Hypertension is personal.
I was diagnosed with hypertension at the age of 38 and have not had a discoverable cause. A friend of mine, a cardiologist from India has told me, “It’s simply how you’re wired”. I did not care for his explanation and he did not offer me any options for treatments other than the regimen of medications he had samples of in his closet. I have been on multiple medical modalities and many of them have failed to control my blood pressure. It was during my quest to heal that I discovered Bikram yoga and I began going to classes four to five days per week. After a few weeks of yoga I noticed that I had a perceptual decrease in my stress and that things normally bothering me were easily dismissed. Upon taking my blood pressures I also noticed that my pressures were not only normal they were low. I began to wean off the medications and dropped two of the three anti-hypertensives I was taking. Over the last two years I have struggled to maintain my practice and I have seen my blood pressure respond inversely proportionate to my ability to attend class. Yoga Helps High Blood Pressure
In the United States, 32% of noninstitutionalized adults over the age of 20 have diagnosed hypertension (http://www.cdc.gov). From this same reference point is has been determined that ambulatory care centers will account for over 40 million visits with hypertension as the primary diagnosis. There has been an increased awareness of stress as a major contributing factor in hypertensive patients. Yoga Helps High Blood Pressure
Individuals have also been seeking alternative methods of treating stress and hypertension with methods such as acupuncture and meditation. With these influences, yoga has also become a sought after modality in the treatment of certain disease processes because of new research in the last few decades. The treatment of hypertension and stress is important as studies have shown 24% of Americans with the disease are not aware they are afflicted (American Heart Association, 2006).
A brief description of hypertension prior to a discussion of treatment with stress reduction and yoga is relevant. Hypertension is a high amount of resistance against the flow of blood though the arterial walls. This translates into the fact that a heart must pump harder in order to get blood from point A to point B. Yoga aids in the treatment of hypertension as it involves Pranayama (breath control), kriyas (meditations), mantras (chanting), and physical exertion. It has been described as a way to yoke the mind and body and calm the mind with concentration, thus improving physical ailments (Lamb, 2001). There are numerous articles claiming the causative effect of genetics and environment, and stress on hypertension (Grassi, 2009). With this link there are also papers that have shown relaxation techniques and biofeedback can decrease blood pressure with a steady practice (Nakao, Yano, Nomura, & Kuboki, 2003). The purpose of this paper will then be to see if there is a correlation between the relaxation and meditative practice of yoga and hypertension. Will a regular practice of yoga have the effect of reducing the blood pressure as do other meditative practices? Yoga Helps High Blood Pressure
Stress
I would like to briefly explain the tenets of stress and how they affect body physiology. Stress is difficult to measure because there is no general consensus on the definition of stress. The reason for this difficulty is the response for stress is different within each of us. For many of us stress is related to work environments, but does that mean a stay at home mother will not have stress because she does not have the stimulation form work? It is also beneficial to mention that stress is not always something that coincides with distress in the sense that some stress might be good for our body. The point being the word stress tends to convey a negative effect on the body, but stress can often keep us alive. When I perform surgery on a patient this is a stressful situation for the body since it is literally being assaulted. In most patients the adrenal glands will produce a multitude of hormones meant to hold the human body adapt to its current environment (Axelrod & Reisine, 1984). Without these hormones the human body has extreme difficulty responding to a stressor. In an individual that has been exposed to exogenous corticosteroids for a chronic disease like asthma, the body will down-regulate its own endogenous production of hormones. Thus when exposed to an acute stressor like surgical intervention, the adrenal glands cannot mount a response. When a patient on chronic exogenous steroids has surgery they must be supplemented with IV steroids until they are 48 hours out from surgery. If they are not supplemented and allowed to fend for themselves there can be serious consequences; hypotension, renal failure, and death. This shows the power of the body’s ability in responding to stress whether it is real or imagined. If the body is able to respond to stress this is a normal evolutionary response and is meant to keep us alive. Problems arise when the stress response is not stopped. Unfortunately none of us know the perfect level of stress for or bodies. There is a delicate balance in the stress response where too little makes us dull and unaware and too much stimulates the body and can aid in degenerative diseases