Yoga Works for BP Lowering in Cardiac Rehab...Just Don't Call It "Yoga"

Shelley Wood

May 12, 2010

May 12, 2010 (Prague, Czech Republic) — An ambitious randomized trial testing two somewhat unconventional add-on components as part of an integrated cardiac-rehabilitation program in Germany has found that an individualized yoga program can produce large reductions in blood pressure on top of optimal medical therapy, even among patients who might never set foot in a yoga studio. The comparator therapy, progressive muscle relaxation (PMR), which is a more common component of cardiac-rehab programs in Germany, did not produce nearly the same degree of blood-pressure improvement, lead investigator for the study, Dr Wolfgang Mayer-Berger (Klinik Roderbirken der Deutschen Rentenversicherung, Germany), told heartwire .

Dr Wolfgang Mayer-Berger

The secret to yoga's success in the male, "blue-collar" group studied, however, may lie in the fact that the word "yoga" was never used, Mayer-Berger acknowledged. Yoga-type interventions would typically be chosen by "intellectual female patients," he admitted, and not by the "low-education males" studied in this trial. But the word, he noted, "was not spoken. You could say that patients were truly blinded to therapy. . . . We called the two randomizations 'relaxation #1' and 'relaxation #2'--most of the patients didn't realize they were doing yoga."

Mayer-Berger presented the results of the trial last week at the EuroPREVENT 2010 meeting.

Relaxation for Rehabilitation

Mayer-Berger et al's study compared two relaxation/stress-reduction practices that have separately been associated with blood-pressure reductions, although not in the setting studied in this trial. PMR is a technique based on alternate tensing and relaxing of muscles developed by Dr Edmund Jacobson and used to reduce stress and anxiety. According to Mayer-Berger, PMR is the "standard" therapy for relaxation and stress management in cardiac-rehabilitation programs, but it has never been tested specifically for blood-pressure lowering in such a large series of cardiac-rehab patients.

Yoga has been shown to reduce blood pressure in younger, healthier, Indian subjects but hasn't been studied as much in older European, heart-disease patients, he noted. The specific yoga practice tested in this study was Viniyoga, a style that permits adaptations of standard yoga positions, under instruction, to suit the unique needs or abilities of the individual practitioner. As such, it is often used in injured or older subjects. According to Mayer-Berger, the Viniyoga instructors in this trial taught a highly standardized program but tailored specific components to individuals' needs.

30 Minutes, Five Days, Three Weeks

For the study itself, 340 male cardiac-rehab patients, all of whom were diagnosed with hypertension following their initial cardiac event, were randomized to a standard intensive cardiac-rehab program that included either PMR or Viniyoga over a three-week period. All subjects were encouraged to participate in five sessions a week, with both programs lasting approximately half an hour each time. To heartwire , Mayer-Berger noted that the trial opted to include men only, given the lower number of women who typically participate in this particular rehab program, which caters specifically to working-age men who need to return to work (mostly in manual-labor jobs) and whose rehab is covered by a pension fund. Most of the men in the trial entered the program after an MI or PCI. After the three-week rehab program ended, men were encouraged to continue doing their programs at home and were told that a questionnaire would be sent to them after six months.

At the end of the three weeks of "in-patient" training, systolic blood-pressure levels in men in the yoga group declined by 8 mm Hg, as compared with 6 mm Hg in the PMR group. Among men with the highest baseline systolic blood pressures (>140 mm Hg), declines in the yoga group were more pronounced: 21.2 mm Hg, as compared with 12.6 mm Hg in the PMR group (p=0.005). Of note, most of the patients were on multidrug regimens, with many taking two or three antihypertensive drugs.

Relaxation Dropouts

By the end of the six months, self-reported dropouts were higher in the yoga group than in the PMR group, with 50% of PMR patients saying they used relaxation therapy at least once per week and just 30% of the yoga group continuing to practice once per week.

According to Mayer-Berger, even these numbers are "surprising"--he and his colleagues had expected dropout rates to be even higher, and he attributes the adherence to the "closed-group" setting used in the study. Whereas cardiac-rehab programs typically have patients coming and going, this study started with set groups that met regularly during the in-patient part of the study and knew that they were all going to be contacted at the end of the six months. "This, I think, created a lot more motivation for both groups, so I think we got a better effect" than would have been seen in standard rehab programs, he stated.

Whatever that magic ingredient, Mayer-Berger says he and his colleagues are working on a follow-up study that will test a yoga program specifically in people with higher baseline blood pressures and that will try to figure out the best way to keep patients motivated--never an easy task. He does think that not using the term "yoga" likely helped keep many unlikely yogis on this particular program, and he says the next study will likely use the same nebulous terms used in the pilot study.

He added that he thinks it is "too early to make yoga a part of usual cardiac-rehabilitation therapy," but should ongoing studies confirm the effect he and his colleagues saw here, "maybe this is really an everyday therapy we can use."

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