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Yoga - A Method of Relaxation
for Rehabilitation after Myocardial Infarction

Dr. T.H. Tulpule, Consulting Cardiologist
and Dr. A.T. Tulpule, Honorary Cardiologist, Bombay

Simple yogic postures and yogic type of breathing were taught to 102 male patients of myocardial infarction who agreed to practise them regularly for one year. An equal number of myocardial infarction patients, well matched for age, served as control. During yogic practice, emphasis was on relaxation of all the other groups of muscles, except those necessary for maintenance of that particular posture. Of the trial group, 96 patients were able to resume work within 6 months. 12 of these needed some assistance of vasodilators or beta blockers; 3 out of 102 in the trial group and 13 out of 102 in the control group died during this period. (T. less than 0.01).

Yogic postures and breathing are easy to learn, need no medical supervision and can be practised at home as a part of the rehabilitation program after myocardial infarction. They reduce long term mortality and have a high rate of rehabilitation.

Rehabilitation is not just a special form of management by which the sick patients are restored to a healthy, useful life, but includes all measures which lead to speedy and complete recovery. Dynamic exercise is one of the most important and useful measures. Exercise testing, either with the help of Master's two steps, bicycle ergometer or more recently the popular and very commonly used treadmill, with constant monitoring of ECG, heart rate, blood pressure, oxygen consumption, are some of the parameters on which the rehabilitation program is determined (*1).

Exercise testing is extremely important in such a program, but is not devoid of risk, however small it may be. It, therefore, is essential that intensive coronary care units are available in the vicinity of exercise testing laboratories to treat an accidental emergency in patients undergoing exercise testing. It is also essential that the exercise has to be very carefully selected and executed under the supervision of an expert medical team. Not many areas, even of developed countries, could afford such a luxury. This method of rehabilitation is available only to a very highly selected few patients. Cost of such a graded exercise program is prohibitive. Moreover, though improved physical fitness may help to relieve angina, to increase physical activity and relieve anxiety and depression, it does not hasten return to work, increase life expectancy or prevent further attacks (*2, 3).

There is thus a need for an alternative which would not be costly, would have no contraindications, would be harmless and would not need expert supervision. Following our earlier experience (3 -A) it was decided to use yoga for rehabilitation. By yoga is meant yogic postures and pranayama. These practices endow positive health and bring about equanimity of mind.

Material and methods

Patients who had unequivocal evidence of acute myocardial infarction were selected for this study. All the patients were males, had a typical history of sudden severe retrosternal pain accompanied by sweating. The confirmation of the diagnosis was achieved by serial ECGs and enzyme changes. All the patients were followed for one year during which time two parameters were looked for, mortality and physical fitness as judged by ability to go back to original work.

All patients received medical treatment wherever necessary and indicated. They were advised to walk slowly in the hospital and then at home after discharge from the hospital. The emphasis was on the time, and not on the distance walked. The patients were then divided into two groups. The criteria for selection was very simple. Those who agreed to learn the yogic postures and breathing, and practise these at home every day for one year, were included in the trial group. The trial group was taught these yogic practices by a teacher and only after the teacher was satisfied with the performance of the patient was he allowed to practise at home without any supervision. The time required to achieve correct performance of the techniques showed a significant variation and depended on ability and adaptability of the patient. The average time required, however, was 10 weeks. All these exercises were started around 6 weeks after myocardial infarction. Selection of patients was not biased by the presence or absence of complications during the acute state of myocardial infarction.