like hypertension and coronary artery disease. Once the stressful period is over the body will try to regulate itself and return physiologic controls back to normal (Myers, 2001). As described in my surgical patient above, when the body is in a state of chronic stress the level of stress related hormones becomes depleted and eventually the body is unable to up regulate in response to an acute stressor. While the chronic stressor is affecting the body, there will be signs and symptoms like hypertension, headache, insomnia, and others that are inflammatory processes on the body. In these days of 70 hour work weeks, pagers, fax machines, and endless committee meetings, stress has become a prevalent part of people’s lives. Although stress may not directly cause hypertension, it can relate to repeated blood pressure elevations, which eventually may lead to hypertension (Kulkarni, O’Farrell, Erasi, & Kochar, 1998). For me, stress is a daily occurrence and is more than likely the main contributing factor towards my hypertension. In therapy, I have discovered that this work stress is additive to other stressors in my life occuring during my childhood, and this stored stress and my inability to purge it from my system is partially responsible for the way I respond to current stressors in my life. An example of chronic stress in my life is my conviction that I will be sued at some point in my medical practice. Because of this fear I treat every patient as a potential lawsuit. The current medical system lends itself to this kind of doctor-patient relationship, but to have one’s guard up at all times can make for a chronic stressor. I have been concerned patients might be tape recording discussions or that they are simply waiting for a moment when there is a complication. I am also not the only physician that practices this way. This may actually be the norm. Counseling from our medical malpractice carriers and reading pieces from lawsuits across the country it is difficult to let my guard down and this effects bonding with my patients.
Hypertension
The diagnosis for hypertension has changed recently but most will agree that systolic blood pressure of 140 mm Hg or greater and diastolic blood pressure of 90 mm Hg or greater is diagnosed as hypertensive (Joint National Committee, 1997). It recent years most physicians are trying to bring blood pressure lower with the help of medications. Most hypertension runs in families and occurs without obvious etiology so it is termed essential hypertension (Moss, McGrady, Davies, & Wickramasekera, 2003, p. 277). In my case, hypertension is only found in my grandmother and potentially my paternal grandfather. I say potentially, because he died from a massive myocardial infarction in his sleep and he never went to the physician. It is stressful in and of itself to be diagnosed with hypertension when you are young. It made me feel like I was somehow a failure and that I had let my life go in such a way that I was being punished for some indiscretion; this would be my Catholic upbringing. My journey with hypertension has been a difficult one, because as a physician I have received care that I would consider substandard. In many cases the doctors treating me would assume that I understood what I needed to do and how I needed to do it, because I am also a physician. Because of this there was limited follow up scheduled and I often found myself changing medical practitioners. My current physician is a lovely woman who allows me to be the patient and it is comforting to know that she is taking care of me. Her care for me has taken some of the stress from my shoulders because I feel like I have a true professional caring for me and that she has my best interests at heart. I realize now, being on the other side of the stethoscope that physicians have a distinctive power to calm the patient simply by their involvement. This is a powerful lesson.
Simply put, blood pressure is the result of two different forces in the body. The first part of blood pressure or the systolic component (the top number) is the result of the pressure generated by the stroke volume of the heart. When the heart pumps it pushes blood into the arteries and this generates a pressure. The second part of the blood pressure is the pressure caused as the arteries resist this flow. The inabilities of the arteries and veins to relax when the heart is at rest is the diastolic component of the blood pressure. Blood pressure affects every portion of the body and every organ and can thus be seen as a disease process in every organ of the body; stroke, coronary artery disease, and kidney failure are all pieces of the hypertensive puzzle. In my case, I am aware that weight loss can be a manner of decreasing my blood pressure, but I was amazed at the results I received when I began doing yoga. I found that I was secondarily more relaxed and in this state I made better food choices than I would make during stressful periods. A few hours after a yoga session I would experience a sense of serenity that would last longer periods if I was more frequent with my attendance to yoga classes. I tried different forms of yoga including Anusara, Kundalini, Hatha, and eventually Bikram; the latter being the type I have connected with. How do stress and hypertension relate and how can yoga control both of these issues directly and indirectly?
