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Effect of Nadi Shuddhi Pranayama on perceived stress and cardiovascular

autonomic functions in 1st year undergraduate medical students

Article  in  National Journal of Physiology Pharmacy and Pharmacology · January 2018

DOI: 10.5455/njppp.2018.8.0205515022018

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Dhanvijay and Chandan Nadi Shuddhi Pranayama on perceived stress and cardiovascular autonomic functions
National Journal of Physiology, Pharmacy and Pharmacology

RESEARCH ARTICLE
Effect of Nadi Shuddhi Pranayama on perceived stress and cardiovascular
autonomic functions in 1st year undergraduate medical students

Anupkumar D Dhanvijay1, Lalita Chandan2

1
Department of Physiology, Rajshree Medical Research Institute, Bareilly, Uttar Pradesh, India, 2Department of Physiology, Seth Gordhandas
Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
Correspondence to: Anupkumar D Dhanvijay, E-mail: [email protected]

Received: January 28, 2018; Accepted: February 15, 2018

ABSTRACT

Background: First year medical students have reported a high level of perceived stress. Yogic breathing technique
“Pranayama” is said to balance two limbs of autonomic nervous system and therefore advocated for stress reduction and
prevention of related diseases. Aims and Objectives: The present study was conducted to evaluate the effects of Nadi
Shuddhi Pranayama on perceived stress and cardiovascular autonomic functions in 1st year medical students. Materials
and Methods: The present study was carried out in one of the tertiary care hospitals of Mumbai. A total of 60 subjects
(age 18–22 years) practised Nadi Shuddhi Pranayama daily for 12 weeks under the supervision of certified yoga trainer.
Following parameters were recorded before and after 12 weeks of training; perceived stress scale (PSS) score, heart rate
(HR), systolic blood pressure (SBP) and diastolic BP (DBP), DBP response to isometric handgrip (IHG) test. Results:
There was a significant decrease in PSS scores after intervention. A significant decrease was also seen in cardiovascular
autonomic functions such as HR, SBP, DBP, and DBP response to IHG test. Conclusion: Regular practice of Nadi
Shuddhi Pranayama helps in reducing stress in 1st year medical students as evidenced by the corresponding decrease in
cardiovascular autonomic parameters.

KEY WORDS: Nadi Shuddhi Pranayama; Perceived Stress Scale; Cardiovascular Autonomic Functions; Medical Students

INTRODUCTION oriented.[4] Stressful environment in medical colleges often exerts

a negative effect on academic performance, physical health, and
Stress is a process whereby an individual perceives and responds psychological well-being of medical students.[5] Several studies
to events appraised as overwhelming or threatening to one’s have reported that perceived stress is high among 1st year medical
well-being.[1] Dr. Hans Selye described stress as the nonspecific students.[6-8] Change of environment, demanding medical
response of the body to any demand made on it.[2] Stress response education, different teaching protocol, unrealistic expectations,
helps us in physical survival in the form of classical “fight or flight lack of time for recreation, and lack of emotional support result
reaction.[3] Stress in medical students is common and is process in stress in newly admitted medical students. Real life stress
in 1st year undergraduate students impairs cardiac autonomic
Access this article online regulation and shifts it toward sympathetic dominance.[6] Self-
Website: www.njppp.com Quick Response code observation, cognitive restructuring, relaxation training, time
management, and problem solving are some ways for stress
management.[9] Progressive relaxation training usually consists
DOI: 10.5455/njppp.2018.8.0205515022018 of a series of structured exercises involving slowly tensing and
relaxing certain muscle groups. Pranayama, the fourth limb of
Ashtanga Yoga is one such relaxation technique.[10] It is said to

National Journal of Physiology, Pharmacy and Pharmacology Online 2018. © 2018 Anupkumar D Dhanvijay and Lalita Chandan. This is an Open Access article distributed under the terms
of the Creative Commons Attribution 4.0 International License (http://creative commons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or
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1 National Journal of Physiology, Pharmacy and Pharmacology 2018 | Vol 8 | Issue 6 (Online First)
Dhanvijay and Chandan Nadi Shuddhi Pranayama on perceived stress and cardiovascular autonomic functions

relieve stress by stabilizing autonomic functions of the body. thumb from the right nostril, and then exhaled through
Slow breathing techniques such as Nadi Shuddhi and Savitri this nostril. This was done to the count of 8 s. This
pranayama are particularly advocated for this purpose. Hence, completed a half round.
the present study was taken to evaluate effects of the practice of 3. He then inhaled through the right nostril to the count of
Nadi Shuddhi Pranayama on perceived stress and cardiovascular 4 s. Now, he closed the right nostril with his right thumb
autonomic functions in 1st year medical students. and exhaled through the left nostril to the count of 8 s.
This completed one full round.
MATERIALS AND METHODS
Each volunteer had practised such cycles for 15 min daily in
the morning for 12 weeks.
Study Design
It is a pre-post designed observational study conducted in a Following parameters were recorded on all the volunteers
well-known tertiary care hospital in Mumbai. The participants before and after the intervention. Before testing, required pre-
of the study were 60 1st year medical students of the age test instructions were given and tests were properly explained
group of 18–22 years. Permission to conduct the study was and demonstrated.
taken from the Institutional Ethics Committee.
Heart rate (HR)