Very simple yogic postures were taught. They included: pranadharana in sukhasana, shavasana, hand postures, utthita eka padasana - raising one leg at a time and raising both legs, ardha pawanmuktasana, bhujangasana, ardha shalabhasana, vajrasana, brahma mudra, chakrasana, vakrasana,janu sirshasana, matsyasana and pranayama. All these are very standard asanas and are described in any standard book of yoga (a, d and e). A special technique and sequence of yogic postures and breathing was evolved. The first asana is pranadharana. In this the patient takes a comfortable pose, either squatting on the floor or sitting in a chair. He first learns to remain steady for at least 2 minutes. During this time, he breathes slowly and evenly. He concentrates on breathing and tries to appreciate that inspiration is slow, that the inhaled air is cool and that the expiration is also slow and even, and the air as it comes out is warm. Thus he is introduced to yogic breathing. The second practice is shavasana or the corpse pose. Here also he tries to lie still for at least 5 minutes and relax the whole body starting from the lower limbs. He is watching the breathing but makes no attempt to control it, and learns to appreciate relaxation. Other asanas starting from hand postures are then introduced. A special effort is made to see that the patients are completely relaxed, physically as well as emotionally, during these exercises. 108 observations were made on pulse rate, systolic and diastolic blood pressure, and respiratory rate during these asanas. Table 1 shows the results of these measurements before, during and after yogic practices.

Table 1
Effect on heart rate, blood pressure, and respiratory rate; before, during and after yoga.

All the patients were instructed to report immediately if any evidence of angina, palpitations, left ventricular decompensation or feeling of exhaustion after yogic practices was present. All patients were reviewed after every 3 months.

102 patients formed the trial group and 103 the control group. Both groups were well matched as far as age and site of infarction were concerned. Table 2 and 3 give the distribution of age and site of infarction respectively.

Table 2
Distribution of Age

Table 3
Site of Infarction

Results

As can be seen from Table 1, the yogic postures did not change the basal status of the patient and did not produce cardiac decompensation or precipitate angina or other catastrophic complications. The following effects were found:

1. Effect of yogic postures and breathing on mortality: Only 3 out of 102 patients in the trial group died during one year of follow up, whereas 13 out of 103 in the control group died during the same period. The difference in the mortality rate between the groups is highly significant (T. less than 0.01).

2. Effect of yogic postures on rehabilitation: Patients were divided into the following three groups:
Grade A- Patients who had no symptoms were working normally, and were able to undergo additional physical stress.
Grade B- Patients who had symptoms, needed supporting treatment with drugs and some adjustment in the nature of their work.
Grade C - All the other patients.

The percentage of patients in each grade according to the above classification in both groups is detailed below.

Table 4

It can be seen from this table that as far as patients in grade 'C' are concerned, both the groups had equal number of patients. It, however, seems from the table that the majority of patients who would have been grade B were helped to be grade A by yogic practices. In other words, in the trial group symptoms were better controlled, adjustment in the nature of work was not reported, nor was supporting treatment by drugs required.

None of the patients developed any evidence of cardiac decompensation or dysrhythmia during a period of one year while doing yogic postures.

Discussion

The results are quite obvious. There was significant improvement in the yoga group compared to the non-yoga group in mortality and the number of patients who could be completely rehabilitated one year after myocardial infarction. Those who develop severe cardiac failure and probably have considerable myocardial akynesia are usually not helped whether they do yoga or not (group C). Luckily, such patients are only few in number. For them, the future is quite bleak, and they must usually resort to such measures as bypass surgery, infarctotomy, and other procedures which also carry a high mortality rate.

The fall in mortality with those practising yogic postures and breathing is impressive and interesting. It would be argued that the selection of patients in this study was not strictly randomised. The protocol of our study, however, could not allow any more randomisation. Once the patient recovers completely from myocardial infarction, it would be extremely difficult to predict which patient would develop either electrical failure, mechanical failure or further episodes of myocardial infarction within a year. Further studies like coronary angiography and left ventricular function tests to define the status of the pump and circulation in patients who survive myocardial infarction is neither convenient nor economical and most of the time not acceptable by the patients.

The only way was, therefore, to take a large sample in two groups to decide whether yoga would help, and this study certainly seems to show that it does. Long term study of these survivals is essential. We have studied a group of 45 patients for well over 5 years with a larger number of patients as control group. The mortality rate in the patients doing yogic postures and breathing regularly for 5 years was only 8%, whereas in patients who did not do yogic practices the cumulative mortality was 21%. This result is similar to the reported mortality by various workers (*4, 5,6).

The difference between the two groups followed for 5 years is significant (T. less than 0.05). Larger study is in progress.

