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Complementary Therapies in Clinical Practice 28 (2017) 38e46
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice
journal homepage: www.elsevier.com/locate/ctcp
The hypotensive effect of Yoga's breathing exercises: A systematic
review
*
Jeniffer Z. Brandani , Julio Mizuno, Emmanuel G. Ciolac, Henrique L. Monteiro
~
Sao Paulo State University (Unesp), School of Sciences, Physical Education Department, Bauru, Brazil
articleinfo abstract
Article history: Theaimofthisreviewwastoevaluatetheeffectofpranayama(Yoga'sbreathingexercises) on BPand its
Received 19 April 2017 applicability in the treatment of hypertension. Thirteen trials, assessing acute (eight studies) and chronic
Accepted 8 May 2017 (five studies) BP response to pranayama were included. Significant BP reductions after pranayama were
Keywords: found in both acute (2e10 mmHg mean SBP reduction, N ¼ 5 studies; 1 mmHg mean DBP reduction,
Cardiovascular diseases N¼1study) and chronic studies (4e21 mmHg mean SBP reduction, N ¼ 3 studies; 4e7 mmHg mean
Complementary therapies DBPreduction,N¼2studies).Thepranayama'seffectonBPwerenotrobustagainstselectionbiasdueto
Hypertension the low quality of studies. But, the lowering BP effect of pranayama is encouraging. The pranayama with
slower rhythms and manipulation of the nostrils, mainly with breaths by the left, present better results
when compared with the other types and should be the main pranayama applied when the goal is to
reduce blood pressure especially in hypertensive patients.
©2017 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 38
2. Methods .............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 39
2.1. Search strategy and study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................39
2.2. Data extraction and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................39
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 39
3.1. Study and subject characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................39
3.2. Assessment of BP and secondary outcomes .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......................................39
3.3. Pranayamas characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........................................41
3.4. Effects of pranayamas on BP and secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................41
4. Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 44
4.1. Implications for clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ...........................................45
4.2. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................................................45
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 45
Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 45
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ 45
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................................................45
1. Introduction
* Corresponding author. Universidade Estadual Paulista e UNESP, Departamento Hypertension is a highly prevalent disease worldwide and an
~ ~
de Educaçao Física, Av. Engenheiro Luiz Edmundo Carrijo Coube 14-06, Bauru, Sao important risk factor for stroke, coronary artery disease and organ
Paulo, 17033-360, Brazil. Tel.: þ55 14 3103 6082.
E-mailaddresses:jeniffer_brandani@yahoo.com.br(J.Z. Brandani),juliomizuno@ failure [1]. In Brazil, nearlly 24.4% and 21.6% of adult women and
gmail.com (J. Mizuno), ciolac@fc.unesp.br (E.G. Ciolac), heu@fc.unesp.br men are hypertensive, respectively [2]. The regular practice of
(H.L. Monteiro).
http://dx.doi.org/10.1016/j.ctcp.2017.05.002
1744-3881/© 2017 Elsevier Ltd. All rights reserved.
J.Z. Brandani et al. / Complementary Therapies in Clinical Practice 28 (2017) 38e46 39
physical exercise is a well-established non-phamarcological treat- 3. Results
mentforhypertension[3e7].Amongthedifferenttypesofexercise,
there is increasing evidence suggesting a hypotensive effect of Electronic databases search identified 347 records. Title and
regular practice of Yoga [8e12]. abstract screening discharged 219 duplicates, 49 reviews, 43 with
Inabroadercontext,Yogaincludestheoreticalandphilosophical no full-text available, 10 with no BP assessment, five with no-
concepts(yamasandniyamas),bodytechniques(asanas),breathing pranayamas intervention, one editorial and one experience
exercises (pranayamas), concentration (dharana) and meditation report. Full text screening discharged one study with participants
[13]. Among these techniques, pranayamas (breathing exercises of with age <18 years and three studies that pranyama was not the
varied time and pace that may be performed with or without air only intervention. Finally, thirteen articles assessing the acute
retentioninthelungs)appearstohaveabetterrisk/benefitratiofor (eight studies) [9,10,19e24] and chronic (five studies) [25e29] ef-
lowering blood pressure (BP) [14]. Moreover, pranayamas practice fects of pranayamas were included in this review (Fig. 1).
doesnothavecostswithspecificequipmentandplaces,whichmay
increase its applicability. The main mechanism for its lowering ef- 3.1. Study and subject characteristics
fect on BP appears to be the improvementin baroceptorsensitivity,
which changes the autonomic balance with an increase in para- General description of each study included is shown in Table 1.