Selection of Subject After complete rest for 5 min, pulse rate per minute was
measured by placing three fingers on the radial artery for
Subjects were randomly selected from 1st year medical 3 times and the average was taken and noted.
students.
Blood pressure (BP)
Inclusion criteria
With the help of automated sphygmomanometer (Omron),
Healthy males and females between the age group of systolic and diastolic pressure was measured in supine
18–22 years without preference to any sex and students living position. BP was recorded 3 times and the average was noted.
sedentary lifestyle were included in the study.
Isometric handgrip (IHG) test
Exclusion criteria
This is a sympathetic test. A detail of the procedure was
Students who had undergone any major surgery, having explained to the subject, and the baseline BP was recorded
any major illness such as hypertension, diabetes mellitus, with the help of sphygmomanometer. The subject was asked to
and history of heart disease, and on any medication were hold the dynamometer (Anand Agencies, Pune) in dominant
excluded. Those who were doing other form of exercises hand at 30% of their maximum voluntary capacity. During
were excluded from the study. the test procedure, the BP was recorded every 30 s with the
help of sphygmomanometer on the non-exercising arm. The
Consent Taking rise in diastolic BP at the point just before the release of hand
grip is taken as the index of response to handgrip test.
Written informed consent was obtained from each student
before the procedure. Perceived stress scale (PSS) questionnaire
The PSS[11] is a 10-item self-report questionnaire that
Study Procedure
measures the persons’ evaluation of the stressfulness of the
History taking, general examination, and systemic situations in the past 1 month of their lives. The PSS is the
examination were performed. Volunteers were instructed not only empirically established index of general stress appraisal.
to practice any other exercise or any yogic exercises other
than prescribed one. Questions are based on five-point Likert scale. For each
question, participant had to choose and tick appropriate
Practice of Nadi Shuddhi Pranayama[10] was done under the option from the following alternatives: 0 - never, 1 - almost
guidance of certified yoga trainer. Subject was made to sit never, 2 - sometimes, 3 - fairly often, and 4 - very often. In
in Vajra Asana, and then, he was asked to perform Nasarga the present study, all students had taken the questionnaire.
Mudra or Vishnu Mudra with his right hand. He then Later, the total score was assessed as follows.
performed Nadi Shuddhi Pranayama in following steps:
1. Subject closed the right nostril with his right thumb and then First, scores were reversed for questions 4, 5, 7, and
inhaled through the left nostril. This was done to the count of 4 s. 8. On these 4 questions, the scores can change from:
2. Immediately he closed his left nostril with his right ring 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0. Then, the scores were
finger and little finger, and at the same time, removed his added up for each item to get the total score. Individual scores

2018 | Vol 8 | Issue 6 (Online First) National Journal of Physiology, Pharmacy and Pharmacology  2
Dhanvijay and Chandan Nadi Shuddhi Pranayama on perceived stress and cardiovascular autonomic functions

