enhanced Usual Care (EUC): Dietary adjustments tailored to address health
concerns.
Hatha Yoga: A style of yoga that emphasizes slow movements in the body, with
focused awareness to how the body responds in different asanas (Brisbon & Lowery,
2009).
Heart Failure: A state in which the heart cannot pump enough blood through the
body (NHLBI, 2014).
Heart Rate (HR): The speed of one’s heartbeat; commonly measured by beats per
minute (bpm) (Laskowski, 2014).
Heart Rate Variability: Variations in length of time between each heartbeat
(AHA, 2014b).
Iyengar Yoga (IY): A slow-paced style of yoga developed by B. K. S. Iyengar
Lifestyle Modifications (LSMs): Positive behavior changes one can make to
improve their BP and overall health.
Mind Body Therapies (MBTs): Practices that focus on connections between the
mind, body, and spirit in an effort to use the mind to improve physical, physiological, and
psychological health (NCCAM, 2014).
Practitioner: One who practices yoga.
Power Yoga: Poses that are sequenced in a rigorous series that flow from one
breath to one movement (Blank, 2006).
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Systolic Blood Pressure (SBP): The force of blood against the artery walls when
the heart beats (AHA, 2014b; CDC, 2014).
Yoga: For the purpose of this study, yoga refers to a practice that incorporates
pranayama, asanas, mindfulness, and meditation.
Assumptions
The assumptions made in this thesis are: 1) the literature published in this field is
scientifically comprehensive and is representative of the findings in this discipline; 2)
BPs are comparable across the published literature, even though different methodologies
and BP monitoring equipment was used; 3) yoga lowers BP (based on existing
publications), and comparisons can be made between human studies; and 4) study
participants responded honestly on the demographic survey.
Limitations
A limitation of this study is the small sample size and the length of time available
for data collection. Another limitation of this study is that the same instructor did not
teach all three styles of yoga; therefore, there may have been some variation among the
instructors; however, this researcher attended all of the scheduled yoga classes in this
study to ensure consistency among instructors and styles of yoga. Another limitation is
that the study took place in only one primary geographical location, the urban city of
Chaska, Minnesota, with an estimated population of 24,444 (one class was taught in an
offsite facility in a neighboring town, however, this was an unusual occurrence; the
students typically met within Chaska) (United States Census Bureau, 2014). This may
limit the generalizability of the study, however, because the students were not
10
preselected, and there was no criteria for attending these classes other than being a studio
member and paying an annual fee or paying $18 for each class, they could be considered
somewhat representative of the population of people who might take yoga as a self-care
method for hypertension. Lastly, a limitation of this study is that participants were not
able to sit for the recommended five to ten minutes, or even any extended period of time
prior to BP being measured before and after Hatha, Power, and Eischens Yoga classes.
However, participants were seated for one minute prior to when their pre- and post-test
measurements were taken.
Delimitations
Delimitations of this study include 1) the use of current and relevant literature for
review; 2) the yoga instructors selected were specifically trained and certified yoga
instructors in the styles of Hatha, Power, and Eischens Yoga respective to the style of
yoga they taught during this study; 3) all styles of yoga were not studied as a result of
limited time and resources, nor could the researcher ascertain to know all of the yoga
instructors and styles of yoga practiced in the Minneapolis area; 4) the studio for this
study was selected based on its yogic principles, accessibility, willingness to participate,
and the researcher’s previous work experience at the studio; 5) data was collected on
100% of willing participants over the greatest length of time available for data collection;
6) the Omron M10-IT Upper Arm Digital Automatic BP monitor (BPM) was chosen due
to its accuracy, reliability, and validity, of which was verified by the Association for the
Advancement of Medical Instrumentation, the British Hypertension Society, and the
International Protocol for the Validation of Automated BP Measuring Devices (AHA,
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2012a); and 7) this study did not measure the effects of long-term yoga on BP, as this has
already been researched.
Significance of the Study
A growing amount of evidence suggests that yoga is an effective CAM for
lowering BP (Ross & Thomas, 2010). Although existing literature supports that longterm yoga practice lowers BP, relatively few studies have examined the impacts of shortterm yoga practice on lowering BP. Additionally, no studies have explored if different
styles of yoga lower BP more than another. Rates of hypertension are the highest in U.S.
history, and those affected continues to grow (CDC, 2014). With more than 15.8 million
yoga practitioners in the U.S. and a variety of different styles of yoga, more research on
short-term effects of yoga, and the effects of differing styles on BP are needed (Hagins et
al., 2013).
The results of this research may help MBT practices, such as yoga, become more
widely recognized for their benefits to health and well-being of the yoga practitioner.
Research in this area may help strengthen previous findings that yoga does lower BP, and
may identify if differing styles of yoga lower BP more than another. If different styles of
yoga have different health benefits, medical and wellness professionals alike, may be able
to refer patients to a yoga style that will best benefit their health needs. Additionally,
yoga is a practice that can be performed in the comfort of one’s own home, which may
allow yoga to be a more accessible and cost effective method for lowering and managing
BP.
Summary and Transition
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Despite medical intervention, hypertension continues to be a growing epidemic
among Americans. Hypertension has serious health implications and can lead to life
threatening conditions such as stroke, heart disease, and heart failure, among other
morbidities (CDC, 2014). A growing body of research shows that positive LSMs and
CAMs are the best defense for preventing, delaying, and reducing BP (CDC, 2014; Ross
& Thomas, 2010). There is evidence suggesting that yoga may be a more effective form
of reducing BP than other forms of physical activity (Ross & Thomas, 2010). It is
believed that yoga and other MBTs may have a greater impact on lowering BP and
improving overall health, as it integrates the elements of pranayama, asanas, mindfulness,
and meditation into its practice (Ross & Thomas, 2010; Ives & Sosnoff, 2000). The aim
of this study was to determine if BP lowers among practitioners after a 60-minute yoga
class, and if the different styles: Hatha, Power, or Eischens Yoga lowers BP more than
another among the practitioners. The remaining chapters will provide details of this
study; Chapter 2 will discuss the existing literature showing the positive health impacts
long-term yoga practice has on lowering BP and the little research done examining the
short-term impacts of yoga on BP. Chapter 3 will explain the methods used to measure
and compare BP before and after 60-minute Hatha, Power, and Eischens Yoga classes;
while Chapter 4 will discuss the research results and lastly, Chapter 5 will provide
conclusions about the and findings, the implications, and topics for further research.
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Chapter 2: Literature Review
Introduction
Hypertension is a global issue that is affecting one billion people worldwide, and
is responsible for more than nine million deaths annually (The World Health
Organization [WHO], 2013). Hypertension knows no borders, and is found among both
developed and developing countries. Millions of Americans are currently being treated
for high BP, and the prevalence of hypertension is only expected to rise in the coming
years as the population continues to grow older (Chobanian et al., 2003). This public
health issue is often referred to as the ‘silent killer,’ as it rarely causes any symptoms; as
a result, many individuals go left untreated (WHO, 2013). It is estimated that nearly 30%
of people living in the U.S. with high BP are unaware that they have it (WHO, 2013).
Public awareness is a significant component to increasing early detection and improving
hypertension outcomes; therefore, it is essential now more than ever to prevent, delay,
and manage high BP (WHO, 2013).
High BP is most commonly treated with antihypertensive medications and LSMs.
Medication is currently the front line treatment; yet many of the medications are costly,
produce negative side effects, and, despite their use, nearly 50% of hypertension patients
still have a BP that is uncontrolled (Chobanian et al., 2003). Fortunately, high BP can be
prevented through healthy LSMs, including CAMs (WHO, 2013). Yoga, a CAM and
form of physical activity practiced in the United States, has been found to reduce and
manage BP among practitioners (Cohen et al., 2011).
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The literature review examines three areas of hypertension management research
associated with pharmacological antihypertensive medications, recommended LSMs for
lowering BP, and yoga as a method for preventing, delaying, and reducing high BP. The
first section addresses the history of hypertension and current treatment modalities. In the
second section, research conducted to lower BP through the implementation of LSMs and
CAMs are assessed, and lastly, the third section discusses existing research on yoga as a
practice for managing high BP.
Literature Search
The literature search was performed using Academic Search Premier and Google
Scholar. The articles chosen were limited to peer-reviewed primary research. Various
combinations of search terms were used to locate the articles reported in the literature
review; these terms included “yoga,” “complementary and alternative medicines,”
“lifestyle modifications” “hypertension,” and “blood pressure.”
History and Primary Treatment Methods for Hypertension
Hypertension is now the most frequent primary diagnosis among U.S. citizens
(Chobanian et al., 2003). However, this was not always true, as the history of BP dates
back only to the mid-eighteenth century (Kotchen, 2011). Stephan Hales, an English
physiologist, was the first individual to quantitatively measure and understand BP after
he inserted a brass tube into the left crural artery of a horse (Booth, 1977). Hales was then
able to witness the rise and fall of blood after each pulse of the horse’s heart (Booth,
1977). Today, BP is measured using non-invasive techniques, most commonly with a
manual or electronic sphygmomanometer, which is a medical instrument that consists of
15
an inflatable cuff and a mercury or mechanical manometer. BP is characteristically
recorded as a ratio, with systolic BP (SBP) written over diastolic BP (DBP) measured in
millimeters of mercury (mm Hg) (NHLBI, 2012). It is normal for BP to vary throughout
the day, and therefore a diagnosis of hypertension is determined by a healthcare
professional. It is common for modern BPMs to also assess HR during BP measurement.
HR is the calculation of how many times the heart pumps in a specified amount of time;
typically recorded as bpm. A lower HR is generally regarded by health professionals as
efficient heart functioning (Laskowski, 2014).
In the early twentieth century, a growing amount of evidence began to suggest
that BP was as an indicator of health (Kotchen, 2011). It has been found that high BP can
cause damage to the heart, arteries, blood vessels, kidneys, organs, and brain (Mayo
Clinic, 2014g). If untreated, hypertension can lead to other health conditions, including
heart attack, stroke, CVD, heart failure, kidney damage, and even death (AHA, 2012b,
WebMD, 2013). As a correlation between high BP and mortality became more apparent,
U.S. insurance companies began to require BP monitoring for insurance customers, and it
has since become standard practice for BP to be measured at various healthcare visits
(Kotchen, 2011). There are three globally recognized stages of hypertension:
prehypertension, with an SBP between 120–139 mm Hg or DBP between 80–89 mm Hg;
Stage 1 hypertension, with an SBP between 140–159 mm Hg or DBP between 90–99 mm
Hg; and Stage 2 hypertension, with an SBP 160 ≥ mm Hg or DBP 100 ≥ mm Hg
(NHLBI, 2012). Normal BP is defined as SBP < 120 mm Hg and DBP < 80 mm Hg. HR
is the measurement of how many times the heart pumps in a specified amount of time. It
16
is most commonly measured by bpm, and a lower HR is generally regarded by health
professionals as efficient heart functioning (Laskowski, 2014).
Pharmaceutical medications are, and always have been, the first line of treatment for
hypertension (Chobanian et al., 2003). The first pharmaceutical treatments for managing
BP were introduced in the 1900s, and primarily consisted of diuretics, thiocayanates,
nitrates, and pyrogens (Kotchen, 2011). In 1931, the medication reserpine was
introduced, followed by ganglion blocking drugs, thiazide diuretics (which rid the body
of excess fluid and sodium), β blockers (used to block hormonal signals to the heart and
blood vessels), angiotensin-converting enzyme (ACE) inhibitors (which widen the blood
vessels), angiotensin-receptor blockers (ARB), and renin inhibitors (slow the production
of the BP rising enzyme, renin), among others throughout the mid- to late-twentieth
century (Kotchen, 2011; Mayo Clinic, 2014d). Best practice and medication regimens for
treating hypertension have changed throughout the decades, and even to date, it remains
unclear which medication, or even if medication should continue to be prescribed for
primary treatment. With the continued introduction of different classes of
antihypertensive medications, changing processes, varying costs, and detrimental side
effects from medication use, more research and alternative treatment methods are needed.
Standard hypertension diagnosis, monitoring, and treatment. Bunker (2014)
conducted an article review to provide the most up-to date information on hypertension
diagnosis, assessment, and management practices. A substantial limitation of this article
is that little, to no information, was provided by the researcher regarding the article
inclusion criteria, number of articles referenced in the analysis, participant demographics,
17
or study settings. The researcher does however explain that peer-reviewed articles and
National Institute for Health and Care Excellence guidelines were used to compile
current, factual information for the analysis (Bunker, 2014).
Bunker (2014) explains that the first step to diagnosing high BP begins with an
accurate measurement of BP. Use of a mercury sphygmomanometer by a trained
professional is the gold standard method for measuring BP; however, mercury is a
dangerous toxic chemical element and use of mercury in BPMs is forbidden in many
countries throughout the world (Bunker, 2014). In place of mercury, automatic and
manual mercury-free sphygmomanometers are used for measuring BP in clinics, as well
as home settings. An automatic BPM measures SBP and DBP by sensing variations in
pressure oscillations from the movement of the arterial wall (Bunker, 2014). BP should
be measured when a patient is either in a seated or horizontal position, and it is
imperative for the BP cuff to adequately fit the individual for an accurate reading to be
obtained. It is recommended that caffeinated products be avoided 30-minutes prior to BP
measurement (Bunker, 2014). Another method for measuring BP is 24-hour Ambulatory
BP Monitoring (ABPM), which consists of a cuff and BP monitor worn on the person
throughout an entire day. ABPM is a technique implemented to measure an individual’s
BP during their daily activities to gauge their routine BP. This method is exercised
because some individuals experience “white coat syndrome,” or an abnormally elevated
BP reading when having BP measured in clinical settings (Mankad, 2014). It is believed
that “white coat syndrome” occurs as a result of increased stress experienced by some
persons at health care appointments (Mankad, 2014).
