ROLE OF YOGA IN NON-COMMUNICABLE DISEASES: A BRIEF REVIEW

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National Yoga Week-2015A Mass Awareness Programme for Health, Happiness and Harmony through Yoga

February 12-18, 2015

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ROLE OF YOGA IN NON-COMMUNICABLE DISEASES: A BRIEF REVIEW.Yogacharya Dr Ananda Balayogi Bhavanani

Director, leYER, Puduchery

INTRODUCTION

Yoga as a mode of therapy (yoga chikitsa) has becomeextremely popular, and a great number of studies andsystematic reviews offer scientific evidence of itspotential in treating a wide range of psychosomaticconditions. Yoga understands health and well-being as adynamic continuum of human nature and not merely a'state' to be reached and maintained. Yoga helps theindividual to establish "sukha sthanam", which may bedefined as a dynamic sense of physical, mental, andspiritual well-being. Yogamaharishi Dr. SwamiGitananda Giri Guru Maharaj, the visionary founder ofAnanda Ashram at the leYER, Pondicherry(www.icyer.com) and one of the foremost authorities onYoga in the past century exclaimed lucidly, "Yoga chikitsais virtually as old as yoga itself, indeed, the return of mindthat feels separated from the Universe in which it existsrepresents the first yoga therapy. Yoga chikitsa could betermed as man's first attempt at unitive understanding ofmind-emotions-physical distress and is the .oldestwholistic concept and therapy in the world." (1)

To achieve this yogic integration at all levels of our being,it is essential that we take into consideration the all

- encompassing multi dimensional aspects of yoga thatinclude the followi~g: a healthy life-nourishing diet, ahealthy and natural environment, a wholistic lifestyle,adequate bodywork through asana, mudra-bandha andkriya, invigorating breath work through pranayama andthe cultivation of a healthy thought process throughjnana yoga and raja yoga.

The International Association of Yoga Therapists (IAYT),USA has taken this idea into account in defining Yogatherapy as follows'": "Yoga therapy is the process ofempowering individuals to progress toward improvedhealth and well-being through the application of thephilosophy and practice of yoga." This has been furtherelabourated by the IAYT in its "Recommended"Educational Standards for the Training of YogaTherapists", published on 1 July, 2012. (3) This is one ofthe best documents on standards in yoga therapy and is

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a path breaking effort covering comprehensively allaspects of yoga as a holistic therapy.

The need of the hour is for a symbiotic relationshipbetween yoga and modern science. To satisfy this need,living, human bridges combining the best of both worldsneed to be cultivated. It is important that more dedicatedscientists take up yoga and that more yogis studyscience, so that we can build a bridge between these twogreat evolutionary aspects of our civilization. Theprocess as well as the goal of yoga is all about becoming"one" with an integrated state of being. (4)

PROMOTES POSITIVE HEALTH

Healthy life can be considered as a by-product ofpracticing yogic techniques since it has been observedthat Yoga practitioners are physically and mentallyhealthier and have better coping skills to stressors thanthe normal population. Knowledge of inexpensive,effective and easily administrable yogic techniques byhealth professionals will go a long way in helping usachieve the goal of the World Health Organisation toprovide "physical, mental, spiritual and social health" forall sections of human society.

Some of the important documented healthpromoting benefits of mind-body practices such asyoga and meditation include:

1. Improvement in cardio-respirato_ry efficiency (5-8)

2. Improvement in exercise tolerance (iJ-12)

3. Harmonious balance of autonomic function (13-16)

4. Improvement in dexterity, strength, steadiness,stamina, flexibility, endurance, and neuro-musculo-skeletal coordination (9,17-22)

5. Increase in alpha rhythm, inter-hemisphericcoherence and homogeneity in the brain (23-26)

6, Improved sleep quality (27)

7. Improved cognitive functions (5,28-34)

8. Alteration in brain blood flow and brainmetabolism (35-38)

9. Modulation ofthe neuro-endocrine axis (39-44)

21st June -International Day of Yoga 53

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Fig1. POSSIBLE FACTORS RESPONSIBLE FOR PHYSICAL PERFORMANCE IMPROVEMENT BY YOGA

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We can say that the Yoga affects every cell of the humanbody bringing about better neuro-effectorcommunication, improve strength, and enhanceoptimum functioning of all organ-systems whileincreasing resistance against stress and diseases withresultant tranquillity, balance, positive attitude andequanimity.

