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KAPALBHATI ON HEALTHY VOLUNTEERS
Submitted to
The Tamil Nadu Dr. M.G.R. Medical University, Chennai
in partial fulfillment of the requirements for the award of the degree of
DOCTOR OF MEDICINE
BRANCH - II: YOGA
DEPARTMENT OF YOGA
CHENNAI
HOSPITAL, CHENNAI – 600 106
CERTIFICATE FROM THE GUIDE
This is to certify that the dissertation entitled “EFFECT OF IMMEDIATE
HAEMODYNAMIC CHANGES OF KAPALBHATI ON HEALTHY VOLUNTEERS” is a
bonafide record of work done by the Post Graduate Dr. M. MALATHI, Department
of Yoga, Government Yoga and Naturopathy Medical College and Hospital, Chennai,
under my guidance and supervision in partial fulfillment of regulations of The Tamil
Nadu DR.M.G.R. Medical University, Chennai, for the award of degree of
DOCTOR OF MEDICINE (M.D.) Branch - II (Yoga) during the academic year
2014 – 2018.
Place: Chennai
Date: 27.09.2017
SIGNATURE OF THE GUIDE Dr. S.T.VENKATESWARAN N.D. (OSM), M.Sc. (Y&N), P.G.D.O.W.M., P.G.D.Y., D.N.H.E., MBA
Professor and Head – Department of Yoga
Government Yoga and Naturopathy Medical College
and Hospital, Chennai – 600 106
GOVERNMENT YOGA AND NATUROPATHY MEDICAL COLLEGE AND
HOSPITAL, CHENNAI – 600 106
I certify that the dissertation entitled “EFFECT OF IMMEDIATE HAEMODYNAMIC
CHANGES OF KAPALBHATI ON HEALTHY VOLUNTEERS” is a bonafide record of
original research work carried out by Dr. M. MALATHI, Department of Yoga,
Government Yoga and Naturopathy Medical College and Hospital, Chennai,
submitted for the degree of DOCTOR OF MEDICINE (M.D.) Branch – II (Yoga)
under my guidance and supervision, and that this work has not formed the basis for
the award of any other degree/diploma/associate-ship/fellowship or other titles in this
university or any other university or Institution of higher learning.
Place: Chennai
Date: 27.09.2017
SIGNATURE OF THE HOD Dr. S.T.VENKATESWARAN N.D. (OSM), M.Sc. (Y&N), P.G.D.O.W.M., P.G.D.Y., D.N.H.E., MBA
Professor and Head – Department of Yoga
Government Yoga and Naturopathy Medical College
and Hospital, Chennai – 600 106
GOVERNMENT YOGA AND NATUROPATHY MEDICAL COLLEGE AND
HOSPITAL, CHENNAI – 600 106
I certify that the dissertation entitled “EFFECT OF IMMEDIATE HAEMODYNAMIC
CHANGES OF KAPALBHATI ON HEALTHY VOLUNTEERS” is the record of original
research work carried out by Dr. M. MALATHI, Department of Yoga, Government
Yoga and Naturopathy Medical College and Hospital, Chennai, submitted for the
award of degree of DOCTOR OF MEDICINE (M.D.) Branch – II (Yoga) under the
guidance and supervision of Dr. S.T.VENKATESWARAN, and that this record of
original research work has not formed the basis for the award of any other
degree/diploma/associate-ship/fellowship or other titles in this university or any other
university or Institution of higher learning.
Place: Chennai
Date: 27.09.2017
SIGNATURE OF THE PRINCIPAL
Dr. N. MANAVALAN N.D. (OSM), M.A. (G.T.), M.Sc. (Y&N), M. Phil., P.G.D.Y.,
P.G.D.H.M., P.G.D.H.H.,
Government Yoga and Naturopathy Medical
College and Hospital, Chennai – 600 106
GOVERNMENT YOGA AND NATUROPATHY MEDICAL COLLEGE AND
HOSPITAL, CHENNAI – 600 106
DECLARATION BY THE CANDIDATE
I, Dr. VARUN.V solemnly declare that this dissertation entitled “EFFECT OF
IMMEDIATE HAEMODYNAMIC CHANGES OF KAPALBHATI ON HEALTHY
VOLUNTEERS” is a bonafide and genuine research work carried out by me in the
Department of Yoga, Government Yoga and Naturopathy Medical College and
Hospital, Chennai, from July 2016 – June 2017 under the guidance and supervision of
Dr. S.T.VENKATESWARAN, N.D. (OSM), M.Sc (Y&N), P.G.D.O.W.M., P.G.D.Y.,
D.N.H.E.,MBA., Professor and Head, Department of Yoga, Government Yoga and
Naturopathy Medical College and Hospital, Chennai. This dissertation is submitted to
The Tamil Nadu DR.M.G.R. Medical University, Chennai towards partial fulfillment
of the requirements for the award of M.D. Degree (Branch – II: Yoga) in Yoga and
Naturopathy.