Rehabilitation by some sort of physical activity after myocardial infarction has been accepted all over the world. Whereas beneficial effects such as psychological and emotional cannot be measured, improvement in effort tolerance has been shown and well accepted. It has also been accepted that a physical exercise program reduces the incidence of sudden deaths (*3).

In spite of world-wide acceptance of exercise in rehabilitation, a number of questions still remain unanswered. It has not been shown categorically to influence the ultimate outcome of the disease, the incidence of second episode and mortality, either short or long term, remain uninfluenced. The rehabilitation through yogic postures used by us certainly shows that there is improvement in the mortality in patients who are followed for one year. It may be argued that the number of patients is small and more studies under different environmental conditions should be done. Though this is acceptable and true, the beneficial effect shown by this study cannot be ignored.

Another possible explanation of usefulness of exercise in the rehabilitation program after myocardial infarction is its effects on the risk factors like obesity and diabetes. Reports on hyperlipidemia are conflicting. Halhuber et al report significant reduction of all risk factors (*8), Good (*9), Hollosly (*10), Naughton (*11), Rochells (*12), Taylor (*13), report reduction of cholesterol while Nussel (*14) finds 50% of patients show no change. Increase in metabolic turnover may be a reason for beneficial effect on risk factors.

Yogic postures and breathing are also shown to decrease hypertension (*15), significantly influence diabetes (*16) and serum cholesterol (*17-19) and help in controlling obesity.

In yogic practices the basic concept is maintenance of the basal state. It, therefore, is difficult to explain the significant reduction in risk factors. Since the advent of the industrial era, stress has become very common. Every person in modern society has to undergo stress of various kinds : physical, social, economic, psychological, etc. It has been shown that stress is responsible for precipitation of hypertension, diabetes (*19), hypercholesterolemia (*19, 20, 21, 22, 23, 24, 25).

It could, therefore, be said that in the rehabilitation program, inclusion of treatment of stress is important. Stress can be treated in 3 ways. The first is to remove it, but this is not always possible as it has become a part of our life. The second is to use drugs, however, this is not always possible because of side effects. The third is to change the reaction of the individual to stress.

Centuries ago, in the famous writings of Patanjali (C) and later hatha yoga (B), the basis of yogic postures was described. They advised total relaxation, physical, emotional and mental, to attain tranquillity of mind and positive health. During yogic practice it was essentially seen that the patients did relax as far as possible, by some efforts on the part of the patient as well as the teacher. The objective evidence for achievement of relaxation is maintenance of basal respiratory rate, heart rate and blood pressure, during the posture. This achievement of relaxation is, in our opinion responsible for reduction of risk factors, by possibly changing the reaction of the individual to stress. Relaxation is thus the most important factor during yogic practices. The physical effects of yogic postures and breathing, like improvement in physical fitness, increase in vital capacity, are well documented (*26,27, 28, 29). As far as improvement of emotional and psychological status is concerned, they are known but cannot be measured and hence will not be discussed.

It can be seen that as far as usefulness of exercise and yogic practices in rehabilitation are concerned, yogic postures and breathing have distinct advantages over exercise. Results of rehabilitation after myocardial infarction by dynamic exercise are reported by numerous workers and show similar results (*30). Though we have not used exercise ourselves, but because of similarity of results reported from various centres, they would be compared with our results of rehabilitation by yogic practices. Reduction in risk factors and sudden death, improvement in effort and tolerance, and higher percentage in rehabilitation are similar by either method.

The yogic postures and breathing, however, have many advantages over exercise. There is no contraindication for yoga. They could be done by anyone irrespective of age or of severity of the episode. The exercise rehabilitation is recommended to only a selected group of patients, as there are definite contraindications for exercise testing. Yogic postures and breathing are completely free of complications, whereas at every centre exercise has produced either death, dysrhythmia, severe angina or precipitated myocardial infarction (*31). Yogic postures should be learned from a teacher, but then they can be performed at home without any supervision.

Yogasanas are safe, inexpensive and useful for every patient of myocardial infarction. They significantly reduce mortality after myocardial infarction. Relaxation seems to be an important factor in the achievement of results in this study. It could be surmised that lack of relaxation is an important risk factor.

(Courtesy Indian Heart Journal, Jan./Feb. '80)

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