MANAGING STRESS

It is well established that stress weakens our immunesystem. Scientific research in recent times has shownthat the physiological, psychological and biochemicaleffects of yoga are of an anti-stress nature. A majority ofstudies have described beneficial effects of yogainterventions in stress with an Agency for HealthcareResearch and Quality (AHRQ) report stating that "Yogahelped reduce stress."?" Reductions in perceived stressfollowing yoga are reported to be as effective astherapies such as relaxation, cognitive behaviouraltherapy and dance therapy.

Mechanisms postulated include the restoration ofautonomic balance as well as an improvement inrestorative, regenerative and rehabilitative capacities ofthe individual. A healthy inner sense of wellbeing

54 218t June -InternatlonalDay otYoga

produced by a life of yoga percolates down through thedifferent levels of our existence from the higher to thelower levels producing health and wellbeing of a holisticnature. Streeter et al recently proposed a theory toexplain the benefits of yoga practices in diverse,frequently co-morbid medical conditions based on theconcept that yoga practices reduce allostatic load instress response systems so that optimal homeostasis isrestored. (46)

They hypothesized that stress produces an:

Imbalance of the autonomic nervous system withdecreased parasympathetic and increasedsympathetic activity,

Under activity of the gamma amino-butyric acid(GABA) system, the primary inhibitoryneurotransmitter system, and

Increased allostatic load.

They further hypothesized that yoga-based practices i)correct under activity of the parasympathetic nervoussystem and GABA systems in part through stimulation ofthe vagus nerves, the main peripheral pathway of theparasympathetic nervous system, and ii) reduceallostatic load.

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According to the theory proposed by them, decreasedparasympathetic nervous system and GABAergicactivity that underlies stress-related disorders can becorrected by yoga practices resulting in amelioration ofdisease symptoms. A review by Bhavanani concludedthat heart rate variability (HRV) testing has a great role toplay in our understanding of the intrinsic mechanismsbehind such potential autonomic balancing effects ofyoga. (47) Innes et al had earlier postulated twointerconnected pathways by which yoga reduces the riskof cardiovascular diseases through the mechanisms ofparasympathetic activation coupled with decreasedreactivity of sympathoadrenal system and HPAaxis. (48)

It is notable that one of the newer applications of yogahas been in managing the aftermaths of naturaldisasters. Studies have shown that yoga significantlyreduces symptoms of posttraumatic stress disorder(PTSD), self-rated symptoms of stress (fear, anxiety,disturbed sleep, and sadness) and respiration rate. (49)

CARDIOVASCULAR CONDITIONS

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---Many studies have tried to explore the mechanisms bywhich yoga modifies coronary artery disease risk factors.Manchanda et al (SO), Ornish et al (51)and Yogendra et al (52)have conducted prospective, randomized and controlledtrials on angiographically proven coronary artery diseasepatients with yoga intervention and demonstrated thatyoga based lifestyle modification helps in regression ofcoronary lesions and improvement in myocardialperfusion. The effect of yogic lifestyle on some of themodifiable risk factors could probably explain thepreventive and .therapeutic beneficial effect observed incoronary artery disease.

A review of 70 eligible studies investigating the effects ofyoga on risk indices associated with the insulinresistance syndrome, cardiovascular disease, andpossible protection with yoga, reported that most had areduction of systolic and/or diastolic pressure. However,the reviewers also noted that there were several notedpotential biases and limitations that made it difficult todetect an effect specific to yoga. (48)Another literaturereview reported significant improvements in overallcardiovascular endurance of young subjects who weregiven varying periods of yoga training. (53)Physical fitnessincreased as compared to other forms of exercise andlonger duration of yoga practice produced bettercardiopulmonary endurance. In fact a detailed review of

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yoga in cardiac health concluded that it can be beneficialin the primary and secondary prevention ofcardiovascular disease and that it can playa primary or acomplementary role in this regard. (54)

RESPIRATORY DISORDERS

Scientific basis of using yoga as an adjunct therapy inchronic obstructive pulmonary diseases is wellestablished with Significant improvements in lungfunction, quality of life indices and bronchial provocationresponses coupled with decreased need for regular andrescue medicinal usage. (55.56)Behera reported perceptibleimprovement in dyspnea and lung function in patients ofbronchitis after 4 weeks of yoga therapy that used avariety of postures and breathing techniques. (57)Yogiccleaning techniques such as dhautikriya (uppergastrointestinal cleaning with warm saline or muslincloth) and netikriya (warm saline nasal wash) removeexcessive mucous secretions, decrease inflammationand reduce bronchial hypersensitivity thereby increasingprovocation threshold while kapalabhati through forcefulexhalations improves the capacity to exhale againstresistance.?" A nonspecific broncho protective orbroncho relaxing effect has been also postulated?" whileimproved exercise tolerance has been reported followingyoga therapy in patients of chronic severe airwaysobstruction. (60)It has been reported that well-performedslow yogic breathing maintains better blood oxygenationwithout increasing minute ventilation, reducessympathetic activation during altitude-induced hypoxia(61)and decreased chemoreflex sensitivity to hypoxia andhypercapnia (62).These help bring about both objectiveand subjective improvem~nts in the condition of patientswith bronchitis. Yoga as a therapy is also cost effective,relatively simple and carries minimal risk and henceshould be advocated as an adjunct, complementarytherapy in our search for an integrated system ofmedicine capable of producing health and wellbeing forall.