(Dr. M. MALATHI)
INSTITUTIONAL ETHICS COMMITTEE
GOVERNMENT YOGA AND NATUROPATHY MEDICAL COLLEGE AND HOSPITAL, CHENNAI – 600 106
Telephone No: 044 – 2622 2516
CERTIFICATE OF APPROVAL
Government Yoga and Naturopathy Medical College and Hospital,
Chennai – 600 106
The Institutional Ethics Committee of Government Yoga and Naturopathy Medical College,
reviewed and discussed your application for approval of the proposal entitled “EFFECT OF
IMMEDIATE HAEMODYNAMIC CHANGES OF KAPALBHATI ON HEALTHY VOLUNTEERS” No. 5052016
The following members of Ethics Committee were present in the meeting held on
17/05/2016 conducted at Government Yoga and Naturopathy Medical College, Chennai.
We approve the proposal to be conducted in its presented form
Sd / Chairman & Other Members
The Institutional Ethics Committee expects to be informed about the progress of the study,
and SAE occurring in the course of the study, any changes in the protocol and patient’s information / informed consent and asks to be provided a copy of the final report.
Member Secretary, Ethics Committee
1. Dr. N. Manavalan, -- Chairperson
Principal, GYNMC, Ch-106 2. Dr. R. S. Himeshwari, -- Deputy Chairperson H.O.D., Dept of AEM, GYNMC, Ch-106 3. Dr. S. T. Venkateswaran, -- Member Secretary H.O.D., Dept of YOGA, GYNMC, Ch-106 4. Dr. K. Padma, -- Medical Scientist/Member Director, Institute of Physiology and Experimental Medicine, MMC, Ch-03 5. Dr. M. S. Ramasamy, -- Medical Scientist/Member Scientist, ISM/NP Lab, AU-KBC Center, MIT, Ch-44 6. Dr. V. Banumathi, -- Member Director, National Institute of Siddha, Ch-47 7. Dr. N. Mangaiyarkarasi, -- Member Reader, GYNMC, Ch-106 8. Dr. K. S. Lakshmi, -- Member
Lecturer, GYNMC, Ch-106 9. Dr. K. Kahlil Subramanian, -- Member Lecturer, GYNMC, Ch-106 10. Mr. R. Ramanathan, -- Layperson O.S., GYNMC, Ch-106 11. Mr. B. Vanakkam Varadharajan, -- Social Activist P.R.O., M.T.C. (Retd), Ch-95
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that The Tamil Nadu DR. M.G.R. Medical University, Chennai,
Tamil Nadu shall have the rights to preserve, use and disseminate this
Dissertation/Thesis in print or electronic format for academic/research purpose.
Place: Chennai
Date: 27.09.2017
© The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu
SIGNATURE OF THE CANDIDATE
1
INTRODUCTION
2
INTRODUCTION
Yoga is the science of right living and, as such, is intended to be incorporated in daily
life. It works on all aspects of the person: the physical, vital, mental, emotional,
psychic and spiritual. 1 The word Yoga is derived from the Sanskrit word Yuj‘ which
essentially means to join or unite. The union referred here is that of
The individual- self uniting with Cosmic Consciousness or the Universal Spirit. 2
Uniting mind and body is yoga. In fact yoga means the union of prana and mind ewith
the Self. 3
Yoga is a right way of life, is characterized by balance in all the aspects, health,
harmony and bliss. It gives comfort to the restless mind. Yoga is used for developing
memory, intelligence and creativity. 4 Practicing yoga enables the practitioner to get
radiant physical health, undisturbed mind, spiritual uplift, and harmony for social
wellbeing. 5
Yoga is one of the six orthodox systems of Indian philosophy. Sage Pathanjali
collated, co-ordinated and systemized the yoga in his classical work, the Yoga Sutras,
which consists of 185 terse aphorisms. 6
Sage Patanjali's treatise on raja yoga, the Yoga Sutras, codified the first definitive,
unified and comprehensive system of yoga. Often called the eight-fold path is
Ashtanga yoga, it is comprised of yama, self-restraints, niyama, self-observances,
asana, pranayama, pratyahara, disassociation of consciousness from the outside
3
with pureconsciousness. 7
Pranayama has been assigned very important role in Ashtanga than the Yoga asanas
by Maharishi Patanjali because of its efficacy in keeping sound health. 8 .