Stress and hypertension
There have been many studies published showing a direct relationship between stress and hypertension (Whittaker, 2001). It has been shown that during times of stress the body will release hormone cortisol and epinephrine which both cause a narrowing of the arteries and thus an increase in the patient’s blood pressure. One such study looked at men working arguably stressful jobs for at least 25 years. Researchers discovered a 4.8 point rise in systolic blood pressure when these men were at work and a 7.9 point elevation when they wee at home (Landsbergis, Schnall, Pickering, Warren, & Scwartz, 2003). The interesting point in this study is that stress is something that did not stop once the subject returned to their home, and in most cases, the stresses of daily life were additive to the stress they perceived at work. There are multiple studies showing certain jobs have higher stress rates. One example of this called The Air-Traffic Controller Health Change Study showed not only were air traffic controllers at increase risk for prolonged hypertension, they had a six fold increase compared to the general population (Ming & et al, 2004). One of the complaints about allopathic medicine is that physicians treat the end organ disease process rather than the cause and there is no focus on prevention of the disease. With stress and hypertension, there is a link between the onset of the stress and the resultant hypertensive issues. As a physician I can treat the underlying hypertension, but I am not treating the stress and if the stress continues then the patient is not really getting the benefit of correcting the process. Personally, I have been treated with three simultaneous medications, and it was not until the additional of yoga that I was able to decrease my medications. The stress-factor has not decreased in my profession, but I am better equipped to deal with the stress if I have a regular yoga practice. Yoga Helps High Blood Pressure
I have unfortunately discovered that cessation of my yoga practice brings back the need for my anti-hypertensive medications. What I have discovered is my work stress is a major obstacle for stress relief and it is persistent. The stressful work environment for me will not change in the near future so I have to adapt and come up with new strategies to treat my hypertension. In my case, this may mean a combination of medications and yoga with exercise. It is my hope that I will someday be able to come off of the medications that have been prescribed for me, but I have a feeling that until I eventually quit y profession there will always be a need for me to deal with the disease process of hypertension. Some individuals resort to positive methods of coping like exercise and meditation while others might resort to alcohol, drugs, and anger. Yoga is a way out of hypertension by helping me deal with the stress. It is not simply the asanas that place me into this sense of serenity; it is the teachings and the mindfulness that bring me peace.
Yoga
Yoga means different things to different people. There are those that have come to view yoga as the simple asanas that we see in yoga studios across the country. Yoga however is defined as a union of the soul with God (Anand, 2000). While there have been masters like Paramhansa Yogananda that pushed the American public more into self-realization, there has been a continuum that yoga is simple posture used for flexibility and strength. Yoga in this country has become a fairly common word and while the definition may be less understood, it has become a widely accepted practice with multiple benefits. There are at least six main styles of yoga as described by Feuerstein (2003): Yoga Helps High Blood Pressure
Hatha yoga or asanas. While originally meaning the seat whereupon the sage would sit, this branch of yoga contains these postures and movements we have come to understand in this country. This is the movement and physical aspect of yoga (p.231)
Jnana Yoga. This is the learned path or the path of philosophical insight. This is not what would be understood as simple wisdom but a higher or illuminative metaphysical type of knowledge. This has been called gnosis by some authors (p.251)
Karma Yoga. This form of yoga is based on the sacred assumption that illuminates our activities and how they affect us and those around us. This is the sacred work of transforming one’s everyday activities (p.262). Simply put, this is the arm of yoga that focuses more on service to humanity and dissolution of the more materialistic side of life or asceticism.
Bhakti Yoga. The force of dedication, love and worship. Traditionally, this form of yoga harnesses the person’s feeling energy so that all of his or her impulses get directed towards the Divine (p. 272).
Kriya Yoga. This branch of yoga seeks to undermine the human innate pattern of suffering so that the person can recover his or her own authentic being (p. 280). It is understood that self-realization is the only manner in which to disrupt the unenlightened cycle of the birth and death process so that the being can become enlightened.