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Diagnosis of high BP is made by a medical professional based on three elevated
BP readings taken at different appointments, a review of the patient’s medical history,
and completion of a physical examination (Bunker 2014, Mayo Clinic, 2014h). It is
common for blood workup to be completed to assess renal function, lipid levels, and
blood glucose; a urine analysis may also be completed to measure kidney function. These
procedures are used in combination to help rule out other complications or causes for
elevated BP readings.
Treatment of hypertension consists of pharmacological medications and LSMs;
the primary goal of treatment is to obtain BP measurements < 140/90 mm Hg, and <
150/90 mm Hg in patients 80 years of age or older (Bunker, 2014). Antihypertensive
medications can help lower BP and reduce one’s risk for stroke, myocardial infraction,
heart failure, and internal organ damage (Bunker, 2014). The different classes of drugs
commonly used to treat hypertension are ACE- and ARB- inhibitors, thiazide-type
diuretics, β blockers, and calcium channel blockers (Bunker, 2014). Research suggests
that the average BP reduction is approximately 10/5 mm Hg with the use of any one
antihypertensive medication, and a large proportion of hypertension patients require
treatment with two or more drug classes in order to achieve a BP < 140/90 mm Hg
(Bunker, 2014; Chobanian et al., 2003).
Despite the effectiveness pharmacological methods have on lowering BP, there
are negative side effects and contraindications for each antihypertensive medication drug
class. ACE- and ARB- inhibitors are common medication classes prescribed to patients
under the age of 55 (Bunker, 2014). ACE inhibitors in the U.S. can include benazepril,
19
lisinopril, and ramiril, among others. Common side effects of ACE inhibitors include an
arid cough, elevated potassium levels, angioedema (predominantly in patients of AfricanCaribbean decent), low BP, and renal complications (Bunker, 2014). Similar adverse
effects are found with the use of ARB inhibitors, with the exception of a less severe
cough reported among patients. ACE inhibitors are not recommended to be used in
combination with ARB inhibitors or among women who are pregnant.
To treat hypertension patients over the age of 55, calcium channel blockers are
commonly prescribed (Bunker, 2014). Calcium channel blockers reduce BP by stopping
calcium minerals from entering blood vessel walls and cardiac muscle cells (Mayo Clinic,
2014b). The side effects of calcium channel blockers can include headaches, constipation,
flushing, rapid heartbeat, dizziness, and swelling of the feet and ankles (Mayo Clinic,
2014b; Bunker, 2014). These drugs are contraindicated for individuals with heart failure,
and patients already prescribed a β blocker (Bunker, 2014).
Thiazide-type diuretics are another drug class used to manage BP, and work by
ridding the body of fluid buildup (Bunker, 2014). Currently, thiazide-type diuretics are not
routinely prescribed as a primary treatment option, but rather are prescribed in combination
with use of, or in place of, an ACE- or ARB-inhibitor, β blocker, or calcium channel
blocker. Adverse effects can include low sodium levels in the blood, increased glucose,
gout, muscle cramps, headaches, excessive thirst, and decreased potassium levels (Bunker,
2014).
Atenolol and bisoprolol are commonly prescribed β blockers. β blockers can be
used in primary treatment, combination therapy, or in place of other drug classes when a
20
contraindication is present. This class of medication blocks the effects of epinephrine and
acts by slowing down the HR, and opening up the blood vessels (Mayo Clinic, 2014a). β
blockers can cause cold extremities, fatigue, upset stomach, diarrhea, and their use is not
recommended for patients with asthma (Bunker, 2004).
Poor medication compliance is a leading issue among long-term hypertension
patients (Bunker, 2014). It has been estimated that 50–80% of hypertension patients do not
adhere to their prescription, which leads to increased hospitalizations, events of stroke and
heart failure, medication costs, and excess drug waste (Bunker, 2014). Adherence issues
are thought to be the fault of both medical professionals and patients. Bunker (2014)
recommends for medical professionals to routinely monitor patients’ medication
adherence, as well as engage in detailed discussions regarding one’s condition, the reason
the medication was prescribed, and the importance of complying with the prescription.
LSMs are encouraged by medical professionals to help reduce BP among
hypertensive patients; however, they are most commonly recommended as a complement
to antihypertensive medication, rather than as a first line approach. Popularity of nonpharmaceutical measures for managing BP have gained momentum in recent years due to
their ability to prevent and delay onset, their absence of adverse side effects, and
widespread accessibility. Per Bunker (2014), additional research is needed to verify the
efficacy of alternative hypertension treatments.
In conclusion, the analysis provided modern diagnosis, assessment, and treatment
processes for hypertension. Antihypertensive medications continue to be the primary
treatment measure for hypertension, despite their negative side effects and poor
21
adherence rates. Alternative non-pharmaceutical treatments are gaining recognition as
effective methods for lowering BP; however, more research is needed. Limitations of this
analysis include a lack of justification and statistical data to support the claim that
primary treatment methods should continue as they currently are. Additionally, limited
information was provided explaining how articles were chosen and how many articles
were reviewed for inclusion in the analysis.
Assessing β blockers as primary treatment. For several years, β blockers have
been used as a primary treatment method for hypertension (Lindholm, Carlberg, &
Samuelsson, 2005). Yet preliminary research suggests that the β blocker, atenolol, may
not be as effective as originally projected at treating high BP, and may be more harmful
than beneficial. Researchers believe that the perceived benefits of β blockers may have
been glorified as a result of several studies analyzing the effects of β blockers when
diuretics were used in combination; therefore masking the true effectiveness of the drug
(Lindholm et al., 2005).
A study completed by Lindholm and colleagues (2005) sought to analyze the raw
effects of β blockers on stroke, myocardial infraction, and mortality of all causes. The
studies included in the meta-analysis were divided into those that compared β blockers
with other antihypertensive medications, and those that compared β blockers with the use
of placebos or no treatment at all (Lindholm et al., 2005). Treatment with β blockers
across all trials was broken down into different subgroups for further analysis: nonatenolol β blockers, mixed β blockers, and diuretics used along with atenolol (Lindholm
et al., 2005). A total of 127,879 participants were included in the meta-analysis; all of
22
whom were diagnosed with hypertension, 50% or more were being treated with a β
blocker, and all were part of randomized controlled trials. Data was entered into the
Cochrane Collaboration review manager program version 4.2, chi-square test, and
relative risk was used to compare and analyze findings.
In all trials comparing β blockers with other drugs (13), the relative risk of stroke
increased by 16% with the use of a β blocker (p = 0.009), all-cause mortality increased by
3% (p = 0.14) (Lindholm et al., 2005). No notable difference was found for risk of
myocardial infarction between β blockers and other medications prescribed (Lindholm et
al., 2005). When the three subgroups of β blocker studies were looked at separately, the
risk of stroke was most significant with the use of atenolol (26%; p < 0.0001). However,
studies that compared β blockers with placebos or with no drug treatment (7) showed that
the risk of stroke decreased by an estimated 19% among β blocker users; which supports
that treatment with a β blocker is beneficial to no treatment at all (Lindholm et al., 2005).
In conclusion, results showed that primary treatment with a β blocker was
associated with an increased risk of stroke, and that their preventative influence was not
comparable to that of other antihypertensive medications (Lindholm et al., 2005).
Lindholm et al. (2005) found that treatment with β blockers did reduce BP; however,
their use had little to no impact on alleviating the risks of myocardial infarction or
mortality. Of the different studies analyzed, data supported that thiazide diuretics
performed equally, if not better than β blockers and resulted in better metabolic outcomes
(Lindholm et al., 2005). Researchers found that when treating hypertension with only one
antihypertensive medication, all antihypertensive drug classes proved to be effective at
23
lowering brachial BP; thus, they concluded that β blockers should not be the first line
treatment (Lindholm et al., 2005). Rather, a less expensive antihypertensive medication
would be equally effective at reducing BP, and would aid in minimizing medication costs
(Lindholm et al., 2005). There were however limitations to the study. For analysis, few
studies were found analyzing non-atenolol treatment, and of the studies that were found,
there was poor documentation, which may have limited the study’s scope to make
comparisons to other β blockers (Lindholm et al., 2005). A limitation stated by Lindholm
et al. (2005), is that they were not been able to correlate the results of the studies to the
dose and dosing of the antihypertensive medications prescribed throughout the trials.
Additionally, the trials included in the study were from across two decades, and therefore,
standard treatment practices may not have been uniform throughout, or thereafter
(Lindholm et al., 2005). Lastly, data for achieved BP was not available, so BP control
could not be adjusted for in the analysis (Lindholm et al., 2005).
Comparison of the different drug classes. The purpose of the study performed
by The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research
Group (ALLHAT) (2002) was to examine the effect of treatment with a calcium channel
blocker or an ACE inhibitor in order to assess if one lowers the rate of coronary heart
disease (CHD) or other CVD events when compared to treatment with a thiazide-type
diuretic. The study design was a randomized, double-blind, United States multicenter
clinical controlled trial sponsored by the NHLBI (ALLHAT, 2002). Participants for the
study were engaged through 623 different centers between February 1994 and January
1998 (ALLHAT, 2002). A total of 33,357 participants ages 55 or older met the study
24
criteria and completed the intervention. Participants consisted of both males (53%) and
females (47%) with Stage 1 or Stage 2 hypertension. Of the participants, 35% were
Black, and 19% were Hispanic (ALLHAT, 2002). Qualifying risk factors included having
one or more risk factors for CHD events (ALLHAT, 2002).
Participants were randomly assigned by a computer generator to receive one of
three different medications: chlorthalidone (n = 15,255) with a dosage between 12.5 to 25
mg/d, amlodipine (n = 9,048) with a dosage between 2.5 to 10 mg/d, or lisinopril (n =
9,054) with a dosage between 10 to 40 mg/d (ALLHAT, 2002). Participants discontinued
any use of antihypertensive medications at the start of the intervention, at which time
they were then administered a study drug (ALLHAT, 2002). The study drugs were placed
in unidentifiable capsules with the dosage levels concealed from view. BP was measured
at physician visits and standard BP measurement processes were followed. The goal in all
intervention groups was to obtain a BP < 140/90 mm Hg. If a BP < 140/90 mm Hg was
not reached, a second drug (atenolol, reserpine, or clonidine) was administered to the
participant; in some instances, a third, or even fourth medication was needed (ALLHAT,
2002).
Follow-up visits were conducted every three months for the first year, and then
every 4 months following for up to eight years (ALLHAT, 2002). Study outcomes were
assessed via follow-up visits, hospital records, death certificates, and confirmation of
death by the Department of Veterans Affairs; the National Death Index; Center for
Medicare and Medicaid Services; and Social Security Administration records (ALLHAT,
2002). A variety of statistical analysis measurements were used including the Kaplan-
25
Meier method, p values, SAS version 8.0, STATA version 7, among others (ALLHAT,
2002).
When comparing amlodipine and chlorthalidone, no significant change in CHD,
all-cause mortality, angina, combined CVD, cancer, or other cardiac and combined
events were found for primary or secondary outcomes (95% CI; 0.90–1.07) (ALLHAT,
2002). A 38% higher risk of heart failure (p < 0.001), with a 35% increased risk of
hospitalized/fatal heart failure (p < 0.001) was found among the amlodipine medication
group (ALLHAT, 2002). Cause-specific mortality rates, not including unintentional
injuries/suicides/homicides, were comparable across groups (ALLHAT, 2002).
When comparing lisinopril and chlorthalidone, no significant change in CHD, allcause mortality, or cancer was found among primary and secondary outcomes (95% CI;
0.91–1.08) (ALLHAT, 2002). An increased risk of stroke (15%; p = 0.02), and combined
CVD (10%; p < .001) was found among the lisiopril medication group (ALLHAT, 2002).
Analysis showed a larger risk of heart failure (19%; p < 0.001), hospitalized/fatal heart
failure (10%; p = 0.11), angina (p= 0.01), and risk of coronary revascularization (10%; p
= 0.05) among lisinopril users (ALLHAT, 2002). A significant variance by race was
found for combined CVD (p = 0.04) and stroke (p = 0.01) (ALLHAT, 2002). Mean BP
among lisinopril users increased by 2 mm Hg when compared to the chlorthalidone
group.
In conclusion, neither amlodipine nor lisinopril were found to be more effective
than chlorthalidone in preventing heart related events or in decreasing mortality rates
(ALLHAT, 2002). The researchers suggest that thiazide-type diuretics should be the
26
preferred pharmacological approach to treating hypertension, and should be included in
all combination therapy regimens, when possible (ALLHAT, 2002). A limitation of the
study is that new antihypertensive medications have entered the market since the
inception of the intervention, and therefore new medications or processes could
potentially have emerged (ALLHAT, 2002). Lastly, due to intervention drug
requirements, some of the multidrug management approaches used throughout the study
were unrealistic of actual practice regimens, which decreases the findings’ versatility
(ALLHAT, 2002).