Pranayama are various voluntary breath control techniques that exert profound
physiological effects on pulmonary cardiovascular and mental functions.
Pranayama has variable effect on cardiorespiratory system 9
. Pranayama consists of
(exhalation) that can be either rapid or slow. 10
Kapalbhati (KB) pranayama is a fast
breathing pranayama. KB is one of the kriya which under the classification of
Shatkarmas (cleansing techniques) in Hatha Yoga. 11
According to Gheranda Samhita there are three forms of KB: vatakrama, vyutkrama,
and sheetkrama. Hatha Yoga Pradipika describes only vatakrama.
Vata means wind‘ or air‘. 12
Regular practice of pranayama in everyday life improves cardio-vascular and
respiratory functions, there by improves autonomic tone from sympathetic to
parasympathetic nervous system and also decreases the effect of stress and strain of
the body and brings improvement in physical and mental health. 13
By voluntarily controlling breathing pattern, it is possible to influence ANS
functions. 14
4
There are few studies which indicates that KB practice decreases sympathetic activity
by increasing parasympathetic activity and this decreases Heart rate (HR),Systolic
blood pressure (SBP) and diastolic blood pressure (DBP). 15
whereas other studies
revealed that fast pranayamas like Kapalabhati and Bhastrika practice alone can
increases sympathetic activity, 16,17
thereby, increasing HR, SBP, and DBP. Some
other studies have found no effect of fast pranayama after 12 weeks of practice. 18
To the best of our knowledge after done a review of literature, there is no study to
evaluate immediate effect of KB pranayama on hemodynamic changes in HR, SV,
CO.
Hence the present study was designed to assess the immediate effect produced in the
haemodynamics after the practice of KB and followed by 10 minutes relaxation in
Savasana on healthy volunteers.
2.0 AIMS AND OBJECTIVES 2.1 AIM:
The aim of this study was to evaluate the effect of immediate haemodynamic changes
of kapalabhati pranayama on healthy volunteers.
2.2 OBJECTIVES OF THE STUDY:
To evaluate the effects of kapalabhati pranayama on haemodynamic changes.
Primary variables are
Heart Rate (HR)
Stroke volume (SV)
Cardiac output (CO)
3.0 REVIEW OF LITERATURE
Breath, the vital force of life, is controlled positively by pranayama to ensure
homeostasis, physical and mental wellbeing in humans. Pranayama,is the procedure of
expansion of the prana or vital energy, occurs through the practices of prananigraha,
or control of the prana. 19
KAPALBHATI
Kapalbhati is highly energizing abdominal breathing exercise. KB is one of the
cleansing procedure of yogic Shat kriyas, this is a cleansing exercise; it purifies the
blood, removes toxins from the body, cleans the nasal passages and removes bronchial
congestion, increases metabolism. In this KB pranayama, complete awareness is given
to exhalation only and hardly any effort is applied to inhale. Inhalation is mild, slow
and longer than the exhalation.
Van Lysbeth states that KB influences the circulation of blood within the brain. KB
changes the volume of the brain according to the respiratory rhythm and, therefore, it
increases the irrigation of the brain matter, 20
it has its influence over every systems of
the body.
Cardiovascular functions are controlled and regulated by neural factors as well as
others such as temperature, hormones, etc.
Of these, neural factors primarily concern the autonomic nervous system (ANS),
which plays a major role in maintaining and regulating cardiac functions, e.g., SBP,
DBP, SV and HR.
tachycardia, bradycardia, ischemia, infarction, etc. 21
The divine science of pranayama teaches us how to regulate the cardiovascular
changes and also reduce the respiratory and HR, while increasing the quantum of
oxygen drawn in and decreasing the outflow of breath. This can be as minimal as two
or three cycles per minute after the advanced practices of KB. 21
CARDIAC CYCLE
The cardiac events that occur from the beginning of one heartbeat to the beginning of
the next are called the cardiac cycle.Cardiac cycle includes both mechanical and
electrical events that occur from the beginning of one heart beat to the beginning of
the next. Each cycle is initiated by spontaneous generation of an action potential in the
sinus node. This node is located in the superior lateral wall of the right atrium near the
opening of the superior vena cava, and the action potential travels from here rapidly
through both atria and then through the A-V bundle into the ventricles by bundle
branches and Purkinje fibers. 23
10
11
0.03 sec
0.13 sec
0.03 sec
0.03 sec
FIGURE 2: Total time required for conduction from the SA node to the endocardial
surface
DIASTOLE AND SYSTOLE
The cardiac cycle consists of a period of relaxation called diastole, during which the
heart fills with blood, followed by a period of contraction called systole.