Mantra Yoga. According to an esoteric explanation, the Sanskrit term mantra signifies “that which protects the mind”. Specifically mantra is a sound that is charged with transformative power (p.297). The power of mantra comes within those whom the kundalini has been awakened. These individuals then have the power to empower themselves with a sound or a mantra. As we learned in our residential week, mantras are sacred and usually transmissible only to the initiated.
Raja Yoga. Royal yoga. This is the type of yoga that specifically refers to the teachings of Patajanli and is used to teach the “eight-fold” path as described by patanjali. It is the high road of meditation, contemplation, and renunciation (p.40).
In this paper I will specifically be speaking to the effects of Hatha yoga and the asanas or postures and its effect on hypertension. I have chosen this specific piece of yoga since this is the more common definition of yoga as used in the medical and scientific literature. Studies done that use the word yoga will be referring to the postures and the physicality of yoga rather than the contemplative processes that can occur with this type of practice.
Stress and yoga
It would follow if yoga can reduce stress then it might have an indirect effect on lowering blood pressure. One benefit of yoga is the cardiovascular aspect might bring weight loss that often lowers blood pressure. Since a vigorous asana practice, for example a number of repetitions of Sun Salutations, can be intense enough to become aerobic exercise, it therefore has the potential to lower blood pressure (McCall, 2007, p. 362). Since we have seen earlier sustained amounts of stress can arguably cause a sustained effect of elevating blood pressure, it would follow that yoga and its ability to lower stress levels could decrease blood pressure if utilized as a sustainable practice. In my life, stress makes me more likely to miss exercise and make poor choices when selecting foods. The practice of yoga in my life makes me not only more aware of my choices, it makes me aware of the stress in my life and gives me the ability to confront the stress.
A small study by Patel (1973) showed that patients participating in yoga asanas (savasana) hooked to biofeedback equipment had a larger decrease in blood pressure than those individuals simply lying on a couch for the same period of time. Those individuals in savasna where acutely aware of the relaxation factor of the pose and the combination of mindfulness and relaxation produced a more profound effect. This then also carried into sustainability when the same subjects were evaluated one year later. Another finding in this study was that those in the yoga group were able to decrease their medication by 41% while the control group had a slight increase in their need for medication. Other studies have also documented the blood pressure lower effects of savasana (McCall, 2007, p. 363). Does the effect of yoga including more active poses have any effect on blood pressure? Another study (Murugesan, Govindarajulu, & Bera, 2000),showed that individuals participating in yogic postures for one hour per day for eleven weeks had a significant blood pressure drop and lost, on average, sixteen pounds of weight, while control groups had no significant change in their blood pressures. Most of these studies are combinations of Pranayama or breathing exercises, meditations, and yogic postures. It also seems that many of the studies show that the effects of yoga take effect within 8 to 10 weeks and they are sustainable for variable amounts of time depending on the continued practices of the individual. It is difficult to separate breath work from yogic practice because the breath is an essential part of the meditative side of the postures.
My practice of Bikram yoga allowed me to see the benefits of yoga with regards to my blood pressures. Off of medications my blood pressure was as high as 170/110 and at that time I was participating in weight lifting and aerobic exercise. Switching completely to the meditative movement of Bikram practice my blood pressures dropped to 90/60. I stopped my yoga practice for about 8 months and had to go back on three different medications in order to control my blood pressures. Even with these three medications my pressures have been as high as 140/90. Since the inception of this class I have been back to my yoga class for at least two days per week and now on only two medications my blood pressure has dropped to 120/86. In my prime I was attending yoga classes four to five times per day and I think this would be ideal. The only negative aspect of this form of hypertensive and stress control for me is that it is a 60-90 minute practice per day and it does require travelling to a Bikram center here in town. I prefer to have the instruction of an actual teacher rather than the radio or television. There is an added bonus that I am practicing in a room with other people. This group gives me a different energy vibe that I am able to carry into my practice.
In finishing this paper I sit quietly having finished a 90 minute session of Bikram yoga. The sweat has dried on my skin and I feel a peace that I can only find after this type of work-out. I have taken my blood pressure to find once-again that I am normotensive and living in the zone. My struggle is to maintain this practice and bring the effects home with me rather than driving to the local pharmacy to pick up my prescriptions.
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