Section summary. The pharmacologic hypertension research literature suggests
that medications are effective measures for lowering BP; however, there are many
harmful and even life threatening side effects and contraindications with their use.
Antihypertensive medications only work if they are taken, and research shows that a
significant number of patients do not adhere to their prescription regimens. Thiazide-type
diuretics were found to be just as effective as other drug classes in managing BP and are
more cost efficient (ALLHAT, 2002). Limitations among the research include several
intervention treatments being unrealistic to real-life practice, contradictory findings
across studies suggesting which medication should be prescribed for frontline treatment,
and BPs < 140/90 mm Hg not being obtained among drug treated trial participants.
Antihypertensive medications do have BP lowering properties; however, their use does
not address the underlying issue of what is causing high BP among patients. Healthy,
long-term alternative treatments are vital to further addressing and reversing this public
health issue.
27
The Use of LSMs and CAMs for Lowering BP
High BP is preventable (WHO, 2013). Controllable risk factors for high BP
include being overweight or obese, consuming an unhealthy diet high in processed fats
and sodium, tobacco use, excess alcohol intake, high cholesterol, and physical inactivity
(AHA, 2012b). There are however, risk factors that are uncontrollable, such as one’s age,
gender, and genetics (AHA, 2012b). LSMs are a non-pharmacologic alternative that can
prevent, delay, and lower high BP (Cohen et al., 2013).
LSMs recommended for hypertension include eating a healthy diet low in sodium,
following the Dietary Approaches to Stop Hypertension (DASH) diet, maintaining a
healthy weight, limiting alcohol, refraining from the use of tobacco products, regular
physical activity, and CAMs (Chobanian et al., 2003; Chohen et al., 2013). CAMs consist
of whole medical systems, biologically based therapies, MBTs, manipulative and bodybased regimens, and/or energy remedies (Mayo Clinic, 2014c; NCCAM, 2014). CAM
techniques include, but are not limited to, homeopathy, relaxation, deep breathing, yoga,
tai chi, biofeedback, mindfulness, acupuncture, massage, and Ayurveda (NCCAM, 2014).
A growing body of research supports that LSMs are effective in preventing hypertension,
lowering high BP, reducing the risk of CVD, and improving the effects of
antihypertensive medications (Chobanian et al., 2003).
Comparison of recommended LSMs. Considering the expansive variety of
alternative methods for managing BP, it is likely that some techniques have a greater
influence on lowering BP than others. In a study conducted by Saptharishi et al. (2009),
investigators measured and compared the effectiveness of physical exercise, restricted
28
salt intake, and yoga on reducing BP. This study was conducted in Kuruchikuppan, India,
and consisted of 102 participants with confirmed prehypertension (74) or hypertension
(39) between the ages of 20–25. For the purpose of this study, researchers defined
prehypertension as SBP 130–139 mm Hg and/or DBP 85–89 mm Hg (Saptharishi et al.,
2009). The intervention was conducted for eight weeks and participants (68 males and 34
females) were divided using a random number generator into four different groups:
control (29), physical exercise (27), salt restriction (25), and yoga (21).
Participants in the control group received no intervention, while participants in the
physical exercise group were encouraged to walk at a fast-pace four days a week, for 50–
60-minutes. To help increase motivation, a researcher exercised periodically with
participants during the intervention. The salt restriction group was encouraged by the
researchers to reduce their current salt intake by half and were provided suggestions on
how to do so. Participants in this group were instructed to use individual salt packets on
their food, to cook their meals separately, and were asked to record their salt intake in a
journal throughout the duration of the study; a self-report questionnaire was administered
to gauge participants’ compliance. Lastly, the yoga intervention group was taught yoga
that consisted of breath work and physical postures on one occasion by a qualified
instructor. Participants were then asked to practice yoga for 30–45 minutes on their own,
five days a week.
Participant’s BP was measured prior to the start of, and upon completion of the
study. BP values collected were analyzed using a paired t-test, and comparisons of BPs
29
between the groups were analyzed using analysis of variance (ANOVA) with a GamesHowell post-hoc test (Saptharishi et al., 2009).
The results demonstrated that all three of the intervention groups experienced a
statistically significant decrease in both SBP and DBP (p < 0.05). The exercise group saw
a pre- and post-test decrease in SBP (128.6 to 123.3 mm Hg), and DBP (87.4 to 81.4 mm
Hg); as well as salt restriction group, SBP (124.0 to 122.9 mm Hg), and DBP (83.7 to
80.0 mm Hg); and the yoga group, SBP (126.8 to 124.8 mm Hg) and DBP (84.5 to 81.9
mm Hg) (Saptharishi et al., 2009). The control group did not show a significant reduction
in SBP (123.1 to 122.9 mm Hg; p > 0.05), nor DBP (82.9 to 82.4 mm Hg; p > 0.05)
(Saptharishi et al., 2009). When comparing between groups, physical activity showed the
greatest reduction in BP.
Several conclusions can be made about pre-hypertensive and hypertensive young
adults in response to the non-pharmacological interventions analyzed in this study. The
randomized controlled trial found statistically significant reductions in BP among all
three intervention groups, with no significant change in either SBP or DBP among the
control group (Saptharishi et al., 2009). The findings were in accordance with previous
research data supporting LSMs as an effective approach to preventing and managing high
BP (Sapatharishi et al., 2009). There were however several weaknesses and limitations to
the study. First, the study had a small sample size, and methodological limitations that
reduce the study’s generalizability to the general population. There was inadequate
information provided as to what was included in the yoga training session, how long the
session lasted, as well as the level of adherence to the recommended format when
30
participants practiced at home. Additionally, participants in each group were not required
to follow the specific group specifications, rather, they were merely encouraged to do so,
and limited measures were taken to monitor compliance. According to the researcher, it
was assumed that all participants underwent the same level of intervention (Saptharishi et
al., 2009). Therefore, no standardized methods were implemented to measure the level of
compliance or intensity of the intervention performed by participants in each group.
Aroma massage. Aroma massage combines massage with the use of essential
oils, and is believed to aid in reducing BP levels. The practice is intended to increase
blood and lymphatic circulation, while also increasing oxygen (Ju et al., 2013). Research
has also shown that aroma massage can minimize pain, release tension in the muscles,
lower BP, and relieve feelings of stress, anxiety, and depression through its effects on the
central nervous system (Kuriyama, et al., 2005).
The purpose of the study performed by Ju et al. (2013) was to analyze the efficacy
of aroma massage on lowering BP and improving sleep quality among adult females with
hypertension. The study design was non-synchronized and used a nonequivalent control
group in order to compare the impacts of aroma massage on Home BP, Office BP, 24hour ABPM, and sleep quality among participants. The researchers had particular interest
in conducting their study on middle-aged women because previous research has shown
that women of this age experience increases in hormone and body chemicals that have
been linked to rises in BP and mood changes (Ju et al., 2013).
The intervention was conducted in South Korea, at the outpatient clinic at E
University Hospital. Participants included 83 females between the ages of 40–59 with
31
prehypertension or Stage 1 hypertension. Additionally, participants had no psychiatric
disorders and were not taking anti-anxiety medications. Participants were assigned to one
of three groups: aroma massage group (28), placebo group (28), and control group (27).
The aroma group received aroma massages with the use of essential oils (lavender,
marjoram, ylang-ylang, and Neroli) and were provided essential oil body lotion for home
use throughout the intervention. The placebo participants were given massages with
artificial fragrance massage oil and were given artificial fragranced body lotion. The
control group received no treatments.
Aroma and placebo group participants received four one-hour massages at the
research office over a four-week period. The research office at E University was divided
in half and used as a waiting room and massage room. Upon the participant’s arrival for
their scheduled massage, they changed into a massage gown and rested in a horizontal
position for ten-minutes prior to having their BP taken. BP was measured using an
Omron HEM-780 digital BPM. Massages were performed by four research assistants
who received one four-hour training on aroma massage theory and methods, and a fourhour practical training with an aromatherapist. Each massage was performed in the same
sequential order (back, legs, stomach, arms, and shoulders), and post-massage BP
measurements were taken ten minutes after completion (Ju et al., 2013). The body lotion
given to each participant was intended to be applied nightly to one’s arms, legs, and
stomach throughout the duration of the study.
Home BP and 24-hour ABPM were measured by all study group participants one
time prior to the start of, and upon completion of the intervention. Sleep quality was
32
measured using an adapted version of the Verran and Snyder-Halpern sleep scale.
Statistical analysis was performed using SPSS 19.0 software, ANOVA, analysis of
covariance (ANCOVA), chi-square test, and Tukey method (Ju et al., 2013).
The results showed that no difference was found in Home SBP and DBP during
the four-week intervention; however, post-hoc analysis of Home SBP showed a
significant difference in the aroma massage group when compared to the other two
groups (p < 0.05). The aroma massage group saw an approximate 15 mm Hg SBP
reduction for Home SBP, and 4 mm Hg drop in DBP; the placebo group saw a 6 mm Hg
SBP reduction, and 3 mm Hg in DBP (Ju et al., 2013). Ju and colleagues (2013)
attributed the greater reduction in BP to the use of pure essential oils among aroma
massage group participants.
Post-massage office BP measurements showed a statistically significant reduction
in BP when comparing the experimental group versus the placebo group after the second
(SBP: 𝑡 = −3.444; p = 0.001, and DBP: 𝑡 = −3.09; p = 0.003), third (SBP: 𝑡 = −2.65; p =
0.01, and DBP: 𝑡 = −2.08; p = 0.04), fourth (SBP: 𝑡 = −3.33; p = 0.002, and DBP: 𝑡 =
−2.38; p = 0.02), and fifth sessions (SBP: 𝑡 = −4.87; p < 0.001, and DBP 𝑡 = −3.76; p <
0.001) (Ju et al., 2013). The results support that a weekly aroma massage has acute
impacts on BP and is effective in lowering SBP and DBP.
No substantial differences in BP were found in either pre- or post-intervention 24hour ABPM between the three groups. Significant differences were however found
between groups after intervention (𝐹 = 6.75; p = 0.002) (Ju et al., 2013). The aroma
group showed a significant difference in sleep quality between groups (𝐹 = 9.32; p <
33
0.001), and at post-hoc analysis (p < 0.05) (Ju et al., 2013). No significant change in sleep
quality was found among the placebo or control group.
Many conclusions can be made from this study. Aroma massage is effective in
lowering Home SBP and short-term Office BP. In addition, aroma massage can improve
sleep quality among females between the ages of 40–59 with prehypertension and Stage 1
hypertension. There were also limitations to this study. Only one essential oil aroma
fragrance was used throughout the intervention, and therefore, psychological and physical
responses may vary among individual users depending on their personal preferences.
Additionally, the intervention was carried out on a rather small and specific subset, and
this limits its generalizability.
Effects of Biofeedback. Biofeedback has been recognized as a popular
alternative treatment for lowering BP, stress, and improving one’s overall health (Hunyor
et al., 1997). Biofeedback involves using electronic sensors to monitor physiologic
information about one’s body and their state of relaxation (Rainforth et al., 2007).
Biofeedback is utilized to give the user information in order to control their body through
their thoughts (Mayo Clinic, 2013a). Biofeedback has been shown to have positive
effects on relaxing the mind and body, as well as reducing BP (Rainforth et al., 2007).
The purpose of the study performed by Wang and colleagues (2010) was to assess
the effects of slow abdominal breathing when combined with electromyography (EMG)
biofeedback training on BP and heart rate variability in females with prehypertension.
The researchers wanted to examine if the treatment modality could be a mechanism to
reduce sympathetic activity, lower BP, and enhance vagal activity specifically in
34
postmenopausal women. The study took place at the Laboratory of Biofeedback, Sun
Yat-sen University, in China, and included 22 females with prehypertension from two
communities of Guangzhou (Wang et al., 2010). All participants were between the ages
of 45–60, postmenopausal, right handed, and had discontinued using any hypertension
medication one month prior to intervention (Wang et al., 2010).
Participants were randomly assigned to either the experimental group
(biofeedback group + abdominal respiratory group [AB + BF]), or the control group
(abdominal breathing group with no biofeedback) (Wang et al., 2010). Before the
intervention, all participants received practical abdominal breath training to ensure that
participants had a basic understanding of the concepts and were comfortable performing
the specific technique. Intervention consisted of both groups receiving a total of ten
sessions of treatment once every three days. Each session was held at the same time of
day and was 25-minutes in length. The first five-minutes of the session were set aside for
baseline BP recording, followed by 20-minutes of treatment, and post treatment BP
measuring. An electrocardiogram (ECG) was used during the intervention to measure
HR. Participants were instructed to arrive 20-minutes early to the session to rest prior to
treatment and to refrain from alcohol use, caffeine and tea consumption, and to avoid
spicy food one day prior to each treatment session (Wang el at., 2010).
