JOURNAL of CHINES CLINICAL MEDICINE VOLUME 41NUMBER 31 March 2009 139) ARTICLES: Effects of yoga and supervised integrated exercise on heart rate variability and blood pressure in hypertensive patients Murthy Niranjan” ,Bhagyalakshmi K’,Ganaraja B’ Prabha Adhikari”* ,Ramesh Bhat’ [Abstract] Objective nomic status has a rel: Heart rate variability (HRV )is a marker of cardiovascular autonomic status . The auto ionship with cardiovascular disorders and physical as well as mental activities . Determination of HRY is used as a technique to assess the autonomic control of heart . The objective of this study was to study the effects of yoga and supervised integrated exercise on HRV and blood pressure in hypertensive patients . Methods ‘The study group consisted of 47 moderately hypertensive patients divided into 3 experimental groups ( viz. 16 in yoga group 16 in exercise group and 15 yoga + exercise group Jand 31 normal controls. The three groups underwent yo- ga.,exercise ,both yoga and exercise together respectively for 9 months. The time domain HRV during deep breathing and blood pressure were measured at 0,3,6,and 9 months in all the groups. Results A significant improvement of HRV was found during the entire duration of exercise (12. 29 £1.75 vs 15. 64 £1.72 at 9 months P <0.001 )..No ant change in HRV was found in yoga group at the end of 9 months. Supervised integrated exercise + yoga signi for 9 months showed a significant HRV improvement in this group (15.41 £2.06 at 6 months vs 17 £2.06 at 9 months P <0. 001 ). The systolic blood pressure (SBP) and diastolic blood pressure (DBP )in these hypertensive pa- tients corrected towards normalcy in different groups ,except in yoga group. There was no significant effect on HRV and BP in control group in the intervening period. Conclusion Supervised integrated exercise improves HRV and BP significantly in hypertensive subjects. Yoga does not cause any significant change in HRV and SBP . Yoga com- bined with regulated exercise was found he very effective in improving HRV and reducing BP. Key words] _ hypertension ; exercise ;yoga ;heart rate variability. y Pp ora: ty INTRODUCTION [As age advances the physiological parameters undergo many changes. Some deleterious changes leads to de- cline in the quality of life in geriatric people. Aging has profound impact on the interacting neural and endo - crine mechanisms that regulate heart rate. The para- sympathetic and sympathetic influences get attenuated , renin and angiotensin ievels fall , circadian hormonal and temperature rhythms lose amplitude '’. This re- flects on cardiovascular system too , thus affecting the quality of life in old age. This results in increase in blood pressure (hypertension ) and reduction in heart Dep st of Physiology, LMC, Mangalore, India * Depantinent of Physiology ,SSMC, Tune ia ** Department of Medicine KMC, Mangalore India Correspondence to Dr Gan il ganas}. W® gail. comms ra862D edit. com 1 BPAD Asser Es rate variability (HRV ) are among them. In the EGG ,RR variance has been shown to decrease as age increa - ses“), Heart rate variability °° is a noninvasive elec- trocardiographic marker reflecting the activity of the sympathetic and parasympathetic components of auto - nomic nervous system (ANS) on the sinus node of the heart. It expresses the total amount of variations of both instantaneous heart rate (HR) and RR intervals. The value of HRV reflects the autonomic functions and can be used as a clinical tool for monitoring autonomic sta - tus on heart. The sympatho-vagal imbalance can be de~ tected by HRV in patients with hypertension”. Lower Professor, Department of Physiology ,KMC Cont for Base Sciences, Beja, Mangalore S75 004, lia140 JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 41NUMBER 31 March 2009 HRV is a signi morbidity” cant predictor of cardiac mortality and = Pharmacological interventions , exercise training ,smoking ” are known to affect HRV marked- ly. The question now is whether the HRV can be in- creased and whether the improved HRV will lead to a better outcome in hypertensive patients. Yoga jas prescribed by the ancient Indian scripts , is understood to have influence on the autono! trol. There is a dearth of prospective studies ing the effects of yoga and exercise on HRV in hyper- tensive patients, The present study was taken up to de- termine and compare the effects of supervised , integrat- ed exercise and yoga on HRV in hypertensi patients after regular pra METHODS Forty seven hypertensive patients and 31 age-matched healthy subjects who attended hypertension camp , dia- betic camp and geriatric camp were selected . A detailed history of subjects was taken . General physical examination including height , weight, blood pressure pulse rate and respiratory rate and a complete systemic examination was done. An electrocardiogram was also reconled. Untreated patients with systolic blood pressure of > 140 mm Hg and/or diastolic blood pressure of >90 mm Hg and all hypertensives on treatment re - gandless of duration of ailment were included in the study. All the hypertensive patients with congestive ear - diac failure ,acute myocardial infarction ,cardiac arthyth- mias serum creatinine > 1.2 mg% and those who were unable to undergo deep breathing test were excluded . All the 47 patients were requested to come to our center regularly for 5 days a week and practice daily exercises or yoga junder the guidance of a physiothera - pist and a yoga teacher. They were divided