Therapeutic role of yoga in hypertension

Table 1 Recommended yoga practice in hypertension

Yoga practice	Details of the yoga practice	Duration1
Shatkriya (Yogic cleansing practices)
Shatkriya	Trataka (concentrated gazing)	10 to 15 min
	Jala neti (nasal cleansing with warm saline water)	5 min (Once a week)
Sharir sanchalana (Warm-up practices)
Sharir sanchalana (Warm-up practices)	Toe bending, ankle bending, knee bending, half butterfly, finger bending, wrist bending, elbow bending, shoulder rotation, and neck movements in a seated position with synchronization of breathing	5 to 10 min
Surya namaskara (Sun salutations)
Surya namaskara (Sun salutations)	Series of dynamic yoga postures in a specific sequence with meditative awareness, practiced at slow-speed with breath synchronization	3–7 rounds as per capacity; The postures can be held for a short period, without straining[6]
Asana (Yoga postures) for relaxation
Shavasana (Corpse pose)	Shavasana with slow, rhythmic diaphragmatic breathing, awareness of the sensation at the nostrils, the temperature of the inhaled and exhaled air, relaxing the muscles, and feeling the heaviness of different parts of the body	5 to 30 min
Restorative Yoga (Conventional poses with props)	Supported and modified stretching to suit individual needs[11]; Shavasana (Corpse pose); Supta baddha konasana (Reclined bound angle pose); Upvistha konasana (Wide-angled seated forward bend); Balasana (Child's pose); Pashchimottanasana (Seated forward bend); Salamba kapotasana (Supported pigeon pose)	15 min[11]
Other Asana (Additional practices)
Standing postures	Tadasana (Palm tree pose); Tiryak tadasana (Swaying palm tree pose); Katichakrasana (Standing spinal twist); Ardhachakrasana (Standing backward bend)	Synchronizing the movements with the breathing cycle; The postures can be held for a short period, without straining
Seated postures	Vakrasana (Seated spinal twist); Gomukhasana (Cow face Pose); Ardha Ushtrasana (Half camel pose); Pashchimottanasana (Seated forward bend); Marjarasana (Cat stretch)
Prone postures	Bhujangasana (Cobra pose); Tiryak bhujangasana (Swaying cobra pose); Ardha Shalabhasana (Half locust pose)
Supine postures	Pavanmuktasana (Wind releasing pose); Eka and Dwipada uttaanpadasana (straight single and both legs raising)
Meditative Postures for Pranayama and Meditation
Meditative postures (Spine erect, shoulders relaxed, face softened)	Seated in a chair; Sukhasana (Comfort pose); Vajrasana (Thunderbolt pose); Ardha padmasana (Half lotus pose); Padmasana (Lotus pose)	During pranayama and meditation
Pranayama (Regulated breathing practices)
Deep abdominal breathing	Gentle deep inhalation and slow longer exhalation	5 min
Sukha pranayama (Easy comfortable breathing)	Conscious, slow and deep breathing with equal duration for inhalation and exhalation) at the rate of 6 breaths/min	5 min[16]
Anulom Vilom/Nadi shodhan pranayama (Alternate nostril breathing)	Gentle inhalation through the left nostril followed by exhalation through the right nostril. Next inhalation through the right nostril and exhalation through the left nostril	Upto 20 min[17]
Chandra nadi pranayama/Chandra bhedan pranayama (Left nostril breathing)	Unilateral left nostril breathing with inhalation and exhalation for an equal count of five; Variation: Inhalation through the left nostril followed by exhalation through the right nostril	27 rounds of 6 breaths/min[19]
Slow bhastrika pranayama (Bellows breath)	Deep inhalation and slow exhalation (Respiratory rate 6/min), imagine the open blue sky while breathing[18]	5 min[18]
Ujjayi pranayama (Ocean breath)	Slow inhalation and exhalation with a slight contraction around the glottis; Can be practiced in seated, supine, or standing position	10 min[15]
Bhramari pranayama (Humming bee breath)	Slow deep inhalation followed by exhalation with a humming sound	5 min[20]
Sheetali pranayama (Cooling breath)	Inhalation through curled tongue in the form of a tube, slow exhalation through the nose	9 rounds each[9]
Pranava pranayama/ AUM chanting	Slow and deep inhalation with complete yogic breathing followed by the audible vibratory resonance of a prolonged AUM chant; Can be practiced in a supine position	5 min[13]
Mudra (Subtle gestures)
Shanmukhi mudra (Closing the seven gates)	Closing the ears with the thumbs, placing the index fingers on the eyes, the middle fingers near the nostrils, the ring fingers, and the little fingers above and below the lips	Practiced during bhramari pranayama
Brahma mudra (Divine spiritual gesture)	Synchronizing neck movements with deep breathing and vibration sounds	3 to 9 rounds of this practice at each sitting
Apan Vayu Mudra (Mudra of the heart)	Placing the tip of the index finger at the base of the thumb and joining the tips of the middle finger, ring finger, and thumb, the little finger extended	15 min
Gyan mudra (Mudra of wisdom)	Joining the tips of the index finger and the thumb, other fingers extended	Practiced during pranayama and meditation; Up to 30 min a day
Meditation (Formal practice)
Concentration Meditation (Focus on a word, sound, prayer, mantra, or phrase)	Examples: AUM japa; Ajapa japa; Anahata (heart) chakra meditation with the mantra 'YAM'	10-15 min
Mindfulness meditation (Open awareness of the present moment with kindness, acceptance, and curiosity)	Examples: Body scan meditation (Awareness of body parts); Mindful breathing meditation (Breath awareness); Loving-kindness meditation (having unconditional compassion towards ourselves and all other beings)
Meditation (Informal/Integrated practice)
Mindfulness (Non-judgmental present-moment awareness during daily activities)	Examples: Mindful yoga (Yoga postures with awareness); Mindful Eating	Can be practiced anytime, anywhere in a day-to-day life
Yoga nidra (yogic sleep or effortless relaxation)
Yoga nidra	Relaxation practice that includes awareness of different body parts and breath, relaxation, auto-suggestions, and imagery	Up to 45 min[29]