Figure 1 shows the different events during the cardiac cycle for the left side of the
heart. The top three curves show the pressure changes in the aorta, left ventricle, and
left atrium, respectively. 23
The fourth curved epicts the changes in left ventricular volume, the fifth the
electrocardiogram, and the sixth a phonocardiogram, which is a recording of the
sounds produced by the heart—mainly by the heart valves—as it pumps.
It is especially important that the reader study in detail this figure and understand the
causes of all the events shown. 23
FIGURE: 3 Phases of cardiac cycle
13
FIGURE-4
Events of the cardiac cycle for left ventricular function, showing changes in left atrial
pressure, left ventricular pressure, aortic pressure, ventricular volume, the
electrocardiogram, and the phonocardiogram.
VOLUME OUTPUT.
END- DIASTOLIC VOLUME
During diastole, normal filling of the ventricles increases the volume of each ventricle
to about 110 to 120 milliliters. This volume is called the end-diastolic volume. 23
STROKE VOLUME
Then, as the ventricles empty during systole, the volume decreases about 70
milliliters, which is called the stroke volume output.
15
END-SYSTOLIC VOLUME
The remaining volume in each ventricle, about 40 to 50 milliliters, is called the end-
systolic volume.
EJECTION FRACTION
The fraction of the end-diastolic volume that is ejected is called the ejection fraction—
usually equal to about 60 percent. 15
HEART RATE
Heart Rate is number of beats per minute, typically 70 to 80 beats/min in young adults
but higher in children and elderly. 24
TACHYCARDIA
The term tachycardia means fast HR, usually defined in an adult person as faster
than 100 beats per minute.
An electrocardiogram recorded from a patient with tachycardia is shown in Figure 2,
is about 150 per minute instead of the normal 72 per minute.
THE GENERAL CAUSES OF TACHYCARDIA INCLUDE
Increased body temperature,
Stimulation of the heart by the sympathetic nerves, or toxic conditions of the
heart. 23
BRADYCARDIA
The term bradycardia means a slow HR, usually defined as fewer than 60
Beats per minute. 23
FIGURE 7 Sinusbradycardia lead-111
FIGURE 8 Bradycardia by vagal stimulation
Any circulatory reflex that stimulates the vagus nerves causes release of acetylcholine
at the vagal endings in the heart, thus giving a parasympathetic effect. 25
STROKE VOLUME
Stroke volume is the amount of blood that leaves the heart with each beat or
ventricular contraction. Normal Adult 70 ml / beat. Stroke volume = end-diastolic
volume – end-systolic volume. 26
EJECTION FRACTION
The fraction of the end-diastolic volume that is ejected is called the ejection fraction—
usually equal to about 60 per cent. 23
INCREASE IN STROKE VOLUME
When the heart contracts strongly, the end-systolic volume can be decreased to as
little as 10 to 20 milliliters. Conversely, when large amounts of blood flow into the
ventricles during diastole, the ventricular end-diastolic volumes can become as great
as 150 to 180milliliters in the healthy heart.
By both increasing the end-diastolic volume and decreasing the end-systolic volume,
the stroke volume output can be increased to more than double normal. 23
CARDIAC OUT PUT
Cardiac output is the amount of blood the heart pumps in 1 minute, and it is dependent
on the HR, contractility, preload, and after load.
Cardiac output, expressed in liters/minute, is the amount of blood the heart pumps in 1
minute. Cardiac output is logically equal to the product of the stroke volume and the
number of beats per minute (HR). 26
Cardiac output is the volume of blood pumped by heart each minute. It is product of
HR and stroke volume and averages about 5.25 L/min.
Cardiac output is HR x stroke volume. 26
19
• Age: Because of less body surface
• Sex: Since the body surface area is less in females than males.
• Diurnal variation: In the early morning cardiac output is low which increases in
the day time.
with an increase in the cardiac output.
.
FIGURE 9 Physiological causes of variation in cardiac output 27
20
FIGURE 10 Cardiac index for the human being at different ages 26
Eating is associated with an increase in cardiac output approximately by 30%
Exercise may increase the cardiac output up to 700% depending upon the
vigorousness of exercise.
Pregnancy. An increase in cardiac output to the tune of 45-60% is reported
during the later months of the pregnancy.
High altitude. The cardiac output is increased at a high altitude due to release
of adrenaline as a consequence to hypoxia.