The subjects in the AB+BF group were exposed to slow abdominal breathing with
frontal EMG biofeedback-assisted relaxation training. AB+BF training participants laid
in a supine position on a bed in the laboratory, with three electrodes placed over the
frontal muscle and connected to a biofeedback machine (Wang et al., 2010). The
35
biofeedback machine was used to assist participants in reducing their frontal EMG signal
through relaxation, while performing six cycles of respiratory breath per minute (Wang et
al., 2010). Between sessions, the AB+BF group performed abdominal breathing for 20minutes at home, two times a day. The control group followed the same processes as the
experimental group; however, the control group did not engage in biofeedback training
throughout the treatment sessions.
BP measurements were taken using a mercury sphygmomanometer before and
after each treatment session by the same researcher, and standard measurement processes
were implemented. Follow-up BP measures were also taken at one month and three
months after completion of the intervention. ECG was recorded using a Cl-810232 and
measurements were processed using an analog-to-digital converter (BL-420) (Wang et
al., 2010). Data was analyzed using SPSS version 12.0, ANOVA, paired t-tests,
independent samples t-test, and Greenhouse-Geisser correction (Wang et al., 2010).
Results indicated that BP progressively decreased each session in both groups
(Wang et al., 2010). The AB+BF intervention group saw a significant reduction in SBP
by 8.4 mm Hg (from 133.58 ± 4.46 to 125.17 ± 5.54 mm Hg; p < 0.001) and in DBP by
3.9 mm Hg (from 81.92 ± 4.83 to 78.00 ± 3.19 mm Hg; p < 0.05) at the end of the
intervention (Wang et al., 2010). Follow-up BP measurements showed that the reduced
levels of SBP lasted for up to three-months (125.25 ± 4.39 and 125.08 ± 4.85 mm Hg), as
well as DBP (78.67 ± 2.87 and 79.17 ± 2.41 mm Hg) (Wang et al., 2010). Slow
abdominal breathing also significantly lowered SBP by 4.3 mm Hg (from 133.90 ± 4.56
to 129.60 ± 4.28 mm Hg; p < 0.05); however, no noteworthy effect on SBP at follow-up
36
was found (Wang et al., 2010). Slow abdominal breathing had no effect on DBP at the
end of the intervention, nor at follow-up. When comparing between groups, AB+BF was
more effective in lowering SBP than breathing alone (Wang et al., 2010). This was also
true for DBP.
In conclusion, EMG biofeedback combined with slow abdominal breathing is a
successful method for managing BP in postmenopausal women with prehypertension.
These effects were shown to last for up to three months, and potentially longer, after
implementation. Results indicated that slow abdominal breathing combined with EMG
biofeedback had a more prominent effect on reducing BP. According to Wang et al.
(2010), participants in the experimental group expressed that using the EMG biofeedback
machine during sessions helped their psychophysiological status, and helped them reach
deeper levels of relaxation. However, there were limitations to the study. Participants
were all postmenopausal females, and the effects found on slow abdominal breathing
combined with EMG biofeedback may not be comparable, or generalizable, to other
populations. Per the researchers, postmenopausal women are more susceptible to
developing hypertension, and as a result, participants of this study may have been more
motivated to make health changes than other populations (Wang et al., 2010). Another
limitation is the small sample size and short length of intervention.
Section summary. Research suggests that people with prehypertension are at a
greater risk for hypertension, CVD, and other cardio events (Mayo Clinic, 2012b). It is
essential to find methods for treating and preventing prehypertension in order to avoid
more detrimental and potentially life threatening health diagnoses. The research literature
37
in this section indicates that managing prehypertension and hypertension through LSMs,
without the use of antihypertensive medications is effective. Additionally, LSMs were
found to have no adverse side effects, were cost effective when compared to
pharmaceutical treatment, and were widely accessible to a variety of people. The three
research articles evaluated in this section provide support for the use of LSMs in treating
high BP; the hypertensive patients in these three studies saw substantial reductions in BP.
However, there were several weaknesses in the studies that limit the generalizability to
other hypertensive patients. Weaknesses included small sample sizes, specific subsets of
adult female participants, and methodological limitations. Despite weaknesses, the
literature supports the need for widespread use of LSMs in hypertension prevention and
management efforts.
Yoga’s Effects on Preventing, Reducing, and Managing High BP
Yoga is an integrative movement-based mind-body practice that incorporates
diaphragmatic breathing, asanas, mindfulness, and meditation to achieve mental and
physical well-being (Cohen et al., 2011). In the United States particularly, yoga has
become an increasingly popular form of physical exercise, relaxation, and treatment for a
variety of chronic and mental health conditions (Ross & Thomas, 2010). Increasing
evidence distinguishes yoga an effective method for preventing, lowering, and managing
BP (Ross & Thomas, 2010).
Iyengar Yoga. Yoga originated in the Eastern world nearly 5,000 years ago, and
throughout its history, has taken many different forms. Iyengar Yoga (IY) is an
adaptation of Patanjali’s Yoga Sutras, with a unique emphasis on precision and alignment
38
through slow gradual movements, and use of props (Ramamani Iyengar Memorial Yoga
Institute, 2014). IY was developed in India by the world renowned Guruji, Yogacharya
B. K. S. Iyengar (Ramamani Iyengar Memorial Yoga Institute, 2014). The purpose of
Iyengar’s yoga adaptation was to make yoga an accessible practice to persons of all skill
levels (Iyengar, 2002). IY is a style of Hatha Yoga that traveled to the West and
continues to be widely practiced today.
Cohen et al. (2011) conducted a randomized controlled trial to compare the
effects of IY versus Enhanced Usual Care (EUC) (individual dietary adjustments) on
lowering BP using 24-hour ABPM in participants with prehypertension and Stage 1
hypertension that were not being treated. The study was conducted in Pennsylvania, and
participants that completed the study included 57 adults, ages 22–69, whom were not
familiar with the practice of yoga.
Participants were randomly assigned to one of seven IY or EUC cohort groups.
Intervention was 12-weeks in length, and groups were spread out over a 23-month period.
Participants assigned to the IY cohort (26 participants) initially attended two 70-minute
yoga classes per week for the first six-weeks, led by two certified IY instructors. During
the second half of the intervention, participants attended only one instructor-led IY class
per week, while also adding a 25-minute home yoga DVD. Participants were required to
record the duration and frequency of home sessions to ensure consistency among
participants. The group was not instructed to make any other lifestyle changes throughout
the intervention (Cohen at al., 2011).
39
Participants in the EUC groups (31) attended four dietician-led educational
classes held during Weeks 1, 2, 3, and 8 (Cohen et al., 2011). The same dietician led each
session and provided participants with dietary recommendations for weight management,
sodium restriction, limited alcohol consumption, balanced dietary habits, and education
around LSMs that have been shown to reduce high BP (Cohen et al., 2011). At each
session, body weight was measured with a calibrated scale; participants also recorded
food and beverage intake for the three days prior to Weeks 0, 6, and 12 of which was
analyzed by using Nutrition Data Systems and Research software, version 4.05. Each
participant also engaged in two phone sessions with the dietician during Weeks 5 and 10
(Cohen et al., 2011).
Salivary cortisol, SBP, DBP, urinary samples, and blood samples were collected
and assessed from all groups (Cohen et al., 2011). Additionally, mood, anxiety, stress,
and quality of life were measured among all participants at pretest, and every six weeks
thereafter, using the Profile of Mood States (POMS), the Perceived Stress Survey (PSS),
and the Short-form Health Survey (SF-36) (Cohen et al., 2011). To test comparisons
between groups, t-tests and chi-squared tests were used.
The results indicated that at six weeks, 24-hour ABPM, SBP and DBP were
significantly lower in the EUC group (SBP = 130 mm Hg; p < 0.05, and DBP = 79 mm
Hg; p < 0.05) (Cohen et al., 2011). No significant improvement at six weeks was found
among the IY group for SBP (133 mm Hg; p > 0.05) or DBP (83 mm Hg; p > 0.05).
However, at Week 12, the IY group showed a significant improvement in 24-hour ABPM
SBP (126 mm Hg; p < 0.05) with a mean reduction of 6 mm Hg. DBP also showed
40
significant reduction (78 mm Hg; p < 0.01). Reductions in BP were no longer significant
among the EUC group at Week 12 for 24-hour SBP (131 mm Hg; p > 0.05) or DBP (80
mm Hg; p > 0.05) (Cohen et al., 2011).
No substantial change in body mass index (BMI) occurred between groups during
the intervention. The EUC group did however see a decrease in weight at Week 12 when
compared to Week 0 (88.8 ± 3 kg to 87.2 ± 1.8 kg); which may be due to the LSM
changes the EUC groups made during intervention (Cohen et al., 2011). No differences
were found throughout the intervention in plasma levels of aldosterone, renin, salivary
cortisol, or urinary cortisol. Results of mood, anxiety, stress, and quality of life data
showed no significant changes at Week 6 or 12.
In conclusion, the results of this study were significant to the field.
Prehypertension and Stage 1 hypertension participants in the IY group saw a clinically
meaningful reduction in 24-hour ABPM SBP and DBP, and an equal, if not greater,
reduction in BP when compared to the EUC group, with the IY group showing a greater
mean SBP reduction at 12 weeks (Cohen et al., 2011). The reduction in SBP and DBP in
the IY group was comparable to other recommended LSMs (weight loss, sodium
restriction, aerobic activity, and the DASH diet) for lowering BP. The level of reductions
in SBP and DBP found throughout the intervention in the IY group can help reduce
cardiovascular morbidity and mortality. There were however some limitations in the
research. Confounding factors may have been present in the study due to the cohort
groups meeting at varying times throughout the intervention (Cohen et al., 2011).
Additionally, the intervention had a small sample size, and the groups were not blinded.
41
Lastly, 20 participants originally assigned to the IY group did not complete the study.
The reduction in participants greatly influenced data collection and statistical analysis for
the IY group, due to there being a higher dropout rate than the researchers initially
calculated for (Cohen, 2011). Despite limitations, IY was found to reduce 24-hour SBP
and DBP among those with prehypertension and Stage 1 hypertension, and showed an
equal, if not greater, reduction when compared to EUC and other LSMs. Further research
could help determine long-term impacts of IY on reducing SBP and DBP.
Impacts of yoga on BP and stress. Research data has shown that stressful
circumstances can cause acute spikes in BP (Mayo Clinic, 2012c). The human body
naturally responds to stress by releasing hormones that prepare an individual to react to
unexpected or dangerous stimuli (Mayo Clinic, 2013b). Transcendental Meditation (TM),
a technique used to reach a state of inner awareness and relaxation, has shown both
clinical and statistical reductions in stress and BP levels (Rainforth et al., 2007). Yoga
practices are therapeutic in nature, and implement similar TM techniques to achieve a
heightened state of conscious awareness and serenity (McCaffrey, Ruknui, Hatthakit, &
Kasetsomboon, 2005). In addition, a growing amount of research findings support that
yoga can reduce feelings and symptoms of stress, while also lowering BP (Smith,
Hancock, Blake-Mortimer, & Eckert, 2006).
A randomized control study completed McCaffrey et al. (2005) examined the
effectiveness of yoga on BP and stress among hypertensive individuals in Thailand. The
researchers based their study off of two different theories, one by Seyle (1976), who
explained the phenomenon of stress as the body’s nonspecific response to endogenous or
42
exogenous stressors; and the other by Monro, Nagarathna, and Nagendra (1995), who
suggested that the mind-body work implemented in yoga, breaks the cycle of the stress
response (McCaffrey et al., 2005). McCaffrey and colleagues (2005) designed an eightweek quasi-experimental study that analyzed the effects of yoga and stress reduction on
SBP, DBP, HR, and BMI. The study took place in Songkhla Province, Southern
Thailand, with 54 participants diagnosed with hypertension (BP > 140/90 mm Hg) who
were not being treated with medication.
Participants were recruited from a mobile clinic during July, 2003 through
November, 2003 using purposive sampling. Participants were randomly assigned into one
of two groups, either a yoga group or a control group, and the researchers found no
notable differences between the group participants prior to the start of intervention
(McCaffery et al., 2005). Based on self-report, very few participants in the study were
tobacco or alcohol users, nearly half had obtained education beyond high school, and a
large proportion exercised regularly (McCaffery et al., 2005).
The intervention group participated in an eight-week yoga program that included
health education and group support to aid in learning yogic philosophies and stress
management tools. Participants engaged in a pranayama and asana based yoga practice
three times a week throughout the intervention. Yoga sessions were held in two
designated locations outside of the hospital and lasted approximately 60-minutes in
length. Classes were guided by yoga cassette tapes, while demonstrations were provided
from a trained research assistant. The yoga cassette included relaxation techniques, breath
work, and 14 asanas. Participants kept a written record of their weekly yoga practices to
43
ensure that intervention standards were being followed (McCaffrey et al., 2005).
Intervention participants were monitored by a physician via outpatient care during the
length of the study. The mean age of participants in the yoga group was 56.7 years of age,
and the group consisted of 17 female, and 10 male participants (McCaffrey et al., 2005).
The control group did not participate in any yoga practices and did not receive
any stress management education. Control group participants did receive routine
outpatient care at the hospital, and were given general hypertension information at the
visits. The cohort group consisted of 18 female, and nine male participants, with a mean
group age of 56.2.