METABOLIC/ENDOCRINE CONDITIONS

A few RCTs have suggested that yoga and meditationpractices act on the hypothalamic-pituitary-adrenal axis(HPA) axis to reduce cortisol levels in plasma, (63-66)aswellas reduce sympathetic nervous system tone, increasevagal activity, (67.68)and elevate brain GABAlevels. (69)

Major systematic reviews of the effects of yoga on riskindices associated with insulin resistance syndrome and

21st June - International Day of Yoga 55

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Fig.2. POSTULATED MECHANISMS BY WHICH YOGA CAN HELP REDUCE RISK FORTYPE 2 DIABETES MELLITUS AND ITS COMPLICATIONS

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risk profiles in adults with type 2 diabetes have beendone in recent times. (48:0)They reported post-interventionimprovement in various indices but with results varyingby population and study design. Another systematicreview addressed the management of type 2 diabetesand concluded that the reviewed trials suggestfavourable effects of yoga on short-term parametersrelated to diabetes but not necessarily for long-termoutcome.?" The AHRQ cites two studies comparing yogaversus medication which reported a large and significantreduction of fasting glucose in individuals with type 2diabetes in one, and a smaller but still significantimprovement in the other. (45)

A recent systematic review of yoga on menopausalsymptoms reported small effects on psychologicalsymptoms with no effects on total menopausalsymptoms, somatic symptoms, vasomotor symptoms, orurogenital symptoms. (72)

56 . 21st June -International Day of Yoga

MUSCULOSKELETAL CONDITIONS

A review by Posadzki et al (73)found that 10 of 11 RCTsreported significantly greater effects in favor of Yogawhen compared to standard care, self-care, therapeuticexercises, relaxing yoga, touch and manipulation, or nointervention. Yoga was more effective for chronic back,pain than the control interventions such as usual care orconventional therapeutic exercises though some studiesshowed no between group differences.'?" Recently twowell-designed trials of yoga for back pain reportedclinically meaningful benefits over usual medical care butnot over an intensive stretching intervention. (75,76)

CANCER

According to the findings of a comprehensive meta-analysis of role of yoga in cancer, improvements inpsychological health were seen in yoga groups whencompared to waitlist or supportive therapy groups,(77)With

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respect to overall quality of life, there was a trend towardsimprovement. To explain the positive outcomes, Smithand Pukall suggested various complex pathways whichmay involve relaxation, coping strategies, acceptance,and self-efficacy. (78) Kochupillai et al reported increase innatural killer cells in cancer patients who had completedtheir standard therapy after practicing Sudarshan KriyaYoga and pranayam breathing techniques. (79)

A systematic review and meta-analysis of RCTs on thephysical and psychosocial benefits of yoga in cancerpatients and survivors by Buffart and colleaguesconcluded that yoga may be a feasible intervention asbeneficial effects on several physical and psychosocialsymptoms were reported. (80) They showed that it hasstrong beneficial effects on distress, anxiety anddepression, moderate effects on fatigue, generalHRQoL, emotional function and social function, smalleffects on functional well-being, and no significant effectson physical function and sleep disturbances. It wassuggested that yoga can be an appropriate form ofexercise for cancer patients and survivors who areunable or unwilling to participate in other traditionalaerobic or resistance exercise programs.

IN CONCLUSION

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All of the above studies and reviews suggest a number ofareas where mind-body therapies such as yoga may bebeneficial, but more research is required for virtuallyevery one of them to establish their benefits conclusively.This is true in the process of introducing any new therapyinto the modern health care system and is not surprisingwhen we realize that the proper studies on yoga as atherapeutic modality are not older than a few decades.

Some of the major issues highlighted by these studiesand reviews include:

1. Individual studies on yoga for various conditions aresmall

2. Poor-quality trials in general with multiple instancesfor bias

3. Substantial heterogeneity with regards to thepopulations studied, yoga interventions, durationand frequency of yoga practice, comparison groups,and outcome measures.