sympathetic and decrease in sympathetic modulation [15,16]. Twelve studies were conducted in India and one in UK. Subjects
Although there are systematic reviews and meta-analyzes sup- with hypertension were included in six of them [9,10,20,23,25,26].
porting the hypotensive effects of Yoga [14,17,18], the broad variety Eight studies assessed the acute effect of pranayamas (BP response
of techniques performed in each individual study (i.e. some studies to a single exercise session) [9,10,19e24], which had a sample size
useonlyonetechniquewhileothersusedtwoormoretechniques) ranging 20 to 90 participants (totaling 266 participants), and
difficults the interpretation of pranaymas lowering BP effect. included only men [24,26], or both men and women
Therefore, the aim of this review was to evaluate the effect of [9,10,19e21,23]. Five studies assessed the chronic effect of pra-
pranayamas on BP and its applicability in the treatment of nayamas(BPresponsetoanexerciseprogram)[25e29],whichhad
hypertension. a sample size ranging 11 to 90 participants (totaling 239 partici-
pants), and included only men [28,29], and both men and women
[25,26] however, one study have no information about sex of par-
2. Methods ticipants [27].
Only three studies assessing the chronic effect of pranaymas
2.1. Search strategy and study selection were randomized controlled trial (RCT) [23,27,28], and only one
study assessing the pranaymas acute effect had a control inter-
PubMed/Medline,ScopusandBiremeelectronicdatabaseswere vention[24].Finally,moststudieswereofpoorquality.Themedian
searched for articles about pranayamas effects on BP. Search was PEDro score was z3, with a range from 1 to 7 (Table 2).
performed by crossing the terms ‘yoga/Yoga’, ‘yogue/yogi’, ‘pra-
nayama’ or ‘breathing’ with ‘blood pressure’, ‘hypertension’ or 3.2. Assessment of BP and secondary outcomes
‘systolic/diastolic BP’.
The present systematic review included only clinical trials, In the studies evaluating the acute effects of pranayamas, BP
published between January 2006 and August 2016, that investi- assessment was performed by means of semiautomatic non-
gated the effect of pranayamas on BP in adult individuals (age 18 invasive [9,10,20], continuous non-invasive [21,24], digital [19]
ys), with or without comorbidities. There were no imposed sex or and standard mercury sphygmomanometer [22,23]. In the studies
language restrictions. Because of the variability of existing
breathingtechniques,onlyexplicitlylabeledinterventionswiththe
term “Yoga” were included. Methodologic or observational
(descriptiveonly)articles,studieswithpranayamasassociatedwith
other intervention were not included. Clinical trials that did not
have the full text available were also not included. Two indepen-
dent reviewers (J. Z. B. and J. M.) performed the literature search
and study assessment.
2.2. Data extraction and analysis
Data on study source, sample size, participant's characteristics
(e.g. age, sex, baseline BP and physical activity levels, comorbidities
…), method used to measure BP, characteristics of breathing exer-
cise (i.e. type, frequency and duration of breath, breath techinique)
and control interventions (i.e. type, frequency and duration), out-
comes and limitations of the included studies were extracted
independently by two authors (J. Z. B. and J. M.). When there was
discrepancy between reviewers, a third reviewer (H. L. M.) was
consulted to solve the discrepancy. Methodological quality of
included studies was assessed using the Physiotherapy Evidence
Database (PEDro) scale (www.pedro.org.au). The results of the
systematicreviewarepresenteddescriptively(e.g.means,standard
deviations, and minimum and maximumvalues). Fig. 1. Flowchart of the results of the literature search.
40
Table 1
General characteristics of included studies.
Author, year and Design of study Nunber/age/sex and characteristics of Experimental intervention/ Control group/ Mesures of blood pressure/kind of
country participants Duration/ intervention device
Adhana et al. (2013) 1 group 38adults(8excluded)/menandwomen Pranayama2:1/twiceadayfor5e7min Nocontrol intervention Aresting measure pre intervention and
(India) [25] (20e50 years)/recently diagnosed for 3 months. weekly measures of BP/automated
hypertension digital
Sphygmomanometer
Bhavanani et al. (2011) 1 group 23 adults (11 men)/55.13 ± 1.54 years/ Sukha pranayama/5 min Nocontrol intervention Onemeasured pre and post
(India) [9] with hypertension intervention/Semiautomatic
Bhavananietal.(2012)a 1 group 22 adults (12 men)/58,14 ± 1,69 years/ Chandra Nadi Pranayama/5 min Nocontrol intervention Onemeasured pre and post
(India) [10] with hypertension intervention/Semiautomatic J.Z.