The Stress Assessment Questionnaire, modified from the Stress of Symptom
Inventory was used to analyze stress levels, while participant’s medical records were
used to gather BP, HR, and body weight data (McCaffrey et al., 2005). Measurements of
BP, HR, and body weight were taken before the intervention and on the last day of yoga
practice every two weeks after the start of the intervention, and were recorded bi-weekly
for control group participants (McCaffrey et al., 2005). Results were analyzed using
SPSS, ANOVA, and paired t-tests. Mean, standard deviation (SD), and range of total
stress score were calculated to compare stress levels between the groups (McCaffrey et
al., 2005).
During analysis, no difference in mean stress score was found prior to the start of
the study (p > 0.162); however, upon posttest, mean stress scores between groups were
significantly different (p < 0.01). This indicates that the eight-week yoga practice
significantly lowered participants’ stress levels. The yoga group saw a significant
44
reduction in mean SBP, DBP, HR, and BMI from pre-to post-test (p < 0.01) (McCaffrey
et al., 2005). SBP, DBP, and HR measures were statistically significant at Weeks 2, 4, 6,
and 8 (p < 0.01). The yoga group saw a significant reduction in SBP and DBP versus the
control group (SBP: 24 mm Hg vs. 2 mm Hg, and DBP: 18 mm Hg vs. 2 mm Hg) (Cohen
et al., 2011). BMI reduced significantly at Weeks 6 and 8 in the yoga group (p < 0.05),
while no substantial change in BMI was found in the control group (p > 0.05); however,
no difference was found when comparing between groups (McCaffrey et al., 2005).
The conclusions from this study were that an eight-week yoga practice
incorporating pranayama and asanas can significantly lower stress levels, SBP, DBP, HR,
and BMI among mild to moderate hypertensive adults (McCaffrey et al., 2005). Yoga
was also found to promote a state of calmness, peacefulness, and awareness among
practitioners (McCaffrey et al., 2005). Despite the significant findings of this study, there
were limitations. The study was conducted for a short time in one location in Southern
Thailand; therefore, the results may not be generalizable to other hypertensive persons in
Thailand. Another limitation of the study is that no information on BP equipment,
methodology, accuracy or reliability was provided.
Effects of yoga and antihypertensive medication compared. A growing body
of research continues to mount on the positive health impacts of yoga on BP. A
prominent study among the literature on yoga and BP is of that performed by Murugesan,
Govindarajulu, and Bera (2000). The purpose of the randomized controlled study was to
analyze yoga’s effectiveness in treating hypertension. Participants consisted of 33
diagnosed hypertensive adults, 35 to 65 years of age. The participants were recruited
45
from the Government General Hospital in Pondicharry, India, and were randomly
assigned to one of three groups: a control group, a yoga group, and an antihypertensive
medication group. Control group participants did not receive any intervention treatments;
however, they were monitored by a physician throughout the duration of the study. The
yoga group engaged in yogic practices both in the morning and evening for a total of onehour per day, six days a week. Lastly, the antihypertensive medication group was
prescribed daily antihypertensive drugs from a physician at Government General
Hospital. The study was conducted for a total of eleven weeks, and all participants
underwent pre- and post-testing for SBP, DBP, HR, and body weight.
A sphygmomanometer of ISI mark was used along with a manual stethoscope to
measure BP both before and after the study (Murugesan et al., 2000). HR was measured
using a calibrated stop watch, and a standard scale was used to measure body weight in
kilograms (Murugesan et al., 2000). To analyze the data collected from participants, an
ANCOVA was used to compare pre- and post-test data to examine the effects of yoga
and antihypertensive medications on controlling high BP (Murugesan et al., 2000). To
compare the difference between the adjusted means, the Scheffe’s post-hoc test was used
(Murugesan et al., 2000).
No difference in SBP was found among groups prior to the start of the study. SBP
taken at the end of the study was however found to be significantly different among the
three groups (Fx = 26.0791; p < 0.01) (Murugesan et al., 2000). For the control group,
posttest SBP was not substantial (F = 0.620; p > 0.05). The yoga group showed a
statistically significant reduction of SBP upon posttest (F = 44.079; p < 0.01), as well as
46
the medication group (F = 40.824; p < 0.01) (Murugesan et al., 2000). SBP fell 33 mm
Hg among yoga intervention participants, compared to a 24 mm Hg reduction in the
medication group, and a 4 mm Hg decrease in the control group (Cohen et al., 2011). The
researchers found that yoga practice proved to be more effective when compared to the
antihypertensive medication group and control group in reducing SBP (Murugesan et al.,
2000).
DBP taken at the end of the study was significantly significant among the three
groups (Fx = 19.350; p < 0.01) (Murugesan et al., 2000). The control group showed no
difference in DBP at posttest (F = 0.540; p > 0.05). A significant reduction of DBP was
found upon posttest in the yoga group (F = 68.253; p < 0.01), as well as the medication
group (F = 64.479; p < 0.01).
The research was able to conclude that both yoga and antihypertensive
medications lower BP among mild to moderate hypertensive adults. Yoga was more
effective than antihypertensive medications in lowering SBP, HR, and body weight
(Murugesan et al., 2000). This is significant because yoga proved to be as effective, if not
more effective as antihypertensive medications in reducing mild to moderate high BP,
while eliminating the short-term and long-term adverse side effects found with
pharmacological use (Murugesan et al., 2000). It is worth noting that severe hypertension
patients may still require the use of antihypertensive medications in order to manage high
BP. The findings of this study are useful, as many people are looking for alternative
measures for managing and preventing high BP. Despite substantial outcomes, there were
limitations to the study. The study had a very small sample size and took place in one
47
city; therefore, results may vary in other parts of India, as well as throughout the world. A
leading limitation of the study was unclear methodology processes, and little, to no
information was provided in regards to medications prescribed to antihypertensive group
participants (Cohen et al., 2011).
Section summary. The research literature indicates that yoga is an effective
alternative for lowering BP and enhancing one’s physical and emotional health. The
research articles provide support that yoga lowers BP equally, if not more, than
antihypertensive medications and other LSMs, among individuals with a prehypertension
to moderate hypertensive diagnoses. Yoga participants showed decreased levels of SBP,
DBP, HR, BMI, and reduced stress levels; however, there were limitations to the studies.
Weaknesses included small sample sizes, limited documentation of methodological
procedures implemented during interventions, and restricted sample populations, in
which could have affected the interpretation of the study findings. Although there were
limitations to the literature studies, their findings were significant.
Summary
Rates of hypertension among Americans are expected to grow in impending
years; thus, it is more crucial now, than ever, to prevent, delay, and manage high BP
(WHO, 2014). Antihypertensive medications are currently used as a frontline treatment
for hypertension, and are found to be effective in lowering BP; however, questions ensue
regarding which antihypertensive medication is most efficient, if treatment with
medication is worth the financial costs and adverse side effects, and whether alternative
methods need to come into the forefront for primary treatment of mild to moderate
48
hypertension. Current estimates suggest that the global pharmaceutical market is worth
$300 billion dollars annually, with more than $15.5 billion dollars a year spent on
hypertension drugs in the U.S. alone (WHO, 2014; ALLHAT, 2002). Health
professionals and citizens alike are calling for alternative methods for managing BP.
The research here supports that non-pharmaceutical LSMs are an effective
treatment approach in reducing and managing high BP. Yoga is an LSM that has been
found to elicit significant health benefits, both physiological and psychological in nature,
and proven to be as efficient as antihypertensive medications in lowering BP (Murugesan
et al., 2000). However, some of the sample sizes in the research literature were small, and
there were methodological limitations. Additionally, some of the studied populations
were narrow in their range of generalizability to the greater population.
Yoga is a specific LSM and popular MBT that has gained substantial recognition
in its ability to prevent and lower BP among practitioners. The practice of yoga has
evolved to include many different styles, each with its own unique emphasis on practice
methodology, breath work, asanas, and meditation customs. Yet despite their differences,
all continue to stem from ancient yogic principles established more than five millennia
ago. No studies to date have compared the effects of different styles of yoga on reducing
BP. This study contributed to the field and existing literature by measuring the short-term
effects of yoga, and the different styles of Hatha, Power, and Eischens Yoga, on lowering
BP.
49
Chapter 3: Research Method
Introduction
LSMs have gained increasing recognition as effective alternatives measures for
managing high BP among public and medical health professionals. However, medical
health professionals commonly recommend LSMs as a supplement to medication, rather
than as an initial treatment option (Bunker, 2014). More research is needed, but current
evidence suggests that LSMs are as effective, if not more so, than antihypertensive
medications at managing BP in patients with prehypertension, and mild to moderate
hypertension (Murugesan et al., 2000). Additionally, LSMs have the ability to not only
reduce high BP, but to delay onset and/or even prevent high BP (Hedayati, Elsayed, &
Reilly, 2011).
Yoga is an LSM that has gained renowned recognition for its ability to lower BP,
as well as improve one’s physical and mental well-being (Jayasinghe, 2004). It has been
hypothesized that yoga reduces BP through its incorporation of synchronized breath
work, physical postures, and mind-body focus which are believed to enhance the
interactions between the body’s endocrine and involuntary nervous system (Cade et al.,
2010). Thus, this research study aimed to 1) confirm that yoga does lower BP, 2) examine
if different styles of yoga lower BP more than another, and 3) determine which style,
between Hatha, Power, and Eischens Yoga lowers BP more than the others.
This quantitative study was accomplished by measuring and comparing BP of
willing participants before and after scheduled Hatha, Power, and Eischens Yoga classes
in the Minneapolis suburb Chaska, Minnesota. A demographic questionnaire was also
50
completed by each participant in order to gain information about their age, weight, race,
gender, activity level, hypertension status, tobacco use, and yoga experience. Data
collected was analyzed using t-tests, mean, SD, ANOVA, ANCOVA, and Bonferroni’s
corrected post-hoc t-test to compare BP and HR between the three different styles of
yoga.
Setting
This study took place at the yoga studio “Good and Twisted Yoga” in Chaska,
Minnesota, which offers a variety of different styles and scheduled class times throughout
the week. The studio is the only yoga studio in Chaska, and the only studio within a five
and a half mile radius or more in any direction. Intervention took place over a three-week
period during the months of August and September, 2014. The intervention was
conducted in the lobby of the studio, where the researcher set up a table and three chairs
35-minutes prior to the start of scheduled classes. The three styles of yoga selected for
this study included Hatha, Power, and Eischens Yoga. These styles were specifically
chosen because they all incorporate the elements of pranayama, asanas, mindfulness,
meditation, and Savasana into their practice. The studio was selected due to the
researcher’s previous work experience there as an instructor, and due to the ease of
accessibility to qualified yoga instructors. Permission to conduct the study was granted
by the studio owner, and written consent was obtained from all selected instructors to
attend their scheduled classes. Yoga instructors were chosen for the study based on their
yoga experience, knowledge, and certification in the respective styles of yoga. Each
instructor was a Registered Yoga Teacher through Yoga Alliance and had received their
51
200-hour (or higher) certification in either Hatha, Power, or Eischens Yoga. All of the
Power Yoga instructors received their Power certification from the same institution,
CorePower Yoga. The Eischens Yoga instructor is the only certified Eischens instructor
in the state of Minnesota, and studied for decades under the creator of the style, Roger
Eischens himself.
Each instructor met with the researcher prior to the start of the intervention to
discuss the nature and purpose of the study, procedures, instructor qualifications;
participants were provided a schedule of the classes the researcher would attend during
the study. All classes were 60-minutes in length, and each instructor was allowed to teach
their own sequence; however, they were instructed to stay true to the fundamental
principles of the respective style of yoga they taught. To ensure consistency, the
researcher observed all of the yoga classes throughout the intervention.
Hatha Yoga classes were taught in an unheated studio and each practice included
slow-paced asanas and stretching. Yoga blocks and straps were used when appropriate
throughout practice to attain proper alignment in each pose. Power Yoga is traditionally a
fast-paced vinyasa taught in a heated room. All Power Yoga classes included in the
intervention were taught in the studio heated to 90 degrees Fahrenheit. The instructors
incorporated the elements of one-breath to one-movement sequencing for a dynamic full
body workout intended to build strength, stability, flexibility, endurance, and focus.
Eischens Yoga classes were led in an unheated room and emphasis was placed on body
awareness, proper alignment, resistance work, and creating space in the body.
Sample
52
The sampling procedure used in the study was non-random convenience
sampling. Exclusion criteria included being: pregnant at the time of the intervention,
under 18 years of age, unable to complete the 60-minute yoga class for any reason, and,
unable to adequately fit the BP cuff. Upon the researcher’s discretion, a participant’s data
was excluded from statistical analysis if the BP cuff did not adequately fit the participant
during measurement. The researcher marked a small “x” in the corner of the participant’s
data so that it would be discarded.
Research Design and Approach
This research study was experimental and quantitative, with no aspects of the
study being qualitative. In this study, the independent variable was the style of yoga class
attended, which included Hatha, Power, or Eischens Yoga. The yoga practice was
intended to have an effect on BP among the practitioners. The dependent variable was
BP. Participants’ BP was measured prior to and upon completion of scheduled 60-minute
yoga classes; each class was identified and scheduled as Hatha, Power, or Eischens yoga
prior to the students’ participation. Inferential and descriptive statistics were used to
analyze the collected data, which included comparisons before and after each of the styles
of Hatha, Power, and Eischens Yoga and the yoga classes in general.