¹The durations mentioned are not necessarily to be practiced during a single yoga session. A customized yoga sequence as per individual requirements is recommended.

Table 2 Effect of yoga practices on hypertension and their mechanism of action

Yoga Practice	Effect on hypertension	Mechanism of action
Shatkriya (Cleansing practices)
Trataka kriya	Significant reduction in BP and HR in patients with primary hypertension[8]	Induces calmness similar to a mental state during meditation[8]
Neti kriya	Clear up the head and neck region producing a sense of lightness[6]; Beneficial in reducing anxiety and depression	Reduce toxic accumulation in head and neck region
Sharir Sanchalana (Warm-up practices)
Sharir Sanchalana	Warm-up exercises prepare the body for the practice of asana	Removes stiffness in the muscles and joints; Improve blood circulation
Surya Namaskara (Sun salutations)
Slow practice of Surya Namaskara	Recommended for pre and stage I hypertension[10]	Produce psychosomatic harmony[6]
Asana (Yoga postures)
Asana practiced with awareness and breath synchronization	Prevent and attenuate the age-related deterioration of physical health, muscular strength, and flexibility[36]; Capable of bringing about the stability of body and mind; Improves the flow of vital energy through the body, resulting in a positive sense of well-being; Preparatory practice for meditation that fosters a quieting of the mind	Holding yoga postures for a few seconds build strength by using body weight for resistance, which in turn slows the onset of sarcopenia[36]; Mental relaxation and a state of “restful awareness”; Changes the long-held patterns of feelings and emotions; Exert controlled pressure on the kidneys and the adrenals, which regulates BP through secretions of hormones like renin, angiotensin, adrenaline, etc.[31]
Restorative Yoga	More effective with significantly greater reductions in BP and HR as compared to stretching[11]	Facilitates stretching, provides support, and induces relaxation. Releases habitual stress patterns that are stored in the body as areas of tension
Shavasana (corpse pose) with breath awareness	Effective in BP reduction[12]	Reduction in the load on the heart by blunting the sympathetic response along with an enhanced parasympathetic activity[12]; Allows the body and mind to integrate through mindful stillness
Forward bending poses	“Head-down” postures confer stress-reducing, calming, and mind-quietening benefits	Forward bends with head supported brings a sense of calm
Backward bending poses	Elevate low mood and have energizing effect	Chest opening poses that allow expansive inhalation; Stimulate the heart chakra associated with emotions and balance
Twisting postures	Release tension, and energize; Helps in de-stressing, relaxing, and unwinding	Relieve spinal stiffness and clear emotional blockages
Meditative postures	Maintain a steady comfortable position for a long time without conscious effort; Improve concentration and peace of mind	The heart rate and the breath slow down, which lowers the BP. Enhance feelings of being grounded, centred, and balanced
Pranayama (Regulated breathing practices)
Slow-paced pranayama	A modest reduction in BP[14]	Optimally balances sympathovagal stress response [27]; Baroreceptor sensitivity can be enhanced significantly by slow breathing[18]
Deep slow abdominal breathing	Effective in reduction of systolic BP	Improve vagal tone, increase parasympathetic dominance, and decrease sympathetic discharges[30]
Sukha pranayama (Easy, comfortable breathing)	A significant reduction in Heart rate, systolic pressure, pulse pressure, and mean arterial pressure[16]	Normalization of autonomic cardiovascular rhythms as a result of increased vagal modulation and/or decreased sympathetic activity and improved baroreflex sensitivity[16]