Bhavananietal.(2012)b 1 group 29 adults (16 men)/49,34 ± 2,36 years/ Pranva Pranayama 1:3/5 min Nocontrol intervention Onemeasured pre and post Bra
(India) [19] with hypertension intervention/Digital ndani
Bhavanani et al. (2014) 1 group 20 adults (13 women)/34,10 ± 13,62 Surya pranayama vs. chandra Nocontrol intervention Onemeasured pre and post
(India) [20] years/8 healthy, 12 reported conditions pranayama vs. surya bhedana vs. intervention/Semiautomatic et
such as hypertension, hypothyroidism, chandra bhedana vs. nadi shuddhi vs. al.
/
type 2 diabetes mellitus, polycystic normal breathing/5min for each Complementary
ovary syndrome, bipolar affective pranayama (6 sessions)
disorder and others.
Critchley et al. (2015) 1 group Twenty-three healthy volunteer Slowbreathingandnormalbreathing/1 Nocontrol intervention Continuous monitoring/Non-invasive
(Reino Unido) [21] participants (8 women 12 men; session z 28min. monitor
34.5 ± 10.4 yrs)
Goyal, 2014 (India) [26] 2 groups 50 adults with hypertension/ GP: Nadi shodana þ Chadar bhedi, GC: No intervention Onemeasured pre and post Ther
Pranayama group (n ¼ 25) and Control Bhramari þ Omkar chanting/6 intervention/Standard apies
group (n ¼ 25)/20e50 years/women weeks z 40 min sphygmomanometer
and men in
Raghuraj et al. 1 group 21 healthy men/27,5 ± 6,3 years right, left, alternate nostril, breath Nocontrol intervention Onemeasured pre and post each Clinical
(2008)(India) [22] awareness and normal breathing/5 session/Manual
sessions of 40 min
Pr
Sharma et al. (2013) Randomized/3 90 healthy subjects/without G1:Slowbreathing;G2:Fastbreathing/ GC: No intervention Three BP and HR recordings at 1min actice
(India) [27] groups informationonsex/agebetween18and 30 min a day, 3 times per week for 12 intervals were taken and the lowest of
25 years weeks these values was included for the 28
present study/Semi-automatic
Telles et al. (2013) Randomized/ 90 adults (60 men)/with hypertension/ G1: Anuloma-villoma pranayama/G2: GC:reading, 10 min per Onemeasured pre and post each (20
1
7
(India) [23] Double Blinded/3 49.7 ± 9.5 years breath awareness/10 min per session session session/Standard mercury )
3
groups sphygmomanometer 8
e
Telles et al. (2014) 2 groups 41 healthy men/PG n ¼ 26 (23.8 ± 3.5 GP: alternate nostril yoga breathing or GC: breathing Continuous monitoring/Non-invasive 46
(India) [24] years) e CG n ¼ 15 (26.1 ± 4.0 years) anulom-vilompranayamaand(b)breath normally/1 session e monitor
awareness/2 sessions 25 min 25 min
Turankar et al. Randomized, 2 11 healthy males aged between PG: AnulomaViloma technique of CG: normal breathing/ Measuting on the end of all stages/
(2013)(India) [28] groups (27.83 ± 0.91 years)/Pranayama group pranayama with Kumbhak (alternative two sessions of 20 Automatic BP measuring apparatus
n ¼ 6, non-pranayama group n ¼ 5 nostril breathing with breath holding)/ mineachdayfor seven
two sessions of 20 days
mineachdayfor seven days
Veerabhadrappa et al. 1 group 50 healthy men/between 18 and 25 MukhBhastrika/30min a day, 5 times Nocontrol intervention Twomeasuredpreandpost
(2011) (India) [29] years per week for 12 weeks intervention/Postural Maneuver
(supine-standing)/Automatic
non-invasive monitor.
AbbreviationsRCT: Randomized controlled trials; PG: pranayama group; CG: control group; BP: blood pressure.