Measurement Instruments and Materials
To measure participants’ BP, an Omron M10-IT Upper Arm Digital Automatic
BPM equipped with Intellisense technology and an adjustable 22–42 cm circumference
arm cuff was used. SBP and DBP readings were recorded in mm Hg, and HR readings
were automatically recorded by the BPM and therefore were recorded along with pre-
53
and post-test BP. The fully automatic oscillometric Omron M10-IT BPM was calibrated
by the manufacturer, as well as tested, validated, and approved with an accuracy of ± 3
mm Hg by the Association for the Advancement of Medical Instrumentation, the
International Protocol for the Validation of Automated BP Measuring Devices, and the
British Hypertension Society (Dabl Educational Trust, 2014). To further verify its
reliability, BP measurements were taken multiple times on the same person within a short
time period to examine if the BP readings were similar.
A one-page study form was administered to each participant prior to the start of
the yoga class. The top half of the form consisted of a nine-question demographic
questionnaire to be completed by the participant. The questionnaire was developed by the
researcher and was intended to gather information regarding each participant’s age,
gender, race, perceived weight, activity level, yoga experience, presence of hypertension,
tobacco use, and overall health. Question format included four Likert-type, two yes or no,
and three free-answer questions. A sample question from the survey included, “How
would you describe your weight? Answer choices were: Underweight, Normal,
Overweight, Obese.” The bottom portion of the study form was used by the researcher to
record the individual participant’s pre- and post-class BP and HR measurements. See
Appendix A for a copy of the form.
Lastly, participants were given a copy of their before- and after-class BP and HR
readings. Along with their readings, each participant received a “Blood Pressure Fact
Sheet” adapted from the AHA (2014). The “Blood Pressure Fact Sheet” provided general,
factual information about BP, BP readings, their meaning, and the standard stages of
54
hypertension. See Appendix B for a copy of the BP form handout and Appendix C for the
“Blood Pressure Fact Sheet” that was given to participants upon completion of their
participation in the study.
Procedures
The study data was collected through BP measurements and a demographic
questionnaire. Collection of data took place over a three-week time period, and
intervention occurred Mondays through Sundays at varying times of the day (between
5:30am and 8:00pm). The researcher arrived at scheduled Hatha, Power, and Eischens
Yoga classes 35-minutes prior to the start of class to set up a research table, three chairs,
the automatic BPM, consent forms, and study forms in the lobby of the studio. As
practitioners arrived, the researcher explained the study, methods, and purpose to all adult
practitioners. Willing participants were then seated at the research table and were given
the consent form to read and initial.
After consent was obtained, participants were instructed to complete the
demographic questionnaire on the top portion of the study form. Questionnaire answers
and pre- and post-BP and HR measurements were all recorded on the same form.
Therefore, when the participant completed the questionnaire, the researcher collected the
study form and documented the participant’s pretest BP and HR reading in the designated
section. All pretest BP and HR measurements were taken within 30-minutes prior to the
start of class. No names were collected on the study form; however, a post-it note with
the participant’s last four digits of their phone number was attached so that the proper
form could be retrieved for posttest measurements. After completion of the yoga class,
55
participants returned to the research table to have their posttest BP and HR measurement
taken by the researcher. All post-it notes were removed and destroyed immediately when
the individual’s form was located for posttest measurement. Each participant was seated
for at least one-minute prior to measurement, and all posttest BP and HR readings were
taken within 30-minutes after the end of class.
BP was measured by the same trained researcher throughout the duration of the
study. The researcher received educational and practical training from a medical
professional on how to accurately apply the cuff, measure BP, and record BP and HR
readings with the Omron M10-IT BPM prior to the start of the study. Standard BP
measurement procedures were followed throughout the intervention. All participants
were seated for at least one-minute prior to conducting both pre- and post-test BP and HR
measurements. Participants were instructed to sit with both feet flat on the floor and with
their arm placed on the table so that the cuff was at the same level as their heart. The BP
cuff was applied to the upper arm by the researcher, and the participant’s same arm was
used for the pre- and post-test readings. Participants were asked to not speak or move
while their BP was being taken. Upon completion, each participant was thanked and
debriefed by the researcher. Participants were also given a copy of their before and after
class BP readings, along with the AHA (2014) “Blood Pressure Fact Sheet.”
Data Measures and Statistical Analysis
To measure differences in baseline characteristics between participants, t-tests
were used to analyze continuous variables collected from the questionnaire, along with
mean and SD. The pre- and post-class BP and HR measurements were entered into an
56
Excel spreadsheet and measurements were further divided by the style of yoga. Analysis
of all pre-and post-class BP and HR readings were achieved through t-test, SD, one-way
ANOVA, ANCOVA, and Bonferroni corrected t-test in Excel and XLSTAT to measure
differences between the styles of Hatha, Power, and Eischens Yoga.
Protection of Human Participants
This study was approved by the Concordia University, Nebraska, Institutional
Review Board. All attending adult (18±) yoga practitioners were explained the nature,
purpose, and methods of the study by the researcher and informed consent was obtained
from each participant. Please see Appendix D for a copy of the form. Participants were
informed that they could withdraw their consent or discontinue participation at any time
throughout the study, without penalty.
All data collected during the intervention was kept confidential; however, signed
initials were obtained on the informed consent form. Names of participants were not
collected or associated with their completed study form, though the last four digits of
their phone number were written on a post-it note and placed on the back side of the
study form during the initial BP reading, and were immediately removed and destroyed
upon completion of the second reading. The phone numbers were visible only to the
researcher and were intended to ensure the correct study form was located for post-class
measurement. BP readings were written down for the participant rather than stated aloud,
where another individual could overhear. All physical data collected was locked up and
the data was entered in an Excel spreadsheet, which was password protected; both of
57
which were only accessible to the researcher and faculty involved in the oversight of the
research.
58
Chapter 4: Results
Introduction
Over the last several decades, hypertension has become a prominent public health
issue among American citizens as rates of high BP continue to rise. High BP is a leading
risk factor for cardiovascular morbidity and mortality (Jadhav et al., 2014). Today,
antihypertensive medication is used as the leading treatment option for hypertension;
however, pharmacological treatment falls short in that it does not address the underlying
issues leading to high BP, but merely treats its symptoms. Additionally, antihypertensive
medications can be costly or cause adverse side effects, and despite their use, may not
successfully manage BP in a large portion of patients (Bunker, 2014). In response,
alternative approaches to lowering BP have been implemented.
LSMs have gained global recognition for their ability to prevent, prolong, and
control high BP. Among the various recommended LSMs, yoga has emerged as a popular
and effective measure and has been recognized for its ability to improve one’s overall
physical and mental well-being (Ross & Thomas, 2010). Research supports that yoga aids
in lowering BP; however, there are many styles of yoga practiced, and each style may
elicit different health responses. Determining such differences could assist public health
and health care professionals, hypertension patients, and citizens alike in taking control of
their BP and overall health. The following sections represent the data collected to address
the three research questions proposed. The research questions were:
1.
Does blood pressure decrease after a 60-minute yoga class?
59
2. Do different styles of yoga alter blood pressure to a greater or lesser degree than
others?
3. Among the styles of Hatha, Power, and Eischens Yoga, which style lowers blood
pressure more?
Data Analysis
A total of 76 participants completed the study, of which 66 (87%) were female,
and 10 (13%) were male. Participants were between the ages of 19 and 72, with an
average age of 46; 100% (76) of the participants were Caucasian. Forty-one percent (31)
were beginner-level practitioners of yoga, and 57% (43) were intermediates; 40% (43)
exercised 2–3 days per week, whereas 3% exercised 0–1 days per week. Most (91%)
reported being in good to very good health, 93% (71) were non-smokers, and 33% (25)
indicated they were overweight or obese, thus, at a higher risk for high BP. Only 18%
(14) were actively being treated for hypertension. The general characteristics of the
participants in the Hatha, Power, and Eischens Yoga groups are shown in Table 1. No
significant differences were found between the groups in race, gender, level of yoga
experience, overall health, and tobacco use. There was however a significant difference
between groups in regards to perceived weight, exercise frequency, and presence of
hypertension.
60
Table 1
Baseline characteristics for participants who completed the study
Categories
Age (yr.)
Race (Caucasian)
Hatha (n = 23)
Power (n = 28)
Eischens (n = 25)
mean ± SD
mean ± SD
mean ± SD
49.1 ± 14.7
35.3 ± 11.3
54.5 ± 14.2
n (%)
23 (100)
n (%)
28 (100)
n (%)
25 (100)
Gender
0
1
0.77
Male
4 (17.4)
3 (10.7)
3 (12.0)
Female
19 (82.6)
25 (89.3)
22 (88.0)
Yoga Experience
0.3
First Time
0 (0.0)
Beginner
13 (56.5)
9 (32.1)
9 (36.0)
Intermediate
9 (39.1)
18 (64.3)
16 (64.0)
Advanced
1 (4.3)
1 (3.6)
0 (0.0)
0 (0.0)
0 (0.0)
Exercise (per wk)
0
0–1 days
0 (0.0)
0 (0.0)
2 (8.0)
2–3 days
9 (39.1)
7 (25.0)
14 (56.0)
4–5 days
12 (52.2)
10 (35.7)
6 (24.0)
6–7 days
2 (8.7)
11 (39.3)
3 (12.0)
0.42
Overall Health
Poor
Fair
0 (0.0)
0 (0.0)
0 (0.0)
2 (8.7)
1 (3.6)
1 (4.0)
Good
12 (52.2)
13 (46.4)
9 (36.0)
Very Good
8 (34.8)
13 (46.4)
14 (56.0)
Excellent
1 (4.3)
1 (3.6)
1 (4.0)
Weight
Underweight
p
0.01
0 (0.0)
0 (0.0)
0 (0.0)
Normal
15 (65.2)
24 (85.7)
12 (48.0)
Overweight
8 (34.8)
4 (14.3)
11 (44.0)
Obese
0 (0.0)
0 (0.0)
2 (8.0)
Hypertension
0
Yes
8 (34.8)
0 (0.0)
6 (24.0)
No
15 (65.2)
28 (100)
19 (76.0)
Tobacco Use
0.55
Yes
1 (4.3)
3 (10.7)
1 (4.0)
No
22 (95.7)
25 (89.3)
24 (96.0)
61
Quantitative Data
The independent variables in this study included the styles of Hatha, Power, and
Eischens Yoga, while the dependent variable was BP. The researcher calculated the
variance between pre- and post-SBP, pre- and post-DBP, and pre- and post-HR for each
study participant to examine if the difference in changes of BP and HR were statistically
significant between the classes of Hatha, Power and Eischens Yoga; as well as examine
pre-and post-differences for all participants for an inclusive comparison of all yoga
participants. T-test, ANOVA, ANCOVA, and Bonferroni’s corrected post-hoc t-test were
used to calculate statistical significance; a statistical significance of p < 0.05 was used.
Hypothesis 1: BP does lower after a 60-minute yoga class. The first hypothesis
was based on pre-established findings that yoga does lower BP. To verify these previous
findings, a paired t-test was used to compare pre- and post-SBP and DBP among all study
participants. A statistically significant difference was found for both SBP (p < 0.05) and
DBP (p < 0.05). SBP decreased by an average of 4.2 mm Hg (from: 119.8 ± 18.60 mm
Hg to 115.6 ± 15.5 mm Hg; p = 0.000), while DBP decreased by 2.4 mm Hg (from: 79.7
± 11.80 mm Hg to 77.3 ± 9.9 mm Hg; p = 0.013). The results indicate that yoga does
significantly lower BP after a 60-minute yoga class, and therefore, the null hypothesis
should be rejected.
Difference in HR was also analyzed for all study participants using a two-tailed
paired t-test. A statistically significant difference was found between pre- and postmeasurements (p < 0.05). HR increased by an average of 2.6 bpm (from: 75.3 ± 12.00
62
bpm to 78.0 ± 13.2 bpm; p = 0.012). Table 2 presents mean pre- and post-measurements
for SBP, DBP, and HR.
Table 2
Mean pre- and post-test measurements for all study participants
All Study
Pretest M
Post-test M
Participants
(± SD)
M (± SD)
SBP (mm Hg)
119.8 (18.6)
115.6 (15.5)
DBP (mm Hg)
79.7 (11.8)
77.3 (9.9)
HR (bpm)
75.3 (12.0)
78.0 (13.2)
*Denotes significant difference in means using p < 0.05.
Mean
Difference
4.2
2.4
-2.6
p Value
0.000*
0.013*
0.012*
Hypothesis 2: Different styles of yoga have varying effects on BP. A paired ttest was used to compare pre- and post-mean SBP, DBP, and HR values of the
participants in each respective style of yoga (Hatha, Power, and Eischens). The results
demonstrated that SBP significantly decreased in the Hatha and Eischens groups (p <
0.05). SBP significantly decreased by an average of 6.1 mm Hg among Hatha Yoga
participants (from: 122.3 mm Hg to 116.2 mm Hg; p = 0.001), and 3.7 mm Hg among
Eischens participants (from: 124.2 mm Hg to 120.5 mm Hg; p = 0.03). Power Yoga
demonstrated a decrease in SBP, but the findings were not significant (3.0 mm Hg; from:
113.8 mm Hg to 110.8 mm Hg; p = 0.07) (Table 3).