on the PSS can range from 0 to 40 with higher scale score DISCUSSION
indicating a higher level of stress.
We found significant reduction in HR (P < 0.001), SBP
(P < 0.001), DBP (P < 0.001), and DBP response to IHG test
Statistical Analysis
(P < 0.001) after practice of Nadi Shuddhi Pranayama for
Data were expressed as a mean ± standard deviation for 12 weeks. A significant decrease was also observed in PSS
parametric and as median for non-parametric parameter. score after intervention (P < 0.001).
All data were entered in Microsoft Office Excel 2007 and
analyzed with the SPSS for Windows statistical package The finding of decrease in HR, SBP, and DBP in our study
(Version 17.0, SPSS Institute Inc., Cary, North Carolina). is similar to findings of other researchers who also studied
Paired t‑test was used for parametric and Wilcoxon signed- the effect of Nadi Shuddhi Pranayama on cardiovascular
rank test for non-parametric parameter. P < 0.05 was variables in healthy young adults and suggested a shift toward
considered as statistically significant. parasympathetic dominance.[12,13] HR is mainly determined
and decreased by parasympathetic nervous system (PNS)
RESULTS and decreases it. SBP is determined by HR and contractility
of heart musculature. Increase in both parameters is function
Analysis with paired t-test shows that there was a significant of sympathetic nervous system (SNS). DBP is a function of
decrease in HR (P < 0.001), systolic BP (SBP) (P < 0.001), peripheral vascular resistance which is mainly determined
and diastolic BP (DBP) (P < 0.001) after practice of Nadi by SNS. Hence, decrease in HR, SBP, and DBP in our study
Shuddhi Pranayama for 12 weeks [Table 1]. group represents an increase in parasympathetic activity
and a decrease in sympathetic activity. This shift toward
Analysis with paired t-test shows that there was a parasympathetic dominance is may be because of direct vagal
significant decrease in DBP response to IHG test (P stimulation.[14] There was a significant reduction in DBP
<0.001) after practice of Nadi Shuddhi Pranayama for stress response to IHG test after the practice of Nadi Shuddhi
12 weeks [Table 2]. Pranayama for 12 weeks. Similar results were observed in
the previous studies which found a significant decrease in
A Wilcoxon signed-rank test shows that there was a DBP response to IHG test after the practice of slow breathing
significant difference (Z = −6.73, P < 0.001) between PSS exercises.[15,16] Voluntary muscle activity is associated with
score for before Pranayama compared to after Pranayama sympathetic outflow to the cardiovascular system. The
[Table 3]. The median PSS score before Pranayama was 19, accumulation of metabolites during the isometric contraction
while after Pranayama, it was 14. Therefore, Nadi Shuddhi initiates the exercise reflex, resulting in sustained sympathetic
Pranayama can be used for reduction of stress in medical activity. In our study, reduced sympathetic reactivity in DBP
students. can be attributed to decreased sympathetic activity because

Table 1: Comparison of pre‑ and post‑HR, SBP, and DBP (n=60)

Parameter Pre (mean±SD) Post (mean±SD) t value P value
HR 76.88±7.753 72.67±5.619 15.86 0.000**
SBP 114.2±5.984 109.93±5.405 14.11 0.000**
DBP 75.60±6.797 71.43±5.729 9.70 0.000**
HR: Heart rate, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, SD: Standard deviation

Table 2: Comparison of pre‑ and post‑DBP response to IHG test (n=60)

Parameter (mean±SD) t value P value
Pre‑DBP ‑ pre‑DBP after IHG Post‑DBP ‑ Post‑DBP after IHG
DBP response to IHG 19.73±1.965 16.67±1.410 9.52 0.000**
test (difference in mm Hg)
DBP: Diastolic blood pressure, IHG: Isometric hand grip, SD: Standard deviation

Table 3: Comparison of pre‑ and post‑PSS score (n=60)

Parameter Median (before pranayama) Median (after pranayama) Z value W value P value
PSS score 19 14 −6.73 0 0.000**
PSS: Perceived stress scale
Analysis was performed by Wilcoxon signed‑rank test; W value represents sum of all signed ranks; Z value represents standardized test
statistics; **P<0.001 ‑ statistically highly significant

3 National Journal of Physiology, Pharmacy and Pharmacology 2018 | Vol 8 | Issue 6 (Online First)
Dhanvijay and Chandan Nadi Shuddhi Pranayama on perceived stress and cardiovascular autonomic functions

although vagal parasympathetic pathways are predominant CONCLUSION

for HR, sympathetic pathways play a major part in BP.[17]
Slow pranayamic breathing increases baroreflex sensitivity To summarize, we conclude that regular practice of
leading to decreased chemoreflex activation and thus reduces Nadi Shuddhi Pranayama helps in reducing stress in
sympathetic reactivity.[18] We observed a significant reduction medical students as evidenced by corresponding decrease
in PSS scores after practice of Nadi Shuddhi Pranayama for in cardiovascular autonomic parameters. It does so by
12 weeks. Reduction in stress may have resulted because of downregulation of HPA axis and the SNS. Ultimately,
increased parasympathetic activity and decreased sympathetic sympathetic dominance, vagal withdrawal, and baroreceptor
activity. Bhimani et al.[19] studied the effect of pranayama on impairments which result due to distress are corrected
stress and cardiovascular autonomic functions and found that and homeostatic balance is reestablished. Therefore, slow
stress level has reduced after 2 months of practicing various breathing exercises such as Nadi Shuddhi Pranayama can be
pranayama. Sharma et al.[20] compared the effect of fast and used as a stress coping tool in 1st year medical students along
slow pranayama on perceived stress and cardiovascular with other stress management techniques.
parameters and concluded that slow breathing exercises are
more beneficial for rebalancing of autonomic nervous system
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Source of Support: Nil, Conflict of Interest: None declared.
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