4. Compliance was not routinely noted, thuspreventing an understanding of the apt 'dosage'requirements with regard to the mind-bodyinterventions

5. Yoga requires active participation and motivation

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that requires active efforts from both the researcheras well as the participants.

6. Changes in attitudes and behavior need to bedocumented and understood better, especially inthe lifestyle, stress induced psychosomaticconditions.

7. It is not clear which patients may benefit from theYogic interventions, and which aspects' of theinterventions or which specific styles were moreeffective than others.

It has been suggested that yoga may help improvepatient self-efficacy, self-competence, physical fitness,and group support, and may well be effective as asupportive adjunct to mitigate medical conditions.Bussing et al concluded that yoga may have potential tobe implemented as a safe and beneficialsupportive/adjunct treatment that is relatively cost-effective, may be practiced at least in part as a self-carebehavioral treatment, provides a life-long behavioralskill, enhances self-efficacy and self-confidence, and isoften associated with additional positive side effects. (81)

It is important to develop objective measures of variousmind-body therapies and their techniques while includingthem in intervention trials. It has also been suggestedthat the publication of specific interventions used infuture studies in manual form can allow reliablereplication and future implementation. It is also importantto develop tools to monitor objectively the participants'self-practice, compliance, and adherence to theinterventions. Yoga has preventive, promotive as well ascurative potential and a yogic lifestyle confers manyadvantages to the practitioner. Since lifestyle relateddiseases are alarmingly 011 the rise in our modernsociety, yogic lifestyle should be given a special place inpreventing and managing these diseases.

As suggested by Bussing et ai, ."Yoga may well beeffective as a supportive adjunct to mitigate somemedical conditions, but not yet a proven stand-alone,curative treatment. Larger-scale and more rigorousresearch with higher methodological quality andadequate control interventions is highly encouragedbecause yoga may have potential to be implemented asa beneficial supportive/adjunct treatment that is relativelycost-effective, may be practiced at least in part as a self-care behavioural treatment, provides a life-longbehavioural skill, enhances self-efficacy and self-confidence and is often associated with additionalpositive side effects"?"

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60· 21st June -International Day of Yoga

70. Innes KE, Vincent HK. The influence of Yoga-basedprograms on risk profiles in adults with type 2 diabetesmellitus: a systematic review. Evidence-BasedComplementary and Alternative Medicine 2007; 4:469-86.

71. Aljasir B, Bryson M, AI-Shehri B. Yoga Practice for theManagement of Type II Diabetes Mellitus in Adults: Asystematic review. Evid Based Complement Alternat Med2010; 7: 399-408.

72. Cramer H, Lauche R, Langhorst J, Dobos G. Effectivenessof yoga for menopausal symptoms: a systematic reviewand meta-analysis of randomized controlled trials. EvidBased ComplementAlternat Med 2012; 2012: 863905.

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74. Posadzki P, Ernst E. Yoga for low back pain: a systematicreview of randomized clinical trials. Clin Rheumatol 2011 ;30: 1257-62.

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76. Tilbrook HE, Cox H, Hewitt CE et al. Yoga for chronic lowback pain: a randomized trial. Annals of Internal Medicine2011;155:569-78.

77. Tsauo JY, Lin KY, Hu YT, Chang KJ, Lin HF. Effects of Yogaon psychological health, quality of life, and physical healthof patients with cancer: a meta-analysis. Evidence-BasedComplementary and Alternative Medicine 2011; 2011:659876.

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78. Smith KB, Pukall CF.An evidence-based review of Yoga asa complernentary intervention for patients with cancer.Psycho-Oncology 2009; 18: 465--75.

79. Kochupillai V, Kumar P, Singh 0, e~ al. Effect of rhythmicbreathing (Sudarshan Kriya and Pranayam) on immunefunctions and tobacco addiction. Ann NY Acad Sci 2005;1056: 242-52.

80. Buffart LM, van Uffelen JG, Riphagen I, Brug J, vanMechelen W, Brown WJ, Chinapaw MJ. Physical andpsychosocial benefits of Yoga in cancer patients andsurvivors,' a systematic review and metaanalysis ofrandomized controlled trials. BMC Cancer 2012; 12: 559.

Bussing A, Michalsen A, Khalsa SB, Telles S, Sherman KJ.Effects of Yoga on mental and physical health: a shortsummary of reviews. Evid Based Complement AlternatMed2012;2012: 165410 .

•••Morarji Desai National Institute of Yoga ~