into three groups viz. Group I [n=16],Group Il [n =16]and Group II [n =15]. Group I patients enrolled for exer- iced exercise for at least 4 days per week (for 9 months du- cise program at our centre ,and all of them pr ration) under the guidance of a physiotherapist . Group I patients enrolled for 9 months of yoga asana practice for at least 4 da sa week under the guidance of a yoga teacher. Group II performed both yoga and exercise for An informed consent was taken from all these pa - tients before enrolling them in the study. The clearance from the Institutional Ethies Committee was obtained and all the experiments were carried out by strictly ad - hering to the guidelines, by qualified doctor and yoga therapist and physiotherap Exercise Program The types of exercises taught to the subjects under the guidance of a physiotherapist were as follows ; Warming up exercise for 5 minutes, followed by cycling or tread - mill exercise , depending on exercising capacity of the patients for 30 minutes. Flowing the exercise , cooling down exercise was done for 10 minutes. The entire du- ration of the exercise was not more than 45 minutes. ‘Yoga Program ‘The yoga was taught to the subjects by a yoga teacher . It included Meditation and Yoga asanas. The session began with the subjects sitting down on the floor in a comfortable position with their back straight . Chants of es. It was followed “OM! were repeated for a few with a prayer. ‘The selected yoga asanas included Tadasana , Pa- dahasthasana , Vrikshasana , Trikonasana , Viparitakari- puta-vajrasana , Vakrasana , Uthanapada- sana , Pavanamukthasana , Bhujangasana , Shalabhasana , Dhanurasana and Makarasana. These yogic postures were followed by Anuloma Pranayama and Viloma Pranayama (breathing tech- niques ) and Savasana (body relaxation by lying su- pine). The entire duration of yoga practice was not more than 60 minutes. Methods to test HRV Before begin to breathe at a rate of 6 respiratory ig the test ,the subjects were instructed 's per minute 55 seconds for each eycle (inhalation and exhalation ) ECG in lead I was then recorded at a speed of 25 mm per second for 60 seconds with the patient breathing as instructed. Beginning of each inspiration and expiration, was noted down on the ECG. ECG was recorded on Day 1 ,and at intervals of 3 months (3" month ,6" month and 9" month ).JOURNAL of CHINES & CLINICAL MEDICINE VOLUME 41 NUMBER 31 March 2009 14 ‘The R-R intervals between adjacent QRS comple - xes resulting from sinus node depolarization were meas - ured manually with a sealed caliper. The R-R interval was measured in each respiratory cycle and an average R-R interval was considered for the measurement of HRV. The varial yy in the heart rate was calculated as the difference between the shortest and longest R -R in- tervals HRV = (1.,500/mean of shortest R-R intervals )- (1.,500/mean of longest R-R intervals ) mea beats per minute. Statistics ‘The statis (Analy: test, Paired ‘1’ test and student unpaired ‘ 1” cal analysis was done by using “ANOVA” her's F Test), Chi Square test. P of Variance value was taken as significant at 5 percent confidence level (P <0. 05) RESULTS ‘The HRV and BP from three study group comprised pa tients doing exercise alone ,yoga alone and a combina tion of these two for 9 months and the parameters from 3,6 and 9 months. 31 healthy persons were taken as control group control. subjects were compared after only for baseline studies as they were not compliant for a follow-up study ‘Table 1 Basal parameters Contd group 13,6822.59 Ry SBP(snm Hg) 125.48 28.50 143.31 215.38" DBP( mm Hy) 83.54-25.30 97.44 20.08 Note; Values mean 2SD° P<0.01 conteal vs hypertensive group ‘The analysis showed that the heart rate variability (HRY ),, systolic blood pressure (SBP) and diastolic nitly higher in hy~ pertensive group than the control group blood pressure (DBP) were sign The analysis of follow-up HRV after 9 months of lly yoga showed a stati ignificant improvement at the end of 9 months compared to Q months,3 months and 6 months HRV, Table 2 HRV during exercise and yoga training in different groups Duration of training exercise yous Exercise + yoga Baseline(Q months ) 12.29 £1.75 13.52 £2.37 12.52 £2.37 3 months 13.70 £2.05° 14.94 22. 46 14.94 £2. 46 6 months 14.17 £2.00" NS 15.41 £2.06 15.41 £2.06" 9 months I5.6421.72°' 15.02 £2.07 1722.06" Note; Values mean SD, ° P<0.001-compared to baseline HRV vs 3,6 and 9 months HRV, *,"P<0.001-0 vs 3 months HRV and 9 months group. Table 3 Systolic blood pressure( SBP) and diastolic blood pressure( DBP) during various durations of training in different groups Dustin of Gr I -Everin Ge Yon Ge W-tsviine + Yop SP DAP sae uP SP DEP “ws (om He) Cum Hy (um Hg) (nH own 1) (on Hy oe 144.94 214.31 99.41 28.82 137.41 213.63 85.76.26.55 137.41 213.63 85, 76 26.55 S mnths 140.8221 49 NS Q6.352-7.35°° SEAT INTL $5.0525.28 16.4717 85.05.85.28 S mths 14035 210.15" 64.79 =5.82°°°" —135,05.213.56 81.05 26.67" 3s214 81.05 26.6% 9 months 137.97 8.90°"* 3.226.928 MM 136429.002.1086.7 wo etn30t* 78.8226" ** Note; P-<0.050 143 & 6onihs 9 months, *P <0. 05-Significant 6 months SUD vs 9 ions SBP, “* P-<0.05-Sisiicast baseline DID vx 3 oath DBD, ** DBP, **P <0. 001-Very hig and 6 month SUD, Values mean 8D month SBP vs baseline P <0. O1-Mighly significant baseline DID ys 6 moths and 9 months DU sigpiticant 3 months DBP v9 mouths DBP,"P <0.05-Significant 6moath DBP vs Smonth DI © p <0. 0S-Sigifcant 3 month DBP y+ 6 month and Snoath Not significant 3