Posture change. Sitting or standing from lying down position may decrease the
cardiac output by 20-30% because of pooling of blood in the lower limb. 27
21
HIGH CARDIAC OUTPUT CAUSED BY REDUCED TOTAL PERIPHERAL
RESISTANCE
Reduced peripheral resistance increases venous return which will increases HR and
stroke volume there by increasing the cardiac output.
22
OUTPUT
↓ CARDIAC OUTPUT
↓STROKE VOLUME
HEART RATE
↑ STROKE VOLUME
HEART RATE
↑ PARASYMPATHETIC ↑ SYMPATHETIC
↑ END-DIASTOLE VOLUME
↑ VENOUS RETURN
↑ CARDIAC OUTPUT
↓PERIPHERAL RESISTANCE
CONTROL OF CARDIAC OUTPUT BY VENOUS RETURN—ROLE OF THE
FRANK-STARLING
MECHANISM OF THE HEART
The peripheral factors are more important than the heart itself in controlling cardiac
Output, the heart has a built-in mechanism that normally allows it to pump
automatically whatever amount of blood that flows into the right atrium from the
veins. This mechanism, called the Frank-Starling law.
This law states that when increased quantities of blood flow into the heart, the
increased blood stretches the walls of the heart chambers. As a result of the stretch,
the cardiac muscle contracts with increased force, and this empties the extra blood that
has entered from the systemic circulation. 26
PATHOLOGICALLY HIGH AND PATHOLOGICALLY LOW CARDIAC
OUTPUTS
RESISTANCE
LOW CARDIAC OUT PUT
(1) Abnormalities that cause the pumping effectiveness of the heart to fall too low
(2) Cause of venous return to fall too low. 26
DECREASED CARDIAC OUTPUT
myocardial infarction,
1. Decreased blood volume
2. Acute venous dilation.
4. Decreased tissue mass. 26
Physiological activities of the cardiovascular system are under the control of the
ANS. 28
VASOMOTOR CENTER IN THE BRAIN AND ITS CONTROL OF THE
VASOCONSTRICTOR SYSTEM.
VASOMOTOR CENTRE:
SITUATION:
It is bilaterally situated in the reticular formation of medulla oblongata and lower
pons.
AREA:
VASOMOTOR CENTER IN THE BRAIN AND ITS CONTROL OF THE
VASO CONSTRICTOR SYSTEM
FIGURE 13 Areas of the brain in the nervous regulation of the circulation
27
CARDIAC SYMPATHETIC AND PARASYMPATHETIC NERVES
FIGURE 14 The vagus nerves to the heart are parasympathetic nerves.
28
ANATOMY OF SYMPATHETIC NERVOUS CONTROL OF THE
SHOWN BY THE RED DASHED LINE IS A VAGUS NERVE THAT
CARRIES PARASYMPATHETICSIGNALS TO THE HEART
FIGURE 15 Anatomy of sympathetic nervous control of the circulation
29
VASOCONSTRICTOR AREA
It is situated in reticular formation of medulla in the floor of fourth Ventricle.
Cardiac Accelerator Centre
VASODILATOR AREA
SENSORY AREA
MOTOR EFFERENT FIBERS TO HEART:
Vagus Nerve (Parasympathetic Nerve)
30
Sympathetic Nerve
BARORECEPTOR REFLEXES
Basically, this reflex is initiated by stretch receptors, called either baroreceptors or
pressoreceptors.locatedat specific points in the walls of several large systemic arteries.
Baroreceptors are located in the wall of almost every large artery of the thoracic and
neck regions baroreceptors are extremely present in
(1) The wall of each internal carotid artery slightly above the carotid bifurcation, an
area known as the carotid sinus, and
(2)The wall of the aortic arch. 29
31
32
Secondary signals inhibit the vasoconstrictor center of themedulla and excite the
parasympathetic center
Vasodilation of veins and arterioles Decrease Heart rate and strength
ofheart contraction
Therefore excitation of baroreceptors by pressure in thearteries reflexly causes
decrease in heart rate and cardiac output. 29
33
RESPONSE OF THE BARORECEPTORS TO PRESSURE.
Figure–shows the effect of different arterial pressure levels on the rate of impulse
transmission in a Hering‘s carotid sinus nerve.
Response to Arterial Pressure
34
Oxygen lack (decreased Partial pressure of Oxygen)
Carbon dioxide excess
CHEMORECEPTORS
pO2 AND pH LEVELS (Hydrogen ion)
FIGURE-18Chemosensitive cell responds
35
HAEMODYNAMICS
Hemodynamics, which refers to…