Yoga Maneuver May Prevent Vasovagal Syncope

Regular practice of a specific yoga maneuver appears to reduce susceptibility to reflex vasovagal syncope, a new study suggests.

The tadasana exercise — a movement-based contemplative practice that gradually corrects orthostatic imbalance by strengthening protective neuromuscular reflexes — practiced for just 15 minutes twice a day, was associated with the complete elimination of episodes of vasovagal syncope for many patients.

Dr Hygriv Rao

“These exercises are very easy to perform, inexpensive, and very effective. This is a very easy fix for a scary and potentially dangerous condition,” lead author Hygriv Rao, MD, told | Medscape Cardiology. “We are excited about these results. We thought it would work, but we did not expect it to be so effective. It seems to work for almost all patients.

“We found that with the tadasana maneuver, episodes of full syncope, where the patient actually loses consciousness, ceased completely, and episodes of near-syncope, where the patient feels faint but does not completely pass out, were greatly reduced,” Rao added. “The actual loss of consciousness, which is the most dangerous part, is practically gone. This gives a lot of confidence to patients and their families.”

The researchers report their initial results from a pilot study of the technique in a letter to JACC: Clinical Electrophysiology that was published online January 26.

Rao, a cardiologist at the KIMS Hospitals, Hyderabad, India, explained that vasovagal syncope is a brief loss of consciousness due to a neurologically induced drop in blood pressure caused by faulty neuromuscular reflexes.

It is typically triggered by emotional stress, prolonged standing, or getting up from a sitting position too quickly.

Very few treatments have been shown effective, with current management approaches involving avoiding triggers, increasing fluids, and if the individual feels an episode coming on, they can take steps to stop it by lying down, raising their legs, or lowering their head to increase blood flow to the brain.

“Recently, there has been a lot of interest in yoga as a preventative therapy for vasovagal syncope,” Rao noted. “We considered various yoga positions and we chose the tadasana maneuver to study in this context as it resembles exercises sometimes given to patients with vasovagal syncope but with some differences including the addition of synchronized breathing, which may help stabilize autonomic tone.”

For the tadasana maneuver, the individual stands straight with their feet together, arms by their side (against a wall if they need support), and alternatively lift the front and back part of their feet.

They first lift their toes with their weight resting on the ball of their feet, then after a few seconds they raise their heels with their weight on the front of the foot. Then after a few more seconds they lift their arms over their shoulders, stretching upward while standing on their toes.

These movements are synchronized with breathing exercises, with the individual taking a deep breath in as they lift their arms and breathing out again on lowering the arms.

“Each movement takes a few seconds, and each cycle of movements takes about 2 minutes. If this is performed 8 times, then this would take about 15 minutes. We recommend this 15-minute routine twice a day,” Rao said.

For the current study, 113 patients diagnosed with recurrent vasovagal disorder were counseled to practice standard physical maneuvers and maintain adequate hydration. Medications were prescribed at the discretion of the treating physician.

Of these, 61 patients were additionally trained to practice the tadasana maneuver and asked to practice the movement for 15 minutes twice a day. The mean durations of symptoms and follow-up in the two groups were similar. The average follow-up was about 20 months.

Results showed that episodes of both near-syncope and syncope decreased in both groups but there was a much larger reduction in the patients practicing the tadasana maneuver.

Before treatment, the 52 patients in the conventional group experienced 163 syncope or near-syncope events. At follow-up, 22 symptom recurrences occurred in 12 patients (23%). Total mean events per patient declined from 3 to 0.4.

Full syncope events in this group declined from 65 in 32 patients to 2 in 2 patients (mean per patient, 1.3 to 1), and near-syncope events fell from 98 in 34 patients to 20 in 10 patients (mean per patient, 2.0 to 0.4).

In the tadasana group, 61 patients had 378 syncope/near-syncope events before treatment; at follow-up, only 6 events occurred in 5 patients (8%). Per patient, total events declined from a mean of 6 to 0.1.

Full syncope events fell from 108 in 48 patients to 0 (mean per patient, 1.8 to 0), and near-syncope events declined from 269 in 33 patients to 6 in 5 patients (mean per patient, 4.4 to 0.1).

“This combination of exercise and breathing influences the neuromuscular reflex malfunction that occurs in vasovagal syncope,” Rao noted. “The movements focus on strengthening neuromuscular reflexes in the quadriceps and the calf muscles, which can increase the blood circulation and venous return, thus preventing blood pooling in the lower body,” he explained.

The researchers say this pilot study offers three main findings. First, both conventional therapy and conventional plus tadasana therapy appeared to benefit patients compared with their respective baseline symptom burden. Second, application of tadasana as an adjunctive treatment was associated with fewer total event recurrences (ie, syncope and near-syncope combined), and third, tadasana was well tolerated, with no adverse events reported.

“The reduction in total events (ie, syncope and near-syncope events) compared with pre-treatment numbers was substantial and most tadasana patients were managed without any pharmacotherapy,” the authors report.

Rao noted that at baseline almost all patients in both groups were taking medications for the condition, but during the study these medications were reduced as fewer episodes occurred. At the end of the follow up, 80% of the conventional group were still taking medication compared with just 14% of those in the tadasana group.

Patients had an initial training session in person with a yoga instructor and then received follow on training by video online. Rao said there was a very high rate of compliance, “almost 100%.”

He reports that a total of 200 patients have now been treated with this approach at his hospital with very similar results to those seen in the initial study.

This work was supported in part by a grant from the Dr Earl E. Bakken Family in support of heart-brain research. Rao has disclosed no relevant financial relationships.

J Am Coll Cardiol EP. Published online January 26, 2022. Letter

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