Immediate Effect of Nadi shodhana pranayama (Alternate nostril breathing)	Reduce the BP and HR[17]	Activating the parasympathetic nervous system and enhancing healthy cardiovascular functioning[17]
Slow pace (respiratory rate 6/min) bhastrika pranayama (Bellows breath)	Reduction in systolic and diastolic BP[18]	Enhanced parasympathetic activity[18]
Chandra nadi pranayama (Left unilateral forced nostril breathing)	An immediate decrease in cardiovascular parameters with the decrease in HR, systolic pressure, and pulse pressure[19]	Normalization of autonomic cardiovascular rhythms with increased vagal modulation and/or decreased sympathetic activity along with improvement in baroreflex sensitivity[19]
Bhramari pranayama (Humming breath)	Immediate positive effect on reducing the systolic BP[20]	Parasympathetic dominance[20]
Ujjayi pranayama (Ocean breath) without breath retention or bandhas	Significantly decreases stress-induced changes in cardiorespiratory parameters and decreases BP[15]	Shift autonomic nervous control toward the parasympathetic side[15]; Exerts gentle pressure on the carotid sinuses that regulates BP through homeostatic mechanisms
Sheetali pranayama (Cooling breath)	The immediate effect: reduce the systolic and diastolic BP in hypertensive patients[21]	Decreasing the sympathetic activity[21]
Pranava pranayama/AUM chanting	Five min of AUM chanting reduces systolic and diastolic BP[13]; Reduces depression, anxiety, and stress[24]; Improves quality of sleep[24]; Promotes relaxation, and provides calmness	Improvement in baroreflex sensitivity resulting in the normalizing of autonomic cardiovascular rhythms[24]
Mudra (Subtle gestures)
Brahma mudra (Divine spiritual gesture)	Induces a sense of relaxation and reinvigoration in the head and neck region that reduces stress[6]	Cultivates psychosomatic harmony, induces relaxation, reduces stress
Apaan vayu mudra (Mudra of the heart)	Reduction in systolic and diastolic BP	The finger position sensitizes nerves in the palm and wrist area resulting in a systemic effect on the cardiovascular system
Shanmukhi mudra (Closing the 7 gates)	Produces a sense of inner calm[6]	This mudra encourages ‘pratyahara’, which means withdrawing the mind inwards by blocking some of the sensory distractions of the surroundings
Gyan mudra (Mudra of wisdom)	Reduces mental stress, indicated in hypertension	Deepens awareness; Enhances meditation experience; Regulates the fire and air elements in the body
Meditation
Formal meditation
Concentration meditation	Significant decrease in the HR and systolic and diastolic BP[22]; Reduces stress and anxiety; Induces relaxation	Modulates the physiological response to stress via neurohumoral activation[22]; Decreases the arterial tone and the peripheral resistance
Mindfulness Meditation (Non-judgmental awareness of the present moment with kindness, acceptance, and curiosity)	Significant effect on reducing systolic and diastolic BP in patients with hypertension[23]	Focus on the moment with “acceptance” and “non-criticism” helps in regulating the emotional state. Emotional stability relieves the somatization symptoms and the BP is reduced[23]
Informal meditation
Mindfulness	Helps to cope face day-to-day challenges and stressful situations	Serves as a ‘micro-meditation’ technique for quick stress relief
Yoga nidra (Yogic sleep or effortless relaxation)
Yoga nidra	Reduces systolic and diastolic BP[29]; Reduces depression, anxiety, and stress[24]; Improves quality of sleep[24]	Improve autonomic functions[24,29]; Influence the brain’s electrical rhythms[29]