63
Table 3
Mean difference of pre- and post-test SBP
Style of Yoga
Pre-SBP (mm Hg) Post-SBP(mm Hg)
M (± SD)
M (± SD)
Hatha
122.3 (20.4)
116.2 (17.7)
Power
113.8 (15.9)
110.8 (10.8)
Eischens
124.2 (18.6)
120.5 (16.8)
*Denotes significant difference in means using p < 0.05.
Mean Difference
(mm Hg)
6.1
3.0
3.7
p Value
0.001*
0.07
0.03*
To measure if different styles of yoga have varying effects on SBP, an ANOVA
was used to compare the difference of participant’s pre- and post-SBP measurements
between the three different styles of yoga. No significant difference was found between
the styles (p > 0.05). This suggests that no style, Hatha, Power, or Eischens Yoga,
significantly lowered SBP more than another style (p = 0.49). An ANCOVA was
performed to statistically control for potential confounding variables, and determine
whether one style of yoga significantly lowers SBP more than another if the covariates
were controlled for. The analysis was performed in Excel XLSTAT using gender, age,
experience level, activity level, overall health, perceived weight, ethnicity, tobacco use,
and the presence of hypertension as covariates. Results indicated that no significant
difference between styles was found when these variables were controlled for (p = 0.39).
Therefore, there was a failure to reject the null hypothesis.
The DBP results showed a significant reduction within the Power group after a
60-minute class, with no significant change in DBP in either the Hatha or Eischens group.
Power Yoga saw a significant decrease of 3.1 mm Hg (from: 76.9 mm Hg to 73.8 mm
Hg; p = 0.03); Hatha demonstrated a mean difference in DBP of 0.8 mm Hg (from: 80.1
64
mm Hg to 79.3 mm Hg; p = 0.35), and Eischens Yoga of 3.2 mm Hg (from: 82.4 mm Hg
to 79.3 mm Hg; p = 0.057) (Table 4). When comparing the three different styles of yoga
to identify if one style of yoga lowered DBP more than another, no significant difference
was found when confounding variables were not controlled for (p = 0.61), nor when they
were controlled for (p = 0.70). Therefore, the null hypothesis could not be rejected.
Table 4
Mean difference of pre- and post-test DBP
Style of Yoga
Pre-DBP (mm
Post-DBP (mm
Mean
p Value
Hg)
Hg)
Difference (mm
M (± SD)
M (± SD)
Hg)
Hatha
80.1 (12.0)
79.3 (12.3)
0.8
0.35
Power
76.9 (11.3)
73.8 (6.2)
3.1
0.03*
Eischens
82.4 (12.0)
79.3 (10.2)
3.2
0.057
*Denotes significant difference in means using p < 0.05.
A two-tailed t-test was used to analyze the effect of 60-minute Hatha, Power, and
Eischens Yoga classes on HR. Difference in pre- and post-test HR values showed to be
significant for both Power and Eischens Yoga (p < 0.05), however, their significant
findings were opposite of one another; Power Yoga significantly increased HR (8.3 bpm;
74.6 bpm to 82.9 bpm; p = 0.000), while Eischens Yoga significantly decreased HR (3.5
bpm; 78.7 bpm to 75.2 bpm; p = 0.008). No significant difference in HR was found
among Hatha Yoga participants (2.5 bpm; 72.7 bpm to 75.1 bpm; p = 0.09) (Table 5).
65
Table 5
Mean difference of pre- and post-test HR
Style of Yoga
Pre-HR
Post-HR
Mean Difference p Value
(bpm)
(bpm)
(bpm)
M (± SD)
M (± SD)
Hatha
72.7 (12.6)
75.1 (11.2)
-2.5
0.091
Power
74.6 (13.6)
82.9 (16.3)
-8.3
0.000*
Eischens
78.7 (9.0)
75.2 (9.1)
3.5
0.008*
*Denotes significant difference in means using p < 0.05.
6
4
2
0
Hatha
Power
Eischens
-2
-4
-6
-8
-10
Style of Yoga
Figure 1. Mean difference between pre-and post-test HR
An ANOVA was used to compare if Hatha, Power, or Eischens Yoga
significantly influenced HR more than the others, and the results indicated that there was
a significant difference between the styles (p < 0.05; p = 0.000). An ANCOVA was also
performed and further confirmed the findings that a significant difference was present
among the styles of yoga (p = 0.000). A Bonferroni corrected post-hoc t-test was used to
66
identify which style of yoga was significantly different. Results indicated that HR was
significantly different between the Hatha and Power groups (p = 0.016), Hatha and the
Eischens group (p = 0.022), and Power and the Eischens group (p = 0.000). In other
words, the difference in HR was significant when comparing each style of yoga to one
another.
Hypothesis 3: Among the styles of Hatha, Power, and Eischens Yoga, one
lowers BP more. The research indicates that no significant difference was found among
the styles of Hatha, Power, and Eischens Yoga in lowering BP). Neither SBP (p = 0.49)
nor DBP (p = 0.61) were found to be significant between groups when an ANOVA was
performed, nor when an ANCOVA was used to account for confounding variables (SBP:
p = 0.39; DBP: p = 0.70). Thus, the null hypothesis could not be rejected.
67
Chapter 5: Discussion, Conclusion, and Recommendations
Introduction
Hypertension is a growing worldwide epidemic and a serious public health concern
(WHO, 2013; Cohen et al., 2013). To date, hypertension is most commonly treated with
anti-hypertensive medications but the medications have often proved to be expensive, can
cause harmful side effects among patients, and ultimately fail to address controllable risk
factors associated with high BP. Hypertension can be debilitating, lead to various micro
and macro vascular complications, and if left untreated, can result in death (Saptharishi et
al., 2009). However, high BP can often be prevented, prolonged, and minimized through
healthy lifestyle choices. As more emphasis has been placed on taking an active role in
one’s own health, yoga has emerged as a popular LSM, form of exercise, and relaxation
tool. Research findings support that yoga can aid in preventing, delaying, and reducing
high BP, among influencing other health factors (Ross & Thomas, 2010).
Yoga is an ancient practice that continues to be a staple in modern society. Through
its joining of the physical, mental, and spiritual bodies, yoga has been found to positively
impacts one’s overall health by increasing flexibility in the spine and joints, toning
muscles, and improving endurance, while also promoting stronger cardiac health, reduced
BP, reversing the body’s stress response, and cultivating a relaxed state of mind (Patel,
Newstead, & Ferrer, 2012; Field, 2011; McCaffrey et al., 2005). Throughout history and
yoga’s introduction to the Western world, several different styles of yoga practice have
emerged. However, in the current literature, there is little information regarding how
different styles of yoga influence health. Since there are a wide variety of yoga styles
68
practiced throughout the U.S., it is possible that different styles have varying effects on BP.
Therefore, the goal of the current research was to determine if one style of yoga, among
the styles of Hatha, Power, and Eischens Yoga, lowers BP more than another after one 60minute session. Quantitative analysis was conducted to address the following three
research questions:
1.
Does blood pressure decrease after a 60-minute yoga class?
2. Do different styles of yoga alter blood pressure to a greater or lesser degree
than others?
3. Among the styles of Hatha, Power, and Eischens Yoga, which style lowers
blood pressure more?
In addition, a demographic survey was completed by each individual to gather
information regarding the participant’s age, gender, race, activity level, yoga experience,
overall health, weight, tobacco use, and presence of hypertension. The following sections
discuss the findings of the research and their implications, not only for those who have
high BP or those who practice yoga, but also for those looking to take an active role in
their health.
Discussion
The data collected throughout the study provided valuable information. The
findings are important because they further support the widespread awareness and use of
yoga as an effective method for lowering BP. In addition, the data may also provide
health professionals with alternative approaches for preventing, delaying, and managing
high BP among patients and citizens alike.
69
Research question 1. The data gathered from all study participants yielded
valuable information. In addressing the first research question listed above, an analysis
was conducted to compare pre- and post-SBP and DBP readings for all participants of the
study, regardless of the style of yoga they participated in. Research findings supported
that yoga did significantly lower both SBP and DBP after one 60-minute yoga session.
SBP decreased by a mean of 4.17 mm Hg, while DBP decreased by a mean of 2.41 mm
Hg. These results are consistent with existing research findings and suggest that yoga
does have an effect on lowering BP. A review and meta-analysis of 17 controlled yoga
studies performed by Hagins et al. (2013) found that yoga had a significant effect on
lowering SBP (4.17 mm Hg) and DBP (3.26 mm Hg). Additionally, the results were
found to be comparable to other forms of LSMs, including reduced intake of alcohol and
sodium, and physical activity (Hagins et al., 2013). These findings further support a
previous eight-week non-pharmacological hypertension study by Saptharishi et al.
(2009), which focused on the effects of exercise, reduced salt intake, and yoga practice
on BP. All three interventions significantly lowered BP, but no method was found to
significantly lower BP to a greater degree than another. Lastly, the results of an 11-week
study performed by Murugesan et al. (2000) compared the effects of yoga, medication,
and no treatment on BP. The researchers found that yoga was as effective, if not more
effective than antihypertensive medications at managing BP among participants with
moderate to mild hypertension post-intervention (Murugesan et al., 2000). SBP improved
by an average of 33 mm Hg among yoga group participants, versus a reduction of 23.87
mm Hg in the medication group, and 4.25 mm Hg in the control group. The yoga
70
intervention significantly lowered DBP by 26.27 mm Hg, compared to 9.91 mm Hg
among medication group participants, and 1.99 mm Hg among the control group
(Murugesan et al., 2000). The current study, as well as the studies aforementioned and
countless others support that yoga, as well as other LSMs, have positive, short-term and
long-term effects on BP.
It is important to note that not every study participant experienced a decrease in
BP; however, this is to be expected, as it is common for BP to rise both during and/or
shortly after engaging in physical activities (New Health Guide, 2014). BP increases
during exercise as a result of the muscles needing more oxygen during physical exertion;
therefore, the heart has to pump harder in order to deliver more blood throughout the
body (New Health Guide, 2014). A study measuring the arterial BP of participants during
a Hatha Yoga practice found that BP and cardiac response increased during the physical
yoga asanas, and even more so during standing postures (Miles et al., 2013). The
researchers’ findings were congruent with other strengthening and isometric exercises
(Miles et al., 2013). BP characteristically returns to normal and/or lower from baseline
shortly after discontinuing the activity (New Health Guide, 2014). Due to the nature of
this study and the minimal length of time between the end of the yoga session and postsession BP measurement, it is reasonable to assume that BP may have lowered among
more participants and/or to a greater degree among participants if more time had been
available for the body to recover post-session.
HR was also assessed, and a significant difference was found among pre-and
post-test measurements when analyzing all study participants. Further analysis indicated
71
that Eischens Yoga significantly lowered HR after one session, which is considered
optimal, as it signifies a stronger heart and more efficient heart beat (Freeman, 2014).
Hatha Yoga also lowered HR post-yoga class, but the findings were not significant.
Wahgmare and Baji (2013) conducted a study to analyze the effect of pranayama on
cardio-respiratory productivity. Study participants engaged in pranayama yoga for 60minutes six days a week for two months (Wahgmare & Baji, 2013). The researchers
found a significant decrease in HR post intervention (2.71 bpm).
Alternatively, Power Yoga significantly increased HR. However, as with BP, it is
also typical for HR to increase with exercise. The greater the intensity of the activity, the
greater the increase in HR (Mayo Clinic, 2014e). Power Yoga is notorious for its
vigorous, fitness-based approach, and therefore the rise in HR among Power Yoga
participants immediately after class is characteristic of the style (Bender Birch, 1995;
Ward, McCluney, & Bosch, 2013).
Research question 2. The second research question assessed whether different
styles of yoga have different effects on BP. The research failed to reject the null
hypothesis; neither Hatha, Power, or Eischens Yoga proved to be significantly more
effective in lowering BP than another. An ANCOVA was performed to control for
covariates, yet a significant difference was still not found. It did, however, appear the preSBP measurements and exercise frequency were correlated to the differences in SBP at
posttest, while a possible correlation was found between pre-DBP and posttest DBP;
however, correlation does not imply causation. Additional research would be needed to
explore those relationships further.
72
Although there was no statistical difference in the mean SBP and DBP values
between groups, when assessing pre- and post-test measurements within each style,
Hatha Yoga lowered SBP by more than 2 mm Hg when compared to Power or Eischens;
DBP lowered most among Eischens Yoga participants. These findings suggest that
different styles of yoga may have varying effects on BP; however, the small sample size
may have underpowered the ability to detect a statistically significant difference between
the three styles posed in this study. In addition, an extended study may further illuminate
if one style significantly effects BP more than the others, as findings suggest that
prolonged LSMs greatly improves BP control over time (AHA, 2014a). A six-week study
by Cowen and Adams (2005) compared the effects of Ashtanga and Hatha Yoga on DBP,
upper body and trunk dynamic muscular strength and endurance, flexibility, perceived
stress, and health perception. Upon post-intervention, both styles of yoga were found to
improve all measured elements, however, Hatha Yoga’s effectiveness was only
significant in upper body trunk dynamic muscular strength and endurance, and flexibility
among participants, while improvements were significant in all five of the measured
parameters among Ashtanga Yoga participants (Cowen & Adams, 2005). At this time, no
other studies were found comparing different styles of yoga and BP. Conclusively, the
benefits of yoga on cardiac outcomes warrants further research.