J.Z. Brandani et al. / Complementary Therapies in Clinical Practice 28 (2017) 38e46 41
assessing pranayamas's chronic effects, BP assessment was per-
Total 1/102/102/102/102/101/104/102/105/107/103/105/102/10 formed by means of automatic non-invasive monitor [25,28,29],
semiautomatic non-invasive [27] and standard sphygmomanom-
eter [26]. Seven studies evaluated mean arterial pressure (MAP)
9,10,20,22
[9,10,19,20,22,27,28] by MAP ¼ DBP þ1/3 x PP ,
27 28
PointmeasureY Y Y Y Y Y Y Y Y Y Y Y Y MAP¼DBPþPP/3 ,MAP¼[SBPx(1/3)þDBPx(2/3)] andone
study didn't report [19]. Eleven studies assessed heart rate (HR)
[9,10,19e22,25e29] by semi-automatic non-invasive BP monitor
[9,10,19,20,27], electrocardiogram [26,29], photoplethysmogrophic
sensors [25], and Portapres [21]. The method for HR assessment
was not reported in two studies [23,24]. Six studies presented
Between-groupstatisticalcomparisonNNNNNNYNYYYY N values of rate pressure product (RPP; [RPP ¼ HR x SBP/
100]9,10,19,20,27; or [RPP ¼ HR x SBP x 102]) [26]. Finally, five
to [9,10,19,20,27] studies evaluated the double product (DP; [DP ¼ HR
9,10,19,20 27
x MAP/100] or [DP ¼ HR x MAP] ).
IntentiontreatNN N N N N N N N N N N N
3.3. Pranayamas characteristics
n
i
f A detailed description of the pranayamas intervention charac-
o
% teristics for each study included in the present review is shown in
outcome85 Table 3. The studies assessing acute pranayamas effects
subjects
Keymorethe N Y Y Y Y N Y Y Y Y Y Y Y [9,10,19e24]hadsessionslasting5e40min.Inthestudiesassessing
chroniceffects[25e29],thepranayamas'sessionslasted5e40min,
all and were performed for 1e12 weeks, with frequency of 3e7 days
of per week.
There was a great variation of interventions, with programs
involving up to four types of pranayamas. All studies assessing
BlindingassessorsNNNN N N N N N Y N N N acute effect of pranayamas used slow breathing [9,10,19e24], and
five used panayamas with manipulation of the nostrils
all [10,20,22e24]. Among the studies evaluating the chronic effect of
of pranayamas, three used slow breathing [25,26,28] (two with air
retention [26,28]), one used rapid breathing with forced expiration
BlindingtherapistsNNNN N N N N N Y N N N [29], oneusedbothslowandrapidbreathingwithforcedexpiration
[27], and three studies used pranayamas with manipulation of the
of nostrils [26e28].
subjects
BlindingallN N N N N N N N N N N N N 3.4. Effects of pranayamas on BP and secondary outcomes
Themaineffects of pranayamas on BP and secondary outcomes
SimilargroupsNN N N N N Y N Y N N Y N of each study are shown in Table 4. All studies with hypertensive
subjects showedthatpranayamaswereeffectivetoacutellyreduce
systolic BP (mean BP reduction from 2 to 10 mmHg) [9,10,19,23];
was however, the diastolic BP was reduced only in one studies [23] and
after only one type of pranayama (mean BP reduction 1 mmHg). In
normotensive subjects, two studies showed systolic BP reduction
AllocationconcealedNNNNN N N N N Y N N N after an acute pranayamas session [21,24], and one study showed
22
no effects on BP , for diastolic BP one study showed reduces [22]
(mean BP reducion 1 mmHg). Finally, one study with subjects
were with different chronic diseases showed a varied acute BP response
mly (mean BP reduction from 1 to 4 mmHg) according to the pra-
SubjectsrandoallocatedNNNNNN N N Y Y N Y N nayamas performed [20].
Amongthestudiesassessing the chronic effects of pranayamas,
PEDro systolic BP was reduced in all studies with hypertensive sub-
jects [25,26] (mean BP reduction from 12 to 21). However, in the
CriteriaEligibilityYYY Y Y Y Y Y Y Y Y Y Y studies with normotensive subjects, systolic BP was reduced in
studies. one[29](meanBPreducionof4mmHg),whiletwostudiesshowed
no. no effects of pranayamas on BP27,28, the diastolic BP was reduced
2011 N: only in two studies [25,27], one with hypertensive and other
included with normotensive subjects, respectively (mean BP reduction
the yes;
f year 2011201220122014 4e7mmHg).
o 2015 2008 2013
e and 2013 2013 HRwasreducedinfourstudiesassessingthechronic[25e27,29]
2014 20132014 and three acute [9,10,19] effects of pranayamas. DP was reduced
2 scor
Author Adhana,Bhavanani,Bhavanani,Bhavanani,Bhavanani,Critchley,Goyal,Raghuraj,Sharma,Telles,Telles,Turankar,Veerabhadrappa,only in one chronic study [27] and three acute [9,10,19] and RPP
able
T PEDro AbbreviationsY: reduce in two chronic studies [26,27] and three acutes [9,10,19].
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