BP: Blood pressure; HR: Heart rate.

Table 3 Yoga for hypertension: Precautions and contraindications

Yoga practice	Details of yoga practice	Precautions and contraindications
Shatkriya (Yoga cleansing practices)
Shatkriya (Yoga cleansing practices)	Shankhaprakshalana (Alimentary tract cleansing); Agnisara Kriya (Activating the digestive fire); Vaman dhauti (Regurgitative cleansing); Vastra dhauti (Cloth cleansing); Nauli kriya (Abdominal massaging); Basti kriya (Yogic enema); Kapalbhati (Skull shining breath)	Contraindicated in hypertension[9]; Kapalbhati increases diastolic BP suggesting sympathetic stimulation[41]; Laghu shankhaprakshalana, the simplified and shorter version of shankhaprakshalana is suggested in mild to moderate hypertension[42]
Asana (Yoga postures)
Inversions and head below the heart postures	Shirshasana (Headstand pose); Sarvangasana (Shoulderstand pose); Chakrasana (Wheel pose); Halasana (Plough pose); Adhomukh shvanasana (Downward facing dog pose); Prasarit Padottanasana (Wide-Legged standing forward bend)	Cause a significant rise in both the systolic and diastolic arterial pressures; Contraindicated in hypertension[9,38]; Increase intrathoracic pressure and strain the cardiovascular system; Pooling of the blood in the head and neck region resulting in the rise of BP
Other asanas	Mayurasana (peacock pose); Dhanurasana (bow pose)	Compress the front of the diaphragm, which can raise the BP
Pranayama (Regulated breathing practices)
Pranayama pace	Fast breathing	Rapid breath practices may be unsafe in patients with hypertension and cardiovascular disease
Pranayama type	Bhastrika pranayama (Bellows breath) with rapid forceful inhalation and exhalation	Increases HR and BP, producing vasoconstriction[39]
Pranayama type	Surya bhedan/surya nadi pranayama (Right nostril breathing)	Sympathetic stimulating effect[39]
Pranayama technique	Kumbhaka (breath retention)	Significant increase in systolic, diastolic BP, and mean arterial pressure[40] due to combined effect of increased level of HR and total peripheral resistance during kumbhaka
Bandha (lock)
Bandha (lock); Practiced with breath retention	Mula Bandha (Root lock, pulling the perineum inward); Uddiyan Bandha (Abdominal lock, lifting of the diaphragm); Jalandhar Bandha (Chin Lock, pressing the chin on the chest and contracting the throat)	Long retention of breath strains the heart and is not recommended for hypertension[9]; If the jalandhar bandha is not performed properly, the BP is raised

BP: Blood pressure; HR: Heart rate.