Research question 3. The third research question examined whether one of the
styles (Hatha, Power, and Eischens Yoga) reduced BP more than the others. This research
question could not be answered as no noteworthy difference was found among SBP
and/or DBP between the three styles after a 60-minute yoga class. SBP and DBP did
73
lower among all three styles; however, no style significantly lowered SBP or DBP more
than another. Due to the nature of this study, BP was measured immediately following
the end of class, and it is reasonable to believe that BP may have lowered even further if
more time was allowed for recovery post class (New Health Guide, 2014).
HR was also assessed, and a significant difference was found among pre-and
post-test measurements when comparing between the three styles. HR decreased among
Hatha and Eischens participants, while HR increased among Power Yoga participants.
The differences between Hatha and Power, Hatha and Eischens, and Power and Eischens
were all significant. A study completed by Cowen and Adams (2007) compared three
different styles of yoga and their effect on HR. A significant increase in HR was observed
among all three styles, Ashtanga (bpm = 95), Hatha (bpm = 80), and Gentle Yoga (bpm =
74), throughout an 80-minute session (Cowen & Adams, 2007). An ANOVA and post
hoc analysis revealed a significant difference for Ashtanga Yoga when compared to the
other two styles (Cowen & Adams, 2007). The researchers concluded that the more
vigorous the style of yoga, the greater the increase in HR. The increases in HR during the
three styles was viewed as beneficial, as increased HR may contribute to improved
cardiorespiratory fitness among practitioners, and was found to be equivalent to other
forms of exercise (Cowen & Adams, 2007). In conclusion, the data suggests that the style
of yoga practiced has a significant impact on HR; however, more studies are needed to
further examine the effects of different styles of yoga on HR and other physiological
responses.
Limitations
74
There were many limitations that can affect the interpretation of this study. The
sample itself was a limitation. Participants in this study were attending yoga classes on
their own accord, and therefore are potentially more likely than the general population to
be motivated in taking a preventative role in their health. Due to the sampling process, it
is also possible that participants attended the specific classes based on the style that meets
their physical and emotional health needs, which may also have affected the findings. A
randomized experiment may provide a truer impact of different styles of yoga on BP.
Adding on, a large proportion of the sample was female, and there was a lack diversity
between participants, which limits the scope of the study’s comparability across varying
genders and ethnic and racial backgrounds. In addition, the study was held in the small
suburb of Chaska, Minnesota, and therefore, it is likely that the sample was not an
accurate representation of the general population. Lastly, a significant limitation was the
small sample size, which may have been too small to yield any statistically significant
findings when comparing SBP and DBP between groups.
Other limitations were related to the methodological processes carried out during
the study. Participant’s BP was measured at varying times before the start of and after the
completion of the scheduled class, and this may have introduced confounding. A more
controlled study could allow for consistent measurement time lengths pre- and post-class
among all participants. Additionally, not all classes, nor all the individual styles were
taught by the same yoga instructor. Measures were taken to ensure that the level of
knowledge, teaching style, and preservation of fundamental concepts of each style were
75
upheld and consistent across the participating instructors. No other studies currently
compare the effects of different styles of yoga on BP.
All of these limitations could have influenced the interpretation of the study data.
The results may have been more significant, or reliable, with a larger and more diverse
sample. In addition, the varying time lengths between the completion of class and postclass BP measurement among participants may have impacted the degree of difference in
BP and HR.
Recommendations for Future Studies
Based on the findings, the researcher has several recommendations for future
studies. First, as aforementioned, a randomized controlled study with consistent
measurement lengths both before and after the yoga session could help reduce
confounding and ensure a fair comparison across participants and styles of yoga. Future
studies could also measure and compare pre- and post-SBP, DBP and HR over a greater
length of time to potentially observe larger and more sustained reductions; research
supports that BP lowers and remains lowered with regular physical activity, as long-term
exercise helps strengthen the heart (AHA, 2014a). In addition, a study with a larger
sample size could potentially better detect if a significant difference between styles is
present. Lastly, a more diverse study population and the incorporation of more study
locations could allow for the findings to be more generalizable to a larger population.
Recommendations for Action
The results of this research present several findings that public health
professionals cannot overlook. As the public health community remains committed to
76
preventative action, the research findings support that yoga can be used as a means to
help prevent and reduce high BP. Yoga and other LSMs continue to be recognized for
their ability to lower BP without the use of medications, while also improving one’s
overall physical, mental, and emotional health (Mayo Clinic, 2012a; Cohen et al., 2011).
As public health professionals are also often involved in city/community planning,
adequate access to yoga facilities and affordable classes can be proposed to aid in
creating a healthy, connected, and proactive community. Also, public health promotions
program coordinators can advocate and educate community leaders, managers,
developers, non-profit organizations, health professionals, and the general public about
the health benefits of yoga and its effects on lowering BP.
From a medical standpoint, health professionals can refer prehypertension and
hypertension patients to yoga as a means for helping to lower and control BP without the
use of potentially harmful medications. This current study and previously existing
research support that antihypertensive medications do not need to be the first line
approach to treating high BP (Murugesan et al., 2000). In addition, healthcare
professionals can support all patients, with and without hypertension, to take an active
and/or preventative role in their health; yoga has been found to increase strength, balance,
flexibility, and endurance, while also improving cardiac health, blood glucose tolerance,
weight management, and reduce pain and stress (Ross & Thomas, 2010; Patel et al.,
2012). Yoga is distinctive in that it offers an ease of accessibility that not all other forms
of exercise and LSMs provide. The practice can be performed in the comfort of one’s
own home, is inexpensive, can be practiced for any length of time, and can be tailored
77
and modified to each individual’s skill level and physical limitations to experience
physical, mental, and emotional benefits.
Conclusion
Although no style of yoga, among Hatha, Power, and Eischens, proved to be
statistically more effective in lowering BP than another, the data gathered from the
survey and pre- and post-BP and HR measurements were of great value. All three styles
were found to lower both SBP and DBP. Additionally, when considering all study
participants for analysis, SBP and DBP were significantly lower upon posttest. This data
coincides with previous research findings and further strengthens the claim that yoga is
associated with significant reductions in BP (Hagins et al, 2013).
Yoga is unique in that its practice cultivates a mind-body connection through
intentional breath control, physical asanas, and mindful cognition. It has been found that
yoga not only lowers BP, but also alleviates pain; reduces stress; improves strength,
flexibility, and endurance. It also helps lower and manage weight and revitalize one’s
physical and mental well-being (Hagins et al., 2013; Bertisch, Wee, Phillips, &
McCarthy, 2009). Yoga offers widespread use, as the practice can be made accessible to
people of all ages, economic status, varying mobility capacities, fitness levels, and
flexibility through movements that range from simple to complex and therapeutic to
physically exerting. Additionally, the practitioner has control of the pace of movements,
and posture modifications are available.
In conclusion, although the research did not suggest that one style of yoga, among
Hatha, Power, and Eischens, lowered BP to significantly greater degree than another, the
78
research does support that yoga has a significant effect on lowering BP. This study is one
of few to consider the short-term effects of yoga on BP, as well as examine how different
styles of yoga may influence one’s health. These study findings provide a platform for
further research to be carried out exploring and comparing different styles of yoga and
their varying levels of positive health and cardiac benefits. Yoga can be used as both a
proactive and reactive approach to improving one’s BP, health, and overall well-being.
As the prevalence of hypertension continues to grow, the styles of Hatha, Power, and
Eischens Yoga can be offered by various health professionals as an effective and
alternative method for preventing, lowering, and managing BP.
79
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91
Appendix A: Study Form
Please circle one answer for each question.
1.
How would you describe your level of yoga experience:
First Time
2.
Beginner
Advanced
How often to do you get 30 minutes or more of exercise per week:
0-1 days
3.
Intermediate
2-3 days
4-5 days
6-7 days
How would you describe your overall health:
Poor
Fair
Good
Very Good
Excellent
4.
Are you being treated for hypertension (high blood pressure):
5.
Do you smoke:
6.
How would you describe your weight:
Yes
No
Underweight
7.
Age: __________
8.
Gender:
9.
Race: __________
Male
Normal
Female
Overweight
Trans
To be completed by the researcher:
Style of Yoga:
Date:
Time of Class:
Instructor
Initial Blood Pressure Reading (Prior to Start of Class):
Systolic: _________
Diastolic: _________
Heart Rate: _________
Blood Pressure Reading (After Completion of Class):
Systolic: _________
Diastolic: _________
Heart Rate:
Yes
_________
Other
Obese
No
92
Appendix B: Blood Pressure Form Handout
Date:
Initial Blood Pressure Reading (Prior to Start of Class):
Systolic: _________
Diastolic: _________
Heart Rate:
_________
Blood Pressure Reading (After Completion of Class):
Systolic: _________
Diastolic: _________
Heart Rate:
_________
93
Appendix C: Blood Pressure Form Handout
Blood Pressure Fact Sheet
Blood pressure is typically recorded as two numbers, written as a ratio like this:
Systolic:
The top number, which is also the higher of the two numbers, measures the pressure in the
arteries when the heart beats (when the heart muscle contracts).
Read as "117 over 76 millimeters
of mercury"
Diastolic:
The bottom number, which is also the lower of the two numbers, measures the pressure in the
arteries between heartbeats (when the heart muscle is resting between beats and refilling with
blood).
This chart reflects blood pressure categories defined by the American Heart Association.
Blood Pressure
Category
Normal
Systolic
mm Hg (upper #)
Diastolic
mm Hg (lower #)
less than 120
and
less than 80
Prehypertension
120 – 139
or
80 – 89
High Blood Pressure
(Hypertension) Stage 1
140 – 159
or
90 – 99
High Blood Pressure
(Hypertension) Stage 2
160 or higher
or
100 or higher
Hypertensive Crisis
(Emergency care needed)
Higher than 180
or
Higher than 110
* Your doctor should evaluate unusually low blood pressure readings.
A single high reading does not necessarily mean that you have high blood pressure. However, if readings stay at
140/90 mm Hg or above (systolic 140 or above OR diastolic 90 or above) over time, your doctor will likely want you to
begin a treatment program. Such a program almost always includes lifestyle changes and often prescription medication
for those with readings of 140/90 or higher.
If, while monitoring your blood pressure, you get a systolic reading of 180 mm Hg or higher OR a diastolic
reading of 110 mm HG or higher, wait a couple of minutes and take it again. If the reading is still at or above that
level, you should seek immediate emergency medical treatment for a hypertensive crisis. If you can't access the
emergency medical services (EMS), have someone drive you to the hospital right away.
Typically more attention is given to the top number (the systolic blood pressure) as a major risk factor for
cardiovascular disease for people over 50 years old. In most people, systolic blood pressure rises steadily with age due to
increasing stiffness of large arteries, long-term build-up of plaque, and increased incidence of cardiac and vascular
disease.
Source: The American Heart Association at
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-PressureReadings_UCM_301764_Article.jsp
94
Appendix D: Informed Consent Form
Informed Consent
DESCRIPTION: You are invited to participate in a research study on the effects of yoga on
blood pressure. The research questions the study intends to answer are: 1) does blood pressure
decrease after a sixty-minute yoga class, 2) do different styles of yoga lower blood pressure
more than another, and 3) what style of yoga, among Hatha, Power, and Eischens Yoga, lowers
blood pressure the most among students after a sixty-minute yoga class. You will be asked to
have your blood pressure taken just prior to your scheduled yoga class and just after. You will
also be asked to complete a brief questionnaire asking some demographic information and
questions about your overall health and general fitness level.
TIME INVOLVEMENT: Your participation will take approximately 10-15 minutes (5-7 minutes
before class and 5-7 minutes after class).
RISKS AND BENEFITS: The risks associated with this study are 1) discomfort from the blood
pressure cuff. Benefits of participating in this study include a free blood pressure reading both
before and after the scheduled yoga class. Your decision whether or not to participate in this
study will not put you at any disadvantage and will not affect your relationship with the yoga
studio or instructor.
PAYMENTS: There is no compensation for your participation, however, you may have a written
copy of your blood pressure readings from before and after the class and you will receive a fact
sheet on interpreting blood pressure readings.
PARTICIPANT’S RIGHTS: If you have read this form and have decided to participate in this
project, please understand your participation is voluntary and you have the right to
withdraw your consent or discontinue participation at any time without penalty or
loss of benefits to which you are otherwise entitled. The alternative is not to
participate. You have the right to refuse to answer particular questions. The results of this
research study may be presented at scientific or professional meetings or published in scientific
journals. Every effort will be made to keep your blood pressure readings private and your
name or identifying information will not be collected. All information will be analyzed and
reported as aggregate findings.
CONTACT INFORMATION:
Questions: If you have any questions, concerns or complaints about this research, its
procedures, risks and benefits, contact the Protocol Director, Dr. Hollie Pavlica at 919-259-0335
or via email at holliepavlica@gmail.com.
Independent Contact: If you are not satisfied with how this study is being conducted, or if
you have any concerns, complaints, or general questions about the research or your rights as a
participant, please contact the Institutional Review Board (IRB) Chair, Dr. Nancy Elwell at 402
643-3651 or toll free at 1-866-680-2906. You can also write to the Concordia University IRB at
800 N Columbia Ave, Seward, Nebraska 68434.
SIGNED INITIALS: ___________________